Industry and FPSO Industry and FPSO Health & Safety PerformanceHealth & Safety Performance
Simon Schubach Regulatory Operations General Manager
12th Annual FPSO CongressSeptember 2011, Singapore
• Background to NOPSA• FPSO health & safety performance• Lessons from inspections• Lessons from incidents
Vision
A safe Australian offshore petroleum industry
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NOPSA’s legislated functions
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Promote Advise
Report
Investigate
Monitor & Enforce
Co-operate
Legal framework
• A ‘General Duties’ regime: reduce risk ALARP• Performance-based, with prescriptive elements• An accepted safety case is required in order to
undertake activities• The primary responsibility for ensuring health
and safety lies with the operator
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What does the regulator do?
• Challenge the Operator – Thorough Safety Case assessments - targeted– Rigorous facility inspections – sampled verification – Comprehensive incident investigation – depending
on severity– Principled Enforcement – verbal / written and
prosecutions
• Independent assurance– Facility health and safety risks are properly controlled
by Operators of facilities through securing compliance with OHS law
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INDUSTRY PERFORMANCE
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2010-11 Activities
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NOPSA33 OHS Inspectors
20 Support staff
INDUSTRY33 Operators210 Facilities
286 Assessments submitted
365 Incidents Notified
43 Accidents
322 Dangerous Occurrences
218 Assessments Notified
152 Facilities Inspections
1 Major Investigations31 Minor Investigations
333 Incident reviews
78 Enforcement actions
Facilities
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* Numbers fluctuate slightly as MODUs and vessels enter the regime and become facilities or leave the regime and cease to be facilities.
Facility Group No. of FacilitiesBased on Current (2011) data *
Platforms 60
FPSOs / FSOs 14
MODUs 15
Vessels 10
Pipelines 110
TOTAL: 210
FPSO Age Distribution
0
2
4
6
8
0-5 years 5-10 years 10-15 years 15-20 years 20-25 years 25-30 years >30 years
Num
ber
Facility Age Group
Age distribution of FPSO/FSOs(all active FPSOs - 2005-2011)
FPSO FSO
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Statistics for FPSOs for the financial year 2010-11
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Activity ALL Facilities FPSO/FSO
Facilities Inspected 152 23 (15%)
Incidents reported 365 83 (23%)
Assessments notified 218 25 (11%)
Enforcement Actions issued 78 32 (41%)
0
40
80
120
Unplanned Event -
Implement ERP
Damage to safety-critical
equipment
Accident -Incapacitation >=3 days LTI
Could have caused
Incapacity ( LTI>3)
Other kind needing
immediate investigation
Could have caused Death
or Serious Injury
Fire or Explosion
Uncontrolled HC gas
release >1-300 kg
Uncontrolled PL release
>80-12 500L
Collision marine vessel
and facility
Accident -Death or
Serious Injury
Pipelines -kind needing immediate
investigation
Number Incidents Notified 2010-11
ALL Facility Types
FPSO/FSOs
More than half of all unplanned events (alarms, medivacs etc.) occur on FPSOs
Incident Categories
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Incidents per Facility Type
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1/3 of all incidents reported to NOPSA occur on FPSO/FSOs
0%
25%
50%
75%
2005 2006 2007 2008 2009 2010 Jan-Jun 2011
% Incidents - Platforms
0%
25%
50%
75%
2005 2006 2007 2008 2009 2010 Jan-Jun 2011
% Incidents - MODUs
0%
25%
50%
75%
2005 2006 2007 2008 2009 2010 Jan-Jun 2011
% Incidents - FPSO/FSOs
0%
25%
50%
75%
2005 2006 2007 2008 2009 2010 Jan-Jun 2011
% Incidents - Vessels
0
5
10
15
20
2005 2006 2007 2008 2009 2010 Q2 2011
Rate
TRC Ratesper million hours worked
ALL FPSO/FSO OperatorsALL Operators
TRC = LTI + ADI + MTI
Injuries
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15
0
2
4
6
8
10
2005 2006 2007 2008 2009 2010 to Q2 2011
Rate
HCR RatesAll Facility Types vs FPSO/FSOs
All Facility TypesFPSO/FSOs
NB: Rates are per milion hours worked
A173767 September 2011
Hydrocarbon Releases
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0%
5%
10%
15%
20%
25%
Valves / Vents
Pipes / Tubes Gaskets / Seals
Joints / Flanges
Other Pumps / Compressors
Tank Instruments Unspecified Engines
Equipment involved in FPSO Hydrocarbon Releases
Almost half of all HCRs involve either Valves/Vents or Pipes/Tubes…
What is this telling us?
