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Using human factors_to_deliver_safety_&_operational_improvements_in_offshore_oil_and_gas
1. Delivering Asset Integrity
Robert Miles, Principal Specialist inspector
Offshore Safety Division, Health and Safety Executive
2. Trade - offs & the “Unrocked boat”
t
Bankruptcy b oa
Protection d
Better defences oc ke
converted to Un-r
increased
production
Increased
investment
in protection Catastrophe
Production
From Reason 1997
3. LTI’s
• Already happened
• “independent”
• Driving using only
the rear mirror?
• very infrequent
(thankfully)
• We need predictors
of safe performance,
“leading indicators”
4. Leading indicators?
• Predictive of accidents
• Gas detection vs fire alarm
• inspection
• attendance at training?
• near miss reports acted upon
• un- actioned defect reports (-ve)
• need to be things that we can change: not
independent
5. Bombay High offshore installation 2005: Risk assessment identified
that the installation was vulnerable to ship collision because a critical
pipe was unprotected. Work was planned to build a guard around the pipe.
6. On 28 July 2005 the dive support vessel collided with the
installation, the edge of the vessel’s heli-deck cut the pipe.
10 employees (from 220) and 40% of India's crude oil supple
were lost.
The hazards identified in risk assessment are real and require action
7. Rig safety check refused before tragedy
Drilling rig operators refused to allow a
safety inspection just days before two
men died in a fire in an oil rig at a
Dundee dock.
Global Marine UK have confirmed that they
turned down a request by the fire brigade to
inspect the installation.
The operators say the rig manager turned
down the inspection request because there
were already additional personnel aboard
and because safety procedures - including
fire cover - were already in place.
Although the fire was put out swiftly it took
fire fighters four hours to recover their
bodies because of the difficulties they
encountered.
10. Accidents Losses &
& injuries bankruptcy
“I don’t know how
to do my job”
Sickness &
Resignations
11. Accidents Losses &
& injuries bankruptcy
“I don’t have the
resources to get
the job done
safely”
Sickness &
Resignations
12. Safety
Stressors
Hazards
Psycho- Incident root
social 75 % overlap causes and
research and reports
assessment
13.
14.
15. • The employee as a • The employee as a
hazard: defence:
• They need to be closely • They need to be trained,
managed. alert and there.
• The less of them the • They are a valuable
better. contribution to the
• Less thinking, more business.
procedures. • How can I make their life
• Blame in investigations. easier?
• QRA will focus on human • QRA will focus on
error rate. “defences in depth”.
16. The UK offshore safety in regime is a
permissioning regime:
• The duty holder (usually the operator) sets out all of
the hazards, and all of the means by which these are
controlled, in a Safety Case.
• The HSE assesses that case and accepts it once it is
satisfied that the measures described are sufficient
for safe operation.
• The duty holder (operator) must then operate the
installation (or rig) in the same manner as described
to HSE in the Safety Case.
• For HSE integrity is “doing what you told us
you would” and through that staying safe.
17. For HSE integrity is “doing what you told us you
would”.
In a safety case operators usually tell us that they:
• Only employ staff competent for the job.
• Allow enough time for planning and completing the
job safely.
• Conduct adequate risk assessment.
• Provide all necessary training.
• Manage contractors to the same standards as their
own operations.
• Have up to date procedures for every hazardous
task.
• Maintain equipment to a safe standard.
• Audit and review their performance.
• Comply with the Regulations.
18. ..but…..
• When we investigate accidents and incidents
or carry out inspections we usually find one or
more of these things has not been
happening.
• The reasons why often relate to the way
people throughout the organisation value (or
not) safety and integrity and how they learn.
• Safety is everyone’s responsibility, it is
shared between workers, managers and
owners.
19. Initiating event
The Intervention Logic Model:
IMT request
PAIT’s
Review safety case:
Inspection plan
Enforcement
referred to Inspect offshore
Review progress IMT
Impact Inspection report:
Feedback to Senior To IMT
management and agree To Duty Holder
action plan. (FOI issues?)
