Tuesday, November 9, 2010

Human Beings . . . Conscious Decisions

In a  New York Times article* dated November 8, 2010, there was a headline to the effect that Fred Bartlit, the independent investigator for the presidential panel on the BP oil rig disaster earlier this year had not found that “cost trumped safety” in decisions leading up to the accident.  The article noted that this finding contradicted determinations by other investigators including those sponsored by Congress.  We had previously posted on this subject, including taking notice of the earlier findings of cost trade-offs, and wanted to weigh in based on this new information.

First we should acknowledge that we have no independent knowledge of the facts associated with the blowout and are simply reacting to the published findings of current investigations.  In our prior posts we had posited that cost pressures could be part of the equation in the leadup to the spill.  On June 8, 2010 we observed:

“...it is clear that the environment leading up to the blowout included fairly significant schedule and cost pressures. What is not clear at this time is to what extent those business pressures contributed to the outcome. There are numerous cited instances where best practices were not followed and concerns or recommendations for prudent actions were brushed aside. One wishes the reporters had pursued this issue in more depth to find out ‘Why?’ ”

And we recall one of the initial observations made by an OSHA official shortly after the accident as detailed in our April 26, 2010 post:

“In the words of an OSHA official BP still has a ‘serious, systemic safety problem’ across the company.”

So it appears we have been cautious in reaching any conclusions about BP’s safety management.  That said, we do want to put into context the finding by Mr. Bartlit.  First we would note that he is, by profession, a trial lawyer and may be both approaching the issue and articulating his finding with a decidedly legal focus.  The specific quotes attributed to him are as follows:

“. . . we have not found a situation where we can say a man had a choice between safety and dollars and put his money on dollars” and “To date we have not seen a single instance where a human being made a conscious decision to favor dollars over safety,...”

It is not surprising that a lawyer would focus on culpability in terms of individual actions.  When things go wrong, most industries, nuclear included, look to assign blame to individuals and move on.  It is also worth noting that the investigator emphasized that no one had made a “conscious” decision to favor cost over safety.  We think it is important to keep in mind that safety management and failures of safety decision making may or may not involve conscious decisions.  As we have stated many times in other posts, safety can be undermined through very subtle mechanisms such that even those involved may not appreciate the effects, e.g., the normalization of deviance.  Finally we think the OSHA investigator may have been closer to the truth with his observation about “systemic” safety problems.  It may be that Mr. Bartlit, and other investigators, will be found to have suffered from what is termed “attribution error” where simple explanations and causes are favored and the more complex system-based dynamics are not fully assessed or understood in the effort to answer “Why?”  

* J.M. Broder, "Investigator Finds No Evidence That BP Took Shortcuts to Save Money," New York Times (Nov 8, 2010).

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