What Trevor Keltz gets right

Madonna has just released another greatest hits CD.  Trevor Kletz has done similar in releasing the fifth edition of “What Went Wrong?” He admits that almost all of the content has appeared elsewhere.  It’s been almost 20 years since I had to read Kletz’s books and articles as part of working in a Major Hazards Branch of an OHS regulator in Australia.  Not being an engineer, the books informed me but were a chore.  This is not the case with the last edition.

Kletz has two parts to the book.  The first is a collection of short case notes recording as he says

“…the immediate technical causes of the accidents and the changes in design and methods of working needed to prevent them from happening again”.

The second discusses the weaknesses of management systems.  In short, the book reflects the expanding nature of safety management over the last forty years.  Kletz may be from the Olde School of safety engineers (he is 87 years old) but often one needs a fresh perspective on a profession and coming from a person with such extensive experience, Kletz is worth listening to.  Thankfully, he does not sound like a grumpy old man.

Kletz notes that process industry lessons seem to fade after a few years.  In my opinion this may be an effect of the transience of modern careers where corporate memory is often fragmented.  It may also be due to the shipping of manufacturing and process industries off-shore and the establishment of large complexes in countries with different (lax) safety requirements.  It may also be due to a corporate performance regime where maintenance is not valued or understood as that supports long term thinking rather than quite returns on investment.

Regardless of the cause, the short-term memory makes the need for such books as this as more important than never.

In anticipation of his look at management systems he notes in his preface, that management systems need maintaining and, more importantly, reading.  In some circumstances, too much faith is placed in the system (I would refer to the Esso Longford explosion as an example).  Kletz says all systems have limitations.

“All they can do is make the most of people’s knowledge and experience by applying them in a systematic way.  If people lack knowledge and experience, the systems are empty shells.”

What Kletz does not write about is human error because, as he says, “all accidents are due to human error”.  He avoids making the weak logic jump that the behaviouralists make where, “if all accidents are due to human error then fix the human and you fix the hazard”.  Kletz devotes a whole chapter to his classification of human errors as

  • Mistakes;
  • Violations or noncompliance;
  • Mismatches;
  • Slips and lapses of attention.

This edition of “What Went Wrong?” provides a baseline for the safety concepts we have come to accept but also a critical eye on safety and manufacturing management shortcomings.  The style is very easy to read although occasionally repetitive.  Thankfully the process technicalities are avoided unless they relate to the technical point Kletz is making.  I found part B hugely useful but it is recommended for all safety professionals.

Kevin Jones

Varanus Island is back to normal

According to various Australian media reports, the natural gas plant at Varanus Island in Western Australia is now back to full capacity following the major pipeline explosion in 2008.

The government has estimated that the explosion blasted $A2 billion from the state economy and will be pursuing the pipeline’s owner, Apache Energy, through the courts.

The government says the pipeline was inadequately maintained and corrosion led to the failure of the pipe.

Apache has already been in the courts seeking an injunction to stop the Western Australian Mines & Petroleum Minister, Norman Moore, from seeing a “a federal-state government report into alleged regulatory lapses that may have contributed to the Varanus Island blast”.

Apache’s move is peculiar but the WA government has become more involved in the investigation of this explosion than others and the company has not been happy with the investigation process for some time.

Kevin Jones

Offshore industry regulator performance

Australia’s National Offshore Petroleum Safety Authority (NOPSA) has released a report of its own OHS performance based on data from 2005 to 2007.  NOPSA has been in the public eye far more than normal due to the Varanus Island explosion and the various investigatory reports.

The report seems to indicate that, as a regulator, NOPSA is performing to expectations.  NOPSA’s CEO John Clegg has acknowledged that the  industry is below the level of its overseas counterparts.  This is peculiar given that other Australian resources industries, like mining, are ahead of other countries and that safety in the offshore industry has had a high profile ever since Piper Alpha.

The report identifies challenges that are difficult but not very surprising:

  • improving leadership – strong leadership is required for the Australian industry to move to the next level
  • dealing with a shortage of skilled personnel
  • managing ageing facilities and minimising gas releases

It will be very interesting to watch the benchmarking of NOPSA and its future role through the OHS harmonisation process that Australia is undergoing.

Below is the full report and the performance summary.

Kevin Jones

NOPSA 2007-08 cover

   NOPSA summary 2007-08

A slap on the wrist – Varanus prosecution

The West Australian government has finally decided to prosecute Apache Energy over the Varanus Island explosion in 2008.  Many people are asking if the effort is worth the bother as the maximum penalty possible is a measly $A50,000.

