Called Fourteen Times, Never Asked Why
The gauge on Tank 912 stuck fourteen times before Buncefield. Every one was noticed. Not one of them was ever added up.
Your defect log is not a record of what fails. It is a record of what was inconvenient.
01Somebody dealt with it. Every time.
Between 31 August and 11 December 2005, the servo-gauge that told the control room how full Tank 912 was failed about once a week for three months. Every time, somebody dealt with it.
Supervisors had their own name for the workaround. Stowing. Run the gauge up to its highest position, let it settle, watch it come back to life. When stowing did not work, they called the maintenance contractor out.
Two organisations were now holding evidence.
02Nobody was short of information
The site had an electronic defect log. The Competent Authority found the Operations Manager did not know the gauge had failed fourteen times in three months — and that the log was used least when a fault was cleared quickest.
The contractor knew how often they had been sent to that one tank. The report's finding on them is a single sentence, and it is the whole argument: they did not analyse why they had been called out so frequently.
So nobody was short of information. The information was complete. It sat in two buildings, in two formats, owned by two companies — and each of them was looking at a normal week.
Fourteen is only frightening as a total.
Split into fourteen small jobs that each got done, it looks like a team doing its job. Because that is exactly what it was.
03Competence is what erases the signal
That is the part worth carrying home. The most dangerous equipment on your site is not the equipment that fails most often. It is the equipment somebody is very good at fixing.
The failures your crew absorbs best are the ones your record will never show you.
Most systems can answer "what happened to this asset?" Very few can answer "how many times have we now done this, and who else has been doing it too?"
Pick one instrument on your floor. Not the worst one — the one somebody always sorts out quickly. How many times has it been attended in the last ninety days, and is there anywhere you could go to count?
Sources: COMAH Competent Authority, Buncefield: Why did it happen? (February 2011), paragraphs 26, 27 and 56.
The fix worked, so almost nothing was raised. The event was real; the record of it barely was. It happens about once a week for three months, and every time somebody writes something down. Nothing is missing. The record is just split between two companies, each seeing a normal week. No one was adding them up. The fourteen only exists because an inquiry counted it later.
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