It was twenty one years ago (21 May 2001) that I received the call that changed my life. I was working at Yule Catto having recently joined them from Dow Chemicals where I had been working in operations and engineering roles. I had been recruited into Yule Catto about a year earlier as the newly created Head of HSE & Risk.
That day, I was at home removing my old kitchen ahead of the new installation when the phone rang. My boss was on the other end, and he told me that there had been an event at the facility in Italy and that I needed to get there as soon as possible. I made the arrangements, and the next day I was at the plant in a small town called Agrate Brianza, near Milan.
There had been an explosion and fire in the pilot plant of the facility that manufactured active pharmaceutical ingredients (APIs). This involved a complex sequence of chemical reactions. Something had gone wrong, and the resulting event killed two of the three workers almost immediately; the third — a young man aged about 28 — was terribly burnt. He was placed into a medical coma but never recovered, and his parents had to make the agonising decision to turn off his life support machine after three months.
I cannot imagine having to turn off a life support machine for my child, and I think with deep regret of the pain that the parents of that young man had to endure.
The investigation was started by ourselves and by the authorities. It soon became clear that there had been violations of operating procedures, that the incorrect equipment had been used and that one of the operators, who had been caught up in traffic, had not changed into his work clothes and was not wearing anti-static shoes. The picture started to appear — operator error.
However, over time and as the investigation continued, another picture started to emerge. Similar patterns of behaviour had happened before but no event had resulted; there was a culture of needing to get the job time on time; dissent from junior operators was not welcomed; working around the standard operating procedures was routine.
Slowly, over the next few months, it began to dawn on me that I was part of the problem. I had a corporate functional role and I had not demonstrated the right leadership behaviours or tried to influence the safety culture, nor had enough of the senior managers at the facility itself. I know I was not to blame for the actual event, but I shared in the responsibility for the circumstances that led to its occurrence.
Far from being a distant on-looker from corporate HQ, I was part of the problem. I was not to blame for the event, but I shared responsibility for it happening.
I decided that trying to address this was what I wanted to do for the rest of my career, despite being encouraged to move back into a senior operations role. I, therefore, made the deliberate decision to make operational risk/process safety management my main focus of attention. I have since been fortunate enough to work in senior leadership roles in process safety and operational risk management in the chemicals, power and oil & gas sectors, most recently as Chief Engineer at Centrica, up until last year.
I have recently co-founded Empirisys with the express purpose of helping improve process safety leadership and culture, and to reduce risk. We use data science to uncover hidden insights from unstructured data (such as maintenance logs, HSE observations etc) and help high hazard organisations make more informed decisions about safety culture, leadership effectiveness and human factors to strengthen the integrity of safety-critical barriers. Despite all the advances we have made, human error caused by latent defects is still the prevailing cause of events; in effect, unless we find and remove these, we are setting our people up to fail….and believe me, in high hazard sectors, I know what this feels like.
Twenty years ago, my children were young boys; now my youngest son is 22, and my eldest is 26. I cannot imagine having to turn off a life support machine for them, and when I think of the pain and grief that the parents of that young man must have gone through, I am proud that I have stayed true to my word and grateful to all my friends and colleagues who have been with me along the way.
Empirisys was set up by Gus Carroll and Peter Sueref to help high-hazard organisations become safer. You can find more about us at empirisys.io or on Twitter at @empirisys or on LinkedIn. And you can drop us an e-mail at info@empirisys.io, or directly to the author of this article, gus@empirisys.io.
