task force zero conference paper 2013
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8 interviews from the safety conference, 27 March 2013.TRANSCRIPT
Eight interviews from the annual safety conference 2013
Still learning to manage the humanfactorin the Oil and Gas Industry
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5Safety ConferenCe 2013Task Force Zero
“Jim Trodden explains: When new
people – green hats – arrive on my
platform they get safety videos
telling them about life boats, es-
cape routes, personal protective
equipment and other basic safety
information. And then they meet
with me. We sit down with a cup of
tea and I tell them the important
things, the things they need to re-
member now – because they have
arrived at what I believe is one of
the best places in the North Sea.
I tell them that there are no dou-
ble standards about safety here, I
tell them about the principles by
which we operate: Do it safely or
not at all. There is always time to
do it right. I assure them that this
is not just another corporate state-
ment but rather a contract between
me, the person who needs to get
some work done, and the people
who will do the work for me. I re-
mind them of their Stop-Work-Au-
thority – if they see things that look
unusual or concern them, they have
the authority and the responsibil-
ity to stop the work, their own work
or someone else’s work. And the
Stop-Work-Authority is used here
on a daily basis – without penalty.
It is a responsibility and its use is
actively encouraged.”
–You have been in the industry for
a long time – what development
have you seen in this period?
Trodden: “I have worked in the oil
industry since 1977 and for Chev-
ron the last 24 years – I have never
regretted my move here. Chevron
is an enlightened company, a
multi-cultural organisation which
runs its operations in a uniform
manner world wide.
The biggest change I have seen
in the North Sea in general is the
move away from a command and
control, strict hierachy where you
did as you are told to do, nothing
more. Today we value contribution,
we encourage ’neck up’ compli-
ance, we advocate personal respon-
sibility for safety and we strive for
meaningful engagement. The in-
dustry is on a long march, moving
from a regime of control to mutual
respect. Some of us are a lot further
down this road than others! But
we all still have a lot to learn and
improvements to make – though
sometimes progress can feel slow,
which worries me at times.”
– Do you think this change has
come as a result of incidents or is
it a ’natural’ development?
Trodden: “Incidents have accel-
erated this development; most
companies will now encourage or
maybe even insist on reporting.
Anything unusual should be re-
ported. And all incidents are to be
investigated appropriately – it is a
clear Chevron requirement that if
a safety device is found to not work
or is not active when it should be
– it is an incident. And all incidents
are to be investigated based on
their potential severity or conse-
quence.”
– What influence did the Macondo
disaster have on your operations –
if any?
Trodden: “Of course the Macondo
disaster had an impact on the or-
ganisation worldwide, in particular
with regards to drilling and Chev-
ron has worked within the industry
to raise standards and improve in-
cident prevention, intervention and
response capability. As always, les-
sons must be learned from a spe-
cific event – real hazard awareness;
comprehensive risk assessment;
compliance with good processes
and procedures and, critically, the
understanding and acceptance that
anyone involved can stop the work
before the consequence of signifi-
cant deviation occurs.
I would like to add the following
because I think that there is a
problem that can only be resolved
at an industry level. When I receive
a temporary piece of equipment
offshore, a diesel generator for ex-
ample, I get data sheets with all the
necessary information about this
generator – input, output, rating,
certification of its lifting frame and
slings. That allows me to plan my
control of this piece of equipment.
When transient workers – contrac-
tors – arrive on the platform, I have
absolutely no idea about their at-
titude regarding safety; I do not
know what has moulded them. I
only know that this person is sup-
posed to be a specialist in his field,
he has the necessary offshore
safety training – and that’s about it.
And it is a concern – because only
about 26 percent of the people on
the platform are directly employed
by the operator. The others – the
majority are contractors, suppliers
from all sorts of companies, differ-
ent backgrounds, different experi-
ence, different nationalities – they
all have to blend in and work effec-
tively inside ’our’ culture. That is
why it is all about people’s attitudes.
I recommend to all to find out
more about ’Step Change in Safety’
and the excellent work they do to
change thinking, attitudes and be-
haviours.
All must understand the impor-
tance of leadership – the message
must be unambiguous, undiluted
and transported right from the top
of the pyramid to the person on the
tools.
I want to mention in particular the
good practice of regular senior
management visits. In the old days
these visits were very infrequent
and an OIM would determine what
was to be seen and who was to be
talked to; out would come the good
china cups and the best coffee.
