CSB's first ever pressing security recommendation was handed out to BP in August 2005, calling on it to convene an independent section to consider security culture and oversight at all five of its US refineries. The description of that section is often referred to as the Baker Report. (Hussey, 2007, pp. 140-145)
In September 2005 BP agreed a register of corrective measures with OSHA, speaking to over 300 supposed violations of OSHA safety regulations. BP paid OSHA $21.3 million by way of a fine, but did not accept the supposed violations. In answering to the OSHA fine BP furthermore clarified that it had set apart $700 million to reimburse the families of those who past away and those influenced by the incident. In October 2005 the CSB handed out both a new pressing security recommendation on the American Petroleum Institute to evolve new security guidance for position of trailers, and initial outcome as to the determinants of the incident and recommendations to advance safety at alike sites. (Hussey, 2007, pp. 140-145)
When reading the findings of the report, one cannot help wondering why was the plant maintained in this apparently degraded level of safety while information was available and opportunities for action obvious (for instance the replacement of the blowdown system by a flare system). But at the same time, some similar reports of investigations of past accidents, such as the presidential commission on the space shuttle Challenger, were revised by social scientists while introducing principle of retrospective fallacy, but also by stressing the associated systemic nature of these types of accidents. (Hussey, 2007, pp. 140-145)
Task 1
The retrospective fallacy advocates that signals present in the past only appear quite clear in retrospect1. They are not as clear for the decision-makers at the time of the events as they are for investigators. “This warning is the warning of the retrospective fallacy understanding organisational failure depends on systematic research that avoids the retrospective fallacy by going beyond secondary sources and summaries, relying instead on personal expertise based on original sources that reveal all the complexity, the culture, the culture of the task environment, and the meaning of actions to insiders at the time” (Vaughan, 1996). Thus, based on this retrospective fallacy argument, Vaughan's “normalisation of deviance” (1996) suggested to revise some of the challenger commission findings. A main principle of this model is that signals at the time were weak rather than strong, and that decision to launch was strongly biased by past experience of engineers regarding joints behaviour as well as biased by their socialisation. This pattern was created and maintained by the production of a culture, a culture of production and a structural secrecy. (Luckmann, 2005, pp. 120-125)
The production of a culture occurs with the uncertainties of the technologies. Engineers introduced the technological uncertainties into qualitative and quantitative behavioural models, offering the ability to predict or to anticipate. Anomalies or signals about the gap between the anticipated behaviours and the observations were closely ...