Streamline Your Security with Pipeline Safety Management Systems for Security

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and I think here's the clicker and Cameron is doing the uh switch right now thank you Jeff for that very kind introduction your check is in the mail some of it was even true that's pretty cool he asked me to be brief but I am an attorney and so that means my number one creto is never use one word when two will suffice but we'll try to get we'll try to be brief I don't think you it's not at the beginning how do we get it to the beginning well we're doing that just briefly for those of you who may not know I'm pretty sure most of you know what the NTSB is but we are the accident investigators we we investigate accidents in all modes of transportation you see us a lot in aviation we were just on TV last week for looking at the Asiana crash in San Francisco but we also do uh railroads and major highway accidents and and Maritime and the reason we're here now is because we also do pipelines so um that's that's what we do and we and our main output is recommendations and we do it with a focus on safe so since we are not a regulator uh the media would have you believe that because we issue recommendations we can't require anybody to do anything the media would have you believe that people just trash them say this is just a recommendation but in reality they do it more than 80% of the time even though it's not required and that's to me that's a tribute to our permanent staff like John VB who's here in the audience that's why it's an honor and a privilege for me to be there to work with such worldclass staff because that means two things one is they are worldclass investigators to find out what really happened what went wrong and two they are worldclass analysts to look at at that investigation and make recommendations to try to prevent it from happening again so we are here because of a recommendation that we made so I'm going to talk about that SMS recommendation and I'm also going to talk about a an example because the best example I have although it's not at an organizational level it's at an industrywide level but I'm going to I I would submit to you that this industry level success story is transferable to organizational level pipeline operators uh in terms of a way to implement SMS because this this model the word SMS the the whole concept SMS never really entered the room but yet it does exhibit all the characteristics of the SMS so it's going to be an aviation success story then after that I want to close with talking about some of the external issues external to the operator namely the role of the regulator the regulator has to be on board with this and they obviously are and also the role of the manufacturer of the equipment that you use they they also need to have a process that feeds into this so first we're here because of the Marshall the Enbridge uh pipeline event and Marshall Michigan and we issued the report in 2012 and our probable cause talked about a lot of organizational problems that the company had and that's the reason we're here we and then one of our findings was this situation would significantly benefit by the implementation of a safety management system so that's what that was one of our recommendations to API was to uh convene a group to look at developing Safety Management systems for your operators so that's the reason we're here and kudos to you guys for being here and for doing this recommendation we can issue recommendations till they're we're blue in the face but what gets us excited is when people actually do what we say and that's why I say they do it more than 80% of the time so we're really pleased with that but but what you did is actually a collaborative model of what I'm going to talk about and kudos to you for doing it in a collaborative way because we found that that's usually successful when you're dealing with complex systems now again back to the aviation model the complex systems and I'm sure that your industry shares a lot of this because I don't claim to be an expert in your industry and I'm not going to say one side fits all but I am going to say there's a lot that could be learned from this success story that and I think a lot of it is transferable to your industry as well so starting with the context the context is it's a very complex system of subsystems that are interconnected and because they're interconnected then if you make a change in one subsystem you have impacts throughout the other subsystem so in our case and in yours I I think as well it's large complex interactive system often tightly coupled and new technologies all the time so we're always on a learning curve that means we're always we we can never sort of rest on our Laurels okay we figured that one out because we're always on a learning curve with the new technologies so in that environment what we find is the safety issues typically are not because of one of the subsystems but they're because of the interactions between the subsystems so that's kind of good news bad news good news is these systems are so robust that one thing rarely hurts anybody but the bad news is they're so complicated that it's very difficult to point to a place and say if we just intervene right there we will stop this from happening again so so that's the good news and the bad news in that situation what we see is when it gets more complicated then it increases the likelihood of human error in three ways first just because it's more difficult to design it without making it error prone second because the operators the people at the pointy end of the spere as James Reon would say are more likely to run into situations that even the designers didn't anticipate and third the people who make the rules and and regulations and the processes and procedures likewise a lot of things they don't anticipate either and so the operators that you have who have good employees who are well trained seasoned PR professionals and they say well if I do it the way the rule says that'll that'll accomplish this but if I do it this way I can do it better faster cheaper and so that's they're deviating from the rule because their experience shows them that that they can do it better faster cheaper so the question is when you know when things go right you say oh Joe that was great you did a wonderful job when things go wrong you say hey wait a minute you didn't follow the rules but when people don't follow the rules because they're trying to do it better faster cheaper the question is what how do you handle that situation