human factors in barrier management - …...ptw review/ ifs technical preventive maintenance system...
TRANSCRIPT
Themes
1 Barrier Management in Maersk Drilling – principles and components
2 Establishing the Barriers Elements in Drilling Operations
3 Thinking Human Factors into Barrier Management
4 Self-verification and Activity Assurance – Leadership and Culture
5 HF in Well Control Situations
6 Case – does this actually work?
page 3
Building blocks to developing our BMS
Hazid & MAH analysis (BowTie
analysis)
Technical barriers
elements
Operational barriers
elements
Organizational barrier elements
BMS
✓ Performance standards
✓ Safety functions✓ SECE
✓ Key safety critical operational activities
✓ Supporting documentation
✓ Key role identification✓ Key capabilities✓ Competency
assessment process
Safety Critical (sub)functions to ensure well control
Mud system
Casing/ Cement
HP RiserTop Drive/
Draw works
Kick detection system
BOP incl. Control
Choke and Kill
system
Diverter system
Mud gas separator
Barrier ManagementEquipment, procedures and competent personnel in place to ensure the barrier integrity
Title of presentation | page 4
Control HC flowIdentify and control HC kickPrevent influx
TECHNICAL BARRIER ELEMENTS
ORGANISATIONAL BARRIER
ELEMENTS
OPERATIONAL BARRIER
ELEMENTS
1. Key Activities
2. Required information
(Input, Manuals, Sup. Docs etc.)
1. Roles
2. Required competency
3. Assurance Activity/ Comp. assessment
Barrier Element
Assurance ActivityVerification Criteria (What does good look
like)
Monitor
Framework for maintaining the barriers on the rigs(Developed to be tested on Maersk Invincible)
page 5
OrganizationalOn the Job Training (OJT)
Operational
Process self-verification
Work Execution Process
Drills and scenario
training (well control)
Audits
100% compliance. w. drills
80% Overall compliance w. OJT training matrix.
100% compliance. w. WEP
100% compliance. w. self-verification matrix
PoBCO
SIRIUS
Self verification matrix/ Synergi
PTW review/ IFS
Technical Preventive Maintenance System100% compliance w.
performance standards
Technical Barrier Status Workbench
(IFS)
Safe
ty C
ritical Function
page 6
Organizational barriers
Technical barriers
Operational barriers
CAP
PobCO Certifications
Minimum hiring requirements
Self Verification & Activity Assurance
Management system
Work Execution Process
After Action Review
Developing a culture where people keep on being developed to fulfil their roles in the safety critical activities
✓ Control performance shaping factors✓ Increase situational awareness✓ Detect/ Comprehend/ Project
Creating the right environment for the people to operate safely
✓ focusing on Human Machine Interactions
✓ HF considerations in the design phase of our rigs
Designing clear procedures with strong links between equipment and operations
✓ Control performance shaping factors ✓ Pattern recognition✓ Trending and thresholds✓ Situational awareness
ISO11064 and NORSOK 002
Preventive maintenance
SECE
Performance standards
Drills and Training
DWOP
Enablers to strengthen the barrier elements and interlink them
Self Verification ProcessAssurance activity in place
page 7
To reach Zero Incidents
• Self-verification is one of the best tools to drive active visible leadership, management accountability and procedural compliance
Testing and ensuring that the right barriers are in place
• Self-verification is a management audit & inspection tool for specific operations
• Self-verification is an coaching and learning process
page 8
Self-verification follows a simple flow• Practical and easy to embed in daily operations• Follows our PDSA approach and philosophy
PlanningConductin
gFollow-up
Activity Assurance
• SV activities as per weekly matrix
• Evaluate current operations for high criticality and safety risks
• Agree which jobs to SV during work permit meeting
• Announce SV to be conducted to crew (pre-tour)
• Prepare (review procedures and OCL)
• Conduct SV at worksite with crew
• Provide feedback to verified crew
• Enter SV into Synergi
• Ensure non-conformance actions are closed
• Discuss SVs conducted during morning call
• Monitor trends and compliance with matrix schedule
• Verify and participate during rig visits
OIM and Heads of Departments Rig Manager and HSE advisor
page 9
HOW:Visual leadership – Heads of Departments and OIMs on the worksite
10 processes to be self-verified in 2017• Shift handover• Well control• Work with pressure• Toolbox Talk• Work Execution Process
Processes are chosen based on criticality as well as incidents and safety issues seen• 8 of the processes are specific• 2 are non-specific and can be applied on all jobs (TBT & Work
Execution Process)
• After initial implementation when our own crew are comfortable with SV, we will review if SV should be expanded in scope, for instance by including verification of service companies
• Red/Restricted zones• Lifting operations• Pipe handling• Fluid and Bulk transfer• Marine barriers (floaters only)
page 10
Human Factors in Well Control
WHY:
• Well control often has multiple complex interfaces
• Frequently not properly understood
• Often caused or exacerbated by people making mistakes under pressure
• Decisions made under pressure often determines the outcome
WHAT and HOW:
• Setting up the individual and the group for success
• Utilizing the strengths and mitigating the weaknesses
• Performance shaping factors and Dynamics associated with cognitive/social biases
page 12
In well control terms HF..
