Posted byMost investigators agree that blame makes an accident investigation more difficult. If someone thinks they are going to be blamed (and perhaps fired), they often provide less information than if they were in a non-blame environment.
Might the same concept be true for companies?
For example, did sending the Attorney General to the Gulf to start a criminal investigation of BP make BP less cooperative?
If you were a senior executive and you might face charges (environmental or corporate manslaughter), would you be open in a Congressional hearing?
It seems we are in the middle of “blame season” for the BP/Transocean Deepwater Horizon accident. But there is so much that could be learned about how an organization can prevent people putting cost and time pressure above safety. It seems a shame that blame should get in the way.
I understand the need for justice and the desire to punish corporate criminals, but if we start down this road, are we missing a chance to learn and prevent similar corporate culture accidents in the future?
Leave a comment … Let me know what you think …
Category: Accidents, Current Events, Investigations, Performance Improvement
26 Comments »
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I agree! I think the blame game must be stopped! The root cause must be investigated, and a serious CAPA put in place now by both BP and with whom ever contractors they are working with. Much more oversight by our government, the EPA and OSHA is warranted too for safety measures. We have to find a way to stop this oil leak pronto and any other oil wells go through an indepth inspection and preventative actions implemented for them as well. We definitely need to learn from this terrible tragedy.
BP must be held accountable, true, but they also need support in order to get this problem solved now. To keep blaming and ripping apart BP is not constructive at this point. We need to get down to business and repair this situation now.
Comment by Alison Tew — June 21, 2010 @ 12:46 pm
Comment from LinkedIn Group: EHSQ Elite [#1 IN SAFETY]
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Of course, without doubt, we must learn lessons from this disaster of an unprecedented scale.
At the same time deterrent penalties are necessary and need to be enforced. Investigations in due course of time will reveal if there was negligence involved.
It is also doubtful whether the industry and regulators learnt enough from similar incidents in the not too distant past. ( Exxon Valdez or the recent Montara spill; see: http://www.nytimes.com/2010/05/03/us/03montara.html )
At present, the priority is for mitigation and close out. And also the question remains if enough is being done to achieve this end.
Posted by Sujith Panikkar
Comment by Mark Paradies — June 21, 2010 @ 1:09 pm
Comment from LinkedIn Group: Health, Safety, Environment and/ or Quality professionals
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
On the Investigation Courses I run I try to instill in senior managers the need for proper investigations to be carried out by trained individuals. In my experience if you have a significant incident and you assign a senior person to investigate only by virtue of their rank within the company then errors in judgements will be made and ‘knee jerk’ solutions result.
Given that you have fully trained investigators available their is no reason why the process should be time consuming and the results meaningful. The BP situation is a tradgedy but is being used for other political agendas. That said BP may have thought that they couldn’t have another issue like Texas City before they got to fully implement the recommendations of the CSB, but this serves to remind us all that there’s no such thing as an ‘Incident Holiday’ n any sector of industry.
Posted by Vince Fisher
Comment by Mark Paradies — June 21, 2010 @ 1:18 pm
In my opinion, the correct answer to this question is all of the above. I have worked on a few BP projects and the Gulf incident comes down to BP management…their style of doing business.
I am not here to bash or defame BP but rather point out that with any accident, incident, near miss, etc the main component of a compelling ethos is to listen, understand, observe and act upon.
Basically, their narcissistic attitude lead to the Gulf incident and this will come out during the investigation. The management method for BP necessities a change from ‘this is the way we do business….my way or the highway’ to ‘listen and learn to what people are saying’…..this will save lives, protect the environment and sustain their safety philosophy for longevity.
So is this considered blame or what when wrong?
Comment by Victor DiOrio — June 21, 2010 @ 5:25 pm
From the LinkedIn Group: Maritime Accident Investigation
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Mark
Please define who “We” is?
Barak Obama?
His advisors?
The US Congress?
The American public?
The traders affected by the pollution?
The US media?
The European media?
The British media?
You’ve identified the problem here.
“Everyone” is so keen to apportion blame and slap that guilty verdict on to BP Petroleum, that flawed conclusions (especially from Congress) are being accepted as fact!
I’m not going to enter into comparisons between this tragic event and the “Alpha Piper” disaster or Bhopal.
But I do think it’s time EVERYONE took a deep breath, a glass of cool water and started thinking calmly and rationally.
And, yes, I mean you Mr Obama as well.
You can’t learn from what went wrong unless and until you KNOW what went wrong – and that’s a few months down the line.
In the meantime, I do sincerely offer my deepest sympathies to those who lost loved ones.
Let’s work together to make sure this doesn’t happen again.
