2011 SPE - Electronic logging to improve safety
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Presented at the Society of Petroleum Engineers Europe Ltd annual meeting. Using electronic shift logging to improve safety. Joint presentation with Infotechnics
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2011 SPE - Electronic logging to improve safety
- 1. 1 Using Electronic Shift Logging to Improve Safety Andy Brazier Tel: +44 1492 879813 andy@abrisk.co.uk www.abrisk.co.uk Brian Pacitti Tel: +44 1224 355260 sales@infotechnics.co.uk www.infotechnics.co.uk Martin Sedgwick Tel: Martin.Sedgwick@ scottishpower.com
- 2. Two part presentation 2 1. Companies need to improve critical communication processes, including shift handover 2. Case study from – role of shift logging in preventing process safety incidents Underlying theme – technology is available to assist improvement (e.g. Opralog from Infotechnics)
- 3. 3 Is there a link between safety and communication? Is communication hazardous? Did it ever kill anyone?
- 4. 4 Deep water drilling in the Gulf of Mexico is: Complex Hazardous At the edge of our technical capabilities The people involved have to know what is going on Day by day Hour by hour Minute by minute
- 5. 5 They need to communicate. But… The work for different companies They report to different people They are restricted in what they can say The result is No one has the full picture of what is going on Bad decisions are made
- 6. 6 Transferring oil products between sites is: Relatively simple Nothing new Hazardous The people involved have to know what is going on otherwise: They may not know a tank is being filled They won’t know it needs to be monitored It may overflow
- 7. 7 And don’t forget: BP Texas City Piper Alpha Bourbon Dolphin Etc…………..
- 8. 8 What is the problem? 1. Knowing what to communicate There are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns – the ones we don't know we don't know. 2. Inadequate systems 3. Inappropriate behaviour
- 9. 9 What can you do? 1. Tell people they have to communicate 2. Train people to communicate better 3. Specify/guide what has to be communicated 4. Make sure they are communicating 5. Make sure communication is effective 6. Identify problems 7. Drive (continual) improvement I.T. Solutions Making it easy to log information that is then readily accessible to anyone who may need it
- 10. What is the problem? Incorrect information given Information misinterpreted No communication 10 All of the above
- 11. What can you do? Tell people they have to communicate Train people to communicate better Specify/guide what has to be communicated Make sure they are communicating Make sure communication is effective Identify problems Drive (continual) improvement 11
- 12. 12 The problem Shift handover is a complex, error prone activity, performed frequently High risk It can’t be ‘engineered out’ Partly driven by systems and procedures Highly dependent on behaviours of people involved Rarely cited as a root cause of accidents. But is anyone looking for it?
- 13. 13 We know there is room for improvement but…. People underestimate its complexity and hence overestimate their ability at shift handover Who has the incentive to put in additional effort? Person finishing their shift – want to go home Person starting their shift – don’t know what they don’t know Managers – rarely present Seems to have fallen into the “too hard” category for many
- 14. 14 Looking for another angle Tackling behaviours head on is not easy Log books used at handover contain a wealth of information Could this be used more widely?
- 15. 15 Offshore study Copies of a week’s logs 3 ½ kg of paper All hand written Multiple formats Contents reviewed
- 16. 16 Information being recorded Human errors Valve ‘inadvertently’ closed, missing parts and information, tasks not complete Minor incidents Small releases, equipment failures Routine tasks 120 operational tasks recorded Solutions to problems Release pressure, manually manipulate valve, use sealing compound
- 17. 17 Other studies using data from log books Component reliability1 Hours of operation, failure and repair time Economic operation2 Model of plant breakdown and identification of items critical to system reliability Reliability3 Development of a fault tree used to identify plant modifications References 1 – Moss 1987 2 – Campbell 1987 3 – Galyean et al 1989
- 18. 18 Findings from these studies Date from log books could be very useful It is relevant to safety and reliability studies Allows models to be developed Supports expert judgement Difficult to achieve Handwritten Not structured with data collection in mind Concerns about consistency.
- 19. 19 Putting these ideas into practice
- 20. 20 Maximising the value of data Improving the quality of data To get the full picture, it is usually necessary to have input from more than one area of the business It is useful to be able to consider logged information alongside the relevant ‘hard’ process data Information may be required in different formats for different purposes Supporting the operator in collecting the data Making it as easy as possible Making it very clear what is required Using the data
Hinweis der Redaktion
- Good afternoon. I am Andy Brazier – a risk consultant specialising in human factors in major hazard industries The paper submitted to SPE was written by myself and Brian Pacitti from Infotechnics. It refers to a case study from Scottishpower. We realised you would probably be most interested in hearing from the horses mouth, so Martin Sedgwick will be presenting instead of Brian.
- So this presentation is a double act. I will make the case that most companies need to improve the way they communicate, with shift handover being an example of where this is particularly critical Martin will tell you about what Scottishpower has done to improve shift handover as part of their aim to prevent process safety incidents The underlying message is that there is now technology available that, if used properly, can support improved communication. An example is the Opralog, which makes logging of information and access to it easy across the business.
- In some ways, I am quite disappointed that this paper was accepted for this conference. Not because I did not want the opportunity to talk to you, but because I had hoped that problems we have known about for years may have been solved by now. I think the problem is that, whilst people see communication including shift handover as important, they don’t really understand the risk. Communication in its own right is not hazardous and I doubt it ever directly harmed anyone, so perhaps it never gets high enough on the list of priorities
- The Deepwater Horizon/Macondo incident illustrates the world we live in. Despite the technology involved, it relies on people (lots of them) to operate safely. To do that they need know what is going on.
- But modern ways of working have made this difficult. We have multiple companies, resulting in different lines of reporting. There may be commercial sensitivities. So people may feel they cannot talk to others. The danger is that no one really knows what is going on. They make decisions based on incomplete information. And we know what can happen.
- It is not just at the cutting edge where we have problems. Transferring oil products from site to site is not conceptually very complicated and is certainly nothing new. The clearest link between Buncefield and Deepwater Horizon is that both were dealing with flammable hydrocarbons. In this case, because people did not know what was going on they did not realise a tank was being filled, so they were not monitoring its level and it overflowed.
- We have had other major accidents where communication and shift handover have been identified as contributing factors. But when I talk to my clients they don’t seem to recognise it as a priority problem for them. I don’t think it is because they don’t believe it to be a problem, but because they don’t really know what to do or it simply fits into the ‘too hard’ category
- I think communication often does not happen because people do not know what information needs to be passed on. This is because the transmitter does not know what the receiver needs. As Donald Rumsfeld said, it is the unknown unknowns that cause us the most problem. One reason people do not know what to communicate is because we have not provided them with suitable systems. But there is a significant behavioural element. If you think of shift handover, the person finishing their shift will inevitably want to leave as soon as they can, and so has little incentive to stay on to make sure all the important information has been communicated.
- I’ll say something along the lines of I had concluded that making data more useful to the business would give an incentive for everyone to improve handovers. I’d looked at what companies were doing and found there was still a lot of reliance on handwritten logs, and where computerised it was usually a word or excel file. Infotechnics contacted me. When we met I had a lot of questions, and Opralog seemed to have the answer to them all.