Presentation - Industry and FPSO Health and Safety …...Industry and FPSO Health & Safety...

Industry and FPSO Health & Safety Performance

Simon Schubach Regulatory Operations General Manager

12th Annual FPSO Congress September 2011, Singapore

• Background to NOPSA • FPSO health & safety performance • Lessons from inspections • Lessons from incidents

Vision

A safe Australian offshore

petroleum industry

Sept 2011 A173767 3

NOPSA’s legislated functions

Sept 2011 A173767 4

Promote Advise

Report

Investigate

Monitor & Enforce

Co-operate

Presenter

Presentation Notes

NOPSA’s role as regulator is to provide independent and robust challenge.

Legal framework

• A ‘General Duties’ regime: reduce risk ALARP • Performance-based, with prescriptive elements • An accepted safety case is required in order to

undertake activities • The primary responsibility for ensuring health

and safety lies with the operator

Sept 2011 A173767 5

What does the regulator do?

• Challenge the Operator – Thorough Safety Case assessments - targeted – Rigorous facility inspections – sampled verification – Comprehensive incident investigation – depending

on severity – Principled Enforcement – verbal / written and

prosecutions

• Independent assurance – Facility health and safety risks are properly controlled

by Operators of facilities through securing compliance with OHS law

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INDUSTRY PERFORMANCE

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2010-11 Activities

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NOPSA 33 OHS Inspectors

20 Support staff

INDUSTRY 33 Operators 210 Facilities

286 Assessments submitted

365 Incidents Notified

43 Accidents

322 Dangerous Occurrences

218 Assessments Notified

152 Facilities Inspections

1 Major Investigations 31 Minor Investigations

333 Incident reviews

78 Enforcement actions

Presenter

Presentation Notes

ASSESSMENTS – difference due mainly 48 revised safety cases not assessed (and the usual lag between submission and completion of the other types) Breakdown of facility numbers on next slide Ask 3 questions ….. Is the Operator doing enough to be safe?? Are they doing what they say they would do?? When something goes wrong – what happened? Did someone break the law? Today we have ?? Inspectors ?? Support staff Robust processes and procedures – ISA 9001 quality accredited Ongoing program of recruitment and staff development

Facilities

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* Numbers fluctuate slightly as MODUs and vessels enter the regime and become facilities or leave the regime and cease to be facilities.

Facility Group No. of Facilities Based on Current (2011) data *

Platforms 60

FPSOs / FSOs 14

MODUs 15

Vessels 10

Pipelines 110

TOTAL: 210

Presenter

Presentation Notes

Crystal Ocean Four Rainbow Pyrenees Venture Stybarrow Challis Venture Jabiru Venture Van Gogh (Operations) MODEC Venture 11 Dampier Spirit Karratha Spirit Cossack Pioneer Nganhurra Vincent (Maersk Nguijima-Yin) CWLH OKHA

FPSO Age Distribution

0

2

4

6

8

0-5 years 5-10 years 10-15 years 15-20 years 20-25 years 25-30 years >30 years

Num

ber

Facility Age Group

Age distribution of FPSO/FSOs(all active FPSOs - 2005-2011)

FPSO FSO

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Statistics for FPSOs for the financial year 2010-11

Sept 2011 A173767 11 11 A173767 September 2011

Activity ALL Facilities FPSO/FSO

Facilities Inspected 152 23 (15%)

Incidents reported 365 83 (23%)

Assessments notified 218 25 (11%)

Enforcement Actions issued 78 32 (41%)

0

40

80

120

Unplanned Event -

Implement ERP

Damage to safety-critical

equipment

Accident -Incapacitation >=3 days LTI

Could have caused

Incapacity ( LTI>3)

Other kind needing

immediate investigation

Could have caused Death

or Serious Injury

Fire or Explosion

Uncontrolled HC gas

release >1-300 kg

Uncontrolled PL release

>80-12 500L

Collision marine vessel

and facility

Accident -Death or

Serious Injury

Pipelines -kind needing immediate

investigation

Number Incidents Notified 2010-11

ALL Facility Types

FPSO/FSOs

More than half of all unplanned events (alarms, medivacs etc.) occur on FPSOs

Incident Categories

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Incidents per Facility Type

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1/3 of all incidents reported to NOPSA occur on FPSO/FSOs

