Fighting the disease of sloppiness to maintain the basis of safety
The previous article in this series described the importance of identifying the basis of safety for the process: the potential major accident scenarios and the measures in place to prevent and mitigate them. In this article we will examine the concept of operational discipline as the means by which we can maintain the basis of safety.
The first article in this series explained how, in the management of process safety, we focus on operational discipline in preference to appealing to “hearts and minds” to “stay safe” that often features in occupational (personal) safety programmes. To maintain the basis of safety means that everybody involved in activities whose purpose is preventing or mitigating process safety incidents must be diligent in exercising these activities.
This will involve a diverse group of people: not just operations and maintenance, but those undertaking work such as protective instrument proof testing, fire protection system testing and maintenance, operating procedure reviewing and updating, alarm management, engineering inspection and maintenance, process isolation and permit-to-work management and, of course, supporting activities such as management of change and purchasing of replacement equipment and components.
It also includes activities that are the responsibility of personnel higher up the management chain: not only direct supervision but activities such as process design and the management and resourcing of ongoing hazard identification programmes and the recommendations arising from them.
So operational discipline requires all levels of the organisation to perform their routine process safety-related functions on a “right first time, every time” basis in design, installation, operation, maintenance and modification.
Most of us would probably say we do this as a matter of course; we might not even recognise the value of using the term operational discipline. However, experience shows us that most significant process safety incidents involve, or are preceded by, a loss in what we have described above as operational discipline.
From outside the process industries, this has been described more simply as “sloppiness”. In the summary of the inquiry into the Herald of Free Enterprise disaster1 (where 188 passengers died on 6 March 1987 following the sinking of the eponymous ferry), the judge – Mr Justice Sheen – described the cause of the disaster in these terms: “From top to bottom the body corporate was infected with the disease of sloppiness”.
A few years later, following the Piper Alpha disaster (in which 169 workers died), Tony Barrell, former Chief Executive of North Sea Safety described Piper Alpha thus: “I wouldn’t put it above or below other disasters. There is actually an awful sameness about these incidents…you always come back to the fact that things are sloppy and ill-organised and unsystematic right from the top of the company downwards”.2
These quotations provide us with an everyday way of describing the loss of operational discipline as “sloppiness”, and emphasise the way it applies at all levels of the organisation, not just to "front-line” roles.
So how can we fight this “disease”? Firstly, we can make sure that activities relating to the basis of safety are organised and systematic, through the application of the process safety management system (PSMS) in the form of detailed programmes implemented through comprehensive procedures.
And then, having done this, we can make sure that we use leading (or predictive) process safety performance indicators (PSPI) to detect the onset of sloppiness. Examples are measuring compliance with safety-critical procedures, inspection and proof testing programmes and isolation-for-maintenance policies; we should be prepared to act on any shortfall in compliance in accordance with the concept of a making a “strong response to a weak signal”.
We should also view failure to follow up recommendations from near-miss incident reports, change management requests and HAZOP studies as important indicators of the disease of sloppiness at more senior management levels.
One organisation I had the pleasure to work with, when reviewing compliance with key systems on a weekly basis, followed this with a look ahead to the next week, in an effort to anticipate circumstances that might threaten operational discipline, such as planned shutdowns, production pressures, serious adverse weather and shortages of personnel, and take action to control such threats. The aim was to generate a continuous consciousness of the operational discipline of the organisation, in the same way we talk about “chronic unease” as an important characteristic of high-reliability organisations.3
In the next article we will examine the concept of the normalisation of deviance and the need to be conscious of it as another mechanism – like the loss of operational discipline – by which the basis of safety can be compromised.
1. Department of Transport, Merchant Shipping Act 1894, MV Herald of Free Enterprise Report of Court Number 8074, Formal Investigation MV Herald of Free Enterprise, ISBN 0-11-550828-7.
2. Spiral to Disaster, Stone City Films for BBC Education & Training, 1996.
3. Managing The Unexpected – Resilient Performance in an Age of Uncertainty, Weick & Sutcliffe, 2nd Edition, Jossey-Bass, 2007, ISBN 978-0-7879-9649-9.
IChemE’s Fundamentals of Process Safety course provides a more detailed exploration of this topic.