Today the visitors still get the best
coffee but they drink it from the
same cups as the regular offshore
people, they determine what is to
be seen and who is to be talked to
– access to anywhere, anything and
everyone on board. Top manage-
ment plays a key role in setting and
sending the message.
That’s why Chevron management
comes out to see for themselves if
the message has been received –
that is why visible leadership is key”.
leadership is keyJim trodden, offshore Installation manager on Chevron’s alba northern platform in the uK north sea emphasises the importance of the right message from top management being received by the people on the installation.
Interview with Jim Trodden
By Hans Jørn Johansen
6 Safety ConferenCe 2013Task Force Zero
the hSe standards and processes need to be relevant to those in the field
Richard Taylor: ”The diversity and
different approaches in driving im-
provement in health and safety is
the interesting challenge for me.
That you can add value and make
a difference.
There is a very advanced legislation
and a very mature workforce in the
north west Europe compared with
some less developed parts of Af-
rica which are in the early stages of
their oil and gas career. You don’t
have the same drivers on health
and safety in some parts of the
world where the legislation devel-
opment and enforcement of HSE is
in the infancy stages.
This makes it even more important
as a company to ensure your have
robust systems in place. It should
not matter where you are working –
compliance should be the same. It
may have to be tackled in different
ways and you need to taylor your
approach.
We apply the SLB HSE standards
globally; however as you are dealing
with different competencies from
the workforce you may not always
get the same results. It is refresh-
ing that even in new and emerging
countries people are eager to learn
and willing to improve.
In terms of developing the safety
culture a simple example of this
is seatbelt usage. In many coun-
tries in which we operate the wear-
ing of a seatbelt is strictly enforced
through legislation and has been
for many years. For these employ-
ees putting a seatbelt on when
they jump in a vehicle is habit; It is
more of a challenge for other em-
ployees operating in other coun-
tries where seatbelt laws are not
enforced or where vehicles are not
fitted with seatbelts. We there-
fore educate the workforce to un-
derstand that this is to help keep
them safe. If we can transfer this
type of safety behaviour to outside
the workplace and to their fam-
ily members then we know we are
making an impact – this is the chal-
lenge. So a major part of our job
is to help develop safety culture:
what you do inside the work place
should be no different from what
you do on the outside.
The security challenges are becom-
ing increasingly important. We are
now seeing increased security risks
from crime and terrorist attacks
that we did not have 5-10 years
ago. So that opens up a new area
that must be handled in close coop-
eration with the client.”
— What did Schlumberger change
as a learning from the Macondo
disaster?
Taylor: ”Tragically M-I SWACO lost
two engineers in the Macondo di-
saster. The focus was there through
the development of our well in-
tegrity barrier standard, no. 22. We
have a very good reporting system
’Quest’. Since the Macondo we have
had a hard look at our reporting
and incident investigation system
’Quest’. We realised that we need
to hone our focus more on process
safety incidents and on our high
potential incidents. A high potential
report is a potential loss which did
not materialise due to another bar-
rier that funtioned – the ’holes’ did
not match up.
The High Potential incidents now
receive the same level of attention
as actual incidents, where we had
a loss. Before HiPo reports were
richard taylor, Hse manager, europe/africa, schlumberger talks about challenges and drivers as an HSE professional who has worked in different parts of the world and with different schlumberger business segments.
Interview with Richard Taylor
By Hans Jørn Johansen
7Safety ConferenCe 2013Task Force Zero
fewer, classification of what is a
HiPo needed improvement and of-
ten only very actions were coming
out of the HiPo investigations. This
has now improved. Last year we
recorded over 600 High Potential
incidents in Europe and Africa with
more actions and timely closure.
In addition our major High Poten-
tial incidents are now also subject
to a full review by corporate senior
management.
Another area of improvement was
Observation-Intervention reporting.
This has also improved with more
widespread participation and in-
creased focus on Line Management
participation We openly acknowl-
edge and reward those employees
that have raised good quality O/Is.”
— Are your employees able to
freely intervene in at-risk situa-
tions?
Taylor: ”It very much depends on
the openness of the operator and
on the site. Sometimes we have had
to stop the job. But there is a reluc-
tance to do so in some cases. For
a young technician or engineer who
is working with an operator with
years of experience it can be quite
tough to stand up to this client rep-
resentative.
We train our people to get used
to handle such situations through
’stop-the-job drill scenarios’ where
fx a senior management represen-
tative from our own company per-
forms an activity which should be
stopped. Through such situations
our people are trained in observ-
ing and intervening. We work hard
to improve the attitude and willing-
ness to voice safety concerns.”
