HSEHealth & Safety
Executive
Safety and performance enhancement in drilling operations by human factors
intervention (SPEDOHFI)
Prepared by Quest Evaluations & Databases Ltd for the Health and Safety Executive 2001
RESEARCH REPORT 264
HSEHealth & Safety
Executive
Safety and performance enhancement in drilling operations by human factors
intervention (SPEDOHFI)
Mrs J A Wilson Prof. N A Stanton
Quest Evaluations & Databases Ltd The Birches Landford
Wiltshire SP5 2AU
Human Factors is a relatively new science. It is concerned with adapting technology and the environment to the capacities and limitations of humans. The challenge for Human Factors is to act as a prescriptive way to make systems and working practices safer and more efficient.
This project was designed to us a systematic process of Human Factors tools, to classify basic causes of human error and poor safety climate, directly in relation to the drilling environment.
This report and the work it describes were funded by the Health and Safety Executive (HSE). Its contents, including any opinions and/or conclusions expressed, are those of the authors alone and do not necessarily reflect HSE policy.
HSE BOOKS
© Crown copyright 2004
First published 2004
ISBN 0 7176 2909 0
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the copyright owner.
Applications for reproduction should be made in writing to: Licensing Division, Her Majesty's Stationery Office, St Clements House, 2-16 Colegate, Norwich NR3 1BQ or by e-mail to [email protected]
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ACKNOWLEDMENTS
Five Major Oil and Gas Operators: Amoco, B Gas Technology, BP, Enterprise Oil, Statoil and The Health and Safety Executive took part in this joint industry venture. The Health and Safety Executive are now funding this Web Site Report to make the results more generally available. The project was intended as an introductory look at how Human Factors can benefit the offshore Industry. The results however, are profound and far-reaching. We thank the participants for their time and involvement in a project, and those who contributed to the collection of the data, which will greatly aid the quest towards continuous improvement in safety and performance.
AUTHORS BIOGRAPHICAL NOTES
Jennifer Wilson has been working exclusively on offshore research projects since 1991, on behalf of the HSE and Oil Companies, collecting and analysing data. This data has been both technical and human Factors. She holds a BSc (Hons) in psychology and is a member of the British Psychological Society. She formed QUEST Evaluations & Databases Limited early in 1997.
Neville Stanton is Professor of Human Centred Design at Brunel University. He has written 6 books on Human Factors and lectured on the subject throughout the world. He holds Bachelors, Masters and a Doctorate in Psychology and Human Factors and is a Chartered Occupational Psychologist.
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CONTENTS
1. INTRODUCTION
2. AIMS OF PROJECT 2 2 2 2 3
2.1 Assess Human Factors techniques 2.2 Determine root causes of incidents 2.3 Benchmark Human Factors data 2.4 Identify remedial strategies and develop recommendations
3 . METHODOLOGY 3 3 4 6
3.1 Sequential Timed event Plotting Procedure (STEPP) 3.2 Safety Culture Questionnaire (SCQ)
3.5 Focus Groups 9
3.3 Hierarchical Task Analysis (HTA) 3.4 Systematic Human Error Reduction and Prediction Approach 8 .
4. RESULTS 4.1 STEPP 4.2 SCQ 4.3 SHERPA 4.4 Focus Groups 4.5 Historical well data
5. REMEDIAL STRATEGIES 5.1 STEPP, SCQ, and Focus Groups 5.2 SHERPA
10 11 12 13 15 16
17 17 18
6. RECOMMENDATIONS 21 6.1 Full Hierarchical Task analysis (HTA) and Systematic Human Error
21 21 21 2 1
Reduction and Prediction Approach (SHERPA) 6.2 Periodic Re-assessment of Safety Climate 6.3 Recording Human Factors data 6.4 Confidential Human Incident Reporting Programme (CHIRP) 6.5 A correlation of the benchmarking qesults and safety statistics 22
7. CONCLUSIONS 23
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SAFETY and PERFORMANCE ENHANCEMENT in DRILLING
WEB SITE REPORT OPERATIONS by HUMAN FACTORS INTERVENTION -
1. INTRODUCTION
This web site report is a condensed version of the original report for this project. For more detailed information please contact the HSE custodian of the full report or the editor at QUEST.
Over recent years there has been a growing recognition of the importance of Human Factors in the management of safety-critical industries. Many of the concepts are new to the Oil and Gas Industry, with much of the seminal work and development of techniques having arisen from the Nuclear and Aviation domains. These having set the standard for Human Factors practice. Whilst there are obvious parallels between the different domains (e.g. they are all safety-critical environments), it cannot just be assumed that techniques and analysis of Human Factors developed for Nuclear and Aviation fields can be directly applied to the Oil and Gas Industry. This project was therefore designed to use a systematic process of Human Factors tools, to classify basic causes of human error and poor safety climate, directly in relation to the drilling environment.
Human Factors has identified the aetiology of most major incidents to human failure. The findings have been that, although most will have multiple causes, over 80% will have a cause which is related to human performance.
In a previous study of 96 kicks J Wilson found evidence that Human Factors are contributing to the incidence of kicks and to their effective handling. It is suggested, therefore, that the intervention of Human Factors techniques, followed up by intervention, will noticeably reduce the incidence of induced kicks, near misses, lost time incidents and accidents. Technological experience and competence has increased in recent years and there is now a better understanding of the geology of the North Sea and as a result accidents and lost time incidents may have reached a low but as most conscientious companies are finding, they have also reached a plateau. If a step change in performance is required, we should be concentrating on the Human Factors
. assessment in all activities, focusing in on the behaviour of individuals in the work system. Safety cases are demanding that risks associated with human performance be identified.
Human Factors is a relatively new science. It is concerned with adapting technology and the environment to the capacities and limitations of humans. The challenge for Human Factors is to act in a prescriptive way to make systems and working practices safer and more efficient.
