Eight interviews from the annual safety conference 2013

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3Safety ConferenCe 2013Task Force Zero

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5Safety ConferenCe 2013Task Force Zero

“Jim Trodden explains: When new

people – green hats – arrive on my

platform they get safety videos

telling them about life boats, es-

cape routes, personal protective

equipment and other basic safety

information. And then they meet

with me. We sit down with a cup of

tea and I tell them the important

things, the things they need to re-

member now – because they have

arrived at what I believe is one of

the best places in the North Sea.

I tell them that there are no dou-

ble standards about safety here, I

tell them about the principles by

which we operate: Do it safely or

not at all. There is always time to

do it right. I assure them that this

is not just another corporate state-

ment but rather a contract between

me, the person who needs to get

some work done, and the people

who will do the work for me. I re-

mind them of their Stop-Work-Au-

thority – if they see things that look

unusual or concern them, they have

the authority and the responsibil-

ity to stop the work, their own work

or someone else’s work. And the

Stop-Work-Authority is used here

on a daily basis – without penalty.

It is a responsibility and its use is

actively encouraged.”

–You have been in the industry for

a long time – what development

have you seen in this period?

Trodden: “I have worked in the oil

industry since 1977 and for Chev-

ron the last 24 years – I have never

regretted my move here. Chevron

is an enlightened company, a

multi-cultural organisation which

runs its operations in a uniform

manner world wide.

The biggest change I have seen

in the North Sea in general is the

move away from a command and

control, strict hierachy where you

did as you are told to do, nothing

more. Today we value contribution,

we encourage ’neck up’ compli-

ance, we advocate personal respon-

sibility for safety and we strive for

meaningful engagement. The in-

dustry is on a long march, moving

from a regime of control to mutual

respect. Some of us are a lot further

down this road than others! But

we all still have a lot to learn and

improvements to make – though

sometimes progress can feel slow,

which worries me at times.”

– Do you think this change has

come as a result of incidents or is

it a ’natural’ development?

Trodden: “Incidents have accel-

erated this development; most

companies will now encourage or

maybe even insist on reporting.

Anything unusual should be re-

ported. And all incidents are to be

investigated appropriately – it is a

clear Chevron requirement that if

a safety device is found to not work

or is not active when it should be

– it is an incident. And all incidents

are to be investigated based on

their potential severity or conse-

quence.”

– What influence did the Macondo

disaster have on your operations –

if any?

Trodden: “Of course the Macondo

disaster had an impact on the or-

ganisation worldwide, in particular

with regards to drilling and Chev-

ron has worked within the industry

to raise standards and improve in-

cident prevention, intervention and

response capability. As always, les-

sons must be learned from a spe-

cific event – real hazard awareness;

comprehensive risk assessment;

compliance with good processes

and procedures and, critically, the

understanding and acceptance that

anyone involved can stop the work

before the consequence of signifi-

cant deviation occurs.

I would like to add the following

because I think that there is a

problem that can only be resolved

at an industry level. When I receive

a temporary piece of equipment

offshore, a diesel generator for ex-

ample, I get data sheets with all the

necessary information about this

generator – input, output, rating,

certification of its lifting frame and

slings. That allows me to plan my

control of this piece of equipment.

When transient workers – contrac-

tors – arrive on the platform, I have

absolutely no idea about their at-

titude regarding safety; I do not

know what has moulded them. I

only know that this person is sup-

posed to be a specialist in his field,

he has the necessary offshore

safety training – and that’s about it.

And it is a concern – because only

about 26 percent of the people on

the platform are directly employed

by the operator. The others – the

majority are contractors, suppliers

from all sorts of companies, differ-

ent backgrounds, different experi-

ence, different nationalities – they

all have to blend in and work effec-

tively inside ’our’ culture. That is

why it is all about people’s attitudes.

I recommend to all to find out

more about ’Step Change in Safety’

and the excellent work they do to

change thinking, attitudes and be-

haviours.

All must understand the impor-

tance of leadership – the message

must be unambiguous, undiluted

and transported right from the top

of the pyramid to the person on the

tools.

I want to mention in particular the

good practice of regular senior

management visits. In the old days

these visits were very infrequent

and an OIM would determine what

was to be seen and who was to be

talked to; out would come the good

china cups and the best coffee.

Today the visitors still get the best

coffee but they drink it from the

same cups as the regular offshore

people, they determine what is to

be seen and who is to be talked to

– access to anywhere, anything and

everyone on board. Top manage-

ment plays a key role in setting and

sending the message.

