Paper No. SPE-190690-MS Paper Title: Proactive Operator ... · can degrade or defeat POM •...

116–18April2018JumeirahatE-hadTowers,AbuDhabi,UAE

SPEInterna5onalConferenceandExhibi5ononHealth,Safety,Security,Environment,andSocialResponsibilityCon-nuingHSSE-SRExcellenceforaSustainableFuture

Paper No. SPE-190690-MS Paper Title: Proactive Operator Monitoring (POM) as a Safety Barrier for a Global Service Company Ronald W. McLeod, Ron McLeod Ltd. Mathew Novia, Baker Hughes, a GE Company Lamberto Nonno, Baker Hughes, a GE Company



Introduc5on

•  Recogni-onthatourindustryreliesheavilyondynamicreal-mehumaninterac-onaspartofarobustassuranceprogram

•  Failuresduringcri-caltaskswhereinsufficientmonitoringorresponsesledtoincidentsoccurring,promptedadeeperreviewofthecausestounderstand‘whatliesbeneath’

•  InorderforProac-veOperatorMonitoringtoperformeffec-velyasabarrierorsafeguard,weneedtoensurethecondi-onsthatsupporteffec-vemonitoringareinplace.

Ref.IOGPReportNo.566



In-depthIndependentReview

•  Commissionedadeeperindependentreviewofourprocess/humanbarriers

•  Use'whatliesbeneath'clearviewthinking•  BeZerunderstandhowhumanfactorsinfluencetheoutcomesoftasks•  Iden-fyifoperatorsarebeingsetuptosucceedortofail

•  Usedexis-ngprocesssafetybow-eassessmentswhereasignificantnumberofbarrierswererelatedtomonitoringtasks

•  Reviewiden-fiedopportunitytotakea‘deep-dive’intooperatormonitoringtaskstobeZerunderstandwhatelementscons-tutethesebarrierandthethreatsagainstthem

TintedView•  Human actions are the cause of incidents •  Asks – who is responsible? •  Answers – why did it go wrong? •  Solutions “fix” the person •  Stops short of digging deeper

ClearView•  Human actions are influenced by systemic

issues •  Asks – are we setting up people for success? •  Answers – how could this happen? •  Solutions include fixing organisational factors •  Digs deeper to find what lies beneath



Basisofthereview•  IndustryGoodPrac-ce

•  CentreforChemicalProcessSafety‘Bow-esforRiskManagement’(2018)•  CharteredIns-tuteofErgonomicsandHumanFactors(CIEHF)‘HumanFactorsinBarrierManagement’www.ergonomics.org.uk

•  BarrierProper-es.Atleast;•  Independent•  Effec-ve•  Auditable

•  Ac-veBarriersmusthaveDetect,Decide,Actfunc-onality•  HumanerrorshouldNOTbemodeledasaThreat(inatoplevelBow-e)

•  ItisaDegrada-onFactorthatdefeatsBarriers.WhatistheBarrieritdefeats?•  RecommendedbybothCCPSandCIEHF.



Observa5onsfromexis5ngBHGEBowTies•  TubularCuengandMilling

•  6Threats•  22Barriers

•  14=Verify/Confirm/Review(Preopera-ons)•  4=Monitor(DuringOpera-ons)

•  PrimaryCemen-ng(Opera-ons)•  8Threats•  20Barriers

•  3=Verify/Confirm/Review(Preopera-ons)•  4=Monitor(DuringOpera-ons)