0%

25%

50%

75%

2005 2006 2007 2008 2009 2010 Jan-Jun 2011

% Incidents - Platforms

0%

25%

50%

75%

2005 2006 2007 2008 2009 2010 Jan-Jun 2011

% Incidents - MODUs

0%

25%

50%

75%

2005 2006 2007 2008 2009 2010 Jan-Jun 2011

% Incidents - FPSO/FSOs

0%

25%

50%

75%

2005 2006 2007 2008 2009 2010 Jan-Jun 2011

% Incidents - Vessels

Presenter

Presentation Notes

7% of all facilities are FPSOs (and if we don’t include pipelines, then 14% of facilities are FPSOs – yet on average 30% of incidents occur on FPSOs. So in effect, they account for twice as many incidents as one would normally expect.

0

5

10

15

20

2005 2006 2007 2008 2009 2010 Q2 2011

Rate

TRC Ratesper million hours worked

ALL FPSO/FSO OperatorsALL Operators

TRC = LTI + ADI + MTI

Injuries

Sept 2011 A173767 14

Presenter

Presentation Notes

NB: LTI includes LTI>=3 day and LTI <3 days

15

0

2

4

6

8

10

2005 2006 2007 2008 2009 2010 to Q2 2011

Rate

HCR RatesAll Facility Types vs FPSO/FSOs

All Facility TypesFPSO/FSOs

NB: Rates are per milion hours worked

A173767 September 2011

Hydrocarbon Releases

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0%

5%

10%

15%

20%

25%

Valves / Vents

Pipes / Tubes Gaskets / Seals

Joints / Flanges

Other Pumps / Compressors

Tank Instruments Unspecified Engines

Equipment involved in FPSO Hydrocarbon Releases

Almost half of all HCRs involve either Valves/Vents or Pipes/Tubes… What is this telling us?

Hydrocarbon Releases

Sept 2011 A173767 16

0

5

10

15

20

25

2005 2006 2007 2008 2009 2010 to Q2 2011

Rate

Damage to safety-critical equipment RatesAll Facility Types vs FPSO/FSOs


Safety Critical Elements

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• Control measures relied on to reduce the risk of one or more MAEs to ALARP

WARNING What is this telling us?


Fires

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0

1

2

3

2005 2006 2007 2008 2009 2010 to Q2 2011

Rate

Fire or Explosion RatesAll Facility Types vs FPSO/FSOs



Presenter

Presentation Notes

NB: No fires reported on FPSOs in 2006

FPSO/FSOs - Incident Root Causes

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Top TapRoot® Root Causes for FPSO/FSOs 2005 2006 2007 2008 2009 2010 ytd 2011

Work Direction

9.2%

Human Engineering

12.1%

Design Specs 13.7%

Equipment Parts / Defects 14.2%

Procedures - Not Followed

20.0%

Design Specs 17.2%

Design Specs 15.3 %


8.2%

Work Direction 10.1%



13.0%



10.5%


Training 5.1%

Mgmt System - Human 10.1%

Preventive Maintenance

9.7%

Design Specs 12.3%

Design Specs 14.2%


9.6%


11.0%


5.1%


10.1%


8.0%


11.7%


11.6%

Equipment Parts / Defects

8.8%

Mgmt System - Human

9.3%

Equipment Parts / Defects

5.1%


9.1%

Human Engineering

5.7%

Tolerable Failure 5.2%

Training 6.3%

Training 6.7%

Mgmt System - Equipment

8.5%

Presenter

Presentation Notes

SPAC = Standards, Policies & Administrative Controls CAR = Corrective Actions Required / Recommended

FPSO CASE STUDY

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FPSO Case study

• Incident: Fire and explosion • Issues:

– Facility Design – Commissioning, QA/QC, carry-over into operations – Competency and training – Control room alarm flooding – Maintenance management

