SlideShare a Scribd company logo
1 of 123
Download to read offline
STUDY OF OFFSHORE RISKS, SAFETY CLIMATE & SAFETY
MANAGEMENT PRACTICE IN OFFSHORE ENVIRONMENTS
by
Mohammad Shafiqul Islam
A thesis submitted in partial fulfillment of the requirements for the
degree of Master of Engineering
Examination Committee: Dr. Preeda Parkpean (Chairperson)
Dr. Vilas Nitivattananon
Dr. Toshiya Aramaki
Dr. Teerapon S. (External Expert from PTTEP)
Mr. Peter Brown (External Expert from PTTEP)
Nationality: Bangladeshi
Previous Degree: Bachelor of Science in Chemical Engineering
Bangladesh University of Engineering & Technology
Dhaka, Bangladesh
Scholarship Donor: France Government scholarship & AIT Fellowship
Asian Institute of Technology
School of Environment, Resources and Development
Thailand
May 2006
i
Abstract
This study was structure, conduct and performance of the risk assessment and safety
management of offshore drilling and production operation, had main four objectives: (1) Risk
Assessment of offshore drilling and production platform (2) Safety Climate and Safety
Management Practice in offshore environments (3) Identifying Root Causes of Offshore
accidents(4) Investigate the Safety and Situation Awareness of offshore crews.
Risk can not be avoided especially for complex projects like offshore drilling and production
platform. The risk events of drilling and production platforms were ranked according to their
occurrence and impact. The principal elements required to manage and mitigate higher risks
are generally considered by :To eliminate or minimize the hazards by design (e.g. inherently
safety, separating the person from the hazard); To prevent realization of the hazard (e.g. good
inspection, maintenance,); To prevent escalation of the hazard (e.g. blowdown); To control the
hazard (e.g. provision of active or passive fire protection); To ensure that personnel can reach
a place of safety for any credible event (e.g. adequate evacuation, escape, and rescue) followed
to As Low As Reasonable Principle(ALARP).
‘Safety Climate Assessment Toolkit’, an assessment technique, based on the use of multiple
methods, was developed for assess the safety climate and safety management practice in
offshore environments and seeks to build on current industry initiatives, such as the cross
industry leadership initiative, general safety behabiour, appreciation of risk etc.
Offshore accident investigation techniques and reporting systems identify what type of
accidents occur and how they occurred. Accident root causes tracing model (ARCTM)
proposes that accidents occur due to three root causes like, failing to identify an unsafe
condition that existed before an activity was started or that developed after an activity was
started; deciding to proceed with a work activity after the worker identifies an existing unsafe
condition; and deciding to act unsafe regardless of initial conditions of the work environment.
Research finding showed that unsafe conditions are due to four main causes as Management
actions/inactions; unsafe acts of worker or coworker; non-human-related event(s); an unsafe
condition that is a natural part of the initial operation site conditions.
One factor to the occurrence of accidents in offshore installations is a reduction in the
‘Situation Awareness’ (SA).Good SA is essential when work is potentially hazardous, as
workers must accurately discern and monitor conditions if they are to reduce accidents.
Accident analyses have shown that a team can lose their shared awareness of the situation
when it is vital to the safety of their operation. This may be particularly relevant to drill crews
given the interactive and hazardous nature of their work. In this way, lack of/reduced SA may
be a predictor of the likelihood of an accident occurring. This part of the report was to presents
a brief history of SA, an overview of the study, a preliminary review of an accident database,
and results from interviews with onshore and offshore oil and gas industry personnel.
iv
Table of Contents
Chapter Title
Page
Title Page i
Acknowledgements ii
Abstract iv
Table of Contents v
List of Tables vii
List of Figures viii
List of Abbreviations ix
1 Introduction 1
1.1 Background 1
1.2 Rational 4
1.3 Problem statement 5
1.4 Objectives of the study 5
1.5 Scope of study 6
1.6 Study methodology 6
1.7 Limitation of research finding 6
2 Literature Review 7
2.1 Risk of offshore drilling and production 7
2.1.1 Definition of Risk 7
2.1.2 Considerations in common source of offshore risks 8
2.1.3 Risks in Offshore Drilling Activities and
Control Operations: Safety Codes and Procedures
10
2.1.4 Quantified Risk Target 11
2.1.5Overview of offshore Hazards Evaluation Methods 13
2.2 Safety Culture/Climate and Safety Management Practice 19
2.2.1 Background 19
2.2.2 Organizational Maturity 20
2.2.3 Safety Climate Assessment Toolkit Process 21
2.3 Identifying Root Causes of Offshore accidents 25
2.3.1 Introduction 25
2.3.2 Accident Causation Models 26
2.3.3 Accident Root Cause Tracing Model (ARCTM) 29
2.3.4 Factors influencing on the occurrences of labour accident 30
2.4 Safety and Situation Awareness in Offshore Crews 31
2.4.1 Summary 31
2.4.2 Situation Awareness(SA): Definition 33
2.4.3 Levels of SA 33
2.4.4 Attention and SA 34
2.4.5 Team Situation Awareness 34
2.4.6 Factors Affecting SA 34
2.4.7 Errors in SA 35
v
2.5 Environmental Assessment of offshore exploration and production 35
3 Methodology 38
3.1 Introduction 38
3.2 Risk Assessment of offshore drilling and production platform 38
3.2.1 Risk Analysis 39
3.2.2 Risks Reduction Process 43
3.2.3 Risk Management 47
3.3 Safety Climate and Safety Management Practice in
offshore environments
47
3.4 Identifying Root Causes of Offshore accidents 50
3.4.1 Introduction 50
3.4.2 Steps to investigate a labor accident using ARCTM 52
3.4.3 Interview checklist based on ARCTM for data
collection from injured workers
54
3.5 Safety and Situation Awareness in Offshore Crews 54
3.5.1 Drilling Accident Analysis 56
3.5.2 Interviews with Drilling Personnel 56
4 Result and Discussion 57
4.1 Risk Assessment of offshore drilling and production platform 57
4.2 Safety Climate and Safety Management Practice in
offshore environments
61
4.3 Identifying Root Causes of Offshore accidents 67
4.4 Safety and Situation Awareness in Offshore Crews 70
5 Conclusions and Recommendations 73
5.1 Risk Assessment of offshore drilling and production platform 73
5.2 Safety Climate and Safety Management Practice 74
5.3 Identifying Root Causes of Offshore accidents 75
5.4 Safety and Situation awareness (SA) of offshore crews 76
5.5 Recommendation for further research 77
References 78
Appendices 89
vi
List of Tables
Tables Title Page
2.1 Cultural descriptions 23
3.1 Risk Index (RI) 42
3.2 Risk Acceptance Criteria 45
3.3 Parameter considered for safety climate and safety management practice 50
4.1 Potential major hazards of offshore drilling and production 57
4.2 Proposed methodology of finding the current exposures 58
4.3 Proposed Job Safety Assessment for Handling tubulars and lifting 60
4.4 Frequency distribution of fatal accident by problems behind accident 67
4.5 Factors influencing the occurrence of accident 68
4.6 Main findings from Interview Analysis. 71
vii
List of Figures
Figures Title Page
1.1 Drilling overview 2
1.2 Onshore platform; fixed platform; jack up rig; semi-submersible; drill ship;
tension leg platform
3
2.1 Group Risk Targets – F/N Curve 12
2.2 A Three Aspect Approach to Safety Culture 19
2.3 Safety Climate assessment process 22
2.4 Health and Safety framework for drivers and controls 24
2.5 Summary influences of factors on the occurrence of labor accident 31
2.6 Accident Root Causes Tracing Models (ARCTM) 32
2.7 Environmental strategy map 36
3.1 Risk Assessment Approach 40
3.2 Risk Assessment Process Step by Step 41
3.3 Risk ranking Matrix 43
3.4 Demonstrating ALARP 44
3.5 Example Bow Tie Analysis 45
3.6 Safety Critical Activity 46
3.7 Multiple Perspective Assessment Models. 49
3.8 A framework of the study process 51
3.9 Accident Root Cause Tracing Model (ARCTM) in details 55
4.1 Blow out can be assessing by Bow-Tie 59
4.2 Results radar plot of drilling and production company (Safety Climate) 62
4.3 Results radar plot of drilling and Production Company
(Safety Management Practice)
63
4.4 Safety Climate Matrixes of drilling and Production Company 64
4.5 Miscellaneous Response for safety performance 65
4.6 Contribution to improvement of Safety Performance 69
4.7 Contribution to preventing the occurrence of accident 70
viii
List of Abbreviations
AFP Active fire protection
ALARP As Low As Reasonable Practicable
ARCTM Accident Root Cause Tracing Model
CBA Cost benefit analysis
CMPT Centre for Maritime and Petroleum Technology
EERA Evacuation, Escape and Rescue Analysis
ETA Event tree analysis
F/N Frequency vs. Number of fatalities
FAC First Aid Case
FAR Fatal Accident Rate
FMEA Failure modes and effects analysis
FTA Fault tree analysis
HAZID Hazard identification
HAZOP Hazard and operability study
HRA Human reliability analysis
HSE Health and Safety Executive
ICAF Implied cost of averting a fatality
LTI Lost time injuries
LTIFR Lost Time Injury Frequency Rate
MODUs Mobile offshore drilling units
MTC Medical Treatment Case
PDCA Plan-Do-Check-Act
PFP Passive fire protection
PLL Potential Loss of Life
PPE Personal protective equipment
QRA Quantitative risk assessment
RI Risk Index
RWC Restricted Work Cases
SA Situation Awareness
SCMM Safety Culture Maturity Model
TEIFR Total Environmental Incidents Frequency Rate
TRCFR Total Recordable Cases Frequency Rate
ix
Acknowledgements
Working on this thesis has been a great adventure of learning process for which I invested
my most fruitful time with much interest and dedication at Asian Institute of Technology,
Thailand.
This research was funded and supported by France Government scholarship, Asian
Institute of Technology Fellowship, PTT Exploration and Production, Plc, Thailand and
Cairn Energy Sangu Field Ltd, Bangladesh. I would like to thank all the participants in the
studies who took time to share their views and feelings with me.
First of all, I wish to express my deep gratitude and heartfelt thanks to Dr. Preeda
Parkpean, my advisor, for her continuing guidance, valuable advice and creative comments
on my work. Having been working under her supervision for a long time, I do appreciate
her encouragement, enthusiasm and endless patience extended towards me throughout the
period of this study and especially during the crucial stage of thesis writing. Her kindness
and great care towards me will ever be memorable.
I am also sincerely indebted to Dr. Vilas Nitivattananon and Dr. Toshiya Aramaki,
members of my thesis committee, whose generous support, advice, criticisms and
recommendations at various stages of this research kept me focused on the problem area.
Significantly, with the kind support from my committees, I was able to overcome all the
obstacles. I feel a deep sense of gratitude.
The deepest and sincerest gratitude is conveyed to my external examiner, Dr. Teerapon
Soponkanabhorn, Chief of Environmental Protection, PTT Exploration and Production Plc,
Thailand for his professional support in refining the final draft of the thesis manuscript.
Without his support, upgrading the thesis quality would have become an immensely more
difficult task.
I feel most grateful to Mr. Peter Brown, Chief of Loss Prevention Engineering, PTT
Exploration and Production Plc, Thailand for kindly accepting to be the external examiner
and for his constructive comments and recommendations on the thesis. Mr. Peter has keen
interest in the subject and gives prompt assessment of this study. I am very fortunate to
have him as the external examiner.
Special gratitude is also expressed to Mr. Iwan Wright, the General Manager of Cairn
Energy Sangu Field Ltd and all the members at the company for their assistance, guidance,
and they also contributed with in depth information and materials. Mr. Iwan Wright, for his
constructive criticisms and valuable suggestions has helped in the improvement in the
quality of this work.
I would like to express my deepest gratitude and sincere appreciation to Dr. Hafez, HSE
Advisor of Cairn Energy Sangu Field Ltd, who patiently gave me continuous guidance,
suggestion, and enthusiastic help during the research period.
My appreciation also goes to Krit Limbanyen, Engineer, Environmental Protection, PTT
Exploration and Production Plc, Thailand for his help, companionship, fruitful
administrative support and encouragements during twelve month thesis period.
ii
All the respondents from PTT Exploration and Production Plc, Thailand, Smedvig Rig T3,
Cairn Energy Sangu Field and Kellog Brown and Root (BD) Ltd. who were interviewed
for data collection deserve sincere thanks for their co-operation.
None of the persons above bears any responsibility if there are any errors that remain in
this thesis which is the sole responsibility of mine.
Finally, I want to dedicate all my work and effort to my parents who have continuously
supported and encouraged me during my study and in my life.
M. Shafiqul Islam
AIT, Bangkok
May, 2006
iii
Chapter 1
Introduction
1.1 Background
The oil and gas industry is truly global, with operations conducted in every corner of the
globe, from Alaska to Australia from Peru to China and in every habitat from Arctic to
desert, from tropical rainforest to temperate woodland, from mangrove to offshore. The oil
and gas industry comprises two parts: ‘upstream’- the exploration and production sector of
the industry; and ‘downstream’- sector which deals with refining and processing of crude
oil and gas products, their distribution and marketing.
Scientific exploration for oil and gas, in the modern sense, began in 1912 when geologists
were first involved in the discovery of the Chushing Field in Oklahoma, USA
Exploration Surveying
In the first stage of the search for hydrocarbon-hearing rock formations, geological maps
are reviewed in desk studies to identify major sedimentary basins. Aerial photography may
then be used to identify promising landscape formations such as faults or anticlines. More
detailed information is assembled using a field geological assessment, followed by one of
three main survey methods: magnetic, gravimetric and seismic.
The Magnetic Method depends upon measuring the variations in intensity of the magnetic
field which reflects the magnetic character of the various rocks present, while the
Gravimetric Method involves the measurements of small variations in the gravitational
field at the surface of the earth. Measurements are made, on land and at sea, using an
aircraft or a survey ship respectively.
The Seismic Method is used for identifying geological structures and relies on the differing
reflective properties of sound waves to various rock strata, beneath terrestrial or oceanic
surfaces. An energy source transmits a pulse of acoustic energy into the ground which
travels as a wave into the earth. At each point where different geological strata exist, a part
of the energy is transmitted clown to deeper layers within the earth, while the remainder is
reflected back to the surface. Here it is picked tip by a series of sensitive receivers called
geophones or seismometers on land, or hydrophones submerged in water.
Special cables transmit the electrical signals received to a mobile laboratory, where they
are amplified and filtered and then digitized and recorded on magnetic tapes for
interpretation. Dynamite was once widely used as the energy source, but environmental
considerations now generally favour lower energy sources such as vibroseis on land
(composed of a generator that hydraulically transmits vibrations into the earth) and the air
gun (which releases compressed air) in offshore exploration. In areas where preservation of
vegetation cover is important, the shot hole (dynamite) method is preferable to vibroseis.
Exploration Drilling
Once a promising geological structure has been identified, the only way to confirm the
presence of’ hydrocarbons and the thickness and internal pressure of a reservoir is to drill
exploratory boreholes. All wells that are drilled to discover hydrocarbons are called
1
‘exploration’ wells, commonly known by drillers as ‘wildcats’. The location of a drill site
depends on the characteristics of the underlying geological formations. It is generally
possible to balance environmental protection criteria with logistical needs, and the need for
efficient drilling.
Operations over water can be conducted using a variety of self-contained mobile offshore
drilling units (MODUs), the choice of which depends on the depth of water, seabed
conditions and prevailing meteorological conditions, particularly wind speed, wave height
and current speed. Mobile rigs commonly used offshore include jack ups, semi-
submersibles and drillships, whilst in shallow protected waters barges may be used.
Figure 1.1 Drilling overview
Drilling rigs may be moved by land, air or water depending on access, site location and
module size and weight. Once on site, the rig and a self-contained support camp are then
assembled. Typical drilling rig modules include a derrick, drilling mud handling
equipment, power generators, cementing equipment and tanks for fuel and water. The
support camp is self-contained and generally provides workforce accommodation, canteen
facilities, communications, vehicle maintenance and parking areas, a helipad for remote
sites, fuel handling and storage areas, and provision for the collection, treatment and
disposal of wastes.
2
Once drilling commences, drilling fluid or mud is continuously circulated down the drill
pipe and back to the surface equipment. Its purpose is to balance underground hydrostatic
pressure, cool the bit and flush our rock cuttings. The risk of an uncontrolled flow from the
reservoir to the surface is greatly reduced by using blowout presenter’s-a series of
hydraulically actuated steel rams that can close quickly around the drill string or casing to
seal off a well. Steel casing is run into completed sections of the borehole and cemented
into place. The casing provides structural support to maintain the integrity of the borehole
and isolates underground formations.
Appraisal
When exploratory drilling is successful, more wells are drilled to determine the size and
the extent of the field. Wells drilled to quantify the hydrocarbon reserves found are called
‘outstep’ or ‘appraisal’ wells. The appraisal stage aims to evaluate the size and nature of
the reservoir, to determine the number of confirming or appraisal wells required, and
whether any further seismic work is necessary. The technical procedures in appraisal
drilling are the same as those employed for exploration wells, and the description provided
above applies equally to appraisal operations. A number of wells may be drilled from a
single site, which increases the time during which the site is occupied. Deviated or
directional drilling at an angle from a site adjacent to the original discovery bore hole may
be used to appraise other parts of the reservoir, in order to reduce the land used or ‘foot
print’.
Figure 1.2 Left to right: onshore platform; fixed platform; jack up rig; semi-submersible;
drill ship; tension leg platform
3
Development and Production
Having established the size of the gas field, the subsequent wells drilled are called
‘development’ or ‘production’ wells. A small reservoir may be developed using one or
more of the appraisal wells. A larger reservoir will require the drilling of additional
production wells. Multiple production wells are often drilled from one pad to reduce land
requirements and the overall infrastructure cost. The number of wells required to exploit
the hydrocarbon reservoir varies with the size of the reservoir and its geology. At this stage
the blowout preventer is replaced by a control valve assembly or ‘Christmas Tree’.
Once the hydrocarbon reaches the surface, it is routed to the central production facility
which gathers and separates the produced fluids (oil, gas and water). The size and type of
the installation will depend on the nature of the reservoir, the volume and nature of
produced fluids, and the export option selected.
The production facility processes the hydrocarbon fluids and separates oil, gas and water.
The oil must usually be free of dissolved gas before export. Similarly, the gas must be
stabilized and free of liquids and unwanted components such as hydrogen sulphide and
carbon dioxide. Any water produced is treated before disposal.
Routine operations on a producing well would include a number of monitoring, safety and
security programmes, maintenance tasks, and periodic down hole servicing using a wire
line unit or a workover rig to maintain production.
In offshore production developments, permanent structures are necessary to support the
required facilities, since typical exploration units are not designed for full scale production
operations. Concrete platforms are sometimes used. If the field is large enough, additional
‘satellite’ platforms may be needed, linked by sub sea flow lines to the central facility. In
shallow water areas, typically a central processing facility is supported by a number of
smaller wellhead platforms. Recent technological developments, aimed at optimizing
operations, include remotely operated subsea systems which remove the requirement for
satellite platforms. This technology is also being used in deep water where platforms are
unsuitable, and for marginal fields where platforms would be uneconomic. In these cases,
floating systems-ships and semi submersibles-’service’ rise sub sea wells on a regular
basis.
Recent advances in horizontal drilling have enhanced directional drilling as a means of
concentrating operations at one site and reducing the ‘footprint’ on land of production
operations and the number of platforms offshore. The technology now enables access to a
reservoir up to several kilometers from the drill rig, while technology is developing to
permit even wider range. This further minimizes the ‘footprint’ by reducing the need for
satellite wells. It also allows for more flexibility in selecting a drill site, particularly where
environmental concerns are raised
1.2 Rational
Offshore work is hazardous work. The National Safety Council reports that in 1996 alone,
near hundred of offshore crew workers lost their lives at work and another several
hundreds received disabling injuries. These studies reveal many important trends about
offshore accidents within a construction and operation trade and also reveal the most
hazardous accidents. Despite the importance of such study findings to guide accident
4
prevention plans, it is our assertion that offshore operation accident investigations stop at a
premature level or are missing important steps to identify the main hazards and root causes
of accidents as well as implements the safety management system. Consequently,
prevention efforts could be directed at the root causes of accidents and not at symptoms,
leading to more effective accident prevention.
1.3 Problem statement
Risk appears in every aspect of our real life. A clear and simple example is that when we
go across a road on which only few vehicles are circulating slowly. Who is sure that an
accident will not happen? This comes from the reason that the real world contains in itself
a lot of changes and uncertainties. The offshore drilling and production project, with its
complex and dynamic nature, is not an exception. It suffers a lot of risks both internal and
external, causing time and cost overruns. For this reason, people started to think how to
handle with risk. At first, they coped with risks through their intuition and experience.
Then, however, they found that it was not sufficient when risks increased and became more
and more complex day by day. Therefore, an effective and comprehensive risk
management system was needed to develop to satisfy this new demand.
In view of the inherent risks in offshore, it is surprising that the managerial techniques used
to identify, analyze and respond to risk have been applied only during last decade(Flanagan
and Norman,1993).That is the reason why the techniques for monitoring and managing risk
have not been fully studied.
Risk has been the subject to many studies which examines or explores definition or risks
(Chapman and Cooper, 1991; PMBOK, 2000; Palisade, 1996; Raftery, 1994) is also an
interesting subject for discussion. Many authors now are going to research for assessment,
control and management of offshore risks to prevent the accident and build up a safe work.
One another aspects of risk is region specific. Every country has own uniqueness and this
contributes to the inherent risks for that specific country.
1.4 Objectives of the study
Based on the necessity for improvement of risk assessment in offshore operations the study
is design to achieve the following four objectives on offshore drilling and production
company.
1. To identify, classify and analyze the offshore drilling and production risk events;
risk influence sources and risk consequences; propose appropriate strategies to
effective mitigate the major risks encountered, find out the difficulties in applying
risk management
2. To produce an assessment technique which provides both a practical tool for the
assessment of safety climate and aids the promotion of a positive safety culture and
safety management in the offshore environment
3. Identifying Root Causes of Offshore accidents
4. Investigate the Safety and Situation Awareness of offshore crews
5
1.5 Scope of study
Offshore -Risk Assessment
Drilling
platform -Safety climate and
safety management
practiceLiterature
Review
Supportive
documents
Offshore
Production
platform
- Identifying Root
Causes of Offshore
accidents
1.6 Study methodology
Principal activities undertaken during the study were
A review of relevant published literature, including technical papers, company
technical literature and information available via the internet and company’s profile
Studying operation procedures of drilling and production activity by reading
contract documents and drawing
Interviews with senior personnel of the offshore engineering community
Preparation of questionnaires which were sent to corporate and onsite level of
drilling and production platform personnel
Synthesis of the data and presentation of this report
Making conclusion and recommendation
1.7 Limitation of research finding
The first limitation concerned size of the sample. Although 15 questionnaires both from
drilling and production platform returned from more then 30 distributed questionnaires, but
it would be better for data analysis if the amount of collected questionnaires is more then
that. Lack of sufficient data was the second limitation, which makes some results not
significant. The third limitation was the personnel time shortness, especially offshore
platform people were quite busy to made interview schedule.
-Situation Awareness
of offshore crews
Conclusion and
Recommendation
6
Chapter 2
Literature Review
2.1 Risk of offshore drilling and production platform
2.1.1 Definition of Risk
For decades, risk has been much studied because of its importance in ensuring and
improving project performance. In order to manage risks effectively, the nature of risk
should be clearly defined. Many researchers have variously defined the term “risk” as:
“Risk is an exposure to the possibility of economic or financial loss or gains, physical
damage or injury or delay as a consequence of the uncertainty associated with
pursuing a course of action.” (Chapman and Cooper, 1991)
“Project risk is an uncertain event or condition that, if occurs, has a positive or a
negative effect on project objectives” (PMBOK, 2000)
“Risk is the volatility of unexpected outcomes” (Flanagan and Norman, 1993)
“Risk is inability to see into the future, or a degree of uncertainty that is significant
enough to make us notice it” (Palisade, 1996)
“Risk and uncertainty characterize situation where the actual outcome for a particular
event or activity is likely to deviate from the estimate or forecast value” (Raftery,
1994)
In addition, Chapman and Ward (1997) gave a broad definition of project risk as
“the implications of the existence of significant uncertainty about the level of project
performance achievable”
In many studies, the term risk and uncertainty are used in some connection or even used
interchangeably. The term uncertainty can be defined as the state of mind characterized by
doubt, based on a lack of knowledge or historical data about what will or will not happen
in future or the situation being considered by decision-makers. In addition, uncertainty is
used to represent the probability that an event occurs, which is judged to be between 0 and
1 (Flanagan and Norman, 1993). An event may be said to be specific in three situations as
impossible (probability = 0), certain (probability = 1) and uncertain (probability between 0
and 1).
Raftery (1994) also stated that the distinction between risk and uncertainty is usually that
risk is taken to have quantifiable attributes, whereas uncertainty does not. Risk arose when
it is possible to make a statistical assessment of the probability of occurrence of a
particular event. Risk, therefore, tends to be insurable.
Uncertainty, on the other hand, is used to describe situations where is possible to attach a
probability to the likelihood of occurrence of an event. Uncertainty tends not to be
insurable.
7
Risks can be characterized by three components
• The risk event: What might happen to detriment or in favor of the project?
• The uncertainty of the event: The chance of the event occurring
• The potential loss/gain: Consequence of the event happening that can be specified as
loss or gain
From these characteristics, many professionals such as Raftery (1994) have quantified risk
in the following equation:
Risk = Probability of event X Magnitude of loss/gain
This equation is the simple way to quantify the risk in order to assess the influence of each
type of risk encountered in the project. Based on this, adequate response will be made to
handle effectively risks to achieve the objectives of the projects as on time, within budget
and as specifications.
Risk exposure: The exposure of risk would be given by the probability of the event
multiplied by the extent of the potential loss/gain. Risk exposure is concerned with the
amount of risk a person or organization is facing. Risk exposure can be measured by
probability distributions which give a profile of the risk being encountered. Statistics are a
tool that helps to measure the risk exposure, but the decision also has to be made on
objective or intuitive perception based upon experience, knowledge and wisdom
Through the probability of occurrence is high, the effect (gain/loss) may be low, and vice
versa also true. There fore, there are four main categories of risk exposure of the
occurrence and outcome of the risk, as follows
High probability----------High gain or loss
Low probability-----------High gain or loss
High probability-----------Low gain or loss
Low probability------------Low gain or loss
Utility Theory: A more formal approach to measuring the decision makes attitude towards
risk uses utility theory. The utility theory says that when individuals are faces with
uncertainty they make choices as if they maximizing a given criterion, the expected utility.
Expected utility is a measure of the individual’s implicit value, or preference, for each
policy in the risk environment.
2.1.2 Considerations in common source of offshore risks
Natural Risks
(1) Environment: The risks resulting from the environment are essentially due to:
(a) Environmental aggressively exhibited by external corrosion of the pipeline material;
(b) Hydrodynamic effects of the waves and currents liable to affect the stability of lines,
whether buried or unburied.
The problem of marine organisms must be considered, in particular on the vertical parts of
lines, at platform risers: the weight of living organisms attaching themselves to the pipes
can cause dangerous loadings.
8
(2) Natural and exceptional phenomena: These phenomena may be classified into two
groups:
(a) Accidental phenomena of limited duration
• cyclones and severe storms;
• earthquakes;
