If we learn one big thing from the pandemic of the last few months, it should probably be this:
Think the unthinkable.
Covid-19 was the “black swan” everyone always knew was out there, but could not quite imagine flying into our pond. In theory, possible. But in the mind’s eye? Inconceivable.
We who work in industrial safety are supposed to deliberately think the unthinkable, every single day. But, of course, we don’t. The human mind naturally rebels at the idea of all normality being overturned in an instant.
And then, well, nature happens.
The Mother of All Industrial Black Swans
The mother of all industrial black swan events occurred exactly 10 years ago this month. The Deepwater Horizon oil rig operated by Transocean exploded and burned in the Gulf of Mexico on the night of April 20, 2010, killing 11 workers, injuring 17, and unleashing the largest environmental disaster in US history.
The numbers were staggering. Some 210 million gallons of oil leaked into the Gulf over a period of 87 days. About 16,000 miles of coastline were polluted. By 2018, the costs to well owner, BP, which was leasing the rig and made most of the fateful decisions, exceeded an incredible $65 billion after it was hit by more than 400,000 claims. Years later, crews were still cleaning millions of pounds of oil sludge from beaches.
For anyone in Health & Safety, Deepwater Horizon remains the singular great lesson in thinking the unthinkable.
Well, maybe until now.
The Movie Everyone in Safety Should Watch
The superb 2016 film about the disaster, Deepwater Horizon starring Mark Wahlberg, shook me when it came out, and it shook me again last week, when I forced myself to rewatch it.
I also found it instructive in an entirely new way.
The movie starts just one day before the disaster, and takes us through the errors, the miscalculations, the failures of redundant systems, and the confused actions of everyone from executives to workers as they failed to think the unthinkable.
The script only somewhat simplifies the chain of events, and stays close to the facts. For anyone in Oil & Gas, the look, the dialogue, and the emotions all feel real. The characters don’t seem like movie stars. The heroics are certainly real—featuring the kind of workers you probably know. It’s rare that Hollywood gets such things right.
Most importantly, the filmmakers put us there, at the moments of decision when the people in the midst of catastrophe are somehow unable to take the actions needed to save those 11 lives and prevent at least some of the horror that followed.
At the moments when training failed, right along with systems.
Consider that a precious nine minutes passed between the time the well blew out, spewing explosive oil onto the platform, and a general alarm was sounded to alert all the 126 people on the rig. Most did not know anything was wrong until their quarters were shaken by explosions. Warning lights were ignored because they often gave false positives. A crew member was at first told not to send a Mayday. No one at first pushed the button which could have severed the pipe to the oilfield 5,000 feet below, and saved the rig. And when that button was finally pushed, it didn’t work.
The list goes on and on: Broken communications equipment. Unclear protocols.
In each case, the instinct of the crew was not to take all emergency precautions. Instead, their instinct was not to overreact to what might not be a true emergency. Until it was too late to react at all.
Remember: Humans Are Always Working to Contain Vast Forces
As in nearly all industrial settings, the crew of Deepwater Horizon was working with enormous forces barely contained by human technology and procedures. For these folks, such forces included the titanic pressure built up within a vast reserve of oil held 18,360 feet below sea level, with 5,000 feet of ocean below the floating rig.
Holding back the underwater monster was nothing but a big cement cap and some heavyweight valves—all of which failed.
BP was ultimately held at fault – they had rushed exploration of the well, along with skipping crucial tests when they fell behind schedule. In the movie, you see how BP pushed crew members of the rig, operated by Transocean, to gloss over uncertain test results and move forward, no matter what.
This might sound like an extreme and unusual situation, but again, anyone in industrial safety knows better.
We know that workers everywhere are regularly exposed to massive forces barely under control. And we know that protocols are often skipped in the name of costs and schedules.
And I do mean nearly all industrial workers.
Even if you are running a simple table saw, the force of that spinning blade is many times stronger than any human hand. That saw is also a thing of titanic force, tamed only by technology and protocol. To an individual, it’s just as potentially catastrophic as any well. At both the micro and macro levels, training matters. Things like the right work gloves matter. And the attitude of management matters probably most of all.
A Series of Small Compromises
Deepwater Horizon had a superb safety record before it experienced total disaster. That fact is not “ironic,” it represents a vital, and all too common lesson.
In the movie, we see the boss of the rig, Jimmy Harrell, receiving his seventh consecutive annual safety award on the very day of the catastrophe: Even as he, and everyone, was aware of numerous mechanical breakdowns and problems on the rig, and even as they sat above what the crew already called “the well from hell,” with a record of troubling indicators.
The lagging indicators were great: no accidents in the past. The leading (forward) indicators for a disaster were right in front of everyone’s eyes.
Once again, this is not actually unusual.
As I point out in my recent book, Rethinking Hand Safety, a “great safety record” often fails to take into account a multiplication of small risks, which creates a large risk. Experience had taught the leaders and supervisors of the rig that “small compromises” made to keep on schedule, were unlikely to be detected, and even less likely to cause a blowout. They never saw the cumulative risk they were creating.
The Myth of the Safety Pyramid
Philosophically, you can see that the Deepwater Horizon risk was created by the fallacy of the “safety pyramid.” In the book, I discuss this common myth, which insidiously combines a blindness to cumulative risk with statistical overconfidence—assuming it takes a lot of minor accidents and near misses before you get a major accident like a fatality. Here’s an actual example of a mistaken pyramid analysis from Conoco-Phillips, published some years ago:
The pyramid seductively claims that you can predict the number of injuries and fatalities based on the numbers below in the pyramid: more minor stuff, more likely to have a major event.
Now, why doesn’t that make sense?
Step back and think logically: In reality, it only takes one at-risk behavior to create a fatality, not 300,000. Also, you can be creating an enormous potential for a catastrophe without experiencing any minor disasters at all—which was the case on the Deepwater Horizon.
The Lessons of Black Swans: Then and Now
At this precarious moment in time you may not want to watch a disaster movie, or see another black swan come to rest. But humans only triumph when we learn from disaster. You can easily rent the movie to stream. If you really want to dig into the details, read the superb article about Deepwater Horizon written in 2010 by the New York Times, on which the movie was based.
The lessons of black swans, then and now?
Think the unthinkable. Look at forward, leading indicators, not at the past. Remember that it takes only one error to create disaster. And when the unthinkable happens anyway? Take care of your brothers and sisters. Leave no one behind.
For more advice on hand protection, you can find Rethinking Hand Safety on Amazon.