Presentation from Jason Devereux at Offshore Europe 2013. Paper written by Jenny Gilroy and Derek Dumolo of Lloyd's Register Constiling's Human Factors team. Hydrocarbon releases (HCR) are a major problem offshore, and most importantly are seen as a direct precursor to potential major accidents (MAs) (Oil and Gas UK, 2010). The UK HSE believe that of the occurring HCRs, 50-70% have causes linked in part or in whole to “things people do (or don’t do) when designing, maintaining and operating systems”, (Step Change in Safety, 2010) i.e. issues associated with Human Factors (HF). An offshore operator contracted LR Consulting to conduct an independent HF-focussed organisational assessment into the underlying contributory factors to HCRs on their platforms, in order to support their own internal initiatives to reduce HCRs. The aim of LR Consulting’s assessment was to help the organisation confirm and identify the key areas of focus in order to combat HCRs and prioritise further actions going forward. LR Scandpower adopted a systematic approach to investigate the HF contributions to HCRs on the organisation’s platforms, including a Thematic Analysis of past incident data, offshore interviews and onshore interviews with staff and detailed analysis of findings to identify common emergent themes issues. Eight key areas were identified as priorities for further action, and LR Consulting provided the operator with recommendations for improvements and/or remedial actions to deal with identified contributory factors This presentation will explain the approach followed by LR Consulting and the findings from the study, including the key Human Factors causal factors that were identified. It will also highlight the key lessons learned that are considered to be potentially relevant to the wider offshore sector.

1. Human Factors Involvement in Hydrocarbon Release on Offshore
Platforms: an organisation wide investigation
Dr. Jason Devereux, Lloyd’s Register Consulting – Energy
Scientific Sub-Committee Secretary for the International Commission on Occupational Health and Safety
Member of the IEA Technical Committee on Human Factors in Organisational Design and Management
Honorary Member of the Business Psychology Unit, University College London
Former Human Factors M.Sc. Director, Robens Institute Industrial Health & Safety
Working together
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2. Outline
1. Background to hydrocarbon release
2. Case study:
•
Methodology
•
Summary of findings
•
Key areas
1. Recommendations for Industry
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3. The problem of hydrocarbon leaks
•
Hydrocarbon releases are a major problem
offshore.
•
A direct precursor to potential major accidents, if
ignited.
(Oil and Gas UK, HSE)
Major gas release on Elgin in March 2012, led to the evacuation of the entire platform
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4. The problem of hydrocarbon releases (HCRs)
50-70% of HCRs have causes linked in part or in whole to human factors
Human error is both universal and inevitable (Energy Institute, 2008). This
implies a system failure and not person failure – the latent antecedents
Judith Hackitt (Chair of HSE) -“Constant Unease”
•
Know the problem is not fixed
•
What could go wrong
•
Can do better
•
Society becoming less tolerant of failures
Consider human factors in designing, maintaining and operating systems
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5. Market forces potentially affecting HCR risk
Competition pressure and cost cutting could increase the use of
technology and reduce staffing offshore
Highly automated systems still need human beings for:
•supervision
•adjustment
•maintenance
•Improvement
Understand the limits of human abilities and capability in the:
•design
•control
•maintenance
of systems
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6. Case study: study objectives
Human-machine interaction as an emerging risk (EU-OSHA, 2005)
•
Psychosocial risk – cognitive load
•
Accident risk
•
operating errors
•
maintenance non-routine errors
•
inappropriate action
Assist in our client’s initiative.
•
To reduce HCRs within the UK.
Conduct an independent Human Factors-focussed organisational
assessment.
•
Identify underlying contributory factors to HCRs offshore.
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(HSE, 1999 HSG
48)

