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Human factors in a performance- based regime: Error and ALARP in offshore petroleum activities Joelle Mitchell Australian Psychological Society 11 th Industrial & Organisational Psychology conference July 2015 Definitions Control

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Human factors in a performance- based regime: Error and ‘ALARP’ in offshore petroleum activities

Joelle Mitchell

Australian Psychological Society 11th Industrial & Organisational Psychology conference July 2015

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SLIDE 2

Definitions

  • Control measure:

– Means of eliminating, preventing, reducing or mitigating the risk of hazardous events arising at or near a facility

  • Hazard:

– A situation with the potential for causing harm

  • Major Accident Event (MAE)

– An event connected with the facility, including a natural event, having the potential to cause multiple fatalities of persons at or near the facility

  • Risk:

– A function of likelihood and consequence

  • Risk Assessment:

– The process of estimating the likelihood of specific consequences of a given severity

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SLIDE 3

About NOPSEMA

  • National Offshore Petroleum

Safety and Environmental Management Authority

  • Petroleum and Greenhouse

Gas Storage activities:

– in Commonwealth waters – in state waters where powers conferred

  • Regulation of:

– Safety – Well integrity – Environmental management

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SLIDE 4

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Legislation – General duties

  • Facility operators must take all reasonably

practicable steps to ensure that:

– The facility is safe and without risk to health – All work and other activities are carried out in a safe manner and without risk to health

  • Specific duties include:

– Implementation and maintenance of safe systems of work – Procedures and equipment for control of emergencies

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SLIDE 5

ALARP

  • As Low As Reasonably Practicable
  • No other practical measures can reasonably be

taken to reduce risks further

  • Involves assessment of:

– The risk to be avoided – The cost involved – The benefit (risk reduction) – ‘Gross disproportion’ between cost and benefit

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SLIDE 6

Risk management

  • Formal Safety Assessment

– Identifies all hazards with the potential to cause a MAE – Assesses the risk – Identifies control measures to reduce the risk to ALARP

  • Safety Management System

– Identifies hazards to health and safety – Assesses the risk associated with each hazard – Identifies how risks will be reduced to ALARP

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SLIDE 7

Control measures

  • Reduce risk

– Lower the likelihood – Minimise the consequence

  • Includes:

– Physical equipment – Process control systems – Procedures – Emergency plan

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Hierarchy of controls – event control

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  • Remove

the hazard

Eliminate

  • Lower the

likelihood

Prevent

  • Detect and limit

escalation

Reduce

  • Protect life

Mitigate

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SLIDE 9

Event control

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SLIDE 10

Event example

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SLIDE 11

Control types

  • Eliminate
  • Substitute

– Use something else

  • Engineer

– Isolate the hazard

  • Administrate

– Do / avoid something

  • Personal protective

equipment

– Wear something

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http://digitalcollections.nypl.org/items/510d47d9-a953-a3d9-e040-e00a18064a99

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Example

  • What is the hazard?

– Vehicle interactions

  • What is the potential event?

– Crash

  • What are the potential consequences?

– Death – Injury – Damage

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Control measures

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Eliminate

  • Walk
  • Public

transport

  • Bicycle

paths

  • Vehicle

separation Prevent

  • Driver

training

  • Road rules
  • Headlights
  • Collision

avoidance technology Reduce

  • Collision

avoidance technology

  • ABS brakes
  • Traction

control

  • Defensive

driver training Mitigate

  • Seatbelts
  • Air bags
  • Crumple

zones

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SLIDE 14
  • What does any of this have to do with
  • rganisational psychology?

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SLIDE 15

Human factors

  • Humans interact with control measures
  • Human error is a potential failure mechanism
  • Errors can contribute to events
  • We can consider the role of error:

– in MAE causation – in the efficacy of control measures – in demonstrating ALARP

  • Where do we start?

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SLIDE 16

Critical human tasks

  • Activities people are expected to perform:

– as barriers against the occurrence of an incident – to prevent escalation – to support or maintain physical and technological barriers

  • OGP (2011). Human factors engineering in projects.

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SLIDE 17

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Case study: BP Texas City refinery

  • What is the MAE?
  • What is the hazard?
  • What is the critical human task?
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Event summary

  • March 23, 2005, 1:20pm
  • Isomerization unit start-up
  • Operators overfilled the

raffinate splitter tower

  • Pressure relief devices

activated

  • Flammable liquid spurted

from a blowdown stack

  • No flare installed
  • Ignition, explosion and fire
  • 15 deaths, 180 injuries
  • $1.5 billion

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SLIDE 19
  • What is the MAE?

