2011 spe - electronic logging to improve safety
TRANSCRIPT
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Using Electronic Shift Logging to
Improve Safety
Andy Brazier
Tel: +44 1492 879813
www.abrisk.co.uk
Brian Pacitti
Tel: +44 1224 355260
www.infotechnics.co.uk
Martin Sedgwick
Tel:
Martin.Sedgwick@
scottishpower.com
Two part presentation
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1. Companies need to improve critical communication
processes, including shift handover
2. Case study from – role of shift logging in
preventing process safety incidents
Underlying theme – technology is available to assist
improvement (e.g. Opralog from Infotechnics)
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Is there a link between safety and communication?
Is communication hazardous?
Did it ever kill anyone?
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Deep water drilling in the Gulf of Mexico is:
Complex
Hazardous
At the edge of our technical capabilities
The people involved have to know what is going on
Day by day
Hour by hour
Minute by minute
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They need to communicate. But…
The work for different companies
They report to different people
They are restricted in what they can say
The result is
No one has the full picture of what is going on
Bad decisions are made
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Transferring oil products between sites is:
Relatively simple
Nothing new
Hazardous
The people involved have to know what is going on
otherwise:
They may not know a
tank is being filled
They won’t know it
needs to be monitored
It may overflow
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And don’t forget:
BP Texas City
Piper Alpha
Bourbon Dolphin
Etc…………..
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What is the problem?
1. Knowing what to communicate
There are known knowns; there are
things we know we know.
We also know there are known
unknowns; that is to say we know there
are some things we do not know.
But there are also unknown unknowns –
the ones we don't know we don't know.
2. Inadequate systems
3. Inappropriate behaviour
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What can you do?
1. Tell people they have to communicate
2. Train people to communicate better
3. Specify/guide what has to be
communicated
4. Make sure they are communicating
5. Make sure communication is effective
6. Identify problems
7. Drive (continual) improvement
I.T. Solutions
Making it easy to log information that is then
readily accessible to anyone who may need it
What is the problem?
Incorrect information given
Information misinterpreted
No communication
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All of the above
What can you do?
Tell people they have to communicate
Train people to communicate better
Specify/guide what has to be communicated
Make sure they are communicating
Make sure communication is effective
Identify problems
Drive (continual) improvement
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The problem
Shift handover is a complex, error prone activity,
performed frequently
High risk
It can’t be ‘engineered out’
Partly driven by systems and procedures
Highly dependent on behaviours of people
involved
Rarely cited as a root cause of accidents.
But is anyone looking for it?
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We know there is room for
improvement but….
People underestimate its complexity and hence
overestimate their ability at shift handover
Who has the incentive to put in additional effort?
Person finishing their shift – want to go home
Person starting their shift – don’t know what they
don’t know
Managers – rarely present
Seems to have fallen into the “too hard” category
for many
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Looking for another angle
Tackling behaviours head on is not easy
Log books used at handover contain a wealth of
information
Could this be used more widely?
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Offshore study
Copies of a
week’s logs
3 ½ kg of paper
All hand written
Multiple formats
Contents
reviewed
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Information being recorded
Human errors
Valve ‘inadvertently’ closed, missing parts and
information, tasks not complete
Minor incidents
Small releases, equipment failures
Routine tasks
120 operational tasks recorded
Solutions to problems
Release pressure, manually manipulate valve, use
sealing compound
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Other studies using data from log
books
Component reliability1
Hours of operation, failure and repair time
Economic operation2
Model of plant breakdown and identification of items
critical to system reliability
Reliability3
Development of a fault tree used to identify plant
modifications
References
1 – Moss 1987
2 – Campbell 1987
3 – Galyean et al 1989
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Findings from these studies
Date from log books could be very useful
It is relevant to safety and reliability studies
Allows models to be developed
Supports expert judgement
Difficult to achieve
Handwritten
Not structured with data collection in mind
Concerns about consistency.
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Putting these ideas into practice
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Maximising the value of data
Improving the quality of data
To get the full picture, it is usually necessary to have
input from more than one area of the business
It is useful to be able to consider logged information
alongside the relevant ‘hard’ process data
Information may be required in different formats for
different purposes
Supporting the operator in collecting the data
Making it as easy as possible
Making it very clear what is required
Using the data