You Say Tomato attended the recent Ergonomics and Human Factors conference (EHF2016), sponsored by the Chartered Institute of Ergonomics and Human Factors. The conference was held over three days in Daventry, UK, and included a number of thought-provoking talks from industries including aviation, rail, healthcare, and occupational health.
An unspoken theme running through the conference was the need for ‘good’ communication, and the part that ‘good’ communication plays in incidents and accidents. What I mean by this is communication that’s clear and concise, where everyone shares the same meaning and understanding of what’s being said.
This type of ‘good’ communication is especially important in emergencies where time is of the essence; the need for ‘good’ communication is consistently emphasised and trained in safety-critical industries, e.g., aviation.
‘Good’ communication can, however, be hampered or difficult to achieve because of organisational influences and other human factors. In a time-critical emergency, loss of ‘good’ communication combined with other contextual issues can have disastrous results.
This type of disastrous result is exemplified by the April 2010 ‘Deepwater Horizon’ oil spill in the Gulf of Mexico. Cheryl MacKenzie of the US Chemical Safety Board (CSB) gave a fascinating keynote talk on ‘Human Factors and the Macondo Blowout”. (Macondo is the code name for the oil and gas prospect operated by BP; Deepwater Horizon is the name of the oil rig which exploded and sank in the accident.)
MacKenzie began her talk by stating that incidents (and accidents) are not usually one-offs which come out of nowhere; organisational practice always plays a part. In the Macondo accident, there was an organisational influence on crew behaviour, and organisational hierarchy played a part in the accident.
The Macondo accident began on 20 April 2010, when high-pressure methane rose into a drilling riser, despite safeguards which were in place and presumed to be working. The crew went into action, and did what they thought was best. However, there were several human factors that MacKenzie’s presentation highlighted that contributed to the disaster, including:
- Seemingly insignificant decisions had great impact on the outcome.
- A well-intentioned crew exhibited natural human tendencies to rationalise the situation.
- There were undefined and unrealistic expectations placed on the well operations crew by management.
- Organisational influences, including organisational hierarchy, impacted crew behaviour during the accident.
For example, in the Macondo accident, one part of the crew did not have contextual information about the data to which they had access that would help them fully understand that data – and therefore help to contain and minimise the accident. Additionally, the length of time crewmembers knew each other, and consequent familiarity with behaviour and communication styles impacted tone and purpose of crew communications during the accident.
If you’re reading these factors and thinking they seem a bit vague and could apply to any safety-critical incident where humans are involved, then you’re right. These are industry-wide issues in safety-critical industries, and if you are a decision-maker in your organisation, the CSB’s findings make for fruitful reading.
Back to April 2010: The high-pressure methane which rose into the drilling riser ignited and exploded. The explosion and resulting fire engulfed the oil rig platform; the oil rig sank the morning of 22 April 2010. Eleven workers were missing and presumed to have died in the explosion. After the explosion, an oil leak was discovered the afternoon of 22 April 2010. The flow of oil continued for 87 days, contaminating huge areas of the Gulf of Mexico and surrounding shoreline and land. It is considered to be one of the largest oil spills in petroleum industry history, resulting in one of the largest manmade environmental disasters in recorded history.
Organisational influences can be insidious when it comes to communication practices, and can have disastrous consequences, as the Macondo accident shows. According to the third volume of the final report:
- There were economic and regulatory consequences for diversion of well fluids overboard, which affected human performance.
- Everyone involved in the explosion relied on subjective judgment of the well operations crew to make crucial decisions.
- Organisational practices influenced the time that was available to the crew to respond to the accident.
Again, if your organisation has safety-critical operations, you need to be aware of these issues. There were safeguards in place on the Deepwater Horizon drilling platform and oil rig. The crew had undergone training. However, there were issues that the crew could not overcome, and despite the well-intentioned crew’s best efforts, the explosion and fire occurred. No-one wanted this accident to happen, but it did.
Some final, broad takeaways from the Macondo accident report:
- Reliance on people in safety-critical operations is pervasive across high-hazard industries. We still need people to do things in safety-critical operations; therefore, it’s imperative that safety-critical organisations invest in human factors training, especially training that helps crew communicate and interact better, more efficiently, and with as little misunderstanding as possible.
- Organisational influences are strong and need to be explored. There are implications for design, planning, and execution of the work. Companies within safety-critical industries need to understand how their organisational culture can impact crew communication and human performance. This is not a joking matter, and it really should not be up for discussion. Organisational culture and hierarchy does and will impact both routine and non-routine operations. If you are a decision-maker in a safety-critical operation, you should be aware of these facts, and take steps to understand what’s impacting your operations, and how you can have the most efficient organisation possible.
- If you have safety-critical operations, your organisation needs a Human Factors safety management system approach, including the need to assess expectations and assumptions of safety critical tasks, and to verify the systems meant to ensure human performance success.
The Macondo disaster is an extreme example of how organisational influences, miscommunication, and other human factors resulted in one of the worst industrial accidents in recent memory. ‘Good’ communication is vital to safety operations, but can be extremely difficult to achieve, and evident only when an organisation most needs it.
You Say Tomato firmly believes in the importance of ‘good’ communication to safety, and that ‘good’ communication is only part of what makes a crew and an organisation safe in all operations. A robust safety culture, transparency, organisational culture which supports, not hinders, staff, and crew who are well trained in all types of scenarios and emergencies can help to minimise disaster if it strikes.