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

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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.

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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

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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

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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

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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

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List of Tables

Tables Title Page 2.1 Cultural descriptions 233.1 Risk Index (RI) 423.2 Risk Acceptance Criteria 453.3 Parameter considered for safety climate and safety management practice 504.1 Potential major hazards of offshore drilling and production 574.2 Proposed methodology of finding the current exposures 584.3 Proposed Job Safety Assessment for Handling tubulars and lifting 604.4 Frequency distribution of fatal accident by problems behind accident 674.5 Factors influencing the occurrence of accident 684.6 Main findings from Interview Analysis. 71

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List of Figures

Figures Title Page

1.1 Drilling overview 21.2 Onshore platform; fixed platform; jack up rig; semi-submersible; drill ship;

tension leg platform 3

2.1 Group Risk Targets – F/N Curve 122.2 A Three Aspect Approach to Safety Culture 192.3 Safety Climate assessment process 222.4 Health and Safety framework for drivers and controls 242.5 Summary influences of factors on the occurrence of labor accident 312.6 Accident Root Causes Tracing Models (ARCTM) 322.7 Environmental strategy map 363.1 Risk Assessment Approach 403.2 Risk Assessment Process Step by Step 413.3 Risk ranking Matrix 433.4 Demonstrating ALARP 443.5 Example Bow Tie Analysis 453.6 Safety Critical Activity 463.7 Multiple Perspective Assessment Models. 493.8 A framework of the study process 513.9 Accident Root Cause Tracing Model (ARCTM) in details 554.1 Blow out can be assessing by Bow-Tie 594.2 Results radar plot of drilling and production company (Safety Climate) 624.3 Results radar plot of drilling and Production Company

(Safety Management Practice) 63

4.4 Safety Climate Matrixes of drilling and Production Company 644.5 Miscellaneous Response for safety performance 654.6 Contribution to improvement of Safety Performance 694.7 Contribution to preventing the occurrence of accident 70

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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

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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.

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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

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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

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‘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.

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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

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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

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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

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1.5 Scope of study

Offshore -Risk Assessment Drilling platform -Safety climate and

safety management practice

Literature 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

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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.

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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.

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(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.

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(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.

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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.

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- 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

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- 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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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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.

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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.

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Table 2.1 Cultural descriptions

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.

WhaCultand OrgaOrgavarieinflu

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?

t drives our culture? ural drivers may focus on two main areas - those which are related to the organization those which relate to ‘key individuals’.

nizational ‘Drivers’ nizational drivers may be characterized by management systems and procedures in a ty of areas of organizational activity. These drivers include both internal and external ences.

Internal drivers might include: • corporate business plan • organizational structure/change• organizational standards • performance metrics • systems and procedures

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

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 proceduresConsiderate? 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

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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 a

• • • •

• Chief Executive • Senior Managers • OIMs • Safety Personnel • Elected Safety

Representatives

framework may be considered for other areas of activisystems and procedures.

Figure 2.4 Health and Safety framew

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Champions All employees Medical team Visitors - external enforcement personnel, etc.

nd Safety Management - a similar ty, for example business goals, or

ork for drivers and controls

The cultural drivers in the organization need to be considered in the activity for this stage of the process, which is described overleaf.

HSsp WImede HOpou 2 2 Tdait A “ot “l At

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 mightinfluence safety culture in the organization. Who or what drives culture may be able to help the change or maintain it?

ow can we check our safety culture? afety climate assessment provides one approach to checking the prevailing culture for afety. It encompasses a number of methods, in order to build as complete a picture as ossible, and will provide a variety of valid and reliable measures.

hat do these checks mean? n each of the assessment sections of the Safety Climate Assessment Toolkit, several easures are derived using the different assessment methods, and a score is computed for

ach of these measures. These can be transferred to a graph to shows how the scores erived from the climate measures can be plotted to provide a graphical representation of ach dimension and an overall picture of the current state of the organisation.

ow can improve the culture? nce the initial safety climate assessment has been completed and interpreted, an action lan needs to be developed, with milestones established, that may be linked to the rganization’s business plan, vision or mission. These milestones should be realistic and nderstandable.

.3 Identifying Root Causes of Offshore accidents

.3.1 Introduction

his part of thesis are reviews several subjects to facilitate the research development and iscussion in later chapter. The definitions of “accident”,” labor accident” and “forms of ccident” are reviewed. Some accident causation models are presented. Major factors nfluencing on the occurrence of labour accident are pointed out. Eventually, the conditions o secure for successful safety program are considered

ccident

An accident is an unplanned and uncontrolled event in which the action or reaction of an bject, substance, person, or radiation results in personal injury or the probability hereof” (Heinrich, 1959).

While the outcome need not include injury, the production of an injury increase the ikelihood that it will be identified as an accident” (Suchman, 1964).

ccording to information processing models “an accident” is described as a breakdown of he information processing system at some stage, e.g. failure to detect warning signals,

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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

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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.

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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

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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

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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

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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

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Management action/inaction

Worker or coworker unsafe acts

Non-human related event

Unsafe Condition The 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).

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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.

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2.4.7 Errors in SA Much of the literature suggesting that it is when SA fails that accidents occur is derived from post-analysis of accident data. By examining the data provided in accident reports, factors can be classified, and SA elements investigated, e.g. misidentification of information, unperceived information, incorrect update of information, and lack of co ordination/communication between team members (leading to non-communication of required information). Endsley reviewed the literature pertaining to human cognition and information processing, and developed a taxonomy describing the areas in which errors in SA can be classified (see Jones & Endsley for more detail). This taxonomy was applied in the analysis of drilling accidents in a database to discover if the cause could be attributed to an error in SA, in an attempt to discover how much of an issue poor SA is in the offshore drilling industry. 2.5 Environmental Assessment of offshore exploration and production Awareness of the importance of environmental issues has become more and more central to the thinking of the oil and gas industry and regulators in the last decades. Integration of development and environment, approached in partnership between stakeholders, was the theme of the UNCED Conference in Rio in 1992. Principle 4 of the Rio Declaration captures this challenge: “In order to achieve sustainable development, environmental protection shall constitute an integral part of the development process and cannot be considered in isolation from it”. Potential Environmental Impacts The potential for offshore operations to cause impact must be assessed on a case-by-case basis, since different operations, in different environments, in different circumstances may produce large variations in the magnitude of a potential impact. With the proper application of managements techniques and best environmental practices, many if not all, potential impacts should be eliminated or mitigated. The assessment of potential impacts and management measures is commonly carried out through an environmental assessment either conducted independently or within the framework of an HSE Management system, and may be required by formal EIA procedures where they apply The potential impact of exploration and production activities must also be considered in the context of national and global protection policies and legislation. Frequently, such policy objectives will provide clear guidance on the relative importance of a given issue or potential impact. For example, an assessment may identify an apparently small level of impact, which, when seen in the context of national objectives, may acquire an increased significance and importance and require especially careful management Environmental Management of offshore exploration and production industry Exploration and Production operations involve a variety of relationships, from company and contractor partnerships, and joint ventures, to dealing with other stakeholders such as government and the public. This, together with the fact that environmental issues are now so numerous, complex, interconnected and continuously evolving, means that an ad hoc approach to problem solving is no longer considered effective. There is, therefore, a need for a systematic approach to management of health, safety and environmental (HSE) issues.

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Figure 2.7 Environmental strategy map Various national and international standards such as the ISO 9000 and ISO 14000 series also provide systems models that can be used by companies and by government agencies. ISO 14000 consists of an evolving series of generic standards developed by the International Standard Organization (ISO) that provides business management with the structure for managing environmental impacts. The standards include a broad range of environmental disciplines, including the basic management system (14001) auditing (ISO 14010); performance evaluation; labelling (ISO 14020 and 14024); life-cycle analysis; and product standards. Any standard may be used in its basic form or further adapted and incorporated into national standards systems. Companies will need to consider how the various standards apply to their operations. Environmental Protection Measures of Offshore Exploration and Production Senior management leadership and commitment has to be converted into action by the provision of adequate financial and personal resources to ensure that environmental protection measures are incorporated in on-site routine operations. The management system will function effectively through the promotion of a company culture conducive to good environmental performance, and fostering active involvement of employees and contractors. Company policy and strategic objectives must be prominently displayed at all operating sires and, as necessary, adapted to include any site-specific requirements. Each operating site may need to develop its own specific objectives, and relevant operational targets in line with the company’s broader strategic objectives. This should be initiated by the site manager, and achieved through a formal communication and consultation process that involves staff, contractors and local stakeholders. The organization, resources and documentation necessary to implement the management system are critical. In each case the site manager and line, staffs are responsible for implementing and communicating policy. The roles, responsibilities, authorities,

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accountabilities and relationships necessary to implement environmental management must be clearly defined, documented and communicated in a document prepared specifically for that site. Line staff in all aspects of operational activity should be assigned specific environmental responsibility and authority within their spheres of control, and must be competent to perform their duties effectively. Each site should assign a management representative or representatives with sufficient knowledge of the company and its activities, and of environmental issues to undertake their role effectively. Whilst maintaining overall responsibility for coordinating environmental management activities across all functions and groups. Representative(s) will act in conjunction with line management in all functions, activities and processes. Documentation provides an adequate description of the management system and a permanent reference to the implementation and maintenance of that system. To implement this on-site a wide variety of documentation is usually prepared, some describing the structure and function of the management system, some providing detailed guidance on environmental protection measures, procedures, progrmmes and plans, communications arid consultative requirements. Others provide information on local regulations and standards and how to monitor and report performance effectively, including requirements for accident and incident reporting and follow-up. Monitoring provides the means of measuring performance against established requirements through inspection, surveillance and analysis. The detail and frequency of measurement should reflect the nature and extent of the risks involved. Other key elements of implementation and monitoring include reporting mechanisms, record systems, and follow up-in particular, non-compliance and corrective action, and incident reporting and follow-up. Finally, audit and review procedures should be established in line with the company’s overall programme. However, in addition to this procedure, it is frequently beneficial to encourage line management to carry our self-assessment programmes, independent of, but allied to, the overall company programme.

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Chapter 3

Methodology 3.1 Introduction This research study followed the following research design and methodology from the beginning to the end. The research methodology was designed in accordance with the objectives defined in chapter 1 and the literature review in chapter 2. First of all, had been identifying the background of the context of offshore drilling and production platform procurement, problem, rational, objective scope and limitation and methodology and secondly, had to acquire the knowledge and experience on the said factors. That requirement was fulfilled through a literature review and discussions with the academicians, researchers, and field experts. After such a process, the research was progresses to achieve the objective selecting the offshore platform procurement as the start to wider and deeper. This research used questionnaire as an effective tool to gather data and statistical analysis to interpret data into meaningful findings. Some in-depth interviews were also carried out to support the findings. Research methodology framework covers

Risk Assessment of offshore drilling and production platform Safety Climate and Safety Management Practice in offshore environments Identifying Root Causes of Offshore accidents Investigate the Safety and Situation awareness of offshore crews

3.2 Risk Assessment of offshore drilling and production platform Risk assessment for an offshore platform looks for answers to these questions.

• What can go wrong? • What are the effects and consequence? • How often will it happen?

The first question relates to risk identification. It is a qualitative analysis and is often called a safety study. The answers to the remaining two questions can be qualitative as well as quantitative. When one employs quantitative risk analysis, the study becomes risk assessment. The aim of risk assessment is to reduce major accident event risk to as low as reasonable practicable (ALARP), including the exposure of hazards has been minimized, firstly through elimination of hazards; and secondly through control of remaining hazards.

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The Risk Assessment process is described below and shown schematically in figure 3.1.Figure 3.2 shows step by step risk assessment process

• Identify all hazards and their potential effects • Rank of the hazards using risk ranking matrix and to determine their

significance • Decide criteria for consideration of urgency of action required • Consider what actions can be taken quickly to alleviate the potential harm,

whether low or high scoring factors • Identify long-term actions needed, within acceptable time scales that do not

further jeopardize the protection of people, property and the business itself • Consider cost implications, ensuring that they are not used as an excuse to avoid

taking action where it is clearly required to safeguard the future of the project • Review risk factors and re-evaluate on the basis of potential results of planned

actions • Consider residual risk and hazards that will still remain despite planned actions.

