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Safety Disasters and Organizational Learning

This article takes a closer study on the extent organizational learning is taking place, or lack of it, on safety management. Organizations in discussion are in particular, the energy (oil and gas), nuclear and chemical industries whereby impacts of the safety accidents can be severe, e.g. a) Bhopal disaster, December 3, 1984, a Union Carbide Corporation pesticide plant leakages of toxic gases, killed 18,000 within two weeks, , b) Piper Alpha, a North Sea oil production platform operated by Occidental Petroleum, exploded on July 6, 1988, killing 167 men, c) The Chernobyl disaster, a nuclear accident that occurred on 26 April 1986 in Ukraine, 985,000 excess deaths occurred between 1986 and 2004 as a result of radioactive contamination, d) Esso Longford gas explosion occurred on 25 September 1998 in the Australian state of Victoria's Gippsland region, killing two workers and injuring eight. Gas supplies to the state of Victoria were severely affected for two weeks. This discussion is from the perspectives of a) personal observations of organizations, b) acting as HSE (Health Safety and Environment) manager of a gas plant during early careerlife, c) insights gathered from recent years in NP/EP coaching to more than 400 cases of various human issues, gaining some insights on how the mind works, or affects the outcome of well being. Reference is made to Lessons from Longford : the Esso Gas Plant Explosion by Professor Andrew Hopkins, a sociologist, an expert witness at the Royal Commission into the causes of the fire at Essos gas plant at Longford. Organizational Approach to Safety Management. Organization, with good intention, tries to manage safety professionally and diligently. However, in spite of such sincere intention, often, un-intended negative consequences occurr, like the above cited examples of safety disasters. Safety investigation reports on accidents often review in-adequacies or deficiencies in the safety management. Organizational approach to safety management is briefly summarized as follow: 1. Safety Policy 2. Safety Management System (documented), inclusive of y Safety procedures, instructions 3. Safety Activities / Practices y HAZOP* y Training y Audit y Safety incident investigation of root causes y Safety sampling

y Management review 4. Safety Performance indicator LTI (Lost Time Injury Report)

(Note: * A hazard and operability study (HAZOP) is a structured and systematic examination of a planned or existing process or operation in order to identify and evaluate problems that may represent risks to personnel or equipment, or prevent efficient operation.) The underlying premise of the above approach is based on the rational thinking that With management commitment to safety as stated in the safety policy, documented procedure on how to manage safety by the various levels of the organization in relation to their tasks and functions, hazards and risks duly identified, assessed, with control and mitigation measures put in place, training conducted to the relevant personnel on the safety awareness and management, regular audit to check safety compliance,.. then logically safety is well managed and controlled. It may be logically sound, but safety accidents still occur. Why? Some parents also have such logical approach to raise children committed to children development and future, work hard to earn the necessary living, provide children with best schools and educations, frequently remind them to study hard . Yet some children turn delinquencies. Why? Is logic all there is to safety management, or for that matter, to wholesome human being or organization towards higher consciousness? In reality, the above logical approach meets with many limitations, gaps in one set of logic to the next, one set of rational activities can create conflict or tension to another parties, there are more and more spin-off to other related logics and hence more activities, in the name of logical thinking, in the name of better safety management. Is it not possible that such proliferation of logic, activities or in-activities, belief in a totally rationalized process contribute to safety disasters? On rational thinking alone, human being has created endless logic, ideas, from primitive days of simple lifestyle harmonious relationship between man, environment and nature, to today highly sophisticated technologies, from simple choice to become a farmer or craftsman to earn a living in the old days to today infinite and confusing choices of professionals, businessman, artists and what not. And with such expansion of logic and using the power of the mind for today advancement, we still find miseries, unhappiness, human conflicts. Samples Scenarios of How such Logic do not work in Safety Management: 1. More information and knowledge can create higher awareness to manage safety better? With respect to the thick volumes of documented safety management system and procedures, even the authors (usually externally engaged consultants / specialists) have difficulty to fully comprehend or remember what is written, let alone the practitioners having to make sense out of them with compliance.

