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Designing management of change procedure to act as barriers to major offshore accidents

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Objective of lecture ...

Objective of lecture
1. Give an understanding of the elements included in the title; Designing management of change
procedure to act as barriers to major offshore accidents
2. Shortly describe experiences from major accidents
3. Give an understanding of the different steps in designing a management of change (MOC)
procedure

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  • 1. Designing management of changeprocedure to act as barriers to major offshore accidents Trial lecture – PhD 06.12.2011 Jon Espen Skogdalen 1
  • 2. Objective of lecture1. Give an understanding of the elements included in the title; Designing management of change procedure to act as barriers to major offshore accidents2. Shortly describe experiences from major accidents3. Give an understanding of the different steps in designing a management of change (MOC) procedure 2
  • 3. Elements in the title• Designing management of change procedure to act as barriers to major offshore accidents• Designing• Management of change• Procedure• Barrier• Major offshore accidents 3
  • 4. Major offshore accidents • Limitation – major offshore accident within the oil and gas (O&G) industry-Designing-MoC • A major accident in the O&G industry is often-Procedure-Barrier understood as an accident out of control with the-Majoroffshore potential to cause five fatalities or more, causedaccidents by the failure of one or more of the system‘s safety barriers. 4
  • 5. Major accidents, offshore O&G-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents Norsok, (2010). Standards Norway. Norsok Standard: Risk and emergency preparedness analysis, Z-013 3ed. Oslo. 5
  • 6. Major accidents, offshore O&G • Blowouts, including shallow gas and reservoir zones, unignited and ignited • Process leaks, unignited and ignited • Utility areas and systems fires and explosions-Designing • Riser and pipeline accidents-MoC • Fire in accommodation areas-Procedure-Barrier • Accidents from subsea production systems-Major • Escape, evacuation and rescue accidents, i.e. until a so-calledoffshoreaccidents ‘safe place’ has been reached • Structural collapse, including collapse of bridges between fixed and/or floating installations • Foundation failure • Loss of stability/position Norsok, (2010). Standards Norway. Norsok Standard: Risk and emergency preparedness analysis, Z-013 3ed. Oslo. 5
  • 7. Designing • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC • Something more than just “make”-Procedure-Barrier • System perspective;-Majoroffshore – Who are the stakeholders?accidents – What is the goal? – What are the surroundings and limitations? 6
  • 8. Management of change (MoC)-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 7
  • 9. Management of change (MoC) • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 7
  • 10. Management of change (MoC) • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 7
  • 11. Management of change (MoC) • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC • ”MoC is a process for evaluating and controlling-Procedure-Barrier modifications to facility, design, operation,-Majoroffshore organization or activities – prior to implementationaccidents – to make certain that no new hazards are introduced and that the risk of existing hazards to employees, the public, or the environment is not unknowingly increased.” Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 7
  • 12. Management of change (MoC) • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC • A socio-technical system:-Procedure-Barrier 1. The work and technological system-Majoroffshoreaccidents 2. The staff level 3. The management level 4. The company level 5. The regulators and associations level 6. The government level Rasmussen,  J.,  (1997).  Risk  management  in  a  dynamic  society:  a  modelling  problem.  Safety  Science,  27:     183-­‐213. 8
  • 13. Management of change (MoC) • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC-Procedure-Barrier-Major “We cannot change the human condition, but weoffshoreaccidents can change the conditions under which humans work” James Reason Reason, J., (2000). Human error: models and management. Bmj, 320: 768-770. 9
  • 14. Procedure • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC • “A procedure is a sequence of actions or-Procedure-Barrier operations which have to be executed in the same-Majoroffshore manner in order to always obtain the same resultaccidents under the same circumstances.” Cook, J.L., (1998). Standard operating procedures and guidelines. Fire Engineering Books & Videos. 10
  • 15. Barriers • Designing management of change procedure to act as barriers to major offshore accidents-Designing-MoC • Safety barriers (barriers) are physical or non--Procedure-Barrier physical means planned to prevent, control, or-Majoroffshore mitigate undesired events or accidents. Barriersaccidents may be passive or active, physical, technical, or human/operational systems. Sklet, S., (2006). Safety barriers: Definition, classification, and performance. Journal of Loss Prevention in the Process Industries, 19: 494-506. 11
  • 16. PSA, Management regulation, #5 Barriers-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents http://www.ptil.no/management/category401.html 12
  • 17. PSA, Management regulation, #5 Barriers • Barriers shall be established that: a) reduce the probability of failures and hazard and accident situations developing,-Designing-MoC b) limit possible harm and disadvantages.-Procedure-Barrier-Majoroffshore – Where more than one barrier is necessary,accidents there shall be sufficient independence between barriers. http://www.ptil.no/management/category401.html 12
  • 18. PSA, Management regulation, #5 Barriers-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents http://www.ptil.no/management/category401.html 13
  • 19. PSA, Management regulation, #5 Barriers – The operator or the party responsible for operation of an offshore or onshore facility, shall stipulate the strategies-Designing and principles that form the basis for design, use and maintenance of barriers, so that the-MoC-Procedure-Barrier-Major barriers function is safeguarded throughoutoffshoreaccidents the offshore or onshore facilitys life. http://www.ptil.no/management/category401.html 13
