52 BULLETIN 2013 VOLUME 108 #6 G E N E R A L

We are facing very complicated changes because we are mov-ing from the Information

Age to the Virtual Age. To preserve our opportunities and control or mitigate threats, an appropriate tool to deal with these changes is essential. The question is, what is that tool? For the purpose of this article, we will call it Integrated Change System (ICS). (Figure 1)

In addition to the use of ICS, any organisa-tion requires an Authority Plan (AP) to deal with changes. Let’s discuss the aforemen-tioned model using a new vision which we will call an integrated Risk Assessment and Root Cause Analysis system (RARCA)

RARCAConsider a recent event such as the Macondo disaster on 20 April 2010. The disaster occurred to a British Petroleum (BP) drilling unit in the Gulf of Mexico and had enormous consequences. By referring to the root cause analysis of the accident by

BY MOHAMMAD AL I NOROUSTA

Lloyd’s Register Risk Consulting Manager Frank Cronin in November 2011, the fol-lowing can be concluded: “Better manage-ment of decision-making processes within BP & other companies, better communi-cation within & between BP & its contrac-tors and effective training of key engineering & rig personnel would have prevented the Macondo incident”.

Risk assessment, root cause analysis, safe-guards and barriers, safety procedures, process safety monitoring, assets integrity, safety cases, etc., are designed to improve Quality, Health, Safety, Environment, Security and Energy management systems (QHSESE). But major events in the last few years have rung alarm bells that these are unable to prevent all major accidents.

Let’s return to the Macondo disaster root cause analysis results by Mr. Cronin: “Deci-sion making process, communication within the organisation and outside the organisation, effective training of frontline

key persons are weakness of British Petro-leum company management”.

In the final investigation report of the Macondo well blowout, prepared by the Deep Water Horizon study group, the find-ings indicated the following root causes: • Industry management failures; • Poor risk assessment of late design

changes and decision making processes within BP; no Management Of Change (MOC) processes;

• Poor communication between BP and other contractors (Halliburton, etc.);

• Failure to communicate lessons from earlier near-miss by drilling contractor (Transocean);

• Inadequate consideration of risks created by time and money saving decisions.

By reviewing the table of Decisions that increased risk At Macondo (Figure 2), it is obvious that all the risky decisions were avoidable. As usual, the first sign of a failure was sensed by frontline personnel; most of these failures could have been prevented by them or at least the consequences/impacts could have been mitigated if the frontline personnel had been authorised to make real-time decisions.

That means they should be able to ignore the instructions of managers, even going as far as stopping operations. The purpose here is the improvement of group decision-making and an increasing self-managing culture in an organisation to prevent major accidents within the framework of an Authority Plan.

Since all the major events are usually caused by non-conformities and chains of minor

breakthrough no deficiencies

persistent & perdurable proactive

Figure No.1Integrated change system (ICS)

Figure 1: Integrated Change System (ICS)

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Transition to the “virtual age” – integrated Risk Assessment and Root Cause Analysis systemThese days, the world is a fast-changing place. These changes are mostly dependent on “x-factors” arising from geopolitical, economic, societal, environmental and technological shifts.

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events, an important way to prevent major accidents is monitoring and controlling minor events by defining measures and thresholds. On the other hand, manage-ment of decision-making processes requires some measures such as key performance indicators (KPI).

Furthermore, effective communications inside companies and between companies and contractors are possible by the Infor-mation and Communications Technology (ICT) network based on KPI. Therefore, when considering non-conformities, minor events and near misses as KPI in the process of preventing major accidents, decision-making and communications is essential. It will improve safety, health, quality, security and the environmental protection culture in an organisation as well.

These recommendations are not enough for organisations facing x-factors or vari-able factors. As previously mentioned, x-factors are external changes which force organisations to change. Variable factors are malfunction of assets or ineffectiveness of safety barriers that cause non-conformi-ties, minor events or near misses when safe-guards have been instituted. To deal with x-factors and variable factors, each organ-isation needs proper reactions within rea-sonable time limits.

Better technology is not always the solution to the problem; also, changing processes

is hard work. However, by changing the vision, the world would be easily changed.

