Tim Bannerman's Theatre Chronicles – Part 9: “It couldn’t happen here”
Dark shape in the mist. Ships in front. Now the flare, like the nostrils of the dragon – and the beast itself in three parts, clear and close now.
Down we go. NUIs to the left. The flare gouting flame and we’re just above now. And down. Onto the platform, perched just above on a tiny space just large enough for the chopper.
Down steel stairs with wobbly handrail. Sheer drop to the sea on the right. “Trailing handrail” technique, using both hands.
“Always follow the green”, they said. So I follow the green, as do the others, as we make our way first to our allocated lifeboat – Number 4 of four, enough for a total of 126 people, more than needed – and then to the obligatory Induction and Safety Briefing.
“Piper Alpha” – never forget. Trust, Confidence, Empowerment and Zero Tolerance – key words to ensure the Safety Culture achieves the mantra: “All accidents are preventable”.
Zero Accidents – the goal. “Safety begins with you”. From the top down and the bottom up.
During the induction, I am acutely aware that I am sitting on a bomb. A huge bomb, comprised of extremely flammable and toxic gas. If the explosion and the subsequent fire doesn’t kill you, the hydrogen sulphide (H2S) or “sour gas” will. If you can smell it, it’s too late. If you hear the H2S alarm, “do not inhale – proceed up wind” – er, which way is the wind blowing? 100 parts per million is all it takes. It is everywhere, in the pipes that are all around you. It is an old platform. They have been known to leak. Hence – “keep it in the pipes!”.
Coveralls, gloves, safety shoes, hard hat, ear plugs – “at all times”. Sleeves not rolled up. Trousers outside boots. Green helmets for visitors like me. Why?
Because I am one of the biggest safety risks on board. Because I don’t know what I don’t know. Which is almost everything.
“All injuries and near misses to be reported, no matter how slight.” Work permit required for all work – red for hot, blue for cold, yellow for confined spaces.
“Do not wander about. Always hold the handrail. Life jackets to be worn outside.”
Smoking strictly restricted. Smoking?! Only 2 people in smoking room at any one time. No jewellery – in case of sparks. “Anyone is empowered to intervene”.
“Your family and friends are waiting for your safe return”.
I, like my colleague before me, was escorted everywhere on my time on the platform. Our job was to meet, talk to people who worked there, from the OIM (Offshore Installation Manager), the toughest seat of all and where the buck stops off-shore, to a whole range of people – engineers, caterers, assistant managers, radio operators, safety specialists, old hands, new hands.
New hands. People like Asseem. Young Asseem who had just started his life off-shore. People who knew, who had worked with Asseem. Asseem who is not there to work with any longer. Asseem whose family and friends are still waiting for his safe return, five years on. Asseem, for whom someone did not intervene, with whom safety did not begin, for whom those Big Words:
TRUST, CONFIDENCE, EMPOWERMENT, ZERO TOLERANCE
- did not prevent his death.
Why?
A psychology professor called James Reason, one of the most respected exponents of safety theory, describes the challenge of keeping people and environments safe in worlds of major accident hazard, as being as if one was protected by slices of “Swiss Cheese”. By which he means that the barriers we put in place to stop things going wrong have holes in them – the risk being that either they are not perfect from the outset and/or suffer from constant risk of damage or deterioration. And one day, the risk is that the barriers designed to protect you from the many potential hazards to Plant (as in structure, or place of work), Process and People – chemical, mechanical, structural, natural, meteorological, environmental, design, cultural, political, behavioural, environmental, actual or latent – will all fail simultaneously, triggered by some unexpected event, causing at best, harm, at worst catastrophe.
For the fact is that no matter how well we may think we have implemented our safety procedures, protected people personally, designed effective engineering solutions, monitored and maintained equipment, improved the way we train the people who operate the machines, learned from things that have gone wrong in the past, created a culture of vigilance, awareness and challenge, and so on and so on – accidents can still happen, and do.
