creating management line of sight aposho november 2011
TRANSCRIPT
Creating management line of sight
APOSHONovember 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 ...
Freehills 317052655
BP Texas City
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 [wellcontrol] 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
Systemshazards
risks&
controls
Culture
Workforce perception of
management commitment
Includes ‘legal’hazards & risks
Quality &
Effectiveness
Minimum expectations
of Courts
EffectiveParticipation
1. Know obligations & risks.
2. Have a process that brings systems failures to your attention.
3. Respond personally and in a timely manner to systemsfailures.
4. Independently verify from time to time.
1. Planning.Safety a demonstrable part of business decisions
2. Active monitoring.Safety toursTalking with employees
3. Reactive monitoring.Safety investigationsSign off on incidentsManagement 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 systemsfailures.
4. Independently verify from time to time.
1. Planning.Safety a demonstrable part of business decisions
2. Active monitoring.Safety toursTalking with employees
3. Reactive monitoring.Safety investigationsSign off on incidentsManagement 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?
You
Systemic Markers
Individual WorkPractices
Critical:ProcessesActivitiesHazardsControls
Feedback Loops
Warning Signs
Incident investigationsAuditsKPIsReporting“Walk arounds”
Budget/schedule slippageOrg changeKey personnel change“No news”Success
2007:Budget cutsIncentive schemesStrategic presentation
2009:World’s deepest well
31 March 2010:Only 6 centralizers available
15 April 2010“Wrong” centralizers
“Errors” 16 – 20 April 2010
$1M a day, 6 weeks behind schedule, $58M over budget
18 Hour turn around
