Major incidents such as Flixborough have strengthened the subject of process safety and rereading the investigation report 50 years on, I can’t help but think how the learnings must still remain relevant today and whether the challenges raised with respect to competence are any different now than they were then.
Among the investigation’s finding was the observation that “the key post of Works Engineer was vacant and none of the senior personnel of the company, who were chemical engineers, were capable of recognising the existence of what is in essence a simple engineering problem let alone solving it.”
Unpacking this statement and asking what it means to smaller organisations, it highlights a need for:
- multi-disciplinary engineering knowledge to come together
- defining roles and responsibilities
- engineers to recognise their limits
- development of knowledge and recognising the importance of experience
Multi-disciplinary engineering knowledge
The investigation report recommended that “all engineers should therefore learn at least the elements of other branches of engineering than their own in both their academic and practical training.”
The importance of a multi-disciplinary team is well accepted in process safety activities such as HAZOP, but do we put enough emphasis on the importance of multi-disciplined input and diverse teams in all process safety related decision making? Is process safety considered a discipline in its own right? In certain organisations there may be a need for engineers to wear multiple hats. This can lead to challenges in focus, and independence.
Do we recognise the importance of non-technical skills such as communication and teamwork, essential if multi-disciplined teams are to function effectively?
Roles and Responsibilities
The Flixborough investigation highlighted the issue of “vacant posts”. In smaller organisations we might be operating without all disciplines being represented by separate individuals. Might we be inadvertently leaving vacant posts, particularly if individuals are being asked to wear multiple hats? We need to be clear what roles they are covering.
Some organisations are reliant on third parties to provide specialist input as and when needed, but how is it decided when it is needed? Operators must remain intelligent customers.
Knowing your limits
You need to know what you don’t know. The Flixborough report highlights the importance that “persons given certain responsibilities are competent to carry out those responsibilities”. Operating within competence limits is a question of ethics. In high hazard industry operating outside of your competence limits could inadvertently lead to unsafe design or operational practice.
In smaller organisations, there may not be the availability of a team to input into key decision-making. For newer industries, the challenges may be novel, and experience is needed to make the right decisions in new and complex situations.
Developing Knowledge and Experience
Smaller teams tend to have fewer opportunities to learn from the experiences of others and may not have multiple people of varying experience in the same discipline. Knowledge sharing is key to developing the skills of younger engineers and experience brings with it the ability to deal with complex and novel engineering problems.
With new technology, there may not be first hand evidence available, but experience brings the wisdom to challenge and recognise subtle cues that things aren’t quite right. It is important to recognise experience gaps to ensure this wisdom is available.
Summary
The challenges organisations are faced with in ensuring they have a competent team appear to be similar now to what they were 50 years ago. Unpacking the investigation report, it is evident the lessons from Flixborough do still hold strong today. Smaller organisations especially have to be smart with their resource, recognise where the gaps are and take positive action to address them.
References
• Rhona Flin, Paul O’Connor: Safety at the Sharp End: A Guide to Non-Technical Skills https://doi.org/10.1201/9781315607467
• The Flixborough Disaster – Report of the Court of Inquiry:
https://bit.ly/41lQBcD
