Presentation from Jason Devereux at Offshore Europe 2013. Paper written by Jenny Gilroy and Derek Dumolo of Lloyd's Register Constiling's Human Factors team. Hydrocarbon releases (HCR) are a major problem offshore, and most importantly are seen as a direct precursor to potential major accidents (MAs) (Oil and Gas UK, 2010). The UK HSE believe that of the occurring HCRs, 50-70% have causes linked in part or in whole to “things people do (or don’t do) when designing, maintaining and operating systems”, (Step Change in Safety, 2010) i.e. issues associated with Human Factors (HF). An offshore operator contracted LR Consulting to conduct an independent HF-focussed organisational assessment into the underlying contributory factors to HCRs on their platforms, in order to support their own internal initiatives to reduce HCRs. The aim of LR Consulting’s assessment was to help the organisation confirm and identify the key areas of focus in order to combat HCRs and prioritise further actions going forward. LR Scandpower adopted a systematic approach to investigate the HF contributions to HCRs on the organisation’s platforms, including a Thematic Analysis of past incident data, offshore interviews and onshore interviews with staff and detailed analysis of findings to identify common emergent themes issues. Eight key areas were identified as priorities for further action, and LR Consulting provided the operator with recommendations for improvements and/or remedial actions to deal with identified contributory factors This presentation will explain the approach followed by LR Consulting and the findings from the study, including the key Human Factors causal factors that were identified. It will also highlight the key lessons learned that are considered to be potentially relevant to the wider offshore sector.
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Human Factors Involvement in Hydrocarbon Release on Offshore Platforms: an organisation wide investigation Dr. Jason Devereux, Lloyd’s Register Consulting – Energy Scientific Sub-Committee Secretary for the International Commission on Occupational Health and Safety Member of the IEA Technical Committee on Human Factors in Organisational Design and Management Honorary Member of the Business Psychology Unit, University College London Former Human Factors M.Sc. Director, Robens Institute Industrial Health & Safety
Transcript
Human Factors Involvement in Hydrocarbon Release on Offshore Platforms: an organisation wide investigation
Dr. Jason Devereux, Lloyd’s Register Consulting – EnergyScientific Sub-Committee Secretary for the International Commission on Occupational Health and SafetyMember of the IEA Technical Committee on Human Factors in Organisational Design and ManagementHonorary Member of the Business Psychology Unit, University College LondonFormer Human Factors M.Sc. Director, Robens Institute Industrial Health & Safety
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Outline
• Lloyd’s Register Energy
• Background to hydrocarbon release
• Poll regarding statements
• Methodology
• Summary of findings
• Recommendations for Industry
• Q & A
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Statement 1 made by an industry leader at Offshore Europe 2013
• Safety is increased if technology is used to reduce the number of staff needed offshore
• Do you agree or disagree with this statement?
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Statement 2 made by an industry leader at Offshore Europe 2013
• We need to do our business with fewer people and pay them less while creating a culture that encourages workers to stay long term and develop their skills and values
• Do you agree or disagree with this statement?
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The problem of hydrocarbon leaks
• Hydrocarbon releases are a major problem offshore.
• A direct precursor to potential major accidents, if ignited.
(Oil and Gas UK, HSE)
Major gas release on Elgin in March 2012, led to the evacuation of the entire platform
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• 50-70% of HCRs have causes linked in part or in whole to human factors
• Human error is both universal and inevitable (Energy Institute, 2008). This implies a system failure and not person failure – the latent antecedents
• Judith Hackitt (Chair of HSE) -“Constant Unease”• Know the problem is not fixed• What could go wrong• Can do better• Society becoming less tolerant of failures
• Consider human factors in designing, maintaining and operating systems
The problem of hydrocarbon releases (HCRs)
(Step Change in Safety, 2010)
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Market forces potentially affecting HCR risk
•Competition pressure and cost cutting could increase the use of technology and reduce staffing offshore
•Highly automated systems still need human beings for:
•supervision•adjustment•maintenance•Improvement
•Understand the limits of human abilities and capability in the:
•design•control •maintenance of systems
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• Human-machine interaction as an emerging risk (EU-OSHA, 2005)
• Psychosocial risk – cognitive load
• Accident risk
• operating errors
• maintenance non-routine errors
• inappropriate action
• Assist in our client’s initiative.