Suggestedtop-levelBow5eforserviceopera5ons

HydrocarbonsinWellbore

Highpressurehydrocarbonsin

reservoir

Pressureinwellexceedsplannedcontrols

`Opera-onconducted

accordingtovalidatedplan

Proac-veOperatorMonitoringand

Response

Confirmedwell

condi-ons

Confirmedstateofexis-ngbarriers

Validatedplan

Opera-onconductedincompliancewithplan

DetectDetect

Decide

Act

AlarmsandOperatorResponse

Decide&Act

AlarmsOperatorresponse

Detect

MOCProac-veOperatorMonitoring

DetectDecide&Act

STOP

Decide



ExamplesofDegrada5onFactorsforProac5veOperatorMonitoring

HydrocarbonsinWellbore

Pressureinwellexceedscontrols

STOP

Operatorproac-vemonitoringandresponse

MoCPOMofplan POMofWell

Workload/compe-ngjobdemands

Compe-ngpriori-esorincen-ves

KRIweak,uncertainorunambiguous

KRIsnotshared

Confirma-onBias

NotawarethatsourceofKRIisnotfunc-onal

KRInotaccessiblewhereandwhenneededforPOM

SignificanceofKRIsnotunderstood

POMnotalignedwithcurrentstateofopera-on

Over-confidenceintechnology/alarms

Over-relianceonotherpeopletoPOM

NotknowingwhatKRIstomonitor

NoindependentsourcesofKRI

UnawareofpersonalroleinPOM

Over-confidenceinotherbarriers

Lackofriskawareness

Over-confidenceinclientwellinforma-on



“Extension”(CCPS)or“Level-1”(CIEHF)Bow5es

Hazard

Threat Barrier1 Barrier2 Barrier3 ConsequenceBarrier4 Barrier5

Humanerror

Safeguard2

Safeguard1Degrada-on

factor

Safeguard4

Safeguard3

FailureofBarrier2

Humanerror

Extension1(Level-1) TopEvent

Degrada-onFactor

Safeguard1 Safeguard2

Safeguard5

Safeguard2

TopEvent



An“Extension”(Level-1)Bow5eforProac5veOperatorMonitoring

Failuretomonitor

proac-vely

KRInotshared

Notconducted

Incomplete

Ambiguous

Don’texist

Notfollowed

Notcovered

Liabilityrisk

Remotenessfromhazards

KRIsnotshared

Datanotavailable

Toobusy

Complacency

Notcompleted

NotEffec-ve

KRIsincorrect

DatanotsharedDistrac-on

NottakenseriouslyKnownfaultsnotshared

Datanotused

Over-confidenceintechnology/

alarms

Pre-jobPOMreview

Awarenessofsystemreliabilityperformance

POMinspec-onrou-nes

Awarenessofcurrentfaults

inSCEs

POMtraining

AwarenessofKRIs

\Chronicunease/

Mindfulness

Shiqhandoverprocedure

ProtocolsforhandlingKRI

data

Contractualarrangements

AwarenessofKRIs



Priori5singSafeguards:Prac5calityxImpactAssessment

Practicality Weighting Easeof

ImplementationSimpleactionscanbeimplementedwithlittleeffort. 1

Resources Littlecapitalorresourcerequirement 1 Stakeholders Fewstakeholders 1 Change Littlechangefromexistingpractice 1Impact Scope WouldalsoimproveotherBarriers 1 Exposure FrequentopportunitiesfortheDegradationFactortoact 1 Effectiveness Confidencetheactionwouldquicklybeeffective 1 Riskreduction

achievedDegradationFactoriswidelyrecognisedasarisk. 1

Agree(score5)SomewhatAgree(score4)

NotSure(score3)SomewhatDisagree(score2)

Disagree(score1).



Prac5calityxImpactPlot

TryingtoimprovethisSafeguardisimprac-calandwouldhaveliZleimpact

Ac-ontoimprovetheseSafeguardsisveryprac-calandwouldhavehighimpact.

20

20



Examplesofchallenge/Barrierverifica5onques5onsforPOM

Degrada5onfactor Descrip5on Challenges/Barrierverifica5onques5ons

Lackofriskawareness Notawareofcri-calityorheightenedriskincurrentopera-onalstate

•  Doestrainingensureacompetentpersonwouldunderstandtherisks?

•  Dopre-jobbriefingsensureallcrewareawareofheightenedrisk?

Over-confidenceinclientor3rdpartyinforma-on

Uncri-callyacceptsKRIinforma-onprovidedbytheclientor3rdpar-es

•  Doclient’sexplainuncertain-esinopera-onalinforma-on?•  Could3rdpar-eshaveadifferentviewofopera-onalrisks?

Over-confidenceintechnology

Overconfidencealarms,ortechnicalsystemswillintervene

•  Dotheteamgetfeedbackonthereliabilityofcri-calalarmsorequipment?

•  Isitnormaltocarryonwithopera-onswhencri-calequipmenthasreliabilityproblems?



ClosingRemarks&Learnings

•  Verifica-on(pre-opera-ons)andProac-veOperatorMonitoring(duringopera-ons)playacri-calroleinassuringthesafetyofservicecompanyopera-ons

•  Applyinga‘WhatLiesbeneath’approachiden-fiedmanyorganisa-onalandpsychologicalfactorsthatcandegradeordefeatPOM

•  Iden-fiedneedforbarrierswithPOMtobestrengthtestedtounderstandandbeconfidentofit’srole–Proac-veOperatorMonitoringAssessmentTool(POMAT)developed(seepaperSPE-190670-MS)

•  Areasofpoten-alweaknessiden-fiedbuiltbackintobarrierThreatResponseScenariostotestandreinforceemployeesresponses

•  Mixedrealitysoqwareatboothtodemonstrateawayofachievingthis

•  Provideditisproperlyimplementedandsupported,POMisvitaltoafullbarriersystem•  Furtherhighlightedtheimportanceofasharedunderstandingandcollabora-onbetweenbarrierownersandthosethatdependontheirabilitytofunc-oneffec-vely



Acknowledgements / Thank You / Questions

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Paper No. SPE-190690-MS Paper Title: Proactive Operator ... · can degrade or defeat POM •...

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