Sequential Failures in Incident Investigation Process Hindering Prevention of Incidents
- Muhammad Tayab (ADNOC Upstream) | Suhail Valappil (ADNOC Onshore) | Vishal Shah (ADNOC Sour Gas) | Takhir Azhibekov (ADNOC GHSE) | Michel Zeinati (ADNOC GHSE) | Mohammed Al Ameri (ADNOC GHSE) | Fatima Al-Hameli (ADNOC Refining)
- Document ID
- Society of Petroleum Engineers
- Abu Dhabi International Petroleum Exhibition & Conference, 11-14 November, Abu Dhabi, UAE
- Publication Date
- Document Type
- Conference Paper
- 2019. Society of Petroleum Engineers
- Root Causes, Errors & Mistakes, Incident Prevention, Corrective Action, Human Factors
- 4 in the last 30 days
- 85 since 2007
- Show more detail
- View rights & permissions
|SPE Member Price:||USD 5.00|
|SPE Non-Member Price:||USD 28.00|
Over the last 10 years, Oil & Gas operations have come under tremendous pressures due to increasing production demands and economic conditions, demanding higher performance and venturing into technically challenging operating conditions. Operating with aging facilities in harsh environmental conditions and higher crew turnaround, have resulted in higher number of serious incidents. Prevention of incidents remains high on the agenda of oil & gas companies and focus is placed on incident investigations to identify root causes of incidents and development of corrective actions. However, repetition of incidents with similar findings and causes have been observed, raising concerns if right root causes were identified and focused corrective actions were identified and/or implemented.
An extended analysis of over one thousand (1000) incidents was conducted to assess degree of repetition of causes and regrouping of causes to assess linkage of human factors with organizational behaviours. It was found that 31% of incidents were triggered by human errors & mistakes whilst 27% were attributed to violations. All violations were deemed as intentional & routine and further investigation was not undertaken. Management Supervion & Employees Leadership was identified a leading root cause category of incidents and this category contributed 20% of incidents followed by Work Planning (18%) and behaviour (12%). 55 % of incidents were caused by human factors and hauman factors were triggered by errors and mistakes rather than violations.
Often efforts are exerted to to influence individual's behaviour however human attitude (cognitive, emotional and commitment) is overlooked as linkage between attitude change leading to behavior change, not fully explored. However, linkage from behavior change to attitude change is much stronger. If worker consciously change their behavior, it requires re adjustment of associated attitudes to align with the new behavior. Positive reinforcement is an effective tool to influence individual's behaviour. If discipline and punishment are used to discourage unsafe behavior, the intended results are not achieved (e.g., incident or near miss are not reported for fear of sanctions).
Assessment of non-compliant behaviors (Violations, mistakes and errors) & conditions and factors influencing such behaviors are often not evaluated and focused action plans to address abilities and motivations with due consideration to isolated or systemic conditions are instrumental in preventing incicidents.
|File Size||912 KB||Number of Pages||13|
Gordon P. E. The contribution of human factors to accidents in the offshore oil industry, Reliability engineering system safety 61, (1998), pp 95–108, Elsevier, [Essex], England. Gordon, R. P. E., Flin, R. H., Meanrns, K., Fleming, M. T. Assessing the human factors causes of accident in offshore oil industry. International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production. 1996, Vol. 2, pp. 635-644. Linda J. Bellamy The influence of human factors science on safety in the offshore industry, Journal of Loss Prevention in the Process Industries, volume 7, Issue 4, 1994, Pages 370-375
Health and Safety Executive. Inspectors Toolkit: Human Factors in the Management of Major Accident Hazards. 2005. http://www.hse.gov.uk/humanfactors/topics/toolkitintro.pdf [Accessed on 20st November, 2009]
HSE publication: Human Factors and the Law. Available on the HSE website: http://www.hse.gov.uk/humanfactors/law.htm [Accessed on 21st October, 2009]
Hudson, P. T.W., Groeneweg, J., Reason, J. T., Wagenaar, W. A., van de Meeren, R. J.W. and Visser, J. P., Application of TRIPOD to measure latent errors in North Sea gas platforms: Validity of Failure State Profiles. In Proceedings from the First International Conference on Health, Safety and Environment. The Hague, the Netherlands, Society of Petroleum Engineers Texas, November, 1991.