  • 20. PSA, Management regulation, #5 Barriers-Designing-MoC-Procedure-Barrier-Majoroffshoreaccidents http://www.ptil.no/management/category401.html 14
  • 21. PSA, Management regulation, #5 Barriers – Personnel shall be aware of what barriers have been established and which function they are intended to fulfil, as well as what-Designing performance requirements have been defined in respect of the technical, operational or-MoC-Procedure-Barrier-Major organisational elements necessary for theoffshoreaccidents individual barrier to be effective. – Personnel shall be aware of which barriers are not functioning or have been impaired. – The responsible party shall implement the necessary measures to remedy or compensate for missing or impaired barriers. http://www.ptil.no/management/category401.html 14
  • 22. Objective of lecture1. Give an understanding of the elements included in the title; Designing management of change procedure to act as barriers to major offshore accidents2. Shortly describe experiences from major accidents3. Give an understanding of the different steps in designing a management of change (MOC) procedure 15
  • 23. Texas City accident,Baker panel, five root causes: 1. inadequate training/qualification of personnel, 2. inadequate review against technical standards, 3. inadequate operational discipline and attention to detail, 4. inadequate management of change reviews, 5. lack of an effective management review system. Baker, J., Bowman, F., Erwin, G., Gorton, S., Hendershot, D., Leveson, N., (2007). The report of the BP U.S. Refineries independent safety review panel, Washington DC. 16
  • 24. Objective of lecture1. Give an understanding of the elements included in the title; Designing management of change procedure to act as barriers to major offshore accidents2. Shortly describe experiences from major accidents3. Give an understanding of the different steps in designing a management of change (MOC) procedure 17
  • 25. Change or replacement-in-kind?• Replacement-in-kind (RIK) – An item (equipment, chemicals, procedures, organizational structures, people etc.) that meets the design specifications, if one exists of the item it is replacing. Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 18
  • 26. Example, replacement and concern Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 19
  • 27. Example, replacement and concern• Replacement-in-Kind? – Replacing rotating equipment with new equipment of the same material, capacity, flange rating, seal design, driver type, horsepower, etc. Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 19
  • 28. Example, replacement and concern• Replacement-in-Kind? – Replacing rotating equipment with new equipment of the same material, capacity, flange rating, seal design, driver type, horsepower, etc.• Change: - Increasing the impeller size - Using a single seal to replace a tandem seal in a pump Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 19
  • 29. Example, replacement and concern• Replacement-in-Kind? – Replacing rotating equipment with new equipment of the same material, capacity, flange rating, seal design, driver type, horsepower, etc.• Change: - Increasing the impeller size - Using a single seal to replace a tandem seal in a pump• Example concern with change - Downstream equipment may not accommodate potentially increased flows. Increased head lifts downstream PSVs - Different spare parts and maintenance requirements - Greater potential for seal leak Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 19
  • 30. Example, replacement and concern Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 20
  • 31. Example, replacement and concern• Replacement-in-Kind? – Replacing the current maintenance contractor with another qualified contractor Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 20
  • 32. Example, replacement and concern• Replacement-in-Kind? – Replacing the current maintenance contractor with another qualified contractor• Change: – Changing from centralized maintenance to decentralized maintenance Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 20
  • 33. Example, replacement and concern• Replacement-in-Kind? – Replacing the current maintenance contractor with another qualified contractor• Change: – Changing from centralized maintenance to decentralized maintenance• Example concern with change – Need to address issues such as: • Responsibility for training • Standardization of procedures and practices • Potential that mechanics will spend a greater percentage of their time in closer proximity to process hazards • Need to train more mechanics on process overviews, chemical hazards, MOCs, etc. Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 20
  • 34. Main steps – designing MOC• Establish Consistent Implementation• Involve competent personnel• Evaluate possible impact• Manage all sources of change• Keep MOC practices effective• Emergency change Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 21
  • 35. Establish Consistent Implementation Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 22
  • 36. Establish Consistent Implementation1. Establish and implement formal procedures to manage changes, excluding Replacements-in- kind (RIKs), Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 22
  • 37. Establish Consistent Implementation1. Establish and implement formal procedures to manage changes, excluding Replacements-in- kind (RIKs),2. Assign a job function to be the "owner" of the MOC system and to routinely monitor MOC effectiveness, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 22
  • 38. Establish Consistent Implementation1. Establish and implement formal procedures to manage changes, excluding Replacements-in- kind (RIKs),2. Assign a job function to be the "owner" of the MOC system and to routinely monitor MOC effectiveness,3. Define the technical scope of the MOC system/ Identify potential change systems, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 22
