Transcript Managerial Error

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:
(Organisation for Economic
Co-operation and Development)
102 fatalities per annum
(4.1 per 100,000 workers)
 369 non-fatal serious injuries
(16.0 per 100,000 workers)

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????
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.
Human Error and Competence?
“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
Organizational
Influences
Latent Failures
Unsafe
Supervision
Latent Failures
Preconditions
for
Unsafe Acts
Active/Latent Failures
Unsafe
Acts
Failed or
Absent Defences
Active Failures
Mishap
The “Swiss Cheese” model of human error causation (adapted from Reason, 1990)
Unsafe Acts
Active failures by the operator……
Categories of unsafe acts committed by operators
UNSAFE
ACTS
ERRORS
DECISION
ERRORS
SKILLBASED
ERRORS
VIOLATIONS
PERCEPTUAL
ERRORS
ROUTINE
EXCEPTIONAL
Violations – Blame?
Violations are the only sort of human error for which
blame is sometimes justified, but first ask:
 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
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”
“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.
An attempt was made to activate the blowout preventer,
but it failed.
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.
Safety?
The rig owner, Transocean, had a "strong
overall" safety record with no major incidents for 7 years
… on the day of the disaster, BP and Transocean managers
were on board to celebrate seven years without a lost-time
accident
… won an award from the MMS for its 2008 safety record
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 remotecontrol 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.
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
According to a report, the blowout preventer (last inspected
in 2005) was damaged in a previously unreported accident
in late March 2010.
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.
Culture?
… 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.
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.
Aftermath….
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.
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
The Captain….
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 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 wrecking
13–14 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
Aftermath….
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".
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
Conclusion
Both 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?”