Managerial Error is also Human Error

Research shows that New Zealand ranked ninth (last!) in workplace health and safety performance for the 2005-2008 period out of nine OECD

countries, with:

102 fatalities per annum (4.1 per 100,000 workers)

369 non-fatal serious injuries (16.0 per 100,000 workers)

(Organisation for Economic Co-operation and Development)

New Zealand’s workplace injury rates are about twice that of Australia and almost six times that of the UK

The economic and social cost of work related injuries to our nation is around $3.5 billion dollars

The emotional cost to families and communities????

“she’ll be rig

ht mate…”

How does this stack up?

Pike River…..

Where we’re at….Following the Pike River disaster an independent taskforce made a number of 'big picture' recommendations, including: • repeal the current Health and Safety in Employment Act 1992

and move to something along the lines of the Australian ‘model law’ legal framework

• replace the current ‘all practicable steps’ test with a requirement for businesses to do all that is ‘reasonably practicable’

• strengthen worker participation• setting up an independent Crown agency to be responsible for

health and safety• increase the obligations on people in control of workplaces

and governance by directors by imposing due diligence obligations to them to ensure businesses are operating safely

Also, the Government and the Institute of Directors launched a set of Guidelines for company directors on leading and managing health and safety in their workplaces.

The guidelines provide directors with advice on how they can influence health and safety performance in their organisations, their roles and responsibilities, diagnostic questions and actions, a checklist and case studies.

Corporate Manslaughter???

Human Error“a departure from accepted or desirable practice on the part of an individual or group of individuals, that can, or does result in unacceptable or undesirable behaviour”

…estimated that up to 90% of all workplace

accidents have human error as a cause !

But … simply writing off accidents to “operator

error” is a simplistic, if not naive, approach to mishap

causation.

“I cannot accept that accidents only befall the incompetent, and

increasingly I find myself wondering…

…how it is that competent people in beneficial surroundings can make

serious mistakes.”

Rod Johnson - U.K. Coastguard Agency Training Officer

Human Error and Competence?

Mishap

Latent Failures

Latent Failures

Active/Latent Failures

Active FailuresFailed or

Absent Defences

OrganizationalInfluences

UnsafeSupervision

Preconditionsfor

Unsafe ActsUnsafe

Acts

The “Swiss Cheese” model of human error causation (adapted from Reason, 1990)

Unsafe Acts

Active failures by the operator……

UNSAFE ACTS

ERRORSERRORS

SKILL-BASED

ERRORS

PERCEP-TUAL

ERRORS

DECISION ERRORS

EXCEP-TIONALROUTINE

VIOLATIONSVIOLATIONS

Categories of unsafe acts committed by operators

Violations – Blame?

Were the instructions known and understood?

Was it possible to follow them?

Did they cover the problem?

Were the reasons for them known?

Were earlier failures to follow the rules overlooked?

Was he or she trying to help? If there had not been an accident, would he or she have

been praised for his or her initiative?

Violations are the only sort of human error for which blame is sometimes justified, but first ask:

Violations

Defined as the “wilful departure from authority”

• Routine• Exceptional

Routine Violations

Commonly referred to as “bending” the rules, these violations are often tolerated and, in effect, sanctioned by supervisory

authority

– that is, you’re not likely to get a ticket going only a “little” over the limit.

The problem is that these violations became the norm – “business as usual”.

“we do it like this all the time and nobody even

notices”

Human Error o

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Human Error o

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Human Error o

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Human Error o

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“The accident starts in the office…”

Human Error – who’s responsible?

2 case studies…………..

Deepwater Horizon drilling rig explosion

(April 20, 2010)

Deepwater Horizon was an ultra-deepwater, dynamically positioned, semi-submersible offshore oil drilling rig owned by Transocean. Built in 2001 in South Korea by Hyundai Heavy Industries, the rig was commissioned by R&B Falcon, which later became part of Transocean, and leased to BP from 2001 until September 2013.

In September 2009, the rig drilled the deepest oil well in history at a vertical depth of 10,683 m in 1,259 m of water.

At 9:45 P.M. on 20 April 2010, during the final phases of drilling the exploratory well at Macondo, a geyser of seawater, and then a slushy combination of mud and methane gas shot 73 meters in the air. The gas component of the slushy material quickly transitioned into a fully gaseous state and then ignited into a series of explosions and then a firestorm.

The blowout killed 11 crewmen and ignited a fireball visible from 56 km away. The resulting fire could not be extinguished and, on 22 April 2010, Deepwater Horizon sank, leaving the well gushing at the seabed and causing the largest offshore oil spill in U.S. history.

An attempt was made to activate the blowout preventer, but it failed.

Safety?