— Schlumberger works for many
different operators around the
world – what challenges do you
see here?
Taylor: ”It is a of course a big chal-
lenge to work for different oper-
ators and with different contrac-
tors. But such is the nature of our
business. Due to confusion about
lock-out/tag-out procedures we
had an incident last year and again
it showed us how important it is
that you know what system you are
working to. Bridging documents
then become important – the sys-
tem itself is not so important as
long as we agree what system is
being used – a typical example is
the permit to work system.
We prefer to become involved in
planning at an early stage – some
clients are very good at this – and
it is beneficial for all parties
Schlumberger is such a diverse
company with many different busi-
ness segments. This has opened
our eyes to the fact that one size
does not necessarily fit all and that
we need to have a risk based ap-
proach to the performance of the
work.
It is important that our standards
are written for the guys out in the
field – not for the HSE profession-
als. And we need to focus on the
big picture look at the High Poten-
tial incidents early on and what
critical lessons we learn and share
– not just the slips, trips and falls.”
A major part of our job is to help develop safety culture: what you do inside the work place should be no different from what you do on the outside.
9Safety ConferenCe 2013Task Force Zero
it’s all about people and their competences
— What were the conclusions by
your workgroup that studied the
Macondo Investigation reports?
Søren Risgaard Jeppesen: ”It was
quite clear to us that we could
make improvements to the equip-
ment – and we have made some
changes to the subsea BOP. The
main observation from this inci-
dent however – as well as other
incidents – is that competent crew
is the key to safe operations. Our
main recommendation was there-
fore to implement a state-of-the-
art training environment.”
”Running an integrated training
program for the assistant driller,
the driller and the toolpusher was
the hard bit because we had to
build a completely new simulator.
The investment was more than 10
million US$. I am happy that our
management fully supported the
recommendation and made the
money available. We strongly be-
lieve that this is necessary to en-
sure that all personnel work to-
gether while you are safe on the
simulator. It allows you to make
mistakes and learn from them. And
most importantly: It is now not just
a matter of passing a test – what
matters is that you can cooperate
with your colleagues and respond
to problems as if it were real life,”
says Søren Jeppesen.
— How can service specialists –
the so-called ’third party’ contrac-
tors – who play an important role
in the well construction and opera-
tions – also become involved in the
training?
Søren Jeppesen: ”We may see the
need in the future. For the time be-
ing we concentrate on our own crew
– we also invite the client represen-
tative to participate – and some of
them think it is a brilliant idea.”
— When the Deepwater Horizon
was unable to fully cut the drill
string one would assume that
changes to the BOP was a simple
and effective solution. Yet Maersk
Drilling chooses to focus on drill-
ing crew?
Søren Jeppesen: “The BOP is a com-
plicated piece of equipment – add-
ing more gear would introduce new
complicity and more maintenance.
We want to focus on prevention
of the accident especially through
crew resource management. But we
have actually upgraded the work-
ing pressure of our subsea BOPs
which means, that we are now able
to shear 6 5/8” pipe at the tool joint
and hence our subsea BOPs can
shear this pipe at any point on the
drill string.”
— The drilling programme is
worked out by the operator of the
license. In your opinion do you
think that the drilling operator is
sufficiently involved in the planning
of drilling operations?
Jeppesen: “We have introduced and
offer to our clients a so-called ’Ser-
vice Delivery Engineer’ (SDE) – a
person with an operational back-
ground who is placed in the client’s
offices. The SDE follows the devel-
opment of the drilling programme
and has the opportunity to deal
with client questions at an early
stage. It has turned out to be a win-
win situation: plans get corrected
before you start operations, safety
is improved and often it results in
reduced operational time also.“
— What has the industry learned
from the Macondo disaster?
Søren Risgaard Jeppesen: ”Many
companies in our industry are still
of the opinion that filling in obser-
vation cards is the most import-
ant element. I think that we need
to focus a lot more on the high po-
tential-low frequency situations.
Constantly being aware that we
stay alert and keep our systems
ready to respond. We do hold hand-
rails when walking on stairs – but
looking out for weak signals and
responding to them is a better way
of preventing major disasters – to
do this we need competent and
assertive crew.”
senior Director søren risgaard Jeppesen, head of maersk Drilling QmHse department was appointed as a specialist member of a work group to make recommendations as a follow up to the Macondo Disaster in 2010.
