Citation

Jan H. Safety Sci. 2012; 50(3): 563-574.

Copyright

(Copyright © 2012, Elsevier Publishing)

DOI

10.1016/j.ssci.2011.10.009

PMID

unavailable

Abstract

The blowout of the Montara H1 well in the Timor Sea off the northwest coast of Australia in August 2009 was the first such incident in Australian offshore waters for 25 years. This article seeks to draw lessons for management of complex hazardous activities from these events by analysing critical decisions regarding well control barriers. Concepts such as trial and error learning, sensemaking and the need for multiple barriers are used to demonstrate why the organisation was blind to the developing problems and hence why lack of technical competence alone is not sufficient to explain the events that occurred. Three organisational improvements are proposed - providing active supervision, improved technical integrity assurance and better use of risk assessment. The article concludes with an appeal for changes in regulatory policy regarding safety to include organisational issues in addition to the traditional technical focus.

Language: en