• To reduce HCRs within the UK.
• Conduct an independent Human Factors-focussed organisational assessment.
• Identify underlying contributory factors to HCRs offshore.
Poll and Study Objectives
(HSE, 1999 HSG 48)
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Methodology
N=60Sept 2011
N=31Nov 2011
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Thematic analysisAn initial analysis of HCR incident report data highlighted the following key
areas
e.g. “the requirements of the flange completion
and recording procedure do not
appear to have been
communicated.”
e.g. “no small bore tubing
training for 2 years”
Hydrocarbon Releases
Failures in engineering
controls
Failures in administrative
processes
Management failures
Failures in maintenance
processes
Failures in competency management
processes
Failures in communications
e.g. “absence of alarms for this event and/or absence of preventative barriers to be able to
close 2 streams.”e.g. “the
requirements of the flange completion
and recording procedure”
e.g. “No supervision”
e.g. “gas compression train out for 2 years “
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Using the data generated from the thematic analysis
Development of a ‘question set’ to explore key HF themes that appeared to be influential in HCRs.
14 ‘lines of enquiry’ explored, including: – supervisory arrangements– safety culture– safety critical communications– quality assurance and procurement
process– procedure usage– planning– staffing – engineering design– etc.
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Summary of findings - corporate level solutions
Work System Offshore
LearLLearL
Organisational learning
Competence management
Planning
Reactivemaintenance
Under manning
Procedures
Silo working
HFI in platformdesign
Visit www.lr.org/HCR for more information
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Contributory failures
Key areas: Organisational learning
Cultural issues
Failures in communicatio
ns
Relevance to hydrocarbon releases
When lessons aren’t learned and a company doesn’t strive for continuous improvement, mistakes are repeated, not recognised and not improved
e.g. Small bore tubing was a known problem for a long time before a survey was carried out; and this survey has not yet led to any improvements
When underlying causes are not dealt with, only the immediately obvious problems may be tackled, leaving the real contributory factors in place
e.g. an individual who made a mistake may be blamed but his competency and the competency of all his colleagues also may be poor due to a lack of training and support
Many wider contributory factors to hydrocarbon releases have been identified in this project, and most have been a problem for some time
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Contributory failures
Key areas: Competency management
Failures in competency management
Relevance to hydrocarbon releases
If people are not fully competent to work on the system, they are likely to make mistakes
e.g. If an operator cannot use SAP correctly they may not input required data about maintenance work that need to be done, and thus a HCR could occur because the work is not carried out
Anyone working with the system who is not fully competent could make a mistake and either:
1. Initiate a HCR
2. Contribute to a series of events that leads to a HCR
3. Escalate a HCR
4. Fail to mitigate and control a HCR
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Contributory failures
Key areas: Lack of planning
Failures in administrative
processes
Failures in maintenance
processes
Failures in communications
Relevance to hydrocarbon releases
The system state may be compromised or the system may fail if:
routine maintenance is postponed or delayed
urgent maintenance needs are not addressed promptly
work is not planned thoroughly, maintenance may get postponed or delayed
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Contributory failures
Key areas: Under manning
Design failures
Management and resourcing
failures
Relevance to hydrocarbon releases
A lack of staff to carry out work means that:
maintenance is constantly being compromised
assets fail because they have not been maintained properly
only had ‘patchwork’ fixes carried out on them
There are also compromises in relation to onshore activities due to under manning. For example:
Not enough engineering team staff
it takes longer to get designs developed
there are delays to making engineering changes
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Contributory failures
Key areas: Reactive approach
Failures in maintenance
processes
Cultural issues
Relevance to hydrocarbon releases
Short-term quick repairs can affect asset integrity:
The underlying problems are not improved
the system can be left vulnerable to further deterioration or failure
Patchwork fixes may create new problems:
They can mean the system is not operating correctly
the system may become damaged
