The Risk Management Tool Box Blog

NOPSEMA in Australia is facilitating a workshop on safety culture.

NOPSEMA's Annual Offshore Performance Report identifies two significant areas of increased safety risk which must be addressed if safety is to improve in the offshore energy sector in Australia:

1.  Inadequate design specification; and 

2.  Procedures not being followed.

2012 proved a costly year in terms of lives lost with two drillers being killed on the Stena Clyde.

But there were also some improvements in performance, specifically:

• The rate of accidents reached the lowest level recorded since 2005; and

• The rate of uncontrolled hydrocarbon releases reached a seven year low, reflecting a 41% drop in the number of unplanned petroleum liquid and gas releases in 2012.

Pressurized air hose couplings which are incorrectly assembled without either a safety pin to secure the fitting or without extending the hose restraint pose a significant risk of a high velocity kinetic energy release. 

Air hose coupling failures have caused a number of serious incidents resulting in injury and fatalities.

Incorrect assembly of air hoses presents a risk not only to the person operating the equipment, but to others in the vicinity.

Equipment operators and supervisors of work activities should review their practices for the use of pneumatic tools, hoses and couplings.

It is important that members of the workforce who use this type of equipment, and those responsible for their supervision, have had the relevant training before work starts.

There has been a dramatic increase in dropped objects occurring offshore Western Australia in the first quarter of 2013. 

Nine dropped object notifications have been received by NOPSEMA so far this year. 

All of these dropped objects have occurred on mobile offshore drilling units (MODUs). 

As a comparison, one dropped object was reported on a single MODU for the same period in 2012 and a total of 13 for the entire year.

The weights and heights of the dropped objects ranged from a couple of kilo's to over 2 tons and from less than 1 metre to 43 metres. 

The ‘DROPS Calculator’ highlights that a mass of as little as 700 grams falling from a height of 15 metres could result in a fatality. 

Dropped objects have included drill pipe and casing, a spool of wire rope, a navigation light fitting, slip inserts, a hose bundle, an equipment handle and a camera located in the derrick. 

Three members of the workforce have recieved injuries as a result of three separate dropped object events. 

Two workers required a medical evacuation from the offshore facility, while another worker required first aid  treatment. 

In another case, a member of the workforce was standing only 2 metres from where a 28 kilogram object landed having dropped from a height of 19 metres. 

Analysis using the industry supported ‘DROPS Calculator’indicates that six of these dropped object events could have resulted in a fatality.

Analysis of the dropped object events in 2012 highlighted the predominant root causes as being: 

1. Poor design of equipment; 

2.  Work procedures not being followed correctly; 

3.  Wrong procedures used or no procedures used; 

4.  Dropped objects not anticipated and factored into the planning for the work; 

5.  Lack of training, lack of instruction, lack of understanding of the task; and 

6.  Preventive maintenance issues.

Operators and other duty holders need to take urgent action  to arrest this worrying trend.

The Risk Management Tool Box re-iterates the requirement for duty holders in offshore and onshore environments to ensure an appropriate balance of preventative and mitigative control measures are identified and implemented during lifting operations.

There is also a critical need to apply the hierarchy of controls to kinetic energy hazards which are present during lifting operations.

In particular, operators are reminded that the control mechanisms should focus on elimination, substitution and engineering controls before consideration of administrative controls and the use of PPE.

I've recieved a safety alert email today from NOPSEMA warning about the number of dropped objects being recorded in 2013.

NOPSEMA has identified a concerning increase in dropped object events since the beginning of 2013. 

Nine dropped object notifications have been received by the authority in the first quarter of 2013. 

All of these dropped object events have occurred on mobile offshore drilling units (MODUs). 

As a comparison, one dropped object was reported on MODUs for the same period in 2012 and a total of 13 for the entire year.

Overall, a total of 31 dropped object events were reported in 2012 from the following facility types: 

+  13 MODUs;

+  11 platforms;

+  Five floating production storage & offloading facilities; and 

+  Two pipelay/accommodation/construction vessels.

The current spate of dropped objects is a cause for concern and should be addressed by Operators revisiting their lifting procedures.

Enclosed here is a Human Factors Information Paper produced by NOPSEMA in Australia and addressing issues around personnel resourcing on offshore platforms. 

It makes for interesting reading.