7. Case study: methodology
N=60
Sept 2011
N=31
Nov 2011
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8. Case study: thematic analysis
An initial analysis of HCR incident report data highlighted the following key areas
e.g. “the requirements of the flange
completion and recording procedure
do not appear to have been
communicated.”
e.g. “absence of alarms for this event and/or
absence of preventative barriers to be able
to close 2 streams.”
e.g. “the requirements of
the flange completion and
recording procedure”
Failures in
engineering
controls
Failures in
administrative
processes
Failures in
communications
Failures in
competency
management
processes
e.g. “no small bore tubing
training for 2 years”
Hydrocarbon
Releases
Management
failures
Failures in
maintenance
processes
e.g. “gas compression
train out for 2 years “
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e.g. “No
supervision”

9. Using the data generated from the thematic analysis
Development of a ‘question set’ to explore key HF themes that appeared to be influential in HCRs.
14 ‘lines of enquiry’ explored, including:
•
supervisory arrangements
•
safety culture
•
safety critical communications
•
quality assurance and procurement process
•
procedure usage
•
planning
•
staffing
•
engineering design
•
etc.
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10. Summary of findings - corporate level solutions
Organisational learning
Competence management
HFI in platform
Planning
design
•Reactive
LearL
LearL
•maintenance
•Under manning
Procedures
• Silo working
Visit www.lr.org/HCR for more information
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11. Key areas: Organisational learning
Relevance to hydrocarbon releases
•
When lessons aren’t learned and a company doesn’t strive for continuous
improvement, mistakes are repeated, not recognised and not improved
•
•
When underlying causes are not dealt with, only the immediately obvious
problems may be tackled, leaving the real contributory factors in place
•
•
e.g. Small bore tubing was a known problem for a long time before a
survey was carried out; and this survey has not yet led to any
improvements
e.g. an individual who made a mistake may be blamed but his
competency and the competency of all his colleagues also may be poor
due to a lack of training and support
Many wider contributory factors to hydrocarbon releases have been identified in
this project, and most have been a problem for some time
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Contributory failures
Failures in
communications
Cultural issues

12. Key areas: Competency management
Relevance to hydrocarbon releases
Contributory failures
If people are not fully competent to work on the system, they are likely to make
mistakes
•e.g.
If an operator cannot use SAP correctly they may not input required data
about maintenance work that need to be done, and thus a HCR could occur
because the work is not carried out
Anyone working with the system who is not fully competent could make a mistake
and either:
1.Initiate
a HCR
2.Contribute
3.Escalate
4.Fail
to a series of events that leads to a HCR
a HCR
to mitigate and control a HCR
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Failures in
competency
management

13. Key areas: Lack of planning
Relevance to hydrocarbon releases
The system state may be compromised or the system may fail if:
•
routine maintenance is postponed or delayed
•
urgent maintenance needs are not addressed promptly
•
work is not planned thoroughly, maintenance may get postponed or
delayed
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Contributory failures
Failures in
communications
Failures in
maintenance
processes
Failures in
administrative
processes

14. Key areas: Under manning
Relevance to hydrocarbon releases
Contributory failures
A lack of staff to carry out work means that:
•
maintenance is constantly being compromised
•
assets fail because they have not been maintained properly
•
only had ‘patchwork’ fixes carried out on them
There are also compromises in relation to onshore activities due
to under manning. For example:
•
Design failures
Not enough engineering team staff
•
it takes longer to get designs developed
•
there are delays to making engineering changes
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Management
and resourcing
failures

15. Key areas: Reactive approach
Relevance to hydrocarbon releases

Short-term quick repairs can affect asset integrity:

The underlying problems are not improved


the system can be left vulnerable to further deterioration or failure
Patchwork fixes may create new problems:

They can mean the system is not operating correctly


Contributory failures
the system may become damaged
Jumping into initiatives and approaches means that the work is more likely to be
done incorrectly
•
e.g. In relation to Small Bore Tubing Surveys. This has wasted
time on an activity that was supposed to aid in reducing HCRs, but
few corrective works have been done
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Cultural issues
Failures in
maintenance
processes

16. Key areas: Poor procedures
Relevance to hydrocarbon releases
Contributory failures
If the procedures are wrong or difficult to use, people will either:
•
follow the incorrect procedure and as a result carry out the task
incorrectly
•
fail to use them and potentially do the task wrong or inconsistently
In both instances there may do damage to the system
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Failures in
administrative
processes