Note, which elements are inherently hazardous and can only be contained through the use of a range of control measures

• Define ‘acceptable’ or ‘tolerable’ risk and consider the level at which the organization accepts such risks exist and that sufficient action has been taken ALARP(as low as reasonably practicable) in the circumstances

• Identify which factors can be reduced so as to virtually eliminate the perceived risks, for example through substitution of materials or changed processes and procedures

• Ensure that any planned changes do not introduce further or new risks to the operation of the business

3.2.1 Risk Analysis Identify all major hazards The objective of this section is to demonstrate that all foreseeable hazards with the potential to cause a major accident have been identified and those safety systems to prevent control and mitigate these hazards have been identified and their response considered both for drilling and production platform. In addition the potential for fire and exploration and the need for evacuation, escape, rescue and recovery have been considered for all of the identified hazards. For hazard identification following points were considered

• Experienced judgments • Knowledge of relevant standards • Knowledge/awareness of the operating environments • Knowledge of the proposed activity • Incident/hazard investigations/Reports

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Figure 3.1 Risk Assessment Approach

Engineered system Qualitative analysis

Semi quantitative analysis

Quantitative analysis

HAZID ~~~~

Benefit

Cost

Decision 1. ---- 2. --- 3. ----

Risk Analysis

Risk Reduction

Risk Management

Objectives

Process (Techniques)

Frequency

Define a scenario

Determine consequence

Determine probabilities

Place on matrix

Identify all major significant Hazards

Risk Reduction Process/Measures

Risk Management

consequence

Figure 3.2 Risk Assessment Process Step by Step Rank of the hazards When the hazards and effects have been identified, risk ranking matrix provides the values and standards against which the significance of the hazards and effects can be judged /ranked. Risk Ranking Matrix A risk matrix has been proposed for a revision of the IMO Guidelines on FSA (IMO 1997) to assist with hazard ranking. The Risk Index (RI) may be used to rank the hazards in order of priority for risk reduction effort. In general, risk reduction options affecting hazards with higher RI are considered most desirable.

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The severity index (SI) is defined as

SI Severity Effects on human safety Effects on ship

Cost (Approximately)

1 Minor Single or minor injuries Local equipment damage

$3K

2 Moderate Multiple or severe injuries Non severe ship damage

$30K

3 Serious Single fatality or multiple severe injuries

Severe casualty $3m

4 Catastrophic Multiple fatalities Total loss Over $30m Source: Det Norske Veritas (2001/63) The frequency index (FI) is defined as

Source: Det Norske Veritas (2001/63)

FI Frequency

Qualitative Definition (Continuous)

Quantitative Definition (Weighting factor)

6 Frequent Likely to continually experienced 1

5 Reasonable probable

Likely to occur often 0.1

4 Occasional Likely to occur several times 0.01

3 Remote Likely to occur some times 0.001

2 Extremely Remote

Unlikely, but may exceptionally occur 0.0001

1 Incredible Extremely unlikely that the event will occur at all, given the assumptions recorded about the domain and the system

0.00001

If risk is represented by the product frequency x consequence, then an index of log(risk) can be obtained by adding the frequency and severity indices. This gives a risk index (RI) defined as:

RI = FI + SI E.g. an event rated “remote” (FI=3) with severity “moderate” (SI=2) would have RI=5 The risk matrix is as follows

Table 3.1 Risk Index (RI) Severity(SI)

4 3 2 1 FI

Frequency Catastrophic Serious Moderate Minor

6 Frequent 10 9 8 7 5 Reasonable practicable 9 8 7 6 4 Occasional 8 7 6 5 3 Remote 7 6 5 4 2 Extremely Remote 6 5 4 3 1 Incredible 5 4 3 2 1 RI value 8-10 Risk class A; 7-Risk Class B; 5-6 Risk Class C; 2-4 Risk class D

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1Risk Class Risk Class Interpretation A Intolerable B Undesirable and shall only be accepted when risk reduction is

impracticable C Tolerable with the endorsement of the Project Safety Review

Committee D Tolerable with the endorsement of the normal project reviews

Catastrophic Serious Moderate Minor

Frequent A

A A B

Reasonable Probable

A B C

Occasional A

B

C

C

Remote B

C C D

Extremely Remote

C

C D

D

Incredible D

D

D

A A A

A B

B

B

C A

C

C

C C

C

C

B

Figure 3.3 Risk ranking Matrix

3 Arac Arhs

.2.2 Risk

ll risk anaegular intet regular inhanges in r

ll operatiooutine activealth/safetchedule be

s Reductio

lysis shouldrvals for ontervals duriisks.

n should dities. This

y /environmnefits by t

A A

C C

Unaccepted Risk (change to procedures or design are required)

n

gn

ei

a

Marginal Risk (Risk reduction measures considered by ALARP Principle

Negligible Risk (Risk reduction not normally undertaken)

Process

be carried out prior to commencing the particular work activity; at oing work to assure effective monitoring of the risks; and revisited g the project life cycle to confirm that there have been no material

velop risk analysis procedures for managing all routine and non-s considerable overlap between the different approach to managing ent /security /community relations risks and substantial cost and king. The main types of major hazard risk reduction includes

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HAZOPs, Quantitative risk assessment (QRA), Qualitative and semi qualitative, Failure modes and effects analysis (FMEA), Cost benefit analysis(CBA) ,ISO Risk matrix , Bow-tie etc be used to reduce the risk by meet the ALARP principle The ALARP Principle To reduce a risk to a level which is ALARP involves balancing reduction in risk to a level, objectively assessed, where the trouble, difficulty and cost of further reduction measures become unreasonable disproportionate to the additional risk reduction obtained as illustrated by Figure 3.4

Figure 3.4 Demonstrating ALARP (Source: Shell HSE policy)

The ALARP principle originated as part of the philosophy of the UK Health and Safety at Work etc. Act 1974, which requires “every employer to ensure, so far as is reasonably practicable, the health, safety and welfare of all his employees”. This remains the basis of the approach by the HSE for risk management in the UK. The term “reasonably practicable” has a particular meaning drawn from legal precedent Asquith (1949): Bow Tie Risk Analysis The Bow-Tie approach has been popularized recently in the Netherlands (EU Safety Case Conference, 1999) as a structured approach for risk analysis within safety cases where quantification is not possible or desirable. The idea is simple, to combine the cause and consequence analyses into a single diagram to carry out formal safety assessment of marine operations ensure that risks are ALARP, and install the safety management system. “Offshore operations” in this context should be considered as a complex socio-technical system with the following categories of defences:

• Engineered defences (hardware) • Systems defences (software) • Human defences (liveware)

If the Major Accident is plotted as a large circle in the middle, this looks like a Bow Tie (see Figure 3.5)

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Figure 3.5 Example Bow Tie Analysis

Some of the activities and tasks of the process model are “safety critical” and they integrate the safety objectives, strategy and review at the senior management level, operating procedures at a technical support level, regulations, responsibilities related to planning and executing work at an operational level, and at task level, the responsibility for direct management of hazard barriers and recovery measures, as shown graphically in Figure 3.6

Table 3.2 Risk Acceptance Criteria Region Criteria

1 Requires a minimum of two effective barriers in place for all threats 2 Requires a minimum of one effective recovery measures(barrier)

for each identified consequence

ALARP

3 Requires a minimum of one effective control in place for all escalation factors

1 Requires a minimum of three effective barriers in place for all threat

2 Requires a minimum of two effective recovery measures (barriers) for each identified consequence

Intolerable

3 Requires a minimum of one effective control in place for all escalation factors

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Figure 3.6 Safety Critical Activity Cost benefit analysis (CBA) Cost-benefit analysis (CBA) is a technique for comparing the costs and benefits of a project, used to assess additional safety measures on a project by comparing the cost of implementing the measure with the benefit of the measure, in terms of the risk-factored cost of the accidents it would avert. A modern approach of risk assessments is to express the risks and costs as a ratio, known as the implied cost of averting a fatality (ICAF), as follows:

In a conventional CBA, future costs and benefits are converted to present values, discounting those that occur in the future. In order to ensure a bias in favour of safety, it is preferable to calculate the ICAF from Life time risk benefits (with no discounting) and the present value of costs (with conventional discounting):

Centre for Maritime and Petroleum Technology (CMPT 1999) suggested that if the ICAF were less than £1m, the measure would be cost effective and hence reasonably practicable even if individual risks were low, and would normally be adopted. If ICAF were in the range £1m to £10m, the measure would not be cost-effective, but might be considered reasonably practicable, especially if the individual risks were high in the ALARP zone. If the ICAF exceeded £10m, the measure would not be considered reasonably practicable, and the money could usually be spent more effectively on other safety measures.

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3.2.3 Risk Management The process for determination of risk reduction measures should be detailed. The risk reduction measures will aim to do one or more of the following points.

• Remove the hazards • Decrease the initiating event frequency • Decrease the consequences of the initiating event • Decrease the potential for escalation • Increase the probability of successful escape, evacuation and rescue

Actually risk reduction measures might be considered include decreasing the vulnerability of emergency systems, well control, ballast stability system, temporary refuge, control room and communications centre during major accident event. For Risk Management the following principles should be adopted, where possible:

• substitution: use of less hazardous materials • simplification: use of simpler process systems • intensification: reduction of inventory of hazardous materials • attenuation: reduction of temperature and/or pressure of hazardous materials, or use

of inert diluents Based on below PDCA (Plan-Do-Check-Act) methodology four below block points may be consider for risk management

Prevention Active

Prevention Passive

Policy Management

Review Planning

Implementation and operation

Continual Improvement

Checking

Mitigation Passive

Mitigation Active

3.3 Safety Climate and Safety Management Practice in offshore environments The main objectives of the studies were

• to examine current techniques used in the assessment of safety climate and culture and safety management practice;

• 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 in the offshore environment;

• to produce appropriate tools for assessment; and to produce process guidelines for the use of such a technique

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There is a broad interest in developing appropriate safety culture offshore organizations. This interest is currently focused on four key areas

• the nature of safety climate (that is, the underpinning concepts and characteristics); • the potential of safety climate assessments in securing continuous improvements in

health and safety; • the development of appropriate safety climate indicators and measures; and • the application of practical (and industry specific) methodologies of safety climate

assessment (for example, monitoring). The ‘Safety Climate Assessment Toolkit’ has been designed to provide appropriate measures of safety climate and safety management practice for offshore drilling and production platform. There are a number of general methods that can be used to gain insight into, and information on, safety climate. More specifically:

• question individuals to assess their attitudes and perceptions; • observe people and facilities and assess behaviour and working conditions; and • examine documents used in the organization, for example the examination of safety

procedures, event records and accident databases. The toolkit seeks to exploit a variety of these approaches and methods so as to give a more complete picture. In particular it utilizes:

• attitude surveys and rating scales; • in-depth, informal discussions with individuals; • focus group meetings; • examination of written records and databases; and • document analysis.

Several safety attitude surveys have been carried out. These surveys, together with group discussions carried out in the background research, have identified a number of general attitude dimensions. Employee attitudes in the organization can be gauged against these dimensions, using a series of key questions directed at a representative sample of workers .Figure 3.7 illustrates how, depending on how it is viewed, Climate can be measured using a variety of methods.

In general terms, the attitude measures, or dimensions, used in this toolkit fit into the following broad areas:

• Organizational Context; • Social Environment; • Individual Appreciation; and • Work Environment.

Organizational Context

• Management Commitment - Perceptions of management’s overt commitment to health and safety issues

• Communication - The nature and efficiency of health and safety communications within the organization

• Priority of Safety - The relative status of health and safety issues within the organization

• Safety Rules and Procedures - Views on the efficacy and necessity of rules and procedures

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Social Environment • Supportive Environment - The nature of the social environment at work, and the

support derived from it • Involvement - The extent to which safety is a focus for everyone and all are

involved

Safety Climate& Safety Management Practice

Figure 3.7 Multiple Perspective Assessment Models Individual Appreciation

• Personal Priorities and Need for Safety - The individual’s view of their own health and safety management and need to feel safe

• Personal Appreciation of Risk - How individuals view the risk associated with work

Work Environment

• Physical Work Environment - Perceptions of the nature of the physical environment How do we analyze the data? The following bullet points provide a step-by-step guide to scoring questionnaire responses:

• Each item should be scored by giving a value of 5 to the ‘strongly agree’ category, 4 to the ‘agree’ response, 3 to the ‘neither agree nor disagree’ category, 2 to the ‘disagree’ response, and 1 to the ‘strongly disagree’ category.