That’s why Chevron management

comes out to see for themselves if

the message has been received –

that is why visible leadership is key”.

leadership is keyJim trodden, offshore Installation manager on Chevron’s alba northern platform in the uK north sea emphasises the importance of the right message from top management being received by the people on the installation.

Interview with Jim Trodden

By Hans Jørn Johansen

6 Safety ConferenCe 2013Task Force Zero

the hSe standards and processes need to be relevant to those in the field

Richard Taylor: ”The diversity and

different approaches in driving im-

provement in health and safety is

the interesting challenge for me.

That you can add value and make

a difference.

There is a very advanced legislation

and a very mature workforce in the

north west Europe compared with

some less developed parts of Af-

rica which are in the early stages of

their oil and gas career. You don’t

have the same drivers on health

and safety in some parts of the

world where the legislation devel-

opment and enforcement of HSE is

in the infancy stages.

This makes it even more important

as a company to ensure your have

robust systems in place. It should

not matter where you are working –

compliance should be the same. It

may have to be tackled in different

ways and you need to taylor your

approach.

We apply the SLB HSE standards

globally; however as you are dealing

with different competencies from

the workforce you may not always

get the same results. It is refresh-

ing that even in new and emerging

countries people are eager to learn

and willing to improve.

In terms of developing the safety

culture a simple example of this

is seatbelt usage. In many coun-

tries in which we operate the wear-

ing of a seatbelt is strictly enforced

through legislation and has been

for many years. For these employ-

ees putting a seatbelt on when

they jump in a vehicle is habit; It is

more of a challenge for other em-

ployees operating in other coun-

tries where seatbelt laws are not

enforced or where vehicles are not

fitted with seatbelts. We there-

fore educate the workforce to un-

derstand that this is to help keep

them safe. If we can transfer this

type of safety behaviour to outside

the workplace and to their fam-

ily members then we know we are

making an impact – this is the chal-

lenge. So a major part of our job

is to help develop safety culture:

what you do inside the work place

should be no different from what

you do on the outside.

The security challenges are becom-

ing increasingly important. We are

now seeing increased security risks

from crime and terrorist attacks

that we did not have 5-10 years

ago. So that opens up a new area

that must be handled in close coop-

eration with the client.”

— What did Schlumberger change

as a learning from the Macondo

disaster?

Taylor: ”Tragically M-I SWACO lost

two engineers in the Macondo di-

saster. The focus was there through

the development of our well in-

tegrity barrier standard, no. 22. We

have a very good reporting system

’Quest’. Since the Macondo we have

had a hard look at our reporting

and incident investigation system

’Quest’. We realised that we need

to hone our focus more on process

safety incidents and on our high

potential incidents. A high potential

report is a potential loss which did

not materialise due to another bar-

rier that funtioned – the ’holes’ did

not match up.

The High Potential incidents now

receive the same level of attention

as actual incidents, where we had

a loss. Before HiPo reports were

richard taylor, Hse manager, europe/africa, schlumberger talks about challenges and drivers as an HSE professional who has worked in different parts of the world and with different schlumberger business segments.

Interview with Richard Taylor

By Hans Jørn Johansen

7Safety ConferenCe 2013Task Force Zero

fewer, classification of what is a

HiPo needed improvement and of-

ten only very actions were coming

out of the HiPo investigations. This

has now improved. Last year we

recorded over 600 High Potential

incidents in Europe and Africa with

more actions and timely closure.

In addition our major High Poten-

tial incidents are now also subject

to a full review by corporate senior

management.

Another area of improvement was

Observation-Intervention reporting.

This has also improved with more

widespread participation and in-

creased focus on Line Management

participation We openly acknowl-

edge and reward those employees

that have raised good quality O/Is.”

— Are your employees able to

freely intervene in at-risk situa-

tions?

Taylor: ”It very much depends on

the openness of the operator and

on the site. Sometimes we have had

to stop the job. But there is a reluc-

tance to do so in some cases. For

a young technician or engineer who

is working with an operator with

years of experience it can be quite

tough to stand up to this client rep-

resentative.

We train our people to get used

to handle such situations through

’stop-the-job drill scenarios’ where

fx a senior management represen-

tative from our own company per-

forms an activity which should be

stopped. Through such situations

our people are trained in observ-

ing and intervening. We work hard

to improve the attitude and willing-

ness to voice safety concerns.”

