Incident Investigation and Analysis for Exploration and Production Operations

Summary

Incident investigation and analysis in Shell E&P operations is part of performance monitoring in health, safety, and environment (HSE) management systems. The focus is on identifying underlying causes. A step-wise approach is given from immediate response through determining the level of investigation, coverage of investigation aspects, analysis, recording, and follow-up. The means to analyze incidents by application of the Tripod system, which is directed toward understanding underlying causes of incidents, are reviewed.

Introduction

HSE performance monitoring has been, and in some areas still is, based on reactive statistical indicators that can identify at best only that past decisions have resulted in unsatisfactory conditions or work climates. To understand how to improve HSE performance and which managerial aspects have to be changed, it is essential to have a meaningful system for assessing the underlying causes of incidents. The system needs to address not only accidents, where there is a measurable impact resulting from failures, but also situations where no adverse consequences occurred but the potential for loss or damage existed. To make a lasting effect on incident reduction requires a timely, balanced, and consistent approach to "blame-free" investigation of all incidents, identification of underlying factors, and correction of systemic causes.

This paper addresses incident investigation and analysis as part of a structured approach to performance monitoring in HSE management systems. Incident investigation forms an essential part of the feedback loop in an ISO 9000 application to company management and is consistent with recent guidance issued by the U.K. Health & Safety Executive. In addition, we discuss the need to develop and use proactive monitoring systems and indicators.

In 1993, Shell IntI. Petroleum Mij. produced a revised guidance document for Shell E&P operating companies. This paper addresses the changing approach to incident investigation in the E&P industry. The terms "accident" and "incident" have specific definitions in the context of this paper (see the Appendix).