Hydrocarbon Releases
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0
5
10
15
20
25
2005 2006 2007 2008 2009 2010 to Q2 2011
Rate
Damage to safety-critical equipment RatesAll Facility Types vs FPSO/FSOs
All Facility TypesFPSO/FSOs
Safety Critical Elements
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• Control measures relied on to reduce the risk of one or more MAEs to ALARP
WARNING What is this telling us?
NB: Rates are per milion hours worked
Fires
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0
1
2
3
2005 2006 2007 2008 2009 2010 to Q2 2011
Rate
Fire or Explosion RatesAll Facility Types vs FPSO/FSOs
All Facility TypesFPSO/FSOs
NB: Rates are per milion hours worked
FPSO/FSOs - Incident Root Causes
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Top TapRoot® Root Causes for FPSO/FSOs2005 2006 2007 2008 2009 2010 ytd 2011
Work Direction
9.2%
Human Engineering
12.1%
Design Specs13.7%
Equipment Parts / Defects14.2%
Procedures -Not Followed
20.0%
Design Specs17.2%
Design Specs15.3 %
Procedures -Not Followed
8.2%
Work Direction
10.1%
Equipment Parts / Defects10.3%
Procedures -Not Followed
13.0%
Equipment Parts / Defects15.3%
Procedures -Not Followed
10.5%
Equipment Parts / Defects11.9%
Training5.1%
Mgmt System - Human10.1%
Preventive Maintenance
9.7%
Design Specs12.3%
Design Specs14.2%
Preventive Maintenance
9.6%
Procedures -Not Followed
11.0%
Preventive Maintenance
5.1%
Preventive Maintenance
10.1%
Procedures -Not Followed
8.0%
Preventive Maintenance
11.7%
Preventive Maintenance
11.6%
Equipment Parts / Defects
8.8%
Mgmt System - Human
9.3%
Equipment Parts / Defects
5.1%
Procedures -Not Followed
9.1%
Human Engineering
5.7%
Tolerable Failure5.2%
Training6.3%
Training6.7%
Mgmt System - Equipment
8.5%
FPSO CASE STUDY
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FPSO Case study
• Incident: Fire and explosion• Issues:
– Facility Design – Commissioning, QA/QC, carry-over into operations– Competency and training– Control room alarm flooding– Maintenance management
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FPSO Case study
• Regulatory intervention: Inspections
• Major deficiencies identified in:– Maintenance backlog management– Effectiveness of operational control– SCEs not meeting performance standards– Reportable incidents – Housekeeping
• Enforcement action included:– Improvement Notices– Prohibition Notice
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FPSO Case study
• Initial response to intervention:– Delegation to contractor – Completion dates not fully met – Over reliance on NOPSA to identify health and safety issues
• Intervention options:– Inspections– Potential escalation of enforcement
• notice of intent to withdraw safety case• request revised safety case
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DesignCommissioningOperations
LESSONS FROM INSPECTIONS
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Design Issues
• Alarm management– Address during design / commissioning
• Material selection– Souring of the reservoir is a common outcome of
facilities that conduct produced water reinjection.– This generally results in a higher than anticipated H2S
content in well, process & rundown streams
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Design Issues
• Critical Function Testing (CFT)– SCEs not meeting performance standards– SCE often requires a production shutdown to CFT
with frequency implications– Systems should allow for performance tracking /
reporting of SCE during unscheduled shutdowns.
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Commissioning Issues
• Safety-critical elements: performance non-compliance: BDVs / SDVs
• Incomplete commissioning– construction debris– excessive punch list items– lack of Quality Assurance/Quality Control
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Operational Issues
• Inadequacies in competency / training– Restart of plant and processes: cyclone disconnection
is a complex task requiring technical skills and experience
• Operators must ensure sufficient time for required competencies to be acquired
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Operational Issues
• Procedures Incorrect / Not Followed – Procedures take time to achieve and should be
considered as dynamic.– Procedures should be validated or reviewed to reflect
the current, best practice. – Use Management of Change (MOC), otherwise
procedures can be undermined, resulting in shortcuts and risk taking.
