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Demystifying Disasters

Posted on August 26th, 2016 by in Chemical Manufacturing Excellence

Demystifying disasters

Transparency defines the value generated by lessons learned from an oil & gas or chemical processing industry incident. Moreover, transparency encompasses not only the incident itself, but perhaps more importantly our response to it. Take, for example, the devastating fire and explosion in a large petroleum refinery complex operated by BP in Texas City, Texas in 2005. In this instance there was immediate transparency with regard to the incident itself. While most process upsets are publicly unnoticed, some incidents are impossible to ignore. This was definitely the case in this instance. The severity of that incident produced a very public spectacle that could not be hidden. The transparency of that incident was set from the moment that it occurred.

I remember working in a large refinery on the other side of the United States when that explosion occurred. Live footage of the fire fight was being broadcast on the national news when I returned home. After a catastrophic industrial event of this magnitude, it is reasonable to expect that legal implications, litigation strategies, or other valid concerns will interrupt the flow of trustworthy information. Company employees are reminded of their responsibility to direct any questions to public relations specialists who are trained to interface with the media. A “hold order” immediately goes into effect to protect information that might serve a useful purpose during court proceedings that are expected to follow. Issuing a hold order also prevents the distortion of technical facts that might create public confusion and misunderstandings, which are difficult to correct.

The day after the BP refinery explosion the Plant Manager in the refinery where I worked appointed a team to determine what could have caused the incident. Our purpose was to recommend what could be done to prevent a similar event. It was acknowledged that we would be working with limited information for the reasons described earlier. BP had certainly invoked the same information control protocol that would be expected in response to a tragic event such as this. With that thought in mind we recognized that we might never be privy to much of the information that would contribute to an effective analysis of the event. Any information we received directly from BP would likely be scrubbed and sanitized before its release. If the technical details behind that incident ever became transparent, it would be long after the study was complete. We were sure about that.

We did not expect for BP to release a complete, uncensored internal investigation report within two months of that fatal incident. In an unprecedented move, BP voluntarily made descriptive knowledge about the explosion and fire fully transparent. The report, which later became known as the Mogford Report” communicated intimate details about management system failures, cultural defects, communication silos, and tribal knowledge that converged to become the disaster. It was a story that anyone with responsibilities in a manufacturing organization could put to immediate use. It demystified the disaster and silenced any rumors about conspiracies or cover-ups that tend to develop when a hold order is issued. As a result, important lessons were learned that we could easily relate to and integrate into our processes.

Compare this sequence of events with the Bhopal disaster, which was also too big to hide and a very legal matter at the same time. Here again we find an example of an incident that was extraordinarily transparent with regard to its public impact. As was expected under these circumstances, a hold order immediately went into effect. Without transparency similar to the previous case study, conjecture and speculation drove the analysis of facts. Without any further clarification, the information that became transparent through the incident itself could not be reconciled. Soon, stories began swirling about how the most successful and responsible company in the chemical processing industry had gone astray and how employees were involved in a cover-up. Charges of corporate misconduct or nefarious acts of sabotage were made. Regardless of the theory of choice, things simply did not add up. Over the course of time, information released through legal channels and recently published in Rethinking Bhopal created the transparency industry needs to move forward. But until that time, the Bhopal disaster remained a mysterious, controversial topic with no absolutes. Sadly, many companies are not aware of the transparency that is now available concerning the Bhopal disaster and have thus not fully integrated vital improvements into their processes.

The contrast between these two case studies provides a very powerful message. Incident prevention is by far the best choice. But the value that a process safety incident generates depends on the way you manage its transparency. Always remember that transparency is established by the severity of the incident. It’s another way of saying that once the genie is out of the bottle you cannot put it back. How you manage the flow of information after a highly-visible incident directly impacts your reputation. Withholding information might be perceived as a cover-up, which can lead to controversy and missed learning opportunities that can permanently damage a good reputation.  Never discount the benefits of taking responsibility for things under your control and making constructive use of reality. When contemplating your response to involuntary transparency, voluntary transparency could be your best option.


All opinions shared in this post are the author’s own.

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