An Organisation-wide Investigation into the Human Factors-Related Causes of Hydrocarbon Release on Offshore Platforms
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This document summarizes the findings of an organizational investigation into human factors contributions to hydrocarbon releases on offshore platforms. The investigation identified several underlying human and organizational failures that increase the risk of hydrocarbon releases, including failures in competency management, lack of planning, understaffing, reactive maintenance approaches, poor procedures, siloed work, and design issues. The investigation recommends that companies integrate human factors experts into the design process, incident investigations, and develop programs to promote organizational learning and resilience to prevent hydrocarbon releases.
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An Organisation-wide Investigation into the Human Factors-Related Causes of Hydrocarbon Release on Offshore Platforms
- 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
- 2. Lloyd’s Register services to the energy industry Outline • Lloyd’s Register Energy • Background to hydrocarbon release • Poll regarding statem ents • Methodology • Sum m ary of findings • Recom m endations for Industry • Q & A
- 3. Lloyd’s Register services to the energy industry Statement 1 made by an industry leader at Offshore Europe 2013 • Safety is increased if technology is used to reduce the num ber of staff needed offshore • Do you agree or disagree with this statem ent?
- 4. Lloyd’s Register services to the energy industry Statement 2 made by an industry leader at Offshore Europe 2013 • We need to do our business with fewer people and pay them less while creating a culture that encourages workers to stay long term and develop their skills and values • Do you agree or disagree with this statem ent?
- 5. Lloyd’s Register services to the energy industry Theproblemof hydrocarbonleaks • Hydrocarbon releases are a m ajor problem offshore. • A direct precursor to potential m ajor accidents, if ignited. (Oil and Gas UK, HSE) Major gas release on Elgin in March 2012, led to the evacuation of the entire platform
- 6. Lloyd’s Register services to the energy industry • 50-70%of HCRs have causes linked in part or in whole to hum an factors • Hum an error is both universal and inevitable (Energy Institute, 2008). This im plies 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 becom ing less tolerant of failures • Consider hum an factors in designing, m aintaining and operating system s Theproblemof hydrocarbonreleases (HCRs) (Step Change in Safety, 2010)
- 7. Lloyd’s Register services to the energy industry Market forces potentially affectingHCR risk •Com petition pressure and cost cutting could increase the use of technology and reduce staffing offshore •Highly autom ated system s still need hum an beings for: •supervision •adjustm ent •m aintenance •Im provem ent •Understand the lim its of hum an abilities and capability in the: •design •control •m aintenance of system s
- 8. Lloyd’s Register services to the energy industry • Hum an-m achine interaction as an em erging risk (EU-OSHA, 2005) • Psychosocial risk – cognitive load • Accident risk • operating errors • m aintenance non-routine errors • inappropriate action • Assist in our client’s initiative. • To reduce HCRs within the UK. • Conduct an independent Hum an Factors- focussed organisational assessm ent. • Identify underlying contributory factors to HCRs offshore. Poll andStudy Objectives (HSE, 1999 HSG 48)
- 9. Lloyd’s Register services to the energy industry Methodology N=60 Sept 2011 N=31 Nov 2011
- 10. Lloyd’s Register services to the energy industry Thematic analysis An initial analysis of HCR incident report datahighlightedthefollowingkey areas e.g. “the requirem ents of the flange com pletion and recording procedure do not appear to have been com m unicated.” e.g. “no sm all bore tubing training for 2 years” Hydrocarbon Releases Failures in engineering controls Failures in adm inistrative processes Managem ent failures Failures in m aintenance processes Failures in com petency m anagem ent processes Failures in com m unications e.g. “absence of alarm s for this event and/or absence of preventative barriers to be able to close 2 stream s.” e.g. “the requirem ents of the flange com pletion and recording procedure” e.g. “No supervision” e.g. “gas com pression train out for 2 years “
- 11. Lloyd’s Register services to the energy industry Usingthedatageneratedfromthethematic analysis Developm ent of a ‘question set’ to explore key HF them es that appeared to be influential in HCRs. 14 ‘lines of enquiry’ explored, including: – supervisory arrangem ents – safety culture – safety critical com m unications – quality assurance and procurem ent process – procedure usage – planning – staffing – engineering design – etc.