It makes the following key messages:

  Appropriate personnel resourcing processes contribute to effective risk management;

  An understanding of the impact of time pressure and fatigue on human reliability should be applied to resourcing activities;

  Emergency response positions should be well resourced at all times;

  Maintenance activities should be designed and scheduled to reduce the likelihood of error, particularly in relation to interruptions and time pressure;

  Maintenance activities should be subject to independent checks to mitigate any errors that may have occurred prior to task closeout;

  Supervisors should develop a working knowledge of human error and performance shaping factors, and should apply that knowledge in their daily activities;

  Organisational systems and structures should be in place to support supervisors in managing relevant performance shaping factors; and

  Supervisors should not be overburdened with administrative tasks; rather their priority should be to spend sufficient time coaching their employees.

Pneumatic hose couplings are easily miss-used when they are incorrectly installed with no safety-pin and no hose-restraints ("whip check").

In Australia, NOPSEMA, the offshore safety regulator has issued a safety alert to highlight the risk, having noticed many instances where hoses have been incorrectly installed.

If hoses are not correctly installed, there is a very real danger of the hose de-coupling and whipping or striking someone.

See the safety alert below for further information.

Enclosed here is a safety alert from NOPSEMA about an incident in which a scafffolder fell from height when dismantling a scaffold on an offshore facility in Australian waters.

Fortunately, the scaffolder was wearing a safety harness and inertia-reel device which prevented him hitting the sea below.

The alert does highlight some failures and key learning, including:

It is considered good practice to install check couplers above the suspension scaffolding coupler as described in AS/NZS 4576 Guidelines for scaffolding;

1.  The scaffold should be visually inspected by the work party prior to using the scaffold;

2.  Scaffolds should be inspected regularly by a competent person;

3.  Only equipment within its certification period should be used;

4.  Safety equipment should be suitably rated for the personnel using it;

5.  Fall arrest equipment should be anchored at a suitably rated anchor point; and

6.  The rescue plan should reflect the hazards the job presents rather than using a generic rescue plan for all scaffold jobs.

When examining and explaining the behaviour of other people, there is sometimes a tendency for incident investigators to overestimate the effect of internal "attitudinal" factors, and underestimate the effect of external factors on that behaviour.

In psychology, this problem is known as the Fundamental Attribution Error.

You'll have seen the Fundamental Attribution Error at work when you hear someone say "the person involved in the incident was a bit stupid, or had a poor attitude."

But the problem with adopting a focus on attitudes as a key safety failure mechanism is that it ignores what Psychologists know about mechanisms of the brain.

Many psychological studies have shown that people will experience attention failures, memory lapses, slips of action and mistakes based on incorrect knowledge or experience.

None of these failures can be explained by attitudes alone.

And an attitudes-based focus to incident causation is unlikely to resolve most of these failure mechanisms.

And even deliberate and willful violations of safety rules which do have a strong "attitudinal componant" often occur in response to external pressures rather than just being driven by internal attitudes.

Good incident investigations avoid the fundamental attribution error by recognising the range of failure mechanisms of the brain and the role of external factors in those failures.

And organizations with mature safety culture design error-tolerant work arrangement based on identifying which errors are most likely to occur.

Moreover, mature organizations view incidents as an opportunity to learn something about their systems, assets, or culture, rather than blaming individual workers and their "negative" attitudes.

Finally, they recognise that safety attitudes are most effectively fostered through genuine leadership practices and leading by example at all levels of the organisation, every day.

I could have saved a life that day, it wasn't that I didn't care, I had the time, and I was there.

But I didn't want to seem a fool, or argue over a safety rule.

I knew he'd done the job before, if I called it wrong, he might get sore.

The changes didn't seem that bad, I've done the same, he knew I had.

So I shook my head and walked on by, he knew the risks as well as I.

He took the chance, I closed an eye.

And with that act, I let him die.

I could have saved a life that day, but I chose to look the other way.

Now every time I see his wife, I'll know I should have saved his life.

That guilt is something I must bear, but it isn't something you need share.

If you see a risk that others take, that puts their health or life at stake.

The question asked, or thing you say, could help them live another day.

If you see a risk and walk away, then hope you never have to say, I could have saved a life that day, but I chose to look the other way.

Attributed to Don Merrell