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Operational Control and Managing Change: the Integration ofNon-technical Skills with Workplace ProceduresJL Thorogood, Drilling Global Consultant LLP and MT Crichton, People Factor Consultants Ltd

Copyright 2013, SPE/IADC Drilling Conference and Exhibition

This paper was prepared for presentation at the SPE/IADC Drilling Conference and Exhibition held in Amsterdam, The Netherlands, 57 March 2013.

This paper was selected for presentation by an SPE/IADC program committee following review of information contained in an abstract submitted by the author(s). Contents of the paper havenot been reviewed by the Society of Petroleum Engineers or the International Association of Drilling Contractors and are subject to correction by the author(s). The material does notnecessarily reflect any position of the Society of Petroleum Engineers or the International Association of Drilling Contractors, its officers, or members. Electronic reproduction, distribution, orstorage of any part of this paper without the written consent of the Society of Petroleum Engineers or the International Association of Drilling Contractors is prohibited. Permission to reproducein print is restricted to an abstract of not more than 300 words; illustrations may not be copied. The abstract must contain conspicuous acknowledgment of SPE/IADC copyright.

Abstract

Some of the common pitfalls and problems associated with managing operations are discussed with suggestions about how

these can be addressed. Existing literature on human error, operational decision-making and industrial psychology is combinedwith the authors experience in researching these problems and working with operations teams. The non-technical skills

required to manage operations effectively are described together with the organisational structures and work processes that

best support operations. Techniques for training teams and helping them to develop the competencies for teams to manageoperations safely and deal with uncertainty are explained.

Mindful that Proper planning prevents poor performance, engineers go to considerable lengths to create quality plans. A

structured well delivery process is followed, complete with peer reviews, risk assessments and technical sign-offs.

Deliverables include statements of requirements, basis of design documents, HAZID sessions, drill the well on paper meetings

and a drilling programme.

Despite these preparations teams make decisions during operations with sometimes costly consequences, especially when

surprised by an unexpected event or when facing high levels of uncertainty. This problem is not unusual and typically occurswhen teams fail to prepare and actively manage the transition from planning to operations, and to anticipate the necessary

change in the functioning of the team. Planning and operations require completely different modes. The lack of preparation forthis transition stems from a common assumption that the team that has done the planning is more than capable of managing a

dynamic operation effectively. Research has identified that two different modes are required; planning teams produce a plan

designed to solve a problem, whereas an operations team has to manage a task requiring the ability to adapt dynamically toshifting demands of the situation.

Effective operations management requires a high degree of operational discipline and teams that are skilled in dealing with

the unexpected and making decisions in time-constrained situations. These skills are not intuitive and must be taught, trained,

practised and assessed. The protocols and decision rights must be clear and the team trained so that it executes these functionsin a fluent and competent manner.

IntroductionNo-one even remotely involved in the oil and gas industry could fail to have noted the volume of publications following

the April 2010 disaster in the Gulf of Mexico. A number of such publications, including the Bly report (BP 2010) and theChief Counsel's report (2011) have focused on technological and managerial deficiencies (Thorogood, 2012a). In the majority

of cases, the resultant recommendations therefore centred on the need for more regulation and control of people, processes and

hardware, competence, training, and assessment (primarily technical). Increasingly detailed procedures and supervision are the

natural response when a root cause, or broken component is identified and, if fixed, can be said to have cured the

problem, (Dekker, 2011).


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Hopkins (2012) took a different approach from the mainstream reports. He examined the event from the perspective of the

human, social and cognitive aspects. His conclusions offer an alternative explanation of the underlying causes of the event; an

explanation which is more consistent with the human and social factors causes associated with accidents in other high hazard

industries. A re-examination of the events at Montara in Australia in September 2009 and the Bardolino incident in the NorthSea in December 2009, using Hopkins form of analysis, may very likely reveal a similar interplay of human, social and

cognitive aspects contributing to the evolution of the event.

In the late 1970s, having experienced a series of major accidents, aviation identified a major underlying contribution as

being human behaviour. The discipline of Crew Resource Management (CRM), a training intervention designed to enhancehuman behaviours was developed based on research from aviation practitioners and psychologists. CRM training has

subsequently become mandatory for all aircrew as part of initial training, licensing and subsequent in-service qualification.

This form of training has equipped aircrew with the non-technical skills and behaviours needed to counteract and overcomethe psychological illusions and cognitive biases associated with problem solving and decision-making during flight operations.

The results have been reflected in a step change improvement in airline safety performance.

The need for some form of CRM training has been recognised by the Well Expert Committee of the Oil and Gas Producers

Association (2011). However, there are fundamental differences between aviation and the oil industry and these have to beunderstood before the issue can be fully addressed (Thorogood, 2012b). The most notable difference is that flight operations

are conducted within a highly disciplined and structured environment. Operational procedures are rigorously standardised

within airlines and deviations are reported, followed up and remedial training administered as required. There is intenseoversight from, and regular audit by, the regulator. The whole framework is coordinated at an international level by the

International Civil Aviation Organisation that, being set up under international treaties, has the authority to publish legally

binding standards and recommended practices.

The oil industry lacks this international regulatory framework. It lacks even basic standardisation about how rigs are

operated, wells are drilled, and operations are monitored. These are essential prerequisites for an environment within which a

standardised CRM discipline can be developed and implemented. The purpose of this paper is, therefore, to propose a

framework for operational governance within which the development of CRM, or non-technical skills, training can be built.

An overview of relevant industry and academic literature on operational control and human and social aspects is presented

here. The key elements involved in taking a well from concept through to execution are described, including the problems of

detecting and responding to anomalous conditions and managing change in a time-constrained environment. The necessarysteps for developing operational readiness in a team, especially training and assessing their non-technical skills are also

described. These threads are pulled together into a framework that could form the basis of a model of good practice for wellsteams.

