Monday Accident & Lesson Learned: Either You Are Leading the Solution or You Are Part of the Problem
I learned the lesson I am sharing in this article while investigating an oil platform fire back in the mid-90′s. But the recent congressional testimony of executives from BP, Transocean, and Halliburton brought the lesson back to mind.
These lessons are NOT just for people in the petroleum industry. They apply to all industries where a major accident could cause loss of life, damage to the company’s reputation (ie, Toyota’s accelerator problems), or a major financial loss.
After a major accident, there are NO clean hands. There is blame enough for everyone. If you are in the chain of command of the organization that had the accident, you WILL be seen as PART OF THE PROBLEM.

It’s not my fault … YOU are to blame!
Finger pointing is counter productive. Managers may be able to point out others that share the blame, but they won’t be able to get rid of their share of the blame.
This is true even for the “blessed” level of the corporation. CEOs, Presidents, and Senior Vice Presidents can usually avoid blame for lesser mistakes. But when a major accident – multiple lives lost, extensive environmental damage, and/or a big hit to the company’s reputation and finances – occurs, even the corporate elite can’t escape the blame from the press and politicians.
That’s why the minor amount of finger pointing by executives at the BP / Transocean / Halliburton hearings only seems to make people more upset. They wanted these executives to accept their responsibility for things that have obviously gone wrong.
BP should have lead the way by taking responsibility for the accident. BP should have admitted that their performance was unacceptable. And BP should have then shown that they were ready to lead the way – for the whole industry – when developing solutions to keep this kind of accident from happening ever again anywhere else.
Instead of the statement made by BP’s President (which you can watch on the CSPAN videos posted previously on this blog), they should have said something like the following:
Statement I proposed for Lamar McKay, President of BP Americas…
“Chairman Bingaman, ranking member Murkowski, and members of the committee, representatives of the press, and people of American and around the world, I come here today with a heavy and contrite heart for the accident that I have allowed on my watch.
First, let me apologize to the families and loved ones of the 11 workers who were killed in the initial explosion on the Deepwater Horizon. Their loss is tragic and unacceptable and I pledge here that I will do everything in my power to discover the root causes of the fatal blast so that we can learn from it and ensure that it never happens again.
Second, I would like to apologize to the people impacted by the subsequent release of oil from our well. We at BP are responsible for the environmental damage. BP will pay all valid claims without regard to any liability caps. We will do this because we feel it is our responsibility to compensate those who have been harmed.
The extent of this spill is larger than anything we thought possible. The fact that it happened means that our preparations and measures to prevent the accident were insufficient. We should have been better prepared for the unimaginable. We are currently bringing all the resources we can to bear on stopping the spill and mitigating the damage of the oil that is being released.
Furthermore, we pledge to take the lessons we have learned in the spill response and continue to research ways that we can be even more prepared if something of this nature happens again. Our goal is to find the root causes of the spill and prevent it. But we should never again be caught unprepared if the unthinkable happens.
At BP, we believe there will be a need for a reasonably priced source of oil for decades to come. We pledge our best efforts to finding and recovering this oil without loss of life or unacceptable environmental damage. By allowing the current accident to occur, we have failed our shareholders, employees, and the American people. For this we are sorry and we hope to be able to prove to you that we can changed course so that we won’t fail again.
As for plans to prevent future accidents, we have put together a team of experts in deepwater oil exploration and root cause analysis to find the causes of this failure. They will be given complete access to all records and personnel to determine what went wrong, how it went wrong, and why it went wrong. The goal of this investigation is not to point fingers and attribute blame. Rather, the goal is to find out how we can improve our performance so that an accident like this one NEVER happens again. Not at BP. Not at any other exploration site around the world.
It is too early to tell exactly what caused the explosion that killed 11 people and started this environmental accident, but I can say that the fact that it happened means that things went wrong. Somewhere down the well, barriers that we thought were sufficient to prevent the blowout failed. Also, the blowout preventer didn’t prevent a blowout. And our planned emergency response efforts were insufficient to deal with the size and scope of the spill that we now face. I am sure that all of these problems could have been prevented if we had foreseen the outcome. Unfortunately, we didn’t. That is a fact that we wish we could change but we can’t.
