1. Learning from other industries
The pipeline industry is very good at reporting failure causes (‘corrosion’, ‘external interference’, etc.), but it does not have the same data on ‘root causes’. A ‘root cause’ of a failure is the factor(s) that when we fix it, the problem goes away and does not come back: we are not interested simply in the failure ‘symptoms’.
Other industries are reporting root causes of failures that are of interest to the pipeline industry, and they give an insight into what the pipeline industry may have to deal with in the future.
1.1 The aircraft industry
NASA and the Department of Transportation in the USA report human error as being responsible for 60% to 80% of aviation accidents [2, 3]. Data from Boeing support these data, and show how accident causes have changed in aviation history, Figure 1.
The same Boeing report emphasised culture, working environment, supervision, and personal character: ‘A contributing factor [to air accidents] is anything that can affect how the maintenance technician or inspector does his or her job, including:
- the technician’s own characteristics;
- the immediate work environment;
- the type and manner of work supervision; and,
- the nature of the organization for which he or she works.’
The aviation industry has seen huge improvements in safety due to :
- improvements in air traffic control; and,
- pilot training.
The industry uses competency-based training, and assessment is based on ‘competency standards’ .
|Figure 1. Causes of Commercial Aircraft Accidents.|
We are seeing a rise in ‘failures’ due to human error in medicine. Figure 2 shows data from the USA, and ‘medical error’ is now the third cause of death in USA . This human error is not confined to the medical profession: ‘It is estimated that up to 80% of accidents may be attributed, at least in part, to the actions or omissions of people’ .
|Figure 2. Major Causes of Death in USA (2013 data – John Hopkins University).|
The Texas City Refinery Report blamed the culture of the organisation on the 2007 deadly failure . Poor organisation was the number one cause of the disaster : ‘… managers and executives… were largely focussed on personal safety – such as slips, trips, falls, and vehicle accidents – rather than on improving process safety performance, which continued to deteriorate…’.
Clearly, management should not focus much of their risk management effort on low consequence, high frequency events, (e.g., minor injuries caused by people tripping over), but much more effort needs to be allocated to lower frequency, high consequence events (e.g., large releases of hazardous chemicals).
1.4 US Navy
‘Near misses’, or poor practices, should never be ignored. Data from the U.S. Navy show that the contributing factors to low-cost/no-injury events were the same contributing factors that caused high-cost/personal-injury events; therefore, addressing the contributing factors to lower-level events can prevent higher-level events .
1.5 Hazardous industries
A review of past major incidents in hazardous industries indicates that the lack of certain skills or knowledge has contributed to the incident. In each case, it had been assumed that an individual with a certain level of experience or training would be competent .
1.6 Nuclear industry
The nuclear industry emphasises the link between human performance and nuclear safety , and uses competency assessments for:
- employee selection;
- trainee assessment;
- qualification and requalification;
- job advancement and promotion; and,
- ‘certification’ or ‘licensing’.
1.7 Chemical process industry
Data from the chemical process industry show how failure causes change with time. Early industry failures were caused by engineering errors (poor materials, poor construction, etc.), Figure 3 . As the industry matured, and technology improved, the engineering failures reduced. The most recent trends in failures are linked to safety culture, and relationships between contractual entities, and the problems that can bring.
|Figure 3. Changing Causes of Accidents in the Chemical Process Industry.|
1.8 Construction industry
‘Design errors’ can cause 80 to 90% of the failures occurring on buildings, bridges, and other civil engineering structures, but design errors can be significantly reduced :
- design checks can detect 32% of errors;
- independent third party verifications can prevent up to 55% of these design errors.
Reducing design errors is, obviously, important, but more important is a conclusion that these design errors have clear root causes : ‘Design errors are a symptom of dysfunctional organizational and managerial practices that prevail within the construction industry…. cost and time pressures appear to be prevailing nemeses contributing to errors and failures’.
1.9 Data management and corporate memory
It is worth noting that often we do not learn from past failures, and one of the reasons is data management : ’The relevant information is almost always available: the problem is that it is either not known to the right people or its significance is not appreciated. Far from each failure or disaster being unique, there is usually a past history of similar events that could have resulted in failure but which for some reason didn’t.’
Industrial accidents occur because we do not use the knowledge that is available : ‘Organisations do not learn from the past or, rather, individuals learn but they leave the organisation, taking their knowledge with them, and the organisation as a whole forgets.’
We know the failure causes of pipelines. These are valuable data, but give little guidance on how to prevent them in future. Other industries are looking closely at safety culture, organisational structure, competence, knowledge/data management, etc., to reduce future failures, and their experiences can be used by the pipeline industry.
We prevent pipeline failures by having effective pipeline integrity management systems , but we can do more, and experience in other industries show us how to reduce failures further, by broadening the pipeline integrity management system considerations and determining the true/root cause of failure, and not simply the failure cause, Figure 4. These root causes could be grouped into:
- safety culture (e.g., staff put safety second);
- staff/corporate competency (e.g., incompetent staff);
- data management (e.g., incorrect or insufficient data);
- knowledge management (e.g., loss of experienced staff);
- organisational error (e.g., contracting error);
- system error (e.g., errors in procedures);
- human error (e.g., poor judgement);
- near miss (e.g., low consequence event ignored);
- malicious act (e.g., theft).
|Figure 4. Reducing Failures and Root Causes.|
- P Hopkins, ‘Learning from Failures: Moving from ‘Failure’ Cause to ‘Root’ Cause’’, Pipeline Technology Conference. Berlin, Germany, March 2019, and Pipeline Technology Journal. Issue 2. 2019.
- Anon., ‘Competency Based Training and Assessment in the Aviation Environment’, Civil Aviation Safety Authority. Australian Government. CAAP 5.59A-1(0). July 2009.
- M A Makary, M Daniel, ‘Medical error – the third leading cause of death in the US’, BMJ. 2016. iacld.ir/DL/elm/95/medicalerrorthethirdleadingcauseofdeathintheus.pdf
- Anon., ‘Reducing error and influencing behaviour’, UK Health and Safety Executive Report HSG 48. 2009. http://www.hse.gov.uk/pUbns/priced/hsg48.pdf
- J Philley, ‘Potential Impacts to Process Safety Management from Mergers, Acquisitions, Downsizing and Re-engineering’, Process Safety Progress, Vol 21, No. 2, pp 153-160. 2002.
- B Sampson, ‘Safety First’, Professional Engineering, 8th July 2009. pp 19-20.
- M Wright, D Turner, C Horbury, ‘Competence assessment for the hazardous industries’, Health and Safety Executive Research Report 086. UK. 2003.
- Anon., ‘Competency Assessments for Nuclear Industry Personnel’, International Atomic Energy Agency. Vienna, STI/PUB/1236. ISBN 92–0–110105–8. 2006.
- P. Körvers, ‘Accident precursors; pro-active identification of safety risks in the chemical process industry’, Dissertation. TUE. Eindhoven, Netherlands. 2004.
- P E D Love et al, ‘What Goes up, Shouldn’t Come down: Learning from Construction and Engineering Failures’, The Twelfth East Asia-Pacific Conference on Structural Engineering and Construction. Elsevier. Science Direct. Procedia Engineering. 14. pp 844–850. 2011.
- A Anderson, ‘Making a success out of a museum of failure’, New Scientist. 8th June, 1991.
- T Kletz, ‘Lessons from Disaster: How Organisations Have No Memory and Accidents Recur’, IChemE. Rugby, UK. 1993.