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Catastrophic Events: Breaking the cycle

17 January 2013

Situated among 35 hectares of high security Ministry of Defence land is one of the UK oil and gas industry’s most valuable facilities. GL Noble Denton’s Spadeadam Test Site is designed to carry out large scale hazard tests on oil and gas assets of all types and sizes, helping operators to validate models and obtain accurate test measurements by simulating real-world environments.

GL Noble Denton’s Spadeadam Test Site is designed to carry out large scale hazard tests on oil and gas assets of all types and sizes
GL Noble Denton’s Spadeadam Test Site is designed to carry out large scale hazard tests on oil and gas assets of all types and sizes

It is here, in a remote location in Northern England, that more than 50 of the oil and gas industry’s safety and risk leaders gathered in early 2012 for an inaugural conference on major accident hazards, which was hosted by GL Noble Denton, - the independent technical advisor to the sector. The event was hosted to discuss one of the sector’s most relevant and fundamental questions: How can we collectively break the cycle of catastrophic incidents caused by our operations?

Held in association with IGEM, the conference also provided delegates with a unique opportunity to witness the destructive force of the major hazards that they spend their professional lives working to prevent. Nine large-scale experimental demonstrations were shown by GL Noble Denton Spadeadam’s team of engineers and scientists over the two-day event, each attached to a realistic industry scenario to help delegates put some perspective on the conference’s crucial discussions and debates.

Catastrophic amnesia

A study into the recurrence of oil and gas accidents presented to the conference by Dirk Roosendans, Total Petrochemicals’ Manager for Health and Industrial Safety, revealed a significant number of examples from across the industry, where the same incidents have taken place on more than one occasion, often resulting in the loss of life.

Citing particular examples of identical repetitive incidents involving falling chain wheels and exploding sulphuric acid storage tanks, Roosendans said: “The oil and gas industry’s stringent approach to health and safety means that a large amount of information is made available following an incident with the specific aim of avoiding repetition. So why don’t we use it effectively to stop accidents from happening again?” Roosendans put to the conference that this dangerous phenomenon could be attributed to the fact that most oil and gas professionals will rarely or never experience a major accident hazard personally in their careers, turning the risk of a hazard from a reality into a concept.

“After 20 years of a major accident occurring, it begins to disappear from our corporate memory, mainly due to the introduction of younger generations who are less aware of past incidents”, he said.

“Most of us will never experience a pool fire or vapour cloud explosion in our careers, so we don’t find it easy to prepare for the risk or follow the guidelines that have been published to mitigate their recurrence.”

In a bid to better understand the root cause of recurring hazardous incidents, Total Petrochemicals has conducted research into the processes used by the industry to reduce the risk of an incident being duplicated. Having studied the ‘return of experience’ - the process of publishing information about the cause of a hazard in order to prevent it from happening again - from a selection of major accidents with potential high consequences, the company found that the quality of accident investigation reports was generally poor, focusing heavily on the technical and organisational elements of accidents, while disregarding the ‘human factor’ decisions behind them.  “One in three of the high potential events we studied were attributed to supervisors not having the competencies and resources required to carry out their roles effectively”, Roosendans said.

“Supervisors have the difficult task of being independent from both management and employees. They have to act independently from both parties if they are to deliver the highest standards of safety in their work, and that role takes a certain type of person. It was clear to us that we should pay more attention to developing our supervisors to aid our major accident risk mitigation strategy.”

Roosendans also stressed the importance of not just communicating relevant information on past incidents, but also to using that information actively in a number of processes such as the development of design standards, operating procedures, risk studies, training and auditing “It is only by applying the lessons learned actively that we have a chance of not repeating the same disasters that happened many times before,” he said.

The human factor

A kerosene pool fire demonstration
A kerosene pool fire demonstration

Peter Bamforth, Safety Engineering Manager, BG Group, agreed that human factors play a key role in breaking the cycle of catastrophic incidents.

In a presentation, Peter told the conference that every barrier put in place to manage the risk of major hazards is an intrinsic mix of plant, processes and, importantly, people. He agreed that, like many others, BG Group’s multinational workforce often lacks a personal frame of reference when it comes to catastrophic incidents.

“The true root causes of incidents are generally people, and the difficulty with that is they can often be far removed from the incident when it occurs. For example, competent operators may work with poorly-designed facilities for years before an incident occurs and, by that time, those responsible for the design may have moved on.” 

“That’s why it is so important that everyone across the company, from our engineers to our finance teams, has a consistent understanding of how important our safety culture is and the events that we are trying to avoid”, he said.  The BG Group principles of major hazard management reflect those of many other operators, but its innovation lies in its approach to raising employee awareness through a specially developed training programme. The company runs regular major hazards awareness courses at GL Noble Denton’s Spadeadam Test Site, during which course delegates experience a series of large-scale demonstrations, and give first-hand experience of the incidents that the company is working to avoid.  

