Mindfulness and paying attention to the wrong things
As I talked about in a previous post on the Deepwater Horizon disaster, I believe one of the underlying reasons, perhaps the reason, for Deepwater’s problems escalating to into a catastrophe was the attentional blindness of management to the indicators of problems on the rig, and that this blindness was due in large part to a corporate focus on individual worker injury rates at the expense of thinking about those rare but catastrophic risks that James Reason calls organisational accidents. And, in a coincidence to end all coincidences there was actually a high level management team visiting just prior to the disaster to congratulate the crew as to their seven years of injury free operations.
So it was kind of interesting to read in James Reason’s latest work ‘A Life in Error‘ his conclusion that the road to epic organisational accidents, is paved with declining or low Lost Time Injury Frequency Rates (LTIFR). He goes on to give the following examples in support:
- Westray mining disaster (1992), Canada. 26 miners died, but the company had received an award for reducing the LTIFR,
- Moura mining disaster (1994), Queensland. 11 miners died. The company had halved its LTIFR in the four years preceding the accident.
- Longford gas plant explosion (1998), Victoria. Two died, eight injured. Safety was directed to reducing LTIFR rather than identifying and fixing the major hazards of un-repaired equipment.
- Texas City explosion (2005), Texas. The Independent Safety Review panel identified that BP relied on injury rates to evaluate safety performance.
As Reason concludes, the causes of accidents that result in a direct (and individual injury) are very different to those that result in what he calls an organisational accident, that is one that is both rare and truly catastrophic. Therefore data gathered on LTIFR tells you nothing about the likelihood of such a catastrophic event, and as it turns out can be quite misleading. My belief is that not only is such data misleading, it’s salience actively channelises management attention, thereby ensuring the organisation is effectively unable to see the indications of impending disaster.
So if you see an organisation whose operations can go catastrophically wrong, but all you hear from management is proud pronouncements as to how they’re reducing their loss time injury rate then you might want to consider maintaining a safe, perhaps very safe, distance.
Reason’s A Life in Error is an excellent read by the way, I give if four omitted critical procedural steps out of five. :)