Jumping into initiatives and approaches means that the work is more likely to be done incorrectly
e.g. In relation to Small Bore Tubing Surveys. This has wasted time on an activity that was supposed to aid in reducing HCRs, but few corrective works have been done
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Key areas: Poor procedures
Contributory failures
Failures in administrative
processes
Relevance to hydrocarbon releases
If the procedures are wrong or difficult to use, people will either:
follow the incorrect procedure and as a result carry out the task incorrectly
fail to use them and potentially do the task wrong or inconsistently
In both instances there may do damage to the system
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Key areas: Silo working
Relevance to hydrocarbon releases
Lack of communication or miscommunication:
Information may not be passed on to those who need to know
information may be misunderstood due to conflicting demands and distraction
the result is mistakes and omissions
Work carried out in isolation:
Conflict with other work being done
can leave the system vulnerable to errors
Contributory failures
Failures in administrative
processes
Failures in communicatio
ns
Management and resourcing
failures
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Key areas: Design issues on the platform
Contributory failures
Design failures
Relevance to hydrocarbon releases
A mismatch between the design specification and the proposed operability of the system:
leads to system operability being compromised
e.g. There are not enough beds, making it difficult to get staff onto the rig
A mismatch between the design and the operating environment:
system may be susceptible to deterioration
e.g. Some equipment and material selection at the design stage is considered to have been inappropriate and of poor quality, leading to high levels of deterioration
Excessive alarms in the control room:
real issues may be overlooked and made worse
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Lessons for industry: For prevention of HCRs
• No simple answer to the question of ‘what causes HCRs?’
• Identify and address all underlying factors
• A suitable framework for assessment is required
– using specialists who are trained to look beyond the engineering problems to organisational factors
• Recommend use of external departments and/or independent parties:
– provides independence– allows honest impartial information to
be elicited
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• Essential that incident investigations go beyond the analysis of ‘front line’ failures
• Take due consideration of the Human Factor within organisational root causes
• Involve Human Factors experts in this process
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Human Error
Underlying Human Factors topicse.g. Procedures, Training & Competence, Safety Critical Communications, Organisational Change, HF Design, Shiftwork & Fatigue, Organisational Culture, Workload, Maintenance, and Human
Failures (HSE, 2012)
Underlying Human Factors topicse.g. Procedures, Training & Competence, Safety Critical Communications, Organisational Change, HF Design, Shiftwork & Fatigue, Organisational Culture, Workload, Maintenance, and Human
Failures (HSE, 2012)
Lessons for industry: Investigation of HCRs
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• Have better integration of Human Factors within the early stages of the design process
• Reduces the likelihood of mismatches between:– Human capability– organisational demands and – system design during the latter stages of projects or in operation
• Planning for a dedicated HF programme at the initial design stage of projects is recommended:
– Equipment design – Workstation/ console design – Workplace layout – Maintenance access and ease of maintenance etc.
Lessons for industry: Have a human factors integration plan
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Develop corporate resilience to avoid HCR outcomes
(UCL Business Psychology Unit Effort Performance Outcome Model)
Abilities and traits, role clarity, organisational support, etc.
Job design, organisational policies and practices
Perceived equity of outcomes/ rewards
Effort
PerformanceOutcome / reward
Satisfaction
Extrinsic outcome/ reward
Intrinsic outcome/ reward
Expectancy Instrumentality Valance
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A final thought!
Competitive investment must be tempered with patience and consideration of the
potential for human-system failures in maintenance, supervision and improvement
Q & A Time
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Services are provided by members of the Lloyd's Register Group. For further information visit www.lr.org/entities
For more information, please contact:
Jason DevereuxPrincipal Consultant, Lloyd’s Register Consulting
Lloyd’s Register group entity71 Fenchurch StreetLondon, EC3M 4BS
