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Health and Safety Executive

© Crown Copyright, HSE 2017 HSL: HSE’s Health and Safety Laboratory

Verification – ‘Fresh eyes oversight can help find problems ahead of time’

Richard Potter Health and Safety Executive (Energy Division)

Justin Holroyd Health and Safety Executive (Science Division)

HSL: HSE’s Health and Safety Laboratory © Crown Copyright, HSE 2017

Targeted fresh eyes oversight can make a significant difference - Summary

• The case studies herein highlight verification’s untapped potential, as unfortunately do numerous MAH incidents

• We have developed targeted ‘line of sight’ coaching style inspections to assess proactive MAH capability / resilience where it really matters

• The Major Accident Hazard Approach adopted is based on the classic barrier model, but underpinned by Proactive Major Hazard Management maturity– The origins of Verification reflect that maturity progression (none,

certification, verification, and its enhancements)

• We believe ‘Effective independent auditing / verification can make a real difference – It’s all about the scope /approach’


Effective safety and environmental critical barriers and their verification require:

• A clear ‘line of sight’ between an installation’s current specific hazards and what is being verified / operational understanding

• A focus on the barriers’ continuing suitability, availability and reliability on demand

• Competent verifiers with the authority to do their job

• A shared understanding of what ‘good practice’ looks like (including the necessary demonstration within the safety case in support of the required governance statement)

• The key is a clear ‘line of sight’, the testing of which is the focus of our ‘line of sight’ coaching style inspections. Coaching draws out, assesses and builds competent behaviour where it is needed and appreciated.


The classic barrier approach is central

Independent barrier incident prevention diagram (taken from HSE’s HID Regulatory Model)

But, we need to be ‘ever’ mindful of the potential for commonmode failure, or unforeseen linkages and weaknesses


Proactive Major Hazard Management Maturity characterized by the ‘What’ and the ‘How’

‘What’ do you focus on?

• Where are your key people on this safety awareness journey?

Occupational health and

safety

Generic major hazard

risk

Installation (role) specific major hazard

risk


Proactive Major Hazard Management Maturity characterized by the ‘What and the ‘How’

‘How’ do you help your people focus on the right things?

Effective proactive hazard management involves:

Again where are you in this journey?

Line of sight coaching style inspections are a way of assessing your arrangements’ effectiveness


What do we mean by a ‘line of sight’

We mean a line of sight should exist between:

– The potential installation specific hazard initiating events;

– The Case for Safety (of which the safety case is a summary);

– The SECEs (including their performance standards);

– The duty holder’s maintenance and assurance activities;

– The verifier’s activities;

– Offshore (and onshore) awareness

The following simplified case studies help explain the ‘targeting’ which is critical


The Case Studies

The Case Studies that follow are simplified and anonymous examples to illustrate the inspection approach’s effectiveness

• Post Piper CRINE era four legged structure with cantilevered topsides

• Early pre Piper self-floater four legged structure


The Process

• Questions to ask, when deciding what to focus on / target, and come to a conclusion on, are:

– What is high consequence / high risk?

– What is different from the norm (and or the routine)? Specific to this installation or type.

– Is anything missing / or added? – it may be a weak signal

– Is it a verification priority?

– Do people offshore appreciate its importance?

• These questions can help to make the safety case a living document by increasing MAH awareness and understanding where it probably matters most


Team / Individual Competence

• It is important for the team / individual to have the skills, knowledge and experience to:

– build the ‘operational big picture’

– identify potential high consequence weak signals that may have been missed

– Test the robustness of the arrangements in place in such a way that you help build key competences / behaviours

– Assumptions are dangerous


Post Piper CRINE era four legged structure with cantilevered topsides

• What we focused on:

– Jet fire impingement on the legs

– Corrosion management of the module with the highest hydrocarbon risk associated with it

• Why did we do that?

– Riser jet fires impinging on the legs had the potential for ‘unacceptable topsides deflections affecting the modules’

– Water circulation system critical and unusual, and no specific mention of it in the verification scheme

– Problem with the management of corrosion under lagging and unclear how its effectiveness was verified


Post Piper CRINE era four legged structure with cantilevered topsides

– What the duty holder did subsequently

• Determined the required minimum flow rate and modified the assurance routine to include a test of the flowrate to ensure it reached that required minimum level

• Reflected on the adequacy of its barriers and the operational and incident response implications

• Highlighted the need to consider ‘known’ defective lagging before deluging an area – ‘The silo effect’


Early pre Piper self-floater four legged structure

• We identified the following weak signals:

– 6 inch gas riser protection

– Gas export line’s potential for brittle fracture during reverse flow (topsides)

– Control system associated with the flare knockout pots

– The need for clarification of issues associated with structural integrity


Early pre Piper self-floater four legged structure

• Our impact

– Riser shut in before sea-state tops the supporting J-tube and attendant vessel movements now subject to more onerous weather restrictions

– ORA on knockout pot control system until modifications completed

– Gas line susceptibility to brittle fracture underlined the need to verify some process valves/systems

– What dominates the tower’s integrity was clarified


Some memorable quotes we have received

• ‘We will learn from this.’

• ‘It has been like this since day one.’

• ‘The pump in the past has been out of action for a considerable period of time, we did not appreciate its significance.’


The message

• We have shown there is always room for improvement in MAH management. This technique can help…..

• ….. as can effective independent auditing / verification

– It’s all in the scope.

• Remember it’s important to focus on the intent of the regulations, ‘the regulatory big picture’

• Missing fire hazards and inappropriate control arrangements can have significant consequences. This technique has ‘proactively’ picked up potentially high consequence missing fire hazard initiators and/or multiple deficiencies in their control arrangements, some of which have been there since day one


Organisation for Economic Co-operation and Development (2012) Leadership Questions

• Finally these OECD leadership questions are just as relevant today as they were in 2012:

– Do you know what the major accident risks are for your organisation?

– Do you know what your main vulnerabilities are?

– How confident are you that all safety systems are operating as they should?

– Are you doing all you can / should to prevent a major accident?

• Could you do more?

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