Commonalities Between Disasters Occupational safety emphasized over process safety Human Factors: • A combination of either individual errors or organizational failures have been reported to cause as much as 80% of oil spills and marine accidents**An Assessment of the Role of Human Factors in Oil Spills from Vessels. Report to Prince William Sound RCAC, 2006.
How Organizational Failure Can Lead to Individual Errors HUMAN FACTORS HUMAN ERRORS INDIVIDUAL FACTORS SKILL-BASED competence action errors stress checking errors motivation GROUP FACTORS RULE-BASED management retrieval errors supervision transmission errors crewORGANIZATIONAL FACTORS KNOWLEDGE-BASED company policies diagnostic errors company standards decision errors systems and procedures
Recommendations Safety Cases • Produced by the operator of a facility to*: – Identify hazards and risks – Describe how the risks are controlled – Describe the safety management system in place to ensure the controls are effectively and consistently applied • Scrutinized by a competent and independent regulator*Australia’s National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA)
Structure of a Safety Case* Strategy Aim Safety Objectives Management Assessors System (SMS) Resources Safety Case Safety Production Safety Manager Case Through Life SMS Safety Management Description Committee Scope Safety Case Supporting Auditors Report Argument Review/Audit Emergency Acceptance Procedures Hazard Identification Targets Safety Assessment Risk System Assessment Description Hazard*Zotov, Dmitri (2007). Safety Cases: Control Hazard LogBeyond Safety Management Systems
Recommendations Process Safety Management (PSM) National Emphasis Program: • Policies or procedures to reduce the workplace hazards associated with the catastrophic release of highly hazardous chemicals at petroleum factoriesOSHA: PSM-NEP. Directive # CPL-03-00-010
Recommendations Communicating and Speaking Up1 • Survey conducted on Transocean crew members working on Deepwater Horizon days before explosion: 46% of crew members feared reprisals for reporting unsafe situations2 • Go through training with peers, supervisors, and subordinates to flatten the corporate hierarchy1. Managerial Practices that Promote Speaking Up Constructively Among Front-Line Employees (2011).2. Commission on BP Oil Spill, pg. 219
Worth the Cost? $40 $35 $30 $25Billions $20 $15 $10 $5 $0 Construction Disaster