- 12. Lloyd’s Register services to the energy industry Summary of findings - corporatelevel solutions Work System Offshore LearLLearL Organisational learning Com petence m anagem ent Planning Reactive m aintenance Under m anning Procedures Silo working HFI in platform design Visit www.lr.org/HCR for more information
- 13. Lloyd’s Register services to the energy industry Contributory failures Key areas: Organisational learning Cultural issues Failures in com m unication s Relevancetohydrocarbonreleases When lessons aren’t learned and a com pany doesn’t strive for continuous im provem ent, m istakes are repeated, not recognised and not im proved e.g. Small bore tubingwas aknownproblemfor alongtime beforeasurvey was carriedout; andthis survey has not yet ledtoany improvements When underlying causes are not dealt with, only the im m ediately obvious problem s m ay be tackled, leaving the real contributory factors in place e.g. anindividual whomadeamistakemay be blamedbut his competency andthecompetency of all his colleagues alsomay bepoor dueto alackof trainingandsupport Many wider contributory factors to hydrocarbon releases have been identified in this project, and m ost have been a problem for som e tim e
- 14. Lloyd’s Register services to the energy industry Contributory failures Key areas: Competency management Failures in com petency m anagem ent Relevancetohydrocarbonreleases If people are not fully com petent to work on the system , they are likely to m ake m istakes e.g. If anoperator cannot useSAPcorrectly they may not input required dataabout maintenanceworkthat needto bedone, andthus aHCR couldoccur becausetheworkis not carriedout Anyone working with the system who is not fully com petent could m ake a m istake and either: 1. Initiate a HCR 2. Contribute to a series of events that leads to a HCR 3. Escalate a HCR 4. Fail to m itigate and control a HCR
- 15. Lloyd’s Register services to the energy industry Contributory failures Key areas: Lackof planning Failures in administrative processes Failures in maintenance processes Failures in communications Relevanceto hydrocarbonreleases The system state m ay be com prom ised or the system m ay fail if: routine m aintenance is postponed or delayed urgent m aintenance needs are not addressed prom ptly work is not planned thoroughly, m aintenance m ay get postponed or delayed
- 16. Lloyd’s Register services to the energy industry Contributory failures Key areas: Under manning Design failures Management and resourcing failures Relevancetohydrocarbonreleases A lack of staff to carry out work m eans that: m aintenance is constantly being com prom ised assets fail because they have not been m aintained properly only had ‘patchwork’ fixes carried out on them There are also com prom ises in relation to onshore activities due to under m anning. For exam ple: Not enough engineering team staff it takes longer to get designs developed there are delays to m aking engineering changes
- 17. Lloyd’s Register services to the energy industry Contributory failures Key areas: Reactiveapproach Failures in m aintenance processes Cultural issues Relevancetohydrocarbonreleases Short-term quick repairs can affect asset integrity: The underlying problem s are not im proved the system can be left vulnerable to further deterioration or failure Patchwork fixes m ay create new problem s: They can m ean the system is not operating correctly the system m ay becom e dam aged Jum ping into initiatives and approaches m eans that the work is m ore likely to be done incorrectly e.g. In relationto Small BoreTubingSurveys. This has wasted timeonan activity that was supposedtoaidinreducingHCRs, but fewcorrectiveworks have been done
- 18. Lloyd’s Register services to the energy industry Key areas: Poor procedures Contributory failures Failures in adm inistrative processes Relevance tohydrocarbon releases 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 m ay do dam age to the system
- 19. Lloyd’s Register services to the energy industry Key areas: Siloworking Relevanceto hydrocarbon releases Lack of com m unication or m iscom m unication: Inform ation m ay not be passed on to those who need to know inform ation m ay be m isunderstood due to conflicting dem ands and distraction the result is m istakes and om issions Work carried out in isolation: Conflict with other work being done can leave the system vulnerable to errors Contributory failures Failures in adm inistrative processes Failures in com m unication s Managem ent and resourcing failures
