Process Plants Accidents: Careful – We Don’t Want to Learn From This
These words are from Bill Watterson's great comic strip, "Calvin and Hobbes." They could be the motto of all the accidents in all the process plants that have killed people through just plain bad alarm management and faulty process safety thinking. Based on the results of the past 30 years, we really don't want to learn anything from what has happened from Bhopal to Deepwater Horizon.
If you read the final report on Deepwater Horizon, you will understand that "the blowout was not the product of a series of aberrational decisions made by rogue industry or government officials that could not have been anticipated or expected to occur again. Rather, the root causes are systemic and, absent significant reform in both industry practices and government policies, might well recur."
Just since January 1, there have been more than a dozen incidents, resulting in at least 36 injuries—some serious and one fatality—in process plants as reported by the ASM Consortium in its RSS feed.
It's not an excuse to say "the process industries are dangerous." If that were a valid reason to ignore safety, then miners would still be going down in the ground with acetylene lanterns and canaries. Not that mining safety is so wonderful either.
We've been doing significant research on safety and promulgating safety standards for nearly 50 years. And the results are poor. We keep trying to figure out how to produce satisfactory alarm management schemas, train operations and maintenance personnel, focus management eyes on safety, and, based on results, none of that seems to work very well.
BP, for example, spent nearly $2 billion from 2005 to just before the Deepwater Horizon incident in a formal attempt to improve the safety culture of the corporation. This was mandated by then-CEO Tony Haywood himself, who reviewed progress weekly. Based on the facts unearthed by the final report, the attempt failed to prevent catastrophic failure after catastrophic failure, each of which, as Béla Lipták has pointed out, could easily have been prevented. The report points out that in order to execute one fail-safe operation, 36 buttons needed to be pushed. And, the operators told investigators that they didn't feel they had permission to push the panic button by themselves.
The definition of insanity is doing the same thing over and over and expecting different results. It is clear that we are doing the same things to try to make our process workplaces safer—and we're not getting different results.
Variously, we've tried alarm management strategies, graphical user interface designs, high fidelity simulations and operator training. In most cases, what we have not tried is mandating safety as "Job One." For example, J. M. "Levi" Leathers, when he was general manager of Dow Chemical Company's Texas division, simply noted that safety was more profitable than unsafety. This dedication to safety before all else, including profit, has held true for Dow in the 50 years since.
Haywood, however good his intentions were, never successfully communicated to his staff and operating managers that there were no ways to skimp, no ways to hurry, and no short cuts to a safety culture. The result was that the Deepwater Horizon operators felt pressure to cut corners and pay lip service to safety in the service of getting the Macondo well dug, capped and producing as fast as they could. And the ultimate payment for that lip service was that 11 of them died.
This column originally appeared on the our sister publication Control Global.