Many companies in our industry are still of the opinion that filling in observation cards is the most important element. I think that we need to focus a lot more on the high potential-low frequency situations.
Interview with Søren Risgaard Jeppesen
By Hans Jørn Johansen
10 Safety ConferenCe 2013Task Force Zero
Tonny M. Møller: ”In the 1990es
Maersk Training developed the
bridge ressource management
training for ship crew. This was
strongly inspired by the aviation
industry who had developed their
crew ressource management.
We designed a dynamic position-
ing simulator for anchor handling
in Maersk Supply vessels working
together with a drilling rig. So it was
quite natural to also develop a rig
ressource management module.
Now we have moved it to another
level which allows you to train not
only selected parts of a rig but the
full scale integrated training where
the rig operator, the client, the
shore base and the head office are
involved to see if all play from the
same sheet. You will be asked to
cooperate in a scenario which looks
very much like the situations one
would experience in ’real life’.”
— Normally the driller gets direct
information on what goes on in a
well and then makes decisions on
the well’s condition – what are the
benefits of running an integrated
training for the whole drill crew?
Møller: ”A small problem in the
crane or in the engine room may
cascade to become a bigger threat
to the offshore installation – there-
fore it is a good idea to train not
only well control but also for exam-
ple let a generator develop a prob-
lem which leads to the rig having
problems with station keeping. This
again requires the driller and the
barge engineer to cooperate about
necessary decisions.
The simulator is really just a tool to
get people to better remember the
theory. If we can make the simulator
close to ’daily work’ it is more likely
that the participants will bring the
desired skills and behaviour back to
their work place.
The final step is when we connect
all simulators. That allows us to
combine training of crane opera-
tors, engine room operators and of
course the drill floor. You can simu-
late a situation where you not only
handle a situation on the rig but
– while training the rig crew – you
also train your shore base and your
home office. They then need to
communicate with next-of-kin, the
media and the regulators via the
crisis management module in a
full scale simulation.
It is about changing people’s be-
haviour such that the safety on
your installation is improved while
at the same time the performance
is also improved. Safety walks
hand in hand with effectiveness.
The team based training is a good
way of improving communication
and train cooperation – not only
between the driller and the tool-
pusher but also with other depart-
ments. You may also include the
client and involve him in the deci-
sion making process.”
— How can the individual benefit
from this kind of training?
Møller: ”It is quite normal for hu-
man beings to ’stick’ to solutions
that they have tried before – but
even if you have done it many times
before it may not always work. This
new training environment allows
the participant to try out new solu-
tions or – if it turns out that a solu-
tion did not give the intended re-
sult you can press ’replay’ and work
through the situation again – safely
– and with the help of your collea-
gues and the trainers. In this way
the participant gets new skills and
the desired behaviour is promoted.
It is particularly important for drill-
ers and toolpushers that they are
allowed to train when to stop the
operation and consult with a supe-
rior if certain parameters can’t be
achieved. Having done this on a
simulator gives them the confi-
dence that they are acting respon-
sibly and in accordance with the
drilling programme.”
— This type of training is devel-
oped for Maersk Drilling – what
should other operators do?
Møller: ”Maersk Training developed
the training because Maersk Drilling
asked for it. The training is open to
all interested oil and gas companies
and rig operators. We have already
got attention from some oil majors
and will of course develop and tai-
lor training as required. For the time
being it is only Maersk Drilling who
perform the integrated, team-based
training.”
— The current rules for training of
drill crew only require some of the
team members to have passed a
test – IADCs WellCap training or the
IWCF test. Do you think your new
concept will also make an impact
on the rules such that more people
on the drill crew need to become
certified?
Møller: ”There are discussions on-
going between IADC and IWCF if
the two standards could become
only one. As it stands today Well-
Cap and IWCF is the lowest com-
mon denominator. It is then up
to the industry decide if the inte-
grated team-based training should
be the standard. And if so, we are
ready to help.”
you can press replaytonny m. møller, maersk training talks about the vision for integrated, team-based training.
Interview with Tonny M. Møller
By Hans Jørn Johansen
The final step is when we connect all simulators. That allows us to combine training of crane operators, engine room operators and of course the drill floor.
11Safety ConferenCe 2013Task Force Zero
More than technical skills
— What was the background for
your decision to develop the Lead-
ership Program ?
”You need to understand the role
you have as a ’company representa-
tive’ Magnus Florvaag explains and
continues: ”As a company represen-
tative you are the client’s on-site
eyes and ears. You are also in a situ-
ation where the rig operator or the
vessel captain has the day-to-day
responsibility for safety. And at the
same time specialist suppliers are
on contract to the client – but their
services have to be delivered in
close co-operation with the rig op-
erator or the vessel owner.”
