APPEA HSR Forum Industry Health and Safety Performance and decision - - PowerPoint PPT Presentation

Industry Health and Safety Performance and decision‐making

Simon Schubach Regulatory General Manager August 2010

APPEA HSR Forum

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NOPSA’s functions

Monitor & Enforce Co-operate Investigate Advise Promote Report

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Australian offshore OHS laws:

• Schedule 3 to the Offshore

Petroleum and Greenhouse Gas Storage Act (OPGGSA)

• Offshore Petroleum (Safety)

Regulations 2009 Available at www.comlaw.gov.au

Offshore Petroleum and Greenhouse Gas Storage (Safety) Regulations 2009 Schedule 3 Offshore Petroleum and Greenhouse Gas Storage Act 2006

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What does the regulator do?

Challenge the operator

• Safety Case Assessments ‐

targeted

• Facility Inspections ‐

sampled

• Incident Investigation ‐

depending on severity

• Enforcement ‐

verbal / written and prosecutions

Independent oversight

• Facility health and safety risks are properly controlled by
• perators of facilities through securing compliance with OHS law

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Facilities

Facility Group Jan‐June 2010 Platforms

Normally attended Not normally attended

56

28 28

FPSOs 14 MODUs 13 Vessels 11 Pipelines 70 TOTAL: 164

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2009‐10 activities

NOPSA

33 OHS Inspectors 20 Support staff

INDUSTRY

33 Operators 164 Facilities

180 Assessments 366 Incidents

38 Accidents 328 Dangerous Occurrences

180 Assessments 94 Inspections 6 Major Investigations 93 Minor Investigations 267 Incident reviews 28 Enforcement actions

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Montara

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Montara Incident ‐ Uncontrolled hydrocarbon release ‐ 21 August 2009

• Failure of well integrity:
• Inadequate barriers
• Primary cementing
• Management System issues: Risk Assessment, Communications,

Records Management, management oversight

• Titleholder ‐ Drilling Contractor Interface
• NOPSA has investigated for a potential contravention
• f OHS laws by the operators
• NOPSA has referred a brief of evidence to the CDPP

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Australian Offshore Injury Rate

4 8 12 16 2005 2006 2007 2008 2009 1/1/10 to 30/6/10 Rate

TRC Rate

per million hours

TRC = LTI + ADI + MTI

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Hydrocarbon Releases

11 15 21 18 15 17 1 3 1 3 5 3 1 9 6 3 2 1

5 10 15 20 25 30 35 2005 2006 2007 2008 2009 1/1/10 to 30/6/10 Number

Number of Hydrocarbon Releases

Uncontrolled PL release >12 500L Uncontrolled PL release >80‐12 500L Uncontrolled HC gas release >300 kg Uncontrolled HC gas release >1‐300 kg

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International Comparison

Australia IRF Countries

4 8 12 2005 2006 2007 2008 Rate

Gas Release Rates

(per million BOE) 4 8 2005 2006 2007 2008 2009 1/1/10 to 31/5/10 Rate

Injury Rates

(per million hours )

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Incident Root Causes

2005 2006 2007 2008 2009

1/1/10 to 30/6/10 Procedures - Not Followed Preventive Maintenance Preventive Maintenance Preventive Maintenance Procedures - Not Followed Procedures - Not Followed Preventive Maintenance Mgmt System - SPAC Design Specs Procedures - Not Followed Design Specs Design Specs Preventive Maintenance Design Specs Procedures - Not Followed Procedures - Not Followed Design Specs Preventive Maintenance

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“it is essential to create a corporate atmosphere or culture, in which safety is understood to be and is accepted as, the number one priority”

MAE Prevention

Lord Cullen – Piper Alpha Inquiry 1990

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BP Texas City Refinery 2005

• People can forget to be afraid
• Maintain vigilance and operating

discipline

Baker Panel Report: BP Refineries Independent Safety Review Panel, 2007

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NOPSA Promotion Process Safety Culture

• 1. Survey of senior management
• Onshore Process Safety Leadership Principles
• 2. Survey of workforce
• Offshore Process Safety Culture

