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Human factors-related causes of hydrocarbon release on offshore platforms

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Presentation from Jason Devereux at Offshore Europe 2013. Paper written by Jenny Gilroy and Derek Dumolo of Lloyd's Register Constiling's Human Factors team. …

Presentation from Jason Devereux at Offshore Europe 2013. Paper written by Jenny Gilroy and Derek Dumolo of Lloyd's Register Constiling's Human Factors team.

Hydrocarbon releases (HCR) are a major problem offshore, and most importantly are seen as a direct precursor to potential major accidents (MAs) (Oil and Gas UK, 2010). The UK HSE believe that of the occurring HCRs, 50-70% have causes linked in part or in whole to “things people do (or don’t do) when designing, maintaining and operating systems”, (Step Change in Safety, 2010) i.e. issues associated with Human Factors (HF).

An offshore operator contracted LR Consulting to conduct an independent HF-focussed organisational assessment into the underlying contributory factors to HCRs on their platforms, in order to support their own internal initiatives to reduce HCRs. The aim of LR Consulting’s assessment was to help the organisation confirm and identify the key areas of focus in order to combat HCRs and prioritise further actions going forward.

LR Scandpower adopted a systematic approach to investigate the HF contributions to HCRs on the organisation’s platforms, including a Thematic Analysis of past incident data, offshore interviews and onshore interviews with staff and detailed analysis of findings to identify common emergent themes issues. Eight key areas were identified as priorities for further action, and LR Consulting provided the operator with recommendations for improvements and/or remedial actions to deal with identified contributory factors

This presentation will explain the approach followed by LR Consulting and the findings from the study, including the key Human Factors causal factors that were identified. It will also highlight the key lessons learned that are considered to be potentially relevant to the wider offshore sector.