Examiningmajoraccidents:themissingpiecePost-event reports typically adopt a technical and managerial analysis of the major accident. Seldom are the human and

social factors fully examined and reported. Yet analyses of events, such as the Challenger (1986) and Columbia (2003) shuttle

losses, the Piper Alpha explosion and fire (1988), and the nuclear accidents at Chernobyl (1986) and Fukushima (2011),highlight the ubiquitous contribution of human behaviours in how the event evolved. Decision making both before and during

an event is often criticised in post-event reports, yet these decisions have frequently been based on a lack of situationawareness, which itself may be a result of inadequate communication, ineffective teamwork and increased stress. By

investigating and reporting the impact of human factors, improvements in terms of preparing individuals and teams to manage

incidents can be made.

A focus on human and social aspects, in particular, is emphasised within the High Reliability Organisation (HRO)approach. HROs are characterised by five key concepts (Weick & Sutcliffe, 2001):

Preoccupation with failure (Failure)

Reluctance to simplify interpretations (Simplification)

Sensitivity to operations (Operations)

Commitment to resilience (Resilience)

Deference to expertise (Expertise)


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SpaceShuttleColumbia:MissedOpportunities1.FlightDay4.RodneyRochainquiresifcrewhasbeenaskedtoinspectfordamage. Noresponse.

2.FlightDay6.MissionControlfailstoaskcrewmemberDavidBrowntodownlinkvideohetookofExternal

Tankseparation,whichmayhaverevealedmissingbipodfoam.

3.FlightDay6.NASAandNational ImageryandMappingAgencypersonneldiscusspossiblerequestfor

imagery.Noactiontaken.

4.FlightDay7.WayneHalephonesDepartmentofDefenserepresentative, whobeginsidentifyingimaging

assets,onlytobestoppedperLindaHams orders.

5.FlightDay7.Mike Card,aNASAHeadquartersmanager fromtheSafetyandMissionAssuranceOffice,

discussesimageryrequestwithMarkErminger,JohnsonSpaceCenter SafetyandMissionAssurance.

Noactiontaken.

6.FlightDay7.MikeCarddiscussesimageryrequestwithBryanOConnor,AssociateAdministrator for

SafetyandMissionAssurance.Noactiontaken.

7.FlightDay8.BarbaraConte,afterdiscussing imageryrequestwithRodneyRocha,callsLeRoy Cain,the

STS107ascent/entryFlightDirector.CaincheckswithPhilEngelauf,andthendeliversano

answer.

8.FlightDay14.MichaelCard,fromNASAs SafetyandMissionAssurance Office,discussestheimaging

requestwithWilliamReaddy,AssociateAdministratorforSpaceFlight.Readdy directsthat imagery

shouldonlybegatheredonanottointerferebasis.Nonewasforthcoming.

http://caib.nasa.gov/news/report/volume1/default.html

HROs typically operate in hazardous environments where the consequences of errors can be catastrophic, in other words,

organisations are constantly striving for reliability and are able to recover efficiently should failures occur. Examples of HROs

include aircraft carriers, nuclear power production plants, and air traffic control systems. Proponents of the HRO approach

suggest that successful HROs manage unexpected events by following the concept of collective mindfulness (Weick, Sutcliffe& Obstfeld, 1999). Organisations remain attentive to and detect weak signals that could lead to unpleasant surprises,

understand the implications of such weak signals, and prepare to recover from the potential consequences of such weak

signals. Figure 1 provides an example of the weak signals, or Missed Opportunities highlighted by the investigation teaminto the Columbia Space Shuttle accident. Hudson (1999) describes the concept of chronic unease, whereby organisations can

adopt both a pessimistic stance (just because everything has gone well means that what might happen will be a newexperience) and an optimistic stance (what does happen will be coped with). Such chronic unease is closely related to

collective mindfulness.

Along with collectivemindfulness is the notion of

individual mindfulness,

especially by those workingat the sharp end. Reason

(2004) refers to the error

wisdom of those on the

frontline who can detect

potentially damaging errors.The non-technical skill of

situation awarenessencourages individuals to be

continuously aware of what is

going on around them

(Endsley & Garland, 2000),

and to prepare to take anynecessary actions as a result

of changes in their

environment. In aviation, lossof situation awareness is

repeatedly identified as a

major contributory factor in

major accidents where humanerror has been a factor,

frequently reported as around88% (Endsley, 1995). Chronic unease is therefore applicable at both the individual and organisational level. Individuals should

be encouraged to monitor for or detect weak signals that could require an intervention before an incident occurs.

Hopkins (2012) provides a human, social, and cognitive analysis of the Macondo disaster. He describes how a strong

confirmation bias, rooted in the belief that the cement job was a success, resulted in failure of the defence in depth on which

safe well operations depend. It led to the rationalisation of inconsistent data and a failure to pick up on weak and contradictoryindications of the wells behaviour. Group-think ensured that misgivings were silenced by peer pressure. Risky-shift ensured

that the collective decision was more risky than that which might have been made by any individual acting on his own.

Addressing human and social aspects, including the current level of training and competence in non-technical skills ofemployees, will benefit organisations in terms of detecting weak signals and developing a state of chronic unease. This

approach, combined with increased standardisation of management systems, should strengthen the safety culture in the oil and

gas industry.

ProblemswithalackofstandardisationManagement systems used by drilling organisations generally contain a policy statement pertaining to securing process

safety through competent people, process and technical standards. They usually include a high level document describing how

the organisation works and a well delivery process showing how wells are progressed from concept to execution. The Policy

and Process may be accompanied by a set of standards, procedures and guidelines that provide the technical framework within

which the engineering staff operate. The required approval levels for various planning documents may, or may not be

formalised.

Figure 1: Examples of Weak Signals


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While there is considerable attention devoted to the planning phases of the well, the detailed steps for transforming the

requirements of the drilling programme into step by step on-site work instructions are rarely written down. This practice may

have arisen because it seems a trivial step; being obvious and commonplace and not worth the effort. Everybody knows how

this is done. The same lack of formalism can be observed in managing the response to unforeseen events which occur and theconsequent need to make changes to the programme. The absence of formal procedures and standardisation of the protocols

creates several practical problems:

Team members with dissimilar backgrounds assume others do things the same way, so there is conflict until thedifferences are resolved: forming, storming, norming and performing.

