Creating management line of sight
APOSHO
November 2011
... the installation of
a proper system to
provide against the
commission of
such offenses and
the provision of
adequate
supervision to see
that the system was
properly carried out
...
BP Texas City
Freehills 31
7052655
BP Texas City
The Panel recognizes that Browne is a very visible chief executive officer.
Browne is generally noted for his leadership in various areas, including reducing
carbon dioxide emissions and developing the use of alternative fuels. During the
last eight years, Browne has spoken frequently on these issues across the
globe. In 2005, The Financial Times named him the fifth most respected
business leader in the world. Browne’s passion and commitment for climate
change is particularly apparent. In hindsight, the Panel believes that if Browne
had demonstrated comparable leadership on and commitment to process safety,
that leadership and commitment would likely have resulted in a higher level of
process safety performance in BP’s U.S. refineries. As observed in the 2003
Conference Board report on best practices in corporate safety and health, “[i]f
the top executive believes in the worth of the strategies, sets expectations for
other managers, follows through on those expectations, and commits
appropriate resources, shared beliefs, norms, and practices will evolve.”
... did not come within a ‘bulls roar’
of sensible oilfield practice ....
company’s systems and processes
were so deficient and its key
personnel so lacking in basic
competence ...
Beyond your comprehension that [well
control] might be compromised ...
...leisurely approach by senior
management ...
... insufficiently vigilant ...
Q. ... the CEO didn't properly inform
himself of the nature and extent of the
project manager's supervision of the
affairs of the well construction
department?
A. It would appear so, yes.
... most of the mistakes and
oversights at Macondo can be
traced back to a single
overarching failure— a failure
of management ...
The best minds in the senior
leadership of a company should
be paying close attention to those
risks. But it didn't happen here.
And now we are all paying the
consequences because those of
you at the top don't seem to have
a clue about what was going on on
this rig.
Aspirations
Systems
hazards
risks
&
controls
Includes ‘legal’
hazards & risks
Quality
&
Effectiveness
Culture
Workforce perception
of
management commitment
Effective
Participation
Minimum
expectations
of Courts
1. Know obligations & risks.
2. Have a process that brings
systems failures to your
attention.
3. Respond personally and in
a timely manner to systems
failures.
4. Independently verify from
time to time.
1. Planning.
Safety a demonstrable part of business decisions
2. Active monitoring.
Safety tours
Talking with employees
3. Reactive monitoring.
Safety investigations
Sign off on incidents
Management review panels/committees
4. Visibility.
Committees (in addition to the above)
1. Know obligations & risks.
2. Have a process that brings
systems failures to your
attention.
3. Respond personally and in
a timely manner to systems
failures.
4. Independently verify from
time to time.
1. Planning.
Safety a demonstrable part of business decisions
2. Active monitoring.
Safety tours
Talking with employees
3. Reactive monitoring.
Safety investigations
Sign off on incidents
Management review panels/committees
4. Visibility.
Committees (in addition to the above)
Defendable
decision making
Defendable decision making
• BP Texas City
• Lord John-Browne
• Gulf of Mexico
• Tony Hayward
• John Guide
• Brett Coacles
• Montara
• Craig Duncan
• Andy Jacob
Why do systems fail?
Systemic
Markers
Incident investigations
Audits
KPIs
Reporting
“Walk arounds”
Feedback
Loops
You
Critical:
Processes
Activities
Hazards
Controls
Warning
Signs
Budget/schedule slippage
Org change
Key personnel change
“No news”
Success
Individual Work
Practices
“Errors” 16 – 20 April 2010
2007:
Budget cuts
Incentive schemes
Strategic presentation
2009:
World’s deepest well
31 March 2010:
Only 6 centralizers available
15 April 2010
“Wrong” centralizers
$1M a day, 6 weeks behind schedule, $58M over budget
18 Hour turn around