Dimensions of organisational change assurance, risks and outcomes

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Dimensions of organisational change: assurance, risks and outcomes


The paper examines and comments on aspects of organisational change at
a partially integrated petrochemical complex owned and run by British
Petroleum (BP). The paper was written during the change process by
Trade Union leaders at the site. The paper examines all aspects of
proposed change and focuses on potential hazards and risks arising from
the review. The paper draws on experience, knowledge and committed
interest from around 1300 trade union members. The paper also attempts
to reflect the views of non-unionised employees as expressed during
workplace dialogue. The paper concludes that the proposed changes have
the potential to increase the risk of minor and major accidents at the
complex, to further endanger employees and members of the public and to
jeopardise safe, reliable and economically viable operation of the plant.


BP has operated from a site at Grangemouth in Central Scotland for
around 75 years and has plant and employees from Oil Refining (BPO),
Chemicals (BPC) and Forties Pipeline System (FPS). In recent years
there has been a drive to integrate the businesses and to reconcile the
differences in culture, operating philosophy and procedure which exists
across the three company streams. It is recognised that business and
economic climate presents challenges to the complex to improve
performance and cost efficiency.

The complex has a history of organisational reviews which have
invariably resulted in the reduction of employee numbers and a drive to
place responsibility for safe and reliable plant operation in the hands of
progressively more junior members of staff. The reviews have also
resulted in the removal of many layers of supervision and the evolution of
the organisational from a hierarchical supervised structure to a more flat
structure with cross layer responsibility for health and safety.

The complex has a history of high potential incidents resulting in injury
to employees and members of the public and extensive damage to process
plant. These incidents have contributed significantly to the poor
economic performance of the site in recent years and have resulted in
high-level media interest and a resulting reduction in safety confidence

among employees, members of the local community and the BP group as
a whole.

The complex underwent a “root and branch” review following three
major incidents in 2000 and the resulting recommendations are partially

The arrival of a new complex director has initiated a further review with
the stated aims of providing plant availability at 98%, a fixed cost
reduction of at least 25% and a threefold improvement in the single
reactive safety indicator i.e. Days Away From Work Cases (DAFWC).
The initial findings of the review point towards the redundancy of up to
1000 of the 2500 existing employees and wholesale changes to almost
every aspect of operation.

The objective of this paper is to outline and introduce the main issues of
concern, held by cross complex trade unions, around fundamental
changes to the organisation, change management procedures and pace of
change proposed at the site.

The paper will look at aspects of proposed operation and offer opinion on
the potential safety, health and environmental impact. The report does
not aspire to give fully developed technical argument on each aspect but
rather to open the issues to further examination and investigation.

The paper will examine reports of previous incidents and accidents,
beyond the site, and highlight similarities and emerging trends in the BP
Grangemouth review. Relevant health and safety legislation will also be
introduced and compared with actions at the site.

The paper will offer conclusions on the review and make
recommendations around both specific changes and also the change
management process itself.

This paper reflects the formal position of trade unions in regard to safety
aspects of the review and is quite distinct from political or negotiating
agendas. It is intended that the paper will be offered in the first instance
to BP company representatives both at Grangemouth and in the wider
group, Trade Union members, Grangemouth employees, Representatives
of the Health and Safety Executive (HSE), Representatives of the Scottish
Environmental Protection Agency (SEPA) and members of the BP
Grangemouth Community Liaison Group. The paper will be submitted to
the HSE and SEPA in recognition of their position as the joint competent

authority with regard to the Control Of Major Accident Hazards
regulations 1999 (COMAH 1999) and will urge investigation of the
issues where appropriate.

Change management is a high interest and current issue in the world of
health and safety and, with company consent, the paper may be offered to
any interested party as contextual information for research into the
methods and effects of organisational change.

Outline of issues

Process plant supervision

This section will look at proposals to fundamentally alter the way that
process plant is supervised. The section will identify flaws in the new
philosophy and describe, with reference to historical process accidents,
the potential results of following fashionable trends in organisational

Process plant supervision, across the complex, varies to some extent from
area to area at Grangemouth. The common principal is, however, that the
first layer of supervisor has an intimate knowledge of plant operation and
is not only able to understand fully the normal operation of equipment but
possesses knowledge, experience, skills and training which enable him or
her to react to plant upsets and to direct the team towards securing or re-
establishing safe and stable plant conditions. The supervisor also has an
embedded role and is regarded as very much a part of the team, this
enables him or her to informally discuss problems, work methods and
procedures and to be regarded by team operators as a source of help
which can be consulted within the local peer group.

