CAKE session no. 13

Prevent major accidents, my role.

What is a major accident?

There are several definitions on a major accident, we have chosen the two most common.

• An accident (an acute incident that leads to loss) where at least 5 people can be exposed.

• An accident caused by faults on one or several of the systems incorporated safety and emergency preparedness barriers.

Major accidents vs small accidents, diffrences;

Often discussed with rig management

Rarely discussed with rig management

Typical theme in safety meetingsRarely discussed in safety meetings

Low costsResource demanding to prevent

Easy to understand/opinion onComplicated and complex

Small accidents (person), high probability and small

concequences.

Major accidents, low probability and big consequences.

Decline in number of personal injuries is considered to be an indicator on major accidentrisk, this is not correct.

On major accidents;

• Often caused by several “small deviations that “find” each other”. Major accidents is the result of several individuals and systems that fails. “A long row” of minor failures can lead to major accidents.

• Many major accidents involve maintenance in one way or the other;– Lack of maintenance or insufficient maintenance, extensive back

log in the maintenance system etc.

• Major accidents is recognised by a lack of sufficient and relevant information within the organisation and the lack of compliance.

– Serious signals is overlooked because they are not considered to be relevant in regards to major accidents.

Example of incident with major accident potential in MDN

Two incidents in January that resulted in overfilling of the flare knock out drum with following abnormal flaring and release of hydrocarbons from flare.

”What if” analysis after the incident revealed that the potential in these accidents was;- Over pressure in the flare system- Burning fluid falling down in the non-hazardous area, crude oil if

the flare was out- Ignition of the cargo vent.

• Oil spill• Actuator/valves not working• Blow outs• Back log in maintenance program• Kick• Collapse of formation• Gas and oil leaks• Fire in engine room• Collision/boat• Heli crash• Too many alarms in CCR• Poor surveillance when offloading• (Silent?) deviations

Results from last CAKE session, Possible major accidents (causes)

Results from last CAKE session, Our most important barriers

• Gas and fire detector• Maintenance routines• Education/training of emergency preparedness personnel• PPE• WP• Fire fighting equipment• Shut down systems• Well control• Certified and educated personnel• Emergency generators• CO2 system• Fire doors• Good planning of jobs/activities

Results from last CAKE session, How can we strengthen our emergency preparedness?

• Reduce back-log and sufficient maintenance budgets• Safety course• Training/exercises• Experience transfer• Variety in routines• Good risk assessments• Shared knowledge• Good and correct evaluations/observations• Incident/accident reports• Visible leadership• Better understanding of SJA, and only use when appropriate• Better risk understanding on junior level• Better risk understanding on all levels?

Humans as hazards vs humans as barriers

• Many accidents have been avoided because individuals have;

– Been observant, used their knowledge (information) and their skills (training/experience) and thereby avoided a critical situation.

• Machines and procedures cannot evaluate, only people can. Humans and the human knowledge and skills is therefore a very important factor in avoiding major accidents.

Barriers-We usually operate with two main sets of barriers:

Probability reducing – The control functions in place to reduce the probability of an incident, such as; maintenance, procedures, SJA etc.

Consequence reducing – The functions that reduce the consequence of an occurred incident. Such as, contingency, sensors, PPE etc.

Probability reducing.Consequence reducing.

CAKE session (OIM will choose a relevant accident from company)

• If individuals often contribute to major accidents;– What could the individual have done to prevent this accidents?

– What tools do we (as individuals) need to have in place in order to prevent a similar situation?

– Why does not the tools we have implemented work? (Do not answer superficially, go in dept, why do we not use these tools?)