7. Commonalities Between Disasters
Occupational safety emphasized over
process safety
Human Factors:
• A combination of either individual errors or
organizational failures have been reported to
cause as much as 80% of oil spills and marine
accidents*
*An Assessment of the Role of Human Factors in Oil Spills from Vessels. Report to Prince William Sound RCAC, 2006.
8. How Organizational Failure Can Lead
to Individual Errors
HUMAN FACTORS HUMAN ERRORS
INDIVIDUAL FACTORS SKILL-BASED
competence action errors
stress checking errors
motivation
GROUP FACTORS RULE-BASED
management retrieval errors
supervision transmission errors
crew
ORGANIZATIONAL FACTORS KNOWLEDGE-BASED
company policies diagnostic errors
company standards decision errors
systems and procedures
9. Recommendations
Safety Cases
• Produced by the operator of a facility to*:
– Identify hazards and risks
– Describe how the risks are controlled
– Describe the safety management system in place to
ensure the controls are effectively and consistently
applied
• Scrutinized by a competent and independent
regulator
*Australia’s National Offshore Petroleum Safety and Environmental Management Authority (NOPSEMA)
10. Structure of a Safety Case*
Strategy Aim
Safety Objectives
Management Assessors
System (SMS) Resources Safety Case
Safety Production
Safety Manager
Case Through Life
SMS Safety Management
Description Committee
Scope
Safety Case Supporting
Auditors
Report Argument Review/Audit
Emergency
Acceptance
Procedures Hazard
Identification Targets
Safety
Assessment Risk
System Assessment
Description
Hazard
*Zotov, Dmitri (2007). Safety Cases: Control
Hazard Log
Beyond Safety Management Systems
11. Recommendations
Process Safety Management (PSM)
National Emphasis Program:
• Policies or procedures to reduce the workplace
hazards associated with the catastrophic release of
highly hazardous chemicals at petroleum factories
OSHA: PSM-NEP. Directive # CPL-03-00-010
12. Recommendations
Communicating and Speaking Up1
• Survey conducted on Transocean crew
members working on Deepwater Horizon days
before explosion: 46% of crew members feared
reprisals for reporting unsafe situations2
• Go through training with peers, supervisors,
and subordinates to flatten the corporate
hierarchy
1. Managerial Practices that Promote Speaking Up Constructively Among Front-Line Employees (2011).
2. Commission on BP Oil Spill, pg. 219
13. Worth the Cost?
$40
$35
$30
$25
Billions
$20
$15
$10
$5
$0
Construction Disaster
Notas do Editor
(in 2009 BP report, they said that injury rates and spills had reduced 75% since 1999).
Human Errors often result from human factors. Focus on organization factors, because the organizational policies, standards, systems, and procedures are what make up the knowledge pool that employees will be pulling from. If these policies are not directed towards a safety culture, then
A safety case is a document produced by the operator of a facility which:Identifies the hazards and risksDescribes how the risks are controlled, andDescribes the safety management system in place to ensure the controls are effectively and consistently applied. Safety cases must be produced by the operator of a facility. The principle here is that those who create the risk must manage it. It is the operators' job to assess their processes, procedures and systems to identify and evaluate risks and implement the appropriate controls, because the operator has the greatest in-depth knowledge of their installation. The safety case must identify the safety critical aspects of the facility, both technical and managerial. Analysis of disasters almost always show a combination of technical and managerial flaws which have led to the event occurring. Appropriate performance standards must be defined for the operation of the safety critical aspects. A 'performance standard' is a standard, established by the operator, of the performance required of a system, item of equipment, person or procedure which is used as a basis for managing the risk of a major accident event. The workforce must be involved. Workforce involvement is necessary so they know what happens in practice and why. This makes it more likely that they do the right thing because they know why, rather than relying on a 'rules-based' culture. The safety case is produced in the knowledge that it will be scrutinised by a competent and independent regulator. NOPSEMA assesses safety cases and 'accepts' a safety case if it is satisfied that the arrangements set out in the document demonstrate that the risks will be reduced to as low as is reasonably practicable. Once 'accepted' NOPSEMA visits facilities to monitor the application of the safety cases in practice.http://www.nopsema.gov.au/safety/safety-case/what-is-a-safety-case/
The decision making process on the rig was excessively compartmentalized, so individuals on the rig frequently made critical decisions without fully appreciating just how essential the decisions were to well safety—singly and in combination. As a result, officials made a series of decisions that saved BP, Halliburton, and Transocean time and money—but without full appreciation of the associated risks. (223)
