What the CSB Got Wrong

At the July 23-24 U.S. Chemical Safety Board public hearing in Houston to discuss the role of performance indicators in preventing catastrophic accidents such as the Deepwater Horizon explosion, there was general agreement throughout the panel discussions and formal paper presentations that more effective leading indicators of potential process failures should be identified and put in place for the offshore drilling industry. Additionally, there was discussion about too much reliance on personal safety lagging indicators, such as Total Recordable Incident Rate (TRIR) and lost time injury frequency rate (LTIFR), at the expense of process indicators.

For instance, Dr. Andrew Hopkins commented that "one of the main lessons coming out of the Texas City disaster was the need for a separate focus on process safety as opposed to personal safety."

Though we support increased efforts to identify leading indicators for process safety, we strongly believe that high-risk industries will assume even greater risk if the current view expressed at the CSB public hearing on prevention of catastrophic accidents causes a loss of focus on personal safety, because process and personal safety are integrally related. As was pointed out at the hearing, "there is no silver bullet" among performance indicators that can predict all catastrophic events. Improved indicators will indeed better provide management the ability to (1) make more proactive/effective decisions, (2) put into place additional processes and procedures, and (3) design and implement additional mechanical safeguards. The reality is, however, that most of our work sites, including deepwater drilling rigs, are highly complex, dynamic environments where it is impossible to predict all failures. Procedural and mechanical safeguards, though absolutely required, are incapable of preventing all incidents.

These tools have been developed to protect against failure under very specific situations that have been identified usually from failure in the past. They are therefore static in nature -- slow to adapt and constrained in their application when new factors are introduced.

To respond to unforeseen or unrecognized hazards within complex environments, high-risk industries must incorporate a more agile component into the overall strategy for managing these high-risk operations that works in concert with the identification of leading process safety indicators. For a safety tool to be "agile," it should meet the following three criteria:

(1) Ubiquitous: present throughout the organization so that it is available when new situations arise.
(2) Reactive: able to respond quickly.
(3) Creative: able to resolve new problems.

Encouraging Employees to Intervene
Such a dynamic tool is already available in virtually all workplaces, and that tool is People. Because people meet these three criteria, they are uniquely suited to prevent both personal and process incidents in complex environments and to provide the feedback needed to inform the development of improved systems and processes. They are capable of quickly intervening in unanticipated hazards as they emerge, but only if they have the requisite skills to do so.

Though absolutely necessary, Stop Work Authority is simply not enough. Our research has demonstrated that, although employees know that they have such authority, they do not use it most of the time. When asked why, they say it is because the other person (including their supervisor) would become defensive or angry if they intervened. In other words, they don't feel capable of effectively stopping the unsafe operation and thus avoid doing so.

Notably, there have been several reports of employees' failing to intervene prior to the Deepwater Horizon explosion. Therefore, to successfully create a safety culture where intervention is both accepted and successful, employees must:

(1) understand their role in preventing incidents of all types
(2) be motivated to perform that role
(3) be enabled to do it effectively and
(4) be supported when they do so.

All employees must understand the critical role that intervention plays in stopping undesired events and creating the data necessary for the development of safeguards. They must be encouraged to intervene whenever they see a potential hazard, whether it be for an individual or for the entire operation. Employees must understand how to stop the work of both an individual and a team in such a way as to prevent defensiveness and encourage exploration. They must understand that the unsafe operation/action is occurring in a highly complex context. They also must understand it is this context that is driving the decision to engage in this action, and only by understanding that context can a real resolution be identified. They also must be confident they will be supported in their attempts to create a safer workplace through utilization of the intervention process.

The effort to stop catastrophic events such as the Deepwater Horizon incident must be multifaceted and take seriously the inherently unpredictable nature of today's highly complex industrial workplaces. Because of the relationship among personal safety, intervention, and the identification of potential process safety risks, significant efforts must be made to improve the frequency and effectiveness of direct, immediate human intervention in unsafe operations.

By developing this component of an overall Safety Management System, the system itself becomes more agile and better suited to respond to the unanticipated hazards that inevitably emerge in complex operational environments.

Dr. Ron Ragain of Conroe, Texas, is co-founder and executive director of The RAD Group (www.theradgroup.com). He received his doctorate in psychology in 1977 from the George Peabody College of Vanderbilt University and has been a consultant to hundreds of organizations around the world since beginning his consulting career in 1981. Mike Allen of Mansfield, Texas, co-founder and director of operations of The RAD Group, is a former teacher and coach who led high school teams to 10 state championships in football and baseball. He spent 16 years in oil and gas industry, reaching the position of corporate director of quality and training, before joining The RAD Group in 1998.

Posted by Ron Ragain, Mike Allen on Aug 06, 2012


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