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  • 1. Human Factors Involvement in Hydrocarbon Release on Offshore Platforms: an organisation wide investigation Dr. Jason Devereux, Lloyd’s Register Consulting – Energy Scientific Sub-Committee Secretary for the International Commission on Occupational Health and Safety Member of the IEA Technical Committee on Human Factors in Organisational Design and Management Honorary Member of the Business Psychology Unit, University College London Former Human Factors M.Sc. Director, Robens Institute Industrial Health & Safety Working together for a safer world
  • 2. Outline 1. Background to hydrocarbon release 2. Case study: • Methodology • Summary of findings • Key areas 1. Recommendations for Industry Lloyd’s Register Energy
  • 3. The problem of hydrocarbon leaks • Hydrocarbon releases are a major problem offshore. • A direct precursor to potential major accidents, if ignited. (Oil and Gas UK, HSE) Major gas release on Elgin in March 2012, led to the evacuation of the entire platform Lloyd’s Register Energy
  • 4. The problem of hydrocarbon releases (HCRs) 50-70% of HCRs have causes linked in part or in whole to human factors Human error is both universal and inevitable (Energy Institute, 2008). This implies a system failure and not person failure – the latent antecedents Judith Hackitt (Chair of HSE) -“Constant Unease” • Know the problem is not fixed • What could go wrong • Can do better • Society becoming less tolerant of failures Consider human factors in designing, maintaining and operating systems Lloyd’s Register Energy
  • 5. Market forces potentially affecting HCR risk Competition pressure and cost cutting could increase the use of technology and reduce staffing offshore Highly automated systems still need human beings for: •supervision •adjustment •maintenance •Improvement Understand the limits of human abilities and capability in the: •design •control •maintenance of systems Lloyd’s Register Energy
  • 6. Case study: study objectives Human-machine interaction as an emerging risk (EU-OSHA, 2005) • Psychosocial risk – cognitive load • Accident risk • operating errors • maintenance non-routine errors • inappropriate action Assist in our client’s initiative. • To reduce HCRs within the UK. Conduct an independent Human Factors-focussed organisational assessment. • Identify underlying contributory factors to HCRs offshore. Lloyd’s Register Energy (HSE, 1999 HSG 48)
  • 7. Case study: methodology N=60 Sept 2011 N=31 Nov 2011 Lloyd’s Register Energy
  • 8. Case study: thematic analysis An initial analysis of HCR incident report data highlighted the following key areas e.g. “the requirements of the flange completion and recording procedure do not appear to have been communicated.” e.g. “absence of alarms for this event and/or absence of preventative barriers to be able to close 2 streams.” e.g. “the requirements of the flange completion and recording procedure” Failures in engineering controls Failures in administrative processes Failures in communications Failures in competency management processes e.g. “no small bore tubing training for 2 years” Hydrocarbon Releases Management failures Failures in maintenance processes e.g. “gas compression train out for 2 years “ Lloyd’s Register Energy e.g. “No supervision”
  • 9. Using the data generated from the thematic analysis Development of a ‘question set’ to explore key HF themes that appeared to be influential in HCRs. 14 ‘lines of enquiry’ explored, including: • supervisory arrangements • safety culture • safety critical communications • quality assurance and procurement process • procedure usage • planning • staffing • engineering design • etc. Lloyd’s Register Energy
  • 10. Summary of findings - corporate level solutions Organisational learning Competence management HFI in platform Planning design •Reactive LearL LearL •maintenance •Under manning Procedures • Silo working Visit www.lr.org/HCR for more information Lloyd’s Register Energy
  • 11. Key areas: Organisational learning Relevance to hydrocarbon releases • When lessons aren’t learned and a company doesn’t strive for continuous improvement, mistakes are repeated, not recognised and not improved • • When underlying causes are not dealt with, only the immediately obvious problems may be tackled, leaving the real contributory factors in place • • e.g. Small bore tubing was a known problem for a long time before a survey was carried out; and this survey has not yet led to any improvements e.g. an individual who made a mistake may be blamed but his competency and the competency of all his colleagues also may be poor due to a lack of training and support Many wider contributory factors to hydrocarbon releases have been identified in this project, and most have been a problem for some time Lloyd’s Register Energy Contributory failures Failures in communications Cultural issues
  • 12. Key areas: Competency management Relevance to hydrocarbon releases Contributory failures If people are not fully competent to work on the system, they are likely to make mistakes •e.g. If an operator cannot use SAP correctly they may not input required data about maintenance work that need to be done, and thus a HCR could occur because the work is not carried out Anyone working with the system who is not fully competent could make a mistake and either: 1.Initiate a HCR 2.Contribute 3.Escalate 4.Fail to a series of events that leads to a HCR a HCR to mitigate and control a HCR Lloyd’s Register Energy Failures in competency management
  • 13. Key areas: Lack of planning Relevance to hydrocarbon releases The system state may be compromised or the system may fail if: • routine maintenance is postponed or delayed • urgent maintenance needs are not addressed promptly • work is not planned thoroughly, maintenance may get postponed or delayed Lloyd’s Register Energy Contributory failures Failures in communications Failures in maintenance processes Failures in administrative processes
