Safety performance, in many companies and even industries, has stalled in the few years. Accidents rates are at a "plateau" and yet, serious accidents and fatality rates are not. In more dramatic cases, such as in the BP Texas disaster, organizations that have "exemplary" safety statistics, suddenly have a catastrophic or multi-fatality event occurring. Other classic examples are the Piper Alpha disaster and NASA's Challenger and Columbia disasters, and even the Chernobyl nuclear reactor. Looking into the root causes of these accidents provides an insight into the events and deficiencies that led up to the accident, but what are the common features in the organization's mindset? What characterizes these organizations' decision-making, their approach to safety and to risk and are there specific cultural features that can be delineated? The research and review presented in this paper covers a period since 1994, which started in the Australian resource industry and since then covered international events. The features of these organizations are summarized as the seven deadly delusions, based on extensive research since 1997 of organizations that suffered unexpected disasters.
The Piper Alpha Oil Rig disaster in the North Sea, on the 6 July 1988, was one of the most pivotal events in safety around the world. It changed the thinking and focus of governments and whole industries, and led to numerous books and papers. It resulted in new legislation, textbooks, and a critical self-examination by the oil and gas industry.
In short, an explosion and fire occurred when a pipe started leaking gas and ignited. A temporary flange, with no safety valve, was used to block off this pipe during a maintenance operation the previous shift. The permit to advise operators not to start the pumps on this line was misplaced and lost. Several deficiencies, problems, and system failures coincided. A key factor was that the water deluge system was inoperable at the time, and failed to extinguish the large fire that erupted, followed by an even larger gas explosion. The accommodation unit, situated on top of the oil rig, was the main "killing field;" most men gathered here to await instructions (which never came), and they died from smoke inhalation. Later, a large explosion of the gas pipeline from an adjoined rig exploded and killed more people.