Posted by John Dalby
Comment by Mark Paradies — June 21, 2010 @ 8:58 pm
From the LinkedIn Group: Human Factors
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Well, on the one hand, BP is at fault, but I’d say that many of the reasons for the failure are Human Factors based as well as based in complacent engineering and oversight. Let me be absolutely clear here, I am NOT referring to action failures by humans. I am referring to systemic failures which failed to offer the necessary recovery options at critical points. If you have, for example, a failure in one well’s flow controls, you need to be able to switch oil flow over immediately to another system. Such backup systems were not in place.
One of the most important things I tell clients is that there are always multiple points for failure and that you must have multiple possibilities for recovering from each of those failures. Simultaneously, you must make sure that if all those scenarios fail, you have steps in place to mitigate the effect of the failure. Also, whenever possible, you should simply eliminate the chance for a system to fail (for example, if you’re making remote, gps driven missile guidance systems for in-the-field use, making it automatically reset the target to the location of the remote will result in many friendly deaths. Eliminate the ability of the system to target “here” without special overrides.).
In this case, eliminating the well’s ability to produce without an operational backup well would serve a similar function.
Posted by Katie Albers
Comment by Mark Paradies — June 21, 2010 @ 9:03 pm
From the LinkedIn LinkedIn Group: EHSQ Elite [#1 IN SAFETY]
Subject: New comment (3) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
We must always learn from our mistakes and take positive steps to introduce procedures or strong enforce present procedure to correct/prevent the same mistakes from re-occuring.
With the present investigations now at hand, the legislators and committee members should be continuing to push a heavy hand on all who are responsible for this catastrophic event including goverment agencies and their duties that may have also been manipulated by the powers of profits from production over safety!
Posted by Dale E Scott, CSO
Comment by Mark Paradies — June 21, 2010 @ 9:10 pm
From the LinkedIn Group: EHSQ Elite [#1 IN SAFETY]
Subject: New comment (4) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
The fact that there is now a criminal investigation makes it an obvious “blame” exercise. Given that guilt needs to be proved in a court of law beyond a reasonable doubt will ensure a standard of rigor that is not usually seen in typical safety investigations. These prosecutors are used to the barriers you suggest in your blog. With the legal tools at their fingertips people will gladly talk to protect their own hides. I don’t think there will be any worries discovering what caused this event once the “small people” start talking.
Lessons will still be learnt, e.g. CSB Texas City Investigation. From what is being reported I believe that we can easily move beyond calling this an “accident.”
Posted by Rob Stewart
Comment by Mark Paradies — June 21, 2010 @ 9:14 pm
Fron the LinkedIn Group: Maritime Accident Investigation
Subject: New comment (3) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
It’s pretty clear that the US Congress committee has little interest in finding out what happened, why, and how to stop it happening again. The Whitehouse has launched a rather unpleasant, unstatemanslike vendetta again Haywood – criticising him for not doing the job the Whitehouse didn’t want him to do. It’s all very ugly, self-seeking and playing to the gallery.
So far no independent investigation has been launched.
It’s worth noting that the Louisiana wetlands have been disappearing at a rate of a field field every 45 minutes, 34 square miles a year, entire towns, communities and habitat have vanished due to human activities. That can’t be blamed on BP, and there is probably little more damage that the GoM spill can do to the wetlands. It’s arguably the worst environmental disaster ever to occur in the United States. Is anyone kicking butt there?
With luck, there will be a backlash .
Posted by Bob Couttie
Comment by Mark Paradies — June 21, 2010 @ 9:18 pm
It is not the first time that BP is involved in relevant incident, remember for example Texas City refinery. The safety culture of BP management is weak and is demonstrated by the facts. Too many serious accidents in a few years. The technical cause may perhaps be identified, but the many failures in the system of management and organization of the business within BP, will be never identified since they require a strength approach to change in the HSE culture of many people. Unfortunately, the same approach is common to all Oil and Petrochemical companies in the management of HSE issues, considered useless, expensive and therefore contrary to the business. Remember that all costs of these disasters have been dumped on the community and future generations, very few times, these companies never had paid for their disaster!
Comment by Fabrizio Gambetti — June 22, 2010 @ 1:37 am
The BP disaster is no different from other disasters: they become agenda driven by organisations or persons who might have a personal gain. These might be politicians or prosecutors, environmental organisations or otherwise.
The usual knee-jerk reaction is one of blame. It is baked into todays society and difficult to ignore. Blame seems to be binary: either one is to blame after an accident or not.
Will more gouvernmental oversight help? If the general opinion is that more rules must be put in place, then the general opinion also says that more enforcement is necessary. Will this help?
I have been following this disaster from Europe and just have information from the media. What can be seen is that all information in the media is about the benefits that BP had in mind when they had the rig in position and quickly come to production. Safe precautions were not taken or deliberately set apart. Are there reasons to think that this is behaviour that must lead to punishment? I would like to add a few things on the comments of Victor DiOrio above: it is listening, understanding, observing, but it is also about asking questions and trying to come to improvements.
