By Phil La Duke
In a recent blog entry on the blog, Fuel Fix http://fuelfix.com/blog/2014/05/12/human-errors-account-for-80-of-offshore-accidents-exec-says/ Oil & Gas executives were quoted as saying that 80% of offshore accidents were caused by human error.
According to the article, Jim Raney, director of engineering and technology at Anadarko was addressing the Ocean Energy Safety Institute at the University of Houston when he said, “You can’t fix stupid…what’s the answer? A culture of safety. It has to be through leadership and supported through procedures — a safety management system.” I’m careful not to use the stupid brush to tar too many people in worker safety. Are their stupid people out there working? I think it’s safety to say yes. But can we blame 80% of worker injuries on stupidity? I don’t think so, at least not among the rank and file. Let’s face it, if 80% of your injuries are because of human error, as the article later suggests, you have some big issues and I would be careful who you go around calling stupid.
Even Smart People Make Mistakes
I’m not going to beat up on Jim Raney. My guess is that at his level he isn’t doing the incident investigations personally, and therefore he is being fed conclusions by his safety practitioners that lead him to believe that the vast majority of the incidents are because he has a bunch of idiots working for him. But stupidity is not the same as making a mistake, and while everyone makes mistakes (it’s a biological imperative) no one should have to die because of it. If there is stupidity in this process it lies with the person who designed it; he or she either refused to believe that people make mistakes or knew people would invariable make mistakes but refused to protect those that did. Stupid? It’s damned near depraved indifference and gross negligence.
Dispelling the “Operator Error” Myth
For years I taught problem solving courses as part of lean implementations. For generations engineers (the folks typically charged with finding out what caused a quality defect) would ultimately conclude that someone screwed up; the report would conclude that “operator error” was the proximate and root cause. The problem was that the engineer never asked “why?” the operator screwed up. I’ve written reams on performance inhibitors, those things like worker fatigue, stress, distraction, drug use, et el, can cause even the smartest people to make mistakes so I won’t revisit them now. But I wonder how many of those 80% of the people working on offshore rigs had been working long hours without a day off or with inadequate sleep? Keep anyone up for days on end working 16+ hour shifts in the elements and even the brightest among them will seem like a drooling idiot. Simply denouncing the people as stupid and then doing nothing about the system issue will not create a culture of safety, it will create a culture of stupidity. If I can go off on one of my well celebrated tangents for a minute, why are Oil & Gas companies hiring so many stupid people? While you may not be able to fix stupid, you don’t have to hire it, you don’t have to seek out the dumbest in society and offer them a job.
Injuries Are Seldom Caused By a Single Root Cause
A part of the problem solving training that I taught for many years dealt with selecting the right tool from the tool box. Traditional root cause analysis, repetitive whys, and similar tools are designed for use in solving problem of a specific structure and a sudden occurrence, that is to say, issues that develop rapidly and happen in response to a single cause. Situation analysis, fishbone analysis, and other tools, are better used for problems of a general structure and a gradual occurrence, in other words, incidents that are the product of a multiple, inter-related elements. In these types of incidents, many factors have to be present to cause an injury, and it is only after a threshold is reached that we see a process failure. In my experience, injuries tend to be the product of multiple factors that contribute to the incident. As long as we continue to use inappropriate tools to find the cause of injuries we will continue to mask hazards instead of removing them. The fact that Oil & Gas executives are concluding that 80% of the workers’ injuries are caused by “human error” leads me to question their methodology used to identify injury causes. Yes people make mistakes, but if those mistakes are leading to injury you have more at play than stupid people, you also have a process that hurts people when they make mistakes.
Protect the Stupid
We may not all be stupid, but we all do stupid things from time to time—we make poor choices, take unreasonable risks, allow distraction, fatigue, or other factors to impair our performance, or generally act in a way at odds with our safety. Some seem to forget that not all safety is about prevention; probability of interaction is only PART of the formula, there is another key component, reduction of severity. Engineers use this formula when identifying which of the hierarchy of controls to apply to everything from the machines we use in the workplace to the consumer goods we use every day. If the probability of interaction is high (people will almost certainly interact with the hazard) but the severity is low (most of the people who interact with the hazard won’t be seriously injured) they will generally slap a “no-kidding?” warning label on it. But if the probability of interaction is low, but the severity is lethal, they will take greater measures to protect people. I don’t believe that 80% of the Oil & Gas injuries are the fault of stupid people making mistakes; frankly it sounds suspiciously close to Heinrich’s Pyramid. But if the processes used in Oil & Gas are so fragile that human error is going to result in injury, the safety practitioners had better take bold initiatives to make these processes safer.
They Have the Answer; They Just Don’t Know It
The last part of Raney’s statement, “It has to be through leadership and supported through procedures — a safety management system” is right on. Unfortunately, organizations can’t achieve a sustainable safety management system that is built on the belief that you can’t fix stupid. Leadership has to drive good decision making and has to reward and encourage worker engagement based on respect; and describing workers as “stupid” is far from respectful.