Listening to the Well, Listening to Each Other, and Listening to the Silence─New Safety Lessons from Deepwater Horizon

Abstract

It is common for accident reports and the analysis of large-scale disasters, such as the Deepwater Horizon blowout, to point to communication failures. This narrow explanation implicitly assumes that accidents could be prevented if employees spoke up about safety. In contrast, the first author of this paper, whose professional experience is introduced in this Commentary to provide context, has frequently observed that there are, in fact, many cases when employees speak up but are not listened to. These patterns of communication (or lack thereof) occur at the intersection of personal, leadership, and organizational factors, which jointly affect how safety issues are recognized, communicated, and addressed. As such, communication problems are at “the tip of the iceberg” of safety problems, not at their root. In this paper, we review research on high-reliability organizations (HROs) with excellent safety records to identify their communication patterns and practices and how they contribute to the ability to enact five principles of HROs: preoccupation with failure, reluctance to simplify, deference to expertise, commitment to resilience, and sensitivity to operations. We then apply this lens to investigate the Deepwater Horizon disaster, based on court documents, expert reports, and personal interviews. Specifically, we investigate how the communication patterns between the onshore experts and the offshore crews compared to the recommendations of HRO theory and how existing discrepancies might help explain the accident. We found that many employees were aware of safety issues and communicated concerns openly, but there was little organizational response to the issues they raised. This failure to listen was largely owed to factors that were not directly related to communication, such as time pressure and lack of resources, and a culture that valued a “can do attitude” and getting things done so much that it got in the way of sensitivity to operations, expert-based guidance, and communication about problems. Moreover, the challenges of the project and its aggressive timeline created an extreme, almost toxic, commitment to resilience. Based on these findings, we discuss recommendations for improving safety in offshore oil and gas production.