1500 - evans - corporate memory collective intelligence

8/10/2019 1500 - Evans - Corporate Memory Collective Intelligence

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and the Struggle against Amnesia

John Evans, Risk and Safety Manager,

g3baxi partnership

Gordon Martin, BSTS Consultancy

May 2014

Corporate Memory - Collective Intelligence


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Knowledge within a Corporation

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Source: CSB interim reportRichmond Refinery Accident of August 2012


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What are Corporate Knowledge and Collective

Intelligence? Trevor Kletz said Organisations have no memory

Corporate Knowledge and Collective Intelligence are most evident whenthey are done badly or not at all.

Some management failures can defeat a safety management system

and its barriers.

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Design Informationthe plant

dossier

Maintenance, Integrity and MoCs

Assessments of Fitness for

Purpose, Engineering Standards,

Risk Assessments

Plant

Processes

People

In addition each part of the organisation must recognise and

communicate the importance and status of its data to other parts.


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Judith Hackittat the OPERA Seminar 2012

Few operators create effective corporate memory.

Increased contractorisation and outsourcing of operation mean knowledge often

exists outside of the company having responsibilityfor the assets.

[In] change of ownership ... design information and records might not be passed

on. Purchasers often do not understand the condition of the assets nor how it

was inspected, maintained and modified. Effective due diligence strategies are

essential.

Sites using 3rdparties for plant management / inspection services deliversignificantly poorer performance in management of plant ageing.

3rdparties have a responsibility to ensure that they are competent and capable

of providing the service they are being contracted to do.

The greatest weakness of all is the widespread inability or unwillingness to learn.

Companies fail to learn even from their own internal sources of learningopportunities - whether across the same site or between sites.

The failure or inability to learn from other types of industry accidents is even

greater.

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Company InterfacesNorth Sea O+G Contracting

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Contractor

Client /Expectations

Live Plant

Information

Assessments

Developing

StandardsPlant

ConditionEPSC

OGPHSE

Engineering

Practices /

KPIs

Plant DesignInformation

Incident

Learnings

Safety

Barriers Contractor

Competences

Asset

Integrity

Maintenance

Succession

Planning

Future /

Previous

Contractor

Future /

PreviousClient


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Normalisation of Deviance

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Symptoms of normalisation of deviance include:

Misdiagnosis of the hazard;

Extended turnaround or inspection intervals;

Reduced maintenance; Operation above design flow rates or pressures;

Ignoring or demotivating staff who identify new hazards.

Loss of staff to retirement is not as significant a source of loss of

corporate memory as renormalising them.

The chart shows the number of dings greater than 1 inch in size. Max on y is 300.


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Learning from Losses (Marsh, 2011)

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Is Normalisation of Deviance a growing problem for insurers?

Even with the above data, the accident frequency per site is low enough to

deceive them (and even their insurers!) into being complacent.

($ Million)


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Industry Changing Events / Improvements to

Engineering PracticesAccidents that have changed

legislation Flixborough (1974)

Seveso (1976)

Bhopal (1984)

Mexico City (1984)

Piper Alpha (1988)

Toulouse (2001)

Buncefield (2005)

Texas City (2005)

Macondo (2010)Average once in 4 years

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Accidents that have not changed

legislation with (year) & fatalities Feyzin (1966)18

Alexander Kielland (1980)123

Ocean Ranger (1982)84

Cubatao (1984)500+

Tenghiz blowout (1986-7)0

Guadalajara (1992) - 252

Vishakpatnam (1997)150+

Ufa (1989) - 575

Gaoqiao (2003)243 Snorre (2004) + Elgin (2012)

Corporations need to learn from outside themselves as well as from their

own experiencetheir structures must be inherently adaptive.


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Learning from AccidentsUnexpected Consequences

The pipe rupture at Richmond led to a drifting cloud of heavy hot

hydrocarbon. 17,000 local residents sought hospital treatment.

(API states it will form a pool no more than 6 m from the leak)

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Transforming Individual Intelligence to the Collective

Most management systems are hierarchical, top down and

are designed to ensure people work to a competentstandard;

A system that promotes collective intelligence would

explicitly recognise the need for:-

Up to date design and plant data; Communicationto create the organisations nervous system;

Appreciation and organisation of the criticality of information;

Synthesising indicators based on the above (i.e. KPIs);

Diagnosing delays in information transmission - schlerosis;

Developing its learning and new ways of synthesising and

communicating information;

Referencing central technical standards;

Learning from others incidents.

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Collective Working within a Systematic Risk Structure

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Hazard Barrier

Alteration to instrument

settings

Incorrect drawings

Changes to design basis

Rotating machinery

problems

Corrosion

Structural integrity

Competence

OperatingWindows concept /

MoC

Audit / Survey / MoC

Technical authority

reference

Data historian, MTBF

as a KPI

Inspection /

reference to TA

Inspection /

reference to TA

Training,

recertification

Corporate

Amnesia

leading to

accident

Knowledge of explosionsfrom FABIG, EPSC, etc.

Behaviour of pressurised

liquid releases

Resulting Accident

Emergency preparedness

drills, learnings

Latest environmental

requirements for dealing with

fire fighting effluent.

Condition and coverage of

gas detectors

Testing regime for fire

pumps

All work done and all information should have a place within the overall system


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These are views of the samelocation on the sameplant.

Inspected 1998

Inspection and Pipe age Data

Process Conditions

Underground Services

Historical Incidents

Nearest Safety Shower

Local Gas Detector Readings

Electrical Feed Status

Permits to Work

P = 50barg, T = 20C

Electricity4kV

Visualisation - Example

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Improve VisualisationData in Context

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400 600 800 1000 1200 1400 1600 1800 2000 2200 24002200

2400

2600

2800

3000

3200

3400

3600

3800

4000

Cont. 1 - 1.0e-03

Cont. 2 - 1.0e-05

Cont. 3 - 1.0e-07

Cont. 4 - 0.0e+00

Cont. 5 - 0.0e+00

Cont. 6 - 0.0e+00


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Areas Addressed by Visualisation, et al.

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Contractor

Client /Expectations

Live Plant

Information

Assessments

Developing

StandardsPlant

ConditionEPSC

OGPHSE

Engineering

Practices /

KPIs

Plant DesignInformation

Incident

Learnings

Safety

Barriers Contractor

Competences

Asset

Integrity

Maintenance

Succession

Planning

Future /

Previous

ContractorFuture /

PreviousClient

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Conclusions

Corporate knowledge, collective intelligence and learning are

seriously undervalued by organisations;

Failings are a cause of many accidents, and raise risk at many

other sites;

Live risk bow ties and visualisation vastly improve knowledge

and identify management system failures in real time;

Organisations must learn from incidents;

Independent industry bodies need to formalise the

standards and methods, using:-

Corporate Knowledge expectations; Positive collective intelligence case studies;

Model Architectures for Co-working.

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Extras

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Data VisualisationPotential of New Technology

Visualisation of Buried Information;

Collates information together to promote cross disciplineworking;

Platform for further development;

All data becomes value added and can be viewed in

context;

It can be linked to standards, data sheets and guidelines;

It takes advantage of current technology, and if Ex rated can

be used on plant, via tablets, etc.

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1500 - evans - corporate memory collective intelligence

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