References
Wilson. J. (1994) Analysis of Kick Data. HSE Report.
Wilson, J. (1 995) A Consideration of Human Factors When Handling Kicks. Presented to the Well control Conference for Europe. Milan, Italy. June 1995.
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2, AIMS OF PROJECT
The project had four main aims: 0
0
0
0
First, to apply Human Factor techniques in the assessment of behaviours, robustness of working practices and perceptions of safety. Second, to identify the root causes of potential problems and human error. Third, to set a baseline of human performance in the Oil and Gas Industry by which all future progress could be judged. Fourth, to derive a set of short-term and long-term strategic activities and recommendations that would ensure improvements in Human Factors throughout participating companies.
2.1 Assess Human Factors techniques
The first aim was met by applying a range of Human Factors techniques that are particularly pertinent to the Oil and Gas domain, i.e. Sequential Timed Event Plotting Procedure (STEPP), Safety Climate Questionnaire (SCQ) developed especially for this project, Hierarchical Task Analysis (HTA), Systematic Human Error Reduction and Prediction Approach (SHERPA) and Focus Groups (FG). Their applicability was assessed and an integrated Human Factors methodology was developed. All of these tools worked extremely well in the Oil and Gas Industry and produced a wealth of useful data. They worked well integrated into a combined Human Factors methodology, as in the JIP, giving a very comprehensive analysis of human errors. They also worked well used independently, looking at different aspects of work- related behaviour, measuring and assessing the potential risks from human errors in that field.
2.2 Determine root causes of incidents
The second aim was achieved from the data derived from the analyses of the techniques. The application of Human Factors methods to the analysis of working practice, perceptions of safety, and accidents provides a rich source of information for determining underlying causes of incidents. Therefore, it was planned that all of the results of these tools were combined to look at convergence and variation between the methods. A large quantity of root causes of human errors and potential human errors which could lead to lost time, unwanted incidents or accidents have been identified. At.fiis stage of the JIP, the participating companies were able to begin to create action plans for corrective and preventive action.
2.3 Benchmark Human Factors data
The third aim was met by proposing industry norms for error potential on several critical drilling activities together with norms for safety climate. These norms allow all future proposed changes to be assessed to determine if any statistically significant improvements in performance have been achieved. In practical terms, these analyses should ensure that safety margins are maintained and safety cases can be made before changes in working practices are introduced.
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2.4 Identify remedial strategies and develop recommendations
The fourth aim was met by offering a set of remedial strategies. These were based upon the assessment of current activities and longer-term recommendations that could lead to further enhancement of Human Factors in the Oil and Gas Industry.
3 METHODOLOGY
There are many tried and tested Human Factors tools available. The ones chosen for this project examine different aspects of human interaction within the work environment and work related performance and subsequently measure and assess the likelihood of human errors or potential human errors in that interaction. Below is a brief description of each technique and its application.
The techniques were applied to tasks and personnel in the Oil & Gas Extraction business, the results therefore, are from real working data.
The Human Factors tools used were: Sequential Timed Event Plotting Procedure (STEPP) Safety Culture Questionnaire (SCQ) which was developed specifically for this project, Hierarchical Task Analysis (HTA) Systematic Human Error Reduction and Prediction Approach (SHERPA) Individual Interviews and Focus Group meetings with 86 drilling personnel, on and off the rigs.
By using these techniques we can a) learn lessons from the past, b) identify the current position and c) predict the future.
3.1 Sequential Timed Event Plotting Procedure (STEPP)
STEPP learns lessons from the past. It is a multiple event sequence technique used to structure incident investigation and accident analysis procedures by piecing together the scenario surrounding the accident or incident. The method distinguishes between people, plant, actions and events. The main aim is to identify the causal paths and the muti-causality of the incident or accident under investigation. The underlying root causes are sought rather than the obvious superficial events. The model is developed through the collection of data about the incident, such as interviews with team members, live and recorded transcripts, data from measured variables, eyewitness testimony, printouts from alarm lists, etc.
At the end of the data collection, a multilinear sequence diagram shows the personnel and plant down the vertical axis with the timeline on the horizontal axis. The finished graph may be several feet long. Lines (causal paths) can then be drawn between events. Some paths may leads nowhere; others may lead to a single event, whereas others may lead to many events. Finally, once the analysis is complete, the underlying root causes for the incident are sought. At this stage the build up of latent or active causes and their effects can be identified.
In the .TIP a well-documented incident (Ocean Odyssey) was used to demonstrate the usefulness of the technique. The exercise shows the importance of collecting information about human communication, actions and decisions as well as the technical factors of the event.
Reference
Hendrick, K. & Brenner, L. (1 987) Investigating Accidents with STEPP. Dekker: New York.
3.2 Safety Culture Questionnaire (SCQ)
Organisational climate is widely acknowledged to be critical to an organisation’s success or failure. Analogously, safety climate is frequently identified, by disaster enquiries, as being fundamental to an organisation’s ability to manage safety-related aspects of its operations. A good SCQ attempts to determine people’s attitudes, values, perceptions and beliefs. When one considers the influence these traits have on an organisation, it is easy to see how they can affect an organisation’s climate for good or bad.
Safety climate is normally assessed via questionnaire. Whilst there are a growing number of safety climate instruments available, it is not certain which of these represents best practice. For this reason an extensive review of accident investigations, literature, safety climate tools and techniques was undertaken for this study, in order to determine factors leading to an accident. The review led to the identification of 88 factors, which alone or with others have caused an accident. These factors were then grouped into one of the following 12 categories:
Safety priorities, Communication, Training, Environment, Individual, Procedures, Design of work/people, Design of thingdequipment, Management, Incident investigation, Emergencies, Maintenance,
Thus the QUEST SCQ has 12 sections, one for each category, with a total 3 19 items. All items require responses on a seven point Likert-type scale ranging from “never” 1 (poor) - “always” 7 (good) and can be completed in about 45 minutes. The SCQ was tested for construct validity and comprehensiveness and piloted on attendees at a drilling school. The SCQ responses have been analysed using the SPSS package and Excel.