The rig owner, Transocean, had a "strong overall" safety record with no major incidents for 7 years

… won an award from the MMS for its 2008 safety record

… on the day of the disaster, BP and Transocean managers were on board to celebrate seven years without a lost-time accident

BUT:

“At nine years old, Deepwater Horizon has never been in dry dock,” one worker told investigators. “We can only work around so much.”

“Run it, break it, fix it…that’s how they work.”

Pre-explosion risks and precautions 

In Feb 2009, BP filed a 52 page exploration and environmental impact plan with the Minerals Management Service (MMS). ……."unlikely that an accidental surface or subsurface oil spill would occur from the proposed activities".

Walruses?  The blowout preventer (BOP) was not fitted with remote-control or acoustically activated triggers…..and, it was unknown whether the dead man's switch was activated. Transocean had previously made modifications to the BOP for the Macondo site which increased the risk of BOP failure, in spite of warnings from their contractor to that effect.

Pre-explosion problems and warnings US Coast Guard had issued pollution citations 18 times between 2000 and 2010, and had investigated 16 fires and other incidents. …not considered unusual....... Some serious incidents, though. In 2008, 77 people were evacuated from the platform when it listed and began to sink after a section of pipe was accidentally removed from the platform's ballast system. 2009 – BP engineers had concerns that the metal casing could collapse under high pressure.

By April 20, 2010 the Deepwater Horizon well operation was already running five weeks late.

According to a report, the blowout preventer (last inspected in 2005) was damaged in a previously unreported accident in late March 2010.

March 2010: Number of problems:

• drilling mud falling into the undersea oil formation, • sudden gas releases, • a pipe falling into the well, and on• at least 3 occasions the blowout preventer leaked fluid

Several serious warning signs in the hours just prior to the explosion. Equipment readings indicated gas bubbling into the well – signalling impending blowout?The heavy drilling mud replaced with lighter seawater on orders of BP - though the rig's chief driller protested.

A House Energy and Commerce Committee statement in June 2010 noted that in a number of cases leading up to the explosion, BP appears to have chosen riskier procedures to save time or money, sometimes against the advice of its staff or contractors.

Visiting VIP’s About seven hours before the accident a group of four company VIPs helicoptered onto the drilling rig. They had come on a “management visibility tour” and were actively touring the rig when disaster struck. The visiting VIP’s all had a detailed knowledge of drilling operations...... But, while the major purpose of the visit was to emphasise the importance of safety, the visitors paid almost no attention to the safety critical activities that were occurring during their visit.

The VIPs appeared to focus their informal auditing activities on checking that certain conditions were as they should be, rather than checking on behaviours.

So for example – checking on whether the harness tests were up to date, on whether a certain slip hazard had been remedied, and whether house keeping was up to standard.

They did not set out to check on what people were actually doing at the time of observation and whether they were complying with safety requirements.

This is a common auditing preference. States or conditions are easier to audit, because they are relatively unchanging. Behaviours are difficult to audit…..

There are lessons here for all senior managers who undertake management visibility tours in major hazard facilities.

… in a survey (of workers on Deepwater Horizon) commissioned by Transocean in March 2010, it was reported that "less than half of the workers interviewed said they felt they could report actions leading to a potentially "risky" situation without any fear of reprisal ... many workers entered fake data to try to circumvent the system”.

As a result, “the company's perception of safety on the rig was distorted”, the report concluded.

On the day the rig exploded, 79 of the 126 people on the rig were Transocean employees.

Culture?

Investigation into explosion Review of seven Major Reports on the Causes of the Blowout indicates that six operations, tests, or equipment functions went wrong in the final 32 hours: 

• Problems with mud circulation.

• Valves to prevent cement backflow did not close.

• Cementing inadequate.

• Pressure test wrongly interpreted.

• Rising oil and gas not monitored.

• Fail-safe on seabed wellhead was unable to close.

The Oil Spill Commission said that there had been "a rush to completion" on the well, criticizing poor management decisions.

"There was not a culture of safety on that rig," co-chair Bill Reilly said.

May 13 – BP CEO, Tony Hayward, calls the oil spill "relatively tiny" in comparison with the size of the "ocean."  July 27 – BP board formally announces that Bob Dudley will replace Tony Hayward as BP CEO effective October 1.  September 19 – BP officially declares oil well completely and permanently sealed.  September 30 – Dudley tells the Houston Chronicle, "We don't believe we have been grossly negligent in anything we've seen in any of the investigations." Dudley also announces BP will create a stronger safety division.

Aftermath….

The Costa Concordia accident

(January 13, 2012)

The Italian cruise ship Costa Concordia partially sank when it ran aground on the coast of Tuscany, on 13 January 2012, with the loss of 32 lives. The ship, carrying 4,252 people from all over the world, was on the first leg of a cruise around the Mediterranean Sea when she hit a reef during an unofficial near-shore salute to the local islanders. To perform this manoeuvre, Captain Francesco Schettino deviated from the ship's computer-programmed route, claiming that he was familiar with the local seabed.