”In this ’triangle’ of responsibilities
you place the company representa-
tive. We realised that our company
representatives sometimes had a
challenge in defining their role. We
therefore developed the so-called
’ground rules’ – rules that every
DONG E&P representative should
follow”
”This was quite elevated rules –
nine areas covering a.o. planning,
execution, evaluation, leadership,
communication, trust and safety
behaviour were described in a
booklet. Each subject was broken
down in individual statements such
as ’I will ensure that…..’ This was the
easy bit. But making sure that the
rules did not just end up in a desk
drawer or in a pocket in the boiler
suit we needed to do more – make
the rules come live – live the rules,
if you like”.
Magnus Florvaag explains that
Center for Ledelse – CfL (Centre for
Management) was approached and
asked to help out. In close co-op-
eration with DONG E&P company
representatives CfL worked out a
Leadership Development Program.
The complete package is a training
course consisting of 3 modules, a
total of 11 days. Each of the mod-
ules are designed such that there
is time to practice what you have
learned and receive feed-back and
coaching from your fellow buddy,
students and the trainers. Three
courses have been held – 36 par-
ticipants have passed the training
and practice their new skills. The
Leadership Program is now a re-
quirement for all DONG E&P pers-
onel who work as CoReps on con-
tracted operations.
”As part of the programme the
students communicate with their
fellow students and with their
trainers while on the job. We have
had two trainers offshore to ob-
serve and coach our CoReps. This
has been very powerful and given
further information to improve the
program”, says Magnus Florvaag.
Magnus continues: ”Another strong
side was the mix of company rep-
resentatives from contracted ves-
sels and drilling rigs. It turned out
that the two groups had a lot in
common and new synergies were
developed by having them on the
same training course.
Another effect was that we needed
to develop a short ’management
version’ of the CoRep training for
managers onshore such that they
were able to understand and sup-
port their offshore Company Repre-
sentatives in the correct manner”.
— This conference mentions that
the Macondo disaster was a game
changer. How did the Macondo inci-
dent influence your Leadership De-
velopment Program?
Magnus Florvaag: “We had started
our work more than a year before
the Macondo disaster. Our internal
task force which studied the rec-
ommendations from the various
incident and investigation reports
confirmed that people skills, com-
petences and clear roles and re-
sponsibilities were key to success.
In that way we could continue the
development of the Leadership De-
velopment Program.”
— What are the results so far?
Magnus Florvaag: “The major
change is that the DONG E&P CoRep
focus on describing the ’what’. The
rig contractor and the specialist ser-
vice provider describe and execute
the ’how’ – as they were contracted
to do in the first place. During exe-
cution the CoRep ensures that de-
liveries are in accordance with the
agreed plan.
Success so far: Service providers
have complimented us for allowing
them to step up to their responsi-
bilities.”
technically competent people need more than ’just’ technical skills. magnus Florvaag, Drilling manager Dong e&p norway tells about the background for the tailored leadership program for non-technical skills.
Interview with Magnus Floorvaag
By Hans Jørn Johansen
12 Safety ConferenCe 2013Task Force Zero
Ramsing: “9/11 in the USA was a
turning point – also for me person-
ally. I had just relocated an IT com-
pany to the United States, when the
terrorist attack caused US Postal to
cancel our project. All of a sudden
a great part of our business was
non-existing.
But when one door closes….We be-
came part of the subsequent large-
scale material handling and logis-
tics projects where, as an example,
the American airports were to han-
dle security screening of domes-
tic luggage – something which was
not done before. In the US hun-
dreds of airports had to be re-built
under intense public and political
scrutiny. On the American scale,
material handling is rather com-
plex, requiring all participants to
play the same tune in a very safe
and coordinated manner; from
green field to 4.500 employees in
just a few years is not uncommon
for new and massively automated
distribution centres. You need
to get a large number of compa-
nies and their people to efficiently
co-operate in order to reach the
common goal. It requires continu-
ous learning, robust change man-
agement processes and strong,
personal leadership – which is what
really what I like to help develop.
Multicultural cooperation is as
much a given in complex indus-
trial installations as it is in our sur-
rounding, modern society. Many
international companies need as-
sistance in handling the corporate
and the interpersonal dilemmas
when you move or expand your or-
ganisation. You need to maintain
the company culture while blend-
ing in new people – often with dif-
ferent cultural or national back-
grounds from different parts of the
world. With projects in Europe, the
Middle East, US, India and China I’ve
seen amazing results with the right
and authentic leadership.”