What we can do is to understand why bad decisions were made so that we can avoid bad decisions in the future. We want to know any mistakes that were made in sealing the well. If industry practices were followed, why they failed. If industry practices were not followed, why that occurred. If we should have preceded differently, we need to find out what went wrong and how we can do to do it right next time. We need to understand why the blowout preventer didn’t function as intended. We also need to understand what we need to do to be better prepared for a large spill.
What I can pledge to you is that BP wants to redeem our reputation. We pledge to become the safest, most environmentally benign oil producer in the world. We pledge to lead efforts to develop safer methods for deepwater drilling and to share the practices across our industry. We will work with our contractors and suppliers to establish much more reliable blowout preventers. We will lead an industry effort to establish an emergency preparedness and response capability up to the challenge of a spill of this size even though we plan to never have anything like this happen ever again.
After my fellow industry colleges have had the chance to share their thoughts about the accident, I would be happy to answer questions about our efforts to discover and eliminate the root causes of this accident and our current efforts to stop the spill and mitigate the environmental damage done.
So to close, thank you for this forum that we can start to express our sincere regret for our past performance and explain how we can start to redeem ourselves with efforts to lead progress in understanding and improving the safety and environmental performance of our company.“
At this point, Mr. McKay would have to really have a plan. BP would have to really be performing a thorough, accurate, critical root cause analysis using advanced root cause analysis tools that aren’t looking to place blame. Tools that have advanced human performance, organizational performance, and equipment performance evaluation methods. They would have to really be committed to leading the industry and taking actions to change the culture that has lead to a string of accidents across BP’s business units.
Maybe that is too much to ask. BP management may not be capable of this critical analysis – admitting that they were wrong and need to change BP’s culture.
Also, some of you might think that MARK IS CRAZY. No executive would take this kind of responsibility. Think of future lawsuits. Think of the corporate liability.
But I believe that the company is already guilty by the fact that an “unthinkable” accident has happened. Only if this was a terrorist act or a case of sabotage, could BP escape blame. Since there is no evidence of this, BP will be found to have made mistakes that contributed to the accident. You can count on that.
So my conclusion is that defensive management … management that points fingers at others … management that rejects or doubts their responsibility … can’t successfully lead the change efforts that are needed to improve performance and prevent future accidents of this magnitude.
Eventually these defensive managers WILL lose their jobs because they can’t change something they are defending.
In other words, management all up and down the line – from BP’s CEO to BP’s Company Man on the rig, must recognize their responsibility and their need to lead change or the Management System root causes (which there will be in an accident of this magnitude) will not be fixed.
Thus my conclusion …
YOU ARE EITHER LEADING THE SOLUTION …
OR YOU ARE PART OF THE PROBLEM.
Of course, after a major accident it is customary that managers will lose their jobs. The first target are those managers on the rig that made decisions the night of the accident. Next, the next level of management up the chain at BP and Transocean. But more senior management should also be worried. The complete management chain – from the Refinery Business Unit Manager to the CEO – eventually resigned or were let go after the BP Texas City explosion.
I believe the ONLY way that managers in this predicament can save their job is to claim their responsibility and then be seen as STRIDENTLY LEADING the change needed to prevent future accidents.
Now for your ideas and comments …
IS MARK CRAZY?
Should management not only admit errors but actually claim their share of the blame?
Can leading positive change save a corporate manager’s job?
Is pointing fingers and shifting blame a better survival strategy?
Is sincerely apologizing and accepting blame too dangerous?
What do you think?
Leave a comment here.
Category: Accidents, Current Events, Human Performance, Performance Improvement
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Well, Mark MAY be crazy, But right none the less.
Take a look at how Toyota handled their reputation problem after the sticking accelerator issue. Yes, there are things they could have done better, and there are still legal issues outstanding. However, they immediately put out an ad campaign that basically said, “We messed up, we want to fix this, and we are putting time and money into the solution.” They took an initial sales hit after the problem surfaced, but they have already turned the corner and are bringing customers back in. Throughout their problem, they had a loyal following of customers that stood behind the company. I don’t think I’ve heard any chorus of support for BP!
Again, I’m not saying Toyota did everything right. There are still investigations on-going. But their public response was definitely different than BP. Whether they really ended up changing anything at their company remains to be seen, but the acceptance of at least some responsibility left a different perception with the consumer.
Comment by Ken Reed — May 24, 2010 @ 9:13 am
Here I am literally the only reply to your great article.