In the JIP, 93 personnel completed the SCQ. The data from this initial study provides a comprehensive industrial norm database, a baseline from which all other
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companies may benchmark and from which all fkture changes may be compared. See figure 1.
Safety Climate Questionnaire Industry Norm No.=93
Figure 1. Mean ratings for each factor
Figure 1 shows the industry norms for the whole questionnaire. As probably is to be expected, after the intensive interventions of recent years, "Safety" and "Emergencies" are rated the highest. As most companies strive for continuous improvement, it is good sign that intervention does work.
An organisation may benchmark against the industry as a whole. By displaying company means for each factor it can be seen where there are general trends (means close together) and where there are company differences (wider distribution of means).
More diagnostic information lies at the level of the 12 sub-scales. This is where the real issues, as perceived by the workers, can be found. The results will detail the workers perceptions of e.g. management effectiveness, management's commitment to workers and many other issues which effect morale, job satisfaction and attitude to safety. Companies can see which areas are working well in their organisation and which are giving cause for concern, and where improvement effort can be targeted. To target the areas of concern, any of the 12 sub-scales may be used independently.
.-
The SCQ is a quick and accurate way of identifying the current situation.
Confidentiality is probably the single most important factor in the collection and analysis of workplace questionnaires. For this reason the respondents should be given an envelope to return the form to a third party for analysis. Return rates are likely to be highest when work time is set aside specifically for the purpose of completing the SCQ.
Reference
Sinclair, M. (1 995) Subjective Assessment. In: Wilson, J. & Corlett, N. (eds) Evaluation of Human Work. Taylor & Francis: London
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3.3 Hierarchical Task Analysis (HTA)
During the JIP an HTA was conducted on a large land rig. The HTA looks at the minute details of task actions and decisions. It was striking that none of this level of documentation already existed. This exercise only needs to be performed once in the lifetime of a task. The analysis does have the distinct benefit of providing a clear specification of what activities are conducted and so removes much of the ambiguity surrounding people’s everyday activities.
The information from the analysis can be used for procedure and equipment design, training and staff selection and the understanding of potential human errors and how they arise. The analysis will highlight actions which may not be necessary or could be performed in a safer way, thereby leading to improved safety and effectiveness. The HTA may be used to understand worker activities before a risk assessment is undertaken and could also form an effective basis for preparing Safety Case material.
An HTA is achieved by observing and interviewing an operator who is working on the task to be analysed. It breaks down the task under analysis into a hierarchy of goals, operations, and plans. Goals are the unobservable task goals associated with operation of the device. Operations are the observable behaviours or activities which accomplish the goals. Plans are the unobservable decisions and planning on behalf of the operator.
The overall goal is specified at the top of the hierarchy. This is then broken down into sub-goals. These sub-goals are then broken down further, until an appropriate stopping point is reached.
The bottom level of any branch will usually be an operation. Everything above has been specifying goals, whereas operations actually say what should be done. They are therefore, actions to be made by the operator. Once all the sub-goals have been fully described, the plans should be added. Plans are the “glue” which dictate how the goals are achieved and are contingent on current conditions in the environment.
A complete diagram of goals, sub-goals, operations and plans makes up an HTA. See figure 2. .. . Reference Patrick, J., Spurgeon, P. & Shepherd, A, (1986), A Guide to Task Analysis: Applications-of Hierarchical Methods. An Occupational Services Publication.
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EAL WITH KICK m I I : Do in order
11.1. Shutwellin Plan 1 I. 1 : Do in order
1 1.1.1. Initial shut in Plan 11.1.1: Do I to 6 then 7 ifrequired
1 1.1.1.1. Stop rotating drillstring 1 1.1.1.2. Raise drill string to predetermined position 11.1.1.3. Stop pumps 1 1.1.1.4. Close upper annular 1 1.1.1.5. Open choke 1 1.1.1.6. Open kill lines 1 1.1.1.7. Regulate pressure
1 1.1.2. Hang off Plan 11.1.2: Do 1 then (2 ifrequired) then 3 to I0
1 1.1.2.1. Inform other parties of well status Plan 11.1.2.1: Do in order
1 1.1.2.1.1. Contact Toolpusher 1 1.1.2.1.2. Contact Drilling Supervisor
1 1.1.2.2. Pressure test kill assembly 1 1.1.2.3. Set the compensator at mid stroke 1 1.1.2.4. Close upper pipe rams and regulate 1 1.1.2.5. Lower the drillstring weight onto the rams 1 1.1.2.6. Actuate ram locks 1 1.1.2.7. Increase operating pressure to 1,500 psi 1 1.1.2.8. Bleed off pressure 1 1.1.2.9. Open annular 1 1.1.2.10. Check that pipe rams are not leaking
1 1.1.3. Measure pressures Plan 11. I . 3: Do in any order
11.1.3.1. Record SICP 1 1.1.3.1. Record SIDPP 11.1.3.1. RecordPit Gain
1 1.1.4. Consult others of well status Plan 1 1.1.4: Do in order
1 1.1.4.1. Contact Drilling Supervisor and convey pit gain and 11.1.4.10. Discuss with Drilling Contractor (DST) . . . ..Continued. . .
D=Driller T=Toolpusher BE=Barge Engineer DS=Drilling Supervisor NB it is acknowledged that tasks and responsibilities vary slightly from rig to rig
Figure 2. An example of HTA auplied to drilling; operations.
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3.4 Systematic Human Error Reduction and Prediction Approach (SHERPA)
Task P step
I1.1.1.1 L
11. I , I .2 L
L
SHERPA predicts potential human error and not only judges the likelihood of that error occurring but also whether the event would be critical or not. It will then show where changes can be made to make working practices less prone to human error.