— So how did your experience
match the work which you now do
for DONG E&P?
Ramsing: “What is particular to the
oil and gas industry is the unforgiv-
ing environment that require re-
al-time decision making. You can-
not just take a time out and say
’let me get back to you next week’.
When an offshore installation is in
operation you are required to bring
the right parties together and ar-
rive at the right decisions based
upon the strengths of all involved.
You need the ability to get people
to cooperate – getting the process
to continue and at the same time
preventing that a conflict develops
– which is especially difficult when
you do not have the ’formal’ author-
ity but have to lead and motivate
resources reporting to other enti-
ties and organisations.
We help the CoRep participants
to find their own strengths and ex-
pression – which may pose a par-
ticular challenge when you work
in a language that is not your na-
tive tongue. Therefore the train-
ing starts on day one with facili-
tated role-play and finishes off in
an extensive real-life simulation.
In the final full-day exercise all par-
ticipants are confronted by profes-
sional business actors who recreate
the participant’s own challenges in
much the same way as live flames
in a fire drill. Through this dry run of
truly difficult situations, the partici-
pants are far more likely to be able
to also handle the tough leadership
challenges in real life.
The participants are trained in
non-confrontational, interpersonal
leadership while simultaneously
avoiding silently accepting at-risk
behaviour. They must step into a
situation and interact without caus-
ing an unnecessary escalation and/
or decision delay. One of the situ-
ations that is role played involves
a sizable roustabout, who acts ag-
gressively – the participants must
handle the intervention and realise
how to overcome the tense and un-
pleasant situation – including look-
ing out for possibilities and allow-
ing others to state their opinion.
Also the training material is differ-
ent. Together with DONG E&P we
have refined the CoRep’s essen-
tial Ground Rules and selected the
matching leadership tools into a
unique deck of playing cards. We
use the different cards for specific
perspectives: Spades cover DONG
E&P requirements, hearts hold the
leadership behaviour while clubs
covers the team and diamonds
are the mental prism and mindset
through which the entire ground
rule must be approached. Addi-
tional information about each card
is available on the participant’s
iPad, which also holds the course’s
portfolio of apps for individual
learning, information sharing and
collaboration.
We offer several different yet mu-
tually supportive leadership tech-
niques for the specific challenges
found on an offshore installation.
The intention and achieved objec-
tive is that the willing participant
understands how to use the differ-
ent techniques for different needs.
A few examples: How to take time
to lead and how to stay observant
within the complex environment.
How to prevent conflicts and how
to give and receive feed-back, how
to use different coaching and ques-
tioning skills, how to intervene,
how to show willingness to reach
decisions and how to allow others
to speak their mind, emphatically:
how to make, motivate, communi-
cate and keep robust agreements
and much more.
Even personnel with long offshore
industry experience compliment
the program and develop new skills
– which is another reason why I am
really proud of being part of this
truly meaningful journey towards
stronger leadership and greater
safety.”
Real time decision makingulrik ramsing, Chief advisor, Cfl (Centre for leadership) with a background from material handling in large, complex organisations was asked to help offshore managers develop their interpersonal and non-technical skills
Interview with Ulrik Ramsing
By Hans Jørn Johansen
13Safety ConferenCe 2013Task Force Zero
John L. Thorogood: ”My journey
into human factors and human er-
ror started in 2001: I was involved
in a deepwater operation within
the Faroe Islands. We made a cou-
ple of decisions which in hindsight
were not as good as they could
have been. It gave me an under-
standing that our decision making
skills could be improved. Together
with Aberdeen University we devel-
oped a programme for non-tech-
nical skills for drilling people in-
volved in decision making. The
programme was deployed within
the company and we actually prac-
tised some of these decision mak-
ing skills when we went back to the
Faroe Islands to abandon the well
the following year.
Our industry had three serious
incidents during a period of only
9 months. In 2009 there was the
Montara blow out, on Christmas
Eve that same year there was an-
other near miss in the North Sea
and then finally the Macondo
disaster in 2010. All these three
incidents – and in particular the
Macondo – were officially explained
as failure of equipment, manage-
ment process or lack of compe-
tence of personel. But an alterna-
tive reading of the investigation
reports suggests less of a problem
with the equipment and proce-
dures and more closely a problem
related to human factors and or-
ganisational questions.
