Fear of Being Safe

Operational Excellence is rapidly developing into the safety culture mindset of modern workforces operating in risk industries. More often than not a ‘zero accident’ policy will be at the centre of the method statements, risk assessments and permit-to-work policy. The truth is ‘operational excellence’ and ‘zero accidents’ are expensive. Changing culture and ensuring the highest standard of professional development for the workforce are not cheap options and both need time. The key to this equation is very straightforward however – compare the cost of ‘operational excellence’ against the cost of a ‘big accident’!

If BP were given the opportunity to go back to pre-Macondo Blow Out, April 20^th 2010, and ‘right’ some of their wrongs, I’m pretty certain they would jump at the chance.

Unfortunately though it often takes a big event to accelerate the culture change needed for initiatives like Operational Excellence to flourish. BP was proud of their safety culture pre-Macondo, even winning awards for excellence in the months leading up to the blow out. These awards, superficially encouraging, somehow contradict the internal messages driven by senior staff and certainly were not consistent with the email correspondence in the weeks leading up to April 20th.

On March 8^th, Deep Water Horizon experienced a ‘severe gas kick back’, which in every way resembled the April 20^th blow out that killed 11 people. During the subsequent Presidential investigation numerous emails were uncovered that do not marry with the ‘safety first’ message projected outwards by BP. Below is one extract taken just 3 days before the deadly Macondo blow out from the BP Well Team Leader to the BP Operations Manager:

David,

“Over the past four days there have been so many last minute changes to the flying operation that the WSL’s have finally come to their wits end. The quote is “flying by the seat of our pants.”… Everybody wants to do the right thing, but this huge level of paranoia from engineering leadership is driving chaos. This operation is not Thunderhorse. Brian [Morel] has called me numerous times trying to make sense of all the insanity… This morning Brian called me and asked my advice about exploring opportunities both inside and outside the company. What is my authority? With the separation of engineering and operations, I do not know what I can and can’t do. The operation is not going to succeed if we continue in this manner.

So, if the outward projection is ‘safety first’, what could drive the content of this email?

I have, in a previous blog, explored Transactional Analysis (TA) and the role it plays in Human Factors and safety critical communication. The belief within TA is that almost 70% of the transactions (communication) between humans have an ulterior level. The words spoken on the surface represent the social part of the transaction, however, the true meaning of the communication lie at the psychological level. We give these mixed signals all of the time, whether it is telling somebody which way it is to the shower, the words mean one thing while the meaning is something completely different.

Looking at the diagram below the words spoken represented by the solid lines and are Adult to Adult:

Stimulus (Adult) - “The showers are just down the corridor.”

Response (Adult) – “Thank you”

The psychological level however is not spoken but both people know the meaning intuitively.

Stimulus (Controlling parent) – “You need a shower.”

Response (Adaptive Child) – “OK, sorry.”

So how does this correlate with the Macondo blow out? BP had a safety system known as the ‘operating management system’ (OMS) that executives described as the “cornerstone of their safety practices”. This was not applied in the Gulf of Mexico. This would also appear counter-intuitive given the heightened risk when drilling in deep water, as Macondo certainly was.

NASA had a mantra of “better, faster, and cheaper” in the lead up to the Columbia disaster. BP’s mantra, as famously communicated by Tony Hayward, BP’s former CEO, was “every dollar counts”. Both of these carry messages that are disseminated throughout their respective organisations and both of these have ulterior transactions. When this message reaches the drilling teams at the ‘coal face’ it will have taken many subliminal twists, turning the ‘safety first’ policy into a ‘safety first’ with the injunction of ‘while not affecting the every dollar counts’ mindset. The social level is an Adult -‘safety first’, the psychological level is a Controlling Parent - ‘profit first’. This mixed message culture leads to confusion, despair and disillusionment, which are all present within the email in the days leading to the Macondo blow out. BP will feel the cost of this culture and mindset for many years but it would be foolish to believe they are alone in pursuing profits before safety. Other industries can and hopefully will learn from the lessons of Macondo. Safety culture is like all other corporate visions, it should be conceptualised at board level, communicated at management level and executed at the coalface. There cannot be a disparity between the policy at the top and the toolbox talk at the bottom. Added to this external analysis should be encouraged to share best practice.

There is a cost, but it is a cost worth bearing. You need look no further than the statement of the HSE for a sobering appraisal:

“If you think safety is expensive, try having an accident!” 

Operational excellence and a true safety culture require many ingredients. The vision needs strong leadership, delivered with energy, empathy and passion; empty words with ulterior transactions will not inspire and lack congruence. Above all transparency is key, this can mean accountability, or re-framed positively it gives ownership and allows honesty to flourish. When people are doing the wrong things its usually when nobody is looking, transparency encourages honesty – this can only be positive when managing risk. 

Phil Quirk