This is because all these measures we have put in place are subject to constant change, either through human intervention – people make mistakes – or through technical failure caused by any number of the factors listed above. In other words, the holes in the cheese are constantly opening or reopening, shifting, changing, which is why you can never, ever, sit back and think – well, that’s all right. Nothing can go wrong now.
Translate this to a processing platform in the middle of the ocean, with all the hazards and the risk of catastrophe you live with as a constant threat, and there are vast numbers of slices of cheese with an even more vast number of potential holes. For all the best intentions, “well-intended actions can have unexpected consequences” – that’s what they say.
So there I was one day, at a meeting with the top brass at HQ, contributing to a discussion about safety strategy and next steps to build on the work we had been doing to help them to date. We had been discussing a recent incident and looking back at some of the disasters that had occurred elsewhere, when someone said:
“It couldn’t happen here.”
That’s what he said, the man at the boardroom table, a director of a major company, in front of the Chief Executive, many of the Board, the Head of Safety and me. He was referring to the likelihood of a major incident of the kind we’d discussed – in their company, their assets around the world. I was there. I heard him. I’d been there. I’d seen them. And this man said, holding the responsibility, accountable, with his executive colleagues, for the safety of everyone in his care:
“It couldn’t happen here.”
There was silence in the room after this statement. Unsurprisingly. I think it was probably the single most frightening thing I heard anyone say at that level in any of the organisations we worked for over the 15 years or more of working in safety in major hazard environments.
To their credit, more than one voice came back after the silence, in which embarrassment played the biggest part, to say that this was not necessarily the wisest thing to say in their business, whatever improvements may have been made over recent years. This was particularly in view of, often, aging assets that needed permanent vigilance to manage the constant deterioration, not least where corrosion was concerned, in all elements of this potentially lethal process.
This was not so many years after the death of Aseem, not so long after Deepwater Horizon, and just after, just before, innumerable fatal accidents in their field of major hazard, let alone elsewhere, whatever, wherever, to whomsoever it was or may be to come. Because it can happen to anyone, anywhere, any time, and the worst thing you can do is to persuade yourself you’ve covered all the bases. It is the opposite of “Chronic Unease”.
And then there are the “Near Misses”. What of them?
These “near misses” were stories that, in whatever field of work we found ourselves, be it construction, air travel, shipping, oil and gas, railways, transport of all kinds, precision engineering and, yes, nuclear – made your hair stand on end. If, in this given story, something had happened slightly differently, very, very slightly in many cases, there would almost certainly have been multiple casualties, deaths and serious injury, let alone the often life-long trauma to those who survived or witnessed it. By sheer luck, it hadn’t. Hence – “Near Miss”.
These were the stories that we heard at almost every workshop where, progressively, we encouraged, coaxed people to share their experiences, so that they could all understand what the reality was in their world. This was the critical thing: Reality. Not just the rhetoric that came, whatever the best intentions, from the mouths of those who called the shots. This is why the conversations between participants, in small groups and then shared in the room, were such a key part of the process. Many people, particularly in mixed workshops, bringing, say middle-management Finance, Support and Operations together, sometimes for the first time, or Executive and Frontline, were shocked to hear a different reality from that which was painted from the statistics.
I still carry a vivid memory of someone coming up to me after a workshop which ended with a celebration, orchestrated by the senior executive presiding, of how brilliantly they had all done and how they should congratulate themselves on their safety record and the improvements that had been made. I noticed at the time that not everyone joined in the dutiful applause.
“It’s all bollocks,” he said, the young man who had approached me afterwards. “They’re kidding themselves. I’ve seen things which would make your hair stand on end. And they do nothing about it.”
“Why didn’t you say something?” I asked him. “We asked you, all of you, to tell us what the reality is, what’s really going on under the surface. You had your chance. People need to know.”
“What did you expect?” he answered. “In front of him? You must be joking. Heard of NRB, haven’t you?”