Comment by Martin Guerrero — May 31, 2010 @ 8:37 am
Having acted as an expert witness for incidents involving multiple fatalities I can assure you that it is the acts and omissions leading upto the accident that will decide liability. Every email, report, witness statement and peice of physical evidence is studied in munute detail over many years in order to assign legal liability (blame).
A heartfelt apology, and a genuine committment to identify and address the root causes for the event, will not add to this liability. It may how ever create the space within the affected organisations for this to occur.
Comment by Russell Scott — June 1, 2010 @ 2:34 am
Is Mark crazy? Maybe, but generations of lawyers are certainly turning over in their graves at the thought of publicly accepting blame. That thought alone makes it worth considering!
Is sincerely apolgizing and accepting blame too dangerous? Maybe, but the public will certainly appreciate sincere, honest, candid responses. Reputation is critical, and evasive answers / finger pointing will not save it.
Can leading change save a corporate manager’s job? If that’s the primary thought behind the manager’s response, I’d suggest that he/she has already missed the boat when it comes to sincerity. While it’s human nature to worry about personal consequences, the primary focus has to be on solving the problem(s). After the accident has occurred, the chips are going to fall where they will. If a manager’s response is primarily guided by how to save his/her job, then he/she will be less effective at solving the problem(s). His/her best chance to save their job was before the accident happened – by preventing the accident from occurring at all!
Good article. Thanks for sharing.
Comment by Eric Stewart — June 1, 2010 @ 3:39 am
Good point about preventing the accident.
In this case, the horse is already gone. All we can do is shut the barn door and plan for ways to keep horses from escaping in the future.
Comment by Mark Paradies — June 1, 2010 @ 3:57 am
Mark I think you are spot on with what BP should have said. Unfortunately had they made this statement I’m sure the lawyers in the room would have stopped listening by the fourth paragraph as they would be calculating how many zero’s they can put on the end of their claims (and what color their new Porsche should be).
It is a sad state of affairs when someone can not own up to their own shortcomings for fear of being taken to the cleaners by the lawyers. This not only affects their public image, but I’m sure it also has a major impact on any investigation quality in a number of cases.
Not that I’m against those that have done wrong being held to account for it and making fair compensation, but in some jurisdictions around the world the concept of ‘fair’ compensation seems to have been lost somewhere along the line – and those being compensated only get a small portion of any settlement while the lawyers walk off with padded pockets. If we can remove this fear of excessive financial punishment perhaps we would see more CEO standing up and owning up to their companies shortcomings – and better quality incident investigations as well.
Just a final thought, instead of BP injecting heavy mud for the top kill, why don’t they round up all the lawyers hovering around the shores of Louisiana and try injecting them into the well to stop the flow.
Comment by Barry Eichler — June 1, 2010 @ 4:01 am
Hot air has never stopped a blowout.
Comment by Mark Paradies — June 1, 2010 @ 4:10 am
But if hot air stopped blowouts, we could inject politicians and stop the leak for sure!
Comment by Mark Paradies — June 1, 2010 @ 4:42 am
We’ve flogged the question of Mark’s sanity pretty well, so I’ll leave that alone. The idea of stuffing lawyers and politicians into the well opening would only increase the gulf’s pollution, no matter how intrinsically satisfying.
But back to the real question. One of BP’s biggest concerns should be public opinion. After Exxon’s lack of real action over their accident, the public is looking for answers. Admitting that the fault goes all the way to the top would go a long way towards helping the public’s perception of them. And as stated earlier, it doesn’t hurt them in the lawsuits that are coming their way and may actually help them a little.
More importantly, by admitting that the problems goes all the way to the top they can address the real problems. If they really embrace that the CEO and everyone beneath shares a portion of the problem, they can start looking for solutions that will prevent future occurrences. Firing people doesn’t change anything. They have to change how they do business, how they balance cost verses consequences, and how they perceive risk.
Comment by Bill Mihalovits — June 1, 2010 @ 9:43 am
Perhaps foreign companies operating in North America have a different view of perceived risk and consequences. These should be evaluated by governments prior to these multinational companies conducting business in North America. Finger pointing doesn’t solve any situations. What are the objectives, morals and values of these companies ?? Are the shareholders comfortable with the knowledge 11 people lost thier lives for profits they’ve now lost as well ??
Comment by Joe Wasylechko — June 1, 2010 @ 10:12 am
Say’to heck with the lawyers, full speed ahead!’
