a spotlight on the human aspects of accident prevention

The “Nut Island Effect” on safety

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Blog 11aThe phrase “nut island effect” was coined by Paul F Levy, head of the Massachusetts Water Resources Authority (MWRA) and became widely known when he published a paper about it in the Harvard Business Review in 2001.  Nut Island is a 5 acre small island in Boston Harbour that was used from 1952 onwards as the site for a sewage treatment facility, until it was decommissioned in 1997.  It was run by a dedicated team that worked in isolation, doing a complex but important job, and who were ignored by management, until things went wrong. 

Until the major disaster in 1982 which resulted in 3.7 billion gallons of raw sewage being released into the harbour, management was blissfully unaware of the issues percolating beneath the surface and instead were distracted by other high profile and political issues and assumed that “no news was good news”.  The team at Nut Island were capable and dedicated to their work.  They took initiative to solve their own problems, often paying for the purchase of parts and supplies themselves, especially when their requests for help were repeatedly ignored by management.  As time went on, this team began to invent its own rules in order to keep things running without help from management and became more isolated and disconnected from the rest of the corporation.  Management rarely came to visit the plant and assumed that all was well.  As a result, an “us against them” mind-set developed over time perpetuating a situation where communication broke down and all problems were hidden, until the crisis erupted which polluted Boston harbour for many years to come.

Paul F Levy became head of the MWRA in 1987 and supervised the clean-up of the harbour and management reforms for the next 4 ½ years.  He identified this organisational behaviour phenomena, which was previously un-named and unrecognised but is actually very common in organisations that have remote teams, which are either psychologically remote or physically remote, or both.    At the Nut Island plant, machinery was kept running long past the time it should have been overhauled or junked.  The pumps were degraded due to deferred maintenance but instead of asking management for funds to obtain new equipment, the workers came up with their own solution instead and lubricated the machinery with oil, which ended up being released into the harbour.  Because management was distracted and often did not respond to initial requests for help or reports of problems, this perpetuated the situation where management and the team at Nut Island stopped communicating and both worked under the assumption that everything was fine and would continue to run smoothly. 

 Blog 11b

Any organisation (eg oil and gas companies) that has remote teams offshore should be aware of the nut-island effect and of how this can cause a major safety incident when left undetected.  To prevent the nut-island effect from developing in your organisation, management should ensure that they install performance measures and reward structures which are tied to both internal operations and companywide goals.  This will ensure the team are clear about their responsibilities but also know how their work contributes to the larger corporate mission.

Secondly, senior management must visit the remote team regularly and be knowledgeable and involved in the community so that workers feel that they are cared for and listened to.  Thirdly, members of the remote team should be integrated with other departments and teams onshore or in other parts of the organisation to get a better sense of the big picture and to prevent them from being isolated in the long-term.  Finally, ensuring that there is a regular turnover of staff every 2-3 years will prevent isolated teams from institutionalizing bad habits and forming their own rules.

The combination of factors that create the “nut-island effect” in any organisation needs to be recognised and prevented before it causes a crisis and compromises safety in their remote teams.  Often management will be content to settle for team leaders’ assurances that all is well and not realise that these same factors are developing underground.  Good and frequent communication, involvement of remote teams in the wider life of the organisation, visits by management and a regular turnover of team members are all good strategies to start with in order to prevent and/or remedy the “nut-island effect” in your organisation.


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