Since then, I have spent a lot of
time studying the relevant litera-
ture on human error, psychology
and decision-making. I came across
the concept of ’high reliability or-
ganisations’. I have then tried to
hold a mirror up to the industry,
asking ’can you recognise the oil
and gas industry – and in particu-
lar the drilling industry – in this pic-
ture?’ Reluctantly, at present, the
answer is: ’no’.
To start moving the drilling in-
dustry to a ’high reliability state’
there are some important things
you need to do; instil a sense of
”chronic unease”, develop a preoc-
cupation with failure, have a reluc-
tance to simplify, be sensitive to
operations, ensure the organisa-
tion is resilient and have a defer-
ence to expertise’. It is these ideas
that I have been presenting at drill-
ing conferences lately.
To be more disciplined when you
drill wells, you need a much more
coherent framework around the
way you control the work. As far as I
know that framework has not been
written down yet. It does exist in
peoples’ minds but it has not been
formally documented. Because it
is not written down you can’t put
people into a classroom and teach
them a doctrine. Then you can’t as-
sess them against a standard and
assess their expected behaviours
and non-technical skills as you can
in aviation. Until we do what avi-
ation does and start to recognise
that the cognitive bit and the psy-
chocological bit have caused the
accidents we are not going to bene-
fit from our ’Macondo moment’.
The aviation industry had its ’Tener-
ife moment’ in 1977, when two
jumbo jets collided and exploded
on the runway in Tenerife killing
583 people. The aviation industry
then started their journey on crew
ressource management which re-
ally took off in the 1980es. Marine
and nuclear have capitalised on it
and belatedly the oil and gas indus-
try has slowly started doing some-
thing similar.”
— Do you think that oil and gas op-
erators seriously consider to move
their organisations to become high
reliability type organisations?
Thorogood: ”I still have not heard
an oil and gas VP of Drilling stand-
ing up and asking explicitly: ’we are
going to be a high reliability organi-
sation, tell me, what does it take?’
There are however some good
things starting – the starting point
in a high reliability journey is the
’chronic unease’ and that has slowly
begun to grow in a few companies.
One company has started training
human factors in well control as
well as training their chain of com-
mand which is being independently
assessed by their national petro-
leum institute.
In the Netherlands a well control
school is training human factors,
Maersk Training has started the in-
tegrated training of drilling crew
and also others train human fac-
tors in well control and non-tech-
nical skills. But as a whole it would
appear that only bits of the jig saw
puzzle are beginning to come to-
gether – in this instance training
and non-technical skills. We do not
see the end state of the high reli-
ability organisation – yet.
The concept of major accident risk
has been taken onboard at an intel-
lectual level and some companies
have re-written their technical stan-
dards or standard operations pro-
cedures to give them more focus
on major accident risk.
It is no problem writing the perfect
drilling programme which is risk
assessed and extensively peer re-
viewed, complies with all known
standards and has been well exam-
ined in extreme detail. The danger
lies in the gap between this perfect
drilling programme and the man
on the brake. It is in this gap, where
well-meaning improvisions occur
that all too easily trigger the spiral
into failure.
Good leaders make sure that their
men are safe at the coal face. In the
old days good generals went to the
front and met their men, made sure
that the kit was checked and mod-
ified if needed. They made sure it
was working as intended. The same
with the US nuclear submarines
which have never had a reactor in-
cident at sea. This was due to their
original commander, Admiral Hy-
man G. Rickover, who always sailed
on the first voyage of every nuclear
powered vessel. They also had ex-
acting standards of personal disci-
pline and ethics. The leaders were
intimately aware of what was hap-
pening at the coal face and made
sure their men were safe. They had
this sense of chronic unease which
is a pre-requisite for a high reliabil-
ity organisation.
Few top managers really show this
sense of chronic unease today. So
I believe that we still have a way to
go to understand and agree what
it takes to become a high reliability
industry.”
only bits of the puzzleDr. John l. thorogood, independant drilling engineering advisor discusses how far the industry has come towards a ’high reliability’ type organisation.
Interview with John L. Thorogood
By Hans Jørn Johansen
14 Safety ConferenCe 2013Task Force Zero
people: the solution – not the problem
Sidney Dekker: “For the past 20
years I have studied why things go
wrong, patients dying of an over-
dose, an airliner crashes and similar
accidents. We used to believe that
things go wrong because some-
body makes an error – or some-
thing breaks.
