Precursors of Consequence

Precursors of Consequence

“Leadership”

A persistent, unresolved topic in the infancy of the urgent focus on the drilling industry is well containment and the emerging discipline of process safety during the drilling and completion of oil and gas wells. There is interest in knowing if there are leading indicators of the safety of our operations and yet few proclamations of any valid examples. Part of the reason of why this is so is both the lacking in our industry of sufficient interest and focus on this subject and the complexity of subject matters that must be mastered in order to develop such indicators. The driving cause behind this lack of interest and focus is the subject of this chapter in my installments of thoughts on engineering management of the most complex and dangerous well construction projects and true leadership and the precursors of consequence in this endeavor.

First of all let’s examine aspects of national culture that we may agree pertain precisely to driving forces, motivations, behaviors, actions, and ethics (what we believe is right and wrong) that may be the driving force behind our industry and the unintended consequences of their ignorance in lack of leadership in the most complex and dangerous operational teams that explore and develop the fields of our future. Our industry’s developments have been lead by nations with cultural traits that innovate and take risks in the face of uncertainty and unknown “worst cases”, in exploring and developing the most accessible and cheapest to develop fields of the past using a “act and mitigate” mindset and yet do not lend themselves to key mindsets needed in order to explore and develop in the most complex and dangerous situations we will be facing more and more as these easier and cheaper to develop fields are depleted luxuries of the past. Examples of the “act and mitigate” mindset can be seen from the Spindletop Field, to the deepwater arena, where at Spindletop the wells were allowed to essentially “blow out” and then oil was contained within “berms” built around the derrick and the oil pool was collected and hauled away to sales. This of course would not meet any of the most lacking standards of today and yet it is still the model by which our industry has been “following” lagging standards of operation and the “act and mitigate” mindset. We also see most recently that our operations have been “act and mitigate” mindset following the recent discovery that even though industry experts had announced in industry technical articles that the danger of drilling in deepwater was the uncontrollable and prolonged blowout. How easily these warnings are ignored are a tribute to the explorer instinct and focus on the “act and mitigate” mindset that acts where other more “uncertainty adverse” mindsets do not, and this mindset should be applauded as a first step to commit to act facing uncertainty and is clearly an advantage to cultures that are adverse to explore because of the uncertainty. Yet we move above and beyond this mindset, to include the explorer spirit and subjugate it to the leadership spirit and mindset that uses the wisest leadership principles and looks to measure and manage leading indicators and apply this to themselves and their organizations that is the essence of the focus on the Precursors of Consequence. Even more so today we are looking at and developing lagging indicators and mitigations and this is the way of strong appetites for uncertainty that have defined the corporate cultures that have brought us here, and must be applauded, and yet will not get us there, to the future full of the most difficult, complex and dangerous projects. In the past we, as an industry, have for the most part skipped over projects involving the deepest of water locations and the sourest of oil and gas reserves with preference for the easier and cheaper alternatives and yet today we are faced with the need to explore and develop in these areas and the good news is we have the technology and the leaderships wisdom right before us and we merely need the discipline of process safety leadership to include them. In order to develop the healthiest of safety culture in the projects with the highest levels of interactive complexity and tightest coupling we must develop that highest levels of leadership, knowledge, understanding and wisdom and relegate our mitigation based safety programs to a lower tier in the safety pyramid. Leading indicators of consequence; "precursors of consequence" are simply the operational envelope as referred to in other industries. In the above Mach 1 flight operational industry this is referred to as the “flight envelope”. Our industry esteemed Dr. Andrew Hopkins cited in his recent article “Why Safety Cultures Don’t Work”, to an air traffic control term known as “maintaining separation". Its not “too simple” to conclude that “leading” means using leading indicators and following means focusing too much on lagging indicators and yet it is strongly asserted that they are exactly appropriately named and safety leadership must lead by prevention and leading indicators and move away from mitigation based safety programs. It’s a delicate balance that’s most important and yet prevention is a focus on the operational envelope that must balance a margin safely between loads and our resistance to them. It’s focusing on things right before us and akin to personal safety issues of how our fingers and toes are interacting with loads, and obstacles while we perform routine operations and yet first and foremost, in the realm of planning interactively complex and tightly coupled operations, and building and managing the teams that are executing them safely in real time. So many lagging indicators are being pursued, very well in fact (WCD designs, capping stacks maintained and ready for use, etc.), that they have become distractions in their simplicity and tendency to focus blame for the incidents on frontline company men and “bungling” in general by the “culprits” that the frontline worker become in the hearts and minds of the “in group” away from the frontline, in management. And mitigating their "failure to follow" (lagging errors) rather than addressing their own immediate shore based operational and engineering "leadership" becomes the norm and the frontline worker is viewed as a dangerous component of an otherwise perfect system rather than the reason their imperfect system works perfectly most of the time. This additional mitigational “arsenal” is a good thing, if companies continue to have these types of blowouts, yet not if they distract focus from "leading" indicators to "lagging" consequences, as this is foolish and dangerous of course. The fact that many asked to follow this logic and agree it is true will not, should only be a further sign of how detrimental the conclusions, of the US Department of Justice indictments of company men minus even the slightest implications of shore based leadership, has been to learning the true lessons needed to avoid the type organizational accidents in the future. Prevention based leadership is focus on our margins and remaining within operational boundaries and mitigation is always from drifting outside of them. We should not spin the fact that boundless operations and the myriad mitigations are safe simply because of low incidence because of the high cost and more importantly because it is not leadership. The fact is that the handling of the “mitigation” based investigation of the Macondo incident is bizarre and even schizophrenic because the US Justice system is pursuing indictments and fines that are aimed at BOTH the frontline workers and organizational causes yet not leadership and with neither the intent nor the diligence necessary to remove the veil of obscurity that engineering management hides comfortably behind in these weakest cultures while the government attorneys can only wish to bring cases against them and must instead go after the easier cases of prosecuting defenseless frontline workers left dangling before them by authories in the same corporation. Is the problem with the frontline worker (the followers), or the engineering management (the supposed leaders), and how can it be both? Even if it is a little of both how can this ambivalent focus be resolved in this way without careful examination of the leadership and procedural compliance aspects of the precursors to the accidents in a situational, instead of attributional scope? We may all wax poetic for “the day we can actually have accountability” in the leadership of the operations in the most individualistic cultures and even legislate attempts to hold key leaders accountable with signatures (Well Containment Plans must be signed by a manager now because of new rules in 30 CFR 250 Subpart D), and document courses of actions and responsibilities and yet until we can sort through this veil of obscurity of the inner workings of the precursors of consequence, that define true leadership, in creating and maintaining corporate culture we are managing by mitigation of our boundless lack of discipline in focus and efforts. This ambivalent opinion of the causes of this type accident is common in these type cultures that have a strong sense of individual responsibility and it is furthermore suggested that some cultures are more susceptible to this type of organizational leadership and communication failure than others, for example the more "individualistic" cultural trait as highlighted by Geert Hofstede, in his world renowned studies on culture and its implications on safety, and the "attributional" culture as highlighted by Dr. Carol Dweck of Stanford. It seems the highly "individualistic" cultures may have tendencies towards both "defects" and be highly prone to these types of organizational failures in leadership, learning, communication and effortful focus on the matter close at hand that are the precursors of consequence. Individualism tends towards challenges in true communication and coupled with low PDI can lead to further disparate silos of information, communication, and decentralization of organization command structure, again, cited by Dr. Hopkins as key to the recent organizational accidents in our industry. Also, the most individualistic cultures are more prone to the “unjust” culture as opposed to the “just” culture that examines accidents and incidents in light of the situation instead of moving too quickly and subjectively to blame of the “individual” (fundamental attribution error), responsible for procedural compliance of designs of engineering and operational leadership teams usually sitting in the ivory towers miles away from the dangers on the frontline. Unfortunately, blaming individuals for organizational failures has no effect other than to further polarize individuals from a sense of loyalty and duty to the group as a whole and further complicates communications, order, responsibility and the reliability of the group as a whole. Transparency and openness most necessary in the healthy function of teams of engineers, mechanics, technicians and operational team members is compromised by the very nature of the isolating and threatening nature of the way these cultures learn lessons, or rather, do not learn them. The 10 countries lowest in UAI in the world are western countries deeply involved in the oil business and the top three, UK, US, and Australia, comprised the organizational personnel involved in Macondo and Montaro. Low UAI in those countries has served those cultures well in terms of innovation and yet has dangerous implications if this cultural trait is not managed and is ignored by engineering operations management. Coupling the highly individualistic cultural traits with low Power Distance Indices (PDI in Hofstede's studies) can lead to a breakdown in supervision and guidance and sever the ties necessary for frontline workers to be encouraged to "stop work" and call in for guidance and support from engineering vital during the most complex operations. In fact some of the interesting discussion surrounding the spectrum of cultural traits in regards to PDI seem eerily close to the causes of organizational failure at Macondo by Professor Hopkins in his book and reports. For example low PDI can result in:

·  Expect to encounter less centralized and even de-centralized organizations, divisions, departments, teams and decision-making

·  Expect a high degree of delegation

·  Expect subordinates to take initiative

·  If unforeseen things happen, frontline workers are less inclined to first go to their direct boss to ask for instruction before acting

·  Expect your work to not be inspected by a team leader from a low PDI culture.

Probably the worst thing that could be added to a culture naturally laden with the issues described above would be a tendency to disregard uncertainty and yet if we look at both extremes of the spectrum of Hofstede’s Uncertainty Avoidance Index (UAI) we most certainly would expect a statement such as, “It will probably be okay”, to be immediately and diligently challenged and only be accepted in a culture of extremely low uncertainty avoidance and yet a careful look at Hofstede’s research shows the British culture of BP to be amongst the lowest UAI of all nations; bottom 6 in fact. Naturally some will claim the accident was the fault of American front line workers yet keep in mind that the US is in the bottom 12 in UAI also. So there really is nowhere to run and hide on this issue. Is it any wonder then, after learning of these facts of the national cultural traits of the UK that their Long Term Orientation (LTO) index is amongst the lowest (4th lowest value) in the world? Of course not since that combination of traits is not sustainable so it would make since that sustainability is not a high priority. The point isn’t to use cultural traits as condemnation and yet to measure the prevalent cultural traits that exist in order to prevent the mishaps that are bound to happen otherwise and put the onus on management and not frontline workers effectively carrying out orders. In light of these cultural facts BP’s management should definitely endeavor to recognize and aggressively balance this national cultural trait with preventative measures especially while working in a nation with equally low numbers on a certain cultural trait. The campaigns are in full gear and the platitudes abound with more safety slogans and assurances than ever before and yet if developing a safety culture is of prime importance truly Hofstede’s work in this area should be fresh and foremost in the minds of managers of the dangerous operations most in need of preventative measures that facilitate prevention based management.