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Presenter

Presentation Notes

Facility management structure Legal operator of facility contracted FPSO owner to operate the facility. Contractor (FPSO owner) manages all maintenance and operations. Issues Facility Poorly Designed Commissioning not completed prior to operations, lack of QA/QC (rushed into production). Carry over of design and construction issues into production Lack of personnel training and competency Control room Alarm flooding problem (Human Factors) Maintenance management failure Backlog unmanageable Unpopulated routines Inappropriate hours required to complete tasks Tasks closed without completion Lack of resources Reactive maintenance Many reported dangerous occurrences (SCE non compliance with performance standards) Conclusion - Failure to meet commitment made in the safety case Result major incident gas explosion and fire Design / construction commissioning issues – Inappropriate material selection for seawater deluge system - carbon steel. Inappropriate safety integrity level for high level trips on vessels including the KO drum- no built in redundancy DCS non compliant with cause and effect. For example Level transmitters – did not fail safe (fail to last location) Water mist system installed incorrectly - did not function on demand during gas explosion

FPSO Case study

• Regulatory intervention: Inspections

• Major deficiencies identified in: – Maintenance backlog management – Effectiveness of operational control – SCEs not meeting performance standards – Reportable incidents – Housekeeping

• Enforcement action included: – Improvement Notices – Prohibition Notice

Sept 2011 A173767 22

Presenter

Presentation Notes

Regulator intervention inspections investigation Major Deficiencies identified: Maintenance management Operator not demonstrating effective day to day management and control Failure of Safety Critical Equipment to meet performance standards Large quantity of reportable incidents Housekeeping Enforcement action taken: 13 Improvement Notices 2 Prohibition Notice (production ceased)

FPSO Case study

• Initial response to intervention: – Delegation to contractor – Completion dates not fully met – Over reliance on NOPSA to identify health and safety issues

• Intervention options: – Inspections – Potential escalation of enforcement

• notice of intent to withdraw safety case • request revised safety case

Sept 2011 A173767 23

Presenter

Presentation Notes

Operator response to non compliance issues Failure to make available adequate resources Inappropriate delegation of responsibility to contractor Repeated failure to meet committed completion dates Short term compliance of systemic issues (maintenance management) Over reliance on NOPSA to identify health and safety issues before operator takes action is unsustainable Sustained improvement not demonstrated

Design Commissioning Operations

LESSONS FROM INSPECTIONS

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Design Issues

• Alarm management – Address during design / commissioning

• Material selection – Souring of the reservoir is a common outcome of

facilities that conduct produced water reinjection. – This generally results in a higher than anticipated H2S

content in well, process & rundown streams

Sept 2011 A173767 25

Design Issues

• Critical Function Testing (CFT) – SCEs not meeting performance standards – SCE often requires a production shutdown to CFT

with frequency implications – Systems should allow for performance tracking /

reporting of SCE during unscheduled shutdowns.

Sept 2011 A173767 26

Presenter

Presentation Notes

Design Issues Consideration of Critical Function Testing A large number of Notifications involve the failure of Safety Critical Equipment to meet it’s performance standard. Many items require a production shutdown to function test and as such, frequency can often be annually during the scheduled yearly ESD function test. Often following intervention to repair, testing can only be conducted under shutdown status (no differential pressure, lower temps etc). Systems should allow for performance tracking / reporting of Safety Critical Equipment during unscheduled shutdowns.

Commissioning Issues

• Safety-critical elements: performance non-compliance: BDVs / SDVs

• Incomplete commissioning – construction debris – excessive punch list items – lack of Quality Assurance/Quality Control

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Operational Issues

• Inadequacies in competency / training – Restart of plant and processes: cyclone disconnection

is a complex task requiring technical skills and experience

• Operators must ensure sufficient time for required competencies to be acquired

Sept 2011 A173767 28

Presenter

Presentation Notes

Inadequacies in Inadequacies in competency / training Procedures Incorrect / Not Followed Cross-training of Marine and Operations personnel on FPSOs is a common practice. Restart of plant and processes, berthing of offtake tankers or preparation for cyclone disconnect are complex tasks requiring technical skills and experience. Operators must ensure sufficient time for required competencies to be acquired.

