They didn’t have to die. That’s the tragic bottom line. Eleven men working on the Deepwater Horizon would be alive today if the companies managing the operation had been more attuned to safety and less attuned to profit. Anyone familiar with the concepts of safety culture management in high-tech operations will recognize virtually everything identified as going wrong in the spill commission’s report – because it’s all about fallible humans interacting with increasingly complex machinery that they, increasingly, misjudged. Worse, we didn’t have to wait for the report – the outlines of disaster were clearly visible. Back in May, when the Macondo well was still spewing millions of gallons of oil into the Gulf of Mexico, I wrote of the investigation: “It will finger a combination of human errors – both managerial and technical, a technology pushed into unknown territory without any comprehensive analysis of the potential failures, and profit pressures propelling everyone full-steam ahead.” But the commission took its findings a significant step forward when it concluded the faulty managerial and regulatory culture was not isolated in one or two companies, but is “systemic” in the industry. If the deaths of those 11 men are to mean anything, that’s the Red Alert both the oil industry and its regulators need to respond to. In the few days since the commission’s conclusions were released, we’ve heard industry representatives and defenders say the conclusions are wrong and the accident was due to a few bad actors – or that, even if the industry had gotten a bit complacent, it has seen the light, learned the lessons, and now can go back to business as usual. Where have we heard this before? Nuclear plants, among others – where after Three Mile Island-2’s accident, the exact same sentiments were uttered -- for a good dozen years. We’ve learned the lessons, we’ve seen the light, now go away, many operators in effect told regulators – and some of their peers. They spent years deluding themselves that preventing another TMI did not require fundamental change. But some nuclear leaders knew better – they knew a true “safety culture” revolutionizes the way a company works. You don’t get it by tacking up “Safety First” posters in the break room. But it took years – and a few shutdowns of ill-managed plants, and threats of more for plants that had become money pits for their owners – before the safety culture leadership prevailed. And they prevailed because good operators bought stinker plants and turned them into well run money-makers. Nothing like a healthy profit to convince risk-averse boards that the long view is indeed the right one. We often hear the question, “Is this safe?” That’s a meaningless question. Safety is a process, not a status. Is a Boeing 747 safe? Is it safe with a 10-year-old in the pilot’s seat? Is it safe if the oil’s never changed? The machinery can be great – but humans can defeat the best engineering. Creating a safety culture in high-tech environments requires an unbroken chain of managers, top to bottom, who recognize that, long-term, an accident is always the most expensive option and short-term costs have to be evaluated in that context. Safety culture involves “flattened” management – complex environments require teams, and everyone is on the safety team. Anyone who sees a condition or a practice that could endanger safety has a duty to raise it, without fear of retribution – and managers have a duty to listen. That means investing in those workers. They need to understand the complex equipment used in the high-tech environment. On-going training becomes a part of every worker’s life – and part of his or her paid workday. Knowledgeable employees can spot something going wrong and save a company’s bottom, and its bottom line. It also means, when an accident happens, there’s no sticking the blame on the tool-pusher on the drilling floor. Maybe he did do something wrong – but why? He wasn’t trained right or supervised right – and why not? Who failed there? Who at the next level of management failed to provide correct direction so the training and supervision would occur? And so on, up the ladder right into the corner office. In a safety culture, the top always takes ultimate responsibility. More, in a culture of safety, managers seek that responsibility. Every near-miss is a golden opportunity to make sure it never happens again – and to lower risk for good. Learning from a precursor instead of an accident is always cheaper – as Transocean has just found out the hard way. Lessons from a near-miss on another Transocean platform just a few months earlier could have saved the Deepwater Horizon – if they’d been learned. And an expert government regulator can be a true partner in the safety culture. Till now, the oil industry has done all it could to marginalize regulators. They’re seen as needless nuisances, just red tape. Far better to have a knowledgeable regulator who can provide intelligent feedback, actually help a company operate safely. It should be the industry, in its own long-term best interests, demanding expert, top-quality safety regulation. But until we see that kind of turnaround in industry attitudes, we can be confident – this tragedy’s lessons haven’t been learned, risks haven’t been lowered, and the president’s commission is right: it can happen again. And next time, how many more will die needlessly? |