Substantial barriers stand in the way of worker empowerment. As with the stakeholders in the offshore oil industry, these barriers exist on different levels and interact across levels. One panel at the workshop looked at these barriers and at possible ways to overcome them, which was a major topic of discussion throughout the workshop.
Donald Holmstrom, who recently retired as director of the U.S. Chemical Safety Board’s (CSB’s) Western Regional Office, began by suggesting that, given its history of involvement with the offshore oil industry, CSB is well positioned to identify and investigate barriers to worker empowerment.1 He explained that CSB, which is modeled after the National Transportation Safety Board, is an independent nonregulatory federal agency that investigates catastrophic chemical accidents in the United States. It determines causes, identifies lessons learned, and makes recommendations for safety improvements, including prevention measures and policies to avoid future accidents, but is prohibited by statute from assigning blame.
Holmstrom used CSB’s investigation of the Macondo disaster to discuss the barriers to worker empowerment and ways to overcome them. The investigation led to four volumes on the incident,2 the third of which overlapped extensively with the themes of the workshop:
- Volume 1—Incident background and general description; deepwater drilling and well completion
- Volume 2—Blowout preventer technical failure analysis, barrier management, and safety-critical elements
- Volume 3—Human and organizational factors, process safety performance indicators, risk management, corporate governance, and safety culture
- Volume 4—U.S. offshore safety regulation before and after Macondo; attributes of an effective regulatory system.
Holmstrom explained that many of the human factors involved in process safety management have been compiled by the Center for Chemical Process Safety (CCPS), which uses a sociotechnical approach that considers complex interactions rather than simply linear causation.3 “We certainly use linear logic trees, linear timelines, and linear causal factor analysis, but we feel we need to go beyond that,” he said. As an example, he cited CSB’s development of “acci-maps” that look at the layers of influence on the causation of an incident.
CCPS considers workforce involvement one of the five pillars of process safety, Holmstrom continued. He explained that it provides a system for enabling the active participation of company and contract workers in the
1 CSB is the name commonly used for the U.S. Chemical Safety and Hazard Investigation Board.
design, development, implementation, and continuous improvement of the risk-based process safety management system. Furthermore, he noted, this applies not just to the right of workers to refuse to undertake unsafe work, but to “the whole panoply of management system elements, from design engineering to management of change to incident investigation.” “Workforce participation is essential to ensuring that all issues are considered and that the expertise and knowledge of workers is incorporated,” he stressed, adding that workers are often the most knowledgeable people about day-today details of operating processes and maintaining equipment and facilities. They know “past incidents, they know what works, they know how things work when you’re talking about procedures.”
Like CCPS, Holmstrom reported, CSB emphasizes the need for a separate and unique focus on process safety over and above the focus on personal safety (see Table 5-1). He stated that “human error” is not a root cause of accidents, and that by focusing on human error, “you’re going to miss a lot of important findings and potential changes that could be made that can prevent an incident from occurring.” Even when companies say
TABLE 5-1 Distinctions between Process Safety and Personal Safety
|Process Safety||Personal Safety|
|Scope||Complex sociotechnical and organizational systems||Preventing injuries and fatalities in workplace behaviors/actions|
|Prevention||Management and organizational systems: design, targeted risk reduction, mechanical integrity, effective barriers||Procedures, training, personal protective equipment, behavioral observation programs|
|Risk||Incidents with catastrophic potential||Slips, trips, falls, health exposures, etc.|
|Primary Actors||Senior executives, engineers, managers, operations personnel||Front-line workers, supervisors|
|Examples of Safety Indicators: Leading and Lagging Examples||Hydrocarbon releases, inspection frequency, closure of process safety management audit action items, challenges to safety systems, etc.||Recordable injury rate, days away from work, timely refresher training, number of behavioral observations|
SOURCE: Adapted from the 2016 U.S. Chemical Safety and Hazard Investigation Board’s Investigation Report, Volume 3, Drilling Rig Explosion and Fire at the Macondo Well.
they have few personal injuries, he added, they can have major accidents, a fact that points to the gap between using injury rates and analyzing safety performance.
As with CSB’s other investigations, Holmstrom continued, the Macondo investigation focused on prevention, not blame. “This is not only critical internally within companies,” he stressed, “but is also important in the broader realm of how safety is regulated and managed in the United States.” With Macondo, he added, criminal investigations started within days of the accident, which greatly hindered the investigative ability of CSB and other agencies. “It changed the whole tenor of the investigation,” he said. “It was an impediment to finding out some of the true causes and delayed not only our investigation but other investigations as well.”
Holmstrom went on to observe that with the Macondo disaster, workers did not participate effectively in key processes, decisions, and procedures. As examples of the key processes and procedures that lacked effective worker involvement, he cited well-specific risk and hazard reviews, management of change reviews, temporary abandonment, investigation of incidents leading to the Macondo blowout, and the negative pressure test. For instance, he said, procedures often lacked specific goals or triggers of a failed test. Workers were not involved in establishing procedures for deviations from what was expected, so they were not able to help identify and correct weaknesses. “The negative pressure test wasn’t even delivered to the rig on the day of the incident,” he observed.