Comparing the disruption to the state’s gas supply to the Esso-Longford explosion, which generated a Royal Commission in Victoria, it illustrates the difference in having an explosion in an isolated area, that does not kill or injure, and that allows a government to ensure domestic gas supplies.  One could argue that a major difference was also that WA did not rely solely on a single gas source.

According to one media report

Apache spokesman David Parker said it would vigorously defend the matter. “The explosion was an unfortunate and unforeseen event”.

Explosions often are unfortunate and usually unforeseen but adequate maintenance requirements of pipelines are foreseeable, just not often profitable.

Apache Energy, a subsidiary of the US energy giant Apache, has not been the most transparent and helpful corporate citizen as it has taken Federal Court action that impedes the government’s investigations.

Kevin Jones

More on the Varanus pipeline can be read by searching for “Varanus” in the search function to the right of this blog page

Varanus Island investigations continue

International safety attention was focused on a tiny island of the northwest Australian cost in mid-June 2008 when a pipeline exploded.  Investigation reports have been presented to government and companies have regained operations after the major gas explosion that disrupted supplies across Western Australia.

In early May 2009, the WA Department of Mines & Petroleum announced a further investigation will be undertaken. WA Mines and Petroleum Minister Norman Moore has said that the department would carry out the final stage of investigations into the  explosion.

Kym Bills and David Agostini have been classified officially as inspectors and will undertake the investigation.

Moore said that the October 2008 report by NOPSA needed additional information which has recently become available.

 “…that investigation was limited by its reporting time frame and the absence of critical evidence, such as the results from destructive and non-destructive testing of the pipeline.”

A ministerial media release identifies the investigation’s scope:

  • the pertinent sequence of events on Varanus Island during the incident
  • the likely cause(s) of the incident
  • any actions and omissions by the operator of the Varanus Island facility, or its contractors, leading up to and during the incident that may have contributed to those events.

The final report will be presented to the department in June 2009.

Background on Varanus Island is available in SafetyAtWorkBlog by searching “Varanus” as a keyword.

Kevin Jones

Economic cost of Varanus Island pipeline explosion

According to the Australian Treasurer, Wayne Swan, has said, on 3 December 2008, that the Varanus Island explosion

“is estimated to have subtracted around a quarter of a percentage point from [Gross Domestic Product] in the September quarter.”

This follows earlier estimates from the Reserve Bank of Australia that the disruption from the explosion would cause a negative blip of $2.5 billion in GDP.

The Senate Economics Committee report to the government yesterday said that the real economic impact will never be known because it occurred amongst other economic confusion.  

Business cases for the importance of occupational safety management are notoriously difficult to quantify, although some OHS colleagues disagree.  OHS has a far stronger argument through the moral imperatives than economics but economics is the language of the business world.  The Senate Committee report includes a lot of macro- and micro-economic data for those who want it.

The fallout from the Varanus Island investigations continue in Western Australia but it may be possible to say that for the wont of regular assessments and maintenance on a pipe in a remote location, Australia has lost billions of dollars in revenue, in a time of economic difficulties.

Longford explosion anniversary, Andrew Hopkins and a new book

October 2008 was the tenth anniversary of the explosion at Longford gas plant in Australia that resulted in many injuries, two fatalities and almost two weeks of severely interrupted gas supply to the State of Victoria.

The Longford explosion at an Exxon-Mobil site resulted in a Royal Commission, an OHS prosecution and a record fine.  Recently it was often invoked in comparison to the Varanus Island pipeline explosion in Western Australia.

Professor Andrew Hopkins, sociologist with the Australian National University, was studying safety management systems well before the Esso Longford explosion but it was that major disaster that added international prominence, and a substantial extra workload, to Andrew.  Other than domestic acclaim, in July 2008, the European Process Safety Centre declared Andrew winner of the EPSC Award for 2008.  He is the first person outside of Europe to win this award.  It is believed that Andrew was formally presented with the award at the EPSC conference earlier this month.

Andrew has a refreshing perspective on safety management systems, partly because he has brought a sociologist’s eye to management decisions; his vision is not clouded by the OHS baggage through which many other analysts struggle.

Andrew’s next book due out this month through CCH Australia is Failure to Learn The BP Texas City refinery disaster and could have him travelling frequently the United States to offer his wisdom.

SafetyAtWorkBlog is working on a new interview with Andrew when he returns to Australia but in the meantime, a 2000 interview with Andrew is available as a page on this blog.  The interview was conducted at a book launch in September 2000 for Lessons From Longford.

Professor Andrew Hopkins (right) receiving the award from Christian Jochum, Director of the European Process Safety Centre
Professor Andrew Hopkins (right) receiving the award from Christian Jochum, Director of the European Process Safety Centre