Somewhere, a line has to be drawn as to what is punishable behaviour and what is not. These lines in the sand are to be drawn by society …. which means politicians. This almost leads us back to my first lines above: agenda driven, which line will be drawn in the sand for the future? And what are we really to learn from this disaster when all kinds of investigations are being done, where some might lead to enforcement and punishment?
Comment by Hans Houtman — June 22, 2010 @ 2:18 am
Mark;
I was stunned to see the complexity of a subsea blow-out-preventer and diverter assembly. It is no wonder it failed. The industry has about a 4 per thousand well incident rate.
This device does not use the well internal pressure for activation, but externally supplied hydraulic pressure to work. Passive design concepts and fault tolerant design would require a self-energizing design based on well pressure to envirionment; and active external pressure to hold open. In a fault mode it closes,period.
I could find no standards published for design criteria or test methodology.
The ‘blame’ should attach to the petroleum industry collectively , for lobbying for lenient rules and less external oversight. Recently through lobbying the test interval for this complex device has been reduced to every 14 days from every seven days. Perhaps a simpler more reliable design would make periodic testing less critical to overall envirionmental impacts.
Comment by Richard lucas — June 22, 2010 @ 6:40 am
From a LinkedIn Group: HSE Network
Subject: New comment (3) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Very interesting comments! People have to understand the meaning of “Blame”. The lessons are obvious to all drillers who are doing job day in and out. The BP style of management is obviously responsible for the incident. If they do not reveal any facts than professionals and investigators have techniques to dig out the facts. So under the pretext that if BP is to be blamed than they will not reveal the fact to learn lesson and prevent such disaster is baseless argument.
We have to be fair with every one; if some body needs to be blamed for the mistakes he committed then they should be punished as this is world’s biggest disaster. If you allow this type of disaster under the cover of no-blame policy then all corporate bodies will take it granted that this type of disasters are permissible to earn more profit. BP has already reached to the level of inability to learn lessons at the time of their refinery disaster. Now enough is enough and BP must change their style of management to prevent accidents.
Posted by Dhirajlal Radadiya
Comment by Mark Paradies — June 22, 2010 @ 10:30 am
From a LinkedIn Group: Aviation Quality & Safety Information Exchange
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
What went wrong is poor government oversight and enforcement.
Everyone wants less government until things like this happen.
Imagine life without the FAA.
Posted by Richard Brown
Comment by Mark Paradies — June 22, 2010 @ 10:34 am
From LinkedIn Group: Safety and Reliability Society
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Yes. Blame versus ‘proactivity’ is a ratio of about 50:1 at the minute I feel. Similar days to the pre Iraq war. WMD, WMD, WMD and we’re still looking for them!
I think that it’s been established that BP is at fault here, but still the politicians and media yammer on about it. As for Hayward’s sailing, just take a look at basket-case, Bush……..
Posted by David Robson
Comment by Mark Paradies — June 22, 2010 @ 11:14 am
From LinkedIn Group: Maritime Accident Investigation
Subject: New comment (4) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Hi Bob
Interesting point you make about the “natural” disappearance of the Louisiana wetlands.
I’m surprised the Brit media haven’t picked up on it – yet!!
Although Tony Hayward is his own worse enemy (PR_wise – he should never have been allowed in front of a camera or mic), you have to hand it to the guy – he’s been on station from the beginning until he was kicked off. And he never shirked.
Then he’s pilloried for taking a perfectly reasonable day off!
From the Congressional hearing witch-hunt, it’s clear that Halliburton, Transocean and the MMS (?) have a lot of questions to answer too. Will they be called to book? Or will that be swept under the already bulging rug?
Posted by John Dalby
Comment by Mark Paradies — June 22, 2010 @ 11:31 am
I do agree with you about promoting the blame-free (but not accountability-free) culture as much as possible, as we seriously need to find the causes and learn from accidents.
I’m afraid, though, the majority of the public don’t give a damn about this, because they as well as the media – pretending to serve the public interest of course – just want quick answers here and now.
The media (and major parts of the public) don’t want to wait 1-2 years for an in-depth inquiry or investigation to explain who to hang for it today.
When and if a result comes out from the inquiry in 2 years, most people (except those affected directly by the accident) have probably forgotten all about it until the media gets another opportunity to sell the story.
And this time we may even have the real culprit pointed out for yet another hanging-party.
But have we learned anything from this?
Who do you think will be ready to admit his/her own fault in public next time?
I may very weel paint a too bleak picture here…? I hope so, but really don’t think so.