• underwater landslides.
These phenomena are always violent and frequently highly damaging to sub sea lines.
(b) Permanent or continuous phenomena. These relate to sediment transportation, erosion,
and scouring.
They have a number of effects:
• uncovering buried pipes;
• creating free spans, i.e. portions of lines no longer resting on the floor, as a
result of scouring.
These free spans may then cause inadmissible mechanical bending stresses and vibration
phenomena (vortex shedding) due to transverse currents.
Risks Due to Human Activities
(1) Risks deriving from offshore activities. The two main risks are:
(a) Dragging of the pipeline by ships’ anchors: The risk level is of course dependent on a
number of factors:
• the depth of water;
• the size of anchors;
• the pipeline diameter;
• pipeline protection (i) whether or not buried, and (ii) the presence and quality of
concrete cladding.
(b) Fishing activities.
The major risk is dredging of the pipeline and impact caused by trawls. Risks due to
anchors are more frequent at the edges of platforms, at construction and service vessel
moorings, than in the general sections of sea-lines, where the risks of trawl dredging are
greater. Regulations on navigation and mooring in these zones are designed to minimize
these risks, but they are not always observed particularly in case of emergency. Similarly,
damage caused by the accidental deposit of rubbish or other items is generally localized
around the edges of platforms.
The consequences of these various types of aggression extend from loss or damage of the
concrete ballast cladding and corrosion proof cladding to complete fracture of the line.
(2) Risks deriving from operation: The risks associated with operation and maintenance
is primarily due to errors in manoeuvring associated with malfunction of the safety
devices. This type of incident is more frequent at the time of commissioning the pipeline,
and the consequences are not generally catastrophic. In spite of the safety precautions
taken, fire and explosion risks can never be zero, since no safety device can attain 100%
reliability.
9
(3) Deficiencies in the installed pipeline: When an engineering company with
considerable experience in sub sea lines is used, design error remains an extremely low
probability. In most cases, incidents are due mainly to inadequate or defective inspection
on acceptance of the materials and equipment, or during construction.
2.1.3 Risks in Offshore Drilling Activities and Control of Operations:
Safety Codes and Procedures
General Approach
Preventive phase: There are two aspects to the preventive phase: risk assessment and the
establishment of preventive procedures.
Risk assessment involves:
• idefinition of the undesirable event(s);
• identification and analysis of its (their) cause(s);
• identification of the immediate consequences or easily detectable
indicators preceding the undesirable event.
Preventive procedures should be implemented when any of these ‘indicators’ is observed.
These procedures are to be based on:
• the inventory of systems installed, and their limitations;
• definition of the responsibilities of each person involved.
Corrective phase: The undesirable event has occurred. The corrective phase has two
levels; (1) action using available resources, and return to the normal situation as applying
prior to the undesirable event; and (2) an escalation in the seriousness of events, following
the failure of corrective action. It is impossible to return to a normal situation without
recourse to external resources.
In both cases, but more particularly in the second, the corrective or control operations will
require:
• a pre-existing emergency organization, known to those involved and in
charge;
• a list of potentially useful and readily available resources;
• selection of a control method based on experience in past events;
• the organization of control operations based on fault trees broken down
into individual operations and translated into operational procedures at
site level.
Drilling Equipment Reliability
Design phase: At the equipment design stage, risk analysis is used to highlight weaknesses
in the system in the light of its conceptual design (which can be modified) and its operating
conditions (which cannot be changed) If the risk of failure of equipment under normal
operating conditions is high, its conceptual design should be revised to reduce this risk to
an acceptable level. If the risk of failure is high only under extreme operating conditions, it
can sometimes be reduced by duplicating weak systems or setting-up an operating
procedure which avoids exposing the equipment to extreme conditions. Risk evaluation at
the design phase is to include the risk of failure as a result of the long-term use of the
equipment, which then becomes subject to fatigue. Fatigue and operating conditions may
be combined, the operating conditions of a fatigued item in fact being liable to constitute
extreme conditions.
10
Testing phase: Once the equipment has been built, it has to be tested under normal and
extreme operating conditions to assign design strengths and locate its potential range of
use. Depending on the gravity of the function to be performed by the equipment, these tests
may be carried out on a sample of systems manufactured, or on each individual system.
Incidence of the integration of a given item of equipment in a system on system failure
risks. In general, this involves applying risk analysis to a system comprising a number of
equipment items, in order to ascertain the usefulness of attaching an item of equipment to
this system intended to make it at least applicable, if not more reliable, under extreme
conditions, in comparison with those for which it was designed.
Safety Codes - Practical Exercises and Tests
Safety codes: All safety codes derive from the concern to limit risks. They are the product
of advanced or rudimentary analysis of the risks involved in a given operation and in the
systems used. The most difficult aspect to take into account is the human factor, but safety
codes affect the men who will be applying them, and they must, therefore, be sufficiently
restrictive at least to limit this factor in operation.
Practical exercises: Practical exercises are the best means of testing the reaction of
emergency teams to undesirable events. Exercises necessarily must follow on from training
on the risk in question, teaching operatives the reactions required in the preventive and
corrective phases, and also indicating the causes of the undesirable event, and how to avoid
them. Practical exercises must be carried out at regular intervals, and should be followed
by a critique. Simulators of the main risk operations in drilling are now available: these
should be of assistance in manpower training and qualification phases. Simulators cannot,
however, totally replace practical exercises in the field.
Testing: This relates to periodic testing of the various critical equipment items. This
testing must provide a check on the ability to function correctly when required. In certain
cases, this testing can introduce a certain degree of fatigue to the equipment, and this must
be taken into account.
2.1.4 Quantified Risk Target
- Individual Risk
If QRA is deemed to be necessary then the Individual Risk concept specifies risk targets
usually for the most exposed individual expressed in terms of deaths per year. This target is
the most commonly used in offshore risk assessments for both workforce and general
public. The following range is used:
Risk Classification
>10-3
Unacceptable
10-3
to 10-6
ALARP
<10-6
Acceptable
When applying Individual Risk targets to offshore installations it may be possible to
identify worker groups that are not exposed to the same potential hazards (e.g. caterers and
drillers). In such cases the individual risk associated with each worker group should be
estimated and compared to the targets separately.
11
- Group Risk
Risk assessment studies yield accident frequency vs. number of fatalities data, e.g. an
explosion scenario is predicted to occur with a frequency of 5 x 10-5
per year resulting in 6
fatalities. Frequency/Number of fatalities or F/N curves allows the summed frequency of
each fatality band to be compared to graphical targets. See below. F/N curves provide the
most detailed information to allow the management of risk because they do not integrate
risk into a single failure, but display “spikes” and “troughs” associated with particular
events or types of event.
Typically for an offshore installation these events would be:
• Riser and pipeline events
• Topsides events (fire, explosion etc)
• Blowout events
• Transportation events
• External events (ship collision, extreme weather etc)
F/N curves consider group risks and take into account the concept of “aversion”. This is
defined as a disproportionate intolerance of high consequence accidents i.e. those with a
large number of fatalities. For example, although the risk from an accident resulting in 100
fatalities once every 100 operating years is the same as from an accident resulting in 1
fatality every year for 100 operating years, society will tolerate the first case much less
than the second. So target F/N curves are weighted against high consequence accidents.
The summation of the product of F and N for each outcome over the entire range of
hazardous events assessed provides Potential Loss of Life (PLL) figure.
Figure 2.1 Group Risk Targets – F/N Curve
12
- Overall Risk
Overall risk comparisons can be made using Fatal Accident Rate (FAR) data. It was
originally developed and used as a means of expressing actuarial data for risk comparisons
between various industries. Example FAR’s for various industries follow:
• Onshore Chemical 3.3
• Construction 8.8
• Shipbuilding 7.0
• Offshore North Sea 1.8 (excluding Piper Alpha)
• 16.2 (including Piper Alpha)
2.1.5 Overview of offshore Hazards Evaluation Methods
1 Safety Review
Purpose: Safety Reviews keep operating personnel alert to the process risks: reviews
operating procedures for necessary revisions: seeks to identify equipment or process
changes that could have introduced new hazards: initiates application of new technology to
existing hazards: and reviews adequacy of maintenance safety inspections
When to Use: Safety Reviews ale usually conducted on a regularly scheduled basis.
Special-emphasis reviews or follow-up/resurvey inspections can he scheduled
intermittently
Type of Results: The inspection teams report includes deviations from designed and
planned procedures and notification of new safety items discovered.
Nature of Results: Qualitative.
Data Requirements: For a complete review, the team will need access to applicable codes
and standards, detailed plant descriptions such as piping and instrumentation drawings and
flowcharts; plant procedures for start-up, shutdown, normal operation, and emergencies:
personnel injury reports: hazardous incidents reports; maintenance records such as critical
instrument cheeks, pressure relief valve tests, pressure vessel inspections and process
material characteristics (i.e., toxicity and reactivity information)
Staffing Requirements: Staff assigned to Safety Review inspections need to be very
familiar with safety standards and procedures. Special technical skills are helpful for
evaluating instrumentation, electrical systems, pressure vessels, process materials and
chemistry and other special emphasis topics
Time and Cost Requirements: A complete survey will normally require a team of 2-5
people for at least a week. Shorter inspections do not allow for thorough examinations of
all equipment or procedures.
2 Checklist Analysis
Purpose: Traditional checklists are used primarily to ensure that organizations are
complying with standard practices.
13
When to use: It can be used to control the development of a project from initial design
through plant decommissioning. However, in general it can be applied at any stage of the
process’s lifetime
Types of Results: An analysis defines standard design or operating practices, then uses
them to generate a list of questions based on deficiencies or differences. Qualitative results
are obtained which vary with the specific situation but generally they lead to a “yes” or
“no” decision regarding compliance with standard procedures. Knowledge of deficiencies
leads to generation of safety improvement alternatives.
Nature of Result: Qualitative
Data Requirement: One needs an appropriate checklist, an engineering design procedures
and operating practices manual
Staffing Requirement: Experienced process engineers of varied background are required
for preparation of the checklist. However inexperienced engineers can be easily taught to
use the checklist
3 Preliminary Hazard Analysis (PHA)
Purpose: Early identification of hazards to provide designers with guidance in final plant
design stage.
When to Use: The PHA is used in the early design phase when only the basic plant
elements and materials are defined.
Type of Result: A list of risks related to available design details, with recommendations to
designers to aid hazard reduction during final design.
Nature of Result: Qualitative listing, with no numerical estimation or prioritization.
Data Requirement: Available plant design criteria, equipment specifications, material
specifications, and other like material.
Staffing Requirements: A PHA can be accomplished by one or two engineers with a
safety background, less experienced staff can perform a PHA but it may not he as complete
as desired.
Time and Cost Requirement: Because of its nature, experienced safety staff can
accomplish a PHA with an effort which is small compared to the effort needed for other
risk evaluation procedures.
4 “What If” Analysis
Purpose: Identify possible accident event sequences and thus identify the hazards
consequences and perhaps potential methods for risk reduction.
When to Use: The “What If” method can be used for existing plants, during the process
development stage, or at pre-startup stage. A very common usage is to examine proposed
changes to an existing plant.
14
Types of Results: Tabular listing of potential accident scenarios, their consequences and
possible risk reduction methods.
Nature of Results: Qualitative listing, with no ranking or quantitative implication.
Data Requirements: Derailed documentation o the plant, the process the operating
procedures and possibly interviews with plant operating personnel.
Staffing Requirements: For each investigation area, two or three experts should he
assigned.
Time and Cost Requirements: Time and cost are proportional to the plant size and
number of investigation areas to be addressed.
5 Hazard and Operability (HAZOP) studies
Purpose: Identification of hazard and operability problems.
When to Use: Optimal from a cost viewpoint when applied to new plants at the point
where the design is nearly firm and documented or to existing plants where a major
redesign is planned. It can also be used for existing facilities.
Type of Results: The results include: identification of hazards and operating problems:
recommended changes in design procedures etc.. to improve safety; and recommendations
for follow-up studies.
Nature of Results: Qualitative
Data Requirements: The HAZOP requires detailed plant descriptions, such as drawings,
procedures instrumentation, and operation and this information is usually provided by team
members who are experts in these areas.
Staff Requirements: The HAZOP team is ideally made up of 5 to 7 professionals.
Time and Cost: The time and cost of a HAZOP are directly related to the size and
complexity of the plant being analyzed. In general, the team must spend about three hours
for each major hardware item. Additional time must be allowed for planning, team
coordination, and documentation. This additional time can be as much ‘as two to three
limes the team effort as estimated above.
6 Failure Modes Effect Analysis
Purpose: Identify equipment/system failure modes and each failure modes potential
effect(s) on the system/plant
When to Use:
a. . Design: FMEA can be used to identify additional protective features that can be readily
incorporated into the design.
b. Construction: FMEA can be used to evaluate equipment changes resulting from held
modifications.
15
c. Operation: FMEA can be used to evaluate an existing Facility and identify existing
single failures that represent potential acc dents, as well as to supplement more detailed
hazard assessments such as Fault Tree Analysis.
Type of Results: Systematic reference listing of system/plant equipment, failure modes
and their effects. Easily updated Par design changes or system/plant modifications
Nature of Results: Qualitative, includes worst-case estimate of consequence resulting
from single failures. Contains a relative ranking of the equipment failures based on
estimates of failure probability and/or hazard severity.
Data Requirements:
(1) System/plant equipment list
(2) Knowledge of equipment function
(3) Knowledge of system/plant function
Staffing Requirements: For an average system evaluation, ideally two analysts should
participate to provide a check for each analyst’s assessments. All analysts involved in the
FMEA should be familiar with the equipment functions and failure modes and with how
the failures might propagate to other portions of the system/process
Time and Cost Requirements: Time and cost of the FMEA is proportional to the size and
number of systems analyzed- in the FMEA. On the average, an hour is sufficient for two to
four evaluations per analyst.
7 Fault Tree Analysis
Purpose: Identify combinations of equipment failures and human errors that can result in
an accident event.
When to Use:
a. Design: FTA can be used in the design phase of the plant to uncover
hidden failure modes that result from combinations of equipment failures.
b. Operation: FTA including operator and procedure characteristics can be
used to study an operating plant to denti1 potential combinations of failures
for specific accidents.
Type of Results: A listing of sets of equipment and/or operator failures that can result in a
specific accident. These sets can be qualitatively ranked by importance
Nature of Results: Qualitative, with quantitative potential. The fault tree can be evaluated
quantitatively when probabilistic data are available
Data Requirements:
a. A complete understanding of how the plant/system functions
b. Knowledge of the plum/system equipment Failure modes and their
effects on the plant/system. This in formation could be obtained from an
FMEA or FMECA study.
Staffing Requirements: One analyst should be responsible for a single fault tree, with
frequent consultation with personnel who have experience with the systems/equipment.
16
Time and cost requirements: Time and cost requirements for FTA are highly dependent
on the complexity of the systems involved in the accident event and the level of resolution
of the analysis.
8 Event Tree Analysis
Purpose: Identify the sequences of events, following an initiating event, which results in
accidents.
When to Use:
a. Design: Event tree analysis can be used in the design phase to assess potential accidents
resulting from postulated initiating events. The results can be useful in specifying safety
features to be incorporated into the plant design.
b. Operation: Event tree analysis can be used on an operating facility to assess the
adequacy of existing safety features or to examine the potential outcomes of equipment
failures.
Types of Results: Provides the event sequences that result in accidents following the
occurrence of an initiating event.
Nature of Results: Qualitative, with quantitative potential.
Data Requirements:
a. Knowledge of initiating events: that is, equipment failures or system upsets that can
potentially cause an accident.
b. Knowledge of safety system function or emergency procedures that potentially mitigate
the effects of an initiating event.
Staffing Requirements: An Event Tree Analysis can be performed by a single analyst.
but normally a team of 2 to 4 people is preferred. The team approach promotes
“brainstorming” that result in a well defined event tree structure.
Time and Cost Requirements: Three to six days should allow the team to evaluate
several initiating events for a small process unit. Large or complex process units could
require two to four weeks to evaluate multiple initiating events and the appropriate safety
function responses.
9 Cause-Consequence Analysis
Purpose: Identify potential accident consequences and the basic causes of these accidents.
When to Use:
a. Design: Cause-consequence analysis can be used in the design phase to assess potential
accidents and identify their basic causes.
b. Operation: Cause-consequence analysis can be used in an operating facility to evaluate
potential accidents.
Type of Results: Potential accident consequences related to their basic causes.
Probabilities of each type of accident can be developed if quantification is desired.
17
Nature of Results: Qualitative with quantitative potential.
Data Requirements:
a. Knowledge of component failures or process upsets that could cause accidents.
b. Knowledge of safety systems or emergency procedures that can influence the outcome
of an accident.
Staffing Requirements: Cause-consequence analysis is best performed by a small team (2
to 4 people) with a variety of experience. One team member should be experienced in
cause-consequence analysis (or fault tree and event tree analysis)
Time and Cost Requirements: Scooping-type analyses for several initiating events can
usually be accomplished in a week or less. Detailed cause-consequence analyses may
require two to six weeks depending on the complexity of the supporting fault tree analyses.
10 Human Error Analysis
Purpose: Identify potential human errors and their effects or identify the cause of observed
human errors.
When to Use:
a. Design: Human Error Analysis can be used to identify hardware features and features of
job design that are likely to produce a high rate of human error.
b. Construction: Human Error Analysis can be used to evaluate the effect of design
modifications on operator performance.
c. Operation: Human Error Analysis can be used to identify the source of observed human
error and to identify human errors that could result in accident event sequences.
Types of Results: Systematic listing of the types of errors likely to be encountered during
normal or emergency operation: listing of factors contributing to such errors; proposed
system modifications to reduce the likelihood of such errors. Easily updated for design
changes or system/plant/training modifications.
Data Requirements:
a. Operation procedures
b. Information from interviews of plant personnel
c. Knowledge of plant layout/function/task allocation
d. Control panel layout and alarm system layout.
Staffing Requirements: Generally, one analyst should be able to perform a Human Error
Analysis for a facility. The analyst should be familiar with interviewing techniques and
should have access to the plant and to pertinent information such as procedures and
schematic drawing.
Time and Cost Requirements: The time and cost are proportional to the size and number
of tasks/systems/errors being analyzed. An hour should be sufficient to conduct a rough
Human Error Analysis of the tasks associated with any given plant procedure. The time
required to identify the source of a given type of error will vary with the complexity of the
tasks involved.
18
2.2 Safety Culture/Climate and Safety Management Practice in offshore
environments
2.2.1 Background
It is widely accepted that an effective management process needs to be in place if risks to
health, safety and the environment from an organization’s activities are to be controlled
effectively. There are limits to what can be achieved through hardware and technological
solutions alone. Similarly, the introduction of safe systems of work and operating rules and
procedures are of limited use if they are not complied with.
Human factors have a specific part to play in achieving and maintaining high standards of
health and safety. A major influence on people's safety related behavior is the prevailing
health and safety culture of the organizations in which they work.
Figure 2.2 A Three Aspect Approach to Safety Culture (based upon Cooper, 2000)
A related approach is that of Correll & Andrewartha (2000) who propose that there are two
ways of treating safety culture
1. Something an organization is (the beliefs, attitudes and values of its members regarding
the pursuit of safety). These are measured through attitude and climate surveys.
2. Something an organization has (the structures, policies, practices controls and policies
designed to enhance safety). This is measured thorough safety audits and safety
performance statistics.
Although most organizations acknowledge that attention needs to focus on the 'people part'
of health and safety it has not always been clear
(a) how to establish the nature of the current situation
(b) how to determine suitable and realistic goals to aim for
(c) what mechanisms could, or should, be used to help reach these goals
(d) how to establish whether real improvements have been made
Over recent years, collaborative effort - from across industry sectors, researchers,
consultants, trainers, regulatory authorities and others - has seen considerable progress
19
being made. A number of safety culture/climate tools and methodologies have been
developed, piloted and applied in real working environments, depending on the nature of
individual tools, they may be applied to address one or more of the needs listed above. Use
of these tools can be an effective way of encouraging and maintaining employee
involvement in their safety climate, if people's views are sought and they are then actively
involved in implementing improvement actions based on the information obtained.
2.2.2 Organizational Maturity
One of the overall objectives of this part is to identify, if possible, which safety climate
tools and/or specific questionnaire items appear to be most useful in helping to establish
the current state of maturity of an organization or installation. This requires an
understanding of the elements that comprise safety culture maturity and of the
developmental stages through which an organization progresses as its safety culture
matures. A draft Safety Culture Maturity Model (SCMM) has been developed to assist
organisations in: (a) establishing their current level of safety culture maturity; (b)
identifying the actions required to improve their culture.
According to the SCMM, the safety culture maturity of an organization consists of ten
elements:
1. Management commitment and visibility 2. Communication
3. Productivity versus safety 4.Learning organization
5. Safety resources 6. Participation
7. Shared perceptions about safety 8.Trust
9. Industrial relations and job satisfaction 10.Training
The level of maturity of an organization or installation is determined on the basis of their
maturity on these elements. It is likely that an organization will be at different levels on the
ten components of the SCMM. Deciding which level is most appropriate will need to be
based on the average level achieved by the organization or installation being evaluated.
The SCMM is set out in a number of iterative stages. It is proposed that organizations
progress sequentially through the five levels, by building on the strengths and removing the
weaknesses of the previous level. The five levels are:
Level 1 - Emerging
Level 2 - Managing
Level 3 - Involving
Level 4 - Cooperating
Level 5 - Continually improving
The key characteristics of each level are described overleaf.
(The Keil Centre's report for further details (Fleming, 1999))
Level One: Emerging
Safety is defined in terms of technical and procedural solutions and compliance with
regulations. Safety is not seen as a key business risk and the safety department is perceived
to have primary responsibility for safety. Many accidents are seen as unavoidable and as
part of the job. Most frontline staffs are uninterested in safety and may only use safety as
the basis for other arguments, such as changes in shift systems.
20
Level Two: Managing
The organization’s accident rate is average for its industrial sector but they tend to have
more serious accidents than average. Safety is seen as a business risk and management
time and effort is put into accident prevention. Safety is solely defined in terms of
adherence to rules and procedures and engineering controls. Accidents are seen as
preventable. Managers perceive that the majority of accidents are solely caused by the
unsafe behavior of frontline staff. Safety performance is measured in terms of lagging
indicators such as lost time injuries (LTI) and safety incentives are based on reduced LTI
rates. Senior managers are reactive in their involvement in health and safety (i.e. they use
punishment when accident rates increase).
Level Three: Involving
Accident rates are relatively low, but they have reached a plateau. The organisation is
convinced that the involvement of frontline employees in health and safety is critical, if
future improvements are going to be achieved. Managers recognize that a wide range of
factors cause accidents and the root causes often originate from management decisions. A
significant proportion of frontline employees are willing to work with management to
improve health and safety. The majority of staff accepts personal responsibility for their
own health and safety. Safety performance is actively monitored and the data is used
effectively.
Level Four: Cooperating
The majority of staff in the organisation is convinced that health and safety is important
from both a moral and economic point of view. Managers and frontline staff recognize that
a wide range of factors cause accidents and the root causes are likely to come back to
management decisions. Frontline staff accepts personal responsibility for their own health
and safety and that of others. The importance of all employees feeling valued and treated
fairly is recognized. The organisation puts significant effort into proactive measures to
prevent accidents. Safety performance is actively monitored using all data available. Non-
work accidents are also monitored and a healthy lifestyle is promoted.
Level Five: Continuous improvement
The prevention of all injuries or harm to employees (both at work and at home) is a core
company value. The organisation has had a sustained period (years) without a recordable
accident or high potential incident, but there is no feeling of complacency. They live with
the paranoia that their next accident is just around the corner. The organisation uses a range
of indicators to monitor performance but it is not performance-driven, as it has confidence
in its safety processes. The organisation is constantly striving to be better and find better
ways of improving hazard control mechanisms. All employees share the belief that health
and safety is a critical aspect of their job and accept that the prevention of non-work
injuries is important.
2.2.3 Safety Climate Assessment Toolkit Process
Safety climate Assessment Toolkit is very popular for assessing the current safety climate
of an organization. Before beginning any assessment of safety climate, need to spend some
time for preparing. This pre-assessment preparation is an essential part of the process. It
allows to consider the existing culture and thus to place any climate data collected into an
appropriate context.
21
As a first step, requires a questioning approach. Which describe an assessment process
which commences with an initial focus on organizational safety culture and the
underpinning drivers, through a description of appropriate checks to the final state of
planning further improvements.
What is our current Safety Culture?
How can we check our Safety Culture?
What drives our Safety Culture?
What do these checks mean?
How can we now improve our Culture?
Figure 2.3 Safety Climate assessment process
What is our current safety culture?
Before attempting to measure organizational safety climate, it may help to consider the
current culture for safety in the organization. The Health and Safety Executive (HSE)
highlight four descriptions which categorize organizational culture in their publication