The basic safety rules have been created based on human experience from major accidents (Figure 3). In this regard, safe-guards/barriers, training, personal protec-tive equipment, safety management systems etc., are driven by root cause analysis of major accidents and disasters. This reactive approach is called “old vision”.

Many companies find it a challenge to bring this idea out of the textbooks and implement it both into day-to-day operations and man-

agement systems. But even if implemented, unfortunately, it has often failed to prevent major accidents. So a new vision was formed as follows: risk assessment and root cause analysis were used simultaneously as a pro-active and reactive model, hence new stan-dards and regulations were developed.

Referring to Health, Safety and the Environ-ment (HSE) reports of major companies, we can see that all of them have been success-ful in reducing accidents and damages. One such company is BP. Let’s have a look at BP’s HSE charting tool. Almost all the KPI indi-ces, such as health and safety, greenhouse gas and environmental graphs indicate suc-cessful reduction trends in losses. But the Macondo disaster shows that the new vision is also unable to prevent major accidents – just like the old vision. The question to bear in mind is why, despite robust safety QHSESE management systems like the ones used by BP, do major accidents still happen? The answers will be obtained by root-cause analysis of the Macondo disaster. Further-more, the effects of x-factors and variable factors in the occurrence of the event will be addressed with RARCA vision.

Changes in the competitive marketplace (x-factors) have led company leaders to think of a way to protect the company’s shares (realising changes). So they use rapid and low-cost implementation of projects as competition tools (decision making). In order to save money and time, some of BP’s processes were affected (variable factors).

Once again let’s consider the decisions that

Figure No.3Example of Decisions That Increased Risk at Macondo While potentially saving time

Decision Was there a less risky alternative available?

Less time than alternative Decision maker

Not waiting for more centralisers of preferred design YES Saved Time BP on shore

Not waiting for foam stability test results and/or redesigning slurry YES Saved Time Halliburton (and perhaps

BP) on shore

Not running cement evaluation log YES Saved Time BP on shore

Using spacer made from combined lost circulation material to avoid disposal issues YES Saved Time BP on shore

Displacing mud from riser before setting surface cement plug YES Unclear BP on shore

Setting surface cement plug 3,000 feet below mud line in seawater YES Unclear BP on shore (approved

by MMS)

Not installing additional physical barriers during temporary abandonment procedure YES Saved Time BP on shore

Not performing further well integrity diagnostics in light of troubling and unexplained negative pressure

test results YES Saved Time BP (and perhaps

Transocean) on Rig

By passing pits and conducting others simultaneously operations during displacement YES Saved Time

Transocean (and perhaps BP) on Rig

Figure 2: Decisions that increased risk at Macondowhile potentially saving time

1980 2000 2010

Safety Cases Introduced

• Unique to each facility

• Emphasizes thinking about hazards instead of just complying with law

HAZIDs and Risk Registers Used in Design

• Identifies hazards as early in the project as

possible

• Reduces cost and improves effectiveness of addressing hazards

Concept of Behavior-Based Safety Defined

• Analyzes staff behavior

• Uses research-based intervention strategy to

improve work

Shell Incorporates Bow Ties Into Risk Analysis

• Comprehensively identifies all threats and

related barriers

• Assists in planning Emergency Response

Plans

Line of Sight Concept Beginning to be

Formulated

• Bottom up operational barrier monitoring

• Provides Management with direct view of the health of barriers and

intervene on safety critical matters where

necessary

Piper Alpha

Jul1988

Kills 176

Macondo

Apr 2010

Kills 11

Torrey Canyon Tanker Spill,1967

Amocco Cadiz Spill, 1978

Ixtoc 1 Well Blowout, 1979

Union Oil Refinery Explosion, 1984

Kills 19

Montara

Aug 2009

Shell Refinery Explosion, Norco, Louisiana, 1988

Kills 7

Exxon Valdez Spill 1989

1990

BP Refinery Explosion in Texas City

2005

Kills 15

Bhopal Disaster, 1984

Kills 20,000 / Injures 500,000

History of process safety methods and tools has progressed

Figure No.4Figure 3: How process safety methods and tools have progressed

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increased risk at the Macondo well in Fig-ure 3. It is evident that x-factors will lead to variable factors (Figure 4). If any area is known to be a high potential area, then that area should be given full authority to make proper decisions when facing imminent dangers (Authority Plan).

