Bully & Blame: Transocean

HSE Investigates Transocean Human Factors late 2009. Report issued in 2010 still kept under wraps by the company. Download it here:-)

Transocean Human Factors: HSE Specialist Inspection Report by the Offshore Division, Human and Organisational Factors Team.

HSE had become aware of significant differences in accident rates between various rigs. Incidents reported varied from zero to 15 across four rigs in the 2-year period 2007-09.

With organisational changes post-merger with GSF completed, the HSE decided the time had come to review the company’s arrangements for health and safety and to undertake a human and organisational factors intervention. This involved interviewing key personnel onshore and offshore on four rigs.

Discussions held with 150 staff identified a number of strengths within the organisation including several safety initiatives that appeared to be working well. This indicated that whatever might be found wanting GSF was a company genuinely trying to improve.

On a very positive note the HSE noted that the company retained a loyal staff with long service and consequently there existed a wealth of accumulated operational experience.

Also of particular note was the emphasis and support for TOFS (Time Out for Safety) from all levels of management. Not only that, there was clear evidence that the process is actually used by offshore staff.

HSE also comments approvingly that management makes significant efforts to communicate to personnel through safety meetings, pre-tour meetings, presentations and inductions.

However, HSE asked if management were communicating the right message and found the answer was, sadly, no.

The prominent and consistent indicator of Transocean’s organisational culture, according to the HSE, is discipline, blame and zero tolerance. The so-called accountability process, represented in the ‘just culture decision tree’, quickly steers investigations toward blame of the employee. Little consideration is given to wider organisational issues such as fatigue, distraction, communications failures, or defective equipment.

Lopsided corporate statements on HSE policy are heavy on the responsibilities of employees but overly light on what should be management’s roles and responsibilities in securing the HSE policy outcomes.

Oddly, the HSE report fails to directly consider origins of this institutional bias but we know from our experience that Transocean accident investigations deliberately focus on blaming an injured workers for his or her own injuries with a view to limiting or eliminating altogether any claim for compensation.

The HSE reports evidence of offshore supervisors under immense strain due to being held accountable for the behaviours of staff should they be involved in an incident or found not to be complying with policies and procedures. Nevertheless, a burden of office work too often prevented supervisors from being present at the workplace.

Unacceptable behaviours by offshore management were raised with HSE on more than one rig visit. Behaviours included bullying, aggression, harassment, humiliation and intimidation. OIMs and other managers are perceived to condone such behaviours through inaction. Staff felt unable to raise these issues with some individuals exhibiting symptoms of work-related stress with potential safety implications.

The HSE report also confirms what many in the industry already know: the one-a-day START card is a devalued currency. The quota system caused it long ago to lose value. In fact, to meet the compulsory daily quota some staff freely admitted to HSE investigators that cards are made up.

Other issues in the HSE Report include Policy and Procedure Manuals uncontrolled with out-of-date versions being relied upon and amended up-to-date copies not issued to operational staff; QHSE and senior management invisibility during fleeting VIP visits to the rig; and, the safety committee system is virtually a dead letter of the law (one rig had not had a safety committee meeting in five months).

The latter is a statutory breach. Safety committees are required in law to meet as often as necessary to satisfy staff consultative needs and, in any case, not less than once in each 12-week period.

Despite the myriad problems, including at least one clear statutory breach, the HSE decided against formal enforcement action and the company instead agreed to cascade the report down to the workforce and safety reps with two months.

September 2010, one full year on from the investigation and eight months on from the HSE issuing the report, and offshore staff and safety reps have yet to see sight of it. One has to wonder why the HSE after expending so much energy and resources on a first class piece of investigation are content to sit back and effectively see their report buried.

Knowledge of a problem is the essential first step to solving that problem. For that reason we are happy to place the HSE’s Transocean Report into the public domain. Please read it and let us know what you think.

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