do you punish them for not following the rules or do you say hm wonder if there's a reason why they're not following the rule like maybe the rule wasn't quite right for this situation and that's that's what we find is if you got good people who aren't following the rules there's probably a reason for that especially if it's been happening for a long time with different people same rule different people and they're not following the rule there's probably a good reason for that and the good reason is probably because the rule itself needs to be Revisited because it doesn't quite fit the situation and that's why you're good people who who know a way to do it better faster cheaper do it better faster cheaper so those are those are what happens when things get more complicated more likely to less less easy to make it error free more likely to have operators an encounter unanticipated situation and more likely to have people do it differently than the rule say the result is added that your Frontline staff who's highly trained competent proud professionals are still committing error and that's the key to it every industry I talked to and I talked to lots of them because when I was at the FAA many Industries came to the FAA and said how are you guys managing risk as well as you do so that's as a result of that I'm talking to nuclear power and chemical manufacturing and petroleum refining and Banks and Healthcare lots of different Industries even a school board came to me to talk to them I said what I don't get it they said well you try to stop plane crashes our plane crashes when someone drops out in the ninth grade wow that's that's an interesting notion so that they had lots of I'm finding out that this is much more generic than I ever knew and that's that's the exciting part and what made me realize how generic it was when I started down this path was a report from The Institute of Medicine in 1999 that estimated somewhere between 90 between 44,000 and 98,000 people die every year in US hospitals due to Medical error wow that was so when I read that report you read that and you replace operating room with airplane and doctor with pilot it looked just like us and that's when I realized that we're inventing the same wheel so that's when I started reaching out to other Industries and they started coming to me and that's the reason I'm speaking to so many Industries and every one of them I say like I said to you I am not an expert in your industry I don't pretend to be so I'm not saying one size fits all but I am saying there's a lot that we can learn so the solution is system think how do you understand what's going to happen in these other subsystems when you make a change in this subsystem the way they did it in aviation was system think via collaboration and that's why I kudos to you guys for collaborating because the collaboration means bring everybody who's got a dog in the fight together so that collectively they can do four things one is identify what the problems are two is prioritize the issues because you're going to find more things and you have resources to fix so you need to decide what's going to be front burner and what's going to be back burner number three is you put some implementations in place for the ones that you put on the front burner and then four is evaluate whether those implementations are a doing what they're supposed to do and B not doing what they're not supposed to do so that's that's the collaborative effort and it's been a huge huge success story and there was a real Catalyst for it in aviation this didn't just happen because some people sat down and said collaboration is a good idea there was there was a real Catalyst and the Catalyst was that their fatal acccident rate had been coming down wonderfully for a whole bunch of years until the early '90s and it started to get stuck so for example introduc introduction of jet engines they're so much more reliable than piston engines that brought that caused a Quantum drop in the fatal accident rate introduction of simulator so now practice the pilots can practice stuff in simulator you never want to do in a real airplane so if they ever actually see it in a real airplane okay been there done that then they know what to do so lots of reasons why that rate was coming down but then it was starting to get stuck so meanwhile the FAA is projecting double of the volume of flying in the next 15 or 20 years so the aviation marketi marketing folks in the aviation world are saying wow that's kind of scary because flat rate times double volume simple arithmetic tells you your aunt and porori is going to be seeing twice as many smoking holes on CNN and your aunt and porori is not interested in don't worry the rat's low your aun pii is counting the number of events and that's what scared that's what scared them in aviation to say we got to do this different because do the Einstein thing you keep doing what you've been doing you're going to keep getting what you've been getting and what we were getting so far is a flat stuck rate so that's what started that was their Catalyst to start something they had never done before which was collaboration so basically what it meant was changing the way they think from we put a lot of money in and training you and if you had absorbed the training you wouldn't have messed up so apparently you weren't careful enough and that means it's time for punishment so that's what they would always do something goes wrong somebody gets punished okay took care of that problem well you didn't take care of that problem because people are human and humans make mistakes what does that mean that means we need to look at why people are making mistakes two aspects of that why did the system allow the mistake and two is why couldn't the system accommodate the mistake without catastrophic consequence and then see what we can do to improve the system so this was a huge shift in thinking from punish punish punish to Wow Let's see if we can fix the system and figure out why these good highly trained competent proud professionals are making mistakes and in the case of pilot they're making mistakes that can kill themselves that they say the pilots are the first to arrive at the scene of the crash and that's not where they want to be so there there was a real big red flag waving here that why are these people making mistakes and these mistakes can kill themselves so if a person is tripping over the step x times out of thousand you have to ask is it because the person is Clumsy what is the problem is it because the person is Clumsy or is the problem