When the company’s staff face variable fac-tors, all related risks should be assessed and recorded in the database. Variable fac-tors should be managed by key persons and their department designated a high-risk area (figure no.5). The role of frontline personnel is very important in preventing major accidents. High-risk areas are deter-mined according to Risk Assessment (RA) and Root Cause Analysis (RCA) records. Accordingly, all RA and RCA data should be collected from all levels of the organisa-tion. This is possible by personnel access to right tools. But before talking about this, let’s talk about RARCA vision.

A simple but very important question is why is risk assessment unsuccessful in pre-venting major accidents? The simple answer is the weakness of the risk assessment pro-cess, which might be due to failure to prop-erly identify risks, incorrect evaluation of identified risks, ineffective or inactive bar-riers (safeguards) etc. In RARCA Vision, any non-conformity, accident, near miss or minor damage is a sign of risk assessment weakness and the collection of this data is the first step in identifying an organisa-tion’s weak points.

Common data collection methods between RA and RCA is the most important step in risk assessment improvement. Because of integration between Risk Assessment and the incidents’ data collection system (as the first step of Root Cause Analysis in Figure 6), the RA and RCA KPI, which is derived from the collected data, can be used for re-checking safeguards or the reassessment of processes.

Furthermore, by reviewing RA and RCA integration in Figure 6, it is obvious that identifying organisational weaknesses is not only very effective in preventing major acci-dents, but the chronic problems would also be identified. Another point is that databases of accident impacts can be used to obtain a frequency to determine actual risk levels, e.g. for each accident in a process, the related fre-

Figure No.5

Changes in competitive marketplace

Protecting of company’s share

To use rapid and low-cost implementation of projects

Change in some processes

X-factor Realizing changes Decision making Variable factors

X-factor and variable factors relation block diagram

Figure 4: Relationship between x-factors and variable factors

Figure No.6

Variable factors

Continues assessment

Non-conformities and accidents Data Base

(organization, industry)

Risks Data Base (organization,

industry)

Record of assessments

KPI’s

KPI’s

Confirm of assessment

Authority plan

Decision making

Managing variable factors Block diagram

Figure 5: Managing variable factors

Figure No.7

Accidents & failures

Inspections , Data gathering and recording Evidences

Database of accidents and failures

Record failure & impacts

Actual risk levelevaluate the possibility of failure analyze.

Identify and record the causal factors

Identify and record the root causes

Identify , collect , and record the suggested solutions

Identification and evaluation of potential risks of solutions

Planning, and follow up the implementation of preventive actions

Hazards identifications & analyze during failure analyze

Identified weaknesses in systems to prevent

occurrence of accidents & failures

frequency

consequence

Inspection /Risk Assessment

Integration between root cause analysis and risk assessment block diagram

Figure 6: Integration between root cause analysis and risk assessment

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quency can be recalculated and according to its impacts, the process risk level will be determined. On the other hand, an asset’s criticalities are obtained by its related acci-dent impacts. So the actual risk level and crit-icality of assets is refreshed by each event.

Qualitative risk reassessment during analy-sis of events can be a remedy to risk assess-ment weakness. Also, risk assessment of

preventive actions will lead to the increased efficiency of safeguards. So it can be said that RCA is a part of risk assessment and there is a strong relation between them that could improve an organisation’s safety.

We have just tried to show that integration between RCA and RA leads to robust risk assessment. Now we will try to explain how to deal with variable factors.

If there’s no opportunity for events to occur due to the changes in variable factors, then it could be said that regular control of vari-able factors in risk assessment systems has been effective. But even if this does happen, then the question is how should the variable factors be controlled? The answer is by con-tinuous monitoring of variable factors.

The followings are details from the check-list in Figure 7, which is prepared to pre-vent occurrences of events during high risk operations: • It is prepared based on industrial expe-

riences and Risk Based Inspection (RBI) from an expert organisational team.