Today, actually since the mid
1980es, we understand that little
things inside the organization are
wrong, have been wrong for a long
time. These are things related to
procedures, culture, design of
equipment, supervision and work
practices. And all these things can
combine to create the potential for
an accident.
Our understanding has now shifted
‘upstream’ – to the system sur-
rounding the people, who do the
work. We now expect organizations
to have vast systems in place. We
are supposed to look for the little
‘holes’ in the system – and fix them
– before they can combine and
create trouble.
The risk becomes that in pursuit of
the good safety culture we invest
in safety work that focuses on the
easy stuff, the higher frequency but
lower consequence events like peo-
ple not wearing safety glasses, hav-
ing their coffee in a cup without a
lid on it, not holding the handrails
when walking on the stairs. The
fiction is that we have a safety cul-
ture because we have low counts
on negative events as a statement
of our safety processes as a whole.
We used to know that we were safe
if we had competent managers and
people at the sharp end knowing
what they were doing.
How do we know whether we are
safe today? We have the paper-
work to show it! And then we blow
stuff up.
How did we end up here? We still
see people as the problem!
We believe that as long as we have
great systems in place and that
people conform and stay within tbe
narrow bandwidth that we have as-
signed to them – then things will
be ok.
But this is an illusion – and it is in-
creasingly a dead end. People are
not the problem that we should
control. People are the solution –
that we should harness!
I believe that things go wrong be-
cause they usually go right.
What does a successful, dynamic
organization need to do in ressou-
rce constrained world ? They make
sure they optimise locally, they hunt
for local efficiencies. But the prob-
lem may be that such gains may be
borrowed from other parts of the
system through a series of inter-de-
pendencies that they don’t know
about. Successful organizations will
make small steps to make produc-
tivity gains but by doing so they
borrow against their safety margins
in ways that they do not measure.
These are normal things for succes-
ful organisations to do. So if you are
a succesful organization, make sure
you have people onboard who are
capable of questioning and critiqu-
ing the way by which you achieve
that success. Make sure you have a
diversity of view points. And if you
really want to prevent failure stop
looking for it. Instead start looking
for why things go right. Start look-
ing for what makes your organiza-
tion successful!”
— It would seem that you are
talking about an advanced safety
culture in which information freely
flows and its personnel are encour-
aged to criticize the way things are
done – how can that be efficient?
Dekker: ”Yeah, that’s a nice way to
put it. Well, I wouldn’t necessarily
say that people need to ‘criticize’
the way things are done, but rather
be inquisitive about it. And yes, that
can be hugely efficient! There are
many cases in which workers have
come up with better, faster, cheaper
and safer ways to do something or
to protect someone from harm in
doing a particular task – there is
a lot of expertise and wisdom out
there that is ready to be tapped.
Don’t see it is as criticism. See it as
valuable intelligence for your busi-
ness for which you are paying al-
ready anyway, since these people
are either your contractor or on
your payroll.”
— Do you see such ’advanced’
organizations in the oil and gas
industry today?
Dekker: ”No, not many. There may
be bits and pieces scattered
throug h out some of them, but a co-
herent, mature approach to safety
is not easy to find. Most oil and gas
companies are still wedded to the
idea that an absence of negatives
means better safety, and that com-
pliance with existing rules and pro-
cedures leads to ‘Safety Nirvana’.”
— There are many ’humans’ in-
volved in the oil and gas industry
today. They often come with dif-
ferent organisational and cultural
backgrounds and have to blend
in and perform in a short span of
time. What do you recommend
that the oil and gas industry should
do to ensure that people differ-
ences are not in the way of safe
operations?
Dekker: ”Perhaps getting them
to ‘blend in’ is the wrong starting
point. For sure, a kind of buddy pro-
gram that helps newcomers in the
beginning and avoids them from
getting in trouble is a very smart
idea, but that does not necessarily
mean that they should blend in, in
the sense of becoming similar and
invisible. Celebrate the diversity of
opinions, backgrounds and experi-
ences that these people bring. Cre-
ate enough room for them to share
their stories and ideas – in your in-
cident reporting systems, your tool-
box meetings, job starts.
In a complex, changing world, com-
pliance and conformity can actu-
ally kill or at least keep dying strat-
egies in place. Indeed, in a complex,
changing world, diversity, novelty
and adaptation can sometimes
save the day.”
sidney Dekker, professor, griffith university, australia discusses what constitutes a successful organization in today’s world.
Interview with Sidney Dekker
By Hans Jørn Johansen