  • 14. Key areas: Under manning Relevance to hydrocarbon releases Contributory failures A lack of staff to carry out work means that: • maintenance is constantly being compromised • assets fail because they have not been maintained properly • only had ‘patchwork’ fixes carried out on them There are also compromises in relation to onshore activities due to under manning. For example: • Design failures Not enough engineering team staff • it takes longer to get designs developed • there are delays to making engineering changes Lloyd’s Register Energy Management and resourcing failures
  • 15. Key areas: Reactive approach Relevance to hydrocarbon releases  Short-term quick repairs can affect asset integrity:  The underlying problems are not improved   the system can be left vulnerable to further deterioration or failure Patchwork fixes may create new problems:  They can mean the system is not operating correctly   Contributory failures the system may become damaged Jumping into initiatives and approaches means that the work is more likely to be done incorrectly • e.g. In relation to Small Bore Tubing Surveys. This has wasted time on an activity that was supposed to aid in reducing HCRs, but few corrective works have been done Lloyd’s Register Energy Cultural issues Failures in maintenance processes
  • 16. Key areas: Poor procedures Relevance to hydrocarbon releases Contributory failures If the procedures are wrong or difficult to use, people will either: • follow the incorrect procedure and as a result carry out the task incorrectly • fail to use them and potentially do the task wrong or inconsistently In both instances there may do damage to the system Lloyd’s Register Energy Failures in administrative processes
  • 17. Key areas: Silo working Relevance to hydrocarbon releases Lack of communication or miscommunication: • Information may not be passed on to those who need to know • information may be misunderstood due to conflicting demands and distraction • the result is mistakes and omissions Work carried out in isolation: • Conflict with other work being done • can leave the system vulnerable to errors Lloyd’s Register Energy Contributory failures Failures in communications Management and resourcing failures Failures in administrative processes
  • 18. Key areas: Design issues on the platform Relevance to hydrocarbon releases Contributory failures A mismatch between the design specification and the proposed operability of the system: • leads to system operability being compromised • e.g. There are not enough beds, making it difficult to get staff onto the rig A mismatch between the design and the operating environment: • system may be susceptible to deterioration • e.g. Some equipment and material selection at the design stage is considered to have been inappropriate and of poor quality, leading to high levels of deterioration Excessive alarms in the control room: •real issues may be overlooked and made worse Lloyd’s Register Energy Design failures
  • 19. Lessons for industry: For prevention of HCRs No simple answer to the question of ‘what causes HCRs?’ Identify and address all underlying factors A suitable framework for assessment is required • using specialists who are trained to look beyond the engineering problems to organisational factors Recommend use of external departments and/or independent parties: • provides independence • allows honest impartial information to be elicited Lloyd’s Register Energy
  • 20. Lessons for industry: Investigation of HCRs • Essential that incident investigations go beyond the analysis of ‘front line’ failures ? ? ? ? • • Take due consideration of the Human Factor within organisational root causes ? ? ? ? Involve Human Factors experts in this process Human Error Underlying Human Factors topics Underlying Human Factors topics e.g. Procedures, Training && Competence, Safety Critical e.g. Procedures, Training Competence, Safety Critical Communications, Organisational Change, HF Design, Communications, Organisational Change, HF Design, Shiftwork && Fatigue, Organisational Culture, Workload, Shiftwork Fatigue, Organisational Culture, Workload, Maintenance, and Human Failures (HSE, 2012) Maintenance, and Human Failures (HSE, 2012) Lloyd’s Register Energy
  • 21. Lessons for industry: Have a human factors integration plan • Have better integration of Human Factors within the early stages of the design process • Reduces the likelihood of mismatches between: • Human capability • • • organisational demands and system design during the latter stages of projects or in operation Planning for a dedicated HF programme at the initial design stage of projects is recommended: • Equipment design • Workstation/ console design • Workplace layout • Maintenance access and ease of maintenance etc. Lloyd’s Register Energy
  • 22. Develop corporate resilience to avoid HCR outcomes (UCL Business Psychology Unit Effort Performance Outcome Model) Expectancy Instrumentality Valance Extrinsic outcome/ reward Performance Effort Abilities and traits, role clarity, organisational support, etc. Lloyd’s Register Energy Job design, organisational policies and practices Outcome / reward Satisfaction Intrinsic outcome/ reward Perceived equity of outcomes/ rewards
  • 23. Avoid the reputational and financial risk BP Down 30% since Jan 2010 high •Has not recovered due to a lack of investor confidence signalled by overhead supply at $50 per share •Not trending with the S&P 500 •“A broken stock in institutional trading terms” Exxon Mobile Up 27% since Jan 2010 high •Trending with the S&P 500 Lloyd’s Register Energy
  • 24. A final thought! Competitive investment must be tempered with patience and consideration of the potential for human-system failures in maintenance, supervision and improvement. For more information and to receive a free copy of the whitepaper this presentation is based on, visit: www.lr.org/HCR Lloyd’s Register Energy
  • 25. Dr. Jason Devereux Lloyd’s Register Consulting – Energy T: +44 (0)23 2345 5432 E: jason.devereux@lr.org Lloyd’s Register Energy 71 Fenchurch Street, London EC3M 4BS @LREnergy Follow LR Energy on LinkedIn Follow Jason Devereux on LinkedIn Working together for a safer world Lloyd’s Register and variants of it are trading names of Lloyd’s Register Group Limited, its subsidiaries and affiliates. Copyright © Lloyd’s Register [Entity]. 2013. A member of the Lloyd’s Register group.