• It is reviewed periodically by an expert team.

• It is used by frontline personnel.

In RARCA vision, frontline personnel are involved in editing checklists in addi-tion to expert teams (continuous monitor-ing of variable factors). But the frontline personnel’s abilities to edit checklists is not enough. Adequate resources and the right tools must also be available to them. In other words, because they are the first people to deal with event alarms before the occurrence of the events, their decisions and functions are very effective in the pre-vention or mitigation of incidents and their consequences.

The basis of risk assessment is knowledge,

Figure No.8

Potential hazards known in the industry(or organisation)

Potential hazards identified by the inspection team

Analysis, evaluation & control

Check list

Before operations & activities

Inspection

Satisfaction

Non-conformities

Start operation

Remove Non-conformities

Periodic inspection and control of variable factors

Monitoring and control of variable factors (by interval)

Figure 7: Monitoring and control of variable factors (by interval)

Figure 8: RAPAS is a maritime version of CMG Software

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Editor’s Note: Mohammad Ali Norousta

holds a BSc in Mechanical Engineer-

ing and a PhD from the University of

South Dakota. He has wide experience

in marine mechanical engineering, both

shore-side and seagoing. At present, he is

Technical Director at CMG and MD Tech-

nical Consultant of an offshore company.

the “authority plan” is an effective tool to develop safety culture.

ConclusionFrom the dawn of time man has been exposed to unknown perils and dangers. At first, he learned by bitter experience how to prevent recurring accidents, as well as how to minimise the risks and impacts of these accidents (Root Cause Analysis). Damage and losses occurred for centuries until man introduced a new kind of preventive action known as Prescriptive Measures. This new idea seriously improved the health and safety of human life but it could not reduce the trend of accident occurrences.

In the 21st century, with technological advances and rapid changes in the world and due to the occurrences of some major accidents, a new vision of Accident Preven-tion (Risk Assessment) and the prevention of recurrences (Root Cause Analysis) is needed.

RARCA is compatible with all the old and new elements of Risk Assessment and Root Cause Analysis and there are no limita-tions on organisations wishing to use the RARCA system. l l

meet an organisation goals or departmen-tal objectives.

The impacts/consequences of assets are used to determine “criticality rankings” of assets in order to improve safety and prior-itise assets. Furthermore, asset information should be categorised and collected for use in a recordable system in order to increase the effectiveness of risk assessments and preventive actions.

Performance Monitoring describes organ-isational measures and their monitoring arrangements to increase the safety perfor-mance of processes, to delineate an image of the organisation and develop the capabil-ities of managers in predicting the effects of changes as decision support tools. Data min-ing, industry leading and lagging KPI and organisational KPI are used as measures.

Emergency response describes objec-tives for “responses to incidents” that must mitigates consequences identified in RARCA and arrangements required for authority plans. To identify high poten-tial areas, the impacts, consequences of RARCA and assets criticality must be considered. Also, it must be realised that

judgment, historical experience and ana-lytical methods. Fortunately, frontline per-sonnel can have these capabilities and in this regard, Cost Monitor Group (CMG) has developed software based on Integrated Risk Assessment & Root Cause Analysis System. (Figure 8)

Summary of RARCAElements of Integrated RA and RCA Sys-tem (Figure 9) are: an integrated manage-ment system, description and supporting information, performance monitoring and emergency response.

An integrated management system encom-passes communication methods within an organisation and among its contractors. It allows the objectives of the organisation and departments to be met, and also ensures that all risks are controlled according to an integrated RA and RCA system. RARCA vision dictates that improved safety perfor-mance is the duty of each person within the department, aside from the departments’ and contractor’s responsibility.

The description and supporting infor-mation describes asset requirements, such as measures and thresholds necessary to

Figure No.10

Risk Assessment & Root Cause Analysis Integrated System

Management System

Emergency Response

Description & Supporting Information

Performance MonitoringElements of Integrated RA&RCA System

RARCA

Figure 9: Elements of Integrated RA and RCA System (RARCA)

Mohammad Ali Norousta

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