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Operational Issues
• Failure to complete Corrective Actions – "Case to Operate", "Deviations”, "Temporary
Operating Procedures”, and such are used to justify continued operations
– Such permissions to operate should be time-limited and tracked to ensure permanent rectification is applied and maintained
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LIFEBOAT LOADINGA topical issue
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Lifeboat Loading
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IMO SOLAS, Lifeboats are designed for 75kg/personOffshore NOPSA found average = 92kg-100kg/person
= some lifeboats 25%-30% overloaded based on their SWLNOPSA has made Operators aware of the problem of lifeboats exceeding their SWL and have required them to take action.
Some Operators have :• reduced the number of POB per
lifeboat;• changed the lifeboats and davits –
bigger boats & increased SWL• added extra lifeboats;
See also NOPSASafety Alert No.47
PROCESS SAFETY CULTURE
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Opportunities for improvement
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Safety Culture Survey TOPIC AREA Areas of concern - FPSOs
Safety Values / Commitment
Pressure to work overtime - loyalty to their own work unit
Process safety programmes don't have adequate funding
Reporting Hazard identification, control and reporting training not adequate
Training Contractors don't receive adequate training to do their job safely
Worker Professionalism / Empowerment Workers don't actively participate in incident investigations
TOPIC BASED INSPECTIONS
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Maintenance management
• Variation between documented maintenance system and how maintenance is actually conducted
• Formal deferrals process not used – risks not assessed• 3rd party competency – EHS assessed but not technical
competencies• Auditing – inadequate
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Emergency Management
• Drills being undertaken with limited number of scenarios
• PA systems ineffective, emergency escape routes not clearly marked or obstructed
• Response times – not subject to performance standards and not tested
• Inadequate debriefs• Auditing - inadequate
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Reason’s Accident Causation
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Blind operations
• Where those operating equipment were unaware of the actual situations they were in– Tendency to interpret events in context of previous
experience despite evidence to the contrary (mind set)– Management's failure to ensure that members of the
workforce have the ability to identify, diagnose and respond to abnormal conditions
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Macondo, 2010
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• 11 fatalities• Commission findings include:
– failure to properly conduct and interpret the negative pressure test
– WRONGLY ASSUMED well could not be flowing
– Kept running tests and coming up with various explanations until they convinced themselves their assumption was correct
• Commission identified a number of potential factors that may have contributed to the failure to properly conduct and interpret the negative pressure test:– no procedures for running or interpreting
the tests– lacking full appreciation of context in
which the test was performed
Montara, 2009
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• No fatalities, well blowout. • Return of fluid indicated float
valve problem • Commission findings include:
– major shortcomings in procedures were widespread and systemic
– circumstances were not recognised or understood by senior personnel at the time
• Commission recommended:– existing well control training
programs should be reviewed, with a focus on well control accidents that have occurred
Texas City, 2005
42
• 15 fatalities• Overfilling of a tower during start-up
releasing flammable liquid to atmospheric vent
• CSB findings included:– lack of supervisory oversight and
technically trained personnel during startup
– Operator training program was inadequate
– Outdated and ineffective procedures did not address recurring problems
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Longford, 1998
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• 2 fatalities, 8 injuries• loss of hot lean oil flow with
subsequent flow causing brittle fracture and hydrocarbons release
• Commission findings included: – ‘Lack of knowledge … was directly
attributable to a deficiency in initial or subsequent training’
• Commission recommendations included:– ‘Operator to demonstrate that its
training programs and techniques impart knowledge of all identifiable hazards and the procedures to deal with them’
Three Mile Island, 1979
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• No fatalities or injuries• Coolant pumps failed, relief valve stuck open
with a partial meltdown of reactor core • Commission concluded:
– inappropriate operator action– deficiencies in training and operating
procedures– failure of organisation to learn lessons
from previous incidents• Commission recommended:
– “Emphasis must be placed on diagnosing and controlling complex transients and on the fundamental understanding of reactor safety.”
What can you do?
• Ensure staff are competent, and supported by effective procedures to diagnose and respond to abnormal conditions
• Share and learn lessons from past incidents both within and outside the industry
• Organise yourselves in such a way that you are better able to notice the unexpected in the making and halt its development (paraphrase of Hopkins, 2009 from Weick and Sutcliffe, 2001)
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Thank you
