The Seven Delusions in Disaster-Prone Organizations (00ec0c95-937d-473b-9762-40a685fd5e37)

"Safety performance in many companies and even industries has stalled in the few years. Accidents rates are at a "plateau" and yet, serious accidents and fatality rates are not. In more dramatic cases, such as in the BP Texas disaster, organizations that have "exemplary" safety statistics, suddenly have a catastrophic or multi-fatality event occurring. Other classic examples are the Piper Alpha disaster and NASA’s Challenger and Columbia disasters and even the Chernobyl nuclear reactor. Looking into the root causes of these accidents provides an insight into the events and deficiencies that led up to the accident, but what are the common features in the organization’s mindset? What characterizes these organizations’ decision-making, their approach to safety and to risk and are there specific cultural features that can be delineated? The research and review presented in this paper covers a period since 1994, which started in the Australian resource industry and since then covered international events. The features of these organizations are summarized as the seven deadly delusions, based on extensiveresearch since 1997 of organizations that suffered unexpected disasters.The Piper Alpha Oil Rig disaster in the North Sea, on the 6 July 1988, was one of the most pivotal events in safety around the world. It changed the thinking and focus of governments, whole industries and led to numerous books and papers. It resulted in new legislation, textbooks and a critical self-examination by the oil and gas industry.In short, an explosion and fire occurred when a pipe started leaking gas and ignited. A temporary flange, with no safety valve, was used to block off this pipe during a maintenance operation the previous shift. The permit to advise operators not to start the pumps on this line was misplaced and lost. Several deficiencies, problems and system failures coincided. A key factor was that the water deluge system was inoperable at the time and failed to extinguish the large fire that erupted, followed by an even larger gas explosion. The accommodation unit, situated on top of the oil rig, was the main "killing field" - most men gathered here to await instructions (which never came) and where they died from smoke inhalation. Later, a large explosion of the gas pipeline from an adjoined rig exploded and killed more people.The line of events and the associated system failures are all very relevant in the analysis of the accident, and provide the only insight into what caused the accident. But much "further back", inside the organization’s culture, lurks more dark matter. The first inclination is to ask what was "deficient" in the culture. Did they not care enough about safety, or about their people? Did they have a culture where production decisions were more important than safety considerations? Did they ‘coerce’ supervisors and employees to ignore safety precautions or did they just "fly by the seat of their pants"?Not surprisingly, it is very difficult to identify the true nature of the culture in that business because in such an aftermath of death and destruction, no one dare say that the safety culture was a ‘positive one, focused and caring’ or that the company was doing well in safety and that this is only a freak accident. Indeed, there were many deficiencies in the organization’s systems and procedures, such as the permit to work system.But there are some niggling questions: How is then that the Piper Alpha Oil Rig was actually considered the company’s most productive and safest oil rig in the North Sea? Why would this rig win a safety competition, 6 months before the disaster, with the deficient permit as its most outstanding successful system?"