the step so should we just say be careful at the step or should we do more than that should we paint it should we light it should you know in other words what is the real problem here is that the person or the step well the real problem is actually the interaction between the person and the step and that's that's where we're coming from is it's not the system it's not the person it's the interaction between the person and the system that we have to try to understand the way we have to try to understand that interaction is by collecting and analyzing and sharing data so that's the fuel for the process is data that's the stuff that's happening every day that's going right that's going wrong that's the fuel for this process and the objective of the process is very simple make the system less likely to cause error in the first place and if it does cause error make it more able to tolerate the error so what was the result of this collaborative process in aviation after that stuck flat rate they started this collaboration in less than 10 years they reduced that flat stuck fatal accident rate by 83% and that was pretty amazing because they Ed system think and they fueled it with that information from proactive information programs and guess what they proved not only safety but they improved productivity and that just flew in the face of conventional wisdom which says if you improve productivity can hurt safety and vice versa they improve both of them at the same time so I have a theory about that my theory is I'm at the table I'm collaborating I'm here to talk about safety but I'm not even going to put an idea on the table if it hurts my productivity because I know what my productivity is and I know what's going to hurt my productivity that's something the regul the regulatory process can never do can never really account for productivity the way that collaboration can and that's why and I'm not surprised to hear Jeff say there were some highly spirited meetings at first because these people have very different interests and that's why oops did I oh okay this is basically talking about the collaborative process and how they brought the Airlines and the manufacturers and air traffic organization Pilots everybody the regulator together to identify prioritize solve and evaluate so the moral the story is if if you're involved in the problem you need to be involved in the solution that's very simple so I'm trying to find out okay there it is why was why have I not ever seen this at an industry-wide level before or since because it's very difficult to do this is not natural this collaboration is not natural the old model is the regulator says I'm in charge here and here's the problem I see and you guys need to fix this problem by doing X so they put out a notice of proposed rule making everybody responds to the notice so the regulator hears what a thinks they hear what B thinks they hear what C thinks hear what D thinks but a never finds out what B and C and D think and the regulator is not privy to any of that A and B and C and D trying to understand each other's perspective so what happens is regulator does this everybody doesn't like it they say fa you don't fly airplanes you don't understand airplanes and I don't like your identification of the problem and frankly Your solution is horrible it'll reduce my productivity it really won't hurt my safety etc etc I'm going to fight it I'm going to litigate it do everything I can not to do it and to the extent I absolutely have to do it I'm going to do it minimally and begrudgingly so that's the adversarial typical regul regulatory process collaboration is night and day different because now by the time something exits that process everybody is on board with it because everybody's involved with identifying the problem so everybody's got Buy in because they helped develop it and so that means they're going to promptly and willingly implement it and not only that but I can guarantee you that it's a if it's a complex system the first one that comes out of the box is not going to be quite right it's going to need some tweaking and so because everybody's got an ownership interest in it they're going to want to tweak it to make it work better that never happens in a regulatory context so the solutions better it's more effective it's more efficient and very much it's it's highly unlikely get given that collaborative participation to have unintended consequences let me add another one another footnote to this they did this whole thing this 83% Improvement in 10 years without a single regulation no new regulation when I made that statement to the American banking Association after the Meltdown of 08 and they're facing a flood of regulations they gave me a standing ovation wow no new regulations so this is a win for the government too because now as a regulator they're actually accomplishing the Improvement of of the risk management impr Improvement without new regulations they're doing it because the people want to do it because they're doing it through this collaborative program so why is this so challenging well first you start with human nature human nature says I'm fine you're not I don't need to go to the marriage counselor you go to the marriage counselor okay so everybody comes in so the manufacturer says hey I built the airplane great if the pilots would just fly right and Airlines would maintain it right we wouldn't have a problem and the and the airline says if they just build the airplane right and the piles of flly right we wouldn't have a problem and the of course the regulator says if you just follow the regulations duh we wouldn't have a problem so everybody says my stuff is okay you got to get your act together so getting people past that is no small feat they often have they are very much very likely to have different interests but also likely to have not only differing but competing interests so labor and management they have competing interests and the Asiana crash I can guarantee you one of the defendants is going to be the airline and one of the defendants is going to be the manufacturer so they're going to be beating up on each other in court but yet we're asking them to come and play in the sandbox together in this collaborative process so that's a huge challenge then the regulator nobody wants the regulator there I'm not about to Bear my soul in front of the regulator so nobody wants him there and by the way the regulator doesn't want to be there because they say wait a minute hold it time out this that smells like a democracy to me this cannot be a democracy