— Schlumberger works for many

different operators around the

world – what challenges do you

see here?

Taylor: ”It is a of course a big chal-

lenge to work for different oper-

ators and with different contrac-

tors. But such is the nature of our

business. Due to confusion about

lock-out/tag-out procedures we

had an incident last year and again

it showed us how important it is

that you know what system you are

working to. Bridging documents

then become important – the sys-

tem itself is not so important as

long as we agree what system is

being used – a typical example is

the permit to work system.

We prefer to become involved in

planning at an early stage – some

clients are very good at this – and

it is beneficial for all parties

Schlumberger is such a diverse

company with many different busi-

ness segments. This has opened

our eyes to the fact that one size

does not necessarily fit all and that

we need to have a risk based ap-

proach to the performance of the

work.

It is important that our standards

are written for the guys out in the

field – not for the HSE profession-

als. And we need to focus on the

big picture look at the High Poten-

tial incidents early on and what

critical lessons we learn and share

– not just the slips, trips and falls.”

A major part of our job is to help develop safety culture: what you do inside the work place should be no different from what you do on the outside.

9Safety ConferenCe 2013Task Force Zero

it’s all about people and their competences

— What were the conclusions by

your workgroup that studied the

Macondo Investigation reports?

Søren Risgaard Jeppesen: ”It was

quite clear to us that we could

make improvements to the equip-

ment – and we have made some

changes to the subsea BOP. The

main observation from this inci-

dent however – as well as other

incidents – is that competent crew

is the key to safe operations. Our

main recommendation was there-

fore to implement a state-of-the-

art training environment.”

”Running an integrated training

program for the assistant driller,

the driller and the toolpusher was

the hard bit because we had to

build a completely new simulator.

The investment was more than 10

million US$. I am happy that our

management fully supported the

recommendation and made the

money available. We strongly be-

lieve that this is necessary to en-

sure that all personnel work to-

gether while you are safe on the

simulator. It allows you to make

mistakes and learn from them. And

most importantly: It is now not just

a matter of passing a test – what

matters is that you can cooperate

with your colleagues and respond

to problems as if it were real life,”

says Søren Jeppesen.

— How can service specialists –

the so-called ’third party’ contrac-

tors – who play an important role

in the well construction and opera-

tions – also become involved in the

training?

Søren Jeppesen: ”We may see the

need in the future. For the time be-

ing we concentrate on our own crew

– we also invite the client represen-

tative to participate – and some of

them think it is a brilliant idea.”

— When the Deepwater Horizon

was unable to fully cut the drill

string one would assume that

changes to the BOP was a simple

and effective solution. Yet Maersk

Drilling chooses to focus on drill-

ing crew?

Søren Jeppesen: “The BOP is a com-

plicated piece of equipment – add-

ing more gear would introduce new

complicity and more maintenance.

We want to focus on prevention

of the accident especially through

crew resource management. But we

have actually upgraded the work-

ing pressure of our subsea BOPs

which means, that we are now able

to shear 6 5/8” pipe at the tool joint

and hence our subsea BOPs can

shear this pipe at any point on the

drill string.”

— The drilling programme is

worked out by the operator of the

license. In your opinion do you

think that the drilling operator is

sufficiently involved in the planning

of drilling operations?

Jeppesen: “We have introduced and

offer to our clients a so-called ’Ser-

vice Delivery Engineer’ (SDE) – a

person with an operational back-

ground who is placed in the client’s

offices. The SDE follows the devel-

opment of the drilling programme

and has the opportunity to deal

with client questions at an early

stage. It has turned out to be a win-

win situation: plans get corrected

before you start operations, safety

is improved and often it results in

reduced operational time also.“

— What has the industry learned

from the Macondo disaster?

Søren Risgaard Jeppesen: ”Many

companies in our industry are still

of the opinion that filling in obser-

vation cards is the most import-

ant element. I think that we need

to focus a lot more on the high po-

tential-low frequency situations.

Constantly being aware that we

stay alert and keep our systems

ready to respond. We do hold hand-

rails when walking on stairs – but

looking out for weak signals and

responding to them is a better way

of preventing major disasters – to

do this we need competent and

assertive crew.”

senior Director søren risgaard Jeppesen, head of maersk Drilling QmHse department was appointed as a specialist member of a work group to make recommendations as a follow up to the Macondo Disaster in 2010.

Many companies in our industry are still of the opinion that filling in observation cards is the most important element. I think that we need to focus a lot more on the high potential-low frequency situations.