The scale of geographical area and plant complexity, which a supervisor
is expected to cover, is the product of many years of experience coupled
with historical risk assessment and the implementation of change
management procedures during frequent management reviews. The
present level of supervision per area is generally viewed, by our members,
as adequate for most normal operating conditions but it is considered in
some areas that supervisors are sometimes stretched during abnormal or
emergency situations.

The current organisational structure provides leaders who have
knowledge of “outside plant” operation and also experience in operating
control panels or control screens. This provides a source of co-ordination,

advice and direction between sometimes remote operating stations and
live process equipment.

The company proposal and stated aim is to remove the familiarisation
between teams and leaders and to provide a force to drive performance
and production. The intention is to empower supervisors to discipline
and appraise team members as necessary.

The proposal is also to remove the current role of shift manager which
provides business wide co-ordination and direction during upsets and
plant emergencies and also assists with people management.

The proposal is to weaken the supervisory link between panel and plant
by appointing plant supervisors and separate panel supervisors. An
example of this is where an optimisation supervisor will oversee the
operation of all process panels in the Refinery area Central Control
Building (CCB) and production supervisors will oversee plant operation.
Trade unions have stated, following member consultation, that this
arrangement has the potential to introduce confusion and lack of co-
ordination across the areas of control and will remove panel operator
support during plant upsets and emergency situations. This also
constitutes the removal of a further layer of supervision i.e. team leaders
and shift managers reduced to one shift supervisor.

The proposal also includes amalgamation of two or more areas in some
cases and a reduction in the total number of supervisors. An example is
the Jetty and Chemical tank field areas where the supervisors will be
reduced from three to one across existing areas. A further example is the
Catalytic Cracking plant which will be combined with the Crude Oil
Distillation area, the areas currently have two team leaders to cover the
Catalytic Cracking plant, the Alkylation plant, No1 Crude Oil Distillation
plant, No2 Crude Oil Distillation plant, the Hydrofiner plant and the
Distillate Hydrotreater plant. Under the latest proposal this will be
reduced to one. It is clear that no supervisor has the necessary local
knowledge of all these areas, gained by workplace experience, and that no
amount of training will equip an individual to provide the present level of
operator support in this role.

The case of a heat exchanger explosion which occurred in Longford,
Victoria, Australia which killed two operators and injured eight has
striking organisational similarities to the proposals at Grangemouth and is
worthy of examination.

The 24th chapter of a book by Trevor Kletz: Learning From Accidents
provides a summary of events at Longford and is entitled Longford: the
hazards of following fashions.

The chapter criticises competence rather than knowledge based training
and the absence of proper Hazard and Operability Studies (HAZOP) but
the main relevance of the text is in the description of “Management re-
organisation and its results”. The section outlines how, in the early
1990s, technical support in the shape of engineers were made more
remote to the process plant how process operators assumed greater
responsibility for plant operations while supervisors became fewer in
number and less involved in “hands on” process operation. The original
report into the accident states that at the time there was much talk of
empowerment and reduced manning.

The writers view on the reference to knowledge based training includes
understanding of the work of Jens Rasmussen and James Reason which
created models of cognitive problem solving skills on three levels (skill,
rule and knowledge) which is vital to risk assessing the success
likelihood of human reliability in the face of major accidents as well as
fairly routine plant deviations.

The supervisors role, at Longford, became more administrative in nature
and left operators without adequate and structured support. The report
also highlights how chats in the control room allow operators to admit
ignorance in an informal way to embedded team supervisors and how this
is depleted when formal management structure is in force.

The lessons from Longford are obvious but appear to be enshrined in the
many cases including The Herald of Free Enterprise, Chernobyl, Piper
Alpha and Flixborough. It is the intention of this report to provide the
missing focus on this recurring mistake before employees, members of the
public and process plants at Grangemouth are exposed to the same risks.

Reduction in core employee numbers

Proposed reductions in core operating team members, as a result of this
review, can be found in all areas of the complex. Examples include
significant reductions in the Utilities areas and at the Rigidex and
Innovene plants in the Chemical areas of the business. A proposal to
amalgamate process control boards in the CCB would also result in one
operator controlling the process equipment currently staffed by two.
Reductions in the in-house day and shift maintenance technician
population have also been proposed.

Possible effects of reducing employee numbers may include increased
physical work, requirement to reduce plant inspection rounds, reduced
level of preventative and first fix maintenance and increased alarm
handling in control posts.