‘Managing Health and Safety’ These are:
• Power Culture - based on a small group wielding central control in running things;
• Support Culture - where the organization exists to support the needs of the
individuals;
• Role Culture - highly structured so that there are clear cut-off points for decision
making; and
• Achievement Culture - where people work together to achieve results and operate
flexibly.
None of these four broad categories is definitive - the important thing is that the
description matches what the organization is. The culture in the organization may
incorporate aspects of two or three of the above types. For example, would any of the
phrases elaborated in Table 2.1 be used to describe it? It may be possible to describe the
specific culture using more than one of these, or indeed, other terms that may be more
appropriate.
22
Table 2.1 Cultural descriptions
Collaborative? where collaboration and teamwork are fostered
Blaming? where the apportioning of blame is seen as important
Compliant? where everyone strives to follow rules and procedures
Considerate? where employees’ views are sought and valued
Co-operative? where everyone is involved and work together
Constructive? where interaction to solve problems is encouraged
Learning? where employees learn from mistakes
Responsible? where unacceptable behaviour is recognized
It may be more appropriate to use a number of guide words or prompts to prepare a
description of the current safety culture, for example:
1. Norms - for example, what is considered acceptable behaviour?
2. Values - for example, what is considered to be important;
3. Working atmosphere - for example, the social environment of the workplace;
4. Management style - for example, the accessibility of managers;
5. Structure and systems - for example, reporting systems; and
6. External perceptions - for example, what competitors think?
The more intangible of these guide words (for example, shared norms and values) may be
enshrined in an organization’s vision or mission statements. Goals such as ‘to be better
than the best’, or ‘to be the industry leader’ give us an indication of organizational
principles and values that are expected to be demonstrated on a day to day basis. One
should consider all of the above when completing the activity described overleaf.
ACTIVITY - Describing the current culture for safety
Take some time need to sketch the current culture for safety. For that need to consider
• Which of the models or cultural descriptions above would best describe it?
• What shared values are aware of?
• How would describe the management style?
• What is the working atmosphere like?
• How is the organization perceived externally?
What drives our culture?
Cultural drivers may focus on two main areas - those which are related to the organization
and those which relate to ‘key individuals’.
Organizational ‘Drivers’
Organizational drivers may be characterized by management systems and procedures in a
variety of areas of organizational activity. These drivers include both internal and external
influences.
23
External drivers might include:
• the extent of alliance contracts
• industry standards (for example, as produced by
The Exploration and Production Forum)
• legal requirements
• regulatory regime
Internal drivers might include:
• corporate business plan
• organizational structure/change
• organizational standards
• performance metrics
• systems and procedures
Individual ‘Drivers’
Individuals, and key groups, within the organization can influence and drive culture both
directly and indirectly through their actions, words and commitment. Some key individual
drivers might be:
Figure 2.4 describes a possible framework for Heath and Safety Management - a similar
• Champions
• All employees
• Medical team
• Visitors - external
enforcement personnel, etc.
• Chief Executive
• Senior Managers
• OIMs
• Safety Personnel
• Elected Safety
Representatives
framework may be considered for other areas of activity, for example business goals, or
systems and procedures.
Figure 2.4 Health and Safety framework for drivers and controls
24
The cultural drivers in the organization need to be considered in the activity for this stage
of the process, which is described overleaf.
ACTIVITY - Identifying the main drivers
Is it Identify who or what drives for the organizational culture?
Whom or what has most influence on safety issues?
Make a list of the key individuals and the key external and internal drivers that might
influence safety culture in the organization.
Who or what drives culture may be able to help the change or maintain it?
How can we check our safety culture?
Safety climate assessment provides one approach to checking the prevailing culture for
safety. It encompasses a number of methods, in order to build as complete a picture as
possible, and will provide a variety of valid and reliable measures.
What do these checks mean?
In each of the assessment sections of the Safety Climate Assessment Toolkit, several
measures are derived using the different assessment methods, and a score is computed for
each of these measures. These can be transferred to a graph to shows how the scores
derived from the climate measures can be plotted to provide a graphical representation of
each dimension and an overall picture of the current state of the organisation.
How can improve the culture?
Once the initial safety climate assessment has been completed and interpreted, an action
plan needs to be developed, with milestones established, that may be linked to the
organization’s business plan, vision or mission. These milestones should be realistic and
understandable.
2.3 Identifying Root Causes of Offshore accidents
2.3.1 Introduction
This part of thesis are reviews several subjects to facilitate the research development and
discussion in later chapter. The definitions of “accident”,” labor accident” and “forms of
accident” are reviewed. Some accident causation models are presented. Major factors
influencing on the occurrence of labour accident are pointed out. Eventually, the conditions
to secure for successful safety program are considered
Accident
“An accident is an unplanned and uncontrolled event in which the action or reaction of an
object, substance, person, or radiation results in personal injury or the probability
thereof” (Heinrich, 1959).
“While the outcome need not include injury, the production of an injury increase the
likelihood that it will be identified as an accident” (Suchman, 1964).
According to information processing models “an accident” is described as a breakdown of
the information processing system at some stage, e.g. failure to detect warning signals,
25
failure to interpret correctly, lack of desire to act deficiency of knowledge, and so on”
(Anderson et al., 1978, Corlett and Gilbank, 1978).
“An accident is an event not only unintended but also unanticipated or random in
occurrence” (Waller, 1979)
“An accident is characteristic as a break down of the person-task system” (Edward, 1981).
“An accident is any avoidable action personnel or any failure of equipment, tools, or other
devices that interrupts production and has the potential of injuring people or damaging
property” (Oglesby, et al., 1989)
“An accident is an unplanned, not necessarily injurious or damaging event, that interrupts
the completion of an activity and is in variably proceeded by an unsafe act and/or
condition or some combination of unsafe act and or conditions” (Stanton, 1990).
“An accident is an unpleasant event that happens unexpectedly and causes damage,
injury” (Crowther et al., 1995).
“An accident is an event that is unplanned and uncontrolled in some way undesirable; it
disrupts the normal function of a normal person or persons and causes injury or near
injury” (Shrestha, 1995).
“An accident is an event or circumstance that unexpectedly or unplanned occurs and it
causes injuries to humans or damage to property or any loss to humans or public”
(Simachokdee, 1994 and Intaranont, 1996 cited in Yuthayanont, 1998).
Labour accident
“Labor accidents are worker injuries, disease, or death resulting from work and other
activities with work-related structures, equipment, raw materials, gases, vapor, dust, etc.”
(Kunishima and Shoji, 1996).
As summarized by Brown (1995), ‘‘Accident reporting is a means to an end, not an end in
itself.’’ In other words, the answers that accident investigations provide for the ‘‘what’’
and ‘‘how’’ questions, should be used to determine the factors that contributed to the
accident causation (i.e., why the accident occurred). Brown (1995) argued convincingly
that accident investigation techniques should be firmly based on theories of accident
causation and human error, which would result in a better understanding of the relation
between the ‘‘antecedent human behavior’’ and the accident at a level enabling the root
causes of the accident to be determined.
2.3.2 Accident Causation Models
Many researchers have tried to understand accidents in industrial applications by
introducing accident causation models. In general, the overall objective of these models is
to provide tools for better industrial accident prevention programs. Accident prevention has
been defined by Heinrich et al. (1980) as ‘‘An integrated program, a series of coordinated
activities, directed to the control of unsafe personal performance and unsafe mechanical
conditions, and based on certain knowledge, attitudes, and abilities.’’ Other terms have
26
emerged that are synonymous with accident prevention such as loss prevention, loss
control, total loss control, safety management, and incidence loss control, among many
others.
Domino Theory
In 1930, research in accident causation theory was pioneered by Heinrich. Heinrich (1959)
discussed accident causation theory, the interaction between man and machine, the relation
between severity and frequency, the reasons for unsafe acts, the management role in
accident prevention, the costs of accidents, and finally the effect of safety on efficiency. In
addition,
Heinrich developed the domino theory (model) of causation, in which an accident is
presented as one of five factors in a sequence that results in an injury. The label was
chosen to graphically illustrate the sequentiality of events Heinrich believed to exist prior
to and after the occurrence of accidents. In addition, the name was intuitively appealing
because the behavior of the factors involved was similar to the toppling of dominoes when
disrupted: if one falls (occurs), the others will too.
Heinrich had five dominoes in his model: ancestry and social environment, fault of person,
unsafe act and/or mechanical or physical hazard, accidents, and injury. This five-domino
model suggested that through inherited or acquired undesirable traits, people may commit
unsafe acts or cause the existence of mechanical or physical hazards, which in turn cause
injurious accidents. Heinrich defined an accident as follows: ‘‘An accident is an unplanned
and uncontrolled event in which the action or reaction of an object, substance, person, or
radiation results in personal injury or the probability thereof.’’ The work of Heinrich can
be summarized in two points: people are the fundamental reason behind accidents; and
management-having the ability-are responsible for the prevention of accidents (Petersen
1982).
Some of Heinrich’s views were criticized for oversimplifying the control of human
behavior in causing accidents and for some statistics he gave on the contribution of unsafe
acts versus unsafe conditions (Zeller 1986). Nevertheless, his work was the foundation for
many others. Over the years the domino theory has been updated with an emphasis on
management as a primary cause in accidents, and the resulting models were labeled as
management models or updated domino models.
Management models hold management responsible for causing accidents, and the models
try to identify failures in the management system. Examples of these models are the
updated domino sequence (Bird 1974), the Adams updated sequence (Adams 1976), and
the Weaver updated dominoes (Weaver 1971). Two other accident causation models that
are management based but not dominoes based are the stair step model (Douglas and
Crowe 1976) and the multiple causation model (Petersen 1971). From these, the multiple
causation model (Petersen 1971) will be briefly described.
Multiple Causation Model
Petersen introduced this management non-domino-based model in his book Technique of
Safety Management (Petersen 1971). Petersen believed that many contributing factors,
causes, and sub causes are the main culprits in an accident scenario and, hence, the model
concept and name ‘‘multiple causation.’’ Under the concept of multiple causation, the
factors combine together in random fashion, causing accidents. Petersen maintained that
these are the factors to be targeted in accident investigation.
27
Petersen viewed his concept as not exhibiting the narrow interpretation exhibited by the
domino theory. To explain his concept, Petersen provided an example of a common
accident scenario, that of a man falling off a defective stepladder. Petersen believed that by
using present investigation forms, only one act (climbing a defective ladder) and/or one
condition (a defective ladder) would be identified. The correction to the problem would be
to get rid of the defective ladder. This would be the typical supervisor’s investigation if the
domino theory was used.
Petersen claimed that by using multiple causation questions, the surrounding factors to the
‘‘incident’’ (Petersen uses the word accident and incident interchangeably) would be
revealed. Applicable questions to the stepladder accident would be: why the defective
ladder was not found in normal inspections; why the supervisor allowed its use; whether
the injured employee knew that he/she should not use the ladder; whether the employee
was properly trained; whether the employee was reminded that the ladder was defective;
whether the supervisor examined the job first. Petersen believed that the answers to these
and other questions would lead to improved inspection procedures, improved training,
better definition of responsibilities, and pre job planning by supervisors.
Petersen also asserted that trying to find the unsafe act or the condition is dealing only at
the symptomatic level, because the act or condition may be the ‘‘proximate cause,’’ but
invariably it is not the ‘‘root cause.’’ As most others did, Petersen emphasized that root
causes must be found to have permanent improvement. He indicated that root causes often
relate to the management system and may be due to management policies, procedures,
supervision, effectiveness, training, etc.
Human Error Theories
Human error theories are best captured in behavior models and human factor models.
Behavior models picture workers as being the main cause of accidents. This approach
studies the tendency of humans to make errors under various situations and environmental
conditions, with the blame mostly falling on the human (unsafe) characteristics only. As
defined by Rigby (1970), human error is ‘‘any one set of human actions that exceed some
limit of acceptability.’’ Many researchers have devoted great time and effort to defining
and categorizing human error [e.g., Rock et al. (1966), Recht (1970), Norman (1981),
Petersen (1982), McClay (1989), DeJoy (1990), and Reason (1990)].
Similar to behavioral models, the human factors approach holds that human error is the
main cause of accidents. However, the blame does not fall on the human unsafe
characteristics alone but also on the design of workplace and tasks that do not consider
human limitations and may have harmful effects. In other words, the overall objective of
the human factors approach is to arrive at better designed tasks, tools, and workplaces,
while acknowledging the limitations of humans physical and psychological capabilities.
This approach stems from the relatively new engineering field known as human factors
engineering.
Behavior Models
The foundation of most behavior models is the accident proneness theory (Accident 1983).
This theory assumes that there are permanent characteristics in a person that make him or
her more likely to have an accident. The theory was supported by the simple fact that when
considering population accident statistics, the majority of people have no accidents, a
relatively small percentage have one accident, and a very small percentage have multiple
accidents. Therefore, this small group must possess personal characteristics that make them
28
more prone to accidents (Klumb 1995). This concept has been accepted by many
researchers; however, there are a number of arguments against it which are documented in
Heinrich et al. (1980).
Many behavior models have been developed to explain the reason for accident repeaters.
These models include the goals freedom alertness theory (Kerr 1957), and the motivation
reward satisfaction model (Petersen 1975). [For other behavioral models, see Krause et al.
(1984), Hoyos and Zimolong (1988), Wagenaar et al. (1990), Dwyer and Raftery (1991),
Heath (1991), Friend and Khon (1992), and Krause and Russell (1994).]
Human Factor Models
The work of Cooper and Volard (1978) summarize the common and basic ideas to the field
of human factors engineering. They stated that extreme environment characteristics and
overload of human capabilities (both physical and psychological) are factors that
contribute to accidents and to human error. Examples of human factor models include the
Ferrel theory (Ferrel 1977), the human-error causation model (Petersen 1982), the McClay
model (McClay 1989), and the DeJoy model (DeJoy 1990).
Ferrel Theory
One of the most important theories developed in the area of human factor models is that by
Ferrel [as referenced in Heimrich et al. (1980)]. Similar to the multiple causation theory,
the Ferrel theory attributes accidents to a causal chain of which human error plays a
significant role. According to the theory, human errors are due to three situations: (1)
Overload, which is the mismatch of a human’s capacity and the load to which he/she is
subjected in a motivational and arousal state; (2) incorrect response by the person in the
situation that is due to a basic incompatibility to which he/she is subjected; and (3) an
improper activity that he/she performs either because he/she didn’t know any better or
because he/she deliberately took a risk. The emphasis in this model is on overload and
incompatibility only, which are the central points in most human factor models.
2.3.3 Accident Root Cause Tracing Model (ARCTM)
ARCTM represents the further development and synthesis of many of the previously
mentioned models. In developing ARCTM, the main purpose was to provide an
investigator with a model to easily identify root causes of accidents versus developing a
model with abstract ideas and complicated technical occupational safety jargon and
confusing definitions for relatively clear terms such as accident and injury. ARCTM
attempts to direct the attention of the investigator to the conditions that existed at the time
of the accident and antecedent human behavior.
ARCTM and Accidents
The main concept proposed in ARCTM is that an occupational accident will occur due to
one or more of the following three roots causes (Figure 2.6):
1. Failing to identify an unsafe condition that existed before an activity was started or that
developed after an activity was started
2. Deciding to proceed with a work activity after the worker identifies an existing unsafe
condition
3. Deciding to act unsafe regardless of initial conditions of the work environment
Clearly, these root causes develop because of different reasons, and also point to different
issues that should be considered for corrective actions. ARCTM was designed to guide the
29
investigator through a series of questions and possible answers to identify a root cause for
why the accident occurred and to investigate how the root cause developed and how it
could be eliminated. Because ‘‘unsafe conditions,’’ ‘‘worker response to unsafe
conditions,’’ and ‘‘worker unsafe acts’’ are cornerstones of ARCTM, they will be
discussed first in the following sections before the use of ARCTM is explained and
demonstrated by considering real-life accident scenarios.
A worker or coworker may be inexperienced or new on site, or may choose to act unsafe,
all of which may lead to unsafe conditions for other workers. Examples of unsafe acts
leading to unsafe conditions include removing machine safeguards, working while
intoxicated, working with insufficient sleep, sabotaging equipment, disregarding
housekeeping rules, unauthorized operation of equipment, horseplay, etc. Non-human-
related events that may lead to unsafe conditions include systems, equipment or tool
failures, earthquakes, storms, etc. Unsafe conditions that are a natural part of the initial
operation site conditions are used in ARCTM to account for a unique type of unsafe
conditions in the offshore industry.
Worker Response to Unsafe Conditions
In addition to distinguishing between types of unsafe conditions and who is responsible for
them, ARCTM emphasizes the need to consider how workers respond to or are affected by
an unsafe condition. Basically, when an unsafe condition exists before or develops after a
worker starts an activity, the worker either fails or succeeds in identifying it. If the worker
fails to identify the unsafe condition, this means there was no consideration of any risks,
and the worker does not recognize the potential hazards. If the worker identifies the unsafe
condition, an evaluation of risk must be made.
The worker’s decision is either to act safe and discontinue the work until the unsafe
condition is corrected or take a chance (act unsafe) and continue working. The reasons
behind failing to identify the unsafe condition or the decision to act unsafe after identifying
an unsafe condition should be thoroughly investigated by management. It should be noted
that some unsafe conditions may never be possible to identify by a worker. Examples of
such conditions are non-human-related events or conditions where there are human factors
violations. Human factors violations are typically responsible for such injuries as
overexertion, cumulative trauma disorders, fatigue, toxic poisoning, mental disorders, etc.
Worker Unsafe Acts
A worker may commit unsafe acts regardless of the initial conditions of the work (i.e.,
whether the condition was safe or unsafe). Example of worker unsafe acts include the
decision to proceed with work in unsafe conditions, disregarding standard safety
procedures such as not wearing a hard hat or safety glasses, working while intoxicated,
working with insufficient sleep, etc. Therefore, the need to investigate why workers act
unsafe is also emphasized in ARCTM.
2.3.4 Factors influencing on the occurrences of labour accident
There are many factors that influence of labor accidents. These factors can be grouped into
four categories which is depicted in the figure 2.5
30
31
Factor related working
conditions
Factor related Operations
resources
Factor related Management &
Organization
Factor related Human
Behaviors
Labour
Accident
Figure 2.5 Summary influences of factors on the occurrence of labor accident
2.4 Safety and Situation Awareness in Offshore Crews
2.4.1 Summary
One factor critical in preventing accidents in everyday life should be maintaining an
adequate understanding of the current situation. This is needed in order to perceive the
conditions of the environment, and judge the consequences of any actions taken in relation
to the safety of the work, in order to avoid adverse events. By having full and correct
understanding of the situation, the potential risk involved in an action can more effectively
be gauged and in turn minimised, reducing the risk of an accident. However, if the
understanding of the situation is impaired, then the ability to predict the outcomes of
actions is more flawed, and due to this the risks of an accident occurring are increased. The
method by which this understanding of a situation arises is known as Situation Awareness
(SA) and the possession and maintenance of good quality SA is fundamental to safe
working practice. This is of paramount importance in the offshore oil and gas industry
where the work is hazardous and in many cases, complex, thus crews must be able to
monitor and understand their environment if they are to keep their accident risk to a
minimum.
The theory of SA has been in existence for many years, stemming from research in the
aviation industry. In the late 1980’s, interest in the area grew and research became more
widespread, including domains such as aircraft maintenance, the military, driving, and
medicine (Adams, Tenney & Pew Endsley Shrestha, Prince, Baker & Salas) However, with
the exception of one article (Hudson & van der Graaf) and a few industry documents (Shell
Exploration and Production) the concept has remained relatively uninvestigated in the oil
and gas industry, despite its importance and relevance, and remains little understood.
Pre-existing
unsafe condition
on the operating
site
32
Management
action/inaction
Worker or
coworker unsafe
acts
Non-human
related event
Unsafe ConditionThe 1st
root cause
Failing to identify an unsafe condition that existed
before an activity was started or that developed
after an activity was started
The 2nd
root cause
Deciding to proceed with a work activity after the
worker identifies an existing unsafe condition
The 3rd
root cause
Deciding to act unsafe regardless of initial
conditions of the work environment
Figure 2.6 Accident Root Causes Tracing Models (ARCTM); source: adapted from abdelhamid et al.
A LABOUR ACCIDENT OCCUR
The root causes
combine together
2.4.2 Situation Awareness (SA): Definition
The theory of situation awareness has been in existence for many years, with references to
the concept believed to originate from the pilot community of World War 1. Definitions of
SA vary greatly, as they are explained in terms of the industry concerned, and as a result,
understanding SA has been hampered since there is no one universally accepted and agreed
upon definition of the concept (Sarter & Woods)
However, there are two definitions widely cited, the fist of which characterizes SA as
“...the perception of the elements in the environment within a volume of space and time,
the comprehension of their meaning, and the projection of their status in the near future”
(Endsley). The other describes SA as “...the up-to-the minute cognizance required
operating or maintaining a system” (Adams, Tenney & Pew’). These definitions are the
most widely cited and accepted as appropriate and accurate descriptions of the concept. SA
therefore, in simple terms, is the ability to successfully pay attention to and monitor the
environment, and essentially ‘think ahead of the game’ to evaluate the risk of accidents
occurring - a vitally important factor in ensuring a safe working environment.
2.4.3 Levels of SA
Endsley’s three-level approach (Endsley) is the most popular view of the construct of SA
due to its simplicity, while the framework also provides a comprehensive theoretical
construct that can easily be applied to a multitude of other domains. Of the model, Level 1
is Perception, Level 2 is Comprehension, and Level 3 is Projection. Each of these will be
discussed in more detail.
Level 1 SA: Perception. This is the basal constituent of SA: the perception of the elements
in the surrounding environment. Without the correct initial perception of the relevant
elements of the environment, it is unlikely that an accurate illustration of the situation
would be formed. This increases the likelihood of an error or accident, since the
fundamental components on which the later stages of SA are based are of poor quality.
Level 2 SA: Comprehension. This involves the combination, interpretation, storage and
retention of the aforementioned information (Endsley) to form a picture of the situation
whereby the significance of objects/events are understood (Endsley; Stanton, Chambers &
Piggott’’) — essentially derivation of meaning from the elements perceived. The degree of
comprehension that is achieved will vary from person to person, and Endsley maintains
that the level attained is an indication of the skill and expertise held by the operator.
Level 3 SA: Projection. The final level is projection, and occurs as a result of the
combination of levels one and two. This stage is extremely important, as it means
possessing the ability to use information from the environment to predict possible future
states and events (Endsley, Sarter & Woods). Having the ability to correctly forecast
possible future circumstances is vital in allowing the best decision to be made regarding
appropriate courses of action, as time is made available to dispel potential discords and
formulate a suitable action course to meet goals (Endsley Stanton et al).
33
2.4.4 Attention and SA
In order for SA to be achieved, objects and information in the surrounding environment
(i.e. stimuli) must be attended to. When we attend to something, it involves the process of
observing the surrounding environment and being made aware of the attentional target’s
presence and the information that it provides (Style).Without the ability to do this, level
one perception could not be achieved, and accurate SA could not be formed. In addition,
we must also be able to concentrate on these stimuli to determine to which ones we should
attend. We must concentrate further still in order to continually monitor the surroundings
and attend to changing stimuli. It can therefore be seen that attentional processing is
intrinsically linked to the theory of SA, but attention is bound by the limits of the working
memory (the construct that allows the perceived information to be processed). The fact that
attention is limited is a problem, as a person is unable to pay close attention to every single
detail of his/her environment. In doing so, critical elements may be missed in the
observation/perception stage. leading to an incorrect mental model (the representations of
objects, people and tasks that people hold in their minds of the understanding of the
various roles and relevance of the items concerned) being formed, and this has been
supported by research (Jones & Endsley) Possession of a poor or incorrect mental model
can increase accident risk as there is no ‘template’ to guide actions.
2.4.5 Team Situation Awareness
Much of the work on an offshore installation/rig requires teamwork. As the successful
attainment of the goal is entirely dependent upon the team collectively working together,
then the nature of the situation dictates that the crew must have a mutual understanding of
the situation. Thus the team should have a collective SA. This amassed awareness is
known as team situation awareness (Bolstad & Endsley; Endsley; Endsley & Robertson;
Salas, Prince, Baker & Shrestha; Shrestha et al)
Team SA can be characterized as follows: “...compatible models of the teams internal and
external environment; includes skill in arriving at a common understanding of the situation
and applying appropriate task strategies” (Cannon- Bowers, Tannenbaum, Salas and
Volpe) This shared knowledge and understanding can then be called upon in order for the
crew to make critical decisions and adapt in order to react to and predict their working
environment.
2.4.6 Factors Affecting SA
The main goal of situation awareness is to keep those involved aware of their surrounding
environment, reacting to and anticipating events and actions, There are many possible
explanations as to why a particular accident has occurred, but it has become apparent that
one factor may be a reduction/loss of the SA of those concerned, SA can be reduced by a
number of different means, but the most salient in the prevailing literature state these as
stress (whereby performance decreases due to the extra pressures imposed on the mental
system) from either physical (e.g. noise, vibration, temperature) or psychological (e.g.
mental workload, anxiety, confidence) stressors; workload ;automation; and the decision-
making process.
34
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC
Thesis MSC