Operational Issues

• Procedures Incorrect / Not Followed – Procedures take time to achieve and should be

considered as dynamic. – Procedures should be validated or reviewed to reflect

the current, best practice. – Use Management of Change (MOC), otherwise

procedures can be undermined, resulting in shortcuts and risk taking.

Sept 2011 A173767 29

Operational Issues

• Failure to complete Corrective Actions – "Case to Operate", "Deviations”, "Temporary

Operating Procedures”, and such are used to justify continued operations

– Such permissions to operate should be time-limited and tracked to ensure permanent rectification is applied and maintained

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LIFEBOAT LOADING A topical issue

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Lifeboat Loading

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IMO SOLAS, Lifeboats are designed for 75kg/person Offshore NOPSA found average = 92kg-100kg/person

= some lifeboats 25%-30% overloaded based on their SWL NOPSA has made Operators aware of the problem of lifeboats exceeding their SWL and have required them to take action. Some Operators have : • reduced the number of POB per

lifeboat; • changed the lifeboats and davits –

bigger boats & increased SWL • added extra lifeboats;

See also NOPSA Safety Alert No.47

PROCESS SAFETY CULTURE

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Opportunities for improvement

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Safety Culture Survey TOPIC AREA Areas of concern - FPSOs

Safety Values / Commitment

Pressure to work overtime - loyalty to their own work unit

Process safety programmes don't have adequate funding

Reporting Hazard identification, control and reporting training not adequate

Training Contractors don't receive adequate training to do their job safely

Worker Professionalism / Empowerment Workers don't actively participate in incident investigations

Presenter

Presentation Notes

e.g. Pressure to work overtime was one of the major issues

TOPIC BASED INSPECTIONS

Sept 2011 A173767 35

Maintenance management

• Variation between documented maintenance system and how maintenance is actually conducted

• Formal deferrals process not used – risks not assessed • 3rd party competency – EHS assessed but not technical

competencies • Auditing – inadequate

Sept 2011 A173767 36

Emergency Management

• Drills being undertaken with limited number of scenarios

• PA systems ineffective, emergency escape routes not clearly marked or obstructed

• Response times – not subject to performance standards and not tested

• Inadequate debriefs • Auditing - inadequate

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Reason’s Accident Causation

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Blind operations

• Where those operating equipment were unaware of the actual situations they were in – Tendency to interpret events in context of previous

experience despite evidence to the contrary (mind set) – Management's failure to ensure that members of the

workforce have the ability to identify, diagnose and respond to abnormal conditions

Sept 2011 A173767 39

Macondo, 2010

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• 11 fatalities • Commission findings include:

– failure to properly conduct and interpret the negative pressure test

– WRONGLY ASSUMED well could not be flowing

– Kept running tests and coming up with various explanations until they convinced themselves their assumption was correct

• Commission identified a number of potential factors that may have contributed to the failure to properly conduct and interpret the negative pressure test: – no procedures for running or interpreting

the tests – lacking full appreciation of context in

which the test was performed

Presenter

Presentation Notes

Montara, 2009

Sept 2011 A173767 41

• No fatalities, well blowout. • Return of fluid indicated float

valve problem • Commission findings include:

– major shortcomings in procedures were widespread and systemic

– circumstances were not recognised or understood by senior personnel at the time

• Commission recommended: – existing well control training

programs should be reviewed, with a focus on well control accidents that have occurred

Presenter

Presentation Notes

No fatalities, well blowout. Return of fluid indicated float valve problem Commission findings include: major shortcomings in procedures were widespread and systemic cement in casing had been over-displaced circumstances were not recognised or understood by senior personnel at the time Commission recommended: decision-making about well control should be professionalised existing well control training programs should be reviewed, with a focus on well control accidents that have occurred Variously, despite evidence to the contrary, managers & supervisors believed that appropriate barriers were in place. [cemented shoe, sufficient hydrostatic head of fluid] Commission findings include: Major shortcomings in procedures were widespread and systemic not one well control barrier complied with the company’s Well Construction Standards or sensible oilfield practice the cemented casing shoe had not been pressure tested; the cement in the casing shoe was likely to have been compromised as it had been substantially over-displaced by fluid, resulting in what is known as a 'wet shoe'. these circumstances were not recognised or understood by senior personnel at the time