Selection, training and competency assessment of new drilling supervisory staff, or inducting new members into ateam becomes difficult in the absence of a framework

Developing the capability of teams to operate competently and demonstrating their readiness to control an operationcannot be structured effectively.

Absence of clarity around processes and ways of doing things leads to improvisation and organisational drift

Diversity within a large organisation results in inefficiencies and additional learning when members are deployedfrom one operation to another.

While these problems may not be apparent in mature or established organisations, they can prove to be crippling in newly

formed teams, especially those operating under intense time pressure. The problems manifest themselves in the form of stressreactions by individuals and ineffective decisions with potentially high safety or cost consequences. In part, the lack of process

and procedure is to blame, but a contributory factor is the lack of training provided for the team in how to work as an

organised unit. At one level, training in process and procedures is relatively straightforward to achieve. Experience in otherhigh hazard industries, including medicine and aviation, stresses the need for training and assessment of team competence in

non-technical skills.

IntegratingnontechnicalskillsandworkplaceproceduresThe integration of non-technical skills competence and a standardised approach to planning and executing wells could

enhance the safety and effectiveness of drilling operations. Situation awareness is the first step in the decision making process,

and is the skill that helps individuals, and therefore organisations, to identify weak signals. Noticing weak signals increases theprobability of identifying the precursors of unexpected events, leading to an increased opportunity to deploy mitigation

strategies. Formalisation of processes and procedures relevant to the execution of a well also enhances the decision making

process by providing clear guidance about role-based decision making boundaries and responsibilities. Such standardisationalso reduces the effects of stressors such as uncertainty and ambiguity in situations.

A further benefit of formalised processes and procedures, especially defining how drilling operations will be conducted, isthat drilling personnel gain more insightful experiences about how operations are managed. This encourages use of rule-basedor intuitive decision making strategies, Figure 2, particularly for offshore-based personnel because rules and procedures guide

the execution of well operations. Whilst it is acknowledged that not all decision making employs these strategies, findings

from other high hazard environments (Klein, 1993; Crichton, 2000; Tissington, 2001) concluded that approximately 85% of

operational level decision making occurs at this end of the continuum. Unanticipated situations not covered by procedures with

consequently less operator experience may still arise, but should be minimised through the use of procedures and rules.

Figure 2 Continuum of decision making strategies (based on Flin, OConnor & Crichton, 2008)

Creative

Deviseanew

solution

IfX,noY,sodesign

newY

Choice

Choosefrom

severalpossible

solutions

IfX,whichY?

Rulebased

Applyastandard

procedure

IfXthenY

search

Intuitive

Rememberone

solution(gut

feel)

IfXthenYno

search

Increasing stress effects

Increasing cognitive workload

Decreasing effect of experience

Decreasing stress effects

Decreasing cognitive workload

Increasing effect of experience

System2 System1


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The rule-based and intuitive decision making strategies relate to System 1 thinking (Kahneman, 2012) whereby System 1

thinking is fast, intuitive and effortless; System 2 thinking is slow, deliberate, and effortful. Disadvantages of System 1 include

the potential for biases, such as framing, confirmation, availability, to influence decision making, whereas disadvantages of

System 2 includes the problem that thinking and reasoning takes time and is open to doubt. Neither system is ideal nor shouldbe used to the exclusion of the other. The essential ability for decision makers is to appreciate when System 1, rule-based or

intuitive, is appropriate and when System 2, choice or creative, is appropriate. Decision-makers must learn to recognise when

the powerful reflexive System 1 characteristics, so essential to our success as a species, can short-circuit the thoughtful anddeliberative System 2 that senses ambiguity, remains sceptical and questioning and forces logic and reason into the assessment

of a situation.

CreationofthedrillingprogrammeWell delivery processes have been described by Clay (1999), Sawaryn (2005), Kayser (2008) and deWardt (2010). They

all feature a stage gated process that enables well planning to proceed in an orderly manner from the initial formulation of the

well objectives, through a basis of design into finalisation in the form of a drilling programme. The process includes provision

for systematic risk assessment, offset well reviews, risk reduction studies and engagement of the rig team through process such

as Technical Limit. Stage gate decisions and associated peer reviews ensure that the requirements of the well are approved and

frozen in a progressive top down manner. These controls and verification of conformance to technical standards reduces thechances of introducing process-safety hazards through uncontrolled changes. Any amendments are handled in accordance with

a formal management of chance procedure. An integral part of the final approval includes a check for compliance with

company standards and relevant guidelines, both internal and industry good practice. For an offshore exploration or appraisalwell, or for a complicated development well, the finalised drilling programme will generally consist of:

1. Information about the prospect, geological prognosis, pore pressure, fracture gradient and temperature data2. Statement of the well objectives and data acquisition requirements3. Information on the location, shallow hazards and environmental conditions4. Description of the drilling unit and key logistical information5. Summary of the key design parameters for casing, cementing, drilling fluids, well placement, well evaluation,

completion, testing and abandonment

6. Section by section description of the operations7. Key process safety-critical parameters for the well, such as mandatory pressure tests, test pressures and associated

acceptance criteria, formation integrity test requirements

8. Major decision criteria: hole section end points and evaluation, side-track, completion, testing and abandonmentoperations.

9. Appendices containing detailed engineering and operational details for the component technical activities in the well.

Although this structure is generally followed, the level of detail contained in the drilling programme varies widely not only

across the industry, but between operating units in the same company and possibly even within the same unit. This variability

results in part from personal preference but also a consensus within the team based on collective knowledge, experience andcompetence.