“Not Required Back – yes, of course I have. But…”
“Don’t say anything,” he said. “It won’t change anything anyway. What’s the point? All they care about is the bottom line.”
So, no, sometimes the stories didn’t come out. Particularly when “the boss” was present. But when they did, and it took considerable courage sometimes, yes, my hair did stand on end.
With that in mind, in addition to the truly tragic events that we all know about and those well known within the industries concerned, we wrote about them, these near misses, with the encouragement of some brave, enlightened people who believed passionately that these stories could help people learn and, above all, avoid the crass and far more dangerous belief that: “It couldn’t happen here.”
The reason I and my colleague went through the hell of the Helicopter Underwater Escape Training and found ourselves out on a platform in the middle of the Arabian Sea, was thanks to one of those brave, enlightened people.
Mark, who is still a good friend and enjoys a fine ale, or an even finer glass of proper, traditionally-made cider, is someone I met way back in 2005, not long after our resident creative genius wrote a story about a man being pulled through a 12” hole, or “mousehole”, in what is known as a man riding incident.
He was on the end of a line, being winched up towards the hole. But instead of stopping as he should have done to do a simple job, or not doing it at all, a series of failures – shortage of people, radio not charged, slipping harness, bullying culture, poor procedure, the list goes on – meant the winch kept pulling him up. Though the hole. As it says in our play: “His spine was pulled through his body.”
The story had come out while we were working with Brian up in Aberdeen, at an early stage in our journey into safety training some years before.
It happened in October 2000 when a man called Gordon Moffat, an assistant derrick-man on a Global Santa Fe rig out in the Franklin Field off-shore of Aberdeen, was dragged to his death through this mousehole because of a series of failures, including the above, revealed in the subsequent investigation.
I was up in Aberdeen after a workshop with Brian, the man who’d given us our first break in safety back in 1998, when he told the appalling story of how Gordon Moffat died. We had been discussing how root cause analysis, tracking back from the accident to investigate the causes, would be an interesting way of structuring our dramatisations of how accidents occurred.
Like many things, they have their moment when they rise to the surface and it was not until four years later that my colleague suggested that this would make a compelling, if not shocking means of engaging people’s attention for a new opportunity that had arisen.
Through connections of connections, from an earlier safety-related relationship, I had just met an extraordinary person who had an approach to safety unlike anyone else I’d ever met. An intensely emotional and driven man, he told me some deeply personal things about his life up that point, in a way that I realised quickly was a key part of how he worked with everyone, including large gatherings of frontline folk who were “up to here” with what they called “safety bollocks” being thrown at them on a daily basis.
He knew that he had to break through that “safety bollocks” barrier if he was ever going to reach the “hearts and minds” of the sea of faces sitting in front of him. There was life and death at stake. We had to look at what he called “The Big Hurt” in the face. So he bared his soul in ways I can’t think of anyone else I know has done, before or since.
More than that, if you worked with him, as I soon found out, he would not tolerate a single second of distraction from our joint purpose of reaching those hearts and minds. I was called out more than once for not being “in the room” every second of that session – and he missed nothing – watching and listening to every flicker of reaction, or lack of it, from every single person in that space.
Between him and Brian before him, let alone the other facilitators I had worked with before and since that time, Graham and Tom in particular, I learned what it is to be a facilitator, for all my personal flaws and failures along the way. They gave me the bar to aspire to. It was very high and I spent my professional working life reaching for it, some times more successfully than others.
And it was the “Big Hurt” man who helped us make the leap from our first, early flowering with Brian in this world of safety training. He personally took the risk of using us as his key engagement tool for his vast global organisation in what he called “Advanced Safety Leadership” and “Personal Responsibility for Safety”. Suddenly we found ourselves in the mainstream and it was the story of “Mousehole” that was the jewel in our crown.
