On the road – so it’s your turn

Last week I was at the Probabilistic Safety Analysis and Management conference.  We had 400 attendees from some over 20 countries.  Notably this was the first time in 20 years that there was a full tract on Safety Culture with about 40 papers presented.  The topics included development of new theoretical models, case studies of safety culture analysis and interventions, and research underway in aviation, medicine, and nuclear power.  The Conference key-note was delivered by Dr. George Apostolakis, formerly of MIT and a new Commissioner of the Nuclear Regulatory Commission; he chose to speak on safety culture.  Over the next few weeks I’ll be summarizing a sampling of the papers presented.

Meanwhile, over the next week or so I invite you to comment on the Deepwater disaster.  True, the full facts are not in and will likely be quite a while in coming.  But as I was flying around the country I re-read “Streetlights and Shadows” by Gary Klein – his latest on decision making.  In it he discusses fallacies about how people make decisions and elaborates on his extensive research on how experts make decisions based on pattern matching.  He does an excellent job of relating his decision research to high reliability.  From what we know about high reliability and organizational failure, I think we have a sense of some of the fundamental organizational and culture issues surrounding the catastrophe.  The President’s Deepwater Commission will consider what should be done to prevent such events in the future.  So how would you advise the Commission on what they should consider?  What should be done by government and industry to transform petroleum drilling and production into a highly reliable operation?  Is it possible?

I look forward to reading your suggestions.

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3 Responses to On the road – so it’s your turn

  1. Charles Nickell says:

    Glad to see you soliciting comments on the drilling debacle. I submit that there are many lessons we can learn from this, and possibly much we can provide to help with the solution — not of how to drill a well — but how to establish an organizational culture that eliminates these types of failures. I look forward to hearing what others contribute on this blog and in our fall ISM Workshop.

  2. Earl and Charles,

    There is a lot to say, but I’ll leave most of it out.

    1. Deepwater Horizon looks like just another chapter in Grossly Outrageous Regulatory Performance (GORP) that includes TMI-2, Davis-Besse, Upper Big Branch, Enron, Texas City, the Subprime Mortgage Meltdown, Exxon Valdez, TVA Ash Release, Berni Madoff, and the like. A dozen or so professionals are exploring this issue. To join send an e-mail to RCSOTP_13_GORP-subscribe@yahoogroups.com

    2. Dr. Apostolakis is always insightful. Please post a link to his talk as soon as you can.

    3. We should encourage the President’s Deepwater Commission to identify the factors that resulted in the natures, the magnitudes, the locations, and the timings of the consequences before recommending the final actions. Surgery before diagnosis is often malpractice.

    All the best.

  3. Bill Roege says:

    I am always cautious about calling for more regulation. The act of regulation is very much a lagging activity and by necessity encourages a “compliance” mindset instead of the “excellence” mindset that is needed to operate highly complex, high-risk, socio-technical systems. I agree that there are good regulatory practices that can contribute to excellence, but few regulators are capable of that.

    I believe the biggest lesson will end up being the confusing command and control situation on the platform. With so many organizations responsible for various parts of the operation it needed a strong decision-making structure. It sounded as if that was lacking. It also sounded if there was no firm criteria on when to stop and push decisions up or to really think things through before proceeding. Classic “hurry up” error precursors were pretty evident.

    When I did work on rebasing all our overseas forces, the impact of synchronizing separate organizations in the military and DOD was very apparent. The “seems” we found between the various combatant commands (not only between the geographical commands, but between geographical and global commands such as TRANSCOM and EUCOM) were incredible. Multiple organizations participating on any decision-making problem increases risk a lot. Jerry Harbour uses the Black Hawk shootdown in Northern Iraq in his risk management course. I believe the key underlying factor in that event was the various organizations that had to communicate and make decisions…that didn’t do it effectively that day.

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