Pathological Complacency: When Things Can Go Wrong By Being the Best

Every day legions of men and women report to work at oil and gas installations worldwide, ensuring that global energy markets receive a steady supply of hydrocarbons and refined products. Although these individuals regularly work in hazardous environments such as offshore drilling rigs and oil refineries, they consistently demonstrate their ability to negotiate the risks inherent in their jobs.

Given the extensive skill and experience that these workers demonstrate and their employers demand on a daily basis, having world-class know-how and safety policies and procedures in place can ironically introduce a very real danger into the mix. When an individual, workforce or facility owner becomes excessively certain of their ability to safely operate a complex oil and gas facility, a mindset called "pathological complacency" can set in.

When workers become pathologically complacent, they "become morbidly self-satisfied that they are 'at the top of their tree,' where they have a certain belief that they are the best or good enough in their field of work," explained Maxine Fawcett, Aberdeen, UK-based Principal Consultant with Intertek Consulting & Training. Fawcett advises oil and gas industry clients in behavioral change in the areas of safety and environment.

"They are so convinced of this that they become unaware of underlying dangers that arise from their lack of awareness or consciousness of their situation or their certainty that they have their situation under control," continued Fawcett. "They are convinced of their own infallibility."

An Insidious Threat

Fawcett contends that using a seemingly extreme adjective like "pathological" to describe this level of complacency is warranted given the potential consequences: death or environmental destruction. Moreover, she notes that the mindset may blind one to the warning signs preceding events such as a well blowout or plant explosion.

"We don't readily see warning signs if we aren't expecting them -- and psychologically it is very easy for us to explain away the warning signs and interpret them based on past experience, even when the situation is very different," said Fawcett.

"We tend to say, 'This is just like that valve breakdown we saw two years ago and we were able to work around it. We could do the same here,'" added Fawcett. "It's not so easy to say, 'This is similar to that old valve, but what's different is the extent of the corrosion -- so this time we should treat it differently.'"

Old Assumptions and New Risks

"There is a general over-reliance on checklists that prevents people from really thinking about risk," commented Fawcett. Although she acknowledges that electronic work control systems with drop-down menus are easy to use and help to prevent workers from forgetting key tasks, she asserts that they serve to speed the workflow and prevent real assessment of risk. She cites the 2010 Macondo well blowout in the Gulf of Mexico as a tragic reminder of the limitations of these systems.

"An example of this appears to be the safety case for Macondo, which seemed to be a cut-and-paste job from another safety case designed for drilling in the Arctic, with its mention of 'walruses,'" Fawcett explained.

"As a result, plans for emergency response in the safety case were woefully inadequate and indicated that the document authors had gone for speed of production of the paperwork rather than a proper assessment of all the contingencies that should have been considered and a review of the real dangers."

Fawcett pointed out that the proliferation of deepwater oil and gas projects, along with the industry's growing interest in Arctic drilling, underscore the importance of relying on more than just past experience. She noted that the deepwater and the Arctic trends remain "highly experimental" and fraught with many dangers, and she cautions against the temptation to rely solely on conventional wisdom in developing safety and training protocols for these areas.

"When you assume you understand or know the conditions in a situation, it doesn't leave a lot of room for doubt, for moving forward cautiously with a sense of fallibility or applying wisdom when faced with massive risk," Fawcett said.

Calling deepwater technology and procedures primarily "an extension of what's been used in the past," Fawcett contends that operating in still-experimental areas such as deepwater and the Arctic demand "a complete rethink" of the real dangers to anticipate in extreme environments.

"Overconfidence masks warning signs -- we can see what we want to see rather than what's really there," Fawcett said.

"The tragedy of the Macondo disaster is that a well-established operator was pathologically complacent about the impact that many years of intense organizational cost-cutting would have on the behaviors of every person in the organization and the risks they were prepared to take," said Fawcett. "Combine this with the additional dangers of deepwater drilling and maybe it was a disaster waiting to happen."