Quote Lessons from Longford : the Esso Gas Plant Explosion by Professor Andrew Hopkins, P83, (Esso Safety Management system) , together with all the supporting manuals, comprised a complex management system. It was repetitive, circular, and contained unnecessary cross-referencing. Much of its language was impenetrable. These characteristics made the system difficult to comprehend by management and by operational personnel. If action needs to be taken, say revision or re-writing, a tenuous task by experts, there could be some improvement, but cannot be perfect enough to satisfy all parties concerned. A stop has to be made on the academic exercise. This again illustrates the limitation of such logic and approach documentation and better documentation. What should be other alternative? We will discuss towards the end of this article. Personnel or workers complain that they could not carry out their basic tasks and function e.g. production, or maintenance if they have to attend to safety requirements, safety training, audit etc. When productivity gets affected, management may direct safety officers to be less stringent on safety requirement, and the pendulum can swing to another extreme, less attention to safety. Here we have a limit to the logic that more information and knowledge is good, as documented requirements need to be implemented or complied with. Today technologies are of such high degree of sophistication that every part of a system that can affect safety can be a very specialized discipline by itself. Can documented system of manuals, procedures and instruction capture the essence with details and translate into practical steps for shop floor personnel, operator, and maintenance crew to comply with good understanding? Safety audit or safety investigation reports often review the above difficulties. Management reaction is to put in more effort for better documentation and awareness training. And the vicious circle continues. Quote Lessons from Longford : the Esso Gas Plant Explosion by Professor Andrew Hopkins, P13, Perrows principal argument against the thesis of operator error is that the situation confronting the operators at Three Mile Island was, so complex and opaque that they could not possibly be expected to understand what was happening or what actions they take to deal with the problem. (Note: Three Mile Island accident : nuclear meltdown on March 28, 1979, at Pennsylvania, USA, resulting in the release of approximately 2.5 million curies of radioactive gases, and approximately 15 curies of iodine-131. ) Note: This writer is not against the above logic (or subsequent points to be discussed) like documentation of management system, but point out the limitation of such logic, and will discuss later what other approach should be considered, if not logic alone.

2. Identification of Hazards can create greater safety awareness and take mitigation action (if procedurized)? It is logical to assume that when one anticipates problems (e.g. hazards), one becomes more alert and in better state of mind to take precautions and corrective action. At the same time, it is impractical to have mind filled with all the anticipated problems and dangers to carry on what needs to be done daily on production and maintenance of the facilities. How does the mind balance between anticipated dangers and day to day work? How much can the mind absorb and understand the numerous documented hazards and their required response and action? Identification of hazards is on best-thinking effort by a group of experts, imaging what could be the possible hazards with what worse scenarios. It is a mind-game, maybe with greater degree of probable safety cases established when the experts are competent. However, even with the best, competent and experienced experts, no precise prediction can be made. Human errors, mis-judgment, lack of inspiration during the thinking, analysis and documenting process may leave out some hazards not identified, which become obvious only after the safety accidents have occurred. There is limit to human intellectualizing and rationalization process. We need to admit. Furthermore there are interactive, multiple failure scenarios, not just one hazard, or one possibility, but several. Precise sequence of hazard-scenarios, cannot be imagined, let alone documented. Since the experts cannot do such a perfect job, we have to rely on the operators or maintenance crews, who are by functions, do not have such high intellectual capacity to comprehend the complexity of the system to take appropriate safety action. We have to rely on the front-liners common sense, or higher consciousness to do the necessary, then? How? (we will discuss more later). 3. Are hazards only confined to the technical / tangibles : in the processes (manufacturing, production, engineering, chemical, electrical, mechanical etc. etc.)? What about the non-technical, the non-tangible? Quote Lessons from Longford : the Esso Gas Plant Explosion by Professor Andrew Hopkins, Page 34, .. the relocation to Melbourne in 1992 of all the engineering staff who had previously worked at Longford, leaving the Longford operators without the engineering backup . There were no engineers on site on the day of the accident and it was left entirely to the operators and their immediate supervisors to deal with the crisis. Hence, management decision, based on whatever rationale at that time, is now, on retrospect seen as a hazard! Management decision on staff relocation is a non-technical, hence nontangible aspect that can constitute a hazard.

