There is a saying in the military that you ‘get what you inspect.’ In other words, unless you are constantly inspecting and testing and questioning, people will not carry out the tasks assigned and ‘things will go wrong.’ It is often associated with draconian leadership and ‘Theory X’ management, pooh-poohed by business schools around the world.
But, while the MBAs may not like it, the system has worked fairly well in both the maintenance and readiness of US nuclear weapons, and the safety record of the Navy’s nuclear powered ships and submarines. The two figures most responsible for establishing the control regimes around both US nuclear weapons and the Navy’s nuclear reactors are never mentioned when discussing modern management theory: General Curtis Lemay and Admiral Hyman Rickover. But their success speaks for itself.
That success was and is predicated on a clear understanding on their part that what they were doing was engaging not in risk management but in consequence management, the simple thought that the outcome of an event, not the probability of the event, should drive your planning considerations. Because the failure to be ready to wage war might lead the Soviets to consider attacking the US or its allies, Lemay developed a readiness program for the Strategic Air Command that was without parallel in history. This program was expensive and difficult. It required frequent and painful inspections. It was neither friendly nor polite. It was exacting, demanding and often professionally painful. But it worked. Further, in a setting where the consequences of any mistake were (and are) potential dire, does anyone really want to experiment with any other form of management or leadership? It is worth noting that Rickover’s style was no less extreme – and the record of safety on US submarines and around the Navy’s nuclear reactors spotless.
What this has to do with the Deepwater Horizon incident? Simply this: the inspection regime that was and is in place to monitor operations on these rig failed. Why it failed has yet to be definitively determined, but it is certain that it failed. While there is some discussion about how many inspections did or did not take place over the past five years, what is certain is that the inspections failed to either detect or correct the problems on the rig.
Is offshore oil exploration and production simply too risky? No, certainly not. The fact that these operations take place on hundreds of rigs, with thousands of wells in production, is ample proof that operations can be conducted safely. But, with no pun intended, safe operations are no accident. More to the point, safe operations are no mishap. Incidents such as what happened on the Deepwater Horizon last month are not acts of bad luck or the result of some evil spirit; they are the result of failures in maintenance, in operations (and training), in material – both in design and construction, and they are the result of failures in leadership.
It is likely (almost to a certainty) that the incident is not the result of the failure of a single device or a single person, but of several devices and monitoring procedures, meaning that the sequence of events is going to be a complex inter-relationship of devices, installations, maintenance plans, monitoring plans, training plans, and response plans. Mishaps don’t just happen, mishaps are the result of mistakes, omissions, and poor decisions. And, and this is the important point, mishaps can be prevented.
(Note: the US Air Force (AF 11-202 and DASH-1) and US Navy (NATOPS) have detailed procedures in place to ensure mishap rates are as low as possible. This is done without stifling either leadership or creativity and has produced the finest pilots and finest Air Force and Naval Air arm in the world.)
Mishaps are prevented when there is a confluence of several things:
- Training – people properly trained in the maintenance and operation of the systems involved, as well as in safety procedures in the event of a mishap. Training must be comprehensive and continual.
- Maintenance – equipment regularly inspected, maintained, repaired and replaced at rates well within the failure margins for each piece of gear and for the entire system. Preventative Maintenance, and corrosion control, must become the cornerstone of long-term, sustained operations.
- Parts Support – Parts support is the obverse of maintenance, making the requisite investment to insure that the right parts are used, and replaced, and refusing to cut corners to save pennies in the near term, when doing so may well cost a fortune in the long term.
- Leadership – Leadership provides the ‘thread’ that ties together training, maintenance and parts support. Sound leadership, with a focus on long-term success, will integrate these three components into the daily fabric of the organization, recognizing that the cost of preventing a mishap is never as large as the mishap.
And to ensure that there is adequate training, maintenance, parts support and leadership - particularly in an environment where mistakes and shortfalls can lead to such extreme consequences as we see unfolding in the Gulf right now, there needs to be aggressive and exacting inspections. Inspections should consist of the following (similar procedures may already be ‘on the books’ but, whether they are or aren’t, these steps weren’t in fact taken):
- Regular, comprehensive, frequent inspections: a small team of inspectors spends a full day on a rig and probes every major facet of the rig’s operation. As MMS recommends, these inspections should be carried out monthly. If MMS needs to hire more inspectors, then do so.
- No Notice inspections – every rig should be subject to at least two per year, and they should be truly ‘no notice.’
- A training and readiness certification process for every worker on every rig that requires both practical demonstrations and written knowledge of safety and operating procedures, at least yearly.
- Authority to suspend operations. The inspection team must have an unadulterated authority to suspend operations if they find an unsafe situation or a serious violation of procedures.
Consequence Management, not Risk Management
Central to successful thinking in any type of long-term, mishap free operation is recognizing the difference between Risk Management and Consequence Management. Intellectually, Risk Management focuses on input, on minimizing the probability of given events (parts failure, systems failure, etc.), thereby ostensibly providing safe operations. Consequence Management focuses on the fall-out of such an event and then plans backwards to minimize both the likelihood of such an event occurring as well as constructing plans that will allow minimizing the consequences, the impact, if such an event takes place. Consequence management will also identify those activities that simply are too costly to deal with and should therefore be avoided, replaced with other activities that are more easily managed.
Consequence Management, therefore, if executed properly, allows for addressing a situation so as to maximize long-term benefits while ensuring a plan is in place that will reduce to a manageable level the effects of any mishap.
But Consequence Management, as with the maintenance, training and support programs that constitute the principle elements of any sound mishap prevention effort, requires one overriding element: good leadership. Consequence Management is simply another element of a comprehensive strategic plan, and the right leadership will provide sound Consequence Management because it will develop comprehensive strategic plans.
The oil slick in the Gulf of Mexico is not a failure of the technology of the offshore industry, nor is it a failure in the processes and training available to the workers in the offshore industry, nor is it an indictment of the people on that rig. In the end, the failure of the BOP and the resulting oil slick in the Gulf of Mexico was caused by a failure of leadership; fixing the problem will require fixing that leadership. The lesson that any company can learn from that failure is that long-term growth requires leadership and planning, and every company, every organization needs to renew its commitment to developing that leadership and those plans today.
Additionally, in an industry where mishaps carry with them consequences as severe as does the offshore oil industry, leadership must be supported by aggressive and demanding inspections. Inspections, if conducted properly, will identify shortfalls in training and material before they become critical, and before several shortcomings are compounded into a catastrophe like the one that killed 11 men and is now spilling oil in the Gulf of Mexico.
Do we need new regulations? No. What we need is new leadership at MMS and a focus on Consequence Management.
No comments:
Post a Comment