Interview with Søren Risgaard Jeppesen

By Hans Jørn Johansen

10 Safety ConferenCe 2013Task Force Zero

Tonny M. Møller: ”In the 1990es

Maersk Training developed the

bridge ressource management

training for ship crew. This was

strongly inspired by the aviation

industry who had developed their

crew ressource management.

We designed a dynamic position-

ing simulator for anchor handling

in Maersk Supply vessels working

together with a drilling rig. So it was

quite natural to also develop a rig

ressource management module.

Now we have moved it to another

level which allows you to train not

only selected parts of a rig but the

full scale integrated training where

the rig operator, the client, the

shore base and the head office are

involved to see if all play from the

same sheet. You will be asked to

cooperate in a scenario which looks

very much like the situations one

would experience in ’real life’.”

— Normally the driller gets direct

information on what goes on in a

well and then makes decisions on

the well’s condition – what are the

benefits of running an integrated

training for the whole drill crew?

Møller: ”A small problem in the

crane or in the engine room may

cascade to become a bigger threat

to the offshore installation – there-

fore it is a good idea to train not

only well control but also for exam-

ple let a generator develop a prob-

lem which leads to the rig having

problems with station keeping. This

again requires the driller and the

barge engineer to cooperate about

necessary decisions.

The simulator is really just a tool to

get people to better remember the

theory. If we can make the simulator

close to ’daily work’ it is more likely

that the participants will bring the

desired skills and behaviour back to

their work place.

The final step is when we connect

all simulators. That allows us to

combine training of crane opera-

tors, engine room operators and of

course the drill floor. You can simu-

late a situation where you not only

handle a situation on the rig but

– while training the rig crew – you

also train your shore base and your

home office. They then need to

communicate with next-of-kin, the

media and the regulators via the

crisis management module in a

full scale simulation.

It is about changing people’s be-

haviour such that the safety on

your installation is improved while

at the same time the performance

is also improved. Safety walks

hand in hand with effectiveness.

The team based training is a good

way of improving communication

and train cooperation – not only

between the driller and the tool-

pusher but also with other depart-

ments. You may also include the

client and involve him in the deci-

sion making process.”

— How can the individual benefit

from this kind of training?

Møller: ”It is quite normal for hu-

man beings to ’stick’ to solutions

that they have tried before – but

even if you have done it many times

before it may not always work. This

new training environment allows

the participant to try out new solu-

tions or – if it turns out that a solu-

tion did not give the intended re-

sult you can press ’replay’ and work

through the situation again – safely

– and with the help of your collea-

gues and the trainers. In this way

the participant gets new skills and

the desired behaviour is promoted.

It is particularly important for drill-

ers and toolpushers that they are

allowed to train when to stop the

operation and consult with a supe-

rior if certain parameters can’t be

achieved. Having done this on a

simulator gives them the confi-

dence that they are acting respon-

sibly and in accordance with the

drilling programme.”

— This type of training is devel-

oped for Maersk Drilling – what

should other operators do?

Møller: ”Maersk Training developed

the training because Maersk Drilling

asked for it. The training is open to

all interested oil and gas companies

and rig operators. We have already

got attention from some oil majors

and will of course develop and tai-

lor training as required. For the time

being it is only Maersk Drilling who

perform the integrated, team-based

training.”

— The current rules for training of

drill crew only require some of the

team members to have passed a

test – IADCs WellCap training or the

IWCF test. Do you think your new

concept will also make an impact

on the rules such that more people

on the drill crew need to become

certified?

Møller: ”There are discussions on-

going between IADC and IWCF if

the two standards could become

only one. As it stands today Well-

Cap and IWCF is the lowest com-

mon denominator. It is then up

to the industry decide if the inte-

grated team-based training should

be the standard. And if so, we are

ready to help.”

you can press replaytonny m. møller, maersk training talks about the vision for integrated, team-based training.

Interview with Tonny M. Møller

By Hans Jørn Johansen

The final step is when we connect all simulators. That allows us to combine training of crane operators, engine room operators and of course the drill floor.

11Safety ConferenCe 2013Task Force Zero

More than technical skills

— What was the background for

your decision to develop the Lead-

ership Program ?

”You need to understand the role

you have as a ’company representa-

tive’ Magnus Florvaag explains and

continues: ”As a company represen-

tative you are the client’s on-site

eyes and ears. You are also in a situ-

ation where the rig operator or the

vessel captain has the day-to-day

responsibility for safety. And at the

same time specialist suppliers are

on contract to the client – but their

services have to be delivered in

close co-operation with the rig op-

erator or the vessel owner.”