the law says I'm in charge here so don't don't give me this democracy stuff well it really isn't a democracy what it is it's an information sharing process that enables everybody to understand everybody's perspectives including the regulator and and enables improvements without in our case the need for new regulations and it was a huge win-win but it only happened when people realize in their enlightened self-interest that it can be a win-win if they stop their myopic protect my comfort zone and start thinking about how the system can improve so that we can all improve so that was a huge huge Challenge and that to me is the only reason I can figure out why I have never seen this collaborative concept before or since in any other industry and the and the Lynch pin of this is trust so it's that's why it takes so long to build that's why they had heated arguments at first until they started realizing hey you know what we have a common objective here there's no point in US beating up on each other we have a common goal here and so let's take that as a starting point and use that as a way to get moving and develop the trust so that means it takes a long time to build easy to destroy trust is tough so question is I gave you an industry level example can it apply at an operator level and I would submit it can apply at any micro or macro level at which you define a problem that you have with a system that's not working even down to the workplace level I I would submit that this process can be used for workplace safety as well it can be used at any micro or macro level that you define that you have a problem get a collaborative effort around that problem and solve it so I would submit yes it does I would submit that it would work at an operator level now having said that this the beauty of this process is it has all the elements that I saw in the draft safety management system document but they don't they never did use the term safety management system in this entire process when it was underway but yet you will see that every element that's in there is in this process so that's that's a great thing and and and that's why I'm submitting this to you as a a way to do it not the way to do it but a way to implement 1173 now here's some external factors first of all the regulator's got to be on board with this because as I said the fuel for this process is information and if the regulator doesn't Define very care how this information will be protected then people will not provide it because they're afraid they're going to lose their job if they provide it so the regulator has to emphasize the importance of system issues in addition to not instead of but in addition to worker issues because nothing that I've said is get home free get out of jail free for the worker because the worker is always always always ultimately accountable so I'm not talking about don't look at the worker I'm talking about look at the worker who is always accountable and also the system in which this proud highly trained competent professional is trying to do their thing so it's it's worker plus system it's not system instead of worker encourage and participate in industrywide system think and the and right now I'm hearing that the regulator is participating in it and kudos for the for the regulator for participating in this collaborative effort but here's the key as I said the information is very sensitive and that and who's got the ultimate control in most Industries over the protection of the information the regulator does so if the regulator doesn't clearly announce the protections for that information then the people on the front lines who know it live it and breathe it every day and have that information will not put that information into the system because they're afraid for their own job so that's a crucial role by the regulator in order for people to have Safety Management systems at the operator level and last but not least the the regulator if the regulator views that their goal is how many people can I punish then we got a problem here but if the regulator views that their role is how can we improve the management of risk in this system then that's a very different goal and and what I'm hearing from Jeff is they have recognized that their goal is not how many people can we punish and that that's a tough one for them because when they go to Congress and say give me more money and Congress says why should I give you more money if the answer is so I can punish more people well that's easy to measure that's an easy answer to give but what the answer ought to be is so I can improve the management of risk in this industry but that's a tough one to measure and a tough one to go to Congress and say look at how well we've managed the risk more money we can manage the risk better so you know my my sympathy to the industry for how they can do this because their easy metric is how many people do we punish they're more difficult metric is how is the risk management in our industry another external factor is the manufacturer because the manufacturer if they don't if they don't Engage The End user in making what they make then there's a problem by the time you get the equipment as the purchaser of the equipment so let me tell you again using the aviation example what happened there the manufacturers used to just put the airplanes out there and the airplane and the pilots would say Pilots are the end users they would say I don't like this I don't like that so the so a couple of the man some of the manufacturers said wow we could probably make a better airplane if we brought the end users in to help us design it so they bring in the end users to be Consultants early in the design phase you have to wonder when you get some of these software upgrades you say did anybody ever really use this thing because I want to do the outline this way but it won't let me because it's going to make the outline go that way have you ever had that happen where you and the software don't agree you have to wonder did they ever really have a real body use this stuff well that's what they did that's what the manufacturers did they said let's bring the end users the pilots and have them help us with the design okay number two airplane has to be has to in order to be economically viable it has to last for 40 or 50 years which means it better be maintainable so the example I use is if you take your car to get spark plugs changed which you have to do every 10 or 12,000 miles and the mechanic says oh yeah sure I can do that but I have to take the engine out because it fits so tight I