A couple of days ago I started to read the latest report of the Buncefield Disaster. The report highlights some root cause of the disaster in management failings;
Sometimes it seems we never really learn from the past.
A History lesson
An enquiry was established (Cullen Inquiry, reported in late 1990) which was critical of the management of the operator. Cullen commented that senior management were too easily satisfied and relied on “the absence of any problems as indicating that all was well”. Like too many organisations still do, the operators tolerated “known problems” and management demonstrated only a “superficial response when issues of safety were raised by others”.
What changed? The introduction of more controls, audits and reviews. These included things like a Safety Case regime.
The company blamed the operator on duty, but the official inquiry (a Royal Commission) blamed the company (Esso) for not ensuring its staff knew the risks they faced and the correct procedures for dealing with them.
Following the disaster Victoria (and other states) implemented some of the Safety Case regime that was developed after Piper Alpha - but still did not see the recurring cultural problem.
The operator (BP) had not maintained the plant well and had ignored prior incidents and reports about safety.
7 months later
There is a common thread here we can learn from. Culture contributes to all these incidents.
The changes after the incidents are for more regulation and audit but not for changes to culture.
Efficiency is the enemy of reliability.
The root cause of this risk is not just the organisation’s culture – but the market and the wider culture of investment and productivity. We need to promote a culture that supports reliability rather than just a focus on efficiency.
I have written about the principles of High Reliability Organising in other posts, but these aspects need to become part of the culture of an organisation that seeks to be resilient. Especially those who operate in these high risk areas such as oil and gas production.