”In this ’triangle’ of responsibilities

you place the company representa-

tive. We realised that our company

representatives sometimes had a

challenge in defining their role. We

therefore developed the so-called

’ground rules’ – rules that every

DONG E&P representative should

follow”

”This was quite elevated rules –

nine areas covering a.o. planning,

execution, evaluation, leadership,

communication, trust and safety

behaviour were described in a

booklet. Each subject was broken

down in individual statements such

as ’I will ensure that…..’ This was the

easy bit. But making sure that the

rules did not just end up in a desk

drawer or in a pocket in the boiler

suit we needed to do more – make

the rules come live – live the rules,

if you like”.

Magnus Florvaag explains that

Center for Ledelse – CfL (Centre for

Management) was approached and

asked to help out. In close co-op-

eration with DONG E&P company

representatives CfL worked out a

Leadership Development Program.

The complete package is a training

course consisting of 3 modules, a

total of 11 days. Each of the mod-

ules are designed such that there

is time to practice what you have

learned and receive feed-back and

coaching from your fellow buddy,

students and the trainers. Three

courses have been held – 36 par-

ticipants have passed the training

and practice their new skills. The

Leadership Program is now a re-

quirement for all DONG E&P pers-

onel who work as CoReps on con-

tracted operations.

”As part of the programme the

students communicate with their

fellow students and with their

trainers while on the job. We have

had two trainers offshore to ob-

serve and coach our CoReps. This

has been very powerful and given

further information to improve the

program”, says Magnus Florvaag.

Magnus continues: ”Another strong

side was the mix of company rep-

resentatives from contracted ves-

sels and drilling rigs. It turned out

that the two groups had a lot in

common and new synergies were

developed by having them on the

same training course.

Another effect was that we needed

to develop a short ’management

version’ of the CoRep training for

managers onshore such that they

were able to understand and sup-

port their offshore Company Repre-

sentatives in the correct manner”.

— This conference mentions that

the Macondo disaster was a game

changer. How did the Macondo inci-

dent influence your Leadership De-

velopment Program?

Magnus Florvaag: “We had started

our work more than a year before

the Macondo disaster. Our internal

task force which studied the rec-

ommendations from the various

incident and investigation reports

confirmed that people skills, com-

petences and clear roles and re-

sponsibilities were key to success.

In that way we could continue the

development of the Leadership De-

velopment Program.”

— What are the results so far?

Magnus Florvaag: “The major

change is that the DONG E&P CoRep

focus on describing the ’what’. The

rig contractor and the specialist ser-

vice provider describe and execute

the ’how’ – as they were contracted

to do in the first place. During exe-

cution the CoRep ensures that de-

liveries are in accordance with the

agreed plan.

Success so far: Service providers

have complimented us for allowing

them to step up to their responsi-

bilities.”

technically competent people need more than ’just’ technical skills. magnus Florvaag, Drilling manager Dong e&p norway tells about the background for the tailored leadership program for non-technical skills.

Interview with Magnus Floorvaag

By Hans Jørn Johansen

12 Safety ConferenCe 2013Task Force Zero

Ramsing: “9/11 in the USA was a

turning point – also for me person-

ally. I had just relocated an IT com-

pany to the United States, when the

terrorist attack caused US Postal to

cancel our project. All of a sudden

a great part of our business was

non-existing.

But when one door closes….We be-

came part of the subsequent large-

scale material handling and logis-

tics projects where, as an example,

the American airports were to han-

dle security screening of domes-

tic luggage – something which was

not done before. In the US hun-

dreds of airports had to be re-built

under intense public and political

scrutiny. On the American scale,

material handling is rather com-

plex, requiring all participants to

play the same tune in a very safe

and coordinated manner; from

green field to 4.500 employees in

just a few years is not uncommon

for new and massively automated

distribution centres. You need

to get a large number of compa-

nies and their people to efficiently

co-operate in order to reach the

common goal. It requires continu-

ous learning, robust change man-

agement processes and strong,

personal leadership – which is what

really what I like to help develop.

Multicultural cooperation is as

much a given in complex indus-

trial installations as it is in our sur-

rounding, modern society. Many

international companies need as-

sistance in handling the corporate

and the interpersonal dilemmas

when you move or expand your or-

ganisation. You need to maintain

the company culture while blend-

ing in new people – often with dif-

ferent cultural or national back-

grounds from different parts of the

world. With projects in Europe, the

Middle East, US, India and China I’ve

seen amazing results with the right

and authentic leadership.”