can't get to the spark plugs I have to take the engine out of your car in order to replace the spark plugs so what a horrible design that would be not only because it's usually inefficient to have to remove the engine every 10 or 12,000 miles to do a own replacement function but not only not only that it's also look at all the opportunities for error that that introduces when you have to take the engine out just to replace the spark plug so they bring the mechanics in early on in the design phase to make sure the airplane is very maintainable number three this airplane has to fit in the system of air traffic controllers and the air traffic controller is going to ask it to do a lot of things and and most of the time the airplane is on automatic pilot so that means if the automatic pilot can't easily do what the air traffic controllers typically will ask it to do then there's probably the airplane does not not fit in the system there's a misfit and so they bring in the air traffic controllers early on in the design phase to make the airplane fit in the system so so these manufacturers have looked at friendliness at three levels user friendliness maintenance friendliness and system friendliness and I ask you how much of that do you see with your manufacturers I mean it may be happening out there I may I may not just not know about it but to me the equipment that you get by the time you see it should have gone through process like this in order for the manufacturers to make sure that it suits the needs for which it is made so that's the other external Factor one is the regulator and two is the manufacturer to help as supplementary aspects of successful safety management system so a properly structured collaborative safety improvement process includes all of those elements I'm not saying it's the only way to do it but I'm saying it is a way to do it and I ask you to look at that in terms of figuring out how to implement safety management system in your own organization the industry level collaborative success story I think is a model for an organizational level collaborative success model and the regulator plays a key role because they are the ones who Define the protection of the information and the manufacturers play a key role because they are the ones who provide the stuff you work with all the time that has to has to fit comfortably within that system in order for a safety management system to be successful so thanks again for the opportunity to be here I don't know how much time we have left but I'd be happy if we have time to take any questions you might have thank you thank you Chris CH Chris has graciously agreed to take uh any questions so I I welcome those of you who are here and also those of you on the webcast as I said there was I gave you the address earlier um I think it's pipeline Forum at dot.gov right anyone recall Darius pipeline Forum at dot.gov feel free and we have someone monitoring that email address so anyone uh have a question here for Chris Linda yes and I'd just like to ask everybody who does step up in the mic please uh you know tell us who you are and your Association I'm apparently very short Linda you don't count because you've heard this before no just kidding yeah but I have a new question so I'm Linda dy I work for fima office of pipeline safety actually I work for Jeff but here's my question Chris you talked early on about the need to get a variety of people involved and the success of the FAA model is because so many people were involved they were collaborative and engaged and developed a good product and they implemented it what I struggle with is the idea that the people that you see in this room or the people that are watching us on the webcast from the industry or other regulatory groups are engaged I worry about the people who aren't engaged because at this point you know we aren't looking at a regulation we're looking at a good process a good safety standard that people would voluntarily Implement how do we get to those folks that that aren't engaged that say eh it's not a regulation I'm not going to worry about it I got a good safety record right now I don't need to do anything more how do we reach those people and how did the FAA folks do so that's a good question how do we get to the people who aren't engaged the engagement in the in in our industry we have a lot of uh public attention whenever anything slightly goes wrong so an airplane can go off the end of the runway everybody gets off the slide sprains a few ankles in its National media 35,000 people die a year on the highways and nobody really hears about it so so we have a huge impetus in terms of the national attention that we get which is which was the incentive for a lot of people to participate now we also have a lot of players but in situations where we have a lot of players they participated through their trade associations not individually but through their trade Association so the airline for example participate through its trade Association the the manufacturers the big airplane manufacturers there were only two of them Airbus and boing so they participated directly then there were the unions and they participated so so the idea in having that level of participation is first of all that was the vast vast majority of the carriers of passengers in the US so that covered most of them but there were still those people those outliers that you're talking about two things on that one is the the uh intention there was to show what an amazing success this could be and and then let people who weren't participating say wow that's really good news I can participate in that too and number two is when we showed it was sustainable because we safety people hate to say that if it hurts the bottom line if this program hurts a bottom line it's probably not sustainable but unfortunately if it hurts a bottom line it's not sustainable this is sustainable and has lasted since the mid 90s because it does improve productivity at the same time so so showing it's a success story and that it's a success story that improves the bottom line is what starts to bring in slowly but surely the the latecomers so it's basically the snowball that builds on itself but that's a very good question and you know getting that core started and that's why some sometimes when people have a tough time thinking of how am I going to get this process started I recommend taking a beta test on something that's been your your your worst bur under the saddle for years and years like if it's workplace safety what's been what's been a workplace safety problem you've