Viewed as: Viewed as: Viewed as: An Objective Perceptions of the

Organization Individual Perceptions Impact on individual Organizational attribute

‘is’ or ‘has’ how it is ‘seen’

Manifest in: Manifest in: Manifest in: Safety policy, System and Process, Structures, Report

Employee, Contractor and External perceptions

Employee commitment, attitude, responsibility, behaviour

Method: Method: Method: Observation, Audit etc. Interview,

Questionnaires, etc. Questionnaires, Observation, etc

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• Scores should be averaged for each item, across the whole group (or groups). • These average item scores can now be used to calculate dimension scores.

Dimensions in the current questionnaire have different numbers of items and, therefore, scores need to be standardized before plotting and comparing these dimensions. Converting the scores to a 1 to 10 scale can be achieved by dividing the actual score by the total possible score and then multiplying by 10. How should we deal with the results? Interpreting the results of the safety climate assessment should not be done in isolation from other safety appraisal systems. 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. The figures 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 organization. Parameters are used to measured the safety climate and safety management for drilling and production platform in Table 3.3 Table 3.3 Parameter considered for safety climate and safety management practice Parameter used for safety climate Parameter used for safety management

practice 1. Safety policy knowledge 2. Involvement in health &safety 3. Safety management system 4. Perceived management & supervisor

commitment 5. Willing to report accident 6. General safety behaviour 7. Safety behaviour under incentives 8. Communication about safety issue 9. Appreciation of risk 10. Supportive environment 11. Job satisfaction 12. Job Satisfaction with safety activity

1. Health & safety policy 2. Management commitment 3. Workforce involvement 4. Health & safety auditing 5. Safety rules 6. Management styles 7. Management change 8. Training 9. Competence 10. Accident & incident preventing action 11. Cooperation 12.Priority of safety 13.Safety performance

3.4 Identifying Root Causes of Offshore accidents

3.4.1 Introduction

The most typical causes of accidents include equipment failure, personnel mistakes, and extreme natural impacts (seismic activity, ice fields, hurricanes, and so on). Offshore main hazard is connected with the spills and blowouts of oil, gas, and numerous other chemical substances and compounds. The environmental consequences of accidental episodes are especially severe, sometimes dramatic, when they happen near the shore, in shallow waters, or in areas with slow water circulation.

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Drilling accidents are usually associated with unexpected blowouts of liquid and gaseous hydrocarbons from the well as a result of encountering zones with abnormally high pressure. These accidents can be controlled rather effectively (in several hours or days) by shutting in the well with the help of the blowout presenters and by changing the density of the drilling fluid. Unsafe acts and unsafe condition is another important cause of offshore accidents.

This section explains how the root causes behind labour accidents were identified, how safety factors were assessed and how possible solutions were found to prevent the occurrence of labor accident in offshore drilling and production operation. Moreover, appropriate tools for data collection, analyzing result and drawing conclusions were also discussed. This research section describes the utilization of Accident Root Causes Tracing Model (ARCTM) to investigate a labor accident. In addition, the design of interview checklist for data collection from offshore drilling and production engineers, safety personnel and workers.The research framework had been performed step by step based on the framework in figure 3.8 For reach the destination of the goal, the questionnaires were distributed to the drilling engineers, production engineers, and safety personnel and workers.

Interview survey to injured workers

Questionnaire survey to driller, geologist and process engineer

-Investigate about problems behind root causes of accident

-Investigate about safety performance onsite -Assess awareness about safety performance labour accident

-Assess awareness about safety performance

Data collection

Data Analysis

Research finding

Figure 3.8 A framework of the study process

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3.4.2 Steps to investigate a labor accident using ARCTM In order to utilize ARCTM, it was pointed out through the following three steps (Abde and Everett, 2000): Step 1 It should be determined that whether there was one or more unsafe conditions that faced the worker involved in the accident (before or after starting the activity). If a worker was faced by an unsafe condition (before or after starting the activity), it should be determined how the unsafe condition existed or developed, by addressing the questions shown in figure 3.9. As referred earlier (chapter 2), ARCTM proposes that existing or developing unsafe conditions is due to four causes:

• Management actions/in-actions resulted in the unsafe condition: • The investigator should determine why the unsafe condition was not identified and

removed by management, and who is responsible for such tasks. The number [3] after each of the questions in figure 3.9 indicates that there is a problem with management procedures, which requires further investigation and correction.

• Worker or coworker unsafe acts resulted in the unsafe condition: The investigator should determine if the unsafe act was caused by social,

peer, or management pressure. If social or peer pressure led to the unsafe act, this points out a worker attitude problem. If management pressure led to the unsafe act, this points out a problem with management procedures.

The investigator should determine whether the coworker knew the correct procedure of performing the work. If the worker did not, this points out a worker training problem. If the worker did, this points out a worker attitude problem.

The investigator should also determine if the coworker has always/occasionally acted unsafe while performing work. If the worker did, this points out a problem with management procedures because management should have measures in place to detect and discourage worker unsafe acts as they occur. If the worker committed the unsafe act for the first time, the previous questions will reveal the reason behind the unsafe act.

• Non-human-related event or a pre-existing unsafe condition on the construction site was the cause of the unsafe condition:

The investigator should determine whether it was possible for management or workers to identify such an event or condition. If the investigator has reason to believe that it was possible to identify such an event or condition, this points out a problem with both worker training and management procedures. If it was impossible for management or workers to identify such an event or condition, then the accident would have been truly unavoidable.

Step 2 If a worker was faced by an unsafe condition (before or after starting the activity), it should be determined whether the worker had identified the unsafe condition.

• If the worker did not identify the unsafe condition, the investigator should determine the reasons behind this failure by addressing the questions shown in Figure 3.9

• The investigator should determine if the worker made wrong assumptions about the condition, was unable to assess the condition because the task was new, or had insufficient knowledge to identify unsafe conditions related to his/her task. All these reasons for failing to identify the unsafe condition indicate a problem with worker training.

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• The investigator should consider if the worker was informed that the condition was safe. In such a case, the investigator should determine who informed the worker the condition was safe (a coworker or management), and why the informant regarded the condition as safe. If a coworker informed the worker and depending on why the coworker regarded the condition as safe, there could be a problem with either worker training or worker attitude. If management informed the worker, this points out a problem with management procedures.

• The investigator should also determine if the worker did not follow correct procedures in performing the work (i.e., if there were necessary steps that the worker had to perform to check the safety of the condition he! she is working in). If the worker failed to follow these procedures, the investigator should determine whether the worker knew these procedures. If the worker did not, this points out a worker training problem. If the worker did, this points out a worker attitude problem.

• The investigator should also determine if the worker has always/occasionally used the same incorrect, procedure in performing the work. If the worker did, this indicates a problem with management procedures because management should have measures iii place to detect such incorrect procedures. If the worker used an incorrect procedure in performing the work for the first time, the previous questions will reveal the reason for not following the correct procedure.

• If the worker identified the unsafe condition and decided to proceed with the activity, then the investigator should determine the reasons behind the incorrect decision by addressing the questions shown in Figure 3.9

• The investigator should determine if the worker considered that taking a risk was necessary or forced on him or her because of social, peer, or management pressures. If social or peer pressure led to the decision, this points out a worker attitude problem. If management pressure led to the decision, this points out a problem with management procedures.

• The investigator should determine if the worker failed to identify all attributes to the situation. If the worker failed in doing so, this points out a worker training problem.

• The investigator should determine if the worker thought he/she could still perform the job safely. If the worker did, this points out a worker attitude problem.

• The investigator should also determine whether the worker knew the correct procedure of performing the work. If the worker did not, this points out a worker training problem. If the worker did, this points out a worker attitude problem.

• The investigator should determine if the worker has always/occasionally proceeded with the work despite identifying the unsafe conditions. If the worker did, this indicates a problem with management procedures because management should have measures in place to detect and discourage worker unsafe acts as they occur. If the worker proceeded with work despite identifying the unsafe conditions for the first time, the previous questions will reveal the reason behind the decision to proceed.

Step 3 If there were no unsafe condition that faced the worker involved in the accident (before or after starting the activity), the investigator should determine whether the worker acted unsafe or not.

• If there was no unsafe act on the worker’s part, the investigator should reconsider the unsafe conditions surrounding the accident again by revisiting step 1 above.

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• If a worker acted unsafe, the investigator should deter the reasons behind this behavior by addressing the questions shown in Figure 3.9

The investigator should determine if the unsafe act was caused by social, peer, or management pressure. If social or peer pressure led to the unsafe act, this points out a worker attitude problem. If management pressure led to the unsafe act, this points out a problem with management procedures.

The investigator should determine whether the worker knew the correct procedure of performing the work. If the worker did not, this points out a worker training problem. If the worker did, this points out a worker attitude problem.

The investigator should determine if the worker has always/occasionally acted unsafe while performing work. If the worker did, this points out a problem with management procedures because management should have measures in place to detect and discourage worker unsafe acts as they occur. If the worker committed the unsafe for the first time, the previous questions will reveal the reason behind the unsafe act.

3.4.3 Interview checklist based on ARCTM for data collection from engineers, safety personnel and injured workers According to the flow chart in figure 3.9, interview checklist was designed to identify problems behind root causes of labor accidents. These problems were very important to find ways of accident reoccurrence prevention. Depending on the situation, open-ended questions as well as close-ended questions were utilized to interview injured workers. In order to evaluate each item of interview checklist, criteria were designed to identify and record smoothly the interviewer’s answers. These evaluative criteria were necessary to save time of interviews as well as make a systematic ways during the interview process. Data Analysis The data were analyzed utilizing the statistical computing package SPSS version 10.1(Statistical Package for Social Science).In order to determine the significance of the result some of statistical tests were performed. In order to see factors that had strongly influence on labour accident occurrences, respondents were asked to rate the important level of factors represented in questionnaires. The relative importance index was used to determine the ranking of different factors from the point of view of different respondent such as onsite and corporate level engineers, safety personnel and workers. A factor with higher value of relative index (RI) was more important. Ideally, the relative index of a factor to be equal 1 means that all respondents rated that factor as very important. In addition Spearman’s rho correlation coefficient was used to measure the strength relationship between drilling operation and Production operation respondents in identification of factors affecting labour accident occurrence. 3.5 Safety and Situation Awareness in Offshore Crews Much work involved on offshore installations has the capacity to be hazardous, and despite many rules and regulations in place to ensure that accident risk is kept to minimum, accidents still occur. One factor to the occurrence of accidents is a reduction in the ‘Situation Awareness’ (SA) of those concerned. 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.

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Was there an unsafe condition that existed before the activity was started, or that developed after the activity was started?

Yes No

How did this unsafe condition(s) exist or develop?

Did the worker identify the unsafe condition(s)

Management Action/Inaction

Why was the unsafe condition not removed [3] Who is responsible for removing it [3]

(Co) worker Unsafe acts

Why did (co) worker act unsafe? -was it social pressure?[2] -was it peer pressure?[2] -was it management pressure?[3] Does the (co) worker know the correct procedure of doing the work? -Yes [2] -No[1]

Has the (co) worker always/occasionally used the same unsafe act to perform the work? -Yes [3] -No[First time –check previous question]

Non-human related event(s) or unsafe condition is a natural part of the initial operating site conditions

Was it possible for management or workers to identify such event(s) or condition(s) -Yes[1] and[3] -No(unavoidable accident)

No Yes and decided to proceed the work

-worker made wrong assumption about condition [1] -unable to assess condition because condition is new[1] -insufficient knowledge to identify unsafe condition(s)[1] -worker was informed that condition is safe

-who informed the worker and why was the condition regarded as safe -was it (co) worker?[1] or [2] -was it management?[3]

-worker did not follow correct procedure of doing work -does the worker know the correct procedure of doing work -Yes[2] No[1] -Has the worker always/occasionally used the same procedure to perform the work?

-Yes[3] No[First time check previous question]

Why did the worker fail to identify the unsafe condition(s)

Why did the worker decide to proceed?