17. Key areas: Silo working
Relevance to hydrocarbon releases
Lack of communication or miscommunication:
•
Information may not be passed on to those who need to know
•
information may be misunderstood due to conflicting demands and
distraction
•
the result is mistakes and omissions
Work carried out in isolation:
•
Conflict with other work being done
•
can leave the system vulnerable to errors
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Contributory failures
Failures in
communications
Management
and resourcing
failures
Failures in
administrative
processes

18. Key areas: Design issues on the platform
Relevance to hydrocarbon releases
Contributory failures
A mismatch between the design specification and the proposed operability of the
system:
•
leads to system operability being compromised
•
e.g. There are not enough beds, making it difficult to get staff
onto the rig
A mismatch between the design and the operating environment:
•
system may be susceptible to deterioration
•
e.g. Some equipment and material selection at the design stage is
considered to have been inappropriate and of poor quality, leading to high
levels of deterioration
Excessive alarms in the control room:
•real
issues may be overlooked and made worse
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Design failures

19. Lessons for industry: For prevention of HCRs
No simple answer to the question of ‘what causes HCRs?’
Identify and address all underlying factors
A suitable framework for assessment is required
•
using specialists who are trained to look beyond the engineering
problems to organisational factors
Recommend use of external departments and/or independent parties:
•
provides independence
•
allows honest impartial information to be elicited
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20. Lessons for industry: Investigation of HCRs
•
Essential that incident investigations go beyond the
analysis of ‘front line’ failures
?
?
?
?
•
•
Take due consideration of the Human Factor within
organisational root causes
?
?
?
?
Involve Human Factors experts in this process
Human
Error
Underlying Human Factors topics
Underlying Human Factors topics
e.g. Procedures, Training && Competence, Safety Critical
e.g. Procedures, Training Competence, Safety Critical
Communications, Organisational Change, HF Design,
Communications, Organisational Change, HF Design,
Shiftwork && Fatigue, Organisational Culture, Workload,
Shiftwork Fatigue, Organisational Culture, Workload,
Maintenance, and Human Failures (HSE, 2012)
Maintenance, and Human Failures (HSE, 2012)
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21. Lessons for industry: Have a human factors integration plan
•
Have better integration of Human Factors within the early stages of
the design process
•
Reduces the likelihood of mismatches between:
•
Human capability
•
•
•
organisational demands and
system design during the latter stages of projects or in operation
Planning for a dedicated HF programme at the initial design stage of
projects is recommended:
•
Equipment design
•
Workstation/ console design
•
Workplace layout
•
Maintenance access and ease of maintenance etc.
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22. Develop corporate resilience to avoid HCR outcomes
(UCL Business Psychology Unit Effort Performance Outcome Model)
Expectancy
Instrumentality
Valance
Extrinsic
outcome/
reward
Performance
Effort
Abilities and traits,
role clarity,
organisational
support, etc.
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Job design,
organisational
policies and
practices
Outcome /
reward
Satisfaction
Intrinsic
outcome/
reward
Perceived equity of
outcomes/ rewards

23. Avoid the reputational and financial risk
BP
Down 30% since Jan 2010 high
•Has not recovered due to a lack of investor
confidence signalled by overhead supply at
$50 per share
•Not trending with the S&P 500
•“A broken stock in institutional trading terms”
Exxon Mobile
Up 27% since Jan 2010 high
•Trending with the S&P 500
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24. A final thought!
Competitive investment must be tempered with patience and consideration of the
potential for human-system failures in maintenance, supervision and improvement.
For more information and to receive a free copy of the whitepaper this presentation is
based on, visit: www.lr.org/HCR
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25. Dr. Jason Devereux
Lloyd’s Register Consulting – Energy
T: +44 (0)23 2345 5432
E: jason.devereux@lr.org
Lloyd’s Register Energy
71 Fenchurch Street, London EC3M 4BS
@LREnergy
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