had for years and years and years you've tried this fix you've tried that fix the other fix still a bur under the saddle and and take your your worst nightmare and do a beta test a collaborative beta test around that bring all the the players together who have a dog in the fight and if that can if that's successful that's going to be instead of just me talking that's now going to be an experiential example of how successful this can be and that then grows on itself so that's what I suggest when you you know I I don't suggest most people start at an industry level like they did in aviation I suggest a crawl walk run and the crawl would be some micro situation with do a beta test around a micro situation okay other questions Shelly feel free to just raise your hand if you see anything in coming in from webcast I I wonder if I can ask Wiston um I I hadn't made a lot of notes as you were talking I could probably go on on this forever but one of the topics that the committee wrestled with was the role of culture in safety and I know Chris is a thought leader in a lot of areas and I we've talked about safety culture before it's been an important facet uh of attention for the NTSB so I just wondered if we could get you know your quick thoughts on the role of culture and how does that serve the goal of safety or zero incidents that's that's a fair question because again that's another term that was not mentioned in this process safety culture but the fact that these people got together and realized they had a need and that they could actually produce a win-win by getting together that in itself was as a manifestation of a safety culture amongst those groups that were that were doing it but you you never heard the term safety culture as such so so you know I'm I'm not sure that's a direct answer to your question except to say again we had that impetus that we get so much media that we don't want you know anytime we get media it's because it's bad news and so that was our impetus and so it wasn't really somebody saying I have a safety culture with somebody in said it was somebody saying very practically I don't want a crash because another reality in our industry that I haven't seen in other Industries is that everybody's crash is my crash because the public doesn't think oh that was such and such Airline therefore I'm not going to fly on them but I'm going to fly on the others but the public perception is that was an airplane and I'm about to get on an airplane and so like when I saw BP Horizon from from my experience in aviation when I saw BP Horizon I said oh this is just a matter of time before I see all those other companies show up and say you know this was an industry accident this wasn't a BP accident this was an industry accident therefore I'm going to contribute bodies to help with this cleanup didn't see a soul n a soul and that really shocked me about how different our industry is because our industry views even non us I mean the Asiana accident or an accident in Russia or in China India that's National that's an international media and and the the general view in our industry is everybody's accident is my accident so we all need to work together so that's not sort of safety culture as such but it's just the the fear of the B publicity if you will and you know I I was just shocked that all those other oil companies didn't come forth and say this is an industry problem and we are going to contribute bodies to help with this massive cleanup so so that's one of the reasons I say okay maybe one size doesn't fit all because I know all Industries don't share that characteristic obviously because I saw it in with you know with BP Horizon but nonetheless I think there's a lot that can be learned in a lot of this process that is transferable great I know we have one other question over here maybe while you're standing up there I'd just say I'd love to and I bet we could explore for a long time this whole business about how do people react to accidents and how to their enlightened self-interest because oftentimes what I find when we're having discussions with people is we're not aligned on the goal you know the goal was performance of the system right but there uh a lot of people will be obsessed with uh compliance as the goal and there are a lot of problems with obsessing on compliance as the goal you know as we all know that is a negotiated outcome you know often times and it's a litigated outcome so there are a lot of drivers in that world you know whether it's the Congress as you mentioned or others who were calling for blood and I suspect after deep water Horizon there was a lot of that so everybody retreats to their corner so quite interesting um any rate I recognize Stacy Gerard who's who's come a member of the committee and my former boss um who loves this stuff so she stays engag Stacy I know you had a question error and the um the the problem of deviance from rules and you talked about the mix messages that leaders can send when they go great productivities up and however you're doing it keep it up uh and how does the leader become aware of uh a high rate of deviance from procedures and how what would you recommend to a leader to sort of unearth that problem and how to approach remedying it that's a very good question how do leaders become aware that's one of the very fundamental roles of a of a near Miss reporting program so if if the people who do it live it and breathe it every day if one of their reports is I did it ing to the regulation and almost had a problem so therefore I did it contrary to the regulation that kind of reporting from the front lines because I guarantee the front lines they they know better than anybody in the system what's working well what's not working well and they probably also have some very good ideas on what to make how to improve the things that aren't working well so that would be a source of but it's also a source if OSHA shows up and says you're not complying with this rule or that rule and if and if you see a lot of that and it's happening over over the years then that's when when you see for a long-standing non-compliance that's what some of the writers called normalization of deviants and and it's not a good thing the reason it's not a good thing is because there is a disconnect between what the people are doing and what the rules say they should be doing there should not be that disconnect so that so the question is is it because we got bad people and if you do have bad people then I'm first in line to say get rid of them or do you have good people trying to do it