  • 39. 3 Identify potential change systems• Process safety management system• Plant layout or equipment location/ arrangement• New chemicals• Software• Procedures• Chemical specifications and suppliers• Job assignments (individual, shift, or staff)• Organization• Policies• Building locations and occupancy patterns• Other Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 23
  • 40. Involve competent personnel Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 24
  • 41. Involve competent personnel4. Define the MOC roles and responsibilities for various types of company/facility personnel, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 24
  • 42. Involve competent personnel4. Define the MOC roles and responsibilities for various types of company/facility personnel,5. Provide awareness training and refresher training on the MOC system to all employees and contractors, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 24
  • 43. Involve competent personnel4. Define the MOC roles and responsibilities for various types of company/facility personnel,5. Provide awareness training and refresher training on the MOC system to all employees and contractors,6. Provide detailed training to all affected employees and contractors who are assigned specific roles within the MOC system, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 24
  • 44. Evaluate possible impact7. Ensure that the written MOC procedures include the use of an MOC review form and that the following items are addressed prior to any change: – Technical basis for the proposed change – Impact of the proposed change on safety and health – Authorization requirements for the proposed change8. Use appropriate analytical techniques, including qualitative hazard evaluation methods, to review the potential safety and health impacts of a change, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 25
  • 45. Manage all sources of change Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 26
  • 46. Manage all sources of change9. For each type/category of change to be evaluated, develop specific examples of changes and RIKs for each category for use in employee, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 26
  • 47. Manage all sources of change9. For each type/category of change to be evaluated, develop specific examples of changes and RIKs for each category for use in employee,10.Update all process safety information (PSI) prior to startup of the change. If this is not possible, facilities should use temporary records, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 26
  • 48. Manage all sources of change9. For each type/category of change to be evaluated, develop specific examples of changes and RIKs for each category for use in employee,10.Update all process safety information (PSI) prior to startup of the change. If this is not possible, facilities should use temporary records,11.Communicate changes to potentially affected personnel, including contractors, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 26
  • 49. Keep MOC practices effective Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 27
  • 50. Keep MOC practices effective12.Keep a summary log of all MOC reviews, including the items that must be included on an MOC review form, to aid day-to-day management of the MOC process, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 27
  • 51. Keep MOC practices effective12.Keep a summary log of all MOC reviews, including the items that must be included on an MOC review form, to aid day-to-day management of the MOC process,13.Establish and collect data on MOC performance indicators and efficiency indicators, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 27
  • 52. Keep MOC practices effective12.Keep a summary log of all MOC reviews, including the items that must be included on an MOC review form, to aid day-to-day management of the MOC process,13.Establish and collect data on MOC performance indicators and efficiency indicators,14.Provide input to internal audits of MOC practices based on learnings from the MOC performance indicators, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 27
  • 53. Emergency Change Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 28
  • 54. Emergency Change• A change needed in a situation where the time required for following the normal MOC procedure could result in unacceptable safety hazard, a significant environmental or security incident, or an extreme economic loss. Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 28
  • 55. Simple generic MOC work flow Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 29
  • 56. ISO 31000:2009 - Risk management-- Principles and guidelines 30
  • 57. MOC performance indicators, example• Number of incidents having MOC failure as a contributing factor or root cause,• Percentage of changes within the MOC system that were reviewed incorrectly,• Percentage of MOCs that were reviewed but were not properly documented,• Percentage of changes that were properly evaluated but did not have all of the required authorization signatures on the change control document,• Percentage of changes that were processed on an emergency basis, Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 31
  • 58. 32
  • 59. What went wrong?• “Sometimes there is no systematic procedure, sometimes the procedure is not thorough or is not followed, and sometimes the change is so simple that a formal review seems unnecessary. There is also a reluctance in many companies to look in the literature for reports of similar situations.”• Kletz, T.A., (2009). What went wrong?: case histories of process plant disasters and how they could have been avoided. Gulf Professional Pub., Burlington, MA. 33
  • 60. Successfully implementing MOCprocedure• Keep it simple, yet fit for duty• Obtain widespread acceptance and commitment• Field test the system prior to its official implementation• Provide adequate training• Periodically monitor the effectiveness of the MOC system• Use audits and management reviews• Demonstrate management leadership and commitment Center for Chemical Process Safety, (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc. 34
  • 61. Recommended reading• Center for Chemical Process, S., (2008). Guidelines for the Management of Change for Process Safety. John Wiley & Sons, Inc.• Baker, J., Bowman, F., Erwin, G., Gorton, S., Hendershot, D., Leveson, N., (2007). The report of the BP U.S. Refineries independent safety review panel, Washington DC. 35