Investigators say BP was sweating the small stuff
July 25, 2012 by Fred HosierPosted in: Chemical safety, Fatality, fire/explosion, In this week's e-newsletter, Investigations, Latest News & Views
PDF “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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Tags: BP, Chemical Safety Board, Deepwater Horizon, process safety
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July 25th, 2012 at 8:31 am
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.
July 25th, 2012 at 10:38 am
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.
July 25th, 2012 at 4:45 pm
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.
July 26th, 2012 at 1:14 pm
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.
July 27th, 2012 at 10:15 am
Yes very and extremely well