ExecutionofthedrillingprogrammeIn some organisations, as a means of optimising operational performance, during the planning process the rig team are

involved in a detailed examination and improvement of the operations sequence using processes such as the Technical Limit,

Bond et al (1996). The result is a step by step sequence of operations with detail about the preparations necessary for each step

that the operational will flow safely and efficiently. Other organisations may leave the drilling programme at a general leveland delegate responsibility to the team on the rig to work out the detailed operational sequence. Some organisations, with

experienced crews and supervisors carrying out established routine activities, operate with a minimum of formality by

executing the programme with no intermediate guidance basing their actions on the collective memory of how things are done.This practice may be effective where turnover of personnel is low, but may break down if turnover increases or unforeseen

complications develop.

Irrespective of the detail in the programme, there always remains a gap between the programme and the instructions

needed to guide individual crew members in the execution of their tasks. This gap is described by Woods et al (2010) as

inevitable and, if it is not to be filled by improvisation, must be bridged by some form of Written Work Instruction. The

intent of the Written Work Instruction is to provide the rig crew and service contractors with the detailed directions necessaryfor the safe and efficient coordination of activities between the different parties involved. The Written Work Instructions


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ensure that the operating parameters specified in the programme are clearly communicated to those involved. They will also

include, verbatim, any specific safety-critical procedures, such as inflow tests, that are generated by the planning engineers,

approved as part of the programme and issued to the rig for execution exactly as written. To serve this purpose, they should be

prepared by those most directly involved, the team at the wellsite. In this way, they will be Driller friendly with sufficientinformation to ensure that tasks are done in the correct sequence. Serving as an aide-memoire, they will focus on the job in

hand and not be cluttered with distracting explanations and potentially unnecessary background information. Depending on

the organisation, or the criticality of the well being drilled, the Written Work Instructions may be subject to review andapproval by higher level authorities within the organisation.

Critically, the Written Work Instructions should also incorporate by reference specific contractor or service company

standard operational procedures. This point is important because these third party procedures form part of those companies

management systems and cannot be varied unless done in accordance with a formal Management of Change exercise.

RigoperationsmonitoringRig operations are monitored continuously while operations are in progress. The driller is provided with a console

displaying key operating parameters of the downhole operation and status of surface systems. Some of these functions, such as

pit volume and flow in and out of the well are safety-critical systems. Such parameters are normally alarmed with high andlow limits. Depending on the nature of the operation, the operations may be independently monitored from a mud logging

unit. There are informally established protocols for the mud logging personnel to communicate with the driller if anomalous

readings are detected. In turn, the driller will alert the mud loggers if any operations, for example, transfers of mud between

pits, might give rise to anomalous readings in the monitoring system. Rig site systems generally rely on continuous operator

monitoring. However, from a human factors standpoint, this is known to pose risks. Surveillance of critical parameters may beenhanced with computerised event detection systems (Aldred, 2008). Once in operation, the response to alarms has to be

disciplined by first verifying that all the sensor data are correct and the system is functioning correctly before interpreting the

readings and diagnosing the problem.

Other specialist monitoring functions may be required. For example, exploration wells in new areas may employ a

dedicated pore-pressure monitoring service to interpret mud logging and downhole logging while drilling data to derive real-

time estimates of pore pressure. These services impose an added layer of complexity on the operation because possiblechanges to pore pressure have a direct impact on the well design and therefore well integrity. Such specialist monitoring

activities must be carried out by trained and competent people in accordance with a workflow based on defined standards with

rigorous cross-checking and validation procedures. Clearly defined roles, responsibilities, lines of communication and

disciplined change control procedures are essential to ensure safety and maintain integrity of the well design.

Although services like pore pressure monitoring may be located at the rigsite, with the advent of real-time operations

centres, such work is increasingly being removed from the wellsite. While there are added complications due to the physicalseparation of the people involved, there are safety and economic benefits in reducing the number of people on site and

enabling greater levels of expertise to be directed at the problem. The additional monitoring and review reduces the possibilityof cognitive biases such as conformity or group think to emerge by ensuring the non-technical skills competence of wellsite

personnel. Sadlier (2011) describes how remote pressure monitoring has been undertaken and provides an example of the

resulting communications protocol developed for the operation. Sadlier also describes the personnel, training, infrastructure

and implementation activities required to support the operation.

Operations monitoring is a safety-critical activity. Its, capabilities are being further enhanced through the use of model-

based early warning systems for flagging up potential problems (Cayeux, 2012), or case-based reasoning technology (Raja,

2011). New technologies and remote support centres have greatly enhanced the effectiveness of the monitoring process. This

progress comes at a cost. Cayeux (2009) explains how as system complexity increases so does the burden of system set-up,operator training, definition of procedures, communications protocols and the organisational discipline essential to ensure

controlled response and rigorous management of change.

The foregoing has shown how rig operations monitoring has increased in scope and complexity driven by developments in

communications, data acquisition and analytic technologies. It is arguable the extent to which the organisational and socialconsequences have been systematically taken into account. For this reason the monitoring systems must be integrated with a

set of organisational procedures that enable situations to be diagnosed and appropriate actions planned, approved and put into

operation. These steps require a disciplined way of handling change and a formal structure of decision-making rights toimplement them. These points are discussed in the next two sections.


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ManagingchangeduringoperationsManaging change during operations is quite unlike the structured and deliberative process that is possible during the

planning phase of projects. A different mindset is needed to deal with the potentially time-constrained decision making.

Developing the required skills takes practice, especially when newly assembled teams are operating together for the first time.

Operations proceed with the crew following the Written Work Instructions meticulously. Many incidents can be traced

back to the well-intentioned workarounds that happen when a snag occurs and the rig team, instead of stopping immediately to

review and re-plan, starts to improvise. The problem is that this behaviour, while done for the best of reasons, is very difficultto control. The only protection is adherence to very high standards of operational discipline, described by Anguillio (Hopkins2009, ch 7). He emphasises that the goals of high reliability are achieved through consistent leadership by example, the

rigorous implementation of clearly defined management processes and high standards of work that extend down to meticulous

house-keeping This discipline is essential even when handling the smallest deviations from the Written Work Instructions.