C Error Description Consequences Recovery Illustrative remedies 1
! A8 Omit to stop drill string Drill string No Recovery Checklist in prominent position in mode
rotating still Equipment dog-house (D) Shut-down panel. rotating Damage! containing all necessary switches
in logical sequence (D) Automation of shut-down sequence (D)
! A4i Fail to raise drill string Drill string too Potential Sensor from well showing exact high enough low major position of drill string together with
problem optimum position for dealing with kick on display in dog-house (D)
! A4ii Raise drill string too Drill string too Potential Sensor from well showing exact high high major position of drill string together with
problem optimum position for dealing with kick
SHERPA identifies weaknesses in working practices that could lead to a serious incident. It does this by systematically considering what could go wrong with each unit of behaviour and thus which intervention strategies are likely to make the working environment safer. For each potential human error, evaluations of consequences, ordinal probability and criticality are made, e.g. “What would be the consequences of this error occurring”? “Would it be Critical or Non-Critical”? “What is the likelihood (probability) of this error occurring”? H (High, happens fairly frequently, M (Medium, happens occasionally) or L (Low not known to have occurred but would be possible). These judgements are made by a subject matter expert.
1 I . L.1.3.
SHERPA is a development of the HTA in that it utilises each bottom-level task of the hierarchy as its inputs. These tasks are categorised according to a predetermined taxonomy and form the basis of subsequent error identification. An example of a SHERPA analysis is in figure 3.
3 P= probability (H high, M medium, or L low) C= criticality (!) (all or none)
1 I.L.l.3.
I I . I . I .4
on display in dog-house (D)- L ! A8 Omit to raise drill string Drill string Potential Sensor from well showing exact
not raised major position of drill string together with problem optimum position for dealing with kick
on display in dog-house (D)
-. running Equipment necessary switches in logical L ! AS Omit to stop pumps Pumps still No Recovery Shut-down panel, containing all
Damage sequence (D)Automation of shut
L ! A6 Close wrong annular Could operate ? Ergonomic placement of annular down sequence (D)
and ram switches (D) shear rams, cutting drill
11.1.1.5
__ A8
- AS
- A6
string M ! A8 Fail to close annular Annular 1 1 .l.2.4 Shut-down panel, containing
remains all necessary switches in logical open sequence (D)Automation of
shut-down sequence (D) L A8 Omit to open choke Choke not Try later Shut-down panel, containing
all necessary switches in logical sequence (D)Automation of shut-down sequence (D)
open
Omit to raise drill string
Omit to stop pumps
Close wrong annular
Drill string not raised
Pumps still running
major problem
Equipment Damage
Could operate shear rams, cutting drill I-
on display in dog-house (D)- Sensor from well showing exact position of drill string together with optimum position for dealing with kick on display in dog-house (D) Shut-down panel, containing all necessary switches in logical sequence (D)Automation of shut down sequence (D) Ergonomic placement of annular and ram switches (D)
Figure 3. An example of SHERPA applied to drilling operations.
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Some training in the use of SHERPA is necessary, or alternatively, companies may consider the use of a competent facilitator. The results from the SHERPA analysis can be seen in the next section.
Surprisingly, the industry lacks some form of assessing how robust its working practices are. SHERPA may be thought of as a human HAZOP (HAZard and Operability study).
Reference
Stanton, N. A. (1995) “Analysing Worker Activity: A New Approach to Risk Assessment?’ Health and Safety Bulletin 240 (December), 9-1 1.
3.5. Focus Groups and Interviews,
Eighty-six offshore personnel were interviewed, either individually or in small Focus Groups. These interviews proved to be invaluable in highlighting the real issues concerning the workers. The method was an informal, non-directive approach. Interviewees were simply encouraged to talk about their job. Research has shown that in these situations interviewees become more articulate and more able to voice concerns and frustrations. Seemingly trivial complaints may be the symptom of a much deeper personal or social problem requiring more than a superficial response.
To gain the confidence and co-operation of the workforce; 0 The Focus Groups must be conducted by a third party, 0 Confidentiality must be assured,
All personnel in the group must be of the same rawlevel otherwise interviewed individually,
0 The interviews should be conducted during work time.
The best method we have found to work is where the researcher joined the workers at their own workstations. From our research we concluded that, along with the above guidelines, a facilitator is necessary to draw out sensitive issues that are effecting working relationships and safety as these results can not be achieved by any corporate measures. The issues that were raised corresponded with the results of the SCQ, this overlap confirms confidence in the data and shows some solid trends.
Reference
Coolican, H. (1 990) Research Methods and Statistics in Psychology. Hodder & Stoughton: London.
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4 RESULTS: ANALYSIS OF ROOT CAUSES
The root cause analysis comes from combining the assessments for the four different analytical methods (STEPP, SCQ, SHERPA and Focus Groups) to examine the range of underlying Human Factors bases for incidents, as well as looking for the degree of overlap between methods. The convergence between methods may be very strong for some factors. This may be indicative that this factor is a very strong root cause as well as, to some extent, being an artefact of the nature of the analytical method. The analysis reveals 25 principal root causes, as identified in table 1.
Table 1. Root cause analysis based on the Human Factors techniques.
The root causes are assigned the notation XXXXX to signify which technique identified them in table 1. Further, each root cause has been classified into one of six basic types in a taxonomy at the right-hand side of the table.
Each of the underlying root causes may be assessed in turn in order to determine mechanisms for improving the situation. As the taxonomy suggests, different systems need to be addressed. “Management” being the most implicated factor.
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As the table demonstrates there is some overlap of the factors identified by the four different methods. STEPP looks at the root causes which have already happened, SCQ and Focus Groups identify situations as they are at present and SHERPA looks at likely (potential) root causes.
The root causes identified will be listed for traceability, under the heading of the Human Factors tool which identified them.