To continue with this line of thought, what about the personality, psychological make-up, thinking preference of a CEO of the manufacturing complex? Could these non technical, non tangibles constitute of hazard that can lead to safety disaster? Lets look at this scenario The CEO has good leadership attributes as praised by many modern management guru, forward looking, visionary, innovative, always creatively make changes with the intention to improve things. For examples, re-structure the organizations, sending managers overseas for leadership training (with new concepts new ideas). So far the business is doing well, safety records are good. All the more, the CEO increases the momentum of his preferences in accordance to his leadership style. Very subtlety, un-consciously, the CEO dislikes looking into the past. He feels uncomfortable facing the negatives, business mistakes, minor safety accidents, human conflicts. He believes in forgiveness and not digging up the bottom of the problems. He believes in freedom towards innovation and not be constrained by bureaucracy, like documented safety management system (although he does not express such stand consciously, as such behavior is subtle and un-conscious). He believes in pro-active behavior and not compliance behaviors. He does not believe in blame-culture, and he plays the avoidance game strategy. Over time the management team and organization get tuned in to such behaviors people pay less attention to documented procedures (including safety management system), less vigorous in root cause analysis of safety accidents, less importance on compliance behavior to documented safety procedures. etc. etc. Such leadership attributes could be suitable for a dynamically changing IT industry with little safety disasters possibility, but for an industry that needs to be firmly grounded, dependent on well established corporate memories of past accidents and mistakes for lesson learned, stress on stability and reliability and not innovation and constant changes? Isnt such leadership attribute a hazard to industries with potential safety disaster? But HAZOP study team is a team of technical experts, not psychologists or behavioral scientists? HAZOP term of reference would not cover such aspects also. And Management Team in decision making is a team of management experts, not psychologists or behavioral scientists? Furthermore, who is to highlight The Emperor has no clothes!, let alone document it as a hazard or safety case? Readers of this article can also imagine the complexity involved when we examine the personality, emotional state, and psychological make-up of the organizational members managers, supervisors, operators, front-line workers, contractors, that can have impact on safety.

Is the next logical step to hire psychologists or behavioral scientists? This is what I mean there is no end to logic, proliferation of man-made mind activities, which lead to creation of a Frankenstein what we no longer can manage and control! What then is the solution? we will discuss later. 4. Training conducted, competency-test completed, personnel should know how to manage safety. Management often takes comfort and assurance that when staff is trained, with the necessary competency test conducted, especially with documented evidence, verified by auditors, then staff concerned (operators, maintenance) should know better and take appropriate safety measure and control. Quote Lessons from Longford : the Esso Gas Plant Explosion by Professor Andrew Hopkins, Page 11,. The company (ESSO) claimed that operators had been trained about the dangers of cold temperature embrittlement and should have known better. They should have allowed the heat exchangers to thaw out before they began to reestablish the warm liquid flow. With such logic, mindset or belief system, management is satisfied when training was conducted and consider their duty done and no further action required on safety knowledge and awareness. Surely management does not realize the limitations and inadequacy of such logic and belief systems? We will discuss a few of them:
y y

Safety Emergency / Safety Cases training. Unlike Medical Emergency ward, personnel trained in emergencies, handle emergencies cases day-in and day-out. They are constantly practicing and applying what they have been trained to do. But in a manufacturing plant, occurrences of safety incidents are not daily affairs. Often it is a probability case of one occurrence in many years. Can you act appropriately to ensure safety in the event of Tsunami when you had been trained / taught about the characteristics and action required on Tsunami in your school days? Can you perform emergency first aids like CPR (Cardiopulmonary resuscitation) now when you were trained with certified competency during you school day Red Cross activity? There is no corporate memory of the above quoted case of cold temperature embrittlement as it had not happened before in the Longford plant. Can 1-2 day training help built a vivid image in the mind of those come for training for a long period of time? How can then management discharge their managerial responsibility with the logic that training was carried out? Management carries out emergency drill every now and then. However such drills cannot cover all the possible and identified hazard scenarios. Training does not equate learning with mind-shift and behavioral change for the better.

