Gulf Spill report reveals lack of expertise -- of experts reviewing the spill

I read in the Wall Street Journal that an interim report has been selectively released on the causes of the Gulf Spill at the BP oil rig, although not yet made public.

I was saddened by the third hand comments which did not use the terms "mindfulness", "vigilence" or "safety culture",  although cheered that specific "bad people" were not named.

What was reported had a flavor shown by the snippet quoted below:

Gulf Spill Linked to BP's Lack of 'Discipline'

Engineers' Report Blames Oil Giant for Failing to Ensure That Safety Trumped Cost; Regulators' Technical Acumen Is Panned

          By Stephen Power, Ben Casselman, and Russell Gold

An "insufficient consideration of risk" and "a lack of operating discipline" by oil giant BP PLC contributed to the worst offshore oil spill in U.S. history, according to a report due for public release Wednesday from a team of technical experts.

The report from the National Academy of Engineering represents the most comprehensive examination so far of the causes of the disaster. The panel's interim report reaches few firm conclusions, repeatedly saying that possible causes require further investigation....

The 15-member panel includes engineers from several major universities and is headed by Donald C. Winter, a former Navy secretary who is an engineering professor at the University of Michigan.
...

Most of the technical issues covered in the report, such as the failure of a crucial cement seal and the misinterpretation of a key pressure test, have been raised by other investigations.

But the panel also identifies non-technical factors that it says likely contributed to the accident. The panel cites off "a lack of management discipline" and a "lack of onboard expertise and of clearly defined responsibilities."...

The report doesn't attempt to assign blame to individual workers or companies... it criticizes the lack of processes to ensure that safety didn't take a back seat to cost....

In defending itself,  we read this

Mr. Ambrose defended the training and experience of workers aboard the rig. "With a combined total of roughly 80 years of experience, the men who lost their lives on April 20 were considered to be among the best in the business," Mr. Ambrose said.

Not all criticism is targeted at BP and its contractors. Industry-wide training standards, the authors conclude, are "relatively minimal" compared to other high-risk industries.
Government regulators, meanwhile, did not have "sufficient in-house expertise and technical capabilities" to evaluate industry safety practices. The development of new regulations, the report says, "lags behind the rapid development of new technologies for deepwater drilling."

My comments on that:

Nature of causality in SYSTEMS:

I totally agree that attempting to find specific "bad people" and "events" as "causes" is helpful only to attorneys seeking settlements.   The goal should be to find structural processes that established the literal explosive atmosphere in which any random spark could have, and did, set off an explosion.

Ability of SYSTEMS to defeat expertise:

Mr. Ambrose defended the training and experience of workers aboard the rig. "With a combined total of roughly 80 years of experience, the men who lost their lives on April 20 were considered to be among the best in the business," Mr. Ambrose said.

 On the flip side,   the defense statements focus on a "good people" argument,   pointing to aggregate experience and training of individuals.   What this fails to address is that failure of such groups tends to occur as a failure of TEAMWORK,  not as a failure of specific individuals.   

As  extensive research by J. Bryan Sexton, Ph.D. points out, familiarity with others is a critical component of effective teamwork: 74% of all commercial aviation accidents happen on the first day of a crew flying together ( .. In other words, it's not individual training that isn't yet in place, it's the TEAMWORK meta-level processes that are not in place.)

I recently took a course in Patient Safety at Johns Hopkins from Mr. Sexton and Dr. Pronovost, and am familiar with their work.   Importantly,   Sexton's comments with teams that are simply attempting to coordinate with each other, in a neutral cockpit environment.

  What that fails to address is the impact on teamwork and perception of a climate, set by management,  in which the value system everyone understands to be operative  is clearly to suppress surfacing and responding to problems in favor of "making progress".     These can be caused by management, even innocently, with comments such as "I don't want to hear about problems! I want to hear about successes! Get back to work!" as well as outright suppression with comments such as "Don't bring me a problem unless you are bringing me solution!"

In other words the climate of "group think", as in the team that gave Challenger a "go" vote on the fateful day of the disaster, even though every engineer in the room thought it was a bad idea to launch.