-Was it social pressure?[2] -Was it pear pressure[2] -Was it management pressure[3]

Does the worker know the correct procedure of doing the work -Yes[2] -No[1]

Has the worker always/occasionally proceeded with the work despite identifying the unsafe conditions? -Yes[3] -No[First time check previous questions]

Did the worker commit an unsafe act

No (Re check unsafe conditions

Yes

Why did the worker act unsafe -social pressure[2] -peer pressure[2] -management pressure[3]

Does the worker know the correct procedure of doing work

Has the worker always/occasionally used the same unsafe act to perform the work -Yes[3] -No[First time check previous questions]

-Yes[2] -No[1]

Issues to consider as corrective actions: [1]—Worker Training; [2]—Worker Attitude; [3]—Management ProceduresFigure 3.9 Accident Root Cause Tracing Model (ARCTM)

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. The aim of this research part is to initially establish the domain of SA in the offshore oil and gas industry to discover how it is regarded, and the main underlying issues involved. Future work (currently being researched as an Msc thesis) aims to fully understand SA in offshore drill crews, with the hope of providing a means of maintaining and improving SA in the crews in an attempt to reduce accident risk. 3.5.1 Drilling Accident Analysis Method A search was performed on a multinational oil company’s accident database, seeking information on drilling activity accidents (on fixed installations, mobile rigs and well operations) from the period January-October 2005, revealing 330 incidents in total. Of those which were found not to be related to SA errors, or did not provide enough information to identify the error source, were discounted. This left 132 remaining incidents to analyze. These incidents were analyzed and subsequently classified using the aforementioned (Chapter 2) taxonomy. If it was found that an error could fall into more than one category, it was classified at the lowest taxonomy level. 3.5.2 Interviews with Drilling and Production Personnel Once it was discovered that errors in SA were an issue for the offshore industry, interviews were conducted with members of drilling and production personnel, both onshore and offshore, in an effort to understand more about how the concept of SA is viewed in this field. Method Interviews were conducted with 15 drilling personnel of some three offshore oil and gas exploration and production company.12 personnel were based offshore in positions as HSE Managers, Operations Managers, Well Engineering Managers, and Drilling superintend and 3 personnel were based onshore. All interviews were informal and of a semi-structured nature. Questions included “How is the concept of SA known in the offshore industry”; “What factors can affect the quality of a person’s awareness”; ”What are the indicators of reduced awareness”; “How can reduced awareness be improved”; and ”How is team situation awareness achieved” Interviewees were given background information to the study, made aware that they could withdraw at any point, that all information gained would remain entirely confidential, that while de identified quotes may be used, they would not allow for individuals to be identified, and that at no point would the individual’s data be released to their company. Permission to record the interview was requested, after which the interview was transcribed, de-identified, and the record erased. Interview transcripts were then analyzed using a grounded theory approach (developed by Glaser & Strauss) which uses qualitative data such as unstructured interview data to construct new theory (Pidgeon & Henwood)

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Chapter 4

Result and Discussion 4.1 Risk Assessment of offshore drilling and production platform Identified potential hazards are shown in Table 4.1.Analyzed included the rank of the hazard based on the probability and consequences by previous data, discuss with drilling and production engineers, geologist, mud engineers and safety personnel of offshore drilling and production company and found the protection factors & exposure are shown in Table 4.2.When got the exposure, Bow-Tie analysis method was used to reduce the risk with ALARP principle. Figure 4.1 shows the methodology to reducing the blow out risk by Bow-Tie principle However, before start any offshore activity more strongly recommend to follow job safety assessment form sheet. Table 4.3 Proposed Job Safety Assessment for Handling tubulars and lifting. Table 4.1 Potential major hazards of offshore drilling and production Offshore drilling operation Offshore production operation

• Drilling phase blowouts • Dropped objects • Loss of power to emergency evacuation

system • Gas release on rig floor and deck areas • Failure of electrical equipment/pressure

containing equipment • Pipe handling • Structural damage • Ship collision/ Helicopter crash • Extreme weather • People Transfer

• Blowouts • Topsides process gas release • Gas export riser and pipeline

release • Offshore diesel fuel spill and

fires • Ship collision • Dropped objects • Structural damage • Extreme weather • People Transfer

When identified the major hazards, risk factors was measured based on the literature data, company’s previous accident record data and interview with engineers, geologist and workers. Exposure was measured by subtracting between risk index and protection factors. ‘Protection factor’, is the current risk reduction situation which are ongoing of specific hazard. Time to time need to monitor and inspection to check the level of exposure and if exposure is high then it need to take further risk reduction method to reduce major accident. Definately exposure zero is very good and totally safe for work. Some of hazards below (Table 4.2) is zero; it means that the current risk reductions of those hazards are very strong and safe for work. Incase of ‘dropped objects’ risk exposure is 2; it means that, need to use much barriers for safe work. Bow-Tie is one of risk reduction tool that can be

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used in that case. Here only drilling project hazards are considered for measuring the exposures. Incase of time shortness and insufficient data, exposure of Production Company was not measured. Table 4.2 Proposed methodology of finding the exposures No Hazards Frequency

(F) Severity (S)

Risk Index RI=(F+S)

Protection Factors (PF)

Exposure E=RI-PF

1 Drilling phase blowouts

1 5 6 5 1

2 Dropped objects 4 4 8 6 2 3 Loss of power to

emergency evacuation system

2 3 5 5 0

4 Gas release on rig floor mud return and cellar deck areas

3 4 7 5 2

5 Failure of electrical equipment/pressure containing equipment

2 4 6 5 1

6 Structural damage 1 5 6 5 1 7 Flash Fire 1 4 5 4 1 8 Ship collision/

Helicopter crash 1 5 6 5 1

9 Extreme weather 3 2 5 5 0 10 People Transfer 2 2 4 3 1

Scale Frequency 1to 5 Severity 1to 5 Protection Factor

1to10

Exposure Max 10

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Figure 4.1 Blow out can be assessing by Bow-Tie Consequences:

• Initial explosion and fire affecting other containment areas and critical utility facilities

• Drilling rig derrick collapse • Failure of rig and platform primary structures • Extensive environmental impact • Thermal radiation • Smoke logging

Barriers:

• Preventing release pressure vessel and piping system integrity, safeguard system, detecting system

• Plant condition monitoring and operation executives • Well condition monitoring • Materials and equipments procurements • Training and competency

Recovering the consequences:

• Flammable gas detection, fire detection, ESD system, fixed fire fighting system, foam system, fire pumps

• Emergency response procedures

Hazard Blowout Accident

BarriersRecovering

Consequence

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Table 4.3 Proposed Job Safety Assessment for Handling tubulars and lifting

Sub process/ User/ Activity

Hazard/failure mode Initial Assessment Severity Probability

Risk Level Minimize risk by/risk reduction method

Final Assessment Severity Probability

Risk level

Status/ responsible

Drilling Operator Handling tubulars and lifting

-Being struck by rolling or falling tubulars. -Being struck by or caught between tubulars and other objects during movement (for example, being struck by tubulars being tailed into the rig floor). -Slips, trips, and falls. -Getting struck by falling tubulars due to lifting equipment failure.

Significant Frequent

High

-Use powered industrial truck (forklift) properly. -Work the tubulars from the ends from ground level. -Chock or pin tubulars on the racks properly. -Level of pipe racks properly. -Stand clear of suspended, hoisted, or moving loads. Be aware of tubulars or equipment being lifted through the V-door -Instruct workers in the need for proper use, inspection, and maintenance practices. Before each tour inspect the: -Wire rope and slings, -Catline ropes and knots (do not allow a rope to lie in standing water) -Chains and hooks. -Stand clear of suspended, hoisted or moving loads and be aware of your surroundings.

Minimal Remote

Low

Completed Mr. Langta ---------

4.2 Safety Climate and Safety Management Practice in offshore environments Safety Climate and Safety Management Practice In case of Safety Climate, ‘Safety Climate Assessment Toolkit’ were used and resulted value (Figure 4.2) showed that for drilling company some factors like ‘Appreciation of risks’; ‘Safety policy knowledge; and ‘Safety management system’ are very good. However,’ Job satisfaction with safety activity’; ‘Willing to report accident’; ‘Communication about safety issues’; and ‘Job satisfaction of the employees’ should be improved by top management or/and safety department. In case of production company ‘Safety policy knowledge’; ‘Safety management system’; ‘Willing to report accident’; ‘General safety behaviours’; ‘Safety behaviour under incentives’ and ‘Job satisfaction’ were very good where weak points were ‘Job satisfaction with safety activity’; ‘Perceived management & supervisor commitment’; and ‘Appreciation of risks’. Moreover, figure 4.3 showed that the safety management practice for drilling company where some points like, ‘Health & safety policy’; ‘Management commitment’; ‘Accident and incident preventing actions’; ‘Priority of safety’; ‘Organizational practice’ were very good. However, ‘Safety rules’;’ Management change’; and ‘Competence’; ‘Management style’; ‘Safety performance’; ‘Workforce involvement’ grading point was below 8.0 out of 10. It means that these points should regenerate /improve in terms of overall company’s good safety management practice. In production company ‘Health & safety policy’; ‘Management commitment’; ‘Health and safety auditing’ ; ‘Safety rules’; ‘ Management style’; ‘Accident and incident preventing action’; ‘Priority of safety’; ‘Organizational practice’ were very good even grading below 8 were some factors like ‘Management change’; ‘Competence’ and ‘Cooperation’; ‘Training’; ‘Safety performance’ and ‘Workforce involvements’. Using ‘Safety Climate Assessment’ the completed matrix in Figure 4.3 highlights where the strengths (those areas marked (+)) and weaknesses (those marked (-)) of that hypothetical culture lie both for drilling and production company. We can see from the complete matrix figure, the weaknesses apparent in ‘Safety system compliance’; ‘Safe behaviour’; and ‘Personal priorities’ for drilling company while ‘Safety system compliance;’ Cooperation’; ‘Appreciation of risks’ and ‘Personal priorities’ for Production Company. As most of the respondents both from drilling and production company strongly agreed almost all of the above factors, management should realize those points for improving the performance of safety where weakness. This may be the part of key issue of organizations own HSE policy system.

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Drilling company

Production Company

Figure 4.2 Results radar plot of drilling and production company (Safety Climate)

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Drilling company

Production Company

Figure 4.3 Results radar plot of drilling and Production Company (Safety Management Practice)

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Drilling Company safety climate matrix showing strength and weakness Safety Interfaces

Organization Work group /organization system

Individual/organization system

Attitude questionnaires

Management commitment(+ ) Work Environment(+ )

Supportive environment(+) Involvement(-)

Appreciation of risk(+) Personal priorities(-)

Focus group Management style(+ )

Cooperation(+) Shared values(+)

Direct/Indirect observation

Safety system compliance(-)

Safe behavior (-) Safe behavior(+)

Method

Production Company safety climate matrix showing strength and weakness Safety Interfaces

Organization Work group /organization system

Individual/ organization system

Attitude questionnaires

Management commitment(+ ) Work Environment(+ )

Supportive environment(+) Involvement(+)

Appreciation of risk(-) Personal priorities(-)

Focus group Management style(+ )

Cooperation(-) Shared values(+)

Direct/Indirect observation

Safety system compliance(-)

Safe behavior (-) Safe behavior(+)

Method

Figure 4.4 Safety Climate Matrixes of drilling and Production Company Safety Performance Status Assessment Miscellaneous some, six questions were asked namely(1) top management play a crucial role in the securing of drilling safety and safety performance(2) better working conditions prevent the occurrence of accidents(3) safer workers were getting more satisfied with jobs(4) safety improvement will bring higher productivity and smother drilling process(5) safety improvement and better quality will occur together(6) safety improvement with lower production/operation cost to drilling and production personnel regarding the importance of safety performance (shown in figure 4.5) For example 60% drilling and production personnel strongly agree that ‘top management play crucial role in the securing of drilling safety and safety performance’. However 75% of production company respondent believes ‘safety improvement will bring higher productivity and smother drilling /operation processes. Moreover 58% of drilling respondents strongly agree on ’safer worker getting more satisfied job’.

