Safety Culture Lessons from CSB and Other Major Incident Investigations

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Miles Hodge
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1 Safety Culture Lessons from CSB and Other Major Incident Investigations Bill Hoyle Senior Investigator; retired U.S. Chemical Safety Board Sao Paulo, Brazil August 2014

2 Presentation overview Expecting the unexpected New ways to think about safety culture Review of major CSB investigations including Deepwater Horizon, West Fertilizer and BP Texas City Discussion of Fukushima nuclear and San Bruno pipeline incidents

3 3

7 18 Things that have not happened before happen all the time.

8 7 What is the CSB? Independent U.S. government investigation agency began operation in 1998; modeled after the National Transportation Safety Board Makes recommendations for prevention Budget $11million; 18 investigators Conducts safety studies: combustible dust and reactive chemicals

9 San Bruno, California 2010

10 San Bruno fire inch-diameter natural gas ruptured and caught fire in California 8 people killed and many injured 38 homes destroyed and 70 more damaged Company took 95 minutes to stop the release Released 47 million standard cubic feet of gas Workers self-deployed to shut the manual valves Culture of grandfathering safety

11 West, Texas April 2013

12 Apartment building destroyed

13 Fertilizer company destruction

14 Nursing home and schools damaged

15 Fukushima nuclear incident

16 23 Was the earthquake unforeseen? March 11, 2011 major earthquake damages Fukushima nuclear plant A 6.8 earthquake in 2007 cost Tokyo Electric Power Company (TEPCO) nearly $6 billion A 7.8 quake in 1993 created a 30-foot high tsunami in Japan

17 24 Fukushima planning was inadequate Engineers planned for a maximum tsunami wave of less than 11 feet Fukushima was hit by a wave that was 30 to 45 feet high The powerful earthquake was calculated to occur once in 1,000 years, but it took place just 8 years after the analysis TEPCO s cost estimated to be $137 billion Culture of close relationship between company and regulator revealed

20 Blaming BP: a barrier to learning CSB investigation ongoing Transocean, Halliburton, Cameron involvement Oil industry role Government regulatory ineffectiveness Failure of risk management

21 Failure to recognize major risks Past success acted to downplay risk of a catastrophic spill Blowout preventer failure considered extremely unlikely Emergency response planning not taken seriously by industry or regulators

22 Failed emergency response Response plans copied from Alaska Response equipment not available Very little industry or government capacity to address a major leak It took nearly three months to stop the leak

23 Personal vs. major hazard safety BP and Transocean primarily measure safety performance using worker injury data BP executives on the rig to commemorate outstanding safety record Safety bonuses and awards largely based on injury data Transocean celebrated 2010 as the safest year in their history

24 Failure to learn from Texas City Safety management system improvements made in refining were not implemented in offshore operations Continued focus on personal safety rather than major hazard safety 30,000 wells drilled without a major blowout was seen as proof that risk was managed successfully

25 25 Risk assessments that rely on probability do not offer protection from incidents that rarely happen or have not happened before.

26 BP Texas City - 3/23/2005

28 28 BP Texas City oil refinery

29 BP Texas City days away from work

30 31 New ways to think about safety culture Safety culture usually examined at a single facility or within a single company CSB investigations reveal that safety culture should also be studied at the level of an entire industry as well as at the level of the safety regulators

31 Deepwater Horizon: looking beyond BP Regulators, industry and media all focused on BP in the Deepwater Horizon disaster Transocean, Halliburton and Cameron worked for all the major oil companies None of the companies was prepared to address a major blowout and neither were the regulators

32 BP: a renegade company? Almost exclusive focus (and blame) was placed on BP as renegade and outlier company in the Texas City and Deepwater Horizon disasters Assigning blame for major incidents to one person or one company is an act of extreme oversimplification; it detracts from learning and prevention The underlying causes of the Texas City and Deepwater Horizon incidents involved systemic technical and cultural failures at every level of the company, the energy industry and the government

33 Industry and regulators forgot to be afraid The energy industry had a can-do culture Did not recognize that success breeds complacency Did not understand that lack of serious incidents should not be seen as proof that systems are safe; especially when it involves the potential for low-frequency highconsequence events

35 Questions?

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