Creating circumstances for:
• Detecting “something is wrong in the well”
• Comprehension
• forward projection – and foundation for correct forward decision making
• good planning - what does “good” look like? And what is outside safety envelope?
• Disciplined execution – staying inside the safety envelope
• Continuous evaluation and trending against “what “good” looks like”
page 13
How do we do this..?
• Team Based Well Control Training
• Detection skills and pattern recognition
• Non-technical skills (leadership, communication, team work, decision making- and planning strategies, handling stress and fatigue)
• Application of technical skills for well control
• Performance enhancement training – new start-ups
• New team integration and Non-technical skills
• Offshore Simulators Exercises
• Detection, pattern recognition and application of technical skills (+some non-technical skills)
Offshore simulator training offered quarterly to key personnel on our rigs
page 14
Training consist of two elements:
A theoretical questionnaire;Provides the opportunity to practice e.g. calculations and theoretical knowledge around well control
A practical scenario training on simulator; Provides the opportunity to practice detection of and response to well control situations
1
2
After completion of exercises a feedback report will be created; Provides knowledge about areas that can be improved and is an unique opportunity to discuss personal development plans
page 15
IWCF well
control
Team based well control
IWCF well
control
Team based well control
• Maersk Drilling Management Team priority:It is important to develop our competencies to improve our high standard in safe well control management – even more so in tough times.
• Focus on personal development: Crew members have a learning tool to continuously maintain and improve well control competencies.
• Offers onboard training: The training is flexible and easily accessible offshore. This fosters a “learning culture” and gives the opportunity of discussion with peers and supervisors on board. – a knowledge to be used for development and promotions.
Why is the training offered?
• Create awareness of skill level: Supervisors will have a better understanding of the skill level on board.
• Key element in Surface Well Control Manual:The training is a key element in assurance and is in compliance with the new Well Control Manual.
On board simulation
On board simulation
On board simulation
On board simulation
page 16
• Main objective - remain within safety envelope at all times
• Well control process designed to:
• Mitigate plans “drifting” in critical situations
• Help combat mental traps and human errors
• Facilitate non-technical skills and help maintain correct decision making
• Facilitate good team resource use
• Facilitate better communication (onboard and rig/shore)
• Increase ability to identify deviations from expected outcomes or trends
• Must be rig friendly and ensure buy in of all – including clients and other third parties
Human Factor focus in WCM
page 17
Well closed in
Instruct driller to contact WCT if SICP approaches MAASP
Instruct Driller and Mud loggers to
report anomalies
Ensure no other activity in active
system
Consider withdrawing other
work permits
Gather logs and other relevant
information
Call HQ duty phone
Call for meeting:· Company man· Mud Engineer· OIM· DSL· Drilling Engineer· Geologist· Mud loggers· Other relevant personnel
Study and review situation
Call town (both local and HQ)
Unconventional includes:· HPHT· String not on bottom· MPD· Underground blowout· Plugged string /
washout· Black out· Adverse weather· etc.
Confirm the following:· BOP holding pressure· Line up correct to monitor
pressures · Driller monitoring correct
details· Trip tank circulating over
well· Content of choke & kill
lines (if applicable)
Conventional well control
Handle on board Prepare all details for discussion
N
Well Control Management Flowchart 1
Step 1
Step 2
Step 3
Step 4
Step 5
page 18
Action Who Comments
Shut in Driller
Confirm BOP holding pressure and no leaks
Driller / Assistant Driller / Mud logger
Confirm: · valve status· pit status· All
instrumentation working correctly
· Closed loop communication
· Driller to document
· Mud logger to document
Each rig to generate own detailed checklist
Confirm line up correct and pressures
being monitored Driller
Confirm Trip Tank circulating over well
Driller
Confirm contents of choke & kill lines (if
applicable)Driller
Step 1 Establish baselines, confirm shut-in & verify pressures and volumes
Focus area Strategy / Plan
page 22
Summary
• We have developed an operational barrier management framework for our rigs
• Human factors are considered for each elements and for interlinking the elements
• For well control human factors are reflected in the procedures and in the training
• Self verification process support management in driving the safety culture
• It is proven to work in real life.