The drive to reduce employee numbers is an economic one and it is
intended to reduce employee numbers by a prescribed amount to conform
to industry benchmarks, to make defined savings in employee costs and,
having arrived at a number of redundancies, to look lastly at the safety

The synergistic effect of removing core operators while weakening the
supervisory role has the potential to leave employees with heavy and
unreasonable workloads in the absence of supervisory support. The
review team further proposes that operators should become and remain
competent in more plant areas than at present and that the number of
resource operators, to deal with sickness, holidays and training will be

The potential for human factor failures associated with increased
workload in process plant will exist e.g. mistaken priorities, mistaken
actions, misperceptions. These failures can be the result of the
unreasonable role size and are the root cause of many well known major

This paper does not describe and define all jobs reductions within the
review proposal, but is intended to highlight, in a general way, the
existence of the problem and to urge investigation into the possible effect
of removing safety vital roles.

Fire station and emergency response

A proposed reduction of up to nine posts in the area of emergency
response team is essentially covered in the section above. The issue is
highlighted in this section due to reductions in advanced first aid
attendants and the resulting relevance to the COMAH 1999 regulations.

Inherent workplace hazards

It is recognised that areas of the complex have been neglected, in terms of
maintenance, in the recent past. Under-lagging corrosion of pipework is
just one example and has resulted in pipeline failures and resulting loss of
containment of hazardous materials.

A remediation program is partially complete but it will require effort and
resources to achieve the desired level of plant integrity. This single issue
highlights the need for increased operator and maintenance effort at a
time when reductions are proposed.

Safety assurance process

The company has outlined a method of assuring that all organisational
change is safe. The process is fairly standard and includes steps to
identify, evaluate, control, monitor and review hazards. The broad
philosophy of this process is supported by trade unions at the site but the
process appears focused on individual issues and not on the overall effect
of change.

The unions also question the competence of on-site personnel to carry out
risk assessments given that a detailed understanding of human factors is
required. Knowledge of processes such as Technique for Human Error
Rate Prediction (THERP) and Success Likelihood Index Methodology
(SLIM) are clearly required. These methods, coupled with very detailed
job descriptions, and intimate knowledge of the synergistic effect of every
small organisational change are required.

Every job reduction, change to site procedure or method of working must
be fully understood and risk assessed before any change is made.
Employees and employee safety representatives must have meaningful
consultation on changes, both locally and centrally, with adequate time
allocated to ensure safe operating conditions following this review.

Effect on people

The issues outlined above have the potential to increase working hours
for those who remain in employment, to increase workload during normal
working hours, to place additional responsibility on employees, to
increase stress on employees and to lower morale due to the decrease in
employment security in the future.

The evaluation of these factors and their effect on safety and health is a
complex and specialised area which requires expert knowledge and skill.
Trade union representatives do not believe this competence exists on-site.


This short paper can only briefly outline the many complex safety issues
which exist in a review of this kind. The joint site trade unions wish to
formally register their discomfort with the shape texture and extent of this
review and with the safety assurance process offered.

Concerns around the changes have so far been answered with a formula
answer which is heavily reliant on safety assurance procedures, reduction
of existing workload and working “smarter”. The company view gives no
comfort to unionised employees that a full understanding of the
implications of this review exists.

It is the considered opinion of trade union represented employees that this
review has the potential to result in an increased risk of minor and major
accidents and a resulting increased risk to employees, contract workers
and members of the public.


The recommendations of the trade unions are that:

    The pace of change is slowed to allow for detailed assessment and
     consultation on the possible changes
    Team leaders are re-instated in addition to proposed area
    The scale of employee number reductions is reduced.
    A period of sustained safe and reliable operation is demonstrated
     before large-scale changes are made
    Emergency response technicians remain at present levels
    Truly independent, competent and expert resource is employed to
     evaluate the safety of organisational change. This should be

     conducted at local and central level and consider individual and
     collective impact of changes.
    That the competent authority under the COMAH 1999 regulations
     i.e. HSE and SEPA fully investigate this formal submission from
     the trade union leadership at BP Grangemouth.

Mark Lyon Tech SP         Russell Gray
Refinery joint convener   Chemicals joint convener


CULLEN W D. (1990)               The public enquiry into the Piper Alpha
                                 Disaster. London: HMSO

KLETZ T. (2001)            Learning from accidents. Oxford:
                           Butterworth-Heinmann Ltd

RIDDLEY L & CHANNING J. Safety at work. Oxford: Butterworth
(1999)                  Heinmann Ltd

STRANKS J (1994)           Human factors and safety. London:
                           Pitman Publishing


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