It was this same story, performed by two actors, with the facilitator playing the role of a psychologist in the shocking opening scene, as we heard what had happened from a first-hand and deeply traumatised witness of the event, that caught the attention of Mark. He picked it up at a conference where we performed and engaged our audience with what had happened and then took them back in time to show the different factors, cultural, behavioural and technical, that had led to the assistant derrick man’s death. He loved the way we would stop after each scene, as we tracked from some weeks before towards the fatal moment, asking our participants to discuss what they felt and thought about what they’d seen. And even more, how we gave the opportunity and hands-on responsibility to those participants to create a different outcome through engaging directly, in real time, with our protagonists, while bringing home the fact that, in real life, no-one had intervened and, as a consequence, a man died.
We had two weeks from that first meeting to come up with something that would address the “Big Hurt” in a new and unforgettable way. It took my colleague half an hour to write the opening scene in an extraordinary burst of inspiration at the end of a long day. As soon as I read it, I realised that this was something uniquely special, for all the risk of hanging our hat on this leap of faith. It was worth it. 15 years on, it still casts its spell on all who experience it.
When we performed the opening scene of Mousehole for the very first time to Douglas and two of his colleagues, one of them said: “You can’t do this. It’s too hard. Too much, too close. You can’t do it.” It took some careful diplomacy to find a way through the deeply emotional response to what they’d just experienced and persuade them that this was what they needed to bring home the “Big Hurt”. But we did and many thousands of people over the ensuing years still remember vividly what they saw, heard and felt as they travelled through this visceral story in graphic detail – both its horror and, believe it or not, the humour too, from their interactions with the protagonists in the drama.
After his initial baptism, Mark then took us with him on his own journey from one company to another and with whom we travelled from around the UK to India, Kazakhstan, Australia, Egypt, wherever his company had assets that could benefit from our interventions. This included developing a programme with him that ran for many, many years in one of the strangest places in the British Isles, a remote site under tight security which is perhaps the only place where you can witness at first-hand the shockwaves of an explosion, see them actually coming towards you, well before the bang, without being in danger for your life.
Much more dangerous was the “Breakfast Creek Hotel”, known to aficionados as the “Brekky Creek”, near Brisbane in Queensland, Australia. Mark introduced me to its iconic delights – not least to a connoisseur of the best steaks in Australia and “tank beer”, an unpasteurised and unfiltered version of the “amber liquid” that guarantees a unique freshness “as good as drinking it in the brewery itself”.
The major hazard in this case was not so much the wonderful food and drink but the company of a dead ringer for “Captain Hurricane”, if you remember him from the Valiant comics of the ‘60s and ‘70s, in the form of an ex-Special Services Safety specialist in the Australian asset we were working with.
A delightful man, as gentle as a lamb despite many years “being shot at”, as he said, we saw a different side when he cut through what he saw as a “couldn’t happen here” moment in one of our workshops, with the comment:
“What I’ve seen here is way more frightening than what I saw in Afghanistan.”
And he meant it too. The whole mood changed in the room and that’s when we really got down to the business of the reality at work here.
In “Brekky Creek”, however, the workshop done and dusted, all that fell away. The tank beer glasses mounted up and the stories came tumbling out, funny ones this time, and we laughed as you can only laugh after a long, hard haul.
I forget when the real difference between a true Ozzie and a Pommy bastard showed its colours but the phrase “hollow legs” has never loomed so large in my rapidly diminishing consciousness as the evening progressed. Mine just weren’t hollow enough, it seemed. But then, we had finished the gig and it was the end of a tough few weeks for me that had worked its way across continents to this last stop before going home. A series of long, hard, but, we hoped, successful days. A good job done, we thought. And, who knows, a few lives saved along the way.
It took another occasion, with a different organisation in a different world altogether, this time in South Africa, for me to realise that the worst thing I could do was to think: well, that’s all right. Another few lives saved. Another version, if you like of: “It couldn’t happen here.”
Sometimes, as I found out, fiction can tell the future.