- 20. Lloyd’s Register services to the energy industry Key areas: Designissues ontheplatform Contributory failures Design failures Relevanceto hydrocarbon releases A m ism atch between the design specification and the proposed operability of the system : leads to system operability being com prom ised e.g. Therearenot enoughbeds, makingit difficult to get staff onto therig A m ism atch between the design and the operating environm ent: system m ay be susceptible to deterioration e.g. Someequipment andmaterial selectionat thedesignstage is consideredtohavebeen inappropriate andof poor quality, leadingtohigh levels of deterioration Excessive alarm s in the control room : real issues m ay be overlooked and m ade worse
- 21. Lloyd’s Register services to the energy industry Lessons for industry: For preventionof HCRs • No sim ple answer to the question of ‘what causes HCRs?’ • Identify and address all underlying factors • A suitable fram ework for assessm ent is required – using specialists who are trained to look beyond the engineering problem s to organisational factors • Recom m end use of external departm ents and/or independent parties: – provides independence – allows honest im partial inform ation to be elicited
- 22. Lloyd’s Register services to the energy industry • Essential that incident investigations go beyond the analysis of ‘front line’ failures • Take due consideration of the Hum an Factor within organisational root causes • Involve Hum an Factors experts in this process ? ? ? ? ? ? ? ? HumanError UnderlyingHumanFactors topics e.g. Procedures, Training & Com petence, Safety Critical Com m unications, Organisational Change, HF Design, Shiftwork & Fatigue, Organisational Culture, Workload, Maintenance, and Hum an Failures (HSE, 2012) UnderlyingHumanFactors topics e.g. Procedures, Training & Com petence, Safety Critical Com m unications, Organisational Change, HF Design, Shiftwork & Fatigue, Organisational Culture, Workload, Maintenance, and Hum an Failures (HSE, 2012) Lessons for industry: Investigationof HCRs
- 23. Lloyd’s Register services to the energy industry • 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. Lessons for industry: Haveahumanfactors integrationplan
- 24. Lloyd’s Register services to the energy industry DevelopcorporateresiliencetoavoidHCR outcomes (UCL Business Psychology Unit Effort Performance Outcome Model) Abilities and traits, roleclarity, organisational support, etc. Jobdesign, organisationa l policies and practices Perceivedequity of outcomes/ rewards Effor t Performance Outcome/ reward Satisfaction Extrinsic outcome/ reward Intrinsic outcome/ reward Expectancy Instrumentality Valance
- 25. Lloyd’s Register services to the energy industry ExxonMobile Up27% sinceJan2010high Trending with the S& P 500 BP Down30% sinceJan2010high 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 term s” Avoidthereputational andfinancial risk
- 26. Lloyd’s Register services to the energy industry Afinal thought! Competitive investment must be tempered with patience and consideration of the potential for human-system failures in maintenance, supervision and improvement Q&ATime
- 27. Lloyd’s Register services to the energy industry Services are provided by members of the Lloyd's Register Group. For further information visit www.lr.org/entities For m ore inform ation, please contact: Jason Devereux Principal Consultant, Lloyd’s Register Consulti Lloyd’s Register group entity 71 Fenchurch Street London, EC3M 4BS T +44 (0)20 7423 2320 E jason.devereux@lr.org w www.lr.org/hum anfactors Acknowledgem ents: •Jenny Gilroy •Derek Dum ulo •Rachel Bend
- 28. Lloyd’s Register services to the energy industry Lloyd’s Register Energy • Supports the safe and successful exploration, production and transportation of oil and natural gas around the globe. • Lloyd’s Register Consulting – form erly Scandpower / Hum an Engineering / ODS – now a leader in international risk m anagem ent – 500 em ployees worldwide • Servicingtheenergy andtransport sectors – Asset integrity – Com pliance – Inspection – Business Assurance
- 29. Lloyd’s Register services to the energy industry Part of theLloyd’s Register Group • Owned by Lloyd’s Register Foundation Charity • 240 offices in 78 countries • Over 8000 em ployees • Philosophy is to enhance safety of life: – at sea – in the air – on land Lloyd’s Register Today
Notes de l'éditeur