better faster cheaper but the rule isn't quite right so so there are lots of ways to find that out but a near Miss reporting system is is certainly one of the ways hopefully you find it out from that before you find it out from your regulator but that that certainly is a way to find it out is by a reporting system that says I I did it ing to the rule almost had a oops did it another way work better etc etc so that it's it's very important to have a robust reporting system so that the people up top don't have the General Motors thing where the bad news never reaches the top okay any other questions Shelly has one coming in from the webcast so if you'll give me just a second to get in there you know one of the one of the things that we've struggled with too while I wait for this question is you know how do you adapt something like this thank you how how do you adapt something like this um to operators of varying sizes I know in in the aviation world you know you're dominated by some very large players but in the pipeline World there are some very small players um and then also some very large players so the I know the committee wrestled with that tirelessly um and I think the reason that we wrestled with it so much is so many obsess on the compliance aspect and while Linda said we don't intend it you know anytime real soon to make it a regulation we see it as the right answer we're trying to help here uh there are some who will say well even if it's not you a court of law will say it's a standard and therefore we should have been following it regardless of our size so I don't know if you guys struggled with that at all with small players that's a good question and I probably don't have a good answer because my experience is not based on my experience is based on a small number of big players we don't have a lot of small players that actually goes in part to Linda's question too about how do you get the you know the non-compliance to to join the party so to speak and I don't I don't have a real good answer for that because we I didn't I don't have an experiential basis for answering that because that's not our experience but but that's that's a fair question and and hopefully they they too will see the benefit of doing the collaborative thing so that it not only makes them safer but improves their bottom line as well and I think to your point we we did invite in uh in our first Workshop Armando Martinez if some of you may remember him from that Workshop he's uh uh one of the senior guys at Miami air but very small and Armondo I thought very eloquently made the point that he actually made money on it you know it wasn't his productivity did jump he was able to hire somebody else to help him he had done so well on this on the return on his investment so while he was skeptical at first so your point early on I think Armondo made a really good case that is on YouTube if you want to watch it anyone so the question that that came in from the webcast was from Gary at e well hey Gary um question had to do with operator qualifications and Gary was pointing out that that was a collaborative uh process but it wasn't well received by many and what were the Lessons Learned I don't know that that's a fair question for you as much as it might be for us but I you're welcome to swing at it this was we had a negotiated rule making some time ago I think that's one thing that sets it apart from what we're talking about that was a negotiated rul making to establish compliance levels um and it I'm not so sure about the assessment about it not working well I think and there were many things in operator qualification that did benefit I'm not sure I understand the reference operator qualification can you help me we established a negotiated rule making to set qualification requirements for people who were operating and actually physically working on the pipeline uh and so I think it was a good experiment at the time people decided rather than the regulator go off in its corner and think up what they think should be done and throw it out there we entered into negotiated rulle making and so I think in there the difference there was I think that everyone saw compliance as the outcome um you know as opposed to Performance and so we're uh they're coming in great um so I I don't know that that's a fair one for you um I think it was really a sort of a regulatory one um here's one from uh christe Murray someone we all know well um she mentioned she said you mention SMS could be used in various Industries have you seen Regulators apply the system think model internally within their federal agencies if so could you provide an example the only that that's a very good question U and it's interesting for example in aviation that the international uh if you will the international regulator it's actually the aviation organ of the United which is called IO International civil aviation organization they mandate mandated Safety Management systems for airports they Mand mandated them for manufacturers they mandated them for operators strangely enough they didn't mandate them for Regulators so it's kind of like again I'm okay you're not so it was so the answer is the I have seen some Regulators start to do that but they're kind of late in the parade relatively speaking because it's kind of the that's that same thing I'm okay you're not so you need a safety management system I don't so I am starting to see a move in that direction but it is slow to be sure slow at best great any other questions for Gris Andy Chris hars good to see you my name is Andy Drake with Spectre energy um I hear your challenge to us I guess I have a a question that just sort of hit me with with your comment and that is this standard is really being developed with more of an intent I think to be applied to operators how successful do you think think we will be in our bigger charge of driving pipeline safety incidents down if it stays only applied to pipeline safety operators and isn't embraced on this bigger scale that you talk about with the FAA that's a good question I I would suggest to you that a this application operators is could be a good starting point to for a broader application and that's why I'm saying crawl walk run is what I would recommend as opposed to you know starting at this industry level I don't see a lot of industries that can start at the industry level the way we did uh and that's why I suggest starting at a at a more of a crawl walk run type approach then go for the whole nine yards so I I would see this as a assuming it's successful because of the collaboration is