SafetyInsights.org

This qualitative study used a mixed-method approach to understand how a major accident in a Brazilian oil refinery incubated. It’s argued that many accident investigations still result in blame and superficial explanations without exploring deeper issues.

Analysis of the accident and further one-on-one and group interviews, participant observations, document reviews and work analyses were undertaken.

The accident of analysis occurred on an LPG manifold at an oil refinery while the manifold was being isolated to connect a new line. A gas leak occurred which found an ignition source and followed by an explosion, killing six workers. It’s noted that the company investigation indicated an absence of planning, failure of the work permit process, and non-compliance with necessary procedures.

Although there a fair bit of discussion around failure of technical systems in this paper (work permit etc.), I’ll focus more on the organisational factors.

Results:

As part of the deeper analysis by the authors, it’s stated that while some of the workers were in a hurry to carry out the task (involving skipping water purging and not waiting for full line depressurisation), and at one point did switch off the gas detector, an interesting question is posed: what is it that leads experienced operators to skip safety steps?

Rather than being a factor of frontline worker motives, the authors argue that this accident was one that “began in the office”

(p631).

Based on their analysis (some of which I’ll cover shortly), they highlight that this accident “had its origin in the interaction of social and organizational factors” (p617). In particular: (p617)

• Excessively standardised culture
• Management tools and outcome indicators that “give a false sense of safety”
• Production pressures and work intensification
• Environment that encourages the circumvention and adaptation of rules to deliver production goals

Notably, the company investigation and conclusions didn’t go beyond the immediate factors. I’ll now briefly unpack some of the factors discussed in the paper.

One issue was the drive for outsourcing of labour. Over time the outsourcing process decreased the number of company employees, leading to outsourced workers not fully understanding the operating environment and with less internal staff to train and supervise.

Here it’s said that the intensification of outsourcing led to weakening of the internal management structure, with worsened internal communication processes, an increase of tasks being transferred from internal supervisors to outsourced workers, high turnover of contracted workers, reduced training for outsourced workers and more.

The authors then discuss the work tasks and following procedures. For some reasons on why not all requirements of the work were completed by operators:

• Failures of the procedures (eg lack of clarity or applicability, contradictions)
• Time pressures & production deadlines
• Lack of resources & tools to follow procedures

The company culture and norms were said to encourage and even accept rule breaches when tasks were completed quicker. Quoting the paper, “if the activity is successful the supervisor gives his worker a satisfactory evaluation”, however, if the adaptation resulted in an accident then “managers individualize responsibility refusing to recognize their contribution to the causes of such events” (p632).

This mostly invisible situation, between the implemented rules which are officially ordained as important, versus the real priority to achieve production goals no matter what, leads to what the authors call “alibi rules” [NB. Tokenistic systems, rules, norms etc. are also called a “mock bureaucracy” by other researchers.]

Regarding the management systems, the drive of OSHA and ISO systems throughout the 2000s led to standardisation across refineries – replacing bespoke systems which had developed at each refinery but was possibly better suited for that context. Employees believe that this drive for standardisation led to a “more bureaucratic management”, bogging people down with paperwork.

Workers informed that the ISO certified systems had people “more concerned with filling in the forms than performing their tasks properly” (p627).

With also the modernisation and expansion within the industry, more automation and modernisation of business units led to a decrease in frontline workers. However, the workload of those frontline workers didn’t diminish but instead they “assumed more administrative and supervisory functions” (p627). A drive for people to have multiple roles which demanded further work intensification.

Regarding worldviews of safety and risk, it’s said a discontinuity between the company hierarchies is how accidents come to be. For some managers, accidents are mostly about workers not following rules and that workers receive enough training and safety has enough investment. For workers, accidents “take place due to the dynamics of work and the pressure to produce” (p628).

An example of the superficial nature of the company investigation board reports relates to training. The board were said to have only described the presence of absence of technical training of the victims but didn’t discuss the effectiveness of the training given. Another issue related to the company procedures. The board identified that procedures had been breached but failed to question or provide a deep analysis of the reasons why operators felt the need to circumvent rules.

Although there wasn’t any direct bonuses or financial incentives for workers or managers to speed up the project planning and execution phases, it’s argued that meeting the deadline is still critical in the company being able to win new bids. Thus, indirect production pressures influenced decisions.

Regarding the safety management system, it’s stated that it focuses too heavily on the behaviour of individuals  – as opposed to recent criticisms identified post Texas City and others about inadequate focus on process safety. According to their sources, a DuPont-type approach focuses on blaming workers for their own injuries and thus discourages the reporting of incidents. This absent reporting then increases the chance of poor hazard control.

Note I’ve only scratched the surface here as it was a 21-page paper full of findings. In concluding they say that the company performs rapid and superficial incident investigations. The type of investigation methodology they use for instance has been criticised for not considering systems factors (temporal dependencies, interactions, vertical hierarchies etc). In the author’s words, “these methods are insufficient to reveal the organizational factors lying behind the occurrence and/or development of an accident” (p633). In contrast, they argue that investigators should utilise more complex and sophisticated theories and methodologies; particularly those of a non-linear nature.

Finally, it’s said that the company investigation board stopped their investigation when they found human error. Once this was found they didn’t dive deeper into the organisational factors. It’s said that once they arrived at the conclusion that rule improvisation and lack of rule following by workers were the causes of this accident “this led them to ignore the existence of workers’ strategies adopted to adapt to changes in the job” (p633).

Link in comments.

Authors: SL Beltran, RAG Vilela, IM De Almeida, 2018, Work

Study link: https://doi.org/10.3233/WOR-182702

Link to the LinkedIn article: https://www.linkedin.com/pulse/challenging-immediate-causes-work-accident-oil-using-ben-hutchinson