An incident 11 years ago at ConocoPhillips' Humber Refinery in the UK also illustrates a dramatic consequence of missing warning signs. On April 16, 2001, the initial catastrophic failure of an overhead pipe released a cloud of liquefied petroleum gas that ignited and caused subsequent pipe failures and explosions. There were no fatalities or serious injuries from the incident, but it did cause significant damage to the refinery complex and off-site properties.

The 2005 UK Health and Safety Executive (HSE) report following the agency's investigation attributed the incident to "a systematic failure to understand the conditions that the pipework was operating under, and to appropriately inspect pipework in the Saturate Gas Plant of the refinery." In addition, HSE uncovered failings in ConocoPhillips' management of change arrangements.

"At some point in the plant's history, the pipe had been put back into continuous use and a quick-fix put into place for corrosion in the pipeline," explained Fawcett.

"The management of change system did not kick in, and so the opportunity for a multi-disciplinary assessment was missed. The opportunity for responding to surprises was long past. Many opportunities for a thorough inspection were missed, with the pipework in question being left out during risk-based assessment."

In Fawcett's view, the Humberside episode reveals the shortcomings of strategies for risk-based inspections -- in downstream as well as upstream situations.

"If you only inspect those pipes at high risk, at what point do low-risk pipes become high-risk," she asked. "For upstream operators, focusing only on safety-critical elements of maintenance, with the view that non-critical elements are therefore 'safe,' is a common occurrence. Another example of pathological complacency and delusion?"

The Solution?

Although her professional focus as a HSE behavior change consultant has been in the oil and gas and petrochemical industries, Fawcett is quick to point out that pathological complacency exists well beyond the rig floor and the refinery distillation column.

Consider the Jan. 13, 2012, wreck of the Carnival cruise ship Costa Concordia on the rocky shores of the Italian island of Giglio. The ship capsized after the captain allegedly changed course to do a "salute" to give passengers a closer look at the island -- a practice that violated proper procedures and, in this case, has resulted in 17 confirmed deaths. The bodies of 15 others who were aboard the ship still have not been recovered.

Pathological Complacency
in the Oil & Gas Industry

Examples of pathological complacency that Intertek's Maxine Fawcett says she has seen in her experience with the oil and gas industry include the following:
  • Waiting for failure before repairing corroding hoses that can leak or catastrophically fail with discharges to sea or into the water table.
  • Allowing planned maintenance or corrective maintenance activities to build up, reasoning that addressing safety-critical elements will sufficiently manage the risk but not looking at the cumulative risk of the total backlog.
  • Putting vessels into shutdown programs for major inspection or repair but then excluding them as a result of time or monetary constraints. Fawcett notes this process may repeat itself year after year. "The vessel keeps being put onto a list that never changes," she explains.
  • Moving into developing regions around the world, operators assume that local labor forces will follow complex safety-related procedures and think the "Western" way.
  • Relying on checklists for hazard identification but failing to consider what is not on the checklists.
Elaborating on the kinds of things not picked up by a hazard checklist, Fawcett said such items might include: using substandard materials; accepting a work-pack (a project management term describing a subset of a project) that is incomplete and "making do" with whatever materials are at hand; a work colleague whose mind is elsewhere (perhaps on marital troubles); and so on. She pointed out that a checklist can prevent one from looking beyond the obvious when planning or carrying out a task.

"Apparently he'd done the salute before, and it was relatively common for other cruise liners in the company to do so," noted Fawcett. "It would appear that an attitude of arrogance played its part in the disaster -- 'I can do this, I'm good enough', etc. However, a culture must exist in the cruise ship organization that made it acceptable to break the rules in this way, whether by silent consent or by judging that the practice was an 'acceptable risk' with no challenge taking place."

For possible strategies to remedy pathological complacency in virtually any workplace where significant hazards exist, Fawcett recommends approaches employed by the aviation and other industries.

Read more about it Monday on Rigzone and DownstreamToday.

Pathological Complacency - Issues

Matthew V. Veazey has written about the oil and gas industry since 2000. Email Matthew at


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Ron Zanoni | Feb. 9, 2012
Heres another quote that goes back quite a few years ago: "He thats secure is not safe" - Benjamin Franklin

Jose Alves | Feb. 8, 2012
Complacency and apathy can be observed even in groups with high competence. This syndrome is known as Groupthink. The article is very interesting and really reinforces the need to develop further work on risk perception and on the dynamics of groups, including an analysis of the profile of leadership. In pathology Groupthink is the leader primarily responsible for the existence and maintenance of this syndrome in the team. The same took place in Chernobyl and others large industrial accidents.