4.1 STEPP
A classic well control incident was used as the basis for the STEPP analysis and root cause investigation. Whilst we recognise that lessons have been learnt from this event we feel that many of the Human Factor issues remain unresolved. Two of these factors, “weak shift hand-over”, and “poor emergency management” did not become evident in any of the other methods used. It is apparent that they have largely been dealt with by the industry since the incident on the Ocean Odyssey. However, several others have come to light in the analysis of the SCQ and the Focus Groups.
These include: Disagreements about diagnoses of problems amongst key players, Procedures not followed (some procedures were inadequate, others had become outdated) Inaccuracies in thinking Misplaced optimism Communication difficulties Poor Operator/Contractor relations Lines of authority unclear Inter-group problems Lack of relevant training/experience Indecision about nature of problem Group pathologies (group-think) Functional fixedness (tunnel vision) Cognitive lock-up Incorrect analysis Poor management responsiveness Problems with interpretation of instrumentation I . -
The psychological phenomenon of “Group decision making”, or when it goes wrong-“Group Pathologies”, has attracted much research over recent years. Group decision making, at whatever level, it seems, has its difficulties. Some of the worst decisions in history have been made jointly, emanating from deliberations of what Janis calls “victims of group-think.’’ Research has shown that shifts to risk or shifts to extreme caution can occur in group decision making.
References
Janis, L L. (1968) Victims of Group Think. Houghton Mifflin. Asch, S E. (1956) Studies of Independence and Submission to Group Pressure. Psychological Monographs, 70, (9).
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4.2 Safety Climate Questionnaire (SCQ)
The means for all questions are distributed around 4.99 See figure 1, page xxx. Since the scale is from 1 (poor) to 7 (good) most of the ratings tend toward the positive end of the scale and over 50% of the questions rated over 5. The lowest rated sections were “Management”, “Individual”, “Design WorWPeople, and “Training”
Some of the factors in the SCQ, which will contribute to human error, are presented below.
Safety Priorities These questions refer to the Safety Manual, Permits, Conflicts between Production and Time Pressure and Safety and Personal Safety. The lowest rated questions are in “Conflict between Production, Time and Safety”. Personal safety rated highly.
Communication The location of the individual worker on a rig and the background noise are obvious problems for communication. The telephone, radio communication and rig instrumentation systems rated below 6. Communication skills training had a rating of below 4.
Training The ratings from these questions reflect the feeling that more training could be given to “new starts” and more help could be given to their supervisors in relevant training skills. 50% of the questions in this section rated under 5.
Individual In this section 70% of the questions rated under 5. These questions refer to motivation, morale, job satisfaction, shift working, degree of perceived control and trust between management and workforce.
Procedures The questions are asking if procedures are; clear, effective, accurate, reflect working practice, are complete, unambiguous, accepted by the work force, changed, updated and audited. All of these were rated less than 6. This may not be high enough for important safety procedures. See comments and results from Focus Groups.
Design WorWeople This section as a whole was rated one of the fourth lowest. Only 3 of the 27 questions rated over 5. The section mostly refers to perceived time and work pressure and degree of control. See Focus Group results for personnel’s comments on these issues.
._ .
Design Thingsmquipment The ergonomics questions, including controls, alarms and PPE rate just over 5.
Management Seventy four percent (74%) of these questions rated under 5 . These questions refer to perceived management support and openness, trust, participation and control, teamwork,
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decision making, responsibility, relationships and the shift system. (These issues are also discussed in the Focus Groups).
Investigation/Evaluation Question 2 asks if near misses are investigated which rated over 6 . The section then goes on to ask if the analysis of root causes is comprehensive which rates just over 5 , then asks about management support, reprisals and a no blame culture etc. when errors occur, these questions rate just over 4.
4.3 SHERPA
SHERPA has identified 48 task steps from the SHERPA analysis of “Drilling for Oil”, from the sections - “Monitor status of well” -8, “Detect abnormalities” -9 and “Deal with kick” -1 1, (See example “Deal with kick” -1 1 on page 11) which have a high probability of occurring with a potentially critical outcome.
The analysis provided by SHERPA can be summarised into a table showing the dimensions of likelihood and criticality, see figures 4,5 & 6 .
Low Medium High
Probability /likelihood
Figure 4. Error potential for task 8 in Drilling for Oil. .
Figure 4 shows that a total of nineteen potential errors have been identified in task 8. Forty two percent of these potential errors were classified as critical and ten percent were assigned to the critical, high likelihood category. These latter potential errors should be given high priority when developing remedial strategies. It is suggested that companies look in detail at the sections where probability of error is high while at the same time possible critical consequences could occur from that error. This will identify where intervention and remedial strategies are required.
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Fimre 5. Error mtential for task 9 in Drilline for Oil.
As figure 5 shows, the number of potential errors rise with criticality, of one hundred and thirty two potential errors, thirty percent are assigned to the critical, high likelihood, category. This is an unusual pattern, but it does suggest that the successful early detection of incidents is highly dependent upon the vigilance and actions of the Mud Logger and Driller. It is suggested that these activities are worthy of further consideration to reduce the likelihood and criticality of potential errors.
- _ _ . . - . . . . -
" LOW
.. . Medium High
Probability /Likelihood . _ _ - -. -. . .. . __ __ .-
Finure 6. Error mtential for task I I in Drilline for Oil.
Figure 6 shows a more usual picture of potential errors. The relatively low number of critical. high likelihood, potential errors (some four percent from a total of one hundred and thirty six), offers some assurance. There are still some areas of concern however, which should be given the highest priority.
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The Human errors in the task steps are also potential root causes of unwanted
0 Poor procedure following 0 Communication difficulties 0 Cognitive lock up 0 Lack of trainingjexperience 0 Misreading of information 0 Poor instrument interpretation 0 Omit to read instrument 0 Fail to communicate information 0 Inappropriate action 0 Stress management
events:
4.4 Focus Groups
The following issues were raised in the Focus Groups. They are not intended to be in any order of importance.