On detecting conditions that may indicate a departure from expected conditions, whether this is a simple drilling problem,an anomalous flow indication, unexpected geological formation or a sudden mechanical failure, the team has to respond in a

disciplined and structured manner. The immediate tasks are to: a) confirm that there is a deviation from plan; and b) determine

the significance of the change to ensure that the correct people are involved and consulted. Such a procedure is illustrated inFigure 3.

Figure 3: Operational Decision Making Flowchart

In the Green Nominal condition, the rig and OOC monitor the operation. The rig has primary responsibility fordetecting anomalies. Whichever party detects an anomaly cross checks it with the other and the Driller beforeadvising the Drilling Supervisor.

A data quality anomaly could trigger a Yellow Off Nominal condition. This situation may occur with no other wellproblems. Work may continue, albeit with a raised level alertness

In the Yellow Off Nominal condition, the rig and OOC continue monitoring the operation. The Drilling Managerconsiders the time available and assesses whether the situation could deteriorate to Red Abnormal imminently,otherwise develops and implements a solution.

In the Red Abnormal condition, the rig and OOC continue monitoring the operation status. The Drilling Managerassembles a team to assess options and develop solutions.

Following the initial diagnosis, the organisation must simultaneously act to stabilise the situation and maintain wellintegrity while dedicating people to solving the problem at hand. Training and discipline are required to assess the situation,

Rig & OOC Monitoring

Data validation

Cross-check with dril ler

AnomalyValidated?

No

Yes

Advise Drilling Supervisor

Off Nominal

Operational Limits set in

Drilling Programme

Tier 1Condition: Nominal

Decision: Drilling Supervisor

Tier 2Condition: Off Nominal

Decision: Drilling Superintendent

Tier 3Condition: Abnormal

Decision: Drilling Manager

Drilling SuperintendentConfirms Off Nominal

Condition

Drilling Manager confirms

Abnormal Condition

Condition

Resolved?

No

Yes

Resume Planned

Operations

Drlg Manager

Approves action

including MoC

DM consults

stakeholders

Mud Logger & Ops Centrecontinue Monitoring

Condition

Exceeds

Off-nominal?

No

Yes

Drilling Team, Specialists , OOC

assess options & develop solutions,

Risk assessment & MoC

Advise Drilling

Superintendent AbnormalAdvise Drilling Supervisor

Abnormal

Potential

AbnormalCondition?

Wellsite Team, Specialists , OOCassess options & develop solutions,

risk assessment & MoC

No

Drlg Supt Approves actionincluding MoC

Condition

Resolved?

Yes

No

Yes

Resume Planned

Operations


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define the problem correctly and devise a solution that is consistent with the observed facts. Risk assessment under these

circumstances is a difficult task because the pressures of time and cost create inevitable goal conflicts that must be recognised

and managed, Dekker (2011). Hopkins (2010b) stresses that decisions closest to the operation must be rule-based. If left to

work-team discretion, there is a natural bias towards findings that will enable progress to be continued with a minimum ofdelay. It is therefore also essential that risk assessment and approval process involve technical authorities that are independent

of the operational line management, a point consistently emphasised by Hopkins (2010a:43-46, 2010b, 2012 ch 7).

Once a solution has been identified, approval and implementation will follow the organisations Management of Change

procedure. By way of summary, the structure of an operational management of change procedure is outlined in Appendix B.

DecisionmakingproceduresChanges during operations and associated decisions can range from simple adjustments to drilling parameters through

those that have consequences for well integrity to decisions that may require surrendering one or more well objectives. For

consistency with other domains, operational decision levels may be defined in three tiers (Crichton, 2004). For the purposes ofoperational decision-making the three tiers correspond to Tier 1 at the well site, Drilling Supervisor, Tier 2 being the

immediate office-based supervisor, Drilling Superintendent and Tier 3, being the managerial stakeholders, represented here by

the Drilling Manager, as illustrated in Figure 4 and described in more detail in Appendix B.

Figure 4 Decision making structure (based on UK Home Office, 1997)

For effective operational control, the important steps in defining pre-operational decision making rights include:

1. Define the typical events that might fall into each tier.2. Agree the protocol by which deviations are identified and communicated3. Define not only who is responsible for approving each decision, but also those that are to be involved in analysing the

problem and developing the solution

4. Practice the management of change procedure using scenarios based on the upcoming operation

Having classified the decisions belonging to each tier, it is advisable to formalise the roles that different team membersplay in the decision process. The most common procedure involves developing a RACI chart. This acronym stands for:

Responsible, Accountable, Consult and Inform. The terminology, especially the distinction between Responsible andAccountable is often a cause for confusion. There are other variants on this decision structure, which are discussed in anarticle on Wikipedia (2012). While multiple people may be consulted or informed, there will only be a single individual

accountable and one that is responsible. An alternative protocol is RAPID, developed by Bain and Company, where the

acronym stands for:

Recommend: makes the proposal for the decision, builds the case and consults with stakeholders

Agree: potentially exercising a power of veto over a proposal, the Recommender must secure their support for thedecision.

Anywhere;not

usuallyonscene

TIER

3STRATEGIC

TIER2

TACTICAL

Policy,longer

term

planning

Achievestrategic

objectivesAnywhere;not

usuallyonscene

TIER1

OPERATIONAL ExecutetacticalplanFrontline/

onscene


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Perform: executes the decision once made

Input: provides relevant input to support the decision

Decide: the person accountable for making the decision and resolving any differences between R and A.

This tool is worth considering when safety-critical decisions must be made. The I provides technical support and analysis

while the A represents an independent technical authority whose consent is required, for example to approve the results of a

risk assessment, ensuring that operational priorities have not compromised process safety. Pre-defining decision making rights

in this way results in a matrix that clearly shows organisation roles and individual decision rights.