But most organizational management makes such assumptions, some may wake up after many years investment in training, as they do not see fundamental shift in mindset and behavior. Most never wake up. Happily conduct traiing, business as usual. Currency of the training contents / materials If a careful audit is carried out, it is not uncommon to find mis-match, mis-alignment between the contents / materials on safety training with the current documented procedures, and especially current actual practice in the field and / or changing organizational structures with changing job functions and reporting hierarchy. It is similar to the syllabus of today university teaching materials, seldom reflect current world practice or advancement in that particular field of knowledge, be it medicine, engineering, bio-technology etc. Training on the intangible? What is that? Accidents investigation or audit report, sometimes review the intangibles, directly or indirectly are the causes to accidents, like lack of motivation, lack of confidence, lack of commitment, lack of leadership attributes, lack of teamwork, with politicking, lack of professionalism or integrity, or emotional disturbances, etc. etc. of the concerned parties. Are there effective training on such soft issues, except theory, principles, concepts of human behavior. Such intellectualization does not effect mindset shift or behavioral change.

y y

y y

Above are just a few examples of limit to the rationale that : Training conducted, competency-test completed, personnel should know how to manage safety. Should organization management still continue to rely on such logic and belief system? 5. Hijacking management attention Entertaining what are obvious, but not what are hidden: Imagine the entire police force looking for petty thieves all over the city, thieves who steal people wallets, hand-phones etc. while the greatest crimes of the century take place : bank vaults empty of money, famous Picasso paintings disappear from the museum, or time bombs planted at strategic financial and communication centers by terrorists. Organization management, with good intention to manage safety diligently, get caught in the vicious circle of never ending activities and efforts on the symptoms of safety issues like the above analogy. Managers are trained in Leadership / Management Program about iceberg theories, i.e. what are obvious are just symptoms, noises not signals, effects but not causes. What are hidden, the real drivers creating the symptoms are the belief systems, emotional state, psychological make-up and potentialities. And many of the later show in patterns and trends, if only management pay attention. But iceberg theory is seldom or never put into practice, except a theory leaned in the Leadership training class.

The followings are some example of organizational efforts and activities on the travails many:

Safety Performance indicator LTI (Lost Time Injury Report)

It is standard industrial practice, using Lost-Time injury frequency rate as its principal measure of safety performance. For example, an organization with 1000 staff (inclusive of contractors workers working in the manufacturing facilities), with average 10 hours work done in a day, there is no injury to anymore and all can come back to work the next day, then 1000 x 10 = 10,000 hours work completed without injury. Over time, cumulative records of millions hours work completed without injury indicates high safety performance. There are many prestigious awards for such achievement, likewise, punishment if such record is broken. There are consequences to such practice. Quote Lessons from Longford : the Esso Gas Plant Explosion by Professor Andrew Hopkins, Page 69, ..Reporting the number of hours worked without lost-time injury puts enormous pressure on workers not to spoil the tally by reporting an injury, and the greater the number of hours free of injury the greater the pressure not to report. .(companies may ) resort to bringing the walking wounded back to work on alternative duties, the day after the accidents to prevent the accidents counting as a lost-time injury LTI by definition and its implementation , is a measure of the number of routine industrial injuries like slips, trips, falls, cut, knock .. which result in injury to single individuals, dis-able the person to come to work the next day. However, explosions and major fires, toxic chemical spillage, process upsets, and the hazards (as per above discussion, those hazards identified and those not identified) but not causing injuries to persons, do not contribute to the LTI records and, hence do not catch management attention. As routine industrial injuries occur in high frequency, contributing to LTI statistics, perceived as prime importance with its rewards and recognition by the industries, or punishment by upper management, organizational management attention, efforts and energy continue get drawn in this area, much like the analogy of the entire police force looking for petty thieves, with little resources left to look out for big time, infrequent criminals or terrorists. Often major safety incidents investigation reports review problems like non-awareness or non-compliance to documented procedures, lack of attention to pre-warning signals or process upsets etc. not injuries like slips, trips or cuts. Another analogy to LTI in our daily life experience is that LTI is similar to how some people using health indicator like cholesterol level as a health performance indicator. One can beef up good cholesterol level by taking chemical drugs, which certainly just hide the inherent health problems, and make the health issue worse over time. A wise man will face the frequent occurrences of cold and fever, headache or pain (not using drugs to suppress the symptoms) and become more conscious of his or her mental and

