Safety and OSHA News

Investigators say BP was sweating the small stuff

“Don’t sweat the small stuff,” an old saying goes. A federal investigation into the Deepwater Horizon explosion that killed 11 workers says BP was doing just that at the expense of paying attention to more serious safety hazards.

In interim findings, U.S. Chemical Safety Board (CSB) investigators say BP and its partner Transocean focused on personal injury data (such as dropped objects, slips, trips and falls, etc.). That focus overshadowed measuring indicators that could point to more catastrophic incidents.

A number of past CSB investigations have found companies focusing on personal injury rates while virtually overlooking looming process safety issues,” said CSB Chair Dr. Rafael Moure-Eraso. “Furthermore, we have found failures by companies to implement their own recommendations from previous accidents.”

One company that failed to do that was BP.

In its investigation of the Deepwater Horizon disaster, a CSB investigator found an “eerie resemblance” between the 2005 explosion at the BP Texas City refinery that killed 15 workers and the Gulf of Mexico explosion five years later.

At the Texas City refinery in 2005, contract workers had just returned to temporary trailers at the plant after attending a celebratory lunch commending an excellent personal injury record. Shortly after the lunch, the explosion occurred.

On the day of the explosion at Deepwater Horizon in 2010, BP and Transocean officials praised workers for a low rate of personal injuries.

A CSB investigator said companies need to develop indicators that give them information about their potential for catastrophic incidents.

“Safety is not easy to measure,” and that has to be done using “surrogate indicators,” said a companion report by an industry expert released by the CSB.

What are those measures, also known as leading indicators?

Another expert opinion paper released by the CSB provides some suggestions:

  • backlogs of maintenance which is critical to the safety of the facility
  • temporary repairs
  • levels of deferred maintenance
  • number of safety instrument overrides
  • equipment wear (such as corrosion), and
  • percent of time maintenance isn’t completed on time.

Do you think the safety field has focused too much and too long on lagging indicators like injury rates? Have you shifted to attempts to measure leading indicators that show potential for larger, possibly catastrophic incidents? Let us know in the comments below.

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  1. Interesting article. I used it for a discussion with operations in our morning meeting. So, these companies focused on their craft workers behavior while ignoring infrastructure maintenance needs. I asked our supervisors how that applies to our business.

    ex. If you have a painter/ blaster working on a scaffold built with structural defects, it doesn’t matter how safe the painter is working. He is still in danger.

    We had a painter several years back who was working on a scaffold around a tower about 200′ up. He was tied off to an inner handrail (tube and clamp). As he leaned back the rail gave away and he fell backwards but caught himself on the outer rail. He didn’t fall but probably had to change his underwear afterwards. When investigating I found that the nut on the bolt holding the clamp together was completely stripped on it’s threads. You could actually slide it back and forth by hand. We are supposed to inspect these clamps when we build and dismantle and take them out of service when they are bad. Didn’t happen.

    We don’t work in a bubble. Everything we do can affect others.

  2. VJ,
    I am confused. You make a point of saying that focusing on behaviors can result in infrastructure and maintenance needs going by the wayside. You then use an example where someone didn’t properly inspect the scaffold to prove your point. Is that not a behavior?

    The company focused too much on dropped objects, slips, trips, falls? A citation for any one of those could result in a “serious” violation. Someone needs to stop the presses and tell OSHA they are focused on the wrong thing.

  3. alecfinn says:

    Hold on The Chemical Safety Board does many of these investigations. What they are referring to is the focus at BP on the Deepwater Horizon and the Texas refinery was employee behaviors and ignoring Infrastructure problems.
    That was also VJ’s point. Only in VJ’s example there was an infrastructure problem (the bad railing) and an employee problem (inspecting safety equipment). Both are of importance however many will hone in on employee behavior because it appears to be the easiest and cheapest to correct in the short term.
    If you read the Chemical Safety Boards investigations of the Texas refinery that BP owns the reports are enlightening two explosions in about 20 years and tons of toxic gas release by refusing to scale back on production when a piece of equipment went bad.
    Sometimes (and this is something all need to be aware of) it is that both infrastructure and staff behavior are components of a safety program.

  4. I guess I didn’t make my point that well, I got distracted towards the end of writing it. My point is that we ask these guys to work safely. We reward them on the individual level. But a lot of infrastructure needs get overlooked because of the cost involved. We know that bolts on these clamps wear out and the approximate life expectancy of that material. If we estimate the life expectancy of 4 years, then we should have an idea of how many we have bought per year and how many should have been replaced. Lets say you are using 1000 clamps at your site, then in every 4 year period you should be replacing 1000 clamps. If that worker on a scaffold at 200′ was not tied off then he will be terminated automatically by our company rules. If he’s tied off to a rail with a badly worn clamp that fails, is anyone held responsible? That Project Manager may even have been rewarded by the company for saving money when he didn’t replace them.
    I can focus on the painter, his PPE, and best work practices and align all my safety training towards impacting his behaviors. But if he’s working on that platform then he’s not in a bubble. Maintenance backlogs, safety instrument overides, deferred maintenance etc, of infrastructure can be a lot more hazardous to his health.
    Did that make sense? I feel like I’m not getting my point across.