1. Attitudes to Safety 2. Safety Procedures 3 . Staff Turnover 4. Paperwork 5. Bureaucracy 6. Managerial Atmosphere 7. Training
8 Shiftworking 9. Confidential reporting 10. Ownership 1 1. Work pressure 12. Stress 13. Motivation
1 management than from the workforce on how safety procedures are being carried out. There was a strong message coming down from upper management on the importance of safety but judging by all the comments made during the Focus Groups it appears that corners are being cut in the safety procedures where the more dangerous work is being carried out. The reasons given were work pressure, high staff turnover and tedious safety procedures. 2
3
There was the impression given of different messages coming from upper
The crewmembers did not seem to believe that the safety procedures were always
Staff turnover seemed to be a major concern with most Toolpushers, Drillers and necessary, effective, practical, appropriate or applicable in specific locations.
Assistant Drillers who had to spend a lot of their time looking after “New starts”. Often the Toolpusher would be spending many hours a day with them. Watching out for the safety of the “New starts” would hamper the Driller’s and Assistant Driller’s work. It was apparent that this extra involvement was hampering safety and production.
the working day to incorporate this.
agreed by most crewmembers that a good OIM is a good role model when he can interact with the crew in a participative manner with regular communication.
4
5
There were concerns expressed about too much paperwork and not enough time in
OIMs seem to be especially burdened by bureaucracy and paperwork. It was
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6 It was also a common comment that the OIM is very influential in changing the atmosphere on the rig for good or bad. A good OIM, it was often said, makes a good rig.
starts”.
than the 3x8 hours, which they say tires them out for about three days with the potential of more accidents happening during that time.
Most Management hoped that an “open-door” policy was in existence for confidential reporting of near misses. However, the comments suggest that the newer crewmembers do not feel that they are in a position to be confident about this. Some potentially very useful information seems to be going unreported.
maybe due to the strict hierarchy of the system where they do not perceive that they have a voice. Also among a lot of the workforce was a sense of lack of control. If workers perceive the “Locus of Control” is within themselves they work far more productively.
The pressure of work was often mentioned within drilling teams and crewmembers. Most of this they accept as inevitable. However, research has shown that a feeling of being in control increases the desire to meet deadlines.
The environment of a rig, it seems, causes its own stressors. The reasons given were; time, production, paperwork, home problems which are compounded because of the lack of telephone availability to sort out the problems, close working and living proximity with colleagues, supply of skilled staff, and some mistrust of Management.
was pointed out that when alarms go off, even to the point of sitting in the lifeboat for two hours, explanations are not often given. It was voiced that more feedback would increase motivation and understanding.
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More training was often desired and one specific area was the training for “New-
Some crewmembers would prefer the “short-shift” change to be 2x6 hours rather
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10 Ownership of their own safety seemed low in some of the younger workers. This
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13 Crewmembers would like more feedback from near misses or minor incidents. It
It must be stated that in bringing out these issues the project is looking for possible root causes and areas where improvements can be made. Without exception, the personnel interviewed where alert, hardworking and very professional. These issues can be used as hypotheses and cross referenced to test them against the appropriate questions in the Safety Climate Questionnaire, as an industry norm and by individual companies as guidelines for continuous improvement.
4.SHistorical well data
In addition to the Human Factors tools used in the project, twenty historical well control reports were received from the Participants. These reports were scrutinised in detail by a domain expert. There are suggestions that factors like “misplaced optimism” and “poor comm~nication’~ and the crews “not being focussed”, may have played a part in some of these incidents. There is also a suggestion that the procedures could be better focused to give clearer instructions to the crew in that particular scenario. Unfortunately analysis of the historical records failed to reveal any usable Human Factors data simply because these data are not collected as a matter of course. It is recommended that relevant Human Factors data be collected when recording incidents.
5 REMEDIAL STRATEGIES
The analyses conducted within this report have led to guidance for conducting Human Factors interventions. We are aware, however, that some of these issues are being taken care of in some systems. This guidance has been synthesised from STEPP, SCQ, Focus Groups and SHERPA.
5.1 STEPP, SCQ and Focus Groups
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Free OIM of unnecessary bureaucracy and paperwork to enable himher to communicate more with the workforce as a participative role model. An additional Assistant Driller responsible for “New starts” and their training. This would be more cost effective than the situation at present where the Toolpusher and Driller are spending much of their time with the newer crewmembers. This should also help with the problems of staff turnover, lack of ownership, and increase trust for confidential reporting. Increase the perception of “Locus of Control” for Drilling teams by involving them in planning of procedures (the people who carry out the procedures should be able to make a useful contribution), group decision-making, feed back from decisions made and shift patterns. More feedback from near misses and decisions made to increase motivation and understanding. Stress awareness training. The stress we have seen already being experienced from the environment would increase in an exponential curve manner when added stress from a slightly threatening occurrence e.g. a well control incident is introduced. In this state cognitive abilities are greatly impaired. Historically, disastrous decisions have been made in these circumstances and stress awareness training would prepare crews for such eventualities. A system to allow confidential reporting (the “no blame culture” is not happening), by improving the safety culture to encourage openness in reporting problems and near misses. (this may require a confidential reporting system) The responsibility for safety aboard the rig is everyone’s business. Audit and simplification of the “Permit to Work” system and “Safety Procedures”. Careful balancing is needed between production and safety goals. Procedures may need to be location specific. Improve communication problems which are caused by the individual work locations, background noise and the telephone system. Re-evaluation of shift-working patters to optimise human performance. Improve ergonomics of the drill floor. Increase ManagementlWorkforce perceived support and trust and inter-group and intra-group trust. Increase “Root Cause” investigation of incidents and near misses. Near misses are investigated but not always the root causes and not without shedding some blame. Training for Decision-Making, Group Decision-Making and Communication. Data suggests that problem solving is carried out as a team and yet training in group decision making is not carried out. Crews are not always happy with the decisions made.