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Strong AgreeProbably AgreeDont KnowDisagree

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Figure 4.5 Miscellaneous Response for safety performance

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Strong AgreeProbably AgreeDont KnowDisagree

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ent p

lay

a cr

ucia

l rol

e in

the

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ring

of d

rillin

g sa

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and

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perfo

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Columns

0.00

25.00

50.00

75.00

Valu

es

Strong Agree

Probably Agree

Dont Know

Disagree

Figure 4.5 Miscellaneous Response for safety performance (Continued)

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4.3 Identifying Root Causes of Offshore accidents Correlation analysis between drilling company and production company respondents towards ranking the factors influencing the occurrence of labour accident The data were analyzed to see whether the correlation between drilling company and production company respondents towards the ranking of factors affecting labour accident occurrence. The results are shown in Table 4.5. There was significant correlation to be found between some factors that have the high ranking (correlation is significant at .01 level with Spearman’s rho coefficient= 0.532).Although the result shown that the factors assumed different ranking for drilling and production unit but as the correlation coefficient 0.532 so all the factors are moderate correlated for both company incase of the occurrence of labour accident. Fatal accident by problems behind the accident According to the Accident Root Causes Tracing Model (ARCTM), behind each accident there is one of are the three problems as follow

• The problem of worker training • The problem of worker attitude • The problem of management procedures

The interview survey was assessed for company A and company B in table 4.4 showed the rank of those problems behind occurrence of accident Table 4.4 Frequency distribution of fatal accident by problems behind accident

Drilling Company Production Company The types of Problem Percent (%) Rank Percent (%) Rank

Worker Training 53.8 1 62.3 1 Management Procedures 35.2 2 22.7 2 Worker Attitude 11 3 15 3

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Table 4.5 Factors influencing the occurrence of accident

Drilling company Production Company

Index Ranking

(R1) Index Ranking

(R2)

di (R1-R2)

di2

Equipment or tools without safety device

.933 1 .763 10 -9 81

Inadequate site supervision .9066 2 .7867 6 -4 16

Overtime and fatigue of workers

.9066 3 .76 11 -8 64

Lack of planning for equipment operation

.8933 4 .7866 7 -3 9

Poor house keeping .8933 5 .7733 9 -4 16 Inadequate preparatory training

.8933 6 .815 1 5 25

Lack of safety planning .88 7 .7865 8 -1 1 Inadequate safety facilities .8670 8 .798 5 3 9 Inadequate planning of construction work

.8667 9 .8 4 5 25

Improper working postures .866 10 .7066 20 -10 100

Chronic physical stress .8539 11 .729 17 -6 36 Inadequate illumination or poor lighting

.8536 12 .6933 21 -9 81

Inadequate ventilation .8534 13 .7335 15 -2 4

Unorganized site layout .8533 14 .802 2 12 144 Inadequate and improper tool .8533 15 .801 3 12 144

Poor weather condition .8533 16 .7468 12 4 16 Disregarded attitude of contractors and superintendents

.84 17 .7466 13 4 16

Inadequate temporary structures

.839 18 .734 14 4 16

Inadequate working place .8266 19 .723 18 1 1 Financial shortage .8133 20 .72 19 1 1 Emulation and competition among workers

.8 21 .733 16 5 25

The poverty of worker .76 22 .6266 22 0 0 Number of observation(n)=22 Total(Σ) di2= 830

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Spearman’s rho coefficient = 1-nn

di−

∑3

26 2

Contribution to improvement of Safety PerformaRespondents were given four different groups of comanagement, drilling/process engineers on site, setc..) and asked to rank them in order to contrperformance improvements and accident preventioCompany A respondents suggested, top manageperformance and safety personnel for preventing acbelieve both drilling/process engineer working on role for safety performance and safety personnel f4.7 showed in details. The top management’s is important to safety perfostrongly support for safety program at all comresponsible for handling financial concerns and invinfluence to removing unsafe conditions as well as u The significant responsibility of safety personnel accident at project level is evident. They keep recregular job site inspection. They are also involved ion specific matters from time to time. They may ostage of a project because they have good knoactivities.

Safety Performance

Project Nam

PrDrilling company

Mea

n

9

8

7

6

5

4

Figure 4.6 Contribution to improve

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Spearman’s rho coefficient= 0.53

nce as well as Accident Prevention mpany A and company B including top afety personnel and others(contractors ibution of each group towards safety n. The mean rank was then calculated. ment play a crucial role for safety cident where’s company B respondents site and safety personal play important or accident prevention. Figure 4.6 and

rmance improvement because they can pany level. Top management’s are

estment in PPE, safety nets etc. which nsafe acts.

towards preventing the occurrence of ords of job site performance and make n worker orientation to provide training ffer valuable comments in the planning wledge of hazards relating different

can be Improved by

e

oduction company

top management

drilling engineers

w orking on- site

safety personnel

others

(contractors etc..)

ment of Safety Performance

Occurance of Accident can be Prevented by

Project Name

Production companyDrilling company

Mea

n

9

8

7

6

5

4

top management

drilling engineers

w orking on-site

safety personnel

others

(contactors etc..)

Figure 4.7 Contribution to preventing the occurrence of accident 4.4 Safety and Situation Awareness in Offshore Crews Drilling Accident Analyses Overall, it was found that 65.3% were classified as Level 1 SA errors, 19% were Level 2 errors, and the remaining 15.7% were Level 3 errors. Level 1 errors: involved the failure to perceive or the misperception of, information in the environment. Of these errors, the majority were due to a failure to detect the information. This was followed by the information being unavailable for/obscured from perception. Level 2 errors: regarded the incorrect assimilation or understanding of the information. Of these errors, the majorities were due to a lack of, or incomplete, mental model with which to process the information, i.e. the significance of the perceived information was not fully understood due to not having an appropriate mental model of the event. Level 3 errors: were errors in which the projection of future state of affairs was poor, incorrect, or missing. Analysis of the drilling accidents attributable to SA errors discovered that of 132 incidents, the vast majority (65.3%) were due to errors in Level 1 SA (failure to perceive correctly), followed by 19% of errors in Level 2 SA (failure to comprehend correctly), with 15.7% attributable to errors in Level 3 SA. These results are comparable to the distribution pattern of SA errors found in Jones and Endsley’s research (Errors in SA Level 1 is 76.3%, Level 2 is 20.3% & and Level 3 is 3. 4%). This suggests that SA errors in the offshore drilling industry and the

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frequency of their occurrence are similar to those occurring in aviation, indicating the comparative frequencies of SA error causal factors to be a potentially more generalisable pattern. Interviews with Drilling Personnel The main themes and concepts from the interviews both from drilling company and Production Company were extracted and assimilated to understand how SA is seen in the offshore drilling industry. Table 4.6 main findings from Interview Analysis.

1. How is situation awareness known in the offshore industry? Safety and potential awareness 2. What factors affect the quality of a person’s awareness?

Home/family problems; experience; conflict; communication; supportive environments; near-miss; extreme weather

3. What are the indicators of reduced awareness? Involvement in health and safety; cooperation; reduced work standards 4. How can reduced awareness be improved?

Health and safety policy; Interaction; problem solving training, communication about safety issues

5. How is team situation awareness achieved? Planning; good safety management system, Health

As Table 4.6 shows, most questions elicited a number of different answers. However, there was general consensus among all interviewees on these answers, assumed by the frequency of their occurrence (i.e. all interviewees tended to respond with similar answers, indicating general understanding of the concept). The interview findings will be discussed in more detail here. All items will not be discussed, only those most prominent. (Q1 is self-explanatory, so no further details will be given). Q2. What factors affect the quality of a person’s awareness? Having problems with family/at home was felt to be the most prominent factor that could affect awareness. Being offshore meant personnel had no control over the situation, weighing heavy on their minds, which may distract them from work. Fatigue was most problematic when on short change, as this disrupted sleep patterns. Stress from several areas was also a cited issue-as heavy workload increases; supervisor pressure (to get a job done quickly), and also self-imposed pressure to complete a task by a certain time. While it is widely reported that stress can lead to decrements in performance, the significant impact upon awareness should not be ignored-stress can place increased pressure upon already limited cognitive resources, meaning less available resources for attention and awareness, reducing the overall quality of SA. Experience impacted SA in two ways: new hands felt they required time to adjust to rig surroundings, infrastructure, regulations, etc, and were not as aware until this was done; experienced crew felt less experienced workers impacted

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their awareness as they had to “look out for them” and compensate for their inadequate levels of SA, meaning attention was divided between their own job and the inexperienced worker. Routine tasks/complacency impacted awareness in that if a task had been done may times beforehand, there was less inclination to focus on it as operations had gone smoothly in the past-this leads to complacency, less attention to the job, and thus reduced awareness. Q3. What are the indicators of reduced awareness? All personnel interviewed stated that the most important indication of reduced awareness was a character change in the individual. Communication was also reduced, whereby the individual did not talk as much as usual, and became more withdrawn. As a supervisor or colleague, having to repeatedly give the same instructions over a relatively short space of time was also felt to be a good indicator, as it was suggested that the person was not paying as much attention as they should. A drop in work standards of a normally productive individual, and blank, glazed expressions were also believed to indicate reduced awareness. Q4. How can reduced awareness be improved? Communicating with the individual and having a discussion was believed to be the most important (and instantaneous) method of increasing awareness - this brings to their attention the fact that they were not being as attentive as is appropriate, prompting them back to ‘normality’. Also, if the reduced awareness was due to problems weighing on their mind, this provides the opportunity to voice the concerns, ‘getting them off his chest’, thus alleviating the problem. Interaction was believed to aid awareness by keeping the crews alert and focused. Tasking the individual with a job out of harm’s way was perceived as a remedy as this allowed them not to be in harms way (so required less SA), and also gave them time to regain their awareness levels. Reducing workload (if this was the problem area) was felt to have the same effect. If the problem was more severe and a short break with reduced work was ineffective, then removing the individual from the situation entirely and sending them home was felt to be the only option, although rare. Q5. How is team situation awareness achieved? Consistency was felt to be the key factor in achieving team SA-by keeping the same crew together over a period of time, this allowed the crew to fully get to know and understand each other, learning how they worked, their roles and capabilities, traits, strengths and weaknesses, eventually leading to a team which automatically knew how each other crew member would react in a given situation due to their detailed knowledge and understanding “.. An unspoken understanding with everyone working from the same mental plan” and “...pulling in the same direction”.

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Chapter 5

Conclusions and Recommendations This research study main focus was Risk Assessment and Safety Climate & Safety Management Practice of offshore drilling and Production Company. However, based on the questionnaires comments of drilling and production company personnel, found the root causes of accident and safety and situation awareness of the crews. This chapter summarizes the studies and makes conclusion in the following research objectives. Moreover, recommendation for further studies will be presented. 5.1 Risk Assessment of offshore drilling and production platform For Risk Assessment part, Qualitative methods were discussed to analyze the selecting major hazards both for drilling and production company by measuring the the probability and impact as well as risk exposure based on previous company’s data and interview with personnel and developed Bow-Tie risk reduction method with ALARP principles. Risk assessment requires two things. Firstly, understanding and defining a problem properly. This includes clear definition of decision criteria. Unless objectives are clear enough, one cannot expect good risk analysis. Secondly, understand risk analysis methods sufficiently. A failure in doing so can cause wrong perception of risk. It is likely to occur that first selecting methods for analysis and then setting up a problem so that the problem can be analyzed by selecting methods. It is something wrong. Risk analysis methods can be selected only after a problem is structured and well understood. Application of methods only depends on the conditions of the problem which is clearly set up. Obviously, drilling operation is much more risky job compare with production operation as huge lifting, pipe handling involve in drilling operation. Investigated found that most of the offshore accident causes by lifting and pipe handling or gas release on rig floor/production platform. The author wishes this work would be a useful reference for risk management to offshore drilling and production and also given recommend for further study. As a recommend, new approach”10points of Risk Management’ and ‘Risk Controlling Method’ for further risk assessment improvements 10 point of Risk Management The ten elements of operation that represent the main risk areas to the success of a business are considered to be 1. Physical properties-Premises/Product/Purchasing suppliers 2. People elements-People/Procedures/Production 3. Action or process-Processes/Performance 4. Management issues-Policy and strategy/Planning and organization

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5.2 Safety Climate and Safety Management Practice 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. Once the process is underway, its degree of success is improving the safety climate will depend on using data to develop action plans for continuous improvement. There are two primary reasons for this: 1. the people who shared their views and contributed to the exercise will expect there to be some actions or changes based on their efforts and activities; and 2. the data is likely to uncover areas for improvement that have to be resolved in order that a lasting improvement in safety can be achieved. The first step in the action planning exercise may be to go back to the questionnaire or interview items and identify any questions where respondents or interviewees constantly gave points below 8 out of 10. Also, if an issue has been commented on by several different people it might highlight an area for action. Once specific areas have been identified, need to set about trying to improve them. The identification of cultural drivers, carried out earlier in the process, will highlight who may be the most appropriate instigator of climate change. Also, the systems interface to which the weak indicators are aligned, will give the initial direction for such initiatives. For example for drilling company ‘Safety system compliance’; ‘Safe behaviour’; and ‘Personal priorities’ are highlighted as weak and those suggest that some attention should be directed to the individual To keep the process on track, here are some ways to encourage acceptance of changes

• Clearly explain what needs to be changed and why. For example, if there is a clear need to improve performance in one specific area, be able to explain why a change (improvement) is needed. When that is done, the fact that a change is needed is not negotiable. Since the need for some change is accepted, it may be easier to describe how a change in the safety climate can really make a difference. Often this works best when management sends a strong message that safety improvement is needed. Also, if the employees themselves have some ownership of the decision, change may be more clearly explained.