Or, on a larger scale,  a room where every person in it was OK with the launch,  but only because those person who did NOT agree with the process had been previously identified and "weeded out" and removed from the decision-making process.


It is abundantly clear from studies in Group Think,  that putting experts in such an operating climate is fully capable of NEGATING the expertise of everyone in the room. We saw that in Bay of Pigs, in Challenger,  and in other well-known examples.

The panel notes a "lack of clear roles and responsibilities" on the drilling platform.  OK.  My point is, again, that's a SYMPTOM of a deeper structural problem, namely a working culture that did not dig in its heels at that point, detecting itself to have such gaps, and stopping operations until this gap had been fixed.    Were the people AWARE that there was a substantial confusion over who was in charge of what, and who was supposed to be the authority, and who was doing what? Yes, clearly, that was reported in multiple news accounts.


Then my point is it doesn't matter what the exact technical details of deep-water drilling technology  were involved here.  There is a more GENERAL and GENERIC problem in the nature of teamwork of the team, that doesn't take experts in drilling to detect or document.   There was visible confusion. There were substantial complaints.     The "teamwork" was not yet evolved or emerged.


Furthermore, there was no evidence of a process in place to detect and respond to a state of incomplete teamwork.   Management did not create a "detecting and responding atmosphere", nor provide any standard mechanism for resolving such NO-TECHNICAL issues (such as "who's in charge of this?"), nor training in said mechanism, nor stringent requirements that all employees demonstrate FLUENCY in using such mechansms,  not concern that said employees agreed the mechanism was SUFFICIENTLY well developed and deployed to cover that base and meet their needs.

Management might be resistant to giving employees a way to slow-down progress or stop it dead while they work on some issue.   In other words, management might says "I don't care what you think, I'm the boss."   Since it is very doubtful that said boss is an expert in deep water drilling, but is only an expert in managerial survival and tactics,  this completely defeats the point of HAVING people with 80 years experience on the work team.  If the boss is going to override them,  why not put much cheaper people with no experience on the rig?  And if you need good people, what are you doing overriding them?




Ability of SYSTEMS to overcome lack-of-expertise:


How about this quote:

Not all criticism is targeted at BP and its contractors. Industry-wide training standards, the authors conclude, are "relatively minimal" compared to other high-risk industries.
Government regulators, meanwhile, did not have "sufficient in-house expertise and technical capabilities" to evaluate industry safety practices. The development of new regulations, the report says, "lags behind the rapid development of new technologies for deepwater drilling."

This is truly worrisome, and is precisely at the point where lessons could be learned and actions taken that could prevent future disasters "of this type".

It is not necessary for the regulators to understand the details of deep-water drilling, any more than it is necessary for regulators of hospitals to understand the biomedical details of particular patient situations.      The breakdown of technical procedures is a SYMPTOM,   the equivalent of the random spark that is blamed for "causing" the explosion -- in this case literally.

What we need to do is head further upstream and ask what "loaded the gun" or "created an explosive atmosphere in which a single finger twitch or spark or technical failure COULD POSSIBLY have such a dramatic and bad impact."

We know that the most likely cause of such an atmosphere is precisely the lack of a culture of safety, and specifically,  the perception of team members that they are not in a situation in which problems are to be surfaced and dealt with,  but are instead in a situation in which it is understood by the staff that problems are to be brushed aside or ignored or minimized in an effort to "complete the task."

It doesn't even matter at this point whether this climate was intended or accidental -- that's a whole separate question.  What matters is whether the workers PERCEIVED such an environment and BEHAVED in accordance with that set of values,  however they grumbled and bitched while they did it.

And here, the record we can see from the newspaper reports is unambiguous:  YES, the workers FELT that they were under pressure to compromise safety in the interests of speed.


MY CONCLUSIONS

There is nothing new under the sun.

The BP-disaster, viewed at the level of teamwork and command and control systems,  is almost a textbook case of what goes wrong and how it goes wrong.  It is a type of system failure that is entirely general,  NOT restricted to deep-water drilling.  It is a type of system failure that has been seen multiple times before (Challenger, Bay of Pigs,  Financial Meltdown,  add personal anecdotes of your own here.)