Act Plan
Do Study
MAH
Technical Barrier Elements
Operational Barrier Elements
Organisational Barrier Elements
Human factors
Decision flow chart for BM page 29
Planned Activity
Follow normal Work Execution Procedures
Consult Tech Barrier Status Workbench
(IFS)
Consult Qualification
matrix (PoBCO)
Do we have the required competency for the job
Discuss the details of the activity and evaluate the hazard(s) involved and risk of
Hydrocarbon release
Loss of primary well control
Gas release
Fire or Explosion
Structural damage
Helicopter crash
Dropped objects
Risk of causing a
major accident event
Any relevant Deviation Permits or
Active corrective WOs
Do we have procedures/
OCLs in place the activity
Check procedures and checklist in Sirius
Is it safety critical
Have the barrier integrity
been compromised
Make risk assessment on
impact of barrier integrity
Ensure mitigation is in place
Produce the necessary procedures
to ensure safe execution
Follow steps in OCL for verification of Barrier Function
Ensure that task leader is familiar with relevant performance
requirements
Y
?
Y
Y
Y Y YN
N
N N N
N
Ensure mitigation is in place
WHYWHAT
ANDHOW
– SELF-VERIFICATION?
A standard matrix based on unit type defines minimum frequency of SV • Ensures all processes are verified on a regular basis • Allows flexibility based on current operations and specific issues observed• Matrixes for floaters, jack-ups with and without Safety Officers and stacked
units
* matrix for floaters
OCLRole
Shift Handover
Well control
Work with pressure
TBTRed/
Restricted zones
Work Exe. Process
Lifting OpsPipe
handlingMarine
Barriers*Fluid/Bulk Transfer
Total per position
% per position
OIMbi-weekly
Even weeks
weekly weekly weekly 3,5 11%
DSL weekly weeklybi-weekly
Even weeks
bi-weeklyUneven weeks
bi-weeklyUneven weeks
3,5 11%
TP weeklybi-weeklyUneven weeks
weekly weekly weekly weeklybi-weekly
Even weeks
6 19%
TSL weekly weekly weekly 3 10%
Maint. Eng.
weekly weekly weekly 3 10%
MSL/ AMSL
weekly weekly weekly weekly weekly 5 16%
SO 3x weekly weekly 3x weekly 7 23%
Total on weekly basis
3 2 1 8,5 2 7,5 2 1 1 3 31 100%
% split 10% 6% 3% 27% 6% 24% 6% 3% 3% 10% 100%
1. Make the well safe & establish shut in parameters
2. Assemble Well Control Team and gather information about the well (Well control Pull Out Pack)
3. Ensure everything is covered & conclusions are not drawn too early
4. Challenge statements and theories (devils advocate)
5. Agree on kill method
6. Establish parameters and agree on ”what does good look like” during the well kill
7. Communicate to all involved – using verbatim repeat back throughout
8. Start well kill and monitor kill against expected outcomes
Human Factors must be central and not viewed as an “add on”. The process must be designed to incorporate Human Factors from the beginning.
Mapping created the following phases:
Mapping well control31
Continous assessment
Provide user friendly trend sheets for operations
• Volume & pressure control during displacements (mud changes/cement…)
• Ballooning
• Torque, drag and pressure trends
• Cuttings volume vs ROP and cuttings shape and size
• Changes in mud properties
• Volume control (expected mud use vs actual)
• Expected gas expansion
• During HPHT wells various operations are fingerprinted to compare with later readings – why not do similar
32
Mental traps• Well control is stressful and a number of mental traps
(sometimes called cognitive biases) need to be dealt with
• These mental traps have a major influence on individuals and teams to recognise events or deviations from what’s going on around them
• Confirmation bias - is the tendency to interpret information that confirms one’s own observation (which may or may not be flawed)
• Normalization of Deviance - is the gradual process through which unacceptable practices or standards become normal and acceptable
• Groupthink - is the tendency of a decision-making group to strive for consensus that results in avoiding critical examination of alternatives
33
Human factors strategies embedded in the Well control procedures:
page 35
• Closed loop Communication
• Technique to combat mistakes more likely to occur when individual is under pressure and/or fatigued
• “Devils advocate”
• This strategy is used to minimize the risk of the Well Control Team developing what is called “normalization of deviance” and “Groupthink
• Forward Projection and Trending
• Forward projection is used to predefine what “good” and “bad” looks like. Its important methods to understand what to expect.