The latest Andrew Hopkins book steers clear of analysing corporate leadership, and this is a good thing. Australian National University sociologist, Andrew Hopkins, has established an international reputation for his enlightening analyses of the failures of organisational culture in major disasters but his latest book, Disastrous Decisions: The Human and Organisational Causes of the Gulf of Mexico Blowout, purposely leaves leadership out.
This may disappoint many but Hopkins says that
“The critical role of top leaders in accident prevention cannot, however, be overstated. It is they who must learn from major accidents and, unless they do, nothing can be expected to change.
There is one group of decision-makers that has received rather less attention in accident investigations: office-based engineers.” (page 8)
Hopkins says that
“….this book starts with the engineers, since it was their flawed decision-making that initiated the chain of barrier failures that led to the disaster.” (page 8)
Although I have only just received this book and dipped into it, it seems useful to have familiarity with the Hopkins oeuvre since his Longford books, particularly his book on the BP Texas City Refinery Disaster book. He takes pains to emphasise that the current book does not bash BP. There were several corporations involved in the disaster and this book is more of an investigation of the drilling industry, as a whole.
A preliminary look has shown only a small mention of Montara oil incident in the Timor Sea that occurred shortly before the Macondo incident although many have drawn parallels.
I would have liked to know more about this incident but, in a footnote, Hopkins says
“The Montara report appeared after the Macondo blowout and was therefore not available to the Macondo engineers. Whether they would have read it, had it been available, is another matter.” (page 114)
Instead, Hopkins chooses to mention a blowout in the Caspian Sea in late-2008, which involved BP, Chevron, ExxonMobil and others, and early events that occurred at Macondo as well as a “remarkably similar [Transocean] event in United Kingdom waters while completing a well for Shell.” Regardless of years of sharing lessons of loss prevention, oil drilling and offshore safety, the industry still does not learn from incidents beyond their nearby sphere of operations.
Hopkins ends his book on many important lessons but as a safety communicator and a humanities graduate, I was very pleased by his mention of the importance of storytelling.
“Storytelling was one of the most important means of instruction in pre-literate societies. In an era where information is transmitted at ever-increasing rates, taking time to tell the stories is still a vital means of ensuring that lessons are learnt.” (page 177)
I am looking forward to reading the rest of Hopkins’ safety story.
It’s good to see a focus on engineering decision making. Too often I’ve seen managers ignore the engineering, or engineers think that they can’t make decisions. Often people say ‘yes’ to everything, thinking that this is good (from a sociological perspective), but sometimes we must make choices, saying ‘no’ to some things in order to say ‘yes’ to others. However, if we’ve lost the habit, how will we recover it to make that big decision while under pressure?
Another disaster MH 370 , systemic management failure?
The book, Disastrous Decisions, does a great job of picking up the culture in management of plant and systems.
One thing that is missing however, is an understanding of the different disciplines that make up a holistic offshore well drilling and completion operation. It involves the coordinating a range of systems. The primary ones are: The drilling rig system with logistics; the primary and secondary well control management systtem; and the well system itself which includes understanding the earth model it sits in.
The leaders (project coordinators) must always know / understand the nature of the beast at different stages. Like a Captain and Co pilot on an airliner in contact with air control, it takes two plus with different perspectives to put certainty into risk management. Seeing the unknowns.
The cost cutting that has occurred in the oil and gas exploration and development operator and regulator processes relative to project management of well systems is preventing the development of competent teams in the industry. The reasons are cultural and societal so actual fault of loss control due to systemic managment failures is a community responsibility.
The evidence in the book is extremely well documented and the recommendatons / conclusions is that the way forward. It is to get affective learning across the numerous disciplines on a project by project basis. (It was Amoco, later purchased by BP that had developed the TRUE (training to reduce unscheduled events) in the 70’s. Why was it stopped? This is one of the root causes of systemic management failures.
The challenge will be to have regulatory and operating entities to accept the cost in the industry to gain the competence towards facilitating learning.
As indicated in Disastrous Decisions Conclusions, BP’s behavior after the Texas Refinery explosion, everything just gets back to the same because the root causes of how learning isn’t occuring isn’t understood.
A reason its not understood is the missing link again. It related to the issue of money being king and no personal accountability at the front end of management for the waste, like NPT (non productive time) and the numerous systemic management failures that include near miss indicdents..
Possibly a way forward is to take the content of Disastrous Decisions commingled with that in “The Simple Truth” BP Macondo Blowout by JA Turley, who sets the scene on the Deepwater Horizon in the final days of drilling, running and cementing the production casing and in the temporary abandonment.
The gaps as to root cause could be filled by field experience drilling systems project coordinators using the evidence in the two books. An on-line Induction Program and the earth model with well control simulator that used the actual events from spud on the Montara Timor Sea and Macondo Gulf of Mexico blowout.to drilling the relief wells and killing the blowouts.
Simultaneously some key points, like the geological hazard and miss judged mud weights that impact casing and cement design and barrier quality globally can be understood, and then managed in the casing / cement design process, including selection of casing seats..
Note that the way operators are managing drilling and completion operations is very similar to that which is occuring in the BP Macondo Trials. http://www.mdl2179trialdocs.com/
Not enough input by project coordinators expertise. Just searching for blame, right and wrong to mitigate cost, without knowing the root cause of the events amd not bringing the geological hazard of nature into the thinking.
This barrier is in the culture of Western World thinking so the systemic management failures can only continue.
An example of the fix it when it breaks and techonological fix ideology that exists in the Western Wrold is demonstrated in the responses to the current North Korea agressive nature.. Maybe in all this there just needs to be an apology, a reboot of the system that lets everyone be a participant of an ideology where there is self accountability, self respoinsibility and self empowerment in teams around terms of best practices and common sense.
Thank you to Kevin and thank you John. I have read the book and will be interested in any follow up comments you have Kevin after reading the book.
John you have thrown an additional light on the subject. I had not understood about that aspect.
Although I currently work in a different industry, (human services), where performance bonuses are not (much) of a factor, many of the organisational issues apply.
It does feel good to get a clearer picture of some of the dynamics at play.
In my experience the biggest issue is “silo” or “castle with a moat” mentality driven by competitive pressures and/or principle KPI’s aimed at maximising business centre profit/success. I saw it in the Bowen basin where BHP Billiton consortium mines resisted learning from each other because of a concern that this would lead to others seeing what it was that made them successful. Had to visit each of nine mines re a proposal as they were not interested in meeting as a group. Know of another person who had on occassions picked up managers from one mine and driven them to another mine site because it was the only way he could get them to inspect innovative machinery at abother site (and that site placed restrictions on where he could take that manager).
Cooperation between corporations in key areas of competition is rare, though I have seen some cooperation over limited periods in regard to some peripheral areas of safety