— So how did your experience

match the work which you now do

for DONG E&P?

Ramsing: “What is particular to the

oil and gas industry is the unforgiv-

ing environment that require re-

al-time decision making. You can-

not just take a time out and say

’let me get back to you next week’.

When an offshore installation is in

operation you are required to bring

the right parties together and ar-

rive at the right decisions based

upon the strengths of all involved.

You need the ability to get people

to cooperate – getting the process

to continue and at the same time

preventing that a conflict develops

– which is especially difficult when

you do not have the ’formal’ author-

ity but have to lead and motivate

resources reporting to other enti-

ties and organisations.

We help the CoRep participants

to find their own strengths and ex-

pression – which may pose a par-

ticular challenge when you work

in a language that is not your na-

tive tongue. Therefore the train-

ing starts on day one with facili-

tated role-play and finishes off in

an extensive real-life simulation.

In the final full-day exercise all par-

ticipants are confronted by profes-

sional business actors who recreate

the participant’s own challenges in

much the same way as live flames

in a fire drill. Through this dry run of

truly difficult situations, the partici-

pants are far more likely to be able

to also handle the tough leadership

challenges in real life.

The participants are trained in

non-confrontational, interpersonal

leadership while simultaneously

avoiding silently accepting at-risk

behaviour. They must step into a

situation and interact without caus-

ing an unnecessary escalation and/

or decision delay. One of the situ-

ations that is role played involves

a sizable roustabout, who acts ag-

gressively – the participants must

handle the intervention and realise

how to overcome the tense and un-

pleasant situation – including look-

ing out for possibilities and allow-

ing others to state their opinion.

Also the training material is differ-

ent. Together with DONG E&P we

have refined the CoRep’s essen-

tial Ground Rules and selected the

matching leadership tools into a

unique deck of playing cards. We

use the different cards for specific

perspectives: Spades cover DONG

E&P requirements, hearts hold the

leadership behaviour while clubs

covers the team and diamonds

are the mental prism and mindset

through which the entire ground

rule must be approached. Addi-

tional information about each card

is available on the participant’s

iPad, which also holds the course’s

portfolio of apps for individual

learning, information sharing and

collaboration.

We offer several different yet mu-

tually supportive leadership tech-

niques for the specific challenges

found on an offshore installation.

The intention and achieved objec-

tive is that the willing participant

understands how to use the differ-

ent techniques for different needs.

A few examples: How to take time

to lead and how to stay observant

within the complex environment.

How to prevent conflicts and how

to give and receive feed-back, how

to use different coaching and ques-

tioning skills, how to intervene,

how to show willingness to reach

decisions and how to allow others

to speak their mind, emphatically:

how to make, motivate, communi-

cate and keep robust agreements

and much more.

Even personnel with long offshore

industry experience compliment

the program and develop new skills

– which is another reason why I am

really proud of being part of this

truly meaningful journey towards

stronger leadership and greater

safety.”

Real time decision makingulrik ramsing, Chief advisor, Cfl (Centre for leadership) with a background from material handling in large, complex organisations was asked to help offshore managers develop their interpersonal and non-technical skills

Interview with Ulrik Ramsing

By Hans Jørn Johansen

13Safety ConferenCe 2013Task Force Zero

John L. Thorogood: ”My journey

into human factors and human er-

ror started in 2001: I was involved

in a deepwater operation within

the Faroe Islands. We made a cou-

ple of decisions which in hindsight

were not as good as they could

have been. It gave me an under-

standing that our decision making

skills could be improved. Together

with Aberdeen University we devel-

oped a programme for non-tech-

nical skills for drilling people in-

volved in decision making. The

programme was deployed within

the company and we actually prac-

tised some of these decision mak-

ing skills when we went back to the

Faroe Islands to abandon the well

the following year.

Our industry had three serious

incidents during a period of only

9 months. In 2009 there was the

Montara blow out, on Christmas

Eve that same year there was an-

other near miss in the North Sea

and then finally the Macondo

disaster in 2010. All these three

incidents – and in particular the

Macondo – were officially explained

as failure of equipment, manage-

ment process or lack of compe-

tence of personel. But an alterna-

tive reading of the investigation

reports suggests less of a problem

with the equipment and proce-

dures and more closely a problem

related to human factors and or-

ganisational questions.

