Some industrial disaster lessons

What industrial disaster lessons did we learn from multi-fatal incidents such as Texas City plant, Deepwater Horizon, and major safety conferences?

In short, I don’t think we have learned much, writes safety psychologist David Broadbent. Ten years ago the BP petrochemicals plant at Texas City exploded, killing fifteen people.

Eleven of the people killed had worked for Jacobs Engineering and were meeting in one of the demountable buildings near the explosion site, ironically for a merit function, to get a pat on the back.

Another major disaster involving the same company five years ago at BP Deepwater Horizon, killed eleven people. The obvious question is whether this company, this industry, and business at large, ever learn anything from incidents, disasters, and investigations.

The answer really has to be No. A paper by WE Gale Jr, titled ‘Perspectives on Changing Culture and Managing Risk’, suggests that BP learnt nothing, and that their history is peppered with risk tolerance.

And their risk tolerance did not change. The ‘disaster’ CEO was dismissed after Texas City, but his replacement did not do any better.

He was seen out fishing while others tried to clean up the mess. His expression of a ‘laser beam’ approach to safety was naïve, and just plain toxic to safety culture.

What this also demonstrates to us is that a toxic organisational safety culture is a very difficult thing to shift. Organisations such as BP and many others, have well cemented corporate habits.

You can try and move them, but it takes a Herculean effort to ensure that any of these positive changes are actually sustained.

The Houston Chronicle published that 64 people were killed in USA refineries in the decade prior to Texas City. And there have been 58 killed in the decade since.

An artist's rendition of a worker saving the life of an injured colleauge in an industrial disaster in Corpus Christi, Texas.
An artist’s rendition of a worker saving the life of an injured colleauge in an industrial disaster in Corpus Christi, Texas.

Behavioural safety mirage
No change in the body count, despite millions spent on reports and programs. The bulk of these refineries continue to rely heavily on administrative controls, and the mirage of behavioural safety.

They seem to have been seduced into thinking that a good BBS program is all that is required. But when we audit their process safety protocols they are primarily administrative, and have not translated into genuine activity.

They might have read some Andrew Hopkins, and hear him, but they rarely implement what they read and hear.

At the most basic of levels, organisations don’t even bother with the easy stuff. A recommendation after Texas City to removed non-essential employees from risk areas seems a simple task, yet the Chronicle reminds us that some companies still put up tents and trailers in risk areas.

The risk areas are nice and open to dissipate potential blasts and to keep people away from risk, not for tents!

Tesoro refinery disaster
The Tesoro refinery fire and explosion killed seven maintenance workers, while the task required only one operator. After four years of investigations, the US Attorney determined there were no criminal charges to be laid.

US Attorney Jenny Durkan said the evidence reviewed “does not reach the exacting bar for criminal prosecution.” However the investigation by her office and others, including the US Chemical Safety Board, “have prompted changes in how the industry conducts itself.”

I get tired of how often I hear that kind of statement. Whatever these ill-defined magic changes might be, they appear to achieve very little. We have to move past talking and do a lot more walking.

Sadly, I suspect there is way too much hand-washing going on. In 2010 the USA Department of Labor and Industry fined Tesoro US$2.38m, on 44 workplace violations, including wilful disregard of safety regulations and failing to maintain 40-year-old equipment.

In addition, the USA Chemical Safety Board (CSB) concluded in its investigation that Tesoro Refinery failed to use safe equipment, had poor inspection procedures, and allowed its employees to regularly work in unnecessarily dangerous situations.

What truly scares me is the observation that safety has been diminished over the last several years. In short, we are not learning, or worse, we are learning how to get away with less safety effort and a fine or two.

I was part of the Global HSE conference sponsored by Cairn Energy in New Delhi 2013, an exceptional safety event. Has the event resulted in significant improvements in safety culture in India?

History and the jury is still out on that question, although the feedback from my blog subscribers is, Pobably not. The Indian geo-cultural climate makes safety effort very difficult. Should we be distracted? I hope not.

Some employers are dishonest
I have personally become despondent over the last few years. I saw some corporate safety dishonesty around our world. An excellent speaker from Sri Lanka stated bluntly that the Indian practice of trying to “screw every deal down to the lowest price” was directly costing people their lives.

This is the view of a specialist who is part of Indian corporate culture. We have to try to cast off this shroud of despondency. We must give good corporate intentions every support we can.

A safety event in Dubai was also branded as a Global HSE conference, but it was a commercial event with fees, and workshops with additional fees. The event did very poorly in attracting participants.

Commercialization of health and safety is part of the problem, but the slide in the oil price in the months before the conference led to cost-cutting.

Most of these petrochemicals in the MENA region are not at risk of going under. Their gate price does not change, but any dent in the profit margin makes a hole in health and safety budgets.

These organisations loudly proclaim safety as a Number One priority, or core value, which are not the same, but both sound good. Their behaviour proves that their priorities change, and that their only core value is profit.

A South African mining house under profit pressure issued an instruction; “Until further notice all training is cancelled”. When the corporate heat is on, safety and people development is discretionary.

So have we learned anything about safety culture? Well, not much. Mangers have gained some understanding of the influence of High Reliability Organizing (HRO) on disaster-proofing an organisation.

Yet almost organisations forget that they need to maintain a healthy degree of respectful fear of risk in all aspects of the business.

Most organisations quickly become tolerant of risks, and deviate from their own rules. It does not take long for those deviations to become the real norm.

• David G Broadbent is a safety psychologist and the founder of TransformationalSafety.Com, based in Australia. This post is an extract from his circular.

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