done appropriately and what what we saw in aviation was in order to make it successful we needed Progressive leaders in two important places one was in the industry and one was with the regulator and we were lucky to have both of those at the same time to help push that and I'm seeing some Progressive leadership already just from what I've heard about this effort so I think this could be a foundational effort to be used as an example for others to look to how to broaden it okay I think last question we'll take and just I want to be respectful of the people who are participating via webcast Gary out there I'm I'm still struggling with myself on this one Chris so feel free to uh you know punt but uh the comment says the deviation from compliance versus deviation from procedures is the topic one is a regulatory issue but still a problem can you comment well I guess when I'm thinking of compliance I'm thinking of compliance with a a procedure that was established by whoever could be by the regulator could be by the operator could be by whatever level I'm talking about deviation from the way the book says to do it whatever that book might be and to the extent there is deviation from the book whoever invented that because the chances are that whoever wrote the book is not an operator not a Hands-On operator if there's deviation between the way it really works and the way the book says it should work that's a problem and that problem needs to be addressed because you you want to discourage deviation but not discourage it by punishing people who deviate if these are good people who find who are doing it better faster cheaper then that's a a huge red flag to to look at whether the the book is written in the way that responds to the situation and we've seen many of those in aviation where uh the book didn't work right so they you know an example I I give oftentimes is that when United Airlines and I'm not speaking out of school by using names because they were all through the trade press about this when they started looking at flight data recorders routinely they started noticing a lot of situations where the pilots were putting the flaps down too fast so so the flaps are the surface on the trailing edge of the wing that come down for takeoff and landing and the purpose of the flaps is so that you can fly slower and the purpose of being able to fly slower is so that you need less Runway to take off and land but when the flaps are out the wings are less robust so that because of that there's a speed limit on use of the flaps do not use a flaps above 250 knots I'm just picking a number okay if you use flaps above 280 knots you have so exceeded the maximum speed for flaps that you may have reached the structural Integrity of the wing so one of the first things they noticed when they started looking at flight date recorders was numerous instances and that by the way that's called a maintenance event flap over speed because when when there's a possible breach of Integrity then this airplane has to come off the line for three whole days major disassembly inspection reassembly to see if the structure was breached so one of so the the head of safety at United went to the pilots noticing in the flight data recorders numerous instances of not only flap over speeds but maintenance event flap over speeds two questions two two points to the pilots number one point I will not punish you with what you tell me number two why are you putting the flaps down too fast so they said well that's easy because the air traffic controllers are bringing us in too high and too fast and we have to do something to get rid of all that energy or we will not be able to do the landing successfully the first time because we're going too high and too fast then we have to go around do an aborted Landing now it's more work for the controllers more time on the airplane more fuel burn upset passengers etc etc huge huge lose lose but they are putting the flaps town too fast because they're trying to do the right thing and get the landing done the first time so Progressive thinker that he was he went to the FAA who employs the controllers who tell the pilots what to do and they said your controllers are putting my pilots in a situation where they have to do what they should not do in order to complete the landing successfully the first time in other words he realized this is a system problem and not a pilot problem so he addressed it as a system problem and not a pilot problem found out these approaches were great for DC 4S and DC 6s not so hot for 737s and they were just out of date had not been revised in a whole bunch of years so they Revis the approaches bottom line reduced maintenance event flapover speeds by 90% in less than a year wow that was that's when I realized boy there's not only a safety benefit but a huge huge productivity benefit by not taking these h1200 million airplanes off the line for three whole days disassemble inspect reassemble because they reduced flapover speeds maintenance event flap over speeds by 90% so so these Pilots were not complying with the book and even creating potential hazards because they could breach the structural Integrity of the airplane but they were they were trying to get the job done right the first time they weren't bad people that didn't like rules they were good people trying to do it better faster cheaper and what it showed them was that the that the way that they were being led into the system by the controllers was creating this dilemma for them and their solution for the Dilemma was we'll put the flaps down too fast so that was s a huge success story that showed yes these are people who aren't doing what they're supposed to do and you don't want people not doing what they're supposed to do you need to fix that and eliminate that disparity between what the book says and what the people are actually doing is if it wasn't obvious to you before Chris has a commercial pilot's license so is a pretty deep on this area on the aviation Chris I want to thank you I just for to Gary my only uh thing that I would add to that I'm just trying to be responsive to people on the webcast is I think that that's a good example of where we talk about focusing on compliance with the r regulation versus focusing on getting a solution that really works the regulation is always going to be the minimum that's required but certainly not what's needed in all cases it's the minimum that could be established through that negotiated process so with that I hope you'll join me in thanking Chris Hart for talking to us this morning my pleasure