Flirting with Disasters
by David Pescovitz
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Professor Robert Bea is also an expert on ocean environmental forces that can have a dramatic impact on undersea oil and natural gas resources.
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In 1988, Robert Bea was preparing to bring four decades of ocean engineering experience to UC Berkeley as a newly hired professor of Civil and Environmental Engineering. Then something unexpected happened. The Piper Alpha oil production platform in the North Sea exploded, killing 167 people and causing $4 billion in damage. Bea was called in to help determine the cause of the accident. The trail he uncovered led him down a long research path where engineering, business management, and the social sciences intersect.
"It became clear to me that the problem was not technology, but people," he says. "Worker safety is well established. But when you bring people together as operating teams or even corporations, a new set of problems begins to emerge."
In the case of the Piper Alpha, Bea explains, the explosion and resulting fire was sparked by "normalization of deviance." Early warning signs of danger had been normalized over the years in the sense that they no longer raised red flags to operators. On July 6, a gas leak in a pump caused an explosion that started a domino effect of fiery devastation. But why were so many lives lost? How did the evacuation go so wrong? According to Bea, "It was a chain of important errors made by people in critical situations involving complex technological and organization systems." That theme, he says, reared its ugly head over and over as he went on to investigate accidents as seemingly diverse as the Exxon Valdez oil spill and the Space Shuttle Columbia catastrophe.
The Piper Alpha oil platform burned on July 6, 1988, killing 167 people.
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By the time Bea began working with NASA, the Space Agency's approach to human and organizational factors had already been called into question. On January 28, 1986 , the Space Shuttle Challenger exploded shortly after liftoff. The explosion was caused by the failure of an "O" ring seal in a rocket booster. It was revealed that NASA was informed before launch that the performance of the O-rings could be compromised by the cold weather. Still, the decision was made not to delay the mission. Put simply, Bea says, there was a communication breakdown enabled by a counterproductive management philosophy. While a piece of broken foam insulation rather than a cracked O ring brought down the Space Shuttle Columbia last year, NASA's risk-assessment and decision-making process was once again scrutinized.
"We look back now and say these accidents could have been prevented," Bea says. "NASA had delivered incredibly high levels of individual performance, but they struggled with groups."
To suss out the kinks in complex organizations, Bea collaborates with Karlene Roberts, a professor in Organizational Behavior and Industrial Relations at the UC Berkeley Haas School of Business. By analyzing organizational catastrophes, and triumphs, from both an engineering and a human perspective, the researchers hope to develop risk assessment and management approaches that can reduce the impact of accidents when they do occur.
Their methods to enhance reliability in complex organizations may seem intuitive, but they often go against the grain of large corporate or institutional structures. For example, Bea and Roberts posit that organizations should "balance efficiency with reliability." Individuals should be rewarded for safe operational practices even if direct orders suggest that safety should be ignored even momentarily.
"When organizations focus on today's profits without consideration of tomorrow's problems, the likelihood of accidents increases," the researchers wrote in a journal paper entitled "Must Accidents Happen? Lessons from high-reliability organizations."
Another of the researchers' tenants is that large organizations must keep communication channels open and encourage information to flow. Take disaster-response teams that fight massive forest fires, Bea says. To succeed, hundreds of people and thousands of tons of equipment must be appropriately routed by numerous agencies from perhaps dozens of geographical regions. Coordination is the key to saving lives.
"They do this by defining and communicating a common big picture and by quickly establishing a command and control system that fits all the participants into a common goal with a common reporting structure," they wrote.
Accidents will happen, Bea admits. In fact, he points out that the History Channel has dedicated an entire series of television programs to "Engineering Disasters," from a subway tunnel cave-in to the Challenger accident. But every sad tale contains lessons to be learned.
"If you watch a few of the episodes, you'll quickly see the theme of my research emerge," he says. "Organizations need to be engineered at a level appropriate for the complexity of the technology surrounding them."
Robert G. Bea's home page
Karlene H. Roberts's home page
"Far below Gulf's surface, Ivan wreaked havoc on oil industry" by Russell Gold (Wall Street Journal, 27 October 2004)
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