More Related Content

Viewers also liked

Implementation of the oh policy of namibia final report ivanov
Implementation of the oh policy of namibia final report ivanovImplementation of the oh policy of namibia final report ivanov
Implementation of the oh policy of namibia final report ivanovWorld Health Organization
 
Health Facilities Risk Assessment Report Final signed
Health Facilities Risk Assessment Report Final signedHealth Facilities Risk Assessment Report Final signed
Health Facilities Risk Assessment Report Final signedA.M Okoth-Okelloh
 
Maryland Risk Assessment of Shale Drilling & Fracking
Maryland Risk Assessment of Shale Drilling & FrackingMaryland Risk Assessment of Shale Drilling & Fracking
Maryland Risk Assessment of Shale Drilling & FrackingMarcellus Drilling News
 
The business case for safety and health at work
The business case for safety and health at workThe business case for safety and health at work
The business case for safety and health at workLuna Oliveira
 
Overview of EU and National Legislation in Construction Health and Safety
Overview of EU and National Legislation in Construction Health and SafetyOverview of EU and National Legislation in Construction Health and Safety
Overview of EU and National Legislation in Construction Health and SafetyMerve Hacıbayramoğlu
 
The business of safety
The business of safetyThe business of safety
The business of safetyJohn Newquist
 
What is OSH MP 15
What is OSH MP 15What is OSH MP 15
What is OSH MP 15Robert Rao
 
Project Report on Comparative Study Philips LED With Other Competitive Brands
Project Report on Comparative Study Philips LED With Other Competitive BrandsProject Report on Comparative Study Philips LED With Other Competitive Brands
Project Report on Comparative Study Philips LED With Other Competitive BrandsKapil Shelke
 
Thesis writing using apa format
Thesis writing using apa formatThesis writing using apa format
Thesis writing using apa formatBed Dhakal
 
Transportation Assignment
Transportation AssignmentTransportation Assignment
Transportation AssignmentNilam Kabra
 
Related Literature and Related Studies
Related Literature and Related StudiesRelated Literature and Related Studies
Related Literature and Related StudiesJenny Reyes
 

Viewers also liked (16)

Implementation of the oh policy of namibia final report ivanov
Implementation of the oh policy of namibia final report ivanovImplementation of the oh policy of namibia final report ivanov
Implementation of the oh policy of namibia final report ivanov
 
Health Facilities Risk Assessment Report Final signed
Health Facilities Risk Assessment Report Final signedHealth Facilities Risk Assessment Report Final signed
Health Facilities Risk Assessment Report Final signed
 
Maryland Risk Assessment of Shale Drilling & Fracking
Maryland Risk Assessment of Shale Drilling & FrackingMaryland Risk Assessment of Shale Drilling & Fracking
Maryland Risk Assessment of Shale Drilling & Fracking
 
The business case for safety and health at work
The business case for safety and health at workThe business case for safety and health at work
The business case for safety and health at work
 
Overview of EU and National Legislation in Construction Health and Safety
Overview of EU and National Legislation in Construction Health and SafetyOverview of EU and National Legislation in Construction Health and Safety
Overview of EU and National Legislation in Construction Health and Safety
 
The business of safety
The business of safetyThe business of safety
The business of safety
 
Ohs management system
Ohs management systemOhs management system
Ohs management system
 
What is OSH MP 15
What is OSH MP 15What is OSH MP 15
What is OSH MP 15
 
Hirarc
HirarcHirarc
Hirarc
 
Project Report on Comparative Study Philips LED With Other Competitive Brands
Project Report on Comparative Study Philips LED With Other Competitive BrandsProject Report on Comparative Study Philips LED With Other Competitive Brands
Project Report on Comparative Study Philips LED With Other Competitive Brands
 
Thesis writing using apa format
Thesis writing using apa formatThesis writing using apa format
Thesis writing using apa format
 
Transportation Assignment
Transportation AssignmentTransportation Assignment
Transportation Assignment
 
Thesis Writing
Thesis WritingThesis Writing
Thesis Writing
 
Related Literature and Related Studies
Related Literature and Related StudiesRelated Literature and Related Studies
Related Literature and Related Studies
 