In addition, Holmstrom reported, Transocean’s key safety performance indicators focused on process safety, but the primary means of participation for Deepwater Horizon workers was the safety observation program focused on personal safety. He explained that among Transocean’s key performance indicators were (1) health, safety, and environment training compliance; (2) See, Think, Act, Reinforce, Track (START) observation card daily completion numbers; (3) the potential and actual severity rate of personal injuries; (4) the total recordable incident rate; and (5) serious incident/injury cases.
According to Holmstrom, the focus on personal safety resulted in a lack of involvement and empowerment in process safety. As an example, he pointed to the American Petroleum Institute, which has standards on such process safety indicators as fatigue prevention that apply only to oil refineries and other petrochemical facilities. “Those things are equally important for major accident prevention offshore,” he stressed, “and yet those standards don’t apply. We think that’s a significant weakness.” On the day of the incident, a celebration of record-setting low injury rates was being held on the Deepwater Horizon, which he characterized as an indication “of how engrained the focus on personal safety is.”
Holmstrom went on to describe two programs, THINK4 and START, that were the centerpiece of activity and of key performance indicators. He explained that these programs focused on watching and documenting how workers carried out their tasks, and Transocean’s major accident reviews focused on personal safety issues and recommendations. These observation programs were “superficial,” Holmstrom said. He added that workers also feared the programs would lead to their being fired. He reported that a safety culture review that occurred right before the incident yielded some positive findings, but other findings pointed to a fear-of-blame culture. He noted that only 46.3 percent of participants said they felt that if their action (such as forgetting to do something, damaging equipment, or dropping an object from a height) led to a potentially risky situation, they could report it with no fear of reprisal. As one participant said, “People [tried] not to rat people out so to speak, you know like you wanted to be helpful . . . whereas some of the higher-ups in the office, they kind of wanted to weed out problems.”5 According to another, “I’ve seen guys get fired for someone [writing] a bad START card about them.”6 The overwhelming perception on the rig, said Holmstrom, was that workers were distanced from the change decision process and that change was being forced on them.
According to Holmstrom, CSB made a set of recommendations for worker empowerment. It urged the issuance of participation regulations and training requirements for workers and their representatives that would include the following: worker-elected safety representatives and safety committees, stop-work authority with mechanisms to seek regulator intervention if the issue remains unresolved, an annual tripartite forum for workforce representatives to advance prevention of major accidents, protections for workers participating in safety activities that create a workplace free from fear, and process safety culture assessments that measure the effectiveness of workforce empowerment initiatives.
Holmstrom emphasized the importance of safety culture leadership. He noted that leaders can assess the difference between process and personal safety, ensure that hazards are reported all the way to the top of the organization, and be incentivized to drive risk reduction and improve process safety controls. He concluded by listing ways to overcome barriers to workforce empowerment:
4 More information on THINK, a planning and risk management tool, can be found in the 2016 U.S. Chemical Safety and Hazard Investigation Board’s Investigation Report on the Macondo Blowout and Explosion.
5 Page 144, CSB Investigation Report. (2016). Volume 3, Drilling Rig Explosion and Fire at the Macondo Well.
6 Page 144, CSB Investigation Report. (2016). Volume 3, Drilling Rig Explosion and Fire at the Macondo Well.
- Involve workers in all aspects of prevention of major accidents: establish a separate and unique focus on process safety.
- Establish a joint plan and roles with authority for worker empowerment.
- Establish a safety culture that encourages reporting of hazards and incidents, including “bad news.”
- Focus on prevention, risk reduction, and continuous improvement, not blame.
- Provide real protections for workers, anonymous reporting, and whistle-blower protections.
- Drive change and worker empowerment from the top.
In response to a question, Holmstrom noted that CSB had made a number of recommendations to BP that have been successfully addressed. For example, BP developed a suite of more rigorous and more focused indicators for use by safety and operations crews to prevent future incidents from occurring. However, Holmstrom added, some broader recommendations have proven more difficult to implement. For instance, the investigation report pointed out that expectations, requirements, and communications among the lease holder, the operator, and the contractor were critical and that all three had to be held accountable. However, Holmstrom said, some regulations still do not apply to contractors, even though most of the workers on drill rigs are contractor employees. He characterized this as “a significant gap.” Similarly, he noted that some state and federal agencies have not implemented CSB’s recommendations, observing that “the record is actually much better for recommendations to private corporations and standard-setting bodies.”
In response to a question about the need for regulatory oversight, Holmstrom replied that in his experience in the industry, workers have often been involved in designing procedures. “I’ve seen a lot of workforce involvement that was very valuable,” he said, “[including] workers pushing for elimination of unsafe conditions that were eventually successful and that were positive for the enterprise as a whole. . . . I can’t stress enough the importance of workforce participation and empowering workers.” But, he stressed, many conditions need to be met for workers to be empowered, including protections, leadership, and process safety programs. For example, he said, an atmosphere of fear and blame can discourage workers from raising complaints. “Government regulations are important,” he acknowledged, “but at the end of the day those changes have to occur in the plant, they have to occur in the leadership.”
