| Popis: |
Investigations following hydrocarbon leakages from Norwegian Continental Shelf (NCS) installations have focused almost exclusively on measures related to technical and mechanical causal factors, despite human and organizational failures being accepted as a significant underlying contributor to unwanted incidents. The aim of this project was to examine recent large leakage incidents to look for common underlying causes relating to human and organizational factors and write appropriate recommendations based upon the findings. The project formed part of a larger Norwegian Oil Industry Association project to reduce hydrocarbon leakage incidents and subsequently improve HSE performance on the NCS. Hydrocarbon leakage incidents from five offshore installations in the Statoil portfolio were assessed during a series of focus group workshops conducted with management and technical representatives from each installation, process specialists, and Human Factors specialists. The incident reports and HTO (Human, Technology, Organization) annotated timeline diagrams were examined against at 14- point Human Factors keyword list adapted from the UK Health and Safety Executive's Major Hazards website. Eighty one findings relating to the fourteen keywords plus twenty eight existing recommendations in the Synergi incident reporting and follow-up system were grouped into four themes for discussion at a follow-up plenary workshop; governing documentation for issuing permits to work, system understanding during abnormal situations, inspection & maintenance programs, and interaction between modification projects and the operational organization. Based upon the discussion of these four themes, five recommendation topics were prepared; permits to work, land-based support during abnormal situations, understanding of technical systems and risk during abnormal situations, inspection and maintenance (tubing and fittings), and interaction between modification projects and the operational organization. Specific actions relating to each topic were then written for company duty holders for follow-up as part of a company integration process. The keyword method revealed new findings, particularly relating to organizational deficiencies that had not been considered in the initial incident investigations. The methodology also gave operational management insight into how the Human Factors discipline contributes to incident investigation work. |