Since then, I have spent a lot of

time studying the relevant litera-

ture on human error, psychology

and decision-making. I came across

the concept of ’high reliability or-

ganisations’. I have then tried to

hold a mirror up to the industry,

asking ’can you recognise the oil

and gas industry – and in particu-

lar the drilling industry – in this pic-

ture?’ Reluctantly, at present, the

answer is: ’no’.

To start moving the drilling in-

dustry to a ’high reliability state’

there are some important things

you need to do; instil a sense of

”chronic unease”, develop a preoc-

cupation with failure, have a reluc-

tance to simplify, be sensitive to

operations, ensure the organisa-

tion is resilient and have a defer-

ence to expertise’. It is these ideas

that I have been presenting at drill-

ing conferences lately.

To be more disciplined when you

drill wells, you need a much more

coherent framework around the

way you control the work. As far as I

know that framework has not been

written down yet. It does exist in

peoples’ minds but it has not been

formally documented. Because it

is not written down you can’t put

people into a classroom and teach

them a doctrine. Then you can’t as-

sess them against a standard and

assess their expected behaviours

and non-technical skills as you can

in aviation. Until we do what avi-

ation does and start to recognise

that the cognitive bit and the psy-

chocological bit have caused the

accidents we are not going to bene-

fit from our ’Macondo moment’.

The aviation industry had its ’Tener-

ife moment’ in 1977, when two

jumbo jets collided and exploded

on the runway in Tenerife killing

583 people. The aviation industry

then started their journey on crew

ressource management which re-

ally took off in the 1980es. Marine

and nuclear have capitalised on it

and belatedly the oil and gas indus-

try has slowly started doing some-

thing similar.”

— Do you think that oil and gas op-

erators seriously consider to move

their organisations to become high

reliability type organisations?

Thorogood: ”I still have not heard

an oil and gas VP of Drilling stand-

ing up and asking explicitly: ’we are

going to be a high reliability organi-

sation, tell me, what does it take?’

There are however some good

things starting – the starting point

in a high reliability journey is the

’chronic unease’ and that has slowly

begun to grow in a few companies.

One company has started training

human factors in well control as

well as training their chain of com-

mand which is being independently

assessed by their national petro-

leum institute.

In the Netherlands a well control

school is training human factors,

Maersk Training has started the in-

tegrated training of drilling crew

and also others train human fac-

tors in well control and non-tech-

nical skills. But as a whole it would

appear that only bits of the jig saw

puzzle are beginning to come to-

gether – in this instance training

and non-technical skills. We do not

see the end state of the high reli-

ability organisation – yet.

The concept of major accident risk

has been taken onboard at an intel-

lectual level and some companies

have re-written their technical stan-

dards or standard operations pro-

cedures to give them more focus

on major accident risk.

It is no problem writing the perfect

drilling programme which is risk

assessed and extensively peer re-

viewed, complies with all known

standards and has been well exam-

ined in extreme detail. The danger

lies in the gap between this perfect

drilling programme and the man

on the brake. It is in this gap, where

well-meaning improvisions occur

that all too easily trigger the spiral

into failure.

Good leaders make sure that their

men are safe at the coal face. In the

old days good generals went to the

front and met their men, made sure

that the kit was checked and mod-

ified if needed. They made sure it

was working as intended. The same

with the US nuclear submarines

which have never had a reactor in-

cident at sea. This was due to their

original commander, Admiral Hy-

man G. Rickover, who always sailed

on the first voyage of every nuclear

powered vessel. They also had ex-

acting standards of personal disci-

pline and ethics. The leaders were

intimately aware of what was hap-

pening at the coal face and made

sure their men were safe. They had

this sense of chronic unease which

is a pre-requisite for a high reliabil-

ity organisation.

Few top managers really show this

sense of chronic unease today. So

I believe that we still have a way to

go to understand and agree what

it takes to become a high reliability

industry.”

only bits of the puzzleDr. John l. thorogood, independant drilling engineering advisor discusses how far the industry has come towards a ’high reliability’ type organisation.

Interview with John L. Thorogood

By Hans Jørn Johansen

14 Safety ConferenCe 2013Task Force Zero

people: the solution – not the problem

Sidney Dekker: “For the past 20

years I have studied why things go

wrong, patients dying of an over-

dose, an airliner crashes and similar

accidents. We used to believe that

things go wrong because some-

body makes an error – or some-

thing breaks.