She struck her port side on a chartered reef at 21:42 local time. The initial impact was at a point 8 metres below water and tore a 50-metre gash in the ship's port side below the water line, causing a temporary power blackout.

The captain, having lost control of the ship, did nothing to contact the nearby harbour for help but tried to resume the original course it was on prior to the U-turn back to Giglio.

In the end, he had to order evacuation when the ship grounded after an hour of listing and drifting. .... only a fortunate coincidence of winds and tides prevented the ship from sinking in the deep water surrounding Isola del Giglio.

Meanwhile, the harbour authorities were alerted by worried passengers, and vessels were sent to the rescue.

During a six-hour evacuation, most passengers were brought ashore. The search for missing people continued for several months, with all but two being accounted for.

The ship was righted on 17 September 2013

Captain Schettino stated that, before approaching the island, he turned off the alarm system for the ship's computer navigation system. "I was navigating by sight, because I knew those seabeds well.

However, the ship's first officer, told investigators that Schettino had left his reading glasses in his cabin and repeatedly asked him to check the radar for him.

The Captain….

The normal shipping route passes about 8 km offshore, but the captain said that Costa Cruises managers told him to perform the 13 January sail-past, as he had done previously.

At the captain's invitation, the maître d'hôtel of the ship, who is from the island, was on the ship's bridge to view the island during the sail-past.

A further person on the bridge was a Moldovan dancer, who later testified that she was in a romantic relationship with Captain Schettino.

Timeline of the wrecking13–14 January 2012 

21:12: Ship deviates from planned route

21:45: Collision at Le Scole reef

22:06: Harbour Master phoned by passenger's daughter, saying life jackets were ordered

22:14: Harbour Master radios ship; is told that all is well except for an electrical blackout that will be repaired

22:26: Harbour Master is told that the ship is taking on water and listing; no dead or injured; requested a tugboat

22:34: Harbour Master is told that ship is in distress

22:39: Patrol boat reports the ship is listing heavily

22:44: Coast Guard reports the ship is grounded

22:45: Captain denies grounding, says ship still floating and will be brought around

22:58: Captain reports that he ordered evacuation

23:23: Ship reports large starboard hull breach

23:37: Captain reports 300 people on board

00:12: Coast Guard patrol boat reports that port side lifeboats cannot be launched

00:34: Captain says he is in a lifeboat and sees 3 people in water

00:36: Coast Guard patrol reports 70–80 people on board including children and elderly

00:42: Captain and his officers are in lifeboat; Harbour Master orders them to return

01:04: Helicopter lowers Air Force officer aboard, who reports 100 people remain

03:05: Evacuation ferry returns to Porto Santo Stefano with 5 injured and 3 dead

03:17: Police identify captain on quay

03:44: Air Force reports 40–50 remain to evacuate

04:22: 30 reported remaining to be evacuated

04:46: Evacuation concluded

The ship was deemed to be a constructive total loss, with damages of at least US$500 million. Shares in the Carnival Corporation, the American company that jointly with Carnival plc owns Costa Cruises, initially fell by 18% on 16 January 2012. On 22 February 2012, four officers who were on board and three managers of Costa Cruises were placed formally "under investigation" and faced charges of “manslaughter, causing a shipwreck and failing to communicate with maritime authorities".

Aftermath….

On 20 July 2013, five people were found guilty of manslaughter, negligence and shipwreck:

• The company's crisis director received the longest sentence at two years 10 months (not on the ship… but convicted of minimising the extent of the disaster and delaying an adequate response)

• The cabin service director (for his role in the evacuation, which was described as chaotic) – two and a half years.

• The first officer , helmsman (steering the ship in the wrong direction) and third officer were given sentences between one and two years.

Unlikely that any of these individuals will go to jail…..

The Cruise Lines International Association (CLIA), the European Cruise Council (ECC) and the Passenger Shipping Association adopted a new policy requiring all embarking passengers to participate in muster drills before departure.

The new muster policy consists of 12 specific emergency instructions, which include providing information on when and how to don a life jacket, where to muster and what to expect if there is an evacuation of the ship.

Are we learning from accidents though?

Titanic 1912……….Costa Concordia 2012…….

The operation to right the

Costa Concordia

ConclusionBoth of these “Human Error” accidents had elements of risky behaviour / routine violations that had become “business as usual”….

But, responsibility for both these events extend beyond simply the personnel at the coalface.

The management of the Deepwater Horizon was clearly flawed….. And Captain Schettino on the Costa Concordia seemingly believed he could make safety critical decisions unilaterally….and he had done it before…..

So, before you blame the operator, ask yourself,

“Is there managerial error at play here?”