Attendance monitoring system
Attendance monitoring systemAttendance monitoring system
Attendance monitoring system
 
OSH Audit September 2015
OSH Audit September 2015OSH Audit September 2015
OSH Audit September 2015
 

Similar to Thesis MSC

ALONGE JEPHTHAH'S PROJECT
ALONGE JEPHTHAH'S PROJECTALONGE JEPHTHAH'S PROJECT
ALONGE JEPHTHAH'S PROJECTALONGE JEPHTHAH
 
Hazardous waste compliance
Hazardous waste complianceHazardous waste compliance
Hazardous waste compliancemkpq pasha
 
Hazard assessment and risk management techniques
Hazard assessment and risk management techniquesHazard assessment and risk management techniques
Hazard assessment and risk management techniquesPRANJAY PATIL
 
Viva voce 17 may 2018
Viva voce 17  may 2018Viva voce 17  may 2018
Viva voce 17 may 2018Azlan Ayob
 
WASHEQ PPT Afternoon session 2011
WASHEQ PPT Afternoon session 2011WASHEQ PPT Afternoon session 2011
WASHEQ PPT Afternoon session 2011Ella Agbettor
 
öZlem özkiliç makale - en
öZlem özkiliç  makale - enöZlem özkiliç  makale - en
öZlem özkiliç makale - enÖzlem ÖZKILIÇ
 
2015 Trinity Dublin - Task risk management - hf in process safety
2015 Trinity Dublin - Task risk management - hf in process safety2015 Trinity Dublin - Task risk management - hf in process safety
2015 Trinity Dublin - Task risk management - hf in process safetyAndy Brazier
 
Asset Integrity Management approach to achieve excellence in Process Safety
Asset Integrity Management approach to achieve excellence in Process SafetyAsset Integrity Management approach to achieve excellence in Process Safety
Asset Integrity Management approach to achieve excellence in Process SafetyChandrashekhar Kulkarni
 
Safety and Occupational Health Performance Program
Safety and Occupational Health Performance ProgramSafety and Occupational Health Performance Program
Safety and Occupational Health Performance ProgramCrystal Guliford
 
Risk analysis and environmental hazard management
Risk analysis and environmental hazard managementRisk analysis and environmental hazard management
Risk analysis and environmental hazard managementeSAT Publishing House
 
IRJET- Risk Assessment in Automobile Assembly Shop
IRJET- Risk Assessment in Automobile Assembly ShopIRJET- Risk Assessment in Automobile Assembly Shop
IRJET- Risk Assessment in Automobile Assembly ShopIRJET Journal
 
3620720.ppt
3620720.ppt3620720.ppt
3620720.pptger80
 
Dam's Risk Assesment
Dam's Risk AssesmentDam's Risk Assesment
Dam's Risk Assesmentdhani_ahmad
 
Eurocontrol Sqs
Eurocontrol SqsEurocontrol Sqs
Eurocontrol Sqsapcae
 
Aviation safety management
Aviation safety managementAviation safety management
Aviation safety managementS P Singh
 
ECASTSMSWG-GuidanceonHazardIdentification
ECASTSMSWG-GuidanceonHazardIdentificationECASTSMSWG-GuidanceonHazardIdentification
ECASTSMSWG-GuidanceonHazardIdentificationIlias Maragakis
 
cdoif-Learning-from-Buncefield.pdf
cdoif-Learning-from-Buncefield.pdfcdoif-Learning-from-Buncefield.pdf
cdoif-Learning-from-Buncefield.pdfEfari Bahcevan
 

Similar to Thesis MSC (20)

ALONGE JEPHTHAH'S PROJECT
ALONGE JEPHTHAH'S PROJECTALONGE JEPHTHAH'S PROJECT
ALONGE JEPHTHAH'S PROJECT
 
risk analysis
 risk analysis risk analysis
risk analysis
 
Hazardous waste compliance
Hazardous waste complianceHazardous waste compliance
Hazardous waste compliance
 
Hazard assessment and risk management techniques
Hazard assessment and risk management techniquesHazard assessment and risk management techniques
Hazard assessment and risk management techniques
 
Viva voce 17 may 2018
Viva voce 17  may 2018Viva voce 17  may 2018
Viva voce 17 may 2018
 
risk analysis
risk analysisrisk analysis
risk analysis
 
WASHEQ PPT Afternoon session 2011
WASHEQ PPT Afternoon session 2011WASHEQ PPT Afternoon session 2011
WASHEQ PPT Afternoon session 2011
 
öZlem özkiliç makale - en
öZlem özkiliç  makale - enöZlem özkiliç  makale - en
öZlem özkiliç makale - en
 
2015 Trinity Dublin - Task risk management - hf in process safety
2015 Trinity Dublin - Task risk management - hf in process safety2015 Trinity Dublin - Task risk management - hf in process safety
2015 Trinity Dublin - Task risk management - hf in process safety
 
Asset Integrity Management approach to achieve excellence in Process Safety
Asset Integrity Management approach to achieve excellence in Process SafetyAsset Integrity Management approach to achieve excellence in Process Safety
Asset Integrity Management approach to achieve excellence in Process Safety
 
Safety and Occupational Health Performance Program
Safety and Occupational Health Performance ProgramSafety and Occupational Health Performance Program
Safety and Occupational Health Performance Program
 
Risk analysis and environmental hazard management
Risk analysis and environmental hazard managementRisk analysis and environmental hazard management
Risk analysis and environmental hazard management
 
IRJET- Risk Assessment in Automobile Assembly Shop
IRJET- Risk Assessment in Automobile Assembly ShopIRJET- Risk Assessment in Automobile Assembly Shop
IRJET- Risk Assessment in Automobile Assembly Shop
 
Frnt 3 pgs mod 2
Frnt 3 pgs mod 2Frnt 3 pgs mod 2
Frnt 3 pgs mod 2
 
3620720.ppt
3620720.ppt3620720.ppt
3620720.ppt
 
Dam's Risk Assesment
Dam's Risk AssesmentDam's Risk Assesment
Dam's Risk Assesment
 
Eurocontrol Sqs
Eurocontrol SqsEurocontrol Sqs
Eurocontrol Sqs
 
Aviation safety management
Aviation safety managementAviation safety management
Aviation safety management
 
ECASTSMSWG-GuidanceonHazardIdentification
ECASTSMSWG-GuidanceonHazardIdentificationECASTSMSWG-GuidanceonHazardIdentification
ECASTSMSWG-GuidanceonHazardIdentification
 
cdoif-Learning-from-Buncefield.pdf
cdoif-Learning-from-Buncefield.pdfcdoif-Learning-from-Buncefield.pdf
cdoif-Learning-from-Buncefield.pdf
 

Thesis MSC

  • 1. STUDY OF OFFSHORE RISKS, SAFETY CLIMATE & SAFETY MANAGEMENT PRACTICE IN OFFSHORE ENVIRONMENTS by Mohammad Shafiqul Islam A thesis submitted in partial fulfillment of the requirements for the degree of Master of Engineering Examination Committee: Dr. Preeda Parkpean (Chairperson) Dr. Vilas Nitivattananon Dr. Toshiya Aramaki Dr. Teerapon S. (External Expert from PTTEP) Mr. Peter Brown (External Expert from PTTEP) Nationality: Bangladeshi Previous Degree: Bachelor of Science in Chemical Engineering Bangladesh University of Engineering & Technology Dhaka, Bangladesh Scholarship Donor: France Government scholarship & AIT Fellowship Asian Institute of Technology School of Environment, Resources and Development Thailand May 2006 i
  • 2. Abstract This study was structure, conduct and performance of the risk assessment and safety management of offshore drilling and production operation, had main four objectives: (1) Risk Assessment of offshore drilling and production platform (2) Safety Climate and Safety Management Practice in offshore environments (3) Identifying Root Causes of Offshore accidents(4) Investigate the Safety and Situation Awareness of offshore crews. Risk can not be avoided especially for complex projects like offshore drilling and production platform. The risk events of drilling and production platforms were ranked according to their occurrence and impact. The principal elements required to manage and mitigate higher risks are generally considered by :To eliminate or minimize the hazards by design (e.g. inherently safety, separating the person from the hazard); To prevent realization of the hazard (e.g. good inspection, maintenance,); To prevent escalation of the hazard (e.g. blowdown); To control the hazard (e.g. provision of active or passive fire protection); To ensure that personnel can reach a place of safety for any credible event (e.g. adequate evacuation, escape, and rescue) followed to As Low As Reasonable Principle(ALARP). ‘Safety Climate Assessment Toolkit’, an assessment technique, based on the use of multiple methods, was developed for assess the safety climate and safety management practice in offshore environments and seeks to build on current industry initiatives, such as the cross industry leadership initiative, general safety behabiour, appreciation of risk etc. Offshore accident investigation techniques and reporting systems identify what type of accidents occur and how they occurred. Accident root causes tracing model (ARCTM) proposes that accidents occur due to three root causes like, failing to identify an unsafe condition that existed before an activity was started or that developed after an activity was started; deciding to proceed with a work activity after the worker identifies an existing unsafe condition; and deciding to act unsafe regardless of initial conditions of the work environment. Research finding showed that unsafe conditions are due to four main causes as Management actions/inactions; unsafe acts of worker or coworker; non-human-related event(s); an unsafe condition that is a natural part of the initial operation site conditions. One factor to the occurrence of accidents in offshore installations is a reduction in the ‘Situation Awareness’ (SA).Good SA is essential when work is potentially hazardous, as workers must accurately discern and monitor conditions if they are to reduce accidents. Accident analyses have shown that a team can lose their shared awareness of the situation when it is vital to the safety of their operation. This may be particularly relevant to drill crews given the interactive and hazardous nature of their work. In this way, lack of/reduced SA may be a predictor of the likelihood of an accident occurring. This part of the report was to presents a brief history of SA, an overview of the study, a preliminary review of an accident database, and results from interviews with onshore and offshore oil and gas industry personnel. iv
  • 3. Table of Contents Chapter Title Page Title Page i Acknowledgements ii Abstract iv Table of Contents v List of Tables vii List of Figures viii List of Abbreviations ix 1 Introduction 1 1.1 Background 1 1.2 Rational 4 1.3 Problem statement 5 1.4 Objectives of the study 5 1.5 Scope of study 6 1.6 Study methodology 6 1.7 Limitation of research finding 6 2 Literature Review 7 2.1 Risk of offshore drilling and production 7 2.1.1 Definition of Risk 7 2.1.2 Considerations in common source of offshore risks 8 2.1.3 Risks in Offshore Drilling Activities and Control Operations: Safety Codes and Procedures 10 2.1.4 Quantified Risk Target 11 2.1.5Overview of offshore Hazards Evaluation Methods 13 2.2 Safety Culture/Climate and Safety Management Practice 19 2.2.1 Background 19 2.2.2 Organizational Maturity 20 2.2.3 Safety Climate Assessment Toolkit Process 21 2.3 Identifying Root Causes of Offshore accidents 25 2.3.1 Introduction 25 2.3.2 Accident Causation Models 26 2.3.3 Accident Root Cause Tracing Model (ARCTM) 29 2.3.4 Factors influencing on the occurrences of labour accident 30 2.4 Safety and Situation Awareness in Offshore Crews 31 2.4.1 Summary 31 2.4.2 Situation Awareness(SA): Definition 33 2.4.3 Levels of SA 33 2.4.4 Attention and SA 34 2.4.5 Team Situation Awareness 34 2.4.6 Factors Affecting SA 34 2.4.7 Errors in SA 35 v
  • 4. 2.5 Environmental Assessment of offshore exploration and production 35 3 Methodology 38 3.1 Introduction 38 3.2 Risk Assessment of offshore drilling and production platform 38 3.2.1 Risk Analysis 39 3.2.2 Risks Reduction Process 43 3.2.3 Risk Management 47 3.3 Safety Climate and Safety Management Practice in offshore environments 47 3.4 Identifying Root Causes of Offshore accidents 50 3.4.1 Introduction 50 3.4.2 Steps to investigate a labor accident using ARCTM 52 3.4.3 Interview checklist based on ARCTM for data collection from injured workers 54 3.5 Safety and Situation Awareness in Offshore Crews 54 3.5.1 Drilling Accident Analysis 56 3.5.2 Interviews with Drilling Personnel 56 4 Result and Discussion 57 4.1 Risk Assessment of offshore drilling and production platform 57 4.2 Safety Climate and Safety Management Practice in offshore environments 61 4.3 Identifying Root Causes of Offshore accidents 67 4.4 Safety and Situation Awareness in Offshore Crews 70 5 Conclusions and Recommendations 73 5.1 Risk Assessment of offshore drilling and production platform 73 5.2 Safety Climate and Safety Management Practice 74 5.3 Identifying Root Causes of Offshore accidents 75 5.4 Safety and Situation awareness (SA) of offshore crews 76 5.5 Recommendation for further research 77 References 78 Appendices 89 vi
  • 5. List of Tables Tables Title Page 2.1 Cultural descriptions 23 3.1 Risk Index (RI) 42 3.2 Risk Acceptance Criteria 45 3.3 Parameter considered for safety climate and safety management practice 50 4.1 Potential major hazards of offshore drilling and production 57 4.2 Proposed methodology of finding the current exposures 58 4.3 Proposed Job Safety Assessment for Handling tubulars and lifting 60 4.4 Frequency distribution of fatal accident by problems behind accident 67 4.5 Factors influencing the occurrence of accident 68 4.6 Main findings from Interview Analysis. 71 vii
  • 6. List of Figures Figures Title Page 1.1 Drilling overview 2 1.2 Onshore platform; fixed platform; jack up rig; semi-submersible; drill ship; tension leg platform 3 2.1 Group Risk Targets – F/N Curve 12 2.2 A Three Aspect Approach to Safety Culture 19 2.3 Safety Climate assessment process 22 2.4 Health and Safety framework for drivers and controls 24 2.5 Summary influences of factors on the occurrence of labor accident 31 2.6 Accident Root Causes Tracing Models (ARCTM) 32 2.7 Environmental strategy map 36 3.1 Risk Assessment Approach 40 3.2 Risk Assessment Process Step by Step 41 3.3 Risk ranking Matrix 43 3.4 Demonstrating ALARP 44 3.5 Example Bow Tie Analysis 45 3.6 Safety Critical Activity 46 3.7 Multiple Perspective Assessment Models. 49 3.8 A framework of the study process 51 3.9 Accident Root Cause Tracing Model (ARCTM) in details 55 4.1 Blow out can be assessing by Bow-Tie 59 4.2 Results radar plot of drilling and production company (Safety Climate) 62 4.3 Results radar plot of drilling and Production Company (Safety Management Practice) 63 4.4 Safety Climate Matrixes of drilling and Production Company 64 4.5 Miscellaneous Response for safety performance 65 4.6 Contribution to improvement of Safety Performance 69 4.7 Contribution to preventing the occurrence of accident 70 viii
  • 7. List of Abbreviations AFP Active fire protection ALARP As Low As Reasonable Practicable ARCTM Accident Root Cause Tracing Model CBA Cost benefit analysis CMPT Centre for Maritime and Petroleum Technology EERA Evacuation, Escape and Rescue Analysis ETA Event tree analysis F/N Frequency vs. Number of fatalities FAC First Aid Case FAR Fatal Accident Rate FMEA Failure modes and effects analysis FTA Fault tree analysis HAZID Hazard identification HAZOP Hazard and operability study HRA Human reliability analysis HSE Health and Safety Executive ICAF Implied cost of averting a fatality LTI Lost time injuries LTIFR Lost Time Injury Frequency Rate MODUs Mobile offshore drilling units MTC Medical Treatment Case PDCA Plan-Do-Check-Act PFP Passive fire protection PLL Potential Loss of Life PPE Personal protective equipment QRA Quantitative risk assessment RI Risk Index RWC Restricted Work Cases SA Situation Awareness SCMM Safety Culture Maturity Model TEIFR Total Environmental Incidents Frequency Rate TRCFR Total Recordable Cases Frequency Rate ix
  • 8. Acknowledgements Working on this thesis has been a great adventure of learning process for which I invested my most fruitful time with much interest and dedication at Asian Institute of Technology, Thailand. This research was funded and supported by France Government scholarship, Asian Institute of Technology Fellowship, PTT Exploration and Production, Plc, Thailand and Cairn Energy Sangu Field Ltd, Bangladesh. I would like to thank all the participants in the studies who took time to share their views and feelings with me. First of all, I wish to express my deep gratitude and heartfelt thanks to Dr. Preeda Parkpean, my advisor, for her continuing guidance, valuable advice and creative comments on my work. Having been working under her supervision for a long time, I do appreciate her encouragement, enthusiasm and endless patience extended towards me throughout the period of this study and especially during the crucial stage of thesis writing. Her kindness and great care towards me will ever be memorable. I am also sincerely indebted to Dr. Vilas Nitivattananon and Dr. Toshiya Aramaki, members of my thesis committee, whose generous support, advice, criticisms and recommendations at various stages of this research kept me focused on the problem area. Significantly, with the kind support from my committees, I was able to overcome all the obstacles. I feel a deep sense of gratitude. The deepest and sincerest gratitude is conveyed to my external examiner, Dr. Teerapon Soponkanabhorn, Chief of Environmental Protection, PTT Exploration and Production Plc, Thailand for his professional support in refining the final draft of the thesis manuscript. Without his support, upgrading the thesis quality would have become an immensely more difficult task. I feel most grateful to Mr. Peter Brown, Chief of Loss Prevention Engineering, PTT Exploration and Production Plc, Thailand for kindly accepting to be the external examiner and for his constructive comments and recommendations on the thesis. Mr. Peter has keen interest in the subject and gives prompt assessment of this study. I am very fortunate to have him as the external examiner. Special gratitude is also expressed to Mr. Iwan Wright, the General Manager of Cairn Energy Sangu Field Ltd and all the members at the company for their assistance, guidance, and they also contributed with in depth information and materials. Mr. Iwan Wright, for his constructive criticisms and valuable suggestions has helped in the improvement in the quality of this work. I would like to express my deepest gratitude and sincere appreciation to Dr. Hafez, HSE Advisor of Cairn Energy Sangu Field Ltd, who patiently gave me continuous guidance, suggestion, and enthusiastic help during the research period. My appreciation also goes to Krit Limbanyen, Engineer, Environmental Protection, PTT Exploration and Production Plc, Thailand for his help, companionship, fruitful administrative support and encouragements during twelve month thesis period. ii
  • 9. All the respondents from PTT Exploration and Production Plc, Thailand, Smedvig Rig T3, Cairn Energy Sangu Field and Kellog Brown and Root (BD) Ltd. who were interviewed for data collection deserve sincere thanks for their co-operation. None of the persons above bears any responsibility if there are any errors that remain in this thesis which is the sole responsibility of mine. Finally, I want to dedicate all my work and effort to my parents who have continuously supported and encouraged me during my study and in my life. M. Shafiqul Islam AIT, Bangkok May, 2006 iii
  • 10. Chapter 1 Introduction 1.1 Background The oil and gas industry is truly global, with operations conducted in every corner of the globe, from Alaska to Australia from Peru to China and in every habitat from Arctic to desert, from tropical rainforest to temperate woodland, from mangrove to offshore. The oil and gas industry comprises two parts: ‘upstream’- the exploration and production sector of the industry; and ‘downstream’- sector which deals with refining and processing of crude oil and gas products, their distribution and marketing. Scientific exploration for oil and gas, in the modern sense, began in 1912 when geologists were first involved in the discovery of the Chushing Field in Oklahoma, USA Exploration Surveying In the first stage of the search for hydrocarbon-hearing rock formations, geological maps are reviewed in desk studies to identify major sedimentary basins. Aerial photography may then be used to identify promising landscape formations such as faults or anticlines. More detailed information is assembled using a field geological assessment, followed by one of three main survey methods: magnetic, gravimetric and seismic. The Magnetic Method depends upon measuring the variations in intensity of the magnetic field which reflects the magnetic character of the various rocks present, while the Gravimetric Method involves the measurements of small variations in the gravitational field at the surface of the earth. Measurements are made, on land and at sea, using an aircraft or a survey ship respectively. The Seismic Method is used for identifying geological structures and relies on the differing reflective properties of sound waves to various rock strata, beneath terrestrial or oceanic surfaces. An energy source transmits a pulse of acoustic energy into the ground which travels as a wave into the earth. At each point where different geological strata exist, a part of the energy is transmitted clown to deeper layers within the earth, while the remainder is reflected back to the surface. Here it is picked tip by a series of sensitive receivers called geophones or seismometers on land, or hydrophones submerged in water. Special cables transmit the electrical signals received to a mobile laboratory, where they are amplified and filtered and then digitized and recorded on magnetic tapes for interpretation. Dynamite was once widely used as the energy source, but environmental considerations now generally favour lower energy sources such as vibroseis on land (composed of a generator that hydraulically transmits vibrations into the earth) and the air gun (which releases compressed air) in offshore exploration. In areas where preservation of vegetation cover is important, the shot hole (dynamite) method is preferable to vibroseis. Exploration Drilling Once a promising geological structure has been identified, the only way to confirm the presence of’ hydrocarbons and the thickness and internal pressure of a reservoir is to drill exploratory boreholes. All wells that are drilled to discover hydrocarbons are called 1
  • 11. ‘exploration’ wells, commonly known by drillers as ‘wildcats’. The location of a drill site depends on the characteristics of the underlying geological formations. It is generally possible to balance environmental protection criteria with logistical needs, and the need for efficient drilling. Operations over water can be conducted using a variety of self-contained mobile offshore drilling units (MODUs), the choice of which depends on the depth of water, seabed conditions and prevailing meteorological conditions, particularly wind speed, wave height and current speed. Mobile rigs commonly used offshore include jack ups, semi- submersibles and drillships, whilst in shallow protected waters barges may be used. Figure 1.1 Drilling overview Drilling rigs may be moved by land, air or water depending on access, site location and module size and weight. Once on site, the rig and a self-contained support camp are then assembled. Typical drilling rig modules include a derrick, drilling mud handling equipment, power generators, cementing equipment and tanks for fuel and water. The support camp is self-contained and generally provides workforce accommodation, canteen facilities, communications, vehicle maintenance and parking areas, a helipad for remote sites, fuel handling and storage areas, and provision for the collection, treatment and disposal of wastes. 2
  • 12. Once drilling commences, drilling fluid or mud is continuously circulated down the drill pipe and back to the surface equipment. Its purpose is to balance underground hydrostatic pressure, cool the bit and flush our rock cuttings. The risk of an uncontrolled flow from the reservoir to the surface is greatly reduced by using blowout presenter’s-a series of hydraulically actuated steel rams that can close quickly around the drill string or casing to seal off a well. Steel casing is run into completed sections of the borehole and cemented into place. The casing provides structural support to maintain the integrity of the borehole and isolates underground formations. Appraisal When exploratory drilling is successful, more wells are drilled to determine the size and the extent of the field. Wells drilled to quantify the hydrocarbon reserves found are called ‘outstep’ or ‘appraisal’ wells. The appraisal stage aims to evaluate the size and nature of the reservoir, to determine the number of confirming or appraisal wells required, and whether any further seismic work is necessary. The technical procedures in appraisal drilling are the same as those employed for exploration wells, and the description provided above applies equally to appraisal operations. A number of wells may be drilled from a single site, which increases the time during which the site is occupied. Deviated or directional drilling at an angle from a site adjacent to the original discovery bore hole may be used to appraise other parts of the reservoir, in order to reduce the land used or ‘foot print’. Figure 1.2 Left to right: onshore platform; fixed platform; jack up rig; semi-submersible; drill ship; tension leg platform 3
  • 13. Development and Production Having established the size of the gas field, the subsequent wells drilled are called ‘development’ or ‘production’ wells. A small reservoir may be developed using one or more of the appraisal wells. A larger reservoir will require the drilling of additional production wells. Multiple production wells are often drilled from one pad to reduce land requirements and the overall infrastructure cost. The number of wells required to exploit the hydrocarbon reservoir varies with the size of the reservoir and its geology. At this stage the blowout preventer is replaced by a control valve assembly or ‘Christmas Tree’. Once the hydrocarbon reaches the surface, it is routed to the central production facility which gathers and separates the produced fluids (oil, gas and water). The size and type of the installation will depend on the nature of the reservoir, the volume and nature of produced fluids, and the export option selected. The production facility processes the hydrocarbon fluids and separates oil, gas and water. The oil must usually be free of dissolved gas before export. Similarly, the gas must be stabilized and free of liquids and unwanted components such as hydrogen sulphide and carbon dioxide. Any water produced is treated before disposal. Routine operations on a producing well would include a number of monitoring, safety and security programmes, maintenance tasks, and periodic down hole servicing using a wire line unit or a workover rig to maintain production. In offshore production developments, permanent structures are necessary to support the required facilities, since typical exploration units are not designed for full scale production operations. Concrete platforms are sometimes used. If the field is large enough, additional ‘satellite’ platforms may be needed, linked by sub sea flow lines to the central facility. In shallow water areas, typically a central processing facility is supported by a number of smaller wellhead platforms. Recent technological developments, aimed at optimizing operations, include remotely operated subsea systems which remove the requirement for satellite platforms. This technology is also being used in deep water where platforms are unsuitable, and for marginal fields where platforms would be uneconomic. In these cases, floating systems-ships and semi submersibles-’service’ rise sub sea wells on a regular basis. Recent advances in horizontal drilling have enhanced directional drilling as a means of concentrating operations at one site and reducing the ‘footprint’ on land of production operations and the number of platforms offshore. The technology now enables access to a reservoir up to several kilometers from the drill rig, while technology is developing to permit even wider range. This further minimizes the ‘footprint’ by reducing the need for satellite wells. It also allows for more flexibility in selecting a drill site, particularly where environmental concerns are raised 1.2 Rational Offshore work is hazardous work. The National Safety Council reports that in 1996 alone, near hundred of offshore crew workers lost their lives at work and another several hundreds received disabling injuries. These studies reveal many important trends about offshore accidents within a construction and operation trade and also reveal the most hazardous accidents. Despite the importance of such study findings to guide accident 4
  • 14. prevention plans, it is our assertion that offshore operation accident investigations stop at a premature level or are missing important steps to identify the main hazards and root causes of accidents as well as implements the safety management system. Consequently, prevention efforts could be directed at the root causes of accidents and not at symptoms, leading to more effective accident prevention. 1.3 Problem statement Risk appears in every aspect of our real life. A clear and simple example is that when we go across a road on which only few vehicles are circulating slowly. Who is sure that an accident will not happen? This comes from the reason that the real world contains in itself a lot of changes and uncertainties. The offshore drilling and production project, with its complex and dynamic nature, is not an exception. It suffers a lot of risks both internal and external, causing time and cost overruns. For this reason, people started to think how to handle with risk. At first, they coped with risks through their intuition and experience. Then, however, they found that it was not sufficient when risks increased and became more and more complex day by day. Therefore, an effective and comprehensive risk management system was needed to develop to satisfy this new demand. In view of the inherent risks in offshore, it is surprising that the managerial techniques used to identify, analyze and respond to risk have been applied only during last decade(Flanagan and Norman,1993).That is the reason why the techniques for monitoring and managing risk have not been fully studied. Risk has been the subject to many studies which examines or explores definition or risks (Chapman and Cooper, 1991; PMBOK, 2000; Palisade, 1996; Raftery, 1994) is also an interesting subject for discussion. Many authors now are going to research for assessment, control and management of offshore risks to prevent the accident and build up a safe work. One another aspects of risk is region specific. Every country has own uniqueness and this contributes to the inherent risks for that specific country. 1.4 Objectives of the study Based on the necessity for improvement of risk assessment in offshore operations the study is design to achieve the following four objectives on offshore drilling and production company. 1. To identify, classify and analyze the offshore drilling and production risk events; risk influence sources and risk consequences; propose appropriate strategies to effective mitigate the major risks encountered, find out the difficulties in applying risk management 2. To produce an assessment technique which provides both a practical tool for the assessment of safety climate and aids the promotion of a positive safety culture and safety management in the offshore environment 3. Identifying Root Causes of Offshore accidents 4. Investigate the Safety and Situation Awareness of offshore crews 5
  • 15. 1.5 Scope of study Offshore -Risk Assessment Drilling platform -Safety climate and safety management practiceLiterature Review Supportive documents Offshore Production platform - Identifying Root Causes of Offshore accidents 1.6 Study methodology Principal activities undertaken during the study were A review of relevant published literature, including technical papers, company technical literature and information available via the internet and company’s profile Studying operation procedures of drilling and production activity by reading contract documents and drawing Interviews with senior personnel of the offshore engineering community Preparation of questionnaires which were sent to corporate and onsite level of drilling and production platform personnel Synthesis of the data and presentation of this report Making conclusion and recommendation 1.7 Limitation of research finding The first limitation concerned size of the sample. Although 15 questionnaires both from drilling and production platform returned from more then 30 distributed questionnaires, but it would be better for data analysis if the amount of collected questionnaires is more then that. Lack of sufficient data was the second limitation, which makes some results not significant. The third limitation was the personnel time shortness, especially offshore platform people were quite busy to made interview schedule. -Situation Awareness of offshore crews Conclusion and Recommendation 6
  • 16. Chapter 2 Literature Review 2.1 Risk of offshore drilling and production platform 2.1.1 Definition of Risk For decades, risk has been much studied because of its importance in ensuring and improving project performance. In order to manage risks effectively, the nature of risk should be clearly defined. Many researchers have variously defined the term “risk” as: “Risk is an exposure to the possibility of economic or financial loss or gains, physical damage or injury or delay as a consequence of the uncertainty associated with pursuing a course of action.” (Chapman and Cooper, 1991) “Project risk is an uncertain event or condition that, if occurs, has a positive or a negative effect on project objectives” (PMBOK, 2000) “Risk is the volatility of unexpected outcomes” (Flanagan and Norman, 1993) “Risk is inability to see into the future, or a degree of uncertainty that is significant enough to make us notice it” (Palisade, 1996) “Risk and uncertainty characterize situation where the actual outcome for a particular event or activity is likely to deviate from the estimate or forecast value” (Raftery, 1994) In addition, Chapman and Ward (1997) gave a broad definition of project risk as “the implications of the existence of significant uncertainty about the level of project performance achievable” In many studies, the term risk and uncertainty are used in some connection or even used interchangeably. The term uncertainty can be defined as the state of mind characterized by doubt, based on a lack of knowledge or historical data about what will or will not happen in future or the situation being considered by decision-makers. In addition, uncertainty is used to represent the probability that an event occurs, which is judged to be between 0 and 1 (Flanagan and Norman, 1993). An event may be said to be specific in three situations as impossible (probability = 0), certain (probability = 1) and uncertain (probability between 0 and 1). Raftery (1994) also stated that the distinction between risk and uncertainty is usually that risk is taken to have quantifiable attributes, whereas uncertainty does not. Risk arose when it is possible to make a statistical assessment of the probability of occurrence of a particular event. Risk, therefore, tends to be insurable. Uncertainty, on the other hand, is used to describe situations where is possible to attach a probability to the likelihood of occurrence of an event. Uncertainty tends not to be insurable. 7
  • 17. Risks can be characterized by three components • The risk event: What might happen to detriment or in favor of the project? • The uncertainty of the event: The chance of the event occurring • The potential loss/gain: Consequence of the event happening that can be specified as loss or gain From these characteristics, many professionals such as Raftery (1994) have quantified risk in the following equation: Risk = Probability of event X Magnitude of loss/gain This equation is the simple way to quantify the risk in order to assess the influence of each type of risk encountered in the project. Based on this, adequate response will be made to handle effectively risks to achieve the objectives of the projects as on time, within budget and as specifications. Risk exposure: The exposure of risk would be given by the probability of the event multiplied by the extent of the potential loss/gain. Risk exposure is concerned with the amount of risk a person or organization is facing. Risk exposure can be measured by probability distributions which give a profile of the risk being encountered. Statistics are a tool that helps to measure the risk exposure, but the decision also has to be made on objective or intuitive perception based upon experience, knowledge and wisdom Through the probability of occurrence is high, the effect (gain/loss) may be low, and vice versa also true. There fore, there are four main categories of risk exposure of the occurrence and outcome of the risk, as follows High probability----------High gain or loss Low probability-----------High gain or loss High probability-----------Low gain or loss Low probability------------Low gain or loss Utility Theory: A more formal approach to measuring the decision makes attitude towards risk uses utility theory. The utility theory says that when individuals are faces with uncertainty they make choices as if they maximizing a given criterion, the expected utility. Expected utility is a measure of the individual’s implicit value, or preference, for each policy in the risk environment. 2.1.2 Considerations in common source of offshore risks Natural Risks (1) Environment: The risks resulting from the environment are essentially due to: (a) Environmental aggressively exhibited by external corrosion of the pipeline material; (b) Hydrodynamic effects of the waves and currents liable to affect the stability of lines, whether buried or unburied. The problem of marine organisms must be considered, in particular on the vertical parts of lines, at platform risers: the weight of living organisms attaching themselves to the pipes can cause dangerous loadings. 8
  • 18. (2) Natural and exceptional phenomena: These phenomena may be classified into two groups: (a) Accidental phenomena of limited duration • cyclones and severe storms; • earthquakes; • underwater landslides. These phenomena are always violent and frequently highly damaging to sub sea lines. (b) Permanent or continuous phenomena. These relate to sediment transportation, erosion, and scouring. They have a number of effects: • uncovering buried pipes; • creating free spans, i.e. portions of lines no longer resting on the floor, as a result of scouring. These free spans may then cause inadmissible mechanical bending stresses and vibration phenomena (vortex shedding) due to transverse currents. Risks Due to Human Activities (1) Risks deriving from offshore activities. The two main risks are: (a) Dragging of the pipeline by ships’ anchors: The risk level is of course dependent on a number of factors: • the depth of water; • the size of anchors; • the pipeline diameter; • pipeline protection (i) whether or not buried, and (ii) the presence and quality of concrete cladding. (b) Fishing activities. The major risk is dredging of the pipeline and impact caused by trawls. Risks due to anchors are more frequent at the edges of platforms, at construction and service vessel moorings, than in the general sections of sea-lines, where the risks of trawl dredging are greater. Regulations on navigation and mooring in these zones are designed to minimize these risks, but they are not always observed particularly in case of emergency. Similarly, damage caused by the accidental deposit of rubbish or other items is generally localized around the edges of platforms. The consequences of these various types of aggression extend from loss or damage of the concrete ballast cladding and corrosion proof cladding to complete fracture of the line. (2) Risks deriving from operation: The risks associated with operation and maintenance is primarily due to errors in manoeuvring associated with malfunction of the safety devices. This type of incident is more frequent at the time of commissioning the pipeline, and the consequences are not generally catastrophic. In spite of the safety precautions taken, fire and explosion risks can never be zero, since no safety device can attain 100% reliability. 9
  • 19. (3) Deficiencies in the installed pipeline: When an engineering company with considerable experience in sub sea lines is used, design error remains an extremely low probability. In most cases, incidents are due mainly to inadequate or defective inspection on acceptance of the materials and equipment, or during construction. 2.1.3 Risks in Offshore Drilling Activities and Control of Operations: Safety Codes and Procedures General Approach Preventive phase: There are two aspects to the preventive phase: risk assessment and the establishment of preventive procedures. Risk assessment involves: • idefinition of the undesirable event(s); • identification and analysis of its (their) cause(s); • identification of the immediate consequences or easily detectable indicators preceding the undesirable event. Preventive procedures should be implemented when any of these ‘indicators’ is observed. These procedures are to be based on: • the inventory of systems installed, and their limitations; • definition of the responsibilities of each person involved. Corrective phase: The undesirable event has occurred. The corrective phase has two levels; (1) action using available resources, and return to the normal situation as applying prior to the undesirable event; and (2) an escalation in the seriousness of events, following the failure of corrective action. It is impossible to return to a normal situation without recourse to external resources. In both cases, but more particularly in the second, the corrective or control operations will require: • a pre-existing emergency organization, known to those involved and in charge; • a list of potentially useful and readily available resources; • selection of a control method based on experience in past events; • the organization of control operations based on fault trees broken down into individual operations and translated into operational procedures at site level. Drilling Equipment Reliability Design phase: At the equipment design stage, risk analysis is used to highlight weaknesses in the system in the light of its conceptual design (which can be modified) and its operating conditions (which cannot be changed) If the risk of failure of equipment under normal operating conditions is high, its conceptual design should be revised to reduce this risk to an acceptable level. If the risk of failure is high only under extreme operating conditions, it can sometimes be reduced by duplicating weak systems or setting-up an operating procedure which avoids exposing the equipment to extreme conditions. Risk evaluation at the design phase is to include the risk of failure as a result of the long-term use of the equipment, which then becomes subject to fatigue. Fatigue and operating conditions may be combined, the operating conditions of a fatigued item in fact being liable to constitute extreme conditions. 10
  • 20. Testing phase: Once the equipment has been built, it has to be tested under normal and extreme operating conditions to assign design strengths and locate its potential range of use. Depending on the gravity of the function to be performed by the equipment, these tests may be carried out on a sample of systems manufactured, or on each individual system. Incidence of the integration of a given item of equipment in a system on system failure risks. In general, this involves applying risk analysis to a system comprising a number of equipment items, in order to ascertain the usefulness of attaching an item of equipment to this system intended to make it at least applicable, if not more reliable, under extreme conditions, in comparison with those for which it was designed. Safety Codes - Practical Exercises and Tests Safety codes: All safety codes derive from the concern to limit risks. They are the product of advanced or rudimentary analysis of the risks involved in a given operation and in the systems used. The most difficult aspect to take into account is the human factor, but safety codes affect the men who will be applying them, and they must, therefore, be sufficiently restrictive at least to limit this factor in operation. Practical exercises: Practical exercises are the best means of testing the reaction of emergency teams to undesirable events. Exercises necessarily must follow on from training on the risk in question, teaching operatives the reactions required in the preventive and corrective phases, and also indicating the causes of the undesirable event, and how to avoid them. Practical exercises must be carried out at regular intervals, and should be followed by a critique. Simulators of the main risk operations in drilling are now available: these should be of assistance in manpower training and qualification phases. Simulators cannot, however, totally replace practical exercises in the field. Testing: This relates to periodic testing of the various critical equipment items. This testing must provide a check on the ability to function correctly when required. In certain cases, this testing can introduce a certain degree of fatigue to the equipment, and this must be taken into account. 2.1.4 Quantified Risk Target - Individual Risk If QRA is deemed to be necessary then the Individual Risk concept specifies risk targets usually for the most exposed individual expressed in terms of deaths per year. This target is the most commonly used in offshore risk assessments for both workforce and general public. The following range is used: Risk Classification >10-3 Unacceptable 10-3 to 10-6 ALARP <10-6 Acceptable When applying Individual Risk targets to offshore installations it may be possible to identify worker groups that are not exposed to the same potential hazards (e.g. caterers and drillers). In such cases the individual risk associated with each worker group should be estimated and compared to the targets separately. 11
  • 21. - Group Risk Risk assessment studies yield accident frequency vs. number of fatalities data, e.g. an explosion scenario is predicted to occur with a frequency of 5 x 10-5 per year resulting in 6 fatalities. Frequency/Number of fatalities or F/N curves allows the summed frequency of each fatality band to be compared to graphical targets. See below. F/N curves provide the most detailed information to allow the management of risk because they do not integrate risk into a single failure, but display “spikes” and “troughs” associated with particular events or types of event. Typically for an offshore installation these events would be: • Riser and pipeline events • Topsides events (fire, explosion etc) • Blowout events • Transportation events • External events (ship collision, extreme weather etc) F/N curves consider group risks and take into account the concept of “aversion”. This is defined as a disproportionate intolerance of high consequence accidents i.e. those with a large number of fatalities. For example, although the risk from an accident resulting in 100 fatalities once every 100 operating years is the same as from an accident resulting in 1 fatality every year for 100 operating years, society will tolerate the first case much less than the second. So target F/N curves are weighted against high consequence accidents. The summation of the product of F and N for each outcome over the entire range of hazardous events assessed provides Potential Loss of Life (PLL) figure. Figure 2.1 Group Risk Targets – F/N Curve 12
  • 22. - Overall Risk Overall risk comparisons can be made using Fatal Accident Rate (FAR) data. It was originally developed and used as a means of expressing actuarial data for risk comparisons between various industries. Example FAR’s for various industries follow: • Onshore Chemical 3.3 • Construction 8.8 • Shipbuilding 7.0 • Offshore North Sea 1.8 (excluding Piper Alpha) • 16.2 (including Piper Alpha) 2.1.5 Overview of offshore Hazards Evaluation Methods 1 Safety Review Purpose: Safety Reviews keep operating personnel alert to the process risks: reviews operating procedures for necessary revisions: seeks to identify equipment or process changes that could have introduced new hazards: initiates application of new technology to existing hazards: and reviews adequacy of maintenance safety inspections When to Use: Safety Reviews ale usually conducted on a regularly scheduled basis. Special-emphasis reviews or follow-up/resurvey inspections can he scheduled intermittently Type of Results: The inspection teams report includes deviations from designed and planned procedures and notification of new safety items discovered. Nature of Results: Qualitative. Data Requirements: For a complete review, the team will need access to applicable codes and standards, detailed plant descriptions such as piping and instrumentation drawings and flowcharts; plant procedures for start-up, shutdown, normal operation, and emergencies: personnel injury reports: hazardous incidents reports; maintenance records such as critical instrument cheeks, pressure relief valve tests, pressure vessel inspections and process material characteristics (i.e., toxicity and reactivity information) Staffing Requirements: Staff assigned to Safety Review inspections need to be very familiar with safety standards and procedures. Special technical skills are helpful for evaluating instrumentation, electrical systems, pressure vessels, process materials and chemistry and other special emphasis topics Time and Cost Requirements: A complete survey will normally require a team of 2-5 people for at least a week. Shorter inspections do not allow for thorough examinations of all equipment or procedures. 2 Checklist Analysis Purpose: Traditional checklists are used primarily to ensure that organizations are complying with standard practices. 13
  • 23. When to use: It can be used to control the development of a project from initial design through plant decommissioning. However, in general it can be applied at any stage of the process’s lifetime Types of Results: An analysis defines standard design or operating practices, then uses them to generate a list of questions based on deficiencies or differences. Qualitative results are obtained which vary with the specific situation but generally they lead to a “yes” or “no” decision regarding compliance with standard procedures. Knowledge of deficiencies leads to generation of safety improvement alternatives. Nature of Result: Qualitative Data Requirement: One needs an appropriate checklist, an engineering design procedures and operating practices manual Staffing Requirement: Experienced process engineers of varied background are required for preparation of the checklist. However inexperienced engineers can be easily taught to use the checklist 3 Preliminary Hazard Analysis (PHA) Purpose: Early identification of hazards to provide designers with guidance in final plant design stage. When to Use: The PHA is used in the early design phase when only the basic plant elements and materials are defined. Type of Result: A list of risks related to available design details, with recommendations to designers to aid hazard reduction during final design. Nature of Result: Qualitative listing, with no numerical estimation or prioritization. Data Requirement: Available plant design criteria, equipment specifications, material specifications, and other like material. Staffing Requirements: A PHA can be accomplished by one or two engineers with a safety background, less experienced staff can perform a PHA but it may not he as complete as desired. Time and Cost Requirement: Because of its nature, experienced safety staff can accomplish a PHA with an effort which is small compared to the effort needed for other risk evaluation procedures. 4 “What If” Analysis Purpose: Identify possible accident event sequences and thus identify the hazards consequences and perhaps potential methods for risk reduction. When to Use: The “What If” method can be used for existing plants, during the process development stage, or at pre-startup stage. A very common usage is to examine proposed changes to an existing plant. 14
  • 24. Types of Results: Tabular listing of potential accident scenarios, their consequences and possible risk reduction methods. Nature of Results: Qualitative listing, with no ranking or quantitative implication. Data Requirements: Derailed documentation o the plant, the process the operating procedures and possibly interviews with plant operating personnel. Staffing Requirements: For each investigation area, two or three experts should he assigned. Time and Cost Requirements: Time and cost are proportional to the plant size and number of investigation areas to be addressed. 5 Hazard and Operability (HAZOP) studies Purpose: Identification of hazard and operability problems. When to Use: Optimal from a cost viewpoint when applied to new plants at the point where the design is nearly firm and documented or to existing plants where a major redesign is planned. It can also be used for existing facilities. Type of Results: The results include: identification of hazards and operating problems: recommended changes in design procedures etc.. to improve safety; and recommendations for follow-up studies. Nature of Results: Qualitative Data Requirements: The HAZOP requires detailed plant descriptions, such as drawings, procedures instrumentation, and operation and this information is usually provided by team members who are experts in these areas. Staff Requirements: The HAZOP team is ideally made up of 5 to 7 professionals. Time and Cost: The time and cost of a HAZOP are directly related to the size and complexity of the plant being analyzed. In general, the team must spend about three hours for each major hardware item. Additional time must be allowed for planning, team coordination, and documentation. This additional time can be as much ‘as two to three limes the team effort as estimated above. 6 Failure Modes Effect Analysis Purpose: Identify equipment/system failure modes and each failure modes potential effect(s) on the system/plant When to Use: a. . Design: FMEA can be used to identify additional protective features that can be readily incorporated into the design. b. Construction: FMEA can be used to evaluate equipment changes resulting from held modifications. 15
  • 25. c. Operation: FMEA can be used to evaluate an existing Facility and identify existing single failures that represent potential acc dents, as well as to supplement more detailed hazard assessments such as Fault Tree Analysis. Type of Results: Systematic reference listing of system/plant equipment, failure modes and their effects. Easily updated Par design changes or system/plant modifications Nature of Results: Qualitative, includes worst-case estimate of consequence resulting from single failures. Contains a relative ranking of the equipment failures based on estimates of failure probability and/or hazard severity. Data Requirements: (1) System/plant equipment list (2) Knowledge of equipment function (3) Knowledge of system/plant function Staffing Requirements: For an average system evaluation, ideally two analysts should participate to provide a check for each analyst’s assessments. All analysts involved in the FMEA should be familiar with the equipment functions and failure modes and with how the failures might propagate to other portions of the system/process Time and Cost Requirements: Time and cost of the FMEA is proportional to the size and number of systems analyzed- in the FMEA. On the average, an hour is sufficient for two to four evaluations per analyst. 7 Fault Tree Analysis Purpose: Identify combinations of equipment failures and human errors that can result in an accident event. When to Use: a. Design: FTA can be used in the design phase of the plant to uncover hidden failure modes that result from combinations of equipment failures. b. Operation: FTA including operator and procedure characteristics can be used to study an operating plant to denti1 potential combinations of failures for specific accidents. Type of Results: A listing of sets of equipment and/or operator failures that can result in a specific accident. These sets can be qualitatively ranked by importance Nature of Results: Qualitative, with quantitative potential. The fault tree can be evaluated quantitatively when probabilistic data are available Data Requirements: a. A complete understanding of how the plant/system functions b. Knowledge of the plum/system equipment Failure modes and their effects on the plant/system. This in formation could be obtained from an FMEA or FMECA study. Staffing Requirements: One analyst should be responsible for a single fault tree, with frequent consultation with personnel who have experience with the systems/equipment. 16
  • 26. Time and cost requirements: Time and cost requirements for FTA are highly dependent on the complexity of the systems involved in the accident event and the level of resolution of the analysis. 8 Event Tree Analysis Purpose: Identify the sequences of events, following an initiating event, which results in accidents. When to Use: a. Design: Event tree analysis can be used in the design phase to assess potential accidents resulting from postulated initiating events. The results can be useful in specifying safety features to be incorporated into the plant design. b. Operation: Event tree analysis can be used on an operating facility to assess the adequacy of existing safety features or to examine the potential outcomes of equipment failures. Types of Results: Provides the event sequences that result in accidents following the occurrence of an initiating event. Nature of Results: Qualitative, with quantitative potential. Data Requirements: a. Knowledge of initiating events: that is, equipment failures or system upsets that can potentially cause an accident. b. Knowledge of safety system function or emergency procedures that potentially mitigate the effects of an initiating event. Staffing Requirements: An Event Tree Analysis can be performed by a single analyst. but normally a team of 2 to 4 people is preferred. The team approach promotes “brainstorming” that result in a well defined event tree structure. Time and Cost Requirements: Three to six days should allow the team to evaluate several initiating events for a small process unit. Large or complex process units could require two to four weeks to evaluate multiple initiating events and the appropriate safety function responses. 9 Cause-Consequence Analysis Purpose: Identify potential accident consequences and the basic causes of these accidents. When to Use: a. Design: Cause-consequence analysis can be used in the design phase to assess potential accidents and identify their basic causes. b. Operation: Cause-consequence analysis can be used in an operating facility to evaluate potential accidents. Type of Results: Potential accident consequences related to their basic causes. Probabilities of each type of accident can be developed if quantification is desired. 17
  • 27. Nature of Results: Qualitative with quantitative potential. Data Requirements: a. Knowledge of component failures or process upsets that could cause accidents. b. Knowledge of safety systems or emergency procedures that can influence the outcome of an accident. Staffing Requirements: Cause-consequence analysis is best performed by a small team (2 to 4 people) with a variety of experience. One team member should be experienced in cause-consequence analysis (or fault tree and event tree analysis) Time and Cost Requirements: Scooping-type analyses for several initiating events can usually be accomplished in a week or less. Detailed cause-consequence analyses may require two to six weeks depending on the complexity of the supporting fault tree analyses. 10 Human Error Analysis Purpose: Identify potential human errors and their effects or identify the cause of observed human errors. When to Use: a. Design: Human Error Analysis can be used to identify hardware features and features of job design that are likely to produce a high rate of human error. b. Construction: Human Error Analysis can be used to evaluate the effect of design modifications on operator performance. c. Operation: Human Error Analysis can be used to identify the source of observed human error and to identify human errors that could result in accident event sequences. Types of Results: Systematic listing of the types of errors likely to be encountered during normal or emergency operation: listing of factors contributing to such errors; proposed system modifications to reduce the likelihood of such errors. Easily updated for design changes or system/plant/training modifications. Data Requirements: a. Operation procedures b. Information from interviews of plant personnel c. Knowledge of plant layout/function/task allocation d. Control panel layout and alarm system layout. Staffing Requirements: Generally, one analyst should be able to perform a Human Error Analysis for a facility. The analyst should be familiar with interviewing techniques and should have access to the plant and to pertinent information such as procedures and schematic drawing. Time and Cost Requirements: The time and cost are proportional to the size and number of tasks/systems/errors being analyzed. An hour should be sufficient to conduct a rough Human Error Analysis of the tasks associated with any given plant procedure. The time required to identify the source of a given type of error will vary with the complexity of the tasks involved. 18
  • 28. 2.2 Safety Culture/Climate and Safety Management Practice in offshore environments 2.2.1 Background It is widely accepted that an effective management process needs to be in place if risks to health, safety and the environment from an organization’s activities are to be controlled effectively. There are limits to what can be achieved through hardware and technological solutions alone. Similarly, the introduction of safe systems of work and operating rules and procedures are of limited use if they are not complied with. Human factors have a specific part to play in achieving and maintaining high standards of health and safety. A major influence on people's safety related behavior is the prevailing health and safety culture of the organizations in which they work. Figure 2.2 A Three Aspect Approach to Safety Culture (based upon Cooper, 2000) A related approach is that of Correll & Andrewartha (2000) who propose that there are two ways of treating safety culture 1. Something an organization is (the beliefs, attitudes and values of its members regarding the pursuit of safety). These are measured through attitude and climate surveys. 2. Something an organization has (the structures, policies, practices controls and policies designed to enhance safety). This is measured thorough safety audits and safety performance statistics. Although most organizations acknowledge that attention needs to focus on the 'people part' of health and safety it has not always been clear (a) how to establish the nature of the current situation (b) how to determine suitable and realistic goals to aim for (c) what mechanisms could, or should, be used to help reach these goals (d) how to establish whether real improvements have been made Over recent years, collaborative effort - from across industry sectors, researchers, consultants, trainers, regulatory authorities and others - has seen considerable progress 19
  • 29. being made. A number of safety culture/climate tools and methodologies have been developed, piloted and applied in real working environments, depending on the nature of individual tools, they may be applied to address one or more of the needs listed above. Use of these tools can be an effective way of encouraging and maintaining employee involvement in their safety climate, if people's views are sought and they are then actively involved in implementing improvement actions based on the information obtained. 2.2.2 Organizational Maturity One of the overall objectives of this part is to identify, if possible, which safety climate tools and/or specific questionnaire items appear to be most useful in helping to establish the current state of maturity of an organization or installation. This requires an understanding of the elements that comprise safety culture maturity and of the developmental stages through which an organization progresses as its safety culture matures. A draft Safety Culture Maturity Model (SCMM) has been developed to assist organisations in: (a) establishing their current level of safety culture maturity; (b) identifying the actions required to improve their culture. According to the SCMM, the safety culture maturity of an organization consists of ten elements: 1. Management commitment and visibility 2. Communication 3. Productivity versus safety 4.Learning organization 5. Safety resources 6. Participation 7. Shared perceptions about safety 8.Trust 9. Industrial relations and job satisfaction 10.Training The level of maturity of an organization or installation is determined on the basis of their maturity on these elements. It is likely that an organization will be at different levels on the ten components of the SCMM. Deciding which level is most appropriate will need to be based on the average level achieved by the organization or installation being evaluated. The SCMM is set out in a number of iterative stages. It is proposed that organizations progress sequentially through the five levels, by building on the strengths and removing the weaknesses of the previous level. The five levels are: Level 1 - Emerging Level 2 - Managing Level 3 - Involving Level 4 - Cooperating Level 5 - Continually improving The key characteristics of each level are described overleaf. (The Keil Centre's report for further details (Fleming, 1999)) Level One: Emerging Safety is defined in terms of technical and procedural solutions and compliance with regulations. Safety is not seen as a key business risk and the safety department is perceived to have primary responsibility for safety. Many accidents are seen as unavoidable and as part of the job. Most frontline staffs are uninterested in safety and may only use safety as the basis for other arguments, such as changes in shift systems. 20
  • 30. Level Two: Managing The organization’s accident rate is average for its industrial sector but they tend to have more serious accidents than average. Safety is seen as a business risk and management time and effort is put into accident prevention. Safety is solely defined in terms of adherence to rules and procedures and engineering controls. Accidents are seen as preventable. Managers perceive that the majority of accidents are solely caused by the unsafe behavior of frontline staff. Safety performance is measured in terms of lagging indicators such as lost time injuries (LTI) and safety incentives are based on reduced LTI rates. Senior managers are reactive in their involvement in health and safety (i.e. they use punishment when accident rates increase). Level Three: Involving Accident rates are relatively low, but they have reached a plateau. The organisation is convinced that the involvement of frontline employees in health and safety is critical, if future improvements are going to be achieved. Managers recognize that a wide range of factors cause accidents and the root causes often originate from management decisions. A significant proportion of frontline employees are willing to work with management to improve health and safety. The majority of staff accepts personal responsibility for their own health and safety. Safety performance is actively monitored and the data is used effectively. Level Four: Cooperating The majority of staff in the organisation is convinced that health and safety is important from both a moral and economic point of view. Managers and frontline staff recognize that a wide range of factors cause accidents and the root causes are likely to come back to management decisions. Frontline staff accepts personal responsibility for their own health and safety and that of others. The importance of all employees feeling valued and treated fairly is recognized. The organisation puts significant effort into proactive measures to prevent accidents. Safety performance is actively monitored using all data available. Non- work accidents are also monitored and a healthy lifestyle is promoted. Level Five: Continuous improvement The prevention of all injuries or harm to employees (both at work and at home) is a core company value. The organisation has had a sustained period (years) without a recordable accident or high potential incident, but there is no feeling of complacency. They live with the paranoia that their next accident is just around the corner. The organisation uses a range of indicators to monitor performance but it is not performance-driven, as it has confidence in its safety processes. The organisation is constantly striving to be better and find better ways of improving hazard control mechanisms. All employees share the belief that health and safety is a critical aspect of their job and accept that the prevention of non-work injuries is important. 2.2.3 Safety Climate Assessment Toolkit Process Safety climate Assessment Toolkit is very popular for assessing the current safety climate of an organization. Before beginning any assessment of safety climate, need to spend some time for preparing. This pre-assessment preparation is an essential part of the process. It allows to consider the existing culture and thus to place any climate data collected into an appropriate context. 21
  • 31. As a first step, requires a questioning approach. Which describe an assessment process which commences with an initial focus on organizational safety culture and the underpinning drivers, through a description of appropriate checks to the final state of planning further improvements. What is our current Safety Culture? How can we check our Safety Culture? What drives our Safety Culture? What do these checks mean? How can we now improve our Culture? Figure 2.3 Safety Climate assessment process What is our current safety culture? Before attempting to measure organizational safety climate, it may help to consider the current culture for safety in the organization. The Health and Safety Executive (HSE) highlight four descriptions which categorize organizational culture in their publication ‘Managing Health and Safety’ These are: • Power Culture - based on a small group wielding central control in running things; • Support Culture - where the organization exists to support the needs of the individuals; • Role Culture - highly structured so that there are clear cut-off points for decision making; and • Achievement Culture - where people work together to achieve results and operate flexibly. None of these four broad categories is definitive - the important thing is that the description matches what the organization is. The culture in the organization may incorporate aspects of two or three of the above types. For example, would any of the phrases elaborated in Table 2.1 be used to describe it? It may be possible to describe the specific culture using more than one of these, or indeed, other terms that may be more appropriate. 22
  • 32. Table 2.1 Cultural descriptions Collaborative? where collaboration and teamwork are fostered Blaming? where the apportioning of blame is seen as important Compliant? where everyone strives to follow rules and procedures Considerate? where employees’ views are sought and valued Co-operative? where everyone is involved and work together Constructive? where interaction to solve problems is encouraged Learning? where employees learn from mistakes Responsible? where unacceptable behaviour is recognized It may be more appropriate to use a number of guide words or prompts to prepare a description of the current safety culture, for example: 1. Norms - for example, what is considered acceptable behaviour? 2. Values - for example, what is considered to be important; 3. Working atmosphere - for example, the social environment of the workplace; 4. Management style - for example, the accessibility of managers; 5. Structure and systems - for example, reporting systems; and 6. External perceptions - for example, what competitors think? The more intangible of these guide words (for example, shared norms and values) may be enshrined in an organization’s vision or mission statements. Goals such as ‘to be better than the best’, or ‘to be the industry leader’ give us an indication of organizational principles and values that are expected to be demonstrated on a day to day basis. One should consider all of the above when completing the activity described overleaf. ACTIVITY - Describing the current culture for safety Take some time need to sketch the current culture for safety. For that need to consider • Which of the models or cultural descriptions above would best describe it? • What shared values are aware of? • How would describe the management style? • What is the working atmosphere like? • How is the organization perceived externally? What drives our culture? Cultural drivers may focus on two main areas - those which are related to the organization and those which relate to ‘key individuals’. Organizational ‘Drivers’ Organizational drivers may be characterized by management systems and procedures in a variety of areas of organizational activity. These drivers include both internal and external influences. 23 External drivers might include: • the extent of alliance contracts • industry standards (for example, as produced by The Exploration and Production Forum) • legal requirements • regulatory regime Internal drivers might include: • corporate business plan • organizational structure/change • organizational standards • performance metrics • systems and procedures
  • 33. Individual ‘Drivers’ Individuals, and key groups, within the organization can influence and drive culture both directly and indirectly through their actions, words and commitment. Some key individual drivers might be: Figure 2.4 describes a possible framework for Heath and Safety Management - a similar • Champions • All employees • Medical team • Visitors - external enforcement personnel, etc. • Chief Executive • Senior Managers • OIMs • Safety Personnel • Elected Safety Representatives framework may be considered for other areas of activity, for example business goals, or systems and procedures. Figure 2.4 Health and Safety framework for drivers and controls 24
  • 34. The cultural drivers in the organization need to be considered in the activity for this stage of the process, which is described overleaf. ACTIVITY - Identifying the main drivers Is it Identify who or what drives for the organizational culture? Whom or what has most influence on safety issues? Make a list of the key individuals and the key external and internal drivers that might influence safety culture in the organization. Who or what drives culture may be able to help the change or maintain it? How can we check our safety culture? Safety climate assessment provides one approach to checking the prevailing culture for safety. It encompasses a number of methods, in order to build as complete a picture as possible, and will provide a variety of valid and reliable measures. What do these checks mean? In each of the assessment sections of the Safety Climate Assessment Toolkit, several measures are derived using the different assessment methods, and a score is computed for each of these measures. These can be transferred to a graph to shows how the scores derived from the climate measures can be plotted to provide a graphical representation of each dimension and an overall picture of the current state of the organisation. How can improve the culture? Once the initial safety climate assessment has been completed and interpreted, an action plan needs to be developed, with milestones established, that may be linked to the organization’s business plan, vision or mission. These milestones should be realistic and understandable. 2.3 Identifying Root Causes of Offshore accidents 2.3.1 Introduction This part of thesis are reviews several subjects to facilitate the research development and discussion in later chapter. The definitions of “accident”,” labor accident” and “forms of accident” are reviewed. Some accident causation models are presented. Major factors influencing on the occurrence of labour accident are pointed out. Eventually, the conditions to secure for successful safety program are considered Accident “An accident is an unplanned and uncontrolled event in which the action or reaction of an object, substance, person, or radiation results in personal injury or the probability thereof” (Heinrich, 1959). “While the outcome need not include injury, the production of an injury increase the likelihood that it will be identified as an accident” (Suchman, 1964). According to information processing models “an accident” is described as a breakdown of the information processing system at some stage, e.g. failure to detect warning signals, 25
  • 35. failure to interpret correctly, lack of desire to act deficiency of knowledge, and so on” (Anderson et al., 1978, Corlett and Gilbank, 1978). “An accident is an event not only unintended but also unanticipated or random in occurrence” (Waller, 1979) “An accident is characteristic as a break down of the person-task system” (Edward, 1981). “An accident is any avoidable action personnel or any failure of equipment, tools, or other devices that interrupts production and has the potential of injuring people or damaging property” (Oglesby, et al., 1989) “An accident is an unplanned, not necessarily injurious or damaging event, that interrupts the completion of an activity and is in variably proceeded by an unsafe act and/or condition or some combination of unsafe act and or conditions” (Stanton, 1990). “An accident is an unpleasant event that happens unexpectedly and causes damage, injury” (Crowther et al., 1995). “An accident is an event that is unplanned and uncontrolled in some way undesirable; it disrupts the normal function of a normal person or persons and causes injury or near injury” (Shrestha, 1995). “An accident is an event or circumstance that unexpectedly or unplanned occurs and it causes injuries to humans or damage to property or any loss to humans or public” (Simachokdee, 1994 and Intaranont, 1996 cited in Yuthayanont, 1998). Labour accident “Labor accidents are worker injuries, disease, or death resulting from work and other activities with work-related structures, equipment, raw materials, gases, vapor, dust, etc.” (Kunishima and Shoji, 1996). As summarized by Brown (1995), ‘‘Accident reporting is a means to an end, not an end in itself.’’ In other words, the answers that accident investigations provide for the ‘‘what’’ and ‘‘how’’ questions, should be used to determine the factors that contributed to the accident causation (i.e., why the accident occurred). Brown (1995) argued convincingly that accident investigation techniques should be firmly based on theories of accident causation and human error, which would result in a better understanding of the relation between the ‘‘antecedent human behavior’’ and the accident at a level enabling the root causes of the accident to be determined. 2.3.2 Accident Causation Models Many researchers have tried to understand accidents in industrial applications by introducing accident causation models. In general, the overall objective of these models is to provide tools for better industrial accident prevention programs. Accident prevention has been defined by Heinrich et al. (1980) as ‘‘An integrated program, a series of coordinated activities, directed to the control of unsafe personal performance and unsafe mechanical conditions, and based on certain knowledge, attitudes, and abilities.’’ Other terms have 26
  • 36. emerged that are synonymous with accident prevention such as loss prevention, loss control, total loss control, safety management, and incidence loss control, among many others. Domino Theory In 1930, research in accident causation theory was pioneered by Heinrich. Heinrich (1959) discussed accident causation theory, the interaction between man and machine, the relation between severity and frequency, the reasons for unsafe acts, the management role in accident prevention, the costs of accidents, and finally the effect of safety on efficiency. In addition, Heinrich developed the domino theory (model) of causation, in which an accident is presented as one of five factors in a sequence that results in an injury. The label was chosen to graphically illustrate the sequentiality of events Heinrich believed to exist prior to and after the occurrence of accidents. In addition, the name was intuitively appealing because the behavior of the factors involved was similar to the toppling of dominoes when disrupted: if one falls (occurs), the others will too. Heinrich had five dominoes in his model: ancestry and social environment, fault of person, unsafe act and/or mechanical or physical hazard, accidents, and injury. This five-domino model suggested that through inherited or acquired undesirable traits, people may commit unsafe acts or cause the existence of mechanical or physical hazards, which in turn cause injurious accidents. Heinrich defined an accident as follows: ‘‘An accident is an unplanned and uncontrolled event in which the action or reaction of an object, substance, person, or radiation results in personal injury or the probability thereof.’’ The work of Heinrich can be summarized in two points: people are the fundamental reason behind accidents; and management-having the ability-are responsible for the prevention of accidents (Petersen 1982). Some of Heinrich’s views were criticized for oversimplifying the control of human behavior in causing accidents and for some statistics he gave on the contribution of unsafe acts versus unsafe conditions (Zeller 1986). Nevertheless, his work was the foundation for many others. Over the years the domino theory has been updated with an emphasis on management as a primary cause in accidents, and the resulting models were labeled as management models or updated domino models. Management models hold management responsible for causing accidents, and the models try to identify failures in the management system. Examples of these models are the updated domino sequence (Bird 1974), the Adams updated sequence (Adams 1976), and the Weaver updated dominoes (Weaver 1971). Two other accident causation models that are management based but not dominoes based are the stair step model (Douglas and Crowe 1976) and the multiple causation model (Petersen 1971). From these, the multiple causation model (Petersen 1971) will be briefly described. Multiple Causation Model Petersen introduced this management non-domino-based model in his book Technique of Safety Management (Petersen 1971). Petersen believed that many contributing factors, causes, and sub causes are the main culprits in an accident scenario and, hence, the model concept and name ‘‘multiple causation.’’ Under the concept of multiple causation, the factors combine together in random fashion, causing accidents. Petersen maintained that these are the factors to be targeted in accident investigation. 27
  • 37. Petersen viewed his concept as not exhibiting the narrow interpretation exhibited by the domino theory. To explain his concept, Petersen provided an example of a common accident scenario, that of a man falling off a defective stepladder. Petersen believed that by using present investigation forms, only one act (climbing a defective ladder) and/or one condition (a defective ladder) would be identified. The correction to the problem would be to get rid of the defective ladder. This would be the typical supervisor’s investigation if the domino theory was used. Petersen claimed that by using multiple causation questions, the surrounding factors to the ‘‘incident’’ (Petersen uses the word accident and incident interchangeably) would be revealed. Applicable questions to the stepladder accident would be: why the defective ladder was not found in normal inspections; why the supervisor allowed its use; whether the injured employee knew that he/she should not use the ladder; whether the employee was properly trained; whether the employee was reminded that the ladder was defective; whether the supervisor examined the job first. Petersen believed that the answers to these and other questions would lead to improved inspection procedures, improved training, better definition of responsibilities, and pre job planning by supervisors. Petersen also asserted that trying to find the unsafe act or the condition is dealing only at the symptomatic level, because the act or condition may be the ‘‘proximate cause,’’ but invariably it is not the ‘‘root cause.’’ As most others did, Petersen emphasized that root causes must be found to have permanent improvement. He indicated that root causes often relate to the management system and may be due to management policies, procedures, supervision, effectiveness, training, etc. Human Error Theories Human error theories are best captured in behavior models and human factor models. Behavior models picture workers as being the main cause of accidents. This approach studies the tendency of humans to make errors under various situations and environmental conditions, with the blame mostly falling on the human (unsafe) characteristics only. As defined by Rigby (1970), human error is ‘‘any one set of human actions that exceed some limit of acceptability.’’ Many researchers have devoted great time and effort to defining and categorizing human error [e.g., Rock et al. (1966), Recht (1970), Norman (1981), Petersen (1982), McClay (1989), DeJoy (1990), and Reason (1990)]. Similar to behavioral models, the human factors approach holds that human error is the main cause of accidents. However, the blame does not fall on the human unsafe characteristics alone but also on the design of workplace and tasks that do not consider human limitations and may have harmful effects. In other words, the overall objective of the human factors approach is to arrive at better designed tasks, tools, and workplaces, while acknowledging the limitations of humans physical and psychological capabilities. This approach stems from the relatively new engineering field known as human factors engineering. Behavior Models The foundation of most behavior models is the accident proneness theory (Accident 1983). This theory assumes that there are permanent characteristics in a person that make him or her more likely to have an accident. The theory was supported by the simple fact that when considering population accident statistics, the majority of people have no accidents, a relatively small percentage have one accident, and a very small percentage have multiple accidents. Therefore, this small group must possess personal characteristics that make them 28
  • 38. more prone to accidents (Klumb 1995). This concept has been accepted by many researchers; however, there are a number of arguments against it which are documented in Heinrich et al. (1980). Many behavior models have been developed to explain the reason for accident repeaters. These models include the goals freedom alertness theory (Kerr 1957), and the motivation reward satisfaction model (Petersen 1975). [For other behavioral models, see Krause et al. (1984), Hoyos and Zimolong (1988), Wagenaar et al. (1990), Dwyer and Raftery (1991), Heath (1991), Friend and Khon (1992), and Krause and Russell (1994).] Human Factor Models The work of Cooper and Volard (1978) summarize the common and basic ideas to the field of human factors engineering. They stated that extreme environment characteristics and overload of human capabilities (both physical and psychological) are factors that contribute to accidents and to human error. Examples of human factor models include the Ferrel theory (Ferrel 1977), the human-error causation model (Petersen 1982), the McClay model (McClay 1989), and the DeJoy model (DeJoy 1990). Ferrel Theory One of the most important theories developed in the area of human factor models is that by Ferrel [as referenced in Heimrich et al. (1980)]. Similar to the multiple causation theory, the Ferrel theory attributes accidents to a causal chain of which human error plays a significant role. According to the theory, human errors are due to three situations: (1) Overload, which is the mismatch of a human’s capacity and the load to which he/she is subjected in a motivational and arousal state; (2) incorrect response by the person in the situation that is due to a basic incompatibility to which he/she is subjected; and (3) an improper activity that he/she performs either because he/she didn’t know any better or because he/she deliberately took a risk. The emphasis in this model is on overload and incompatibility only, which are the central points in most human factor models. 2.3.3 Accident Root Cause Tracing Model (ARCTM) ARCTM represents the further development and synthesis of many of the previously mentioned models. In developing ARCTM, the main purpose was to provide an investigator with a model to easily identify root causes of accidents versus developing a model with abstract ideas and complicated technical occupational safety jargon and confusing definitions for relatively clear terms such as accident and injury. ARCTM attempts to direct the attention of the investigator to the conditions that existed at the time of the accident and antecedent human behavior. ARCTM and Accidents The main concept proposed in ARCTM is that an occupational accident will occur due to one or more of the following three roots causes (Figure 2.6): 1. Failing to identify an unsafe condition that existed before an activity was started or that developed after an activity was started 2. Deciding to proceed with a work activity after the worker identifies an existing unsafe condition 3. Deciding to act unsafe regardless of initial conditions of the work environment Clearly, these root causes develop because of different reasons, and also point to different issues that should be considered for corrective actions. ARCTM was designed to guide the 29
  • 39. investigator through a series of questions and possible answers to identify a root cause for why the accident occurred and to investigate how the root cause developed and how it could be eliminated. Because ‘‘unsafe conditions,’’ ‘‘worker response to unsafe conditions,’’ and ‘‘worker unsafe acts’’ are cornerstones of ARCTM, they will be discussed first in the following sections before the use of ARCTM is explained and demonstrated by considering real-life accident scenarios. A worker or coworker may be inexperienced or new on site, or may choose to act unsafe, all of which may lead to unsafe conditions for other workers. Examples of unsafe acts leading to unsafe conditions include removing machine safeguards, working while intoxicated, working with insufficient sleep, sabotaging equipment, disregarding housekeeping rules, unauthorized operation of equipment, horseplay, etc. Non-human- related events that may lead to unsafe conditions include systems, equipment or tool failures, earthquakes, storms, etc. Unsafe conditions that are a natural part of the initial operation site conditions are used in ARCTM to account for a unique type of unsafe conditions in the offshore industry. Worker Response to Unsafe Conditions In addition to distinguishing between types of unsafe conditions and who is responsible for them, ARCTM emphasizes the need to consider how workers respond to or are affected by an unsafe condition. Basically, when an unsafe condition exists before or develops after a worker starts an activity, the worker either fails or succeeds in identifying it. If the worker fails to identify the unsafe condition, this means there was no consideration of any risks, and the worker does not recognize the potential hazards. If the worker identifies the unsafe condition, an evaluation of risk must be made. The worker’s decision is either to act safe and discontinue the work until the unsafe condition is corrected or take a chance (act unsafe) and continue working. The reasons behind failing to identify the unsafe condition or the decision to act unsafe after identifying an unsafe condition should be thoroughly investigated by management. It should be noted that some unsafe conditions may never be possible to identify by a worker. Examples of such conditions are non-human-related events or conditions where there are human factors violations. Human factors violations are typically responsible for such injuries as overexertion, cumulative trauma disorders, fatigue, toxic poisoning, mental disorders, etc. Worker Unsafe Acts A worker may commit unsafe acts regardless of the initial conditions of the work (i.e., whether the condition was safe or unsafe). Example of worker unsafe acts include the decision to proceed with work in unsafe conditions, disregarding standard safety procedures such as not wearing a hard hat or safety glasses, working while intoxicated, working with insufficient sleep, etc. Therefore, the need to investigate why workers act unsafe is also emphasized in ARCTM. 2.3.4 Factors influencing on the occurrences of labour accident There are many factors that influence of labor accidents. These factors can be grouped into four categories which is depicted in the figure 2.5 30
  • 40. 31 Factor related working conditions Factor related Operations resources Factor related Management & Organization Factor related Human Behaviors Labour Accident Figure 2.5 Summary influences of factors on the occurrence of labor accident 2.4 Safety and Situation Awareness in Offshore Crews 2.4.1 Summary One factor critical in preventing accidents in everyday life should be maintaining an adequate understanding of the current situation. This is needed in order to perceive the conditions of the environment, and judge the consequences of any actions taken in relation to the safety of the work, in order to avoid adverse events. By having full and correct understanding of the situation, the potential risk involved in an action can more effectively be gauged and in turn minimised, reducing the risk of an accident. However, if the understanding of the situation is impaired, then the ability to predict the outcomes of actions is more flawed, and due to this the risks of an accident occurring are increased. The method by which this understanding of a situation arises is known as Situation Awareness (SA) and the possession and maintenance of good quality SA is fundamental to safe working practice. This is of paramount importance in the offshore oil and gas industry where the work is hazardous and in many cases, complex, thus crews must be able to monitor and understand their environment if they are to keep their accident risk to a minimum. The theory of SA has been in existence for many years, stemming from research in the aviation industry. In the late 1980’s, interest in the area grew and research became more widespread, including domains such as aircraft maintenance, the military, driving, and medicine (Adams, Tenney & Pew Endsley Shrestha, Prince, Baker & Salas) However, with the exception of one article (Hudson & van der Graaf) and a few industry documents (Shell Exploration and Production) the concept has remained relatively uninvestigated in the oil and gas industry, despite its importance and relevance, and remains little understood.
  • 41. Pre-existing unsafe condition on the operating site 32 Management action/inaction Worker or coworker unsafe acts Non-human related event Unsafe ConditionThe 1st root cause Failing to identify an unsafe condition that existed before an activity was started or that developed after an activity was started The 2nd root cause Deciding to proceed with a work activity after the worker identifies an existing unsafe condition The 3rd root cause Deciding to act unsafe regardless of initial conditions of the work environment Figure 2.6 Accident Root Causes Tracing Models (ARCTM); source: adapted from abdelhamid et al. A LABOUR ACCIDENT OCCUR The root causes combine together
  • 42. 2.4.2 Situation Awareness (SA): Definition The theory of situation awareness has been in existence for many years, with references to the concept believed to originate from the pilot community of World War 1. Definitions of SA vary greatly, as they are explained in terms of the industry concerned, and as a result, understanding SA has been hampered since there is no one universally accepted and agreed upon definition of the concept (Sarter & Woods) However, there are two definitions widely cited, the fist of which characterizes SA as “...the perception of the elements in the environment within a volume of space and time, the comprehension of their meaning, and the projection of their status in the near future” (Endsley). The other describes SA as “...the up-to-the minute cognizance required operating or maintaining a system” (Adams, Tenney & Pew’). These definitions are the most widely cited and accepted as appropriate and accurate descriptions of the concept. SA therefore, in simple terms, is the ability to successfully pay attention to and monitor the environment, and essentially ‘think ahead of the game’ to evaluate the risk of accidents occurring - a vitally important factor in ensuring a safe working environment. 2.4.3 Levels of SA Endsley’s three-level approach (Endsley) is the most popular view of the construct of SA due to its simplicity, while the framework also provides a comprehensive theoretical construct that can easily be applied to a multitude of other domains. Of the model, Level 1 is Perception, Level 2 is Comprehension, and Level 3 is Projection. Each of these will be discussed in more detail. Level 1 SA: Perception. This is the basal constituent of SA: the perception of the elements in the surrounding environment. Without the correct initial perception of the relevant elements of the environment, it is unlikely that an accurate illustration of the situation would be formed. This increases the likelihood of an error or accident, since the fundamental components on which the later stages of SA are based are of poor quality. Level 2 SA: Comprehension. This involves the combination, interpretation, storage and retention of the aforementioned information (Endsley) to form a picture of the situation whereby the significance of objects/events are understood (Endsley; Stanton, Chambers & Piggott’’) — essentially derivation of meaning from the elements perceived. The degree of comprehension that is achieved will vary from person to person, and Endsley maintains that the level attained is an indication of the skill and expertise held by the operator. Level 3 SA: Projection. The final level is projection, and occurs as a result of the combination of levels one and two. This stage is extremely important, as it means possessing the ability to use information from the environment to predict possible future states and events (Endsley, Sarter & Woods). Having the ability to correctly forecast possible future circumstances is vital in allowing the best decision to be made regarding appropriate courses of action, as time is made available to dispel potential discords and formulate a suitable action course to meet goals (Endsley Stanton et al). 33
  • 43. 2.4.4 Attention and SA In order for SA to be achieved, objects and information in the surrounding environment (i.e. stimuli) must be attended to. When we attend to something, it involves the process of observing the surrounding environment and being made aware of the attentional target’s presence and the information that it provides (Style).Without the ability to do this, level one perception could not be achieved, and accurate SA could not be formed. In addition, we must also be able to concentrate on these stimuli to determine to which ones we should attend. We must concentrate further still in order to continually monitor the surroundings and attend to changing stimuli. It can therefore be seen that attentional processing is intrinsically linked to the theory of SA, but attention is bound by the limits of the working memory (the construct that allows the perceived information to be processed). The fact that attention is limited is a problem, as a person is unable to pay close attention to every single detail of his/her environment. In doing so, critical elements may be missed in the observation/perception stage. leading to an incorrect mental model (the representations of objects, people and tasks that people hold in their minds of the understanding of the various roles and relevance of the items concerned) being formed, and this has been supported by research (Jones & Endsley) Possession of a poor or incorrect mental model can increase accident risk as there is no ‘template’ to guide actions. 2.4.5 Team Situation Awareness Much of the work on an offshore installation/rig requires teamwork. As the successful attainment of the goal is entirely dependent upon the team collectively working together, then the nature of the situation dictates that the crew must have a mutual understanding of the situation. Thus the team should have a collective SA. This amassed awareness is known as team situation awareness (Bolstad & Endsley; Endsley; Endsley & Robertson; Salas, Prince, Baker & Shrestha; Shrestha et al) Team SA can be characterized as follows: “...compatible models of the teams internal and external environment; includes skill in arriving at a common understanding of the situation and applying appropriate task strategies” (Cannon- Bowers, Tannenbaum, Salas and Volpe) This shared knowledge and understanding can then be called upon in order for the crew to make critical decisions and adapt in order to react to and predict their working environment. 2.4.6 Factors Affecting SA The main goal of situation awareness is to keep those involved aware of their surrounding environment, reacting to and anticipating events and actions, There are many possible explanations as to why a particular accident has occurred, but it has become apparent that one factor may be a reduction/loss of the SA of those concerned, SA can be reduced by a number of different means, but the most salient in the prevailing literature state these as stress (whereby performance decreases due to the extra pressures imposed on the mental system) from either physical (e.g. noise, vibration, temperature) or psychological (e.g. mental workload, anxiety, confidence) stressors; workload ;automation; and the decision- making process. 34