Home / 2015 / Amid cost constraints, industry must guard against drift into failure
The industry is really moving ahead on human factors, which affects everything. IADC’s initiative to hold a conference on this (21-22 October in Galveston, Texas)...

Amid cost constraints, industry must guard against drift into failure

Maintaining sense of chronic unease is critical as industry juggles safety, production demands

By Joanne Liou, Associate Editor

DSC_6977-1.jpgDr John Thorogood is Senior Technical Advisor for Drilling Global Consultant.

The industry has implemented numerous changes in safety practices and requirements since Macondo. What more can be learned from that incident?

The industry is really moving ahead on human factors, which affects everything. IADC’s initiative to hold a conference on this (21-22 October in Galveston, Texas) is absolutely first class.

I highly recommend “Engineering a Safer World” by Nancy Leveson. Ms Leveson is Professor of Aeronautics and Astronautics and Engineering Systems at MIT. She takes a systems approach to safety by analyzing the barriers and the controls that are placed on not just technical systems and computer-based systems but also on human systems. She cites examples where different industries have used the systems approach to look at various problems – in the medical industry where pharmaceutical companies failed to withdraw drugs from the market or NASA reorganizations after the Columbia disaster. They used the systems approach as a tool to do a gap analysis. The question I would like to pose is, if the drilling industry were to take a systems view of all the technical, procedural, regulatory, technological and legal controls over our operations, are there any more gaps?

We have to maintain a sense of chronic unease and carry on asking questions. If we stop asking questions, we’ll drift back into failure.

Chronic unease is key component of high-reliability organizations. How can the industry instill a sense of chronic unease into its organizations?

It’s difficult to institutionalize chronic unease. Apart from being wary about the physical environment around us, being uneasy means understanding psychological pressures behind things like groupthink and risk aversion. Decision makers from the rig upward have to understand how powerful these behaviors are.

Human factors and crew resource management is not just about the six non-technical skills – teamwork, communication, decision making, situation awareness, personal resources and leadership. I would like to see more understanding of other aspects, such as threat and error management. Furthermore, people should be able to describe the basic characteristics of risk aversion and talk about cases from their own operations and their own experience. Chronic unease has to be institutionalized in the way we work, and that has to be underpinned by a deep understanding of the psychology.

One of the things we rarely ask ourselves is how can the errors, mistakes or violations that we make cause other problems. We’ve found that tools we use like toolbox talks and the use of risk registers have partially institutionalized chronic unease but in a haphazard way. If we think about threat and error management as an approach, then we should be training our leaders to ask questions about risk, about what could go wrong. We must train our supervisors to understand the traps that our brains set for us. We have to start thinking about the human errors and shortcuts that we might see on the rig and ask ourselves whether it could happen to us.

These six non-technical skills are at the core of human factors, but other aspects such as threat and error management also must be understood before chronic unease can be institutionalized in the way the industry works.

These six non-technical skills are at the core of human factors, but other aspects such as threat and error management also must be understood before chronic unease can be institutionalized in the way the industry works.

In the September/October 2014 issue of DC, you stated that the drilling industry is in its infancy when it comes to human factors. What are the next steps for industry to better understand and utilize human factors?

We have to continue talking about it so that people accept it as the new normal and it isn’t seen as strange, threatening or dangerous. We have to bring human factors alive by continuing to promote industry initiatives through conferences, articles and meetings. We have to make human factors part of everyday life on our rigs and in the chain of command.

We also have to look at human factors in incident investigations. When an incident occurs, instead of saying the crew was incompetent, negligent or just plain stupid, we have to consider that they were sensible people and then think very hard about what really made them do what they did. What was it in the situation as they saw it that prompted their actions?

What critical challenges do you see for the industry as oil prices drop?

In a cost-constrained period, we risk repeating mistakes of the past. We’re going to fire good people, and we’re going to decrease the capacity to run our industry safely because we’re going to end up juggling safety against production. Even with the lessons of the last few years, human nature will end up making compromises.

The industry must remain vigilant, maintain that sense of chronic unease and continue asking questions. It is a fact of life that the industry responds to economics. It is vital that we look at history to continuously remind ourselves of how easily organizations can drift into failure. We have to guard against this drift.

What are the industry’s strengths and weaknesses when facing periods of cost constraint?

This is a free-market economy. At a high level, companies will be driven by the stock market. Shareholders understand the license to operate, but they don’t understand the cost of process safety. However, we have a very strong technical industry. The people who join this industry are real characters – larger than life. Having these talented and committed people is our strength.

An interesting paradox is that we attract strong individuals into drilling, but then we tie them up with detailed procedures that allow little scope for innovation. The traditional safety response to incidents is to introduce more training, more testing and stricter procedures. However, when things go wrong, you rely on these people, their skills and their flashes of genius to sort the problem out. This is the paradox we have to address, and academic