- Largest high-pressure / high-temperature development Elgin-Franklin is the world's largest high-pressure / high-temperature (HP / HT) development. Due to the extreme reservoir conditions - an initial pressure of approximately 1,100bar and temperatures of 190°C and complex geological structures - the fields pose a considerable development challenge. Brought on-stream in 2001, by March 2002 the fields had achieved peak production of 140,000 barrels of condensate and 485 million cubic feet of gas a day. In 2003, a new, record-breaking well was developed from the Elgin-Franklin platform to the West Franklin reservoir, which is the hottest, highest-pressure reservoir in the world. The well was drilled to a depth of 6,100m and stepped out 1.5km to tap an accumulation with a temperature of 197°C and a pressure of 1,155bar. The field is controlled by normally unmanned wellhead platforms on Elgin and Franklin, which are connected to and remotely controlled from a single production / utilities / quarters (PUQ) platform on Elgin. The Elgin wellhead platform consists of 1,743t topsides and a 2,715t, four-leg steel jacket containing 12 platform slots. The Franklin platform consists of a 2,800t jacket supporting 2,093t topsides. It contains nine platform slots. The jackets supporting the topsides were constructed at Stornoway and transported, by barge, to their offshore sites, where they were positioned in and piled into the seabed. Santa Fe's drilling rigs Galaxy 1 and Magellan continued the drilling programme through the jackets, until the topsides were lifted into place. The rigs drilled five production wells (and reconnected two existing appraisal wells) on Elgin, then drilled five production wells on Franklin. The drilling programme took 2,883 days. So far Total has invested more than £1.65bn (€2.8bn), in the two fields including €33m for R&D. At peak production the fields were turning out approximately 220,000 barrels of oil equivalent a day, or around seven percent of total UK production. Production / utilities / quarters (PUQ) platform The wellhead platforms were connected to an integrated, permanently manned PUQ platform on Elgin. The Elgin drilling platform is linked by a 100m access bridge (along which hydrocarbons will be piped), while the Franklin platform is connected via an interfield pipeline system. The PUQ platform is of a jack-up-style TPG 500 design, conceived by Technip Geoproduction. This was chosen in preference to a conventional fixed production platform, because it could be built onshore as one complete unit, reducing the need for heavy lifts offshore. The majority of the hook-up and commissioning work was carried out onshore before sailaway. The contract for the fabrication, installation, hook-up and commissioning was won by a consortium of three companies - Technip UK Limited, McDermott Marine Construction Limited and BARMAC. The TPG 500 was towed out to the Elgin field and manoeuvred into position, where its legs were lowered. On contact with the seabed, its 24,500t deck was be jacked-up by 34m. Hydrocarbon exportation and liquids pipeline To transport the liquids via the Forties System, a new 24in-diameter spur line, called the Southern Spur, was constructed, running from the PUQ to a subsea connection close to BP's Marnock platform. Liquids from the nearby Shell-operated Shearwater platform are also transported through this spurline, via the Shearwater Spur, tied in at a 'T' piece, about two kilometres north of the Elgin PUQ. Elf was the operator throughout the design, construction and pre-commissioning phases, but BP now operates the Southern Spur, and Shell the Shearwater Spur. Gas export pipeline - Shearwater Elgin area line (SEAL) A new 34in-diameter 468km-long pipeline - the SEAL pipeline - exports the commercial-quality gas from the Elgin-Franklin development and Shell's Shearwater development to the SEAL terminal in Bacton, Norfolk (operated by Shell). The pipeline originates at the Shearwater platform, with the Elgin-Franklin development also tied in with a subsea 'T' connection. From there, the gas is routed one of two ways - either through a 450m, 24in pipeline to the Transco Terminal, or through a 900m, 34in pipeline called SILK (SEAL Interconnector LinK) and operated by Total E&P UK to the Interconnector terminal. Although the gas produced from Elgin-Franklin and Shearwater is processed offshore to meet sales gas specifications, the new facilities at Bacton adjust the temperature and pressure of the gas and meter its delivery to the Transco and Interconnector terminals. From the Transco terminal, it is sent to the UK's National Grid, and