• Communicate the benefits of a climate change, details of the process, and as much other information as possible.

• Be open to constructive discussion to improve understanding. Also ask for suggestions and follow up on them.

• Ask for co-operation in focusing on improvements, rather than asking people to change their attitudes.

• Have a realistic schedule for change, realizing that major cultural shifts cannot happen quickly.

• Be flexible - be willing to negotiate on details of the process that will help improve acceptance and participation.

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However, safety performances were analyzed with some, six factors and find out the importance of those based on the drilling and production company’s personnel comments. This result may be importance for reviewing the company’s safety policy. 5.3 Identifying Root Causes of Offshore accidents This section has presented ARCTM, which complements offshore labor accident investigation techniques by raising many important questions and possible answers that help identify the root causes behind occupational accidents. ARCTM emphasizes the need to consider worker training, worker attitude, and management procedures when prevention efforts are contemplated. The accident scenarios analyzed using ARCTM show that the analysis of events-whether they are existing or developing unsafe conditions or unsafe acts, and how workers respond to or are affected by these events is a logical route to take to accurately determine the root causes of accidents on operation sites. In addition to identifying the root cause(s) of accidents, using ARCTM also provides solutions or possible areas to consider preventing accident reoccurrence. ARCTM’s philosophy can be summarized into three main points. First, workers who do not have sufficient training or knowledge about their jobs should not be expected to identify all unsafe conditions surrounding their work and avoid the possible accident situations. Second, workers who do have the training or knowledge about their jobs but still decide to work unsafe will never be accident-free unless their attitudes toward safety change. Third, management procedures should be designed to identify and remove unsafe conditions in a proactive manner, and management should always reinforce the value and importance of safety among workers. ARCTM provides a template for systematically and rapidly determining areas requiring more investigations, so that worker and management may provide more effective measures for preventing accidents. It should be emphasized that the objective of using ARCTM as a complement to the investigation process should not be limited to finding the party responsible for the accident but to use it to help find answers to the questions of why accidents occur in offshore operation and how to prevent their reoccurrences. Research study showed that (Table 4.4) 53.8% of drilling company’s personnel and 62.3% of production company’s personnel are strongly agree that most of the labor accident may occur by inadequate training. However, Figure 4.6 and Figure 4.7 showed that the contribution to preventing the accident and safety improvement. Drilling company’s personnel suggested top management play a crucial rule for improvements of safety performance where production company’s personnel believe drilling engineer working onsite and safety personnel. For preventing the occurrence of accident both drilling and production personnel were accord safety personnel peoples are most important. Occurrences of labor accident were analyzed and find out the ranking of unsafe acts and unsafe condition based on the questionnaire of drilling and production onsite and corporate level and determined the Pearson correlation coefficient (0.532) which suggested both company’s personnel support alls the unsafe acts and conditions are significant correlated for occurring the labor accident.

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Critical success factors for safety improvement as well as accident prevention programs

• Periodically safety-training programs: Management should make pertinent efforts to improve safety awareness of their employees and workers through periodically safety- training programs. Training should be at the core of every safety program (Hinze, 1997).

• The true commitment of top management to safety improvement program: Top management should be persuaded by more formal communication about benefits from labour safety improvement to raise their commitment to the safety objective of the company. In addition, top management recognized as a group that have highest responsible for the implement of safety programs at company level

• An effective accident report system: Safety problem can be determined and pertinent information will be returned to safety division in order to make timely decisions.

• An “not cutting corners" attitude of top managers: Management should recognize that such attitudes in their projects can increase the chance of the occurrence of labour accident.

• An appointment of safety officers: Safety officers are recognized as a group that have highest responsible for the implement of safety programs at project site. Companies should appoint a safety officer for each project.

• Mutual obligation of all employees in safety programs: Cooperation in safety

improvement programs is needs because safety culture can not be maintained from the endeavor of anyone.

• The enforcement of safety performance, adequate providing of PPE, using safe equipment/tools, good physical working conditions: The survey outcomes indicate that human behaviour and working conditions are the most important factors affecting labour accident occurrence at sites.

• Updating of safety knowledge and safety managerial skills for onsite managers: Because failure of management procedure is identified as a big problem behind of fatal accident and injuries, it is needs to periodically update by proper training courses in construction organizations.

• The establishment of adequate safety management procedures at sites: To have a powerful influence on operation site worker safety.

• Not using hazardous methods/procedures, sufficient providing of supports/guards: To remove main unsafe conditions that existed very common at sites.

• Safety and Labour Code inspections at sites: It is needs to inspect Safety and Labour Code in order to raise safety performance and to reduce the amount of unskilled workers at sites.

5.4 Safety and Situation awareness (SA) of offshore crews The initial accident analysis has shown SA to be an issue for the drilling industry, while indicating possible factors underlying losses to SA, and also the frequency/causes of various types of SA error (failure to detect information being the largest category). The interviews conducted with both drilling and production company’s personnel have led to a more detailed understanding of what is a relatively uninvestigated area of the exploration

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and production industry, and it is anticipated that with further research SA can be more acutely understood not only in the conceptual form, but also to provide companies with guidance regarding effective actions that may help to reduce the risk of accidents in the future. 5.5 Recommendation for further research This study provided an initial survey related to risk assessment and safety improvement process as well as accident prevention programs of offshore drilling and production operation. Although several findings have been found in this study, it is useful to recommend for further research as follows 1. Further researcher with large sample should be conducted to broaden the findings. 2. More research should be conducted regarding a sensible rate on incentives, the influence of psychological factors on labour accident. 3. Although crucial safety factors have been found and appreciated, it is need to conduct future researcher related to determination of correlation among factors, the quantified influence level of each factors on safety performance. More research is also necessary to explore and quantify relationship between direct as well as indirect cost with labour accident. 4. Some case study should be conducted to develop detailed safety improvement programs and accident prevention programs which are set up based on identified problem in this study. 5. Further study should be conducted to identify ways to modifying company’s own safety policy so that it would have greater impact on safety, relationship between psychological factors and accident occurrence, the influence of crew cohesiveness to safety performance

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Appendices

89

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Appendix 1

Questionnaires

The questionnaire on Safety climate, safety management practice and safety performance and occurrence of labor accident Dear Sir I am conducting a study in the Asian Institute of Technology (AIT) concerned with “Study of offshore production risks and safety climate, safety management practice & safety performance in offshore environments”. I would like to find out how you feel about your company safety climate as well as practices and principles, and in order to do this I would like you to complete this questionnaire -confidentiality is assured. Your responses are expected to be great source to develop a system for safety improvement efforts and the accident occurrence prevention in offshore platform. The questionnaire is in THREE parts and is relatively simple to complete and asks about your attitudes to safety issues; as well as any suggestions you might have to improve things. Please try to answer all of the questions, being as open and honest as you can. The conclusions will be fed back to you on completion of the survey. I appreciate your helping and many thanks for your assistance. With best Regards M.Shafiqul Islam PART A You will be presented with a series of statements on the following pages about health and safety. You should indicate your response by ticking the appropriate box. For example, if you agreed with the following statement you would tick under the ‘I agree’ category, thus

Please tick the appropriate box to indicate your level of agreement

Strongly Disagree

Disagree

Neither agree nor disagree

Agree

Strongly Agree

Policy is shaped at the highest level and that the commitment of the Senior executive is visible throughout the management chain

Co-workers often give tips to each other on how to work safely

Health & safety Policy

The services parties agreed a process for identifying and assessing health and safety hazards that may arise from shared activity

Management operates an open door policy on safety issues

Management clearly considers the safety of employees of great importance

Management commitment

Management acts decisively when a safety concern is raised

Managers, supervisors and team leaders regularly communicate safety-related messages

Safety advisors, safety representatives and committees have a high status, operate proactively, work and communicate effectively

Communications on safety from all levels of personnel communicated back to the OIM

Communication

All communication systems are considered for the key safety messages - this includes formal and information systems

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Please tick the appropriate box to indicate your level of agreement

Strongly Disagree

Disagree

Neither agree nor disagree

Agree

Strongly Agree

all critical training and retraining were culminate in formal assessment and approval

Perceived supervisor competence & perceived management competence to safety

Quality of training monitored regularly

Competence, training and co-operation

Contractor training programmes are reviewed The offshore operation have safety related rules/initiatives that go beyond the requirements at corporate level

There is a requirement to report near misses/errors when they were immediately corrected or had no detectable effect

Safety rules and procedures are carefully followed Strongly encouraged to report unsafe conditions Job satisfaction with safety activities

Safety rules/local practices

Company will stop work due to safety concerns, even if it means they are going to lose money

Senior management receive regular reviews of the safety performance of the installation

The results of safety reviews acted on in an appropriate/timely way and feedback to managers on the implementation of lessons learned

Staffs are routinely read and understand reports on operational issues and resumes of the safety case

There is a system of safety performance indicators with a programme for the improvement of performance and the safety performance indicators understood by all staff

Review of safety performance

Managers are aware of the trends of safety performance indicators

Safety Management system

High effectiveness of health and safety management system

Part B Several of the following question requests that you respond with an answer form a scale from 1 to 5. The number in the scale corresponds to the following definitions. Please use these for each of scale question and circle one number. 1 Strongly disagree 2 Probably disagree 3 Don’t know 4 Probably agree 5 Strongly agree 1. Do you agree that safety improvement is important in the offshore operation activities?

1 2 3 4 5 2. If you feel that safety improvement is important in the offshore operation activities, where did you get that idea? (Please select one which you think is the most influencing to your idea)

• From your company’s policy • From your work experience • Other (please specify)

3. Do you think that safety improvement will bring out lower operation cost? 1 2 3 4 5

4. Do you think that higher safety improvement and better quality will occur together? 1 2 3 4 5

5. Do you think that the safety improvement will bring out benefits to your company and your workers? 1 2 3 4 5 6. Do you think that the most benefit derived from safety improvement on-site is achievement higher productivity and smoother offshore operation process? 1 2 3 4 5 7. Do you think that safer workers were getting more satisfied with their jobs?