One of the drivers for BG Group introducing the major hazards awareness training was the major incident at the BP Texas City refinery in March 2005, in which 15 workers were killed and more than 170 injured. The inquiry into the incident recommended that operators develop a programme that would give ‘an appropriate level of process safety knowledge’ to all levels of the organisation, from the executive team down to front-line workers.  “We started off by bringing our senior management team to Spadeadam and showing them some large-scale demonstrations as part of the awareness course. They were so affected by their visit that they insisted that their direct reports also attend.” 

“It was important for us to start with our senior management because their buy-in has led to a demand for the course cascading throughout the organisation, and is effective in empowering people to implement new initiatives, since their managers will already have attended”, Bamforth said.  

BG Group wants the major hazards awareness message to reach all levels of its organisation and, while the course has been successful in raising incident safety awareness across the business, Bamforth admitted that it would be unrealistic to expect that every single one of the company’s people could attend the training course at Spadeadam. It’s for this reason that the Group has introduced a range of interactive tools to its safety training programme.

“In addition to developing e-learning modules, we’ll be providing training materials from the Spadeadam course to allow a series of major hazards awareness workshops to be run across the Group, encouraging our businesses and regions to openly share best practice,” said Bamforth.

BG Group has also been using interactive drama workshops to highlight the role of the human factor causing major accidents.  The company has engaged a team of actors to re-enact events leading up to incidents that it has faced, allowing its employees to be involved in real-life scenarios and discuss where things went wrong.

“The great thing about the drama workshops is that it gives people a chance to deal with real incidents that BG Group has encountered. This brings an element of authenticity to the training, “said Bamforth.

The introduction of techniques such as drama to safety training represents a significant evolution to operators’ approach to safety and risk in the oil and gas industry, according to Lee Allford, Operations Manager for the European Process Safety Centre and facilitator of the conference.

A demonstration showing the ignition of gas escaping from a pipe flange at 70 barg
A demonstration showing the ignition of gas escaping from a pipe flange at 70 barg

“The sector took a far more technical approach to its safety training ten years ago. The introduction of techniques such as learning through drama shows a real shift towards focusing on helping people understand how the decisions they make can affect the development of a major accident.” 

The renewed focus on the human factor in safety training is underlined by the results of Total Petrochemicals’ study into the link between employees’ behaviours and high potential events.  Working in partnership with a leading psychology association, the company has revisited its safety culture framework and processes and worked on delivering greater clarity and consistency in the way it delivers information to employees.  

“The purpose of this exercise was to ensure we were capturing and re-presenting ‘return of experience’ from past accidents as effectively as possible. The continued recurrence of incidents in the sector evidently shows that our industry is not effectively referring to and learning from information produced in the wake of major accident hazards. The knowledge of relevant past experience is vital, and by reviewing the way that we present that information to our employees, we have been able to reduce the risk of accidents taking place in the future”, said Roosendans.  

Total Petrochemicals’ safety framework review saw the company make a number of changes to the HSE information it presents to its employees. Some of those were as simple as adding visible alert symbols to written procedures, helping to bring attention to areas where people have been previously been harmed through neglect. The company also undertook a project to make information more accessible to employees through enhanced intranet search facilities, and by introducing a dedicated research team to collate and publicise safety information published following accidents across the industry.

Leading by example

Delegates at the conference agreed that an organisation’s leadership behaviours are key to ensuring that safety is taken seriously throughout its workforce.

Delivering a presentation on the role of senior management in developing safety cultures, Chris Murray, Chief Executive of Xoserve and a member of the National Grid leadership team, suggested that, in addition to leading by example, the role of a company’s senior management is to instill a sense of safety leadership within every employee, giving them the confidence to speak up when they feel that any aspect of operations may be unsafe.

“We need to ensure that employees don’t look the other way when a potential hazard faces them because they’ve not been given the confidence to speak up or they feel that the senior management is difficult to get in front of on a day-to-day basis,” Murray said.

He also questioned the audience as to what factors might stop us from intervening when we see something about to go wrong, suggesting that other misplaced priorities might conflict with hazard intervention.

“One possibility is that senior leadership teams think that their workforce has understood the safety messages that they are communicating, when they haven’t”, said Murray.  

“Despite our assertions that safety is our number one priority we need to be mindful of the fact that some supervisors and employees might believe that management want them to focus on production. As management, we need to ensure that we really have empowered supervisors and employees to put safety over and above time and expense.”

Explosion test at Spadeadam
Explosion test at Spadeadam

Murray suggested that one potential cause for this is that employees can interpret management messages around safety as corporate spiel.