Liability (blame) will end up being based on what is found to be the real causes of the incident/s – let BP’s lawyers earn their money by ensuring that valid claims are covered, invalid ones are dumped. Put the rest of the company to work on finding the root cause and generating solutions!
It;s fairly obvious that no one has a good solution at this time to either stopping the oil (what about using a pneumatically inflated ‘pig’ to plug the end of the line. I bet that there are many Navy folks in many ships’ deck and mechanical divisions that would be willing to take a shot at stopping the leaks.) or stopping the oil from reaching the shoreline. Wonder how fast a solution would be found if BP would offer $1 million cash to the first group that could stop the spill ??
Comment by Steve Yandle — June 1, 2010 @ 10:42 am
I’m quite sure there would be herds of high priced lawyers, who have passed several ethical tests, supplying these executives with advice on how to minimize both the personal & company liability risks involved here.
The “right thing to do” is lost in the fallout.
Comment by Dwight Geldart — June 1, 2010 @ 11:38 am
Great article!! NASA may comes closest to the dispassionate mishap investigation, corrective action, and communication of hard learned lessons that is needed and may be a good role model.
To comment on Joe Wasylechko who said on June 1, 2010 at 10:12 am
Perhaps foreign companies operating in North America have a different view of perceived risk and consequences.
===============
I would worry just as much about North American companies who go overseas with their economic endeavors. Part of the lower price of operating overseas are lax liability and accountability infrastructures.
Comment by Ron Montague — June 1, 2010 @ 11:52 am
Mark,
Good post and right on target.
There is a classic perception of a trade-off between production and protection. Managers think that workers automatically default to protection, so they emphasize the company’s bottom line of profitability. The reality is that workers are motivated to get stuff done and actually default to production.
So what’s a manager to do? They know better than anyone what the profit staus of their company is. But they don’t do their company any good if they also don’t continually stress safety at every opportunity. Without a constant management emphasis on safety, workers believe that they will be rewarded more for making money for the company, rather than by safely working. Managers must be explicitly aware of what their company’s reward mechanisms are. If the company only rewards productivity, then how is the safety message received?
Comment by Bill Rigot — June 1, 2010 @ 12:26 pm
Mark:
Well said – I agree with virtually everything except where you said:
“Only if this was a terrorist act or a case of sabotage, could BP escape blame.”
Terrorism and Sabatage are real risks the same as an oil rig explosion. All oil companies are responsible to identify those potential outcomes and their causes and manage them including having appropriate emergency plans in place – they can’t say “don’t blame us” to those either.
Comment by Wayne MacLeod — June 1, 2010 @ 1:24 pm
Excellent post. Unfortunately the self-preservation tends to win out over the greater good more often than not. Not to mention the advice from the lawyers to avoid taking responsibility. I agree, though, that taking responsibility isn’t going to change all those law suits anyway. Its going to be bad regardless so take your lumps and own up to the mistakes and ensure a proper root cause is completed to find and fix the problems.
Comment by Dave Kilborn — June 1, 2010 @ 1:30 pm
What does BP’s Health Safety and Environmental Policy state? If we cannot hold the companies to what they state in their Policies, what good are their HSE systems that is there for this purpose? In court if we say we will do something we are held accountable for it. As stated in the article do it constructively and rather learn from it. If we do not learn from this and do it right we will continue to putt fear into companies and the people that operate these companies and they will never take responsibly.
Comment by Hannes Riekert — June 1, 2010 @ 9:08 pm
Wayne
I agree that BP would not be completely off the hook if it was a terrorist attack or a case of sabotage. They just wouldn’t be seen as accountable as they are now.
Thanks
Mark
Comment by Mark Paradies — June 2, 2010 @ 1:16 pm
Great article.
Regardless of fault, the Gulf and, in fact, the world is faced with an environmental disaster. Pointing fingers, apologizing, invoking enormous financial penalties and sending people to jail will not solve the problem. Are the potential penalties really a deterrent? Remember the trimming of costs usually starts at the HSE level.
I realize we need to learn so recurrence is prevented but, my perception of BP’s handling of this, I wonder if any lessons have been really learned?
Granted, the investigation is ongoing and I know I should not jump to conclusions but the process is very frustrating.
God bless the families of those lost on the platform. I really hope this leak can be stopped without any further delay.
