Change Management - Inadequate Mental Model
The real causes of accidents are the human and organisational factors which we find at work in many big process safety accidents.
On the 20th of April 2010, the Macondo blowout in the Gulf of Mexico became the biggest oil spill in US history.
The people conducting tests on the barriers of the Macondo oil well did not have situational awareness. Situational awareness is a useful term. We can say the same thing about the operators in the Texas City refinery accident. They lacked any awareness of the situation they were in. Why did the Macondo team not have a clear picture? Partly because they had limited competency. These people were not professional engineers. They were tradesmen who had worked their way up the ranks and had learnt what they knew on the job. They didn’t have the analytic or conceptual way of thinking that is more characteristic of professional engineers.
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