Safety case compliance
21. KP3 Report Analysis:
Best performing areas
• 2004/5
• 2005/6
• Defined life repairs • Defined life repairs
• Maintenance system • Reporting to senior
evaluation mngmt on integrity
• Supervision status
• Measuring quality of
maintenance work
Monitoring and reporting • Key indicators for
are looking good maintenance
effectiveness
22. KP3 Report Analysis
Worst performing areas
• 2004/5 • 2005/6
• Maintenance of • Maintenance of
SCEs SCE's
• Backlogs • Backlogs
• Physical state of
• Corrective plant
maintenance
• Deferrals
Plant
SCE’s! Backlogs!
condition!
23. KP3 Report Analysis
Maintenance of SCEs
• Not all SCEs adequately defined or prioritised.
• Maintenance/testing of SCEs not carried out
to schedule to avoid process interruption.
• Performance standard/action to be taken
should SCE not meet performance standard not
defined.
• No reference to performance standards in
work orders.
24. KP3 Report Analysis
Backlogs
• Definition of backlog inappropriate/ not clear
• Lack of technical resource to carry out work.
Problems with recruiting/retaining skilled staff.
• Low priority backlog not managed – allowed to
grow to excessive proportions.
• Unable to adequately staff maintenance
needs because of problems with lack of beds.
25. KP3 Report Analysis
Corrective maintenance
• No formal procedure for assessment of
significance of SCE failure or defect
• No involvement of technical
authorities
• Corrective maintenance not entered onto
management system
• Roles and responsibilities of personnel not
clear
26. KP3 Report Analysis Good!
Keep doing this!
Examples of Best Practice
•Workforce awareness
• Training of safety representatives by in house technical authorities
• Notice board display of performance standard status
• Identification of safety critical work
•Maintenance management
• Dedicated experienced person to manage maintenance system
• Dialogue between onshore and offshore
•Supervision
• The effective use of Lead Technicians in the practical supervision of
maintenance tasks on safety critical equipment.
• The Maintenance Supervisor takes the medic round the plant in advance of
major works
31. The role of audit:
• Historically focussed on compliance;
based on a financial model.
• Has a tradition of being costly,
disruptive, divisive and unwelcome.
• Benefits can be limited in relation to
cost.
• But; there is no specific
impediment to making better use
of audit .
32. Audit and learning:
• Organisations often separate learning and
continuous improvement from audit.
• Different objectives, different departments,
different teams.
• But: at the shop floor an outsider sent by
management to ask questions is an outsider
sent by management to ask questions …..
• You can only ask someone once if you claim
to be listening.
• Think in terms of limited opportunity and the
need to maximise gain.
33. What would a learning audit look like?
• Engaging questions: what do you find does
not work?
• Improvement questions: how could we
avoid this problem?
• Can you suggest a better way?
• If we resourced a team to address this
would you like to be part of it?
• Do you have suggestions to improve our
audit? (double loop learning)
34. We ask:
• Could you show us the tasks you find most
dangerous or least want to do because of the
risk?
• If we could get your employer to fix 3 things
what would they be?
• How does this site compare with others you
have worked on?
• What do you think could be the next accident
here?
• Where do you think we should look? (not
installation specific)
35. What do we find:
• A valve actuator that had to be barred round
with fixings sheared to get the bar on.
• A corroded riser.
• A corroded crane cab.
• A seized fire hose.
• Long hours and overtime.
• Consecutive tours hidden in Vantage.
• Non-English speakers kept out of view.
• Consultant’s reports hidden in drawers.
36. What do we find:
• A valve actuator that had to be barred round
with fixings sheared to get the bar on.
• A corroded riser.
• A corroded crane In just about every
cab.
• case the management
A seized fire hose.
• were not aware of
Long hours and overtime.
• these problems!
Consecutive tours hidden in Vantage.
• Non-English speakers kept out of view.
• Consultant’s reports hidden in drawers.
37. What do we find:
• A valve actuator that had to be barred round
with fixings sheared to get the bar on.
• A corroded riser.
