Rig Safety Report: Human Factor During Disaster

Wednesday, July 7, 2010 @ 01:07 PM gHale


When Captain Chelsey Sullenberger landed a USAirways plane loaded with passengers in the Hudson River in 2009, he and the crew were highly trained and ready for any type of emergency that may come their way. The result of that training led to all passengers escaping without injury.
While an emergency most likely will never occur in most pilots’ careers, they all undergo training to that teaches them to deal with and react to emergency situations.
While the world’s attention remains focused on the massive environmental damage along the Gulf coast caused by the April explosion on the Deepwater Horizon oil rig, operated by BP in the Gulf of Mexico, which killed 11 workers, that isn’t the only disaster that occurred on a rig.
In another case, in 1988, the Piper Alpha oil platform in the North Sea suffered from a fire and explosion, which killed 167 people.
What comes into question during that case is exactly what happened during the emergency landing in the Hudson River: The competence and abilities of decision makers during disasters.


That is where Rhona Flin comes in. Flin is a professor of applied psychology at the University of Aberdeen’s Industrial Psychology Research Center and she has been researching North Sea offshore oil safety since 1987.
Flin has been investigating how decision makers react during catastrophic occurrences, not only on oil platforms, but in several high risk professions where those in charge must take immediate action during extremely stressful situations.
Following the Piper Alpha incident, a Public Inquiry Report by the British government concluded the platform’s operator, Occidental Petroleum, was unprepared for the kind of disaster that hit and the platform’s offshore installation manager was overwhelmed and not properly trained to handle the fast-breaking developments. His inaction and the resulting breakdown of the platform’s command system contributed to an unnecessarily higher number of fatalities, the report stated.
Following the Piper Alpha incident, Flin won a grant from the United Kingdom’s Health and Safety Executive (HSE) to look at the selection, training and competence of offshore managers to handle crisis management situations, not only in the oil industry but also within other organizations who may deal with major incidents including the military, emergency services and aviation.
“Although the Piper Alpha platform was well-equipped to deal with the evacuation and the crew was trained in firefighting and emergency response procedures, it appears the crisis on board Piper could have been managed more effectively,” Flin wrote in her report. “This led the HSE to look more carefully at the human factors aspects of safety management systems,” she added.
In a number of major disasters she reviewed, Flin investigated the common threads that led to problems because of incident commanders’ inability to immediately assess and be aware of the developing situation.
The fundamental skill sought in incident commanders across high risk professions is the ability to make decisions under pressure and to provide leadership to ensure the crew members know how to perform their roles, Flin said. The goal is to avoid confusion and chaos among the crew.
She pointed out those in charge of high risk operations “to some degree already possess desired characteristics, including self-confidence, ability to cope with stress, like being a leader, and are comfortable making decisions quickly and with minimal, if any, consultation.”
Offshore installation managers operate an oil platform or rig and their goal is to meet production schedules. Managers “accept the role of crisis manager as a minor element of their overall job requirements,” Flin said.
Just because a manager is effective in routine situations, it does not mean he or she can handle a crisis situation, Flin said.
Organizations then need to ensure they employ people with the “right stuff” to successfully manage emergencies. To find those people, they need to properly assess and train workers. Organizations can determine if their managers possess these qualities through a variety of psychological assessments. They then can undergo training in specific skills for incident command positions and practice making difficult decisions in ambiguous, high risk, time-pressured situations, usually using some kind of simulation, Flin said.
“The training is normally conducted in simulators and simulated scenarios in offshore sites. They are schooled in the most likely problems, such as fires, explosions helicopter and boat crashes,” she said. “However, major incidents usually have unforeseen combinations of problems or failures and that is why it is important to have command managers who can quickly assess situations and make timely and accurate decisions.”
While most disasters are low likely events, they still need to undergo study. “One way to produce scenarios with unexpected failures is to take them from the companies’ ‘near miss’ data set,” Flin said.
By studying and examining “near miss” events, organizations can review the risks and institute procedures that can help prevent, or at least minimize, disasters like the Gulf oil spill.
One highly reliable training method is Crew Resource Management, which has been a successful program in the aviation industry. Crew Resource Management focuses on human factors responses to error management during routine and emergency operations.
“The Hudson River incident was an excellent example of Crew Resource Management teamwork,” said Diane Damos, president of Damos Aviation Services in Gurnee, IL, a consulting company that offers services on all aspects of pilot hiring.
Flin added one significant innovation following the Piper Alpha disaster was the introduction of formal assessment of offshore mangers’ competence in crisis management. She added regular evaluations in commanders’ skills to deal with emergencies are important to the success of any crisis management program and regulatory authorities for high reliability industries should demand evidence of competent assessments for key decision makers in emergency response situations.
Sometimes, though, there is a conflict between production and the safety commitment of an organization, Flin noted.
“I think there existed on the Piper Alpha a very strong production culture,” Flin said. “Oil platforms cannot be turned off and on like a tap. If they are shut-down, it can take days and a lot of work to get them back to full production, thus costing thousands of dollars in lost revenue.
“There was a reluctance to shut down the Piper Alpha as well as two connected platforms because the offshore managers did not fully assess the developing crisis and it was too late by the time they did act,” Flin said.
“I think one of the very key cultural variables is where the balance is set between production and safety trade-offs and how site and senior managers are ‘calibrated’ in this respect. Companies need to assess the level of safety commitment and risk awareness in all their managers,” she said.



Leave a Reply

You must be logged in to post a comment.