(in 2009 BP report, they said that injury rates and spills had reduced 75% since 1999).
Human Errors often result from human factors. Focus on organization factors, because the organizational policies, standards, systems, and procedures are what make up the knowledge pool that employees will be pulling from. If these policies are not directed towards a safety culture, then
A safety case is a document produced by the operator of a facility which:Identifies the hazards and risksDescribes how the risks are controlled, andDescribes the safety management system in place to ensure the controls are effectively and consistently applied. Safety cases must be produced by the operator of a facility. The principle here is that those who create the risk must manage it. It is the operators' job to assess their processes, procedures and systems to identify and evaluate risks and implement the appropriate controls, because the operator has the greatest in-depth knowledge of their installation. The safety case must identify the safety critical aspects of the facility, both technical and managerial. Analysis of disasters almost always show a combination of technical and managerial flaws which have led to the event occurring. Appropriate performance standards must be defined for the operation of the safety critical aspects. A 'performance standard' is a standard, established by the operator, of the performance required of a system, item of equipment, person or procedure which is used as a basis for managing the risk of a major accident event. The workforce must be involved. Workforce involvement is necessary so they know what happens in practice and why. This makes it more likely that they do the right thing because they know why, rather than relying on a 'rules-based' culture. The safety case is produced in the knowledge that it will be scrutinised by a competent and independent regulator. NOPSEMA assesses safety cases and 'accepts' a safety case if it is satisfied that the arrangements set out in the document demonstrate that the risks will be reduced to as low as is reasonably practicable. Once 'accepted' NOPSEMA visits facilities to monitor the application of the safety cases in practice.http://www.nopsema.gov.au/safety/safety-case/what-is-a-safety-case/
The decision making process on the rig was excessively compartmentalized, so individuals on the rig frequently made critical decisions without fully appreciating just how essential the decisions were to well safety—singly and in combination. As a result, officials made a series of decisions that saved BP, Halliburton, and Transocean time and money—but without full appreciation of the associated risks. (223)
1. Sarah Edwards
2. 1988 1989 2000 2005 2010 Piper Alpha Rig Fire Location: North Sea, off Scotland Company: Occidental Petroleum Damages: $3.4 billion Deaths: 166 Injuries: 62
7. Commonalities Between Disasters Occupational safety emphasized over process safety Human Factors: • A combination of either individual errors or organizational failures have been reported to cause as much as 80% of oil spills and marine accidents**An Assessment of the Role of Human Factors in Oil Spills from Vessels. Report to Prince William Sound RCAC, 2006.
8. How Organizational Failure Can Lead to Individual Errors HUMAN FACTORS HUMAN ERRORS INDIVIDUAL FACTORS SKILL-BASED competence action errors stress checking errors motivation GROUP FACTORS RULE-BASED management retrieval errors supervision transmission errors crewORGANIZATIONAL FACTORS KNOWLEDGE-BASED company policies diagnostic errors company standards decision errors systems and procedures
9. Recommendations Safety Cases • Produced by the operator of a facility to*: – Identify hazards and risks – Describe how the risks are controlled – Describe the safety management system in place to ensure the controls are effectively and consistently applied • Scrutinized by a competent and independent regulator*Australia’s National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA)
10. Structure of a Safety Case* Strategy Aim Safety Objectives Management Assessors System (SMS) Resources Safety Case Safety Production Safety Manager Case Through Life SMS Safety Management Description Committee Scope Safety Case Supporting Auditors Report Argument Review/Audit Emergency Acceptance Procedures Hazard Identification Targets Safety Assessment Risk System Assessment Description Hazard*Zotov, Dmitri (2007). Safety Cases: Control Hazard LogBeyond Safety Management Systems
11. Recommendations Process Safety Management (PSM) National Emphasis Program: • Policies or procedures to reduce the workplace hazards associated with the catastrophic release of highly hazardous chemicals at petroleum factoriesOSHA: PSM-NEP. Directive # CPL-03-00-010
12. Recommendations Communicating and Speaking Up1 • Survey conducted on Transocean crew members working on Deepwater Horizon days before explosion: 46% of crew members feared reprisals for reporting unsafe situations2 • Go through training with peers, supervisors, and subordinates to flatten the corporate hierarchy1. Managerial Practices that Promote Speaking Up Constructively Among Front-Line Employees (2011).2. Commission on BP Oil Spill, pg. 219
13. Worth the Cost? $40 $35 $30 $25Billions $20 $15 $10 $5 $0 Construction Disaster