Texas City, 2005

42

• 15 fatalities • Overfilling of a tower during start-up

releasing flammable liquid to atmospheric vent

• CSB findings included: – lack of supervisory oversight and

technically trained personnel during startup

– Operator training program was inadequate

– Outdated and ineffective procedures did not address recurring problems

42 Sept 2011 A173767

Presenter

Presentation Notes

The US Chemical Safety Board (CSB) technical findings included above plus -Supervisor and operators poorly communicated critical information regarding startup during shift turnover - Prior to incident, 8 serious releases from the stack had occurred – none investigated

Longford, 1998

Sept 2011 A173767 43

• 2 fatalities, 8 injuries • loss of hot lean oil flow with

subsequent flow causing brittle fracture and hydrocarbons release

• Commission findings included: – ‘Lack of knowledge … was directly

attributable to a deficiency in initial or subsequent training’

• Commission recommendations included: – ‘Operator to demonstrate that its

training programs and techniques impart knowledge of all identifiable hazards and the procedures to deal with them’

Presenter

Presentation Notes

CCPS: “Throughout the sequence of events, operators and supervisors had not understood the consequences of their actions to re-establish the plant”. 2 fatalities, 8 injuries Loss of hot lean oil flow resulted in low temperature in a vessel causing embrittlement re-start of flow resulted in higher temperature causing stress in the vessel and brittle fracture release of hydrocarbons that ignited causing an explosion and fire Commission findings included: Lack of ‘knowledge of dangers associated with loss of lean oil flow and did not take steps necessary to avert those dangers’ ‘Lack of knowledge … was directly attributable to a deficiency in initial or subsequent training’ Commission recommendations included: ‘Operator to demonstrate that its training programs and techniques impart knowledge of all identifiable hazards and the procedures to deal with them’ Longford Royal Commission recommendations included: Demonstrate periodic review of operating standards, practices and policies and documentation

Three Mile Island, 1979

Sept 2011 A173767 44

• No fatalities or injuries • Coolant pumps failed, relief valve stuck open

with a partial meltdown of reactor core • Commission concluded:

– inappropriate operator action – deficiencies in training and operating

procedures – failure of organisation to learn lessons

from previous incidents • Commission recommended:

– “Emphasis must be placed on diagnosing and controlling complex transients and on the fundamental understanding of reactor safety.”

Presenter

Presentation Notes

PWR = Pressurised Water Reactor 1º = Primary 2º = Secondary Coolant pumps failed reactor pressure rose and pressure relief valve lifted and stuck open caused a sustained loss of coolant and a partial meltdown of reactor core Commission concluded: inappropriate operator action deficiencies in their training lack of clarity in their operating procedures failure of organisation to learn lessons from previous incidents Commission recommended: “Emphasis must be placed on diagnosing and controlling complex transients and on the fundamental understanding of reactor safety.” US President’s Commission on the Accident at Three Mile Island (1979), concluded: “while the major factor that turned this incident into a serious accident was inappropriate operator action, many factors contributed to the action of the operators, such as deficiencies in their training, lack of clarity in their operating procedures, failure of organizations to learn the proper lessons from previous incidents, and deficiencies in the design of the control.” Commission found: “the training program gave insufficient emphasis to principles of reactor safety” and “emphasis was not given to fundamental understanding of the reactor”. Commission recommended in relation to training : “Emphasis must be placed on diagnosing and controlling complex transients and on the fundamental understanding of reactor safety.”

What can you do?

• Ensure staff are competent, and supported by effective procedures to diagnose and respond to abnormal conditions

• Share and learn lessons from past incidents both within and outside the industry

• Organise yourselves in such a way that you are better able to notice the unexpected in the making and halt its development

(paraphrase of Hopkins, 2009 from Weick and Sutcliffe, 2001)

Sept 2011 A173767 45

Sept 2011 A173767 46

Thank you

Presentation - Industry and FPSO Health and Safety …...Industry and FPSO Health & Safety...

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