Today, actually since the mid

1980es, we understand that little

things inside the organization are

wrong, have been wrong for a long

time. These are things related to

procedures, culture, design of

equipment, supervision and work

practices. And all these things can

combine to create the potential for

an accident.

Our understanding has now shifted

‘upstream’ – to the system sur-

rounding the people, who do the

work. We now expect organizations

to have vast systems in place. We

are supposed to look for the little

‘holes’ in the system – and fix them

– before they can combine and

create trouble.

The risk becomes that in pursuit of

the good safety culture we invest

in safety work that focuses on the

easy stuff, the higher frequency but

lower consequence events like peo-

ple not wearing safety glasses, hav-

ing their coffee in a cup without a

lid on it, not holding the handrails

when walking on the stairs. The

fiction is that we have a safety cul-

ture because we have low counts

on negative events as a statement

of our safety processes as a whole.

We used to know that we were safe

if we had competent managers and

people at the sharp end knowing

what they were doing.

How do we know whether we are

safe today? We have the paper-

work to show it! And then we blow

stuff up.

How did we end up here? We still

see people as the problem!

We believe that as long as we have

great systems in place and that

people conform and stay within tbe

narrow bandwidth that we have as-

signed to them – then things will

be ok.

But this is an illusion – and it is in-

creasingly a dead end. People are

not the problem that we should

control. People are the solution –

that we should harness!

I believe that things go wrong be-

cause they usually go right.

What does a successful, dynamic

organization need to do in ressou-

rce constrained world ? They make

sure they optimise locally, they hunt

for local efficiencies. But the prob-

lem may be that such gains may be

borrowed from other parts of the

system through a series of inter-de-

pendencies that they don’t know

about. Successful organizations will

make small steps to make produc-

tivity gains but by doing so they

borrow against their safety margins

in ways that they do not measure.

These are normal things for succes-

ful organisations to do. So if you are

a succesful organization, make sure

you have people onboard who are

capable of questioning and critiqu-

ing the way by which you achieve

that success. Make sure you have a

diversity of view points. And if you

really want to prevent failure stop

looking for it. Instead start looking

for why things go right. Start look-

ing for what makes your organiza-

tion successful!”

— It would seem that you are

talking about an advanced safety

culture in which information freely

flows and its personnel are encour-

aged to criticize the way things are

done – how can that be efficient?

Dekker: ”Yeah, that’s a nice way to

put it. Well, I wouldn’t necessarily

say that people need to ‘criticize’

the way things are done, but rather

be inquisitive about it. And yes, that

can be hugely efficient! There are

many cases in which workers have

come up with better, faster, cheaper

and safer ways to do something or

to protect someone from harm in

doing a particular task – there is

a lot of expertise and wisdom out

there that is ready to be tapped.

Don’t see it is as criticism. See it as

valuable intelligence for your busi-

ness for which you are paying al-

ready anyway, since these people

are either your contractor or on

your payroll.”

— Do you see such ’advanced’

organizations in the oil and gas

industry today?

Dekker: ”No, not many. There may

be bits and pieces scattered

throug h out some of them, but a co-

herent, mature approach to safety

is not easy to find. Most oil and gas

companies are still wedded to the

idea that an absence of negatives

means better safety, and that com-

pliance with existing rules and pro-

cedures leads to ‘Safety Nirvana’.”

— There are many ’humans’ in-

volved in the oil and gas industry

today. They often come with dif-

ferent organisational and cultural

backgrounds and have to blend

in and perform in a short span of

time. What do you recommend

that the oil and gas industry should

do to ensure that people differ-

ences are not in the way of safe

operations?

Dekker: ”Perhaps getting them

to ‘blend in’ is the wrong starting

point. For sure, a kind of buddy pro-

gram that helps newcomers in the

beginning and avoids them from

getting in trouble is a very smart

idea, but that does not necessarily

mean that they should blend in, in

the sense of becoming similar and

invisible. Celebrate the diversity of

opinions, backgrounds and experi-

ences that these people bring. Cre-

ate enough room for them to share

their stories and ideas – in your in-

cident reporting systems, your tool-

box meetings, job starts.

In a complex, changing world, com-

pliance and conformity can actu-

ally kill or at least keep dying strat-

egies in place. Indeed, in a complex,

changing world, diversity, novelty

and adaptation can sometimes

save the day.”

sidney Dekker, professor, griffith university, australia discusses what constitutes a successful organization in today’s world.

Interview with Sidney Dekker

By Hans Jørn Johansen