human factors-related causes of hydrocarbon release on offshore platforms

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Human Factors Involvement in Hydrocarbon Release on Offshore Platforms: an organisation wide investigation

Dr. Jason Devereux, Lloyd’s Register Consulting – EnergyScientific Sub-Committee Secretary for the International Commission on Occupational Health and SafetyMember of the IEA Technical Committee on Human Factors in Organisational Design and ManagementHonorary Member of the Business Psychology Unit, University College LondonFormer Human Factors M.Sc. Director, Robens Institute Industrial Health & Safety

Lloyd’s Register Energy

Outline

1. Background to hydrocarbon release

2. Case study:

• Methodology

• Summary of findings

• Key areas

3. Recommendations for Industry


The problem of hydrocarbon leaks

• Hydrocarbon releases are a major problem offshore.

• A direct precursor to potential major accidents, if ignited.

(Oil and Gas UK, HSE)

Major gas release on Elgin in March 2012, led to the evacuation of the entire platform


The problem of hydrocarbon releases (HCRs)

50-70% of HCRs have causes linked in part or in whole to human factors

Human error is both universal and inevitable (Energy Institute, 2008). This implies a system failure and not person failure – the latent antecedents

Judith Hackitt (Chair of HSE) -“Constant Unease”• Know the problem is not fixed• What could go wrong• Can do better• Society becoming less tolerant of failures

Consider human factors in designing, maintaining and operating systems


Market forces potentially affecting HCR risk

Competition pressure and cost cutting could increase the use of technology and reduce staffing offshore

Highly automated systems still need human beings for:

•supervision

•adjustment

•maintenance

•Improvement

Understand the limits of human abilities and capability in the:

•design

•control

•maintenance of systems


Case study: study objectives

Human-machine interaction as an emerging risk (EU-OSHA, 2005)

• Psychosocial risk – cognitive load

• Accident risk

• operating errors

• maintenance non-routine errors

• inappropriate action

Assist in our client’s initiative.

• To reduce HCRs within the UK.

Conduct an independent Human Factors-focussed organisational assessment.

• Identify underlying contributory factors to HCRs offshore. (HSE, 1999 HSG 48)


Case study: methodology

N=60

Sept 2011

N=31

Nov 2011


Case study: thematic analysis

An initial analysis of HCR incident report data highlighted the following key areas

e.g. “the requirements of the flange completion and recording procedure

do not appear to have been communicated.”

e.g. “no small bore tubing training for 2 years”

Hydrocarbon Releases

Failures in engineering

controls

Failures in administrative

processes

Management failures

Failures in maintenance

processes

Failures in competency management

processes

Failures in communications

e.g. “absence of alarms for this event and/or absence of preventative barriers to be able

to close 2 streams.”e.g. “the requirements of the flange completion and

recording procedure”

e.g. “No supervision”

e.g. “gas compression train out for 2 years “


Using the data generated from the thematic analysis

Development of a ‘question set’ to explore key HF themes that appeared to be influential in HCRs.

14 ‘lines of enquiry’ explored, including:

• supervisory arrangements

• safety culture

• safety critical communications

• quality assurance and procurement process

• procedure usage

• planning

• staffing

• engineering design

• etc.


Summary of findings - corporate level solutions

LearLLearL

Organisational learning

Competence management

Planning

•Reactive

•maintenance

•Under manning

Procedures

• Silo working

HFI in platform

design

Visit www.lr.org/HCR for more information


Key areas: Organisational learning

Relevance to hydrocarbon releases

• When lessons aren’t learned and a company doesn’t strive for continuous improvement, mistakes are repeated, not recognised and not improved

• e.g. Small bore tubing was a known problem for a long time before a survey was carried out; and this survey has not yet led to any improvements

• When underlying causes are not dealt with, only the immediately obvious problems may be tackled, leaving the real contributory factors in place

• e.g. an individual who made a mistake may be blamed but his competency and the competency of all his colleagues also may be poor due to a lack of training and support

• Many wider contributory factors to hydrocarbon releases have been identified in this project, and most have been a problem for some time

Contributory failures

Cultural issues



Key areas: Competency management


If people are not fully competent to work on the system, they are likely to make mistakes

•e.g. If an operator cannot use SAP correctly they may not input required data about maintenance work that need to be done, and thus a HCR could occur because the work is not carried out

Anyone working with the system who is not fully competent could make a mistake and either:

1.Initiate a HCR

2.Contribute to a series of events that leads to a HCR

3.Escalate a HCR

4.Fail to mitigate and control a HCR


Failures in competency management


Key areas: Lack of planning


The system state may be compromised or the system may fail if:

• routine maintenance is postponed or delayed

• urgent maintenance needs are not addressed promptly

• work is not planned thoroughly, maintenance may get postponed or delayed



processes


processes



Key areas: Under manning


A lack of staff to carry out work means that:

• maintenance is constantly being compromised

• assets fail because they have not been maintained properly

• only had ‘patchwork’ fixes carried out on them

There are also compromises in relation to onshore activities due to under manning. For example:

• Not enough engineering team staff

• it takes longer to get designs developed

• there are delays to making engineering changes


Design failures

Management and resourcing

failures


Key areas: Reactive approach


Short-term quick repairs can affect asset integrity: The underlying problems are not improved the system can be left vulnerable to further deterioration or failure

Patchwork fixes may create new problems: They can mean the system is not operating correctly the system may become damaged

Jumping into initiatives and approaches means that the work is more likely to be done incorrectly

• e.g. In relation to Small Bore Tubing Surveys. This has wasted time on an activity that was supposed to aid in reducing HCRs, but few corrective works have been done



processes

Cultural issues


Key areas: Poor procedures


If the procedures are wrong or difficult to use, people will either:

• follow the incorrect procedure and as a result carry out the task incorrectly

• fail to use them and potentially do the task wrong or inconsistently

In both instances there may do damage to the system



processes


Key areas: Silo working


Lack of communication or miscommunication:

• Information may not be passed on to those who need to know

• information may be misunderstood due to conflicting demands and distraction

• the result is mistakes and omissions

Work carried out in isolation:

• Conflict with other work being done

• can leave the system vulnerable to errors



processes


Management and resourcing

failures


Key areas: Design issues on the platform


A mismatch between the design specification and the proposed operability of the system:

• leads to system operability being compromised

• e.g. There are not enough beds, making it difficult to get staff onto the rig

A mismatch between the design and the operating environment:

• system may be susceptible to deterioration

• e.g. Some equipment and material selection at the design stage is considered to have been inappropriate and of poor quality, leading to high levels of deterioration

Excessive alarms in the control room:

•real issues may be overlooked and made worse


Design failures


Lessons for industry: For prevention of HCRs

No simple answer to the question of ‘what causes HCRs?’

Identify and address all underlying factors

A suitable framework for assessment is required• using specialists who are trained to look beyond the engineering

problems to organisational factors

Recommend use of external departments and/or independent parties:• provides independence

• allows honest impartial information to be elicited


Lessons for industry: Investigation of HCRs

• Essential that incident investigations go beyond the analysis of ‘front line’ failures

• Take due consideration of the Human Factor within organisational root causes

• Involve Human Factors experts in this process

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Human Error

Underlying Human Factors topics

e.g. Procedures, Training & Competence, Safety Critical Communications, Organisational Change, HF Design, Shiftwork & Fatigue, Organisational Culture, Workload,

Maintenance, and Human Failures (HSE, 2012)

Underlying Human Factors topics

e.g. Procedures, Training & Competence, Safety Critical Communications, Organisational Change, HF Design, Shiftwork & Fatigue, Organisational Culture, Workload,

Maintenance, and Human Failures (HSE, 2012)


Lessons for industry: Have a human factors integration plan

• Have better integration of Human Factors within the early stages of the design process

• Reduces the likelihood of mismatches between:• Human capability

• organisational demands and

• system design during the latter stages of projects or in operation

• Planning for a dedicated HF programme at the initial design stage of projects is recommended:

• Equipment design

• Workstation/ console design

• Workplace layout

• Maintenance access and ease of maintenance etc.


Develop corporate resilience to avoid HCR outcomes(UCL Business Psychology Unit Effort Performance Outcome Model)

Abilities and traits, role clarity, organisational support, etc.

Job design, organisational policies and practices Perceived equity of

outcomes/ rewards

Effort PerformanceOutcome / reward Satisfaction

Extrinsic outcome/ reward

Intrinsic outcome/ reward

Expectancy Instrumentality Valance


Avoid the reputational and financial risk

Exxon Mobile

Up 27% since Jan 2010 high

•Trending with the S&P 500

BP

Down 30% since Jan 2010 high

•Has not recovered due to a lack of investor confidence signalled by overhead supply at $50 per share

•Not trending with the S&P 500

•“A broken stock in institutional trading terms”


A final thought!

Competitive investment must be tempered with patience and consideration of the

potential for human-system failures in maintenance, supervision and improvement.

For more information and to receive a free copy of the whitepaper this presentation is based on, visit: www.lr.org/HCR

Lloyd’s Register and variants of it are trading names of Lloyd’s Register Group Limited, its subsidiaries and affiliates.Copyright © Lloyd’s Register [Entity]. 2013. A member of the Lloyd’s Register group.

Dr. Jason DevereuxLloyd’s Register Consulting – Energy T: +44 (0)23 2345 5432 E: [email protected]’s Register Energy71 Fenchurch Street, London EC3M 4BS

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