from the Interconnector terminal it is sent to Europe (Belgium). Proposed future developments at the North Sea field In 1999 Total E&P UK discovered the Glenelg accumulation in Block 29/4d, located just four kilometres west-south-west of the Elgin PUQ platform. Development of this discovery was being worked on even before Elgin-Franklin started production. "A major gas leak in the Elgin field on 25 March 2012, has forced the operator of the field Total to shut down the Elgin field and stop production at all three fields." Glenelg has a difficult geology in that it is a tilted fault block structure. The reservoir lies around six kilometres below the seabed, where the pressure is 1,100bar and the temperature is 200°C, which is similar to Elgin-Franklin. The exploration well, 29/4d-4, was drilled by the heavy-duty jack-up rig, Transocean Nordic, in 1998/99. Oil and gas were encountered in the Upper Jurassic Fulmar sandstones below a depth of 5,400m with initial tests indicating a daily flow rate of 0.65 standard cubic metres of gas and 2,100 barrels of condensate. First production from Glenelg was brought on-stream in March 2006. In October 2007, production started from the F7 well of West Franklin. The F9 of West Franklin well was spudded in June 2007 and production started in August 2008, boosting reserves to 200,000 barrels of oil equivalent. The company also drilled Franklin Infill Well in 2007 and demonstrated the potential to drill infill wells into depleted HP/HT reservoirs. This technological advancement paves the way for future phased development of HP / HT fields. West Franklin Phase II development, including three additional wells and a new platform, was approved in November 2010. The production is expected to start by the end of 2013. By 2010, two infill wells were drilled on the Elgin field, also known as EIA. The company completed extended well test on Kessog discovery appraisal well 30/1c-9 in 2009. Concerns remain over the risks posed by the gas leak at French oil company Total's Elgin well in the North Sea. The company has yet not decided on the best option to tackle the leak, but is looking into pumping heavy mud into the well to suppress the flow of gas. Total health, safety and environment manager David Hainsworth told the Good Morning Scotland programme that his company was taking action, but risks were still apparent. "The gas is flammable but the platform power was turned off to minimise risk of ignition, but clearly there is a risk," he said. "We have taken away a series of risks but there is always a possibility, it's low but you never say never." In a statment on its website, the oil firm confirmed that the flare was still alight on the Elgin platform "The flare is still lit because when the platform is shut down and de-pressurised in an emergency, it cannot be fully purged as done in a controlled shutdown," the statement said. "This is perfectly normal. Some liquids do remain in the system and these liquids are now evaporating."
- Thematic Analysis to identify key HF themes from past hydrocarbon release incident reports Development of a Question Set to facilitate the exploration of key HF themes that appear to be influential in hydrocarbon releases Offshore interviews with a cross section of personnel, followed by analysis to identify significant issues Onshore interviews with a cross section of personnel to validate and respond to offshore issues, and identify new issues Collation of findings and conclusions, and presentation Large cross section of roles explored All roles (front line through to management) The first platform required pressure maintenance through water injection from the onset of production. approximately 140-150 platforms in the north sea
- No one factor leads to hydrocarbon leaks. Many of the failures are multi-faceted, highly inter-connected and are both influential and dependant on each other A wide variety of human and organisational failures are significant in relation to the occurrence of hydrocarbon leaks Failures that influence hydrocarbon leaks are apparent: Across all roles and levels of seniority Across all technical disciplines Throughout all phases and stages of the asset lifecycle Considered likely to be most influential to HCRs as they either: were frequently cited as significant were influenced by many underlying factors These key issues are specific to the investigation conducted They may not be directly applicable to other operators
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