This article was written By: Michael Farber, Senior Advisor to the Director of BSEE and I am posting it here as there is no means to “share” this great piece via social media.
General Motors (GM) recently released the findings of its internal investigation into the various failures that led to 12 fatalities and many injuries resulting from collisions caused by faulty ignitions switches in a number of its models. The company found that the ignition switches failed to keep the cars powered in certain circumstances, but they initially did not understand that this failure would prevent airbags from deploying. The internal investigation determined that there were at least 54 frontal-impact collisions in which airbags did not deploy as a result of the faulty ignition switches. GM used the faulty switches for 11 years without issuing any type of recall.
GM’s experience provides a window into how companies of any size and sophistication can lapse into systemic problems that can result in tragic consequences. Lessons learned from the GM experience can be applied to offshore oil and gas operations, as well as any other industry where lives are at stake every day. These lessons include:
- Test what you think you know. Workers should continuously test their own conclusions. According to GM’s internal investigation, for at least two years after the ignition switch defect was identified, numerous GM teams (composed of engineers and other professionals) saw the problems as one of customer convenience and not safety. These GM employees did not treat the problem with urgency because they did not consider the safety implications of the failure, notwithstanding the fact that internal documents and outside studies linked the ignition switch failure to airbag non-deployment.
- Offshore Lesson: Maintaining control of a well requires constant attention to various pressure readings and testing and re-evaluation of such readings to ensure that you know what is happening with the well. Offshore workers should test what they think they know to avoid loss of well control incidents. Companies that experience a loss of well control should thoroughly investigate, regardless of whether or not the incident resulted in death, injury, harm to the environment, or damage to the rig.
- Conduct thorough and disciplined incident investigations. Serious incidents deserve close analysis of all potential causes and consequences. The internal investigation determined that GM’s own investigations into airbag non-deployments were “neither diligent nor incisive.” In addition, investigators failed to take basic investigative steps – such as attempting to take apart and reconstruct both faulty and properly functioning switches. As a result, for years, GM was not able to determine the cause of the non-deployments.
- Offshore Lesson: As part of a robust safety culture, companies should thoroughly investigate all serious incidents (including incidents in which serious consequences were avoided) and should evaluate all potential causes of the incident to avoid the chances of recurrence. This often should include equipment testing that requires an investment of time and resources.
- Set timetables; demand action. Without timelines and deliverables, investigations and other important tasks will not be completed in a timely way. The internal investigation found that GM officials did not act with a sense of urgency and failed to set timetables and demand action. The various investigations of non-deployment of airbags were delayed, and information was not shared between GM components. As the report noted, “everyone had responsibility to fix the problem, nobody took responsibility.”
- Offshore Lesson: Offshore companies must work to ensure the timely conduct of incident investigations and clear lines of communication on recommendations that result from these investigations. A robust safety culture requires that companies, even for incidents where severe consequences are avoided, demand changes where problematic, unsafe conduct is revealed.
- When in doubt, “wake the captain.” Much as the captain of a sea-going vessel should be informed of problems that might imperil the vessel and crew, company executives should be alerted to safety issues with potentially grave consequences. The internal investigation found that GM personnel repeatedly failed to raise the growing concerns about the faulty switches with those at the top of the company. This resulted in the problems persisting for years after they were first identified.
- Offshore Lesson: If incident investigations reveal significant safety problems, company officials should be promptly briefed and should initiate follow-up actions. Keeping unsafe operating problems “in the field” can have catastrophic consequences. If company leaders are informed, and those companies are committed to a robust safety culture, they can bring all necessary resources to bear on solving the problem.
Companies operating offshore should closely review reports like the GM report for lessons on the establishment and maintenance of a strong safety culture. Perhaps more importantly, companies should be vigilant in thoroughly investigating all of their own incidents with actual or potentially serious consequences and in finding ways to share pertinent information learned with others across the industry. Information sharing to address operational risks is an important feature of a well-developed safety culture,as highlighted in a recent speech by Brian Salerno, Director of the Bureau of Safety and Environmental Enforcement (BSEE).
BSEE is leading efforts to promote the continued development of robust safety cultures in companies that operate offshore. You can find the June 2013 policy statement from the Director of BSEE regarding safety culture here.
