Organisation culture and mindfulness

A case study and training exercise Based on BP Texas City explosion and fire

Case study exercise from the DVD package - Risk Maker Risk Taker Nicholas and Smith Pty Ltd

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Organisation culture and mindfulness - Training Exercise

Why talk about culture in your training programs?

Asking people to think about their organisations culture is an excellent introduction to many important organisation training topics. This is especially the case for those relating to safety, health, environment, quality and risk management training. The reason is that culture is reflected in behaviour and if you are asking someone to adopt new behaviours, they have to fit with the organisation culture. Of course, defining organisation culture is not a simple task. Most people have a vague idea of what it is but have some difficulty describing it in any detail. This training exercise was developed specifically to give managers, team leaders and employees an overview of culture, what it is and what it can mean in their organisation.

How to use this training exercise

Ask for ideas

Step 1 - Introduce Organisation Culture in simple terms Give your audience the following statements and get a conversation going by asking for input on what each statement means. If practical, write the key words people say, on to a white board. 1. Organisational culture is a system of shared values and beliefs. 2. Organisational culture is unique to the organisation and is reflected in daily practices. 3. Organisational culture is about what is important and what behaviours are appropriate. 4. Organisation culture determines what we see as normal and acceptable.

Case study exercise from the DVD training program - Risk Maker Risk Taker Nicholas and Smith Pty Ltd - April 2012 Page 2 of 10

Organisation culture and mindfulness - Training Exercise

Step 2 - What does your organisation culture look like?

Ask specific questions

Now that your audience is thinking about culture, take them to the next level by asking specific questions which can help paint a more detailed picture of their organisation. If practical, write the key words people say, on to a white board. 1. Is power centrally held or shared between individuals? Give at least 3 examples to validate the answers. 2. Is management style entrepreneurial or bureaucratic and conservative? Give at least 3 examples to validate the answers. 3. Does the organisation pay attention to the detail or is the focus mainly on the big picture? Give at least 3 examples to validate the answers. 4. Is the organisation process driven or does it focus on outcomes? Give at least 3 examples to validate the answers. 5. Does the organisation run people or is it run by people, working together in teams? Give at least 3 examples to validate the answers. 6. Does your organisation embrace new ideas and approaches or is it more conformist in nature? Give at least 3 examples to validate the answers. 7. Does your organisation have a learning culture, characterised by a climate of trust, mutual support, and sharing information? Give at least 3 examples to validate the answers.

Case study exercise from the DVD training program - Risk Maker Risk Taker Nicholas and Smith Pty Ltd - April 2012 Page 3 of 10

Organisation culture and mindfulness - Training Exercise

Step 3 - Linking values, culture and behaviour

A written exercise Print and hand out to participants the following pages 4,5 and 6.
The following exercise will show clearly how culture aspects impact on behaviours that can contribute to an organisations inability to manage risk. By analysing this case study, participants will be able to identify the behaviours that contributed to the event. Importantly, they will also be able to identify the desirable behaviours that will underpin a risk awareness culture. Case study 1 - BP Texas explosion What happened? On March 23, 2005, at 1:20 p.m., the BP Texas City Refinery suffered one of the worst industrial disasters in recent U.S. history. Explosions and fires killed 15 people and injured another 180, alarmed the community, and resulted in financial losses exceeding $1.5 billion. The explosion occurred in an isomerisation unit. According to a report issued after the accident, actions taken or not taken led to overfilling the raffinate splitter with liquid, overheating of the liquid and the subsequent over-pressurisation and pressure relief. Hydrocarbon flow to the blowdown drum and stack overwhelmed it, resulting in liquids carrying over out of the top of the stack, flowing down the stack, accumulating on the ground, causing a vapor cloud, which was ignited by a contractor's pick-up truck when he repeatedly attempted to start the engine. The people in the trailer located near the process unit's battery limit, holding a meeting, were unaware of the unit start-up condition. The people on the side of the meeting table with their backs to the process unit were killed due to blunt force trauma. A number of people on the side of the table facing the unit survived the blast.

Case study exercise from the DVD training program - Risk Maker Risk Taker Nicholas and Smith Pty Ltd - April 2012 Page 4 of 10

Organisation culture and mindfulness - Training Exercise

The following is a LIST of management and employee behaviours evident at BP Texas City prior to the disaster. A. There was a fear to challenge and say no. B. Deficiencies in BPs mechanical integrity program resulted in the run to failure of process equipment at BP Texas City. C. Personnel were not encouraged to report safety problems and some feared retaliation for doing so. So, personnel did not share bad news. The lessons from incidents and near misses, therefore, were not captured or acted upon. D. No consequences of good or bad performance. E. Personnel completed paperwork and checked off on safety policy and procedure even when those requirements had not been met. F. The BP Board of Directors did not provide effective oversight of BPs safety culture and major accident prevention programs. The Board did not have a member responsible for assessing and verifying the performance of BPs major accident hazard prevention programs. G. Cost cutting, failure to invest. H. A check the box mentality was prevalent at Texas City, were deficient at all levels of the refinery, managers showed a lack of involvement in safety issues and did not lead by example. I. BP Texas City did not effectively assess changes involving people, policies, or the organisation that could impact process safety. J. Safety campaigns, goals, and rewards focused on improving personal safety metrics and worker behaviours rather than on process safety and management safety systems. K. While compliance with many safety policies and procedures was deficient at all levels of the refinery, managers showed a lack of involvement in safety issues and did not lead by example. L. Numerous surveys, studies, and audits identified deep-seated safety problems at Texas City, but the response of BP managers at all levels was typically too little, too late.

Case study exercise from the DVD training program - Risk Maker Risk Taker Nicholas and Smith Pty Ltd - April 2012 Page 5 of 10

Organisation culture and mindfulness - Training Exercise

Ask the participants to MATCH the aspect of culture from the BP enquiry findings with the behaviours at BP Texas City. Culture at BP Texas City Behaviours Select the behaviours that reflect the aspect of Culture. eg A or B or C etc and write the letters in this column. Example A, C, H, etc

1. Executive management valued profit ahead of the risks associated with process safety performance. There were also production pressures from BP Group executive managers. 2. BP Texas did not value learning from mistakes. There was a lack of a reporting and learning culture. 3. Lack of role models at supervisor and superintendent levels. 4. Poorly motivated and disempowered workforce. 5. Lack of enforcement of following procedures. 6. BP Texas valued improving personal safety rather than process safety and management system safety.

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Organisation culture and mindfulness - Training Exercise

ANSWERS Culture/value 1. Executive management valued profit ahead of the risks associated with process safety performance. There were also production pressures from BP Group executive managers. G Behaviour Cost cutting, failure to invest.

Deficiencies in BPs mechanical integrity program resulted in the run to failure of process equipment at BP Texas City. Personnel were not encouraged to report safety problems and some feared retaliation for doing so. So, personnel did not share bad news. The lessons from incidents and near misses, therefore, were not captured or acted upon. BP was not learning from mistakes.

2.

BP Texas City did not value learning from mistakes. There was a lack of a reporting and learning culture. Note: Weick et al1 identified Reluctance to Simplify as a process for mindful organisations. An organisation can only be adequately informed if it resists the temptation to discard and ignore information, that is, if it is reluctant to simplify.

Numerous surveys, studies, and audits identified deep-seated safety problems at BP Texas City, but the response of BP managers at all levels was typically too little, too late. There was a fear to challenge and say no. The BP Board of Directors did not provide effective oversight of BPs safety culture and major accident prevention programs. The Board did not have a member responsible for assessing and verifying the performance of BPs major accident hazard prevention programs.

A 3. Lack of role models at supervisor and superintendent levels. F

Case study exercise from the DVD training program - Risk Maker Risk Taker Nicholas and Smith Pty Ltd - April 2012 Page 7 of 10

Organisation culture and mindfulness - Training Exercise

While compliance with many safety policies and procedures was deficient at all levels of the refinery, managers showed a lack of involvement in safety issues and did not lead by example. A check the box mentality was prevalent at BP Texas City, were personnel completed paperwork and checked off on safety policy and procedural requirements even when those requirements had not been met. Management was not adequately informed or motivated.

4.

Poorly motivated and disempowered workforce. Note: Weick et al1 identified Sensitivity to Operations as a process for mindful organisations. Weick notes that people who refuse to speak up out of fear enact a system that knows less than it needs to know remain effective

5.

Lack of enforcement of following procedures. Note: Weick et al1 identified that Mindful organisations needed to understand that long periods of success breed complacency. Mindful organisations are wary of success. They are preoccupied with the possibility of failure. They hunt for lapses, errors and incongruencies, recognising that these may be the precursors to larger failures.

BP Texas City did not effectively assess changes within the organisation involving people, policies and procedures that could impact process safety.

D 6. BP Texas City valued improving J personal safety rather than process safety and management system safety.

No consequences of good or bad performance. Safety campaigns, goals, and rewards focused on improving personal safety metrics and worker behaviours rather than on process safety and management safety systems.

K Weick, K Sutcliff & D Obstfeld , Organising for high reliability: processes of collective mindfulness, Research in Organisational Behaviour

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Organisation culture and mindfulness - Training Exercise

Is Safety Culture embedded in your organization?

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Professor Andrew Hopkins is an internationally renowned author, consultant and presenter in the field of process safety and accident analysis. Professor Hopkins was an expert witness at the Royal Commission in to the Longford gas plant fire in 1998. He was also consultant to the US Chemical Safety Board investigation of the BP Texas City incident. Andrew is the recipient of the 2008 European Process Safety Centre Process Safety Award. He was consultant to the Australian Defence Forces on organizational culture and was engaged by the US Chemical Board to assist in the investigation of the BP Gulf of Mexico oil spill. Customers using these DVDs in their training include: GlaxoSmithkline, Maersk North Sea, Petrofac, GE Caledonian, Qatar Petroleum, Balfour Beatty, Conoco Phillips, South Hook LNG, TAQA Bratani, Fluor, Tokyo Electron, Rhodia, EON, Atomic Weapons UK and many more. Each DVD title is a Complete Training Package and includes DVD and CD containing workshops, study guides, and slide presentations. They are available in a range of languages. DVD 1: Mindful Leadership with references to BP Texas City How do you get your managers and supervisors to "walk about"? Leadership is important because the leaders of an organization determine its culture. Professor Hopkins identifies the key aspects of "Mindful Leadership" and illustrates how lapses in leadership contributed to the BP Texas City disaster. Read more and watch the trailer.

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Organisation culture and mindfulness - Training Exercise DVD 2: Mindful Leadership Communication Skills Face to face communication with workers on site - how do you get your managers and supervisors to do this. Professor Hopkins focuses on the communication skills of safety leaders. Read more and watch the trailer. DVD 3: Creating a Mindful Organization Organizational culture is one of the key reasons why companies fail to recognize the warning signs prior to workplace accidents. What are the warning signs? This training workshop will give managers the tools to significantly improve management of OH&S risk systems. Read more and watch the trailer. DVD 4: Preventing Disaster - Learning from Longford This video workshop is a detailed analysis of the Esso Gas plant explosion at the Longford plant. Two workers were killed, and the gas supply to the city was interrupted for two weeks. Read more and watch the trailer.

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