It is a type of failure that is far larger than ANY amount of individual expertise that workers can bring to the table,  that negates all of the advantages of such expertise.    Having a huge number of hours in individual training does not protect against this failure mode.

It is a type of failure that does NOT require highly-technical regulators to detect and respond to. The only thing the regulators need to do is carry out an assessment of whether the workers FEEL subjectively,  under pressure to suppress safety concerns.  This can be as simple as a YES/NO response to a single question.   There are entire standard questionnaires covering "safety culture" and assessing psychological conditions of workers,  but there are short versions as well.

So, where does this lead?

The conclusion is the same one each disaster leads to.   What we call "standard management practice" -- whip in hand,  pushing "lazy" or "reluctant" workers to achieve a goal despite their "bitching" and "grumbling" without dealing with the issues leading to that -- is fatally flawed.

This accident was not due to an aberration,  not due to some special circumstances on the oil platform, not due to "bad people" on the rig.    This accident, as thousands before it,  was not caused by failures of concrete, or by failures of "blowout-preventers", or by any other technical issue, although those were the symptoms and sparks that triggered the failure.    The accident was CAUSED by failure of our business culture to FIX a broken model of how managers treat teams, and how managers treat problems.

I say this because actions taken after this oil-spill to give additional training to regulators, or additional educational training to oil-platform workers,  will NOT prevent this kind of problem from happening again and again and again.   Worse, it will not feed into fixing this VERY SAME FLAW in management culture that is producing disasters on the financial front, or in every other industry, or most hospitals in the world.

These are problems of MANAGEMENT CULTURE.    The CULTURE is broken.  The CULTURE is really, really, really good at pinning blame on anything and anyone except itself.

This disrespectful attitude towards workers,  and dismissive attitude towards worker concerns,  and non-feasance regarding processes to address these issues is what McGregor's "Theory X" of management is all about.  (There is an alternative, called Theory Y, in which workers are listened to, the organization is not running blind and has a learning curve, and results are generally spectacularly better. It's called Theory Y. It's not popular among those soaked in the brine of current theory X.)

It is a parasitic disease, destroying our industries and our payrolls and our economy and our health care. It is all around us.  it is a communicable disease in that new recruits into management circles are trained in how to disregard,  dismiss, and abuse employees on a routine basis as being a virtue and "being tough".

The Gulf Spill is just another symptom, another breakout, from the same contaminated source of "acceptable management behavior".     Technical fixes to deep-water drilling equipment and worker education in individual skills will not fix this problem.  It will, like "whack-a-mole", simply emerge elsewhere, again and again, until we get ourselves upstream and fix it at the source.

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WARNING

 It's pretty well documented that "theory Y" management produces a far better "bottom line" than "theory X" management,  so we might ask why stockholders don't demand this of companies they invest in.

The biggest problem is that both Theory X and Theory Y are like stable mountaintops in a sea of instability.     ONCE YOU HAVE theory X in operation, it is locally optimal.   Once you HAVE theory Y in operation, it is locally optimal.

But locally optimal means if you make a SMALL change, a TENTATIVE step  it will FAIL. It means, every local small step you might take on the pathway to a HIGHER PEAK will, in fact, at first, take you the opposite direction, downhill.

If managers have been consistently disregarding,  over-riding, and abusing workers, and treating them badly,    and the managers suddenly stop doing that and give the workers room to maneuver,  it is fully expectable that there will be a temporary, transient period of time in which the first reaction of the workers will be one of retaliation for past injuries,  of abusing THEIR new power of control by similarly causing slow-downs,  demanding more pay for less work, or otherwise being a true pain.

The question of how you GET from a stable "theory X" condition to a stable "theory Y" condition is a whole topic in itself.    I'll promise to my readers to pull together what is known about how to make that TRANSITION as smoothly as possible, so that the company does not die during surgery, and no managers lose their heads in the process.  Note - Theory Y managing, itself, is far easier than theory X managing..  You no longer need to pretend that you know everything -- by itself, that's worth the trip.

Most people who dump on "Theory Y"  are actually dumping on what they see if they attempt to take a small step from their Theory X mountain top, and notice it makes things worse -- so they extrapolate and say "I tried that, and it backfired, and I learned not to ever try that again."