In brief comments after Holmstrom’s presentation, Claude Allen, senior SEMS specialist with Shell, noted that many offshore processes are too complicated, often because they are written by people in an office. As a result,
once he began working in an office, he emphasized processes that front-line workers can understand and own. Furthermore, he argued, the risk on a rig is dynamic, not static, and processes need to change over time, which means continually evaluating and improving them to ensure that they are effective.
Chris Beckett, former chief executive officer (CEO) of Pacific Drilling, pointed to four key barriers to worker empowerment. The first is that having an empowered workforce requires effective communication up and down the organizational chart. “If you sit in the corner office and never hear about things because they get filtered before they get to you,” he noted, “then you can’t do much about it.” He observed that the leadership of every company working offshore prioritizes the safety and well-being of its workforce. The problem, he said, is getting information to the people who need to hear it. He stressed that companies need defined paths so that anyone offshore can talk to an individual who can walk into the CEO’s office and report exactly what is going on.
Beckett cited leadership as the second critical key barrier. “To me,” he said, “the single most important failure that we have as an industry is we promote people based on their technical competence. We don’t give them any training in how to supervise, manage, or lead, and then we put them in roles where that’s increasingly important and technical skills are less and less important. Then, when they fail, we’re surprised.” All workers, including leaders, he argued, need to have the skills and knowledge to evaluate their circumstances and the ability to communicate those circumstances and their concerns. “That’s a key part of leadership,” he said, “and it’s something that is certainly missing in most organizations.”
The third barrier Beckett identified is what he called legal aversion. “Like it or not,” he noted, “lawyers have a lot to say about what we can and can’t say in meetings like this. And frankly what we can and can’t record and pass on and store and share, whether it’s internally or with regulators or even with our peers.” He reported that when he was CEO of Pacific Drilling, other companies were shocked when the company shared the full details of any safety incidents that arose. “Nobody wants to put out in public that we made this mistake for fear that it is going to come back and bite you,” he said. “And until we can find a way to remove that fear from the industry, you’re never going to get the ability to address these things and put in place the continuous improvement elements that we need as an industry.”
Finally, Beckett briefly mentioned the tension between procedural discipline and chain of command on the one hand and worker empowerment on the other. He argued that the two need not be mutually exclusive; however,
procedures have to be appropriate for the context in which they are being used, and employees need to know when they can and cannot follow them based on the situation.
Beckett observed that developing leadership is a challenge for every company in the world. He stated that the offshore oil industry needs a high level of technical knowledge and expertise, and companies need to find a way to keep that knowledge and expertise in-house. One way to do that, he explained, is to promote people up the ranks, giving them bigger salaries and more recognition in an organization. However, he said, some people can be promoted to a position in which they have exceeded their leadership skills.
Beckett identified as one option the establishment of two tracks: one for people with management and leadership skills who can rise up through the organization with increasing responsibility for process management, and the other for people with technical skills who can continue to increase their technical knowledge and experience. However, he said, this approach is not easy for small organizations. He suggested that the better solution for small companies is to be flexible about job descriptions and responsibilities so that people can take on the responsibilities for which they are suited.
As CEO of a small company, Beckett said he was able to bring together the leadership teams and technical teams from all the company’s rigs twice a year to share experiences and incidents and develop best practices. But, he added, “you have to be willing to invest in the cost of both time and travel to make that happen.”
According to Beckett, tools that have been developed outside the United States should be part of U.S. operations. But tools such as the Safety Case need to be “living documents,” he argued, that can be continually improved and used every day by the drilling industry. He added that some drilling contractors have started developing and using such tools, but the challenge is to develop and use them throughout the industry.
Finally, S. Camille Peres, assistant professor in the Departments of Environmental and Occupational Health and Industrial and Systems Engineering at Texas A&M University, summarized some of the main messages from this workshop session. She began with the observation that the offshore oil industry deals with complex sociotechnical systems and complex problem spaces. She added that it has made progress in terms of personal safety, but it has made far less progress on process safety. Furthermore, she said, process safety and personal safety typically are not integrated, and as a result, workers and managers have to deal with a host of forms, procedures, and documents.
Peres suggested that factors unique to the Gulf of Mexico may be one source of these problems. In her research, she has noted that best practices developed by companies often cannot be shared with other companies because of legal restrictions. She added that research on process safety management has been taking place in other parts of the world, but very little has occurred in the Gulf of Mexico. “We’re not seeing that research here about how managers and leaders can do worker empowerment,” she said. Other barriers, she argued, originate in the tension between a dynamic environment and the need for standardization in a global industry and in the tension between procedural discipline and worker empowerment.
Meetings such as this workshop are important, Peres said, because they demonstrate where research and practice need to be communicating. “What do we need to be focusing on? How can we do it in a way that keeps the lawyers happy?” Why have changes not been occurring in the Gulf of Mexico “with the robustness that we’ve seen in other parts of the world”?
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