Hazards Forum: Learning and Learning Systems
From 18:00 until 21:00
1 Birdcage Walk
Free to members
Learning from Experience – Barriers and Opportunities
“…Those who were operating…did not have knowledge of the dangers associated with loss of lean oil flow…Nor did those charged with supervision of the operations have the necessary knowledge…”
“…Key individuals…displayed lack of applied skills and knowledge and there was a lack of supervisory presence and oversight…”
The above where taken from the public domain official investigations into two major incidents, both resulting in loss of life and major plant damage, and both involving oil majors. The incidents whilst separated by 7 years had within their root causes worrying similar factors.
In 2015, 7 offshore workers were killed and 45 injured in an explosion and fire on an offshore hub platform. Investigations showed that remote platforms feeding hydrocarbons to the damaged platform failed to stop flow, significantly increasing the flammable inventory, and escalating the incident. In 1988, on the Piper Alpha platform, the tragic loss of 167 lives was without doubt escalated by the failure of other platforms to stop their flow of hydrocarbon to Piper Alpha.
Why do we continue to see the same root causes with incidents, with the examples above all within the same oil & gas sector and in both cases the first incident received global publicity and benefit from a high quality public investigation?
In this Hazards Forum event – sponsored by the IChemE, we have the pleasure of three esteemed speakers, who will consider this question of our apparent inability to learn, but more importantly offer solutions from different but complementing perspectives.
Dr Nancy Leveson will recognise that we could learn so much more from events if we were willing to change practices that inhibit such learning. In her presentation she will describe the inhibitors to learning and how a systems approach to accident analysis could greatly enhance the learning process.
Faith Wainwright, will consider the challenges of how an organisation can create a sustained learning culture. Using Arup as a case study, Faith will discuss the cultural and organizational aspects of fostering a connected organization where colleagues freely share their expertise, and how communities of practice generate both the vision for future capabilities and the infrastructure for capturing and re-using knowledge gained particularly lessons learned. The talk will provide insights into the tangible benefit and some of the challenges of managing the rather intangible concept of communities, from her experience in leading Arup’s Skills Networks.
Robert Robinson, will consider the question from the perspective of the Oil & Gas Insurance sector, with examples of major incidents presented where the lessons were not learned and the same mistakes subsequently repeated elsewhere at great cost. Suggestions are to be given as to what might have been the barriers to the lessons being learned, and what could be done to reduce the risk of being condemned to repeat the failures of the past.
The evening will conclude with a drinks reception staring at 19:30 which is open to all attendees.