Safety Moment #38: Memories

Memories of process safety incidents

Piper Alpha Monument

Many of our Safety Moments stress the value of learning from incidents — large and small. Some of the larger incidents become part of the mental furniture of those of us who work in the process safety business. But we need to recognize that events that are part of our background are “just history” to younger people. (The same idea lies behind Safety Moment #31: The 26-Year Old HAZOP — topics that seem fresh and interesting to those that have been in the business for many years are actually quite old, and maybe they are stale.)

For the sake of argument, let’s say that a person has no internalized memory of events that occurred before they were eighteen years old. They do not have an answer to the question, “Do you remember where you were when you heard about ___?”

The Table below shows some major events, and how old one (in the year 2018) for them to have been internalized.

Event Year Age to be Aware
Bhopal 1984 52
Piper Alpha 1988 48
9/11 2001 35
Deepwater Horizon/Macondo 2010 26

Therefore, anyone who recalls the occurrence of the Bhopal event and the emotions and feelings that it created, is likely now to be at least thinking about retirement. For younger people Bhopal is just something that they read about.

This lack of personal memory matters because safety is an emotional subject — someone is not likely to feel all that much passion about an event that they just read about or are hear about in meetings and presentations.

So how do we keep not just the lessons learned from these events, but also their emotional impact, front and center? There is no easy answer to this question. However, three approaches that can be considered are:

  1. Ensure that the facts of these catastrophes are known to all and that they do not drift into oblivion.
  2. Use these events as a foundation for analyses, standards and regulations.
  3. Write stories based on what happened and on the personal and emotional consequences.

The first approach — simply maintaining an awareness of the facts of the events — is done through the books, web pages, papers at conferences and articles. A description of these catastrophes can also be made part of the increasing number of higher education courses that incorporate the topic of process safety management.

The second approach — the analysis of catastrophic events as the basis for analysis and lessons learned — is widely used. If, for example, it is found that improperly managed change is a factor that crops up in the analyses, then the Management of Change element of process safety programs can be improved.

Similarly, these events often trigger the writing of new standards and regulations. The SEMS (Safety and Environmental Management Systems) rule that was published following the Deepwater Horizon explosion is an example, as is the formation of the Center for Chemical Process Safety following the Bhopal catastrophe.

The third approach — the writing of stories — is an important theme that has been discussed elsewhere at this site. One of the reasons for the success that Trevor Kletz had as a leader in process safety was that he was a fine story teller, as discussed in That Would Be Telling. J.A. Turley’s book The Simple Truth is a semi-fictional book written about the Deepwater Horizon explosion that follows the same approach.

It is important to distinguish between a story and a simple narration of an event. The article Once Upon A Time notes that a story generally has the following structure:

  • Characters
  • Siting
  • Plot
  • Conflict
  • Resolution

It is the nature of the plot, the presence of conflict and the resolution of that conflict that makes a story fundamentally different from a simple, what-happened narrative.

Of the three methods of communicating memories probably the best is story-telling. However, this is difficult. Most engineers and technical types do not possess the skills or interest in writing stories. Moreover, the writing of a story is time-consuming and requires considerable effort. It is easier simply to narrate what happened. 

Copyright © Ian Sutton. 2018. All Rights Reserved.