• A corroded crane In just about every
cab.
• case the management
A seized fire hose.
• Allegedly………. were not aware of
Long hours and overtime.
• these problems!
Consecutive tours hidden in Vantage.
• Non-English speakers kept out of view.
• Consultant’s reports hidden in drawers.
38. Is audit the answer?
• It is reasonable to promote other learning processes:
– Safety reviews
– STOP cards
– Safety committees
• But audit is
– More systematic
– Part of the SMS
– Resourced from the centre
– Goes further up the management chain
– Can address business improvements,
environment and safety
42. The assessment markers
Overall improvement process
Completeness
of cycle
Do
Plan
Review
Audit effectiveness
Effective link from audit
to implementation
43. The “Engineers Graph” or why I don’t need to do anything...
Engineering
Safety management
Accident
rate
Human factors
Time
44. The “Engineers Graph” or why I don’t need to do anything...
Engineering
Safety management
Accident
rate
Human factors
Time
I need to design
better engineering
45. The “Engineers Graph” or why I don’t need to do anything...
Engineering
Safety management
Accident
rate
Human factors
Time
I need to design More
better engineering procedures!
46. The “Engineers Graph” or why I don’t need to do anything...
Engineering
Safety management
Accident
rate
Human factors
Time
I need to design More Behavioural modification
better engineering procedures! will fix it…(theirs not mine)
47. The “Engineers Graph” or why I don’t need to do anything...
Continuous improvement
Engineering
Safety management Workforce
Accident
rate
involvement
Human factors
Time
I need to design More Behavioural modification
better engineering procedures! will fix it…(theirs not mine)
48. CORPORATE MATURITY AND CONTINUOUS IMPROVEMENT…..
Maturity Responsibility Reporting Enforcement? Knowledge
Continually We suggest Collaboration
We all develop solutions and developing Double-loop
improving. safety together work on these with safety including leaning
level 5
IMPROVING SAFETY CULTURE
management regulation
Safety is shared Collaboration
Co-operating. with the team We fill in forms Single loop
INCREASING TRUST
on solutions learning
Level 4 and management for near misses too
Safety is both We try to Corporate
Involving my and include reasons Education knowledge
management and information
Level 3 on the form is codified
responsibility and verified
Safety is the Knowledge
Managing management's’ We complete the Enforcement is unverified
Level 2 statutory forms notices and local
responsibility
We don’t report Surprise visits No one knows
Emerging Safety gets in anything to and what they are
Level 1 the way. management Prosecution doing
49. Dinosaurs: Safety is a competitive disadvantage
Safety Profit
Costs Revenue
Safety managers don’t stay long….
50. Stage 1 Enlightenment: The separation of safety
from finance
Safety
Profit
Costs Revenue
Accidents
The safety department is separate and powerful
51. Fully Enlightened: Safety is a competitive advantage
Doing Doing
Things Things
Badly Well
Accidents Profit
Safety
Costs Revenue
These Organisations typically do not have a safety department
52. Apply a large dose
of common
sense……
• ..during the leaf fall
season the leaves fall
onto the sensors
rendering them
inoperable.
• “We are advised that
Railtrack switch the
lights off during leaf-fall
so that the crossing
cannot be used, and
therefore maintaining a
safe method of
working”.
Editor's Notes
17
The UK offshore safety regime is a “permissioning” regime based around a formal safety case combined with inspection. For HSE integrity is both the integrity of the process plant and the organisation as a whole. The organisation in made up of the people in it but in the end it is the senior management that run the organisation and set the standards for both plant and organisational integrity.
These are examples of the commitments that duty holders make to HSE, and by implication, to all their employees. Sometimes they do not delivery on all of these commitments. The PRfS process requires similar commitments and the matrix sets out behaviours that will be demonstrated by everyone in the organisation.
We have to investigate complaints and accidents and so we see when things go wrong. We find that individuals and organisations have not kept to the standards they told us they would. PRfS also sets high standards. Safety and integrity are delivered when everyone knows what do do and does it as a team.