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Improvements associated with social-psychological phenomena include concerns about trust, relationships, group decision making and communication. The historically strict hierarchy of the drilling environment is still in evidence. Research has shown that in this type of environment communication between levels is restricted. Poor communication, or lack of communication, has obvious connotations for breakdowns in the optimum performance of workers. The reliance upon verbal communication for transferring most of the information around the rig, particularly safety-critical information, became clear in conducting the HTA.
Improvements in communication skills are likely to have many “knock-on” benefits for all personnel. Thus the recommendation that such developments also include participation in group decision making workshops and training. Together with the proposal that management provide more rapid feedback, is the suggestion that greater participation by the drilling crew in decisions that effect them, could enhance the perception of mutual trust and improve relationships between the work force and management.
The high turnover of staff and poor procedure following are inter-related to some extent. The lack of experiencehraining staff and poor procedure following may be corrected if staff retention was better. This would enable more experienced personnel to amass within the drilling crew who would be in a better position to train newcomers. The relatively high turnover rate mitigates against a longer-term training investment, but this might also be seen by employees as a lack of commitment by the drilling company. This last point makes it clear that there is a complex interdependence between most of the factors, as indicated in the content analysis of the Focus Group material. Maximum benefit will be obtained by a holistic and strategic approach that acknowledges that many of the factors are intertwined.
5.2 SHERPA
The data presented in figures 4, 5 & 6 may be used as a baseline from which to compare all future proposed changes in working practice. Ideally, the SHERPA analysis would be performed, either prior to undertaking the changes or at a test rig, where the new working practices are being evaluated. Statistical comparisons can be undertaken with SHERPA data in order to determine whether or not the improvements are beyond the chance effect.
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Improvements in equipment design and group decision-making skills should help avoid attention lapses and cognitive lock-up respectively. Given that very little, if anything, can be done to change the cognitive system, improvements in the working environment (physical and social) should help capitalise on human capabilities rather than exposing their limitations.
Environmental improvements need to address the physical conditions under which work is performed, i.e. the extremes of temperature and ambient background noise. Both noise and the thermal environment are potential distractions from the task in hand. If people are uncomfortable (too hot or too cold) they are less able to devote all of their concentration to their jobs. Similarly, the mental cost of shutting out an aural distraction is to make less attentional resources available for the job of work.
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Research has shown that even quite moderate levels of background noise (i.e. 75-85 dBA) have a detrimental effect upon performance. The effect is worse for more complex tasks than for simple tasks. Thus resources committed to reducing these distractions would lead to corresponding benefits in improved task performance. In addition, noise can cause communication difficulties on the rig which relies heavily upon verbal communication. When people are required to shout over a background noise in order to pass on information, some of that information can be lost and the message may be incomplete or misconstrued. This has obvious implications for safety effectiveness of operations. Apart from blocking the noise at source or protecting the drilling crew from the noise, other remedial strategies have been proposed, such as not relying so heavily upon verbal communication.
Poor design was implicated in the three of the root causes in table 4.1. These were largely associated with the manner in which information was presented to people. Ergonomic improvements in the information design, display and location would lead to corresponding improvements in human performance. The remedial strategies detailed here indicate where many of these design changes should occur.
Computer-promptedperiodic check for Mud Logger -particularly for key variables.
Disabling of Alarm setting not optional for some variables.
More central placement of key displays, using Human Factors Layout analysis. Parameter Variables presented separately to prevent misreading
Re-design of trend displays by computer presentation so increases are made more obvious.
Computer-prompted alarm level tolerances to assist the Mud Logger.
Alarm buffer to reduce the likelihood of false alarms.
Transmit important information e.g. high gas, to all parties automatically.
Transmit information to all parties by electronic link- gives permanent record, less prone to human error, ambiguities and forgetting. Several people receive message at same time.
Standardise information communication procedures.
Computer-generated tables (expert system) to suggest expected mud loss.
Computer-based, hypertext, procedures to replace paper- based manuals.
Closed Circuit Television (CCTV) to help diagnose problems e.g. presenting the Mud Logger with CCTV on the mud shakers could help him/her determine ifthe shakers are blocked or not.
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Task-based displays that only present information relevant to the task being undertaken.
Checklist in prominent position in dog-house or mud hut.
Layout analysis of shut-down panel.
Automation of shut-down sequence.
Sensorfiom well showing position of drillstring to Driller.
Ergonomic placement of annular and ram switches.
Kill assembly pressure test.
Automate operating pressure testing.
Computer-basedpro formas for information.
Automatic logging of SICP information.
On-line satellite weather systems.
Expert systems could assist in the selection of the appropriate well kill method.
Mechanized slips.
Sem i-automated bleeding procedure. Design of assembly could be improved to make the differences between assemblies clearly apparent and improve the ease of3tting.
Handheld data communicatorsTo improve communication between all of the individuals on the rig, and to reduce some of the inherent weakness of relying totally upon verbal communication.
Each of the ergonomic remedial strategies has been assessed in terms of their incident prevention efficacy (IPE: the degree to which the recommendation would help to prei-ent incidents from occurring), cost-effectiveness (CE: the ratio of cost of the incident of the incident by the expected frequency of the incident), user acceptance (UA: the degree to which workers and organisation are likely to accept the implementation of the recommendation), and practicability (P: the technical and social feasibility of the recommendation
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6 . RECOMMENDATIONS
In conclusion to this report, there are a number of recommendations that follow on from the analyses. These recommendations relate directly to methods for optimising Human Factors in the Oil and Gas Industry
6.1 Full Hierarchical Task Analysis (HTA) and Systematic Human Error Reduction and Prediction Approach (SHERPA)
The HTA and SHERPA analysis undertaken in this report were of a preliminary nature and would benefit from more extensive study in the Oil and Gas Industry. A full analysis of each person’s tasks (e.g. Site Controller, Drilling Supervisor, Geologist, Toolpusher, Directional Driller, Assistant Driller, Mudlogger, Mud Engineer, Derrickman, Crane Operator, Roughneck, and Roustabout), based on a more refined HTA would reduce the chances of near misses and incidents and lead to improvements in both effectiveness and safety. This effort and expense could be shared between Drilling companies.