  5. alecfinn says:

    Yes very and extremely well

  6. Trish R says:

    While I agree that there is, perhaps, an overly focused behavioral agenda, might I remind you all that proper maintenance is also behavior-based unless there are reports of required maintenance being ignored or disregarded. However, again, that is behavioral from the top.

    Part of each worker /crew’s responsibilities is to inspect all tools and equipment prior to starting work. Having intimate knowledge of time-sensitive maintenance should be required of each job supervisor / project manager, and carried out.

    If a company refuses to subscribe to a fully-rounded safety culture, then someone dropping a measuring tape while on a ladder is really inconsequential.

    EVERY Accident IS Preventable.

    As an OSHA Authorized Trainer, I let every trainee know that we are human and every one of us will “blip” periodically. Unfortunately, that’s typically when something happens. Therefore, it is EVERYONE’S responsibility to be accountable to themselves and their co-workers.

    If we all RESPECT each other and watch each others’ backs fewer accidents will occur.

    The only way to analyze how safe each worker is working is to track injury / illness rates. It is also the only way to truly change process and procedure. However, I cannot imagine not tracking maintenance issues such as those suggested in this article.

    At an aircraft manufacturer that I worked for, this was paramount and could shut down all work if anything was over its allowable margin. Each worker noted anything observed right at the work center which allowed for individual and management accountability. A daily Walkaround meeting was held with all Executives to address those issues right then and there. Was it worth 30 minutes to an hour of their time? Their question was “ is a person’s life worth this small investment”?

  7. I think so and I believe most of the people that read this site also believe in Safety Management as a responsibility that all are accountable for. That the cost of Safety is minimal compared to folk getting injured or killed.

    I find articles like this and reading the reports of the investigations on OSHA’s and the Chemical Safety Boards site as well as the other agencies appalling. I also find it appalling to read where folk complain about the cost of Safety Management and OSHA’s rules.

    In the past Administration there was a reduction of regulations and outright deregulations in many areas and look at what has happened.

    One report I was upset to the point of outrage was about the Safety Bonus’ given to BP and their subcontractors for achieving Safety Goals just as the Deepwater Horizon incent was happening.

    Another was the man who died in a stampede on black Friday at a Wal-Mart on Long Island and Wal-Mart contesting the OSHA fine because there was no standard for crowd control. Wal-mart tried to say the General duty clause did not cover workers in that situation. The fine (as I remember) was less than $10,000.00 and they had spent millions as well as OSHA’s court costs that money could be of better use to help workers be educated in safety rather than trying to not pay the fine.

    There are some organizations that are unscrupulous and uncaring so that anything that impacts on their cash flow no matter how small or what the negative ramifications to the workers may be is not done so even though Safety Management is relatively inexpensive it is not done.

  8. I understand your “outrage” over those examples you gave. There are other factors in play as well that should be factored in though. Without knowing for certain I’d wager that BP gave those bonuses because A.) They were obligated to under a bonus system that had goals identified by KPI’s that were met, or B.) in an effort to retain managers that would have gone to their competitors. Is it right? No. Is it necessary? They probably thought so. Calling it a “safety bonus” is extremely insensitive on their part for certain. A cynical argument could be made for “Hey, look how many people we didn’t kill this year”.
    I worked for a very, very large trucking company in management for 10 years. When I was a lower level “fleet manager”, really no more than a dispatcher, one of my drivers was involved in a multi vehicle collision. Our truck rolled completely over a small car and killed 3 people, a family. I had to testify in the civil trial as experts hired by their family went over ALL of my drivers logs with a fine tooth. Every discrepency, every error, and yes every falsification, was pointed directly at me as corrupt, inept, evil and vile. I am none of those. The strangest part was that I had gone from an unknown lower level manager, to someone that every executive in the company knew by name. I was told it was the way I handled myself at the trial and my career took off. If that collision had never happened I probably would have stayed at that level. I ended up walking away anyway because I just didn’t like the business. Working as a Safety Manager in refineries and chemical plants is a lot more rewarding.

  9. Try blowing a small hadufnl of powered sugar or flour across your gas burner. (DO NO LET KIDS DO THIS) It’s explosive alright! and Imperial well knows it. I guess they will move to Mexico now, so they won’t be sued by greedy lawsuit happy burned and dead workers anymore. I guess Georgia’s laws weren’t business friendly enough.

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