Another way of defining critical decisions that may be worth considering has its origins in the NASA manned spaceflight

programme. Keyser (1974) describes how the concept of flight mission rules, which evolved throughout the shuttle

programme, came into being. Developed before the mission, they provided guidelines for flight control and flight crew to

facilitate decision-making in time-critical situations.

This concept was used during a well abandonment campaign West of Shetland in 2002 where the operation was subject to

tight time constraints and where multiple options were possible. The Mission Rule concept was used, exactly as with NASA,

to provide the rig team with the essential criteria for executing the operation without detailed and potentially time-consuming

reference to shore-based authority.

While well operations may not demand such tightly constrained decision-making on a routine basis, it is highly beneficial

to adopt the discipline of thinking through critical decisions and to have pre-planned courses of action systematically reviewed

by management and coordinated across the contractors and service companies involved in the operation. It provides practicefor the organisation in discussing problems, identifying solutions and making a range of decisions. It enables scenarios to be

explored without the pressure of time and the space to think through their practical implementation to search for deeper

problems.

TrainingofnontechnicalskillsCrew Resource Management (CRM) training has been undertaken in the aviation industry over the past 20 years. CRM

training has been defined as an instructional strategy that aims to improve teamwork in the cockpit by training crews to makeoptimal use of all available resources: equipment, procedures and people, to promote safety and enhance efficiency of flight

deck operations (CAA, 2006).

CRM training focuses on helping operators in high risk environments to establish barriers to human error by preventingerrors occurring in the first place, trapping errors if they do occur before they have an operational effect, and mitigating the

consequences of errors (Helmreich, et al, 1999). Aviation safety has subsequently increased such that the risk of becoming avictim of an adverse event in aviation is 1 in 5 million flights (JAA CAP 716).

CRM-type training has since been introduced across a wide range of industries, including nuclear power production,medicine, and shipping/maritime. The Space Flight Training Division of NASA Johnson Space Center also introduced CRM

training for space shuttle astronauts (Pruyn & Sterling, 2008). In each case, the aim has been to enhance safe and effective

performance by focusing on the non-technical skills of the individual along with the technical skills.

Non-technical skills are the social and cognitive skills that complement technical skills (Flin et al, 2003). Safe and effectiveperformance occurs as operators draw on and integrate both technical and non-technical skills. Competence in non-technical

skills helps to deal with non-routine, high stress, high uncertainty situations, particularly by reducing negative stress effects on

performance.

There are some caveats surrounding CRM-type training as discussed by Salas and colleagues (Salas, Wilson, Burke, &Wightman, 2006). The training intervention needs to be designed to meet the requirements of the context or organisation. The

most benefit from CRM training comes not from transferring a training course deemed successful in one setting, for example,

aviation, into another setting, such as medicine, but from designing, developing, and introducing a CRM-type trainingintervention customised to the setting and to the role(s), in this case in wells teams.


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CognitivebiasesandotherpsychologicaltrapsSince the seminal work described by Tversky and Kahneman (1974; 1986), recognition has been growing of the impact of

cognitive biases on decision making. Biases refer to the shortcuts, or rules of thumb, that people use as guidelines when

making decisions. Examples include: availability bias where people assume that when things come readily to mind then theyare more common than things that do not come as readily to mind; confirmation bias which describes how people are more

likely to seek information that confirms what they expect to be true; and framing where the way in which a question or

statement is phrased can influence a persons thinking process.

Further biases that can strongly influence decision making are attentional biases, where certain data or activities in theenvironment are given more attention than others. In a series of studies, Chabris and Simons (1999; 2011) famously illustrated

how attention can be narrowly constrained to only part of an activity and that something as unexpected and unpredictable as a

gorilla walking into the middle of a group of people passing basketballs around, thumping its chest, and leaving, can bemissed. To many people who were asked to concentrate on counting the number of passes of the basketball in the video, they

completely missed the appearance of the gorilla.

A further trap that can affect the decision making process is that of cognitive dissonance, particularly in a team or group

setting. When a team has made a decision to resolve a problem, but the outcome did not match the teams expectations, thenthe team will seek a justification as to why the solution did not succeed. For example, Festinger (1956) described how a cult

had predicted the end of the world on a certain date. When that date passed without incident, then the cult justified that the

world did not end so that they could continue to spread their preaching.

This unwitting reliance on rules of thumb, and the existence of other cognitive traps, therefore guides decision making, andis frequently the cause of human errors. If people are unaware of these biases, and more critically, their effects, cognitive

processing and decision making can be flawed. Awareness of these biases and their effects can, on the other hand, assist the

decision making process of both individuals and teams. Kahneman (2012) writes that recognising the signs associated with

situations in which errors might arise can reduce the influence of the bias, for example, recognising when reframing a problemmight lead to different options. This can be difficult to achieve if in the midst of a decision making event, therefore, the role of

an observer or external person can be valuable in helping the decision maker to recognise when a cognitive minefield arises

(Kahneman, 2012; pg 417).

The effects of confirmation bias can be reduced if decision makers deliberately look for information that disconfirms theirexpectation, that is, that they gather information from the environment that they might have initially overlooked. For

organisations, the use of checklists, such as mission rules, and standardised procedures can assist decision makers to reduce the

negative influences of biases. Training individuals in human factors, specifically non-technical skills is also particularly

valuable in raising awareness of the factors influencing the decision making process and the effects of cognitive biases.

In terms of operational readiness in drilling teams, the distinction between action teams and planning teams (Klein, 2000)

must be borne in mind. An operational drilling team tasked with executing the drilling programme fulfils the definition of an

action team in that it is essentially a team in which expertise, information, and tasks are distributed across specialised

individuals, where team effectiveness depends on rapid, complex, and co-ordinated task behaviour, along with the ability todynamically adapt to the shifting demands of the situation (Kozlowski, Gully, McHugh, Salas, & Cannon-Bowers, 1996). In

contrast to other types of teams, such as planning and production teams, action teams contain more specialised skill sets, relymore heavily on co-ordination, frequently perform in less familiar and more challenging environments, and may be more

temporary (Sundstrom, 1999). An action team may have a limited duration as a unit, and team members may then be

reassigned to other teams. Action team members must therefore have specialised task-related skill sets as well as honed

teamwork abilities to be able to co-ordinate their activities with teammates, especially if they are operating in challenging

environments. Action teams are thus highly interdependent, as overall effective performance would not be attainable withouttask contributions from each member and with successful interaction among team members (Marks et al., 2002). CRM-type

training interventions that focus on strengthening individuals performance are particularly appropriate for individuals that

work within this type of team to ensure that they are more effective in whatever team they find themselves.