6.2 Periodic Re-assessment of Safety Climate
It is recommended that the Safety Culture Questionnaire be conducted annually as a climate indicator as well as identifying differences where intervention has occurred. It is important that all parties recognise that the SCQ is part of an overall improvement process and that the implication of an action plan to address the most significant weaknesses be carried out as soon as possible after the initial assessment. The data are suitable for statistical comparison, making it possible to test for differences over time as well as between individual rigs. Operators also may find the results from the SCQ an aid in the selection of Drilling Contractors.
6.3 Recording Human Factors data
During the analysis of historical data, it became clear that Human Factors data is not being recorded. It is recommended that these data be recorded on all incidents and near misses if headway into understanding Human Factors contributions is to be made. This would require a change in the emphasis placed upon incident investigation, to gain the co-operation of people rather than encouraging them to close ranks. Verbal communications via telephones could be recorded in the same way that flight recordings are made by the black box in aircraft. Collecting and analysing these data would provide greater insight into human fallibility
a group activity has been shown to be an excellent way of building “team spirit”, increasing knowledge and safety awareness for “new-starts’’ and identifying mistakes which may be avoided in future.
Carrying out the STEPP procedure on near misses or minor unwanted incidents as
6.4 Confidential Human Incident Reporting Programme (CHIRP)
The industry as a whole could adopt a CHIRP-type database, to record Human Factors concerns from near-miss reports submitted by the personnel on board rigs. The model for this style of reporting is well established in the aviation industry. In the event of a near miss (an event which could have led to a serious problem), pilots
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voluntary file a CHIRP report to the Civil Aviation Authority (CAA). The CAA collate all of the data for analysis and regularly feed this information back to pilots, airline companies, aircraft designers, and aircraft manufacturers. The system works because confidentiality is maintained and the benefits of being involved far outweigh any disadvantages. The operation of CHIRP is supported by an annual fee levied on the airline companies.
A similar operation could be supported by the Oil and Gas Industry. The concept of an Oil CHIRP could be promoted to oil companies and personnel. One implementation might take the form of a global anonymous electronic STOP card. The report is sent electronically to the database, and no record is kept on the computer at the rig. The Human Factors team at the database could analyse the data as it arrives and complete quarterly or monthly reports which are sent to all co-operating rigs and companies. This sharing of information in this type of exercise could benefit the industry enormously.
6.5 A correlation of the benchmarking results and safety statistics
In line with 6.2 it is recommended that the participating companies compare their benchmarking data results to their safety statistics i.e. near misses and lost time accidents. If action plans, in the light of the identification of the root causes and recommended remedial strategies, are to be taken, it is recommended that the effectiveness of the intervention be validated. A correlation of these should be carried out before and some time after intervention. The results should show a correlation between the safety culture and safety performance and would be a measure of the effectiveness of the intervention in improving operational performance.
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7. CONCLUSIONS
0 Five Human Factor techniques were applied to personnel in the offshore environment. They all worked very well and a substantial amount of data have derived from their application. Data resulted from, a Sequential Time Event Plotting Procedure (STEPP), a Safety Culture Questionnaire (SCQ), a Systematic Human Error Reduction and Prediction Approach (SHERPA) and the Focus Groups. A STEPP Analysis has illustrated how near misses or incidents can be analysed to look for the “root causes” of the incident and learn lessons from past mistakes. A SCQ was designed for this project. The analysis of the SCQ data allows for scrutiny of people’s perceptions of, and attitude towards, safety and other relevant issues. Ninety-three SCQ have set a baseline of the industrial norm. Each company has been supplied with their own means from each of the 12 sections in the SCQ for benchmarking purposes. They can also look in detail at the specific issues and areas they wish to improve upon. The SCQ is recommended for the assessment of “culture temperature” every 12 months. A SHERPA analysis has identified many defined areas in drilling tasks which have a high likelihood of error while at the same time a high probability of a critical outcome. The SHERPA tables indicate priorities for addressing the potential errors identified. SHERPA is recommended for the assessment of changes in working practices The eighty-six personnel interviewed in the Focus Groups contributed many issues for thought and discussion. Focus Groups are recommended for gathering more qualitative information and are a cost-effective method of “getting to the root” of these issues on a rig. The overlap of root causes from the SCQ and Focus Groups confirms confidence in the data and shows some solid trends. Benchmarking was achieved from the SCQ and SHERPA to provide industry norms as well as a basis for comparing with re-test results after the subsequent intervention of remedial strategies. The analysis of Root Causes comes from combining the results of STEPP, SCQ, SHERPA, and Focus Groups and was undertaken at a meta-level. A total of 25 underlying Human Factors root causes of accidents were identified. From this in- depth analysis, the report highlights many areas of human behaviour, perceptions, beliefs and potential hazards in working practices which culminate into the real issues which effect safety and performance in the drilling environment.
0 --The analysis led to over 40 remedial strategies being proposed. These span the drilling environment allowing for action plans to be taken at many levels for corrective and preventive action. These strategies would help in realising immediate benefit from the consideration of Human Factors in drilling operations, as they were derived from an in-depth analysis of credible problems arising from human activity. Recommendations have been made for continued improvement in the Oil and Gas Industry. The project has, we believe, proved that Human Factors can offer powerful tools for the identification of root causes and remedial strategies in the Oil and Gas Industry. In summary, these analyses show that Human Factors has a valuable contribution to make in achieving step changes in safety and efficiency of drilling operations.
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