emotional state (positive or negative) and his or her lifestyle (balanced or not), which will bring him or her better health. Likewise, a wise and highly conscious organizational management, will use the true LTI incidents as clues to the state of mind and emotions of the staff and workers, and not be lured by the artificial prestigious safety awards based on millions hours achieved without injuries. This is a case of management mindset, belief and value system against the logic and rationale to follow and comply with the industrial practice. The management is not in a high state of consciousness, not in congruency with their whole being. Isn't this a greater issue and attention rather than continuing perfecting the safety management system, which is full of logic but not soul? 6. Blasting the tip of the iceberg will get you another tip to blast, endlessly. There are many sincere efforts and intention on the part of the organization management to manage safety. For example : Audit, Safety sampling, Safety incident investigation of root causes, Management review. These results in huge amount of activities and energies spent : trying to improve things and solve problems. As per Albert Einsteins ..It is impossible to solve a problem with the same level of thinking that originally caused the problem. The level of thinking, as per the above discussion, is the use of logic-thinking, rationalization and intellectualization. This level of thinking will spin off to more other logic and more efforts and action. For example: Many audits conducted, safety samplings made, incident reports filed, root cause analysis carried out, .. with the following findings and recommendations
y y y y y y

Lack of safety awareness, In adequate training more training is initiated. Lack of hazards identification, .. more hazard identification is made. Unclear procedure and instruction, .. revision made Lack of maintenance, .. more maintenance is planned High maintenance backlog .. outsource to contractors to close the backlog Lack of communication and collaboration between shift staff .. more teambuilding workshops Etc. etc.

It is a Reactive-Action-Behavior, logically make sense, but it is like blasting off the tip of the iceberg, full of symptoms, issues, and more tips emerge to be blasted. The underlying drivers to such behaviors and symptoms are the bottom of the iceberg the belief systems (usually subconscious), the emotional state (the EQ), the potentialities (to be manifested positively or negatively), the personalities, the value-system.

How these underlying forces manifest individually and collectively that form the pattern of behaviors and lead to safety accidents / disasters is an alien subject to most organizational management. But this is the most essential question that needs to be addressed!

If there is some indication in these directions, management will use the all-toofamiliar approach, i.e. organize more training, engaging management guru or psychologists to give talk, theories and principles on motivation, psychology, .., which obviously cannot help to actually shift mindset and behaviors

Organization Management Dilemma Management has no escape route! When organization gets caught in the above discussed maze of logic, with missing linkages of one logic to another, with gaps, with mis-alignment, with internal conflicts among different sets of logic , management has no escape route when safety disaster occurs and when the investigators drill hard to find evidence, evidence of management accountability and responsibility. There is no perfect management system. Surely one can find loopholes here and there, especially on the hindsight, after safety accidents occur. What can organizational management do otherwise? Organizational Consciousness Professor Andrew Hopkins in his book Lessons from Longford : the Esso Gas Plant Explosion devoted a chapter (Chapter 11) on the topic An Absence of Mindfulness. Quote : Page 139, In this final chapter I want to explore the concept of organizational mindfulness, developed by theorists of high reliability, and to argue that Essos failure amount to an absence of mindfulness. This article writer, with his experience gained from NP/EP coaching (Number Psychology / Energy Psychology) to more than 400 clients with all sorts of human issues , prefer to use the term Organizational Consciousness the lack of which that could lead to safety disasters, or business failures for that matter. This is because many of the NP/EP coaching clients problems are the result of being controlled by the mind, identification of the mind with whatever may be the difficult situations, using so called logic and rationale thinking, not able to free the mind. Hence consciousness is used to include a) Mind, particularly the belief systems, conscious or sub-conscious, b) emotion or EQ ,c) psychological balancing, the conditioning that took place over time, d) physical, sensation in the body. These four basic ingredients make up the total consciousness of a being, simply stated. The inability to leverage the total being consciousness, except the logic and rational thinking, is curtailing organizational members, individually and collectively to unleash their enormous potentialities, towards high consciousness to manage safety, or any area of performance.