Comment by Jesper Mogensen — June 23, 2010 @ 10:16 am
Fron LinkedIn Group: Root Cause Analysis
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
The first route in any investigation should, ideally, be an open, blame free one. However, there does come a point when other action is required. This is where the incident was caused by reckless or malicious violations.
I think the concern with this particular disaster is that the management of either company involved (not just BP), may have behaved in a reckless manner.
The concern would, therefore, be that to delay, going first for an open blameless investigation, may mean that some lines of enquiry are lost by those who wish to minimise their accountability.
Posted by Angela Legge
Comment by Mark Paradies — June 23, 2010 @ 7:06 pm
From LinkedIn Group: Cool Hand Nuke
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
If I based my answer on the news media reporting I would say yes, more blame than learning. However, knowing that industry is likely more evaluative than we would be led to believe, I think there is probably a decent root cause evaluation in the works. I wouldn’t be surprised to see an extensive report summarizing the root and contributing causes someday in the future. Exxon’s Valdez incident has some remarkably detailed reports and television expose’s on the incident. I see the same coming out of the Horizon incident. Learning about the spill will occur as the information becomes available. I am not quite so confident regarding learning on the clean up effort. Primarily because our government is “leading” that effort and, I do not see evidence that the Federal Government would be interested in a detailed transparent causal analysis. My gosh, that would be to admit fault….. no, not in this administration I’m afraid!
Posted by Edward (Ted) Bergner
Comment by Mark Paradies — June 23, 2010 @ 7:28 pm
From LinkedIn Group: Cool Hand Nuke
Subject: New comment (3) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
Don’t forget that there is a criminal investigation as well. That will slow the public release of information. Personally as someone that is from the affected area of country I’m willing to wait. And if laws were broken I hope that people go to jail for a long time.
Posted by Glen Granberry, CHP
Comment by Mark Paradies — June 23, 2010 @ 9:20 pm
From LinkedIn Group: HSE Network
Subject: New comment (5) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
There seem to be a conflict between the interest of Operations/Production Management and HSE Mangement.
Recently a shipbuilder in Holland had an accident in one of their workshops. My colleaugue, an HSE manager in this company, wrote a critical report and got fired for it.
Posted by Ruud de Jong
Comment by Mark Paradies — June 24, 2010 @ 3:05 pm
I know some others have said that they trust BP to come out with a good report.
I bet that report will be so scrubbed by lawyers that nothing pointing blame at BP management (or even suggesting ways to improve) will make it into the report.
I would be their focus will be on the BOP failure and any bad decisions or mistakes that were made locally or by contractors.
Anyone want to bet?
Comment by Mark Paradies — June 24, 2010 @ 3:08 pm
From LinkedIn Group: HSE Network
Subject: New comment (6) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
A very quick response to Ruud above would be that there is ALWAYS a conflict of interest between Ops and HSE.
Whatever happened to Ops managers that actually cared for their workforce rather than the balance sheet?
I suppose they got eaten by Bean counters.
Posted by Anthony Broomfield
Comment by Mark Paradies — June 24, 2010 @ 3:09 pm
Fron LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends
Subject: New comment (2) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
The BP CEO drew fire on himself because of a lack of transparency in their corrective procedures. His platitudes did not impress the US public whereas stronger leadership, a defined plan and progress, however slow, would have been better.
I hope that the new man has the courage to be honest & open. There will still be anger but this approach may reduce the rhetoric from the media and White House. Then the focus can be on resolving the current issue and implementing preventive actions for the future.
Posted by Paul Huyton
Comment by Mark Paradies — June 24, 2010 @ 3:25 pm
From LinkedIn Group: Root Cause Analysis
Subject: New comment (3) on “Blog Archive » Are We Blaming BP Rather Than Learning From What Went Wrong?”
I agree completely with your comments Angela.
Sounds like there are a number of investigations that need to happen here. One is to document the “technical/immediate cause” so others can plan risk around what has happened and the other is to look at the underlying reasons (possible reckless manner) that may have lead to this disaster occurring. Different and essential learning would be achieved by both investigations.
Posted by Andrew Sauter
Comment by Mark Paradies — June 24, 2010 @ 5:00 pm
Fabrizio
You might as well say that the safety culture in the US is weak, since that is the region where BP’s incidents have occurred.
Generally speaking, the current rush to apportion blame on just one company is simply skimming over the case. There are many similar incidents occurring in different locations, except they don’t have the same drastic outcome as this one. You have to look at the skills base, the regulatory framework and the monitoring arrangements as well.
Th US should get it’s head out of the sand (or wherever it is) on this one, there are legislative and regulatory issues to be explored here as well as internal company issues. Bad as this one is, the cumulative effect is probably only a couple of a hundredths of a percentage point of the global environmental impact of oil exploration and production over the last 30 years.
Comment by Chris Black — July 13, 2010 @ 8:16 am