It has often been assumed that the team that is undertaking the planning can then become the team to perform the executionof the plan. As the distinction between action and planning teams above highlights, the requirements of these two different

types of teams vary massively. Notably, members of the action team actually executing the plan demand a high level of

competence in the non-technical skills described above. Personal experience has indicated that the failure of a teamsuccessfully to make this transition has been a contributory factor to ineffective decisions and operational problems. Therefore,

especially for new teams, a programme of table-top decision-making exercises against scenarios derived from the planned

drilling programme provides a valuable learning experience for the team and a preparation for the operation itself.


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StandardisedoperationalframeworkThe preceding paragraphs have discussed operational control in terms of creating and then executing a drilling programme,

requirements for rig operations monitoring and managing change and finally, key elements of decision-making procedures,

mission rules and the non-technical skills issues associated with operations management.

Within the industry, there is considerable diversity in how operations are managed. There is no commonly accepted

doctrine for the command and control of operations. The lack of standardisation at all levels of operations management

practice makes it difficult to select, educate, train and assess personnel or to transfer personnel safely between operationswithout extensive induction. Specifically, it makes it difficult to construct effective Crew Resource Management training

programmes, because the purpose of the practical exercises is to instil a discipline of problem solving within a structured

framework of process, procedure and decision rights. Pulling together the themes of this paper, a standardised framework for

operational control should consist of eight key elements, which are presented in Appendix A. These should address thefollowing topics:

1. How Drilling Programmes are written2. The process for generating Written Work Instructions3. Procedures for monitoring the operation4. How deviations and changes are handled5. Decision-making Procedure6. The elements of Operational Discipline7.

Operational doctrine and rules8. Competency, Training and Assessment of the people.

To be effective, this framework must apply equally on both sides of the Operator-Drilling Contractor interface. So, while

the Operator prepares and oversees execution of the programme, the Contractor would be well advised to:

Evolve towards a high reliability organisation exhibiting a high level of operational discipline, institutionalisingchronic unease and training leaders in non-technical skills.

Exercise due diligence over the operation by independently reviewing programmes and assessing competence ofOperator supervision

Have a written procedure in the management system that complements the Operators procedures for preparing andapproving written work instructions, monitoring the operation and handling deviations from the instructions

CaseStudy:

integrating

astandardised

operational

framework

and

non

technicalskillsA multi-cultural operational team preparing for a deep water rank wildcat well in the South Atlantic took part in a training

intervention specifically designed to assist operational decision making. Prior to spudding the well, team members spent a

week working through the process for executing operations, managing change and studying the impact that the team members

non-technical skills had on decision-making. Previously, a Training Needs Analysis (TNA) had been undertaken with keyroles in the wells team to identify the relevant skills required by role, and to ensure a foundation of a formalised command and

control structure (in line with the Tier 1 to Tier 3 concept).

During the week-long training intervention, team members were presented with information about the key non-technical

skills: decision making, situation awareness, communication, teamwork, leadership, and stress management, especially relatedto a well operations environment. Moreover, an Operations Management of Change document, outlining formal processes and

procedures, was presented and team members discussed the contents prior to trying them out in a series of exercises.

A set of four decision exercises was designed around dilemmas at pre-identified critical decision points that might emerge

during the operations. These decision exercises, each lasting around 1 to 1.5 hours, required team members to make decisions,

within the framework of the document, to resolve a challenging situation. Rig-site and on-shore personnel were presented with

role-specific scenario information, which was ambiguous, uncertain and where some information was missing.

On termination of the decision exercise, once a decision had been made, team members were debriefed about what they

did, why and how. Team members were able to ask for and receive individual feedback about their non-technical skills and

areas for personal improvement.


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Once operations were completed and the well drilled, a review of benefits the team accrued from this decision making

week was undertaken. The Drilling Manager commented that the opportunity to practise, in a safe environment, how the team

would manage critical decision points was immensely valuable to the team.

DiscussionAn approach that looks at leadership as the means of driving safety culture is necessary but not sufficient. Also required

are the crucial elements of operational discipline and non-technical skills. The combination of these three aspects, as shown in

figure 5, provides a stronger, more reliable basis for safe and efficient operations.

The aim of this paper has been to outline some of the problems associated with managing drilling operations, to identify

the causes of those problems, and to suggest ways in which those problems can be reduced and mitigated. Effective operationsmanagement requires that the drilling industry codifies how it manages operations, both for the Operator and Drilling

Contractor and introduces training interventions that provide greater understanding of human limitations, with respect to the

potential for error.

To overcome many of the hurdles inherent in

managing drilling operations, it is further

proposed that the drilling community learns the

lessons from aviation and other hazardousindustries. Almost 30 years ago, aviation

recognised the necessity for such formalisation

and standardisation along with the developmentand introduction of training in non-technical

skills, leading to improved safety. Other highhazard industries have taken these lessons on

board and have reported benefits both in safety

and effectiveness by introducing traininginterventions to address the non-technical skills

of individual team members, while developing

the organisational framework that encourageseffective decision making. With focus and

discipline, oil and gas can achieve similar

improvements in process safety.

Academic research along with reviews of practices from other industries has illustrated the benefit of reducing the potential

for accidents and incidents through the combination of standardised processes and procedures and attention to human factors.The industry must therefore continue to learn from organisations who have demonstrated high reliability in hazardous

environments and to implement those learnings.

