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Inspectioneering Journal

Learning from the Past: Not Letting the Pendulum Swing to the Opposite Extreme in Our Mechanical Integrity Programs

Part 1

By Greg Alvarado at Inspectioneering Journal. This article appears in the September/October 2008 issue of Inspectioneering Journal
This article is part 1 of a 2-part series.
Part 1 | Part 2

 

It has been over 3 years since the fatal blast at the BP Texas City Refinery on March 23, 2005. The explosion resulted in the loss of 15 lives, more than 170 injuries, and countless lives forever changed.

Historical memory can be an odd thing.

It is important to preserve as accurate an account as possible if we are to learn from the past. We must protect ourselves from rationalizing the past to justify movement toward “normalization of abnormalities”. This concept was explained well by Mr. Don Holmstrom, a lead investigator for the U.S. Chemical Safety and Hazard Investigation Board (CSB). In a statement released for the BP Independent Safety Review Panel, in which Mr. Holstrom presented a summary of the BP incident findings, he stated:

One of my aspirations is that all industrial managers treat safety and major accident prevention with the same degree of seriousness and rigor that is brought to financial transactions. Few people would operate a major corporation today without a strict system of financial controls and auditing, where everyone within the corporation recognizes the severe consequences for noncompliance. (Paragraph 20)

That same standard of diligence is not always applied to risk management and safety. If you get away with a flawed safety decision one day or repeatedly, far from facing penalty you may actually end up rewarded, perhaps from boosting production. You may come to believe that what was thought to be unsafe is actually safe, based on your experience. It is a phenomenon that is sometimes called 'normalization of abnormalities'. (Paragraph 21)

The panel was charged with performing an independent investigation of the 2005 BP incident and was headed by James A. Baker III, former US Secretary of State.

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