Kevin Kolmetz | Feb. 7, 2012
Agreed that the article above drifts into some volatile references with no hope of supporting linkages in a short article but the phenomenon does clearly exist in various ways - call it complacency, errant strategic frame, over-rationalization / "norming" - whatever, its a dangerous trap to fall into as a person or as a company. The most severe Real Life example of this principal was the Space Shuttle Thruster program where acceptance of new "norms" for seal integrity was based on flight experience, deviating from original design parameters. We now know that more comprehensive data analysis would have shown trends and highlighted key flaws that eventually lead to seal breach & total system failure.

Jez | Feb. 7, 2012
From an operations and maintenance perspective, management in various companies have given us far more to think about than the safety aspect of the job at hand. Gone are the days when you were handed the days work & permits on paper and you just went about your tasks diligently and with forethought. Nowadays we are also responsible for stores management, maintenance system cordination & management, drawing system management etc, etc. I am lucky to get in a third of a day actual work. Most of the day I sit tied to a computer, demotivating, deskilling, depressing. No wonder the incident frequency is lower, we dont actually do as much as we used to.

william | Feb. 6, 2012
Pressure from investors demanding the maximum return on their investment, filter down to managers and the workforce with rewards of attractive bonusses to produce above average can led to over eagerness and physical exploitation causing the lost of focus on safety issues.

Eric Hevle | Feb. 6, 2012
While the psychological principle would appear to have some merit, it was not developed beyond the introduction. The credibility of the article went south when political undertones emerged in references to mysterious risks of deepwater and the arctic, and the implication that cost cutting was the root cause of Macondo.

Daniel Dominick | Feb. 4, 2012
I totally disagree with this assertion on the north sea work force. We are constantly thinking about and assessing each task on its own merits. You can not compare the safe systems of work and workers awareness to American standards that if that are the same offshore America as they are onshore their on site safe systems of work are a joke. If the Discovery channel is anything to go by. I have heard lots of first hand stories from the GOM that I would not even consider applying for employment in that area. Gung ho get it done American management attitude. From A Worker

Barbara Saunders | Feb. 4, 2012
Wow, Rick! Great quote! Im putting it above my DESK!

Mark | Feb. 3, 2012
Something I think that has changed over the years, is now nobody has experience. Years ago people worked their way up the ladder. But today it is about moving up and fast. Today, nobody is allowed to get hurt. The smallest cut is treated like the worst thing possible. After I went for a few stiches I learned to take care of my fingers. I remember when we first started getting safety guys right on the rigs, it was usually a lazy floorhand. But those guys had actually worked on a rig. Now the safety guys need to go to school and come out with a degree. They can make fancy charts, tell me to do the "Step Back 5 x 5" Talk about the "Mission to Zero", "Watch your slip, trip and Fall" "Pinchpoints". But really cant tell me anything about my job. I have worked on land rigs to big offshore and the bigger and more expensive the offshore rig, the bigger the attitude. How many useless people were on the Macondo well at the time of the blowout? Creating a distraction. I remember sitting in a safety meeting one time after an incident and somebody for the oil co. suggested we needed to do more paper work. But according to their own safety stats the rigs that had the most paper work, were the ones that had the most accidents. Actual on the job training. Good quality. That is what we need today

Robert Gaston | Feb. 3, 2012
This consultant confuses complacency with competence. A competent hand is not standing around unaware and trembling just because hes working in a potentially dangerous situation. Were there to get a job done as safe and good as possible, while being aware of the hazards. Ill guarantee that this consultant has never pulled slips or worked on a monkey board!

Rick Weiss | Feb. 3, 2012
"Success breeds complacency. Complacency breeds failure. Only the paranoid survive." Andrew Grove, fromer CEO of Intel Corp in his book, Only the Paranoid Survive, Doubleday (1996)


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