Comment by Sean Hiscock — June 2, 2010 @ 6:32 pm
Someone (Thos Sowell, I think) once said a company’s most important asset is its reputation. Reputation should not be sacrificed in a feeble attempt to avoid potential liability. The cost in the court of public opinion may easily exceed the cost in the legal system. It is actions that count, and BP has been unsuccessful both before and after the event. I doubt legal advice is keeping management from doing/saying the right thing; it is more likely their culture. We should not start blaming lawyers for the loss of BP goodwill, the accident, or its mitigation just yet.
I agree that what you said is pretty close to what BP leadership should have said. I also think that if BP embraced those values, they probably would have dealt with precurser events and avoided this one. Management will ultimately have to change culture for the company to survive. From their current public statements, management does not seem ready to lead a culture change.
Comment by David White — June 4, 2010 @ 8:51 am
Of course finger pointing will not do because first – it does not get to the root cause of the disaster and second, at the end of the day the finger would point straight back to us, the consumer (and voter).
Our insatiable thirst for oil has created the politico-industrial paradigm where all oil exploration companies operate with only enough safety measures in place that have been seen, historically, to be sufficient.
Let’s face it – this disaster could probably have happened to any company. It was just BP’s bad luck that it happened to them. But, sooner or later it was going to happen. Granted, BP has committed a few fumbles in their PR response – but to their credit they have not harped to much on the blame game and are committed to cleaning up the mess and compensating. Time will tell if they actually survive long enough to do all of this. Big calamities like this tend to reduce companies to ashes – remember Arthur Anderson or Swiss Air?
Now – on to solutions. I think it should be obvious from the sequence of events and the consequences of this fiasco that a secondary relief well should always be drilled at some distance from and at an angle to the primary well. In case of a major disaster, the flow can be stopped quickly and efficiently. This should be legislated hence resetting, to a degree, the politico-industrial paradigm. Now, let’s get to work on alternative energy too ;-)
Comment by Paul — June 6, 2010 @ 2:09 pm
A secondary relief well for every well seems to double the drilling activity.
Wouldn’t a a good well design, built to the design, capped properly, with proper testing, and a working BOP be a better solution (making the already existing safeguards better).
Note, a relief well means we are willing to sacrifice those 11 workers. I’m not willing to go along with that.
Comment by Mark Paradies — June 7, 2010 @ 12:03 pm
That’s a very good point you have Ron. Let this incident be a lesson to all the multi national compaines around the globe. We must put the safety of people and environment ahead of production and profits.
Comment by Joe Wasylechko — June 8, 2010 @ 9:43 am
He’s a comment reprinted from one of the LinkedIn site where I posted this page:
BP has a retention of $700 mill so the initial clean up costs and business interruption claims are on their dime. The $3.5 bill number we have been hearing is a WAG essentially. Something out there about it being August before they are able to effectively cap this thing and drill relief wells …. truly amazing. Not too many people are talking about Cameron and the possibility of a defective preventer valve. If BP can successfully subrogate they may pull this out.
I think not paying their quarterly dividend if the least of their worries. This could very well be the end of BP.
Posted by Damon Schneider
Comment by Mark Paradies — June 12, 2010 @ 9:30 am
Tony Hayward, the CEO of BP, had just as bad a performance as Lamar McKay … maybe worse. See:
http://www.taproot.com/wordpress/2010/06/17/watching-the-tony-hayward-congressional-hearings/
The next morning I was watching CNBC and they reported that the BP Chairman had started requesting input from people about a replacement for Tony Hayward (the BP CEO).
You are either part of the solution or part of the problem. Carl-Henric Svanberg (the BP Board Chairman) wants to be on the solution side of the equation.
I guess the question that is left up to the shareholders is … who on the board is part of the solution and who is part of the problem?
Comment by Mark Paradies — June 18, 2010 @ 9:46 am
And here is how the BP Chairman got himself in trouble:
http://www.youtube.com/watch?v=th3LtLx0IEM
Comment by Mark Paradies — June 18, 2010 @ 9:49 am
And here is his apology:
http://www.smh.com.au/small-business/bp-chairman-apologises-for-small-people-gaffe-20100618-ylsy.html
Comment by Mark Paradies — June 18, 2010 @ 1:45 pm
Also, it was announced this afternoon that Tony Hatward would be relieved of his duties for the Gulf of Mexico.
Comment by Mark Paradies — June 18, 2010 @ 1:46 pm