ConclusionsSeveral important threads emerge from the foregoing discussion:

1. Addressing human and social aspects, including the current level of training and competence in non-technical skills ofemployees, will benefit organisations in terms of detecting weak signals and developing a state of chronic unease,

leading to improved reliability.

2. Having all personnel trained and assessed as competent in non-technical skills will help teams both in routine andnon-routine situations, particularly by reducing negative stress effects on performance and overcoming traps

associated with cognitive biases.

3. The absence of formal procedures and standardisation of the protocols creates a number of practical problems. BothOperators and Drilling Contractors will benefit from codifying their respective procedures for executing andmonitoring well operations, making decisions, and managing change within a Standardised Operational framework.

4. To begin to approach the ideal of High Reliability Organisations in drilling, the industry will have to adopt a level ofoperational discipline related to the execution of workplace activities that is routinely in evidence in other high hazard

industries.

Figure 5: Integration of Non-technical Skills with Workplace Procedures


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AcknowledgementsThe Authors acknowledge the assistance provided by Charles Cowley, Brian Crichton, George Galloway, John Gidley and

Lisa Reed in the development of this paper.

RAPID is a registered trade mark of Bain and Company, Boston, Mass, USA

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AppendixA:OutlineofaStandardisedOperationalFramework1. Drilling Programmes:

a. Set clear criteria on which operational decisions are to be basedb. Specify safety-critical design parameters that must be verified during the operationc. Define operational ranges within which operations must be conducted: drilling parameters, fluid properties,

directional parameters

d. Detail the safety-critical procedures that must be executed exactly as writtene. Document the operational sequences to a level sufficient for a competent rig team to derive appropriate Written

Work Instructions for the crew.

2. Written Work Instructionsa. Bridge the gap between the programme and individual actions at the work siteb. Prepare jointly by the company supervisor and contractorc. Provide the framework within which safety-critical procedures and contractor standard operating procedures are

executed

d. Ensure coordination of activities between rig crew and service contractors at the wellsitee. Communicate clearly the operating parameters defined in the programme to those personnel required to

implement them

3. Operational Monitoring Proceduresa. Document required procedures for each monitoring activity

b. Assign set responsibilities to specific individualsc. Make reporting thresholds and response plans explicitd. Require individuals involved to be trained and assessed as competent in their respective duties

4. Management of Changea. Document the procedures for problem solving, risk assessment, option identification, and selectionb. Require a written amendment to the programme and Written Work Instructionsc. Demand conformance to original review and approval levels

5. Decision-making Procedurea. Specify the decision making rules of each team member for document approvals and operational decisionsb. Define the boundaries of decision making for each level in the organisationc. Establish the process of recording decisions with justification

6. Operational Disciplinea. Display exemplary leadership characteristics

b. Implement well defined and followed management processesc. Maintain high standards of work

7. Operational doctrinea. Rules for conducting safety critical tasksb. Rules for handling exceptions to procedures or Written Work Instructionsc. Rules for stopping the job in response to weak signals

8. Competency, Training and Assessmenta. Develop and adopt a competency framework outlining core knowledge, skills, and abilities, both technical and

non-technical, for individual roles

b. Ensure individuals are trained in role-specific knowledge and skillsc. Confirm that individuals have been assessed as competent in the required knowledge and skills


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AppendixB:OperationsManagementofChangeProtocolTier 1 (Decision maker Drilling Supervisor)

These events have no impact on well integrity or implications for achieving the well objectives. Tier 1 decisions include

developing the Written Work Instructions, setting operating parameters within programmed limits, taking actions followingsatisfactory completion of programmed operations or tests. Decisions can be made to optimise performance within the scope

of the Drilling Programme.

Tier 2 (Decision maker Drilling Superintendent)

Events involving Tier 2 decision-makers have consequences for well integrity and therefore require an amendment to theDrilling Programme. They will not impact delivery of well objectives or scope of the well, but will:

have implications on well cost and duration, but not more than 5% of AFE

impact well examination criteria, where applied

involve activation of planned contingencies or decision trees

include changes to bottom hole assemblies, reviewing decisions where results are marginal or ambiguous, changingparameters of mud or cement properties outside programmed limits or responding to down hole or surface equipment

problems

These decisions require a Drilling Programme Amendment developed as follows:

1. Document the incident that triggered the need for the change.2. In consultation with Drilling Contractor, service companies, define the required changes to the Drilling Programme

with associated risk assessment and required mitigation measures.3. Identify well integrity impact and required approvals4. Quantify the cost consequences5. Confirm no change to objectives or data acquisition programmes.6. Identify requirement for review and approval by the competent authorities7. Notify the stakeholders of the changes, and:

a. Obtain approvals from Competent Authorities or Well Examiner as appropriateb. Prepare and issue amendment to the Drilling Programme.

Tier 3 (Decision maker Drilling Manager)

These events deal with the consequences of a geological surprise, protracted equipment failure or major safety or

environmental incident. These are decisions with clear potential to compromise agreed well objectives or the scope of the wellor have a cost impact of more than 5% of the AFE. Should circumstances require this level of deviation, operations may need

to be suspended except for those tasks strictly necessary to ensure safety of personnel and assets. Stakeholders will be fully

engaged in the development of the revised plan and associated risk assessments. These decisions require a Drilling Programme

Amendment developed as follows:

1. Document the incident that triggered the need for the change. Drilling manager consults senior management and otherstakeholders to identify possible options. Review and rank options. High-grade and select preferred option.

2. Specify the necessary changes to objectives, data acquisition programmes and well design.3. In consultation with Drilling Contractor and service companies, detail the required changes to the drilling programme

with associated risk assessment and required mitigation measures.

4. Identify well integrity impact and required approvals5. Quantify the cost consequences

6. Identify requirement for review and approval by the competent authorities and well examiner7. Seek approval from the Exploration Manager and, when approved:a. Revise Well Objectives Document as required

b. Obtain Partner approvalc. Obtain approvals from Competent Authorities

8. Prepare and issue amendment to the Drilling Programme.

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