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Workforce Survey Context

• Process safety awareness
• Shared at 2009 HSR Forum
• Safety culture perceptions
• Industry benchmarks used
• Responses confidential
• Small number of responses
• 9 surveys

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Benchmarking

TOPIC AREA

• No. Facilities

BELOW benchmark

Supervisory Involvement 3 Worker Professionalism/Empowerment 3 Reporting 4 Safety Values/Commitment 3 Procedures and Equipment 2 Training 5

n = 8

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Opportunities for Improvement

TOPIC AREA Most common issues scoring in the bottom ten survey question responses Safety Values / Commitment Pressure to work overtime - loyalty to work unit Reporting Hazard identification, control and reporting training not adequate Safety Values / Commitment Process safety programmes don't have adequate funding Training Contractors don't receive adequate training to do their job safely Professionalism / Empowerment Workers don't actively participate in incident investigations

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Safety Promotion and Advice by NOPSA

Safety Case Guidance Notes

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Learning from history

“The past seldom obliges by revealing to us when wildness will break out in the future.”

Against the Gods, the Remarkable Story of Risk, P Bernstein 1996

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Learning from history

War, depressions, stock‐market booms and crashes, and ethnic massacres come and go…….

But they always seem to arrive as surprises.

Against the Gods, the Remarkable Story of Risk, P Bernstein 1996

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After the fact, when we study what happened…..

• the source of the wildness

appears to be so obvious

• it’s hard to understand how

people on the scene were

• blivious to what lay in wait

for them.

Learning from history

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Consider this scenario…

• The quality of a cement job is uncertain and you

are faced with either: a) a loss of 4 days rig time b) a small chance of a loss of well integrity sometime in the future. Pause for thought ! What would you do?

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Making decisions, taking risks …

• Decisions involving losses – we are risk‐takers
• Experiment

– you have a choice between:

1. 100% chance of losing $3000 2. 80% chance of losing $4000 and 20% chance of breaking even expectation of loss = $3200

• 92% of subjects chose the second option with

the greater expectation of loss!

Kahneman & Tversky, 1979

The risky choice !

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Think again

Going back to the cement job

• If the quality of the cement job is uncertain

and you are faced with a loss of 4 days rig time, compared with a small chance of a loss of well integrity sometime in the future…

What would you do?

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Lets try again

Job: change filter elements in filter vessel with leaking isolation valve. Option 1:

Simply change out the filter elements. With an experienced crew you can do this quickly and they just need to ensure no sources of ignition are present. Time to change‐out: 30 minutes.

Option 2:

Fix the core problem of the leaking valves. Time to repair: Several days.

What would you do?

How many times do you think you can get away with this?

99% of the time?

Lets try another question?

Job: If you are asked to perform a quick man‐riding job in the derrick that will take <2 minutes, and nobody was watching, would you: Option 1: Just jump in the man‐riding harness and go? Option 2: Carry out a JSA, spend 15 minutes setting up an inertia reel secondary fall protection device. Carry out all the pre‐job safety checks then perform the job following the approved man‐riding procedures?

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Individual decisions – safety culture at every level

"It is easy to point the finger at the management and assume that a culture of cutting corners started at the top, and was motivated by money. It's worth remembering that the same culture can also originate at the bottom, driven by a desire to get things done. The task of management is to know this and insist it is done properly". Trevor Kletz, The Chemical Engineer, August 2010

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Black Swan event

1. Outlier – doesn’t happen very often 2. Extreme impact 3. After the event, it is explicable and predictable

The Black Swan: The Impact of the Highly Improbable, Nassim N Taleb 2007

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Vulnerability + decision risk = black swan

If you reach a step that doesn’t meet the required conditions,

• r where circumstances have changed……

Pause and Reflect

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So, what can you do?

Understand

‐

Specific hazards of materials ‐ Safe‐handling responsibilities ‐ Specific hazards of operations

Understand your role in process safety activities

‐ Hazards analysis ‐ Management of change ‐ Incident reporting and investigation ‐ Maintenance & testing ‐ Following safe work practices

Maintain operating discipline and vigilance

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Thank you And … don’t forget your HSR handbook!