“When I say that safety is my number one priority, I really mean it and I use examples of personal experience to demonstrate that sentiment is heartfelt. There have been occasions in my career when I’ve had to break bad news to employees’ families because of safety incidents; it’s a horrible place to be. I never want to be there again and I never want any of my colleagues to be in that position either.”

“A zero per cent accident rate is achievable in every company. All accidents are avoidable and only zero is an acceptable number.  No matter what the incident, or who’s involved, you can always do something to improve safety”, Murray said.  

Citing Albert Schweitzer: Example is not the main thing in influencing others; it’s the only thing, Murray suggested that, in addition to having sound policy, processes and procedures, management need to demonstrate “supernormal” safety behaviour and engage with their teams with ambition and passion for excellent safety performance, persuading staff that accidents don’t have to happen, and urging employees to take management to task in the event that they themselves are not adhering to safety rules.

Petrofac’s Richard King cautioned that “a lesson from Texas city is that better personal safety doesn’t directly lead to better Process Safety. Indeed if management teams over-focus on “personal” safety issues this can be to the detriment of “process” safety. A proliferation of notices about holding handrails going up and down stairs certainly contributes to fewer falls, but does little or nothing to reduce the likelihood of a major process safety incident.  

“We need to be careful that an over-emphasis on the “easy to deal with” personal safety stuff doesn’t divert attention from the “hard to deal with” major accident hazards facing our industry. A zero per cent accident rate is an excellent target, I would argue that an even better one is for zero Macondo, zero Texas City and zero Jaipur type incidents.”

Reducing risk at the drawing board

Discussion generated by delegates at the conference shows that the miscommunication between management and employees on production versus safety is most critical during oil and gas asset design.

BG Group’s Peter Bamforth explained that the early stages of design provide the most significant, efficient and cost effective opportunity for risk reduction changes to be made to an asset. 

“A thorough safety review during the early design stages of a new asset is absolutely critical. If risk reduction opportunities aren’t identified at this stage, opportunities will be missed, and there will be greater resistance to changes during the later stages of the design process.”

“There is a perception that anything missed during conceptual design will be fixed during the detailed design process, but that’s a flawed argument. Schedules and budgets become more fixed in the detailed design process, and safety and design teams find it more difficult to slow the momentum of a project at that stage,” said Bamforth 

Steel pipeline explosion
Steel pipeline explosion

Conference facilitator Lee Allford agreed: “One cycle that the oil and gas industry needs to break is that of the continual missed opportunities for risk reduction in the early stages of design. We need to get out of the mindset that safety-related changes are possible in equal weight at any stage of an asset’s design. As time and financial pressures begin to apply in the later design stages, the time-old balance between production and safety become more complicated for everyone involved. “ 

Another conference delegate added that the wider economic climate also has an impact on the level of resistance that safety professionals encounter when requesting to make changes during the latter stages of asset design.

“Our job is to ensure that ‘risk is as low as reasonably practical’ during the design phase, but how do you define ‘reasonably practical’? It seems that the term means different things depending on the price of oil. When it’s high, more capital is available to work with and get things right, but there is a greater time pressure to finish the development of the asset. If oil prices are low, lower levels of investment can restrict the ability to make changes in any but the very earliest stages of design.”

A cycle of cycles

While summarising the discussions that were raised at GL Noble Denton’s inaugural conference on major accident hazards, facilitator Lee Allford brought delegates’ attention to the question that had brought them together; how can the industry break the cycle of catastrophic events that it causes?  That question isn’t easy to answer it seems, principally because there is no single cycle to break. Allford suggested that the true cycle to be dealt with is the sector’s collective failure to learn from previous mistakes. In order to do that, other cycles need to be tackled.

Total Petrochemicals’ Dirk Roosendans highlighted how the sector’s tendency to neglect recommendations that follow past incidents is a critical cycle that the industry should address; while the BG Group’s Peter Bamforth showed how a focus on the human decisions behind an accident is crucial to helping employees understand the part they play in the loop. 

Xoserve’s Chris Murray effectively demonstrated oil and gas professionals’ can struggle to prioritise safety over production, causing an essential cycle that management teams should invest in resolving.  The inability to be able to identify all safety critical elements during the very earliest design phases of an asset highlights an altogether different cycle that the industry needs to concentrate on.  

The topics raised during the conference have outlined some of the significant progress that operators are making towards mitigating the risk of major hazards, some of which is being realised through inspired technical innovation, and others through a modern approach to revisiting safety processes and evaluating the behavioural causes of incidents.  

The safety and risk professionals attending the conference agreed that, it’s only by continually sharing this best practice and discussing new safety initiatives being delivered, that the oil and gas sector will stand a much stronger chance of breaking the overarching cycle that causes the loss of life.

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