The previous post received a comment from Adrian Amey which made me realise that I had not properly explained one of my key points. So rather than just reply to the comment I thought I should write another post.
There is in fact some technical information around on both the Varanus Island and Belgian failures. (I would like to make it available through this blog but I’m not sure if it’s in the public domain and don’t want the risk of being sued.) I think Adrian and I have seen the same documents and we draw the same conclusions about the immediate causes of the failures.
But those documents show only the immediate technical cause. What I’m interested in, and what everybody in the industry and the public should be interested in, is the broader context of the human and organisational failures that lead to the physical cause arising in the first place. The physical failures don’t occur spontaneously – they happen because people made mistakes of commission or omission, and they made those mistakes within organisations that have systems and cultures that affect the likelihood of human error or oversight.
To protect against failures we need to understand the organisational cultures that promote or prevent them. That’s what I want to see in accident investigations.
More specifically, the Varanus Is incident was a corrosion failure. What the world should be told is how the corrosion was allowed to progress to the point where the pipeline failed. What processes and cultures within Apache failed to find and fix it it in time? How did the regulatory systems fail in their oversight role? Simple questions, but the answers can be very complex.
Similarly the Belgian incident was a mechanical damage failure, possibly compounded by what might have been an inappropriate response to an initial leak (the pipe did not rupture immediately the damage was done and a number of the fatalities were among the people investigating the leak). But we have been told little or nothing about the systems that were in place to prevent unauthorised activity over the pipeline and to supervise activity that had been authorised. How effective were those systems? Why did they fail? What could have been done better in response to the initial leak? How appropriate was the emergency response? Was the regulatory regime adequate? Again, simple questions that are likely to have complex answers.
It is very fortunate that there are so few pipeline catastrophes. But when they occur we should take every opportunity to learn as much as possible from them so that the rate of failures can be pushed ever closer to zero.
Just looking at the immediate physical causes will miss all the really important lessons that could be learned.