Consciousness is on a higher dimension, more than the rationalization process of managing safety system or business system, as a way out from the vicious circle of logic and mental activities created discussed above. Examples of high state of consciousness

A baby is in a high state of consciousness in learning to sit, to stand, to crawl, to run a complex maneuvering that the most advanced robot cannot do, without mental indoctrination or training on theory of walking and instruction how to walk, but with a lot of care, love and encouragement from adults around. Gandhi non-resistance movement is in a high state of consciousness when masses march hand-in-hand peacefully against armies of aggressors with guns and batons. (Imagine organizational members do the same against hazards!) Charity body with high consciousness response swiftly, effectively, seamlessly without in fighting to world disasters like typhoons, earthquake, with volunteers bravely sacrifice their lives in rescue.

How Can Organization help to raise and expand Consciousness, individually and collectively, so that people is always in a high state of alertness in their work, whereby safety management is intrinsically linked? This question is paramount to be the focus of organization. And we need to discuss further what is consciousness? Or, what is lack of consciousness? More often than not, people is not in high state of consciousness, i.e. their potentialities or energies are being blocked. In another word, there are mental blockages (e.g. limiting beliefs), emotional blockages (e.g. insecurity, fear, anxiety), psychological blockage (past conditioning becoming today habits or part of personalities), and physical blockage (like stress, sickness). This writer personally uses NP/EP coaching (for individual) and NP/EP facilitation (for group of people). That is, NP and EP are set of tools to help identify the above named blockages, release the stuck energies thus unleash the potentialities. We will discuss how these techniques are used in the above written examples, whereby too much mental logic and rationale are used, but not EQ and the others. For example Managements obsession with LTI Safety Indicator

What underlying belief you hold true to insist on good records of LTI be served by all means? What emotion you detect in yourself by doing so? (maybe the managers feel guilt, insecurity thus creating internal conflict and stress, but rationalize it, .. )

The above is just an example, there can be so many different hidden human drivers, which may get reviewed through the coaching process. When the manager is helped to be more congruent with himself : mind, emotion and body, his consciousness is raised. His resulting action may become more human, more sympathetic to the wounded party, and not force him

to come back to the office to suffer the pain, but properly rest in the hospital. This in term can create positive messages to the rest of the organization, and help to build more consciousness. On staff / operator repeatedly not complying with the written procedure, though the instruction is understood.

Is there some underlying resistance in you that you feel the need to rebel? What past similar issues you still have that is still not resolved? What emotions get triggered? (may be the operator had difficult childhood, continue with the rebellious behavior to seek attention and love. )

Another example on group behavior: shifts (Note: 24 hour production requires 2-3 shifts to operate the facilities. It is vital that current shift communicates well with the next shift on problems or potential issues as handing over to ensure smooth and safe operation) Example : Frequent complaint of a particular shift with poor or inadequate handing over information, resulting in next shift having to cope with many surprises that constitute near miss incidents. NP / EP facilitation to the operators of that shift may review:

Common thinking preferences or personality that they have difficulty to pay attention to details, but prefer bigger picture thinking; they prefer freedom and not bounded by rules. This behavior is also being reflected in their own personal life. (with such information reviewed, either they are coached to learn detailing-skills or assigned with different tasks that suit their thinking preference.)

Operators with high consciousness can use common sense and intuition to capture signals that could be warning sign to potential safety disasters. They also have high EQ, with confidence, speak and discuss with the supervisors, engineers or experts on their observations. Hence operators, who may not have the intellectual capacity and engineering know-how, need not be trained and drilled repeatedly to understand the complexity of the manufacturing processes, but uses matured EQ to communicate with the right parties. The above example serves to demonstrate that people have infinite potentials, people come to work with good intention to serve and do good, it is now the responsibility of the organization to use the appropriate and effective coaching and facilitation tools to help raise the collective consciencesness. The theory that a person has infinite potentials, should not remain as a concept or theory, but put into practice. The theory that no person (operator or management) intends harm to themselves and others like safety problems, should not remain as a theory or concept, but put in practice. Early in this article I posted a question: Is the next logical step to hire psychologists or behavioral scientists? Surely not, otherwise you will turn a manufacturing company into a mental institution!

What you need is not theory-filled qualifications / certifications of psychologists or behavioral scientists , or management guru on psychology and behavior, but learn and practice conversation and interaction with members of the organization with focus to help raise each other consciousness with plenty of COMPASSION and CARE. Organizational management, are you ready for a self transformation and self-renewal journey to raise your own consciousness, and thereby influence your organization towards Organizational Consciousness.