– Explosion from hydrocarbon ignition

  • What is the hazard?

– Raffinate liquid

  • What is the critical human task?

– Operators were required to maintain the correct level of liquid in the raff tower

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SLIDE 20

Activity

  • Video - US Chemical Safety Board investigation

– Human factors extract

  • List the controls that failed

– Where do they fit on the hierarchy?

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Hierarchy of control

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  • Remove

the hazard

Eliminate

  • Lower the

likelihood

Prevent

  • Detect and limit

escalation

Reduce

  • Protect life

Mitigate

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SLIDE 22

CSB Video – Human factors

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https://youtu.be/XuJtdQOU_Z4?t=35m6s

Note: Human factors content concludes at 44:17, video continues with other findings

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Control measures at BP

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Eliminate

  • Not possible

Prevent

  • Control Panel
  • Instrumentation
  • Alarms
  • Supervision
  • Communication
  • Training
  • Procedures
  • Personnel

Reduce

  • High level

alarms

  • Instrumentation
  • Pressure relief

devices

  • Procedures

Mitigate

  • Blowdown drum
  • Vent stack
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Prevention (1)

  • Control panel

– Flow data split between screens – No material balance indicator

  • Instrumentation

– Malfunctioning

  • Alarms

– Routine violation to fill tower past 9 feet

  • Supervision

– Absent

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Eliminate

Prevent

Reduce

Mitigate

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Prevention (2)

  • Communication protocols

– Poor

  • Training

– Poor quality – Poor risk awareness

  • Procedures

– Outdated

  • Personnel

– Not enough

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Eliminate

Prevent

Reduce

Mitigate

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Reduction

  • High level alarms

– Broken

  • Instrumentation

– Malfunctioning

  • Pressure relief devices

– Switched to manual operation

  • Possible but not present

– High level ‘trip’ on tower

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Eliminate

Prevent

Reduce

Mitigate

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SLIDE 27

Mitigation

  • Blowdown drum

– Worked as designed

  • Vent stack

– Not upgraded to flare system

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Eliminate

Prevent

Reduce

Mitigate

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SLIDE 28

Multiple controls

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Prevent

  • Control Panel
  • Instrumentation
  • Alarms
  • Supervision
  • Communication
  • Training
  • Procedures
  • Personnel

Reduce

  • High level

alarms

  • Instrumentation
  • Pressure relief

devices Mitigate

  • Blowdown drum
  • Vent stack
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SLIDE 29

Multiple failures

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Prevent

  • Control Panel
  • Instrumentation
  • Alarms
  • Supervision
  • Communication
  • Training
  • Procedures
  • Personnel

Reduce

  • High level

alarms

  • Instrumentation
  • Pressure relief

devices Mitigate

  • Blowdown drum
  • Vent stack
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SLIDE 30
  • How can we reduce error risk to ALARP?
  • risk = likelihood x consequence

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Reducing error risk

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Organisation Individual Job

Human Reliability

Human Error Event Near Miss Desired Performance

Error Prevention Error Mitigation Minimise likelihood Minimise consequence

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SLIDE 32

Prevent and mitigate error

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SLIDE 33

Texas City

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SLIDE 34

Error prevention

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Training Simulation Drills Competence assurance Policy Training Risk indicators HF in design Procedure Quality indicators Communication conventions Policy Risk indicators Planning rules

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SLIDE 35

Error mitigation

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HMI Maintenance Error management training Drills

Tower overfill

High-level trip

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SLIDE 36

Where to start?

  • Evidence-based practice!
  • Evidence of uncontrolled error:

– Events – Dangerous occurrences (could have but didn’t)

  • Performance-shaping factors

– Latent conditions – Broader implications

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How to reduce error risk

  • Identify critical human tasks

– What errors are possible? – What are the consequences? – What are the performance-shaping factors (hazards)?

  • Identify existing controls

– Do they prevent and mitigate error? – Is risk reduced to ALARP?

  • Develop appropriate controls

– Eliminate the opportunity for error – Prevent – lower the likelihood of error – Reduce – facilitate error identification and recovery – Mitigate the consequences of error

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SLIDE 38

Summary

  • Human error can contribute to events
  • Error risk is most significant for critical human tasks
  • Apply a hierarchy of controls to reduce error risk
  • Effective risk reduction includes:

– error prevention – error management

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SLIDE 39

Online resources

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  • nopsema.gov.au
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SLIDE 40

Questions?