Wednesday, June 9, 2010


The world is once again aghast at a man made disaster. This time it is the oil drilling “Deep Horizon” tragedy in the Gulf of Mexico. Every time I learn of one of these significant disasters I consider once again the work done by Dr. Edwin Zebroski and his “11 Indicators of Impending Doom.”


Back in the 1990’s Dr. Zebrowski made a detailed analysis of four significant man made tragedies (the Chernobyl nuclear reactor fire, the Piper Alpha oil rig fire, the first space shuttle explosion, the Bhopal gas release). Each was initially classified as an “accident.” However, his in depth research uncovered 11 common threads (human decisions) to each of these disasters. Here they are:

1. Diffuse responsibilities with rigid communication channels and large organizational distances between decision makers and the plant

2. Mindset that success is routine and neglect of severe risks that are present

3. Rule compliance that this is enough to ensure safety

4. Team player emphasis with dissent not allowed even for evident risk

5. Experience at other facilities not processed systematically for application of lessons learned

6. Lessons learned disregarded and neglect of precautions widely adopted elsewhere

7. Safety analysis and responses subordinate to other performance goals in operating priorities

8. Emergency procedures, plans, training and regular drills for severe events lacking

9. Design and operating procedures allowed to persist even though recognized as hazardous elsewhere

10. Project and risk management techniques available but not used

11. Organization with undefined responsibilities and authorities for recognizing and integrating safety matters

Only a detailed analysis over time will determine if the BP oil rig fire and subsequent oil leak disasters have any, or all, of Dr. Zebroski’s “11 Indicators of Impending Doom.” You and I will have little or nothing to do with this research and “search for the guilty parties.” However, as safety professionals for our own organizations we can, and must, analyze our own operations for the presence of any of these “Ticking Time Bombs.” Once you are convinced that one or more of these potentially dooming realities exist the next question is what to do about it? An approach I have used for this reads a little like a fault tree diagram, i.e., what does it take to eliminate this issue? For Item #6 an overview might read something like this:

• Continuous Improvement (CI) team error proofs Accident Investigation process so it delivers multiple root cause analyses, active work group participation, Action Item Matrix tracking of needed tasks, Safety Accountability reviews, condition fixes and the like

• CI team error proofs Communication process that delivers an active communication channel throughout the whole organization whereby Near Miss lessons & corrective measures are disseminated and discussed with employees within XXX number of days of a Near Miss

• CI team error proofs Near Miss process including proper easy to use forms in appropriate languages, easy tracking system, red/yellow/green work team risk assessment, etc.

• Action Item Matrix from Accident Investigation and significant Near Miss teams are meaningful and end results are communicated appropriately

• All design team have safety accountabilities and an active line level operations/safety member

• Method Of Change a serious, error proofed, well utilized process with accountabilities for each work group

You and your organization need to relentlessly pursue “Doom” eradication before personal disasters have a chance to occur. However, your organization may very well need some culture improvement training before taking on such a task. Most do as they fit this excellent continuous Improvement team error proofing process into their zero incident safety culture.

The Doc

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