1 2 3 4 5 8. Do you think that provision better working conditions to offshore operation workers is one of effective ways to prevent the occurrence of labor accidents? 1 2 3 4 5 9. Do you think that top management play a crucial role in the securing of offshore operation safety and safety performance at company level? 1 2 3 4 5 If you agree that, please indicate how top management contribute to secure safety performance of company-------------------------------- 10. According to your opinion, the occurrence of accidents can be prevented with the greatest contribution of the following groups of offshore operation people. Please rank groups in accordance with the principle as follows: the rank of 1 is for a group with the greatest contribution and the rank of 5 is for a group with the least contribution. Rank Groups of drilling people ________ Top management ________ Operation engineers working on-site ________ Safety personnel _________ Other (please specify) Please give me the reasons why you think so---------------------------------

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11. According to your opinion, the safety performance can be improved with the greatest contribution of the following groups of offshore operation people. Please rank groups in accordance with the principle as follows: the rank of 1 is for a group with the greatest contribution and the rank of 5 is for a group with the least contribution Rank Groups of construction people ________ Top management ________ operation engineers working on-site ________ Safety personnel _________ Other (please specify) Please give me the reasons why you think so---------------------------- 12. Please respond to the following question to describe status of safety performance in this site by drawing a circle a round the appropriate The possible rankings for each question are: Nonexistent Poor Fair Good Excellent 1 2 3 4 5 a. Do your workers have proper training for equipment operating? 1 2 3 4 5 b. Are the spare parts for maintenance work sufficient? 1 2 3 4 5 c. Is the unsuitable equipment for site conditions selected? 1 2 3 4 5 d. Has your site a safety representative 1 2 3 4 5 e. Has your site a fast aid 1 2 3 4 5 f. Are new workers in your crew trained and oriented to safety? 1 2 3 4 5 g. Does toolbox meeting is often organized in your site? 1 2 3 4 5 h. Was your site often inspected about safety performance? 1 2 3 4 5 13. The following items are possible causes to high accident rate. At which level do you think they influence the occurrence of accidents? (please circle one number) Very important- Quite important- Important - Somewhat important - Not at all important 5 4 3 2 1 Inadequate planning of construction work 1 2 3 4 5 Unorganized site layout 1 2 3 4 5 Lack of planning for equipment operation 1 2 3 4 5 Lack of safety planning 1 2 3 4 5 Inadequate site supervision 1 2 3 4 5 Inadequate and improper tool 1 2 3 4 5 Financial shortage 1 2 3 4 5 Overtime and fatigue of workers 1 2 3 4 5 Emulation and competition among workers 1 2 3 4 5 The poverty of workers 1 2 3 4 5 Disregarded attitude of contractors and superintendents 1 2 3 4 5 Inadequate preparatory training 1 2 3 4 5

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14. The following items are possible causes to high accident rate in terms of working conditions and environment. At which level do you think they influence the occurrence of labor accidents? Inadequate working spaces 1 2 3 4 5 Poor weather conditions 1 2 3 4 5 Inadequate ventilation 1 2 3 4 5 Inadequate illumination or poor lighting 1 2 3 4 5 Chronic physical stress 1 2 3 4 5 Poor house keeping 1 2 3 4 5 Inadequate temporary structure 1 2 3 4 5 Inadequate safety facilities 1 2 3 4 5 Equipment or tools without safety devices 1 2 3 4 5 Improper working postures 1 2 3 4 5 15. How would you describe the workers experience of this project? (a) Excellent (b) Good (c) Fair ( d) Poor (e) Terrible

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PART C1 (Only for managerial position person)

Do you prepare a separate annual safety report?

Do you have clear safety policy knowledge of your company

Health and safety policies

How is the health and safety policy communicated on this installation?

How often during 2005 were reviews of health and safety performance on the installation carried out?

Organizing for health and safety

Is the installation H&S performance rewarded? If yes, how is it appraised and rewarded?

Workforce involvement

Are offshore employees actively involved in the following? Please describe how they are involved.

• Carrying out risk assessments

• Setting installation H&S objectives and or improvement plans?

• Discussing the effectiveness of the H&S management system?

• Discussing procedures and instructions for risk control

• Proactive health and safety auditing

Health &Safety performance

Is the Health &Safety performance of individuals working on the installation rewarded? If yes, how is it appraised and rewarded?

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PART C2 (Only for managerial level person) Organizational Practices Indicator % Observed

Percentage of planned training undertaken Percentage of planned inspections undertaken Percentage of planned safety meetings undertaken Percentage of staff trained in behaviour based safety techniques

Percentage of Health &Safety audits have been achieved against the audit review plan for this installation in the last year

Percentage of Health &Safety goals was achieved during the last year

Total (average of % observed)

Accident and incident reports per 1000 employees: Accidents/1000 Score

0 9 1-5 8 6-10 7 11-15 6 16-20 5 21-25 4 26-30 3 31-35 2 35+ 1

Finally Score:

Personal statement:

Department/position: Years of experiences in similar field: Age range: Highest degree:

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The questionnaire on identifying the root causes of offshore accidents Dear Sir I am conducting a study in the Asian Institute of Technology (AIT) concerned with “Study of offshore drilling risks and safety climate, safety management practice & safety performance in offshore environments”. I would like to find out how you feel about your company’s safety practices and principles, and in order to do this I would like you to complete this questionnaire -confidentiality is assured. Your responses are expected to be great source to develop a system for identifying the root causes of labour accident in offshore platform. The questionnaire is relatively simple to complete and asks about your attitudes to safety issues; as well as any suggestions you might have to improve things. Please try to answer all of the questions, being as open and honest as you can. The conclusions will be fed back to you on completion of the survey. I appreciate your helping and many thanks for your assistance. With best Regards M. Shafiqul Islam

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PART I: To measure the characteristics of accident 1 The date of accident take place ---------a.m/p.m --------2005 2 How long have you work with? Current crew month(s)---

Current site month (s)---- 3 How long have you been working for the

current company? -----------

4 How many injuries (requiring either first aid or physician’s attention or absent yourself from work are more than one day) have you had?

This drilling site----- From 1/1/2001 upto now---

5 Types of accident Struck by falling objects Electrical shock Overexertion by lifting or carrying materials Equipment failures Others-------------------------

PART II: To identify root causes using accident root causes tracing model (ARCTM) II-1: To check the existence of unsafe conditions 6 There was unsafe condition that existed before the activity was

started or that developed after the activity was started If No, go to question 12

• Improperly (inadequately guarded) guard Equipment • Defective equipment • Hazardous procedures (construction method) in, on, or

around machine or equipment • Unsafe storage — congestion, overloading • Improper illumination - glare, insufficient light • Improper ventilation — insufficient air change, impure air

source • Improper assignment of personnel • Other unsafe conditions — physical factors

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No --------

II-2: To determine the development and existence of unsafe conditions 7 Management actions/in-actions

Why was the unsafe condition not removed?

Who is responsible for removing it? (according to the safety regulation of company or this site)

Management fail to identify Management identify but don’t remove Site engineer or safety manager Foreman Workers by themselves

8 Worker or Co-worker unsafe act Why did (co) worker act unsafe? Does the (co) worker know the correct

Social pressure Peer pressure Management pressure Yes/No

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procedure of doing the work? Has the (co) worker always /occasionally used the same unsafe act to perform the work?

Yes No (first time - check previous questions)

9 Non-human related event or unsafe condition is a natural part of the initial construction site conditions Was it possible for management or workers to identify such events or conditions?

Yes No (unavoidable accident)

II-3 The worker identified or do not identify the unsafe conditions The worker identified the unsafe conditions Yes→2nd root cause→ Go to II-4 No→1st root cause→ To continue with question 10 10 Why did the worker fail to identify the unsafe

conditions? Worker made wrong assumptions about condition Unable to assess condition because condition is new Insufficient knowledge to identify unsafe conditions Worker was informed that condition is safe Does the (co) worker know the correct procedure of doing the work? Has the (co) worker always/occasionally used the same unsafe act to perform the work?

Yes→ Go to Question11 No→ continue Yes No→ check next Yes No→ check next No→ check next sub-question Yes→ check who informed(management/co-worker) Yes/No Yes No→ first time check previous question

II-4: The worker identified the unsafe conditions (2nd root cause) 11 Unsafe conditions were identified and worker decided

to proceed with work Why did the worker decide to proceed? Did the worker fail to identify all attributes to the situation? Did the worker think that he/she could still do the job? Does the (co) worker know the correct procedure of doing the work? Has the (co) worker always /occasionally used the same unsafe act to perform the work?

Social pressure Peer pressure Management pressure Yes No→ check next sub question Yes No→ check next sub question Yes/No Yes No→ first time check previous questions

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II-5: There were no unsafe condition that the worker has to face 12 Did the worker commit an unsafe act? No→ recheck step 1. If it has

still no reason – Overexertion Yes→ 3rd root cause→ go to question 13 (the same as with question 8)

13 Why did (co) worker act unsafe? Does the (co) worker know the correct procedure of doing the work? Has the (co) worker always /occasionally used the same unsafe act to perform the work?

• Social pressure • Peer pressure • Management pressure

Yes/No Yes No→ first time check previous questions

Assessing the awareness of workers about safety performance 14 Have you learn any safety training? Yes/No 15 Do you often work overtime? Yes, Do you like it? Yes/No

No 16 Do you feel satisfied with your current work?

(it is a good job for you?)

• Very satisfied • Satisfied • Don’t know

17 Do you satisfy with the current wage?

Yes/No

Assessing the awareness of workers about safety performance(Cont) 18 Do you often work in competition with

others in your crew? Do you like it?

Yes/No/Don’t know Like/Dislike

19 How do you describe the relationship among your crew members?

• Very pleasant • Somewhat pleasant • Don’t know

20 Would you change the current job if you get the same money with the other work?

Yes/ absolutely No / No

21 How do you feel about the physical working conditions on this site?

• Very good • Good • Don’t know

22 How do you feel about safety regulation in

your site?

• Satisfied, it is useful for you

• Your work is obstructed

• You did not like it but have to conform

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The questionnaire on Safety and Situation Awareness in Offshore Crews Dear Sir I am conducting a study in the Asian Institute of Technology (AIT) concerned with “Study of offshore drilling risks and safety climate, safety management practice & safety performance in offshore environments”. I would like to find out how you feel the Safety and Situation Awareness in your offshore Crews, and in order to do this I would like you to complete this questionnaire -confidentiality is assured. Your responses are expected to be great source to develop a system for drilling and production operation safety improvement efforts and the accident occurrence prevention in offshore platform. Much work involved on offshore installations has the capacity to be hazardous, and despite many rules and regulations in place to ensure that accident risk is kept to minimum, accidents still occur. One factor to occurrence of accidents 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. These questionnaires relatively simple to complete and asks about your attitudes to SA issues; as well as any suggestions you might have to improve things. Please try to answer all of the questions, being as open and honest as you can. The conclusions will be fed back to you on completion of the survey. I appreciate your helping and many thanks for your assistance. With best Regards M. Shafiqul Islam

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Questionnaires of safety and situation awareness in offshore crews

1. How is situation awareness known in the offshore industry?

2. What factors affect the quality of a person’s awareness?

3. What are the indicators of reduced awareness?

4. How can reduced awareness be improved?

5. How is team situation awareness achieved?

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Interview Schedule Cooperation 1. Does a senior manager participate in health and safety meetings? Never = 0 ;Sometimes = 1; Always =2 2. Are employees involved in setting health and safety standards and rules, accident investigation and measuring and auditing activities? Never = 0 ;Sometimes = 1; Always =2 3. Do managers conduct regular safety inspections? Never = 0 ;Sometimes = 1 ;Always =2 4. Do you feel that management involves you in matters relating to health and safety? Never = 0 ;Sometimes = 1;Always =2 5. Are suggestions relating to health and safety welcomed by your manager? Never = 0 ;Sometimes = 1 ;Always =2 Further Comments: Total Co-operation score = Competence and training 1. Do managers ensure the competence of all people in health and safety matters? Never = 0 ;Sometimes = 1; Always =2 2. Is health and safety training appropriate for your job? Never = 0 ; Always =2 3. Do you feel competent in health and safety issues that affect your work areas? No = 0 ; In all issues =2 4. What training is available to you in health and safety? In some cases = 1 ;In all cases =2 Further Comments: Total Competence and Training score =

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Interview Schedule (continued) Management Styles 1. Does your manager operate an open door policy with regard to health and safety issues? Never = 0 ;Sometimes = 1; Always =2 2. Does your immediate manager: Hardly talk to you = 0; Tell you what to do &how = 1 Tells you what to do & you decide how = 2 3. Does your immediate manager: Not discuss the job with you = 0 ; Discuss the job with you & tell you how to do it = 1 Discuss the job with you & you decide how to do it = 2 4. Do you feel that your manager sets a good example in relation to health and safety matters? Never = 0 ;Sometimes = 1;Always =2 5. Do you feel that you receive enough information regarding health and safety matters? No information = 0 Some information = 1 Enough information = 2 Further Comments: Total Management Style score Management Change 1. When there is a change in working procedures are you kept fully up to Never = 0 ;Sometimes = 1; Always =2 2. When there is a change in the facilities here are you kept fully up to date? Never = 0 ; Always =2 3. Do you think management implement changes efficiently? Sometimes =1 ; Always = 2 4. facilities here? Sometimes =1 ; Always = 2 Further Comments: Total Managing Change score

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Appendix 2 Example Generic offshore Hazard Checklist (CMPT 1999)

- Drilling support vessel (jack-up or barge) Blowouts - Blowout in drilling - Offshore loading tankers - Blowout in completion - Drifting offshore vessels (semi-subs, barges, storage

vessels) - Blowout in production (including wirelining etc) - Blowout during workover - Icebergs - Blowout during abandonment For each vessel category, different speeds of events,

such as - Underground blowout Also covered under blowouts are: powered and drifting may be separated. - Well control incidents (less severe than blowouts) Structural events

- Structural failure due to fatigue, design error, subsidence etc

- Fires in drilling system (e.g. mud pits, shale shaker etc) Riser/pipeline leaks - leaks of gas and/or oil from:

- Extreme weather - Import flow-lines - Earthquakes - Export risers - Foundation failure (including punch-through) - Sub-sea pipelines - Bridge collapse - Sub-sea wellhead manifolds

Process leaks - leaks of gas and/or oil from: - Derrick collapse - Crane collapse - Wellhead equipment - Mast collapse - Separators and other process equipment - Disintegration of rotating equipment - Compressors and other gas treatment equipment

- Process pipes, flanges, valves, pumps etc Marine events - Anchor loss/dragging (including winch failure) - Topsides flow lines - Capsize (due to ballast error or extreme weather) - Pig launchers/receivers - Incorrect weight distribution (due to ballast or cargo shift)

- Flare/vent system - Storage tanks

- Icing - Loading/unloading system - Collision in transit - Turret swivel system - Grounding in transit Non-process fires

- Fuel gas fires - Lost tow in transit Dropped objects - objects dropped during: - Electrical fires

- Accommodation fires - Construction - Methanol/diesel/aviation fuel fires - Crane operations - Generator/turbine fires - Cargo transfer - Heating system fires - Drilling - Machinery fires - Rigging-up derricks

Transport accidents - involving crew-change or in-field transfers

- Workshop fires Non-process spills - Chemical spills - Helicopter crash into sea/platform/ashore - Methanol/diesel/aviation fuel spills - Fire during helicopter refueling - Bottled gas leaks - Aircraft crash on platform (Inc military) - Radioactive material releases - Capsize of crew boats during transfer - Accidental explosive detonation - Personal accident during transfer to boat Marine collisions - impacts from: - Crash of fixed-wing aircraft during staged transfer

offshore - Supply vessels - Stand-by vessels - Road traffic accident during mobilization - Other support vessels (diving vessels, barges etc) Personal (or occupational) accidents

Construction accidents - accidents occurring during: - Passing merchant vessels - Fishing vessels - Construction onshore - Naval vessels (including submarines) - Marine installation - Flotel - Construction offshore - Drilling rig - Hook-up & commissioning

- Pipe laying continued…………… Attendant vessel accidents Diving accidents

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Example Generic offshore Keyword Checklist (Ambion 1997) Key word used in HAZID Example of Hazard Direct fire Ignited blow-out

Ignited process fire Fire in paint store

Loss of breathable atmosphere Smoke ingress from HVAC Asphyxiation

Direct toxic Toxic gas release Explosion overpressure Explosion from process gas leak Dropped objects Dropped load from crane

Swinging load hit to process Vehicle collision Helicopter crash

Ship collision to legs Structural collapse Crane collapse

Leg failure in design load Extreme weather

Mechanical failure Gas turbine rotor blade failure Electrocution Occupation accident Pressure/loss of containment Air receiver failure

Unignited process vessel failure Water/drowning Deluge in process

Man overboard Direct chemical Drilling chemical leak

Lab chemical exposure Occupational accidents Trips, falls Hydrocarbon leak general Diesel tank failure

Process leak

Appendix 3

Summary of Potential Environmental Impacts of offshore Exploration and Production Activity Source Potential impact Component

affected Comments

Seismic operations (offshore)

Seismic equipment Vessel operations

Noise Emissions and discharges Interference

B At/Aq/T H

Acoustic sources, disturbance to marine organisms (may need to avoid sensitive areas and consider seasonally). Short-term and transient Atmospheric emissions from vessel engines; discharges to ocean: bilges, sewage; spillages; waste and garbage disposal to shore. Low-level, short-term, transient. Interaction with other resource users (e.g. fishing). Short-term, transient.

Exploratory and appraisal drilling (offshore)

Site selection Operations

Interaction Discharges emissions wastes

H/B/Aq H/At/B/Aq/T

Consider sensitivities in relation to biota, resource use, cultural importance, seasonally. Secondary impacts related to support and supply requirements and potential impact on local ports and infrastructure Discharges to ocean—mud’s, cuttings, wash water, drainage, sewage, sanitary and kitchen wastes, spillages and leakages. Emissions from plant equipment; noise and light; solid waste disposal onshore and impact on local infrastructure. Disturbance to benthic and pelagic organisms, marine birds. Changes in sediment, water and air quality. Loss of access and disturbance to oilier marine resource users. Emissions and discharges from well test operations, produced water discharges, burning and flare, additional noise and light impact. Short-term and transient. Effects of vessel and helicopter movements on human and wildlife.

H = Human, socio-economic and cultural; T -Terrestrial; Aq - Aquatic; At = Atmospheric; B - Biosphere

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109

Summary of potential environmental impacts of offshore Exploration and Production (continued) Activity Source Potential

impact Component affected

Comments

Exploratory and appraisal drilling (offshore) continue

Decommissioning Footprint B/Aq Proper controls during operations and careful decommissioning should effectively remove risk of long-term impact. Improper controls can result in sediment and water contamination, damage to benthic and pelagic habitats, organisms, biodiversity.

Development and production (offshore)

Site selection Operations

Interactions Discharges emissions waste Socio-economic cultural

H/B/Aq H/At/B/Aq/T H

Long-term site selection based upon biological and socio-economic sensitivities and minimum disturbance. Risk of impact to sensitive species, commercially important species, resource conflict, access. Long-term support and supply base requirement and impacts on local port infrastructure Long-term, chronic effects of discharges on benthic and pelagic biota; sediment and water quality. Impact of drill cuttings and mud discharges, produced water, drainage, sewage, sanitary and kitchen wastes, spillage and leakage. Emissions from power and process plant and impact on air quality. Noise and light impact from facilities and flaring. Solid waste disposal and impact on onshore infrastructure. Increased vessel and helicopter movements. Loss of access and resource use interactions. Local port, harbour and community interactions related to supply and support functions.

H = Human, socio-economic and cultural; T -Terrestrial; Aq - Aquatic; At = Atmospheric; B - Biosphere

Appendix 4 Environmental Protection Measures of Offshore Exploration and Production activities Activity Source of

potential impact Environmental protection measures

Aerial survey

Aircraft Use environmental assessment to identify protected areas/sensitivities. Schedule operations during least sensitive periods

Seismic operations (offshore)

Seismic equipment Vessel operations

Use environmental assessment to identify protected areas and local sensitivities. Schedule operations during least sensitive period. Consult local authorities and other stakeholders regarding survey programme, permitting and notifications. Remain on planned survey track to avoid unwanted interaction. Dispose all waste materials and oily water properly to meet local, national and international regulations Apply proper procedures for handling and maintenance of cable equipment particularly cable oil. All towed equipment must be highly visible. Make adequate allowance for deviation of towed equipment when turning. Prepare contingency plans for lost equipment and oil spillage Attach active acoustic location devices to auxiliary equipment to aid location and recovery. Label all towed equipment. Store and handle explosives according to operator’s procedures and local regulations. Consider using guard boat in busy areas. Report all unplanned interactions with other resource users alternatively, marine life to the authorities. Use local expertise to support operations e.g. spotting marine mammals, wildlife etc.

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Environmental Protection Measures of Offshore Exploration and Production activities (Continued) Activity Source of

potential impact

Environmental protection measures

Site selection

Access

Use environmental assessment to identify & protected areas and sensitivities. Schedule operations during least sensitive periods. Consult with local authorities regarding site selection and support infrastructure-ports, vessel and air traffic. Select least sensitive location within confines of bottom target/drilling envelope. Consider directional drilling to access targets beneath sensitive areas. Consider cluster well drilling. Local conditions must be fully assessed-wave, wind and currents. In coastal areas, select site, equipment to minimize disturbance, noise, light, and visual intrusion. Exercise strict control on access and all vessel and rig activity. In coastal areas where sensitivities dictate, use vessels in preference to helicopters.

Exploration and appraisal drilling (offshore)

Operation

Consult with local authorities regarding emissions, discharges appraisal drilling and solid waste disposal/notifications concerning other resource users. Requirements specified in planning process must be met including supply vessel operations. Aqueous discharges: Oily water from deck washing, drainage systems, bilges etc. should be treated prior to discharge to meet local, national and international consents. Sewerage must be properly treated prior to discharge to meet local and international standards. Treatment must be adequate to prevent discoloration and visible floating matter. Biodegradable kitchen wastes require grinding prior to discharge, if permitted under local regulations.

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Environmental Protection Measures of Offshore Exploration and Production activities (Continued) Activity Source of

potential impact

Environmental protection measures

Exploration and appraisal drilling (offshore) (continued)

Operation (continued)

Most spills and leakage occur during transfer operations- ensure adequate preventative measures are taken and that spill contingency plan requirements are in place. Store oils and chemicals properly in contained, drained areas. Limit quantities stored to a minimum level required for operational purposes. Ensure proper control documentation and manifesting and disposal. Do not dispose of waste chemicals overboard. Produced water from well tests must meet local regulations or company specified standards prior to discharge. Preferentially separate and store oil from well test operations. If burnt, ensure burner efficiency is adequate to prevent oil fallout onto sea surface. Solid wastes. Ensure requirements specified in the planning process are met with regard to waste treatment and disposal. Collect all domestic waste and compact for onshore disposal. Ensure proper documentation and manifesting. Ensure onshore receiving and disposal meet local requirements. Consider waste segregation at source for different waste types-organic, inorganic industrial wastes etc. No debris or waste to be discarded overboard from rig or supply vessels. Waste containers must be closed to prevent loss overboard. Spent oils and lubes should be containerized and returned to shore. Consider bulk supply of materials to minimize packaging wastes.

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Environmental Protection Measures of Offshore Exploration and Production activities (Continued) Activity Source of

potential impact

Environmental protection measures

Exploration and appraisal drilling (offshore) (continued)

Operation (continued)

Decommissioning and restoration

Muds and cuttings. Preferentially use low toxicity water- based drilling muds. Minimize use of oil-based muds (OBM). Mud make-up, mud, and cuttings disposal requirements addressed in the planning process must be met. Do not dispose of whole OBM to sea, Any oily cuttings discharged must meet local regulations or company specified standards.

Consider down hole disposal of OBM wastes

Atmospheric emission/noise/light. Ensure requirements addressed in the planning phase are met with regard to emissions, noise and light.

Well test burners must be efficient, maintained and effectively burn gas and oil.

All debris must be removed from seabed.

Decommissioning of onshore support facilities must meet planning requirements.

Development and production (offshore)

Site selection

and access

Operation

Long-term occupation of sites, including supply and support base, will require detailed assessment of environmental implications, particularly where resource use conflicts arise and commercially important species may be affected.

All aspects identified for exploration drilling should be applied to permanent sites.

Consult with local authorities.

Consider site and route selection for flow lines and pipelines.

Evaluate construction and drilling activities and impacts separately from operational activities.

Maximize use of central processing facility and use of satellite and cluster wells to minimize footprint.

All aspects identified for exploration drilling should be applied to permanent sites.

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Environmental Protection Measures of Offshore Exploration and Production activities (Continued) Activity Source of

potential impact

Environmental protection measures

Development and production (offshore) continued

Operation (continued)

Decommissi- oning and

rehabilitation

Assess full implications of well treatment and work over, process, storage, power generation and other support and accommodation facilities in terms of long-term disturbance and impact.

Evaluate implications of development on local infrastructure, in particular, infrastructure related to onshore service functions-port and harbour operations, resource use conflicts, waste treatment and disposal, socio-economic implications, employment, local services and supply, support infrastructure for employee and family accommodation etc.

Incorporate oily water treatment system for both produced water and contaminated water treatment to meet local, national and international discharge limits.

Include sewerage treatment system, particularly if close to shore, to meet local requirements.

Assess treatment of waste gases and emission limits, particularly where gas is flared. Avoid gas venting.

Treatment and disposal of solid, toxic and hazardous wastes onshore will require proper planning, particularly if local infrastructure is limited in capacity and capability. A detailed waste management plan will be required.

Prepare detailed contingency plans, personnel training and regular exercise of response, taking into consideration storage and export systems.

Establish consultation and local liaison activities.

Monitor waste streams in order to meet compliance requirements.

Develop a full decommissioning and rehabilitation plan in consultation with local authorities.

Any facilities and infrastructure handed over to local authorities must include proper instructions for use,

Decommissioning of offshore structures is subject to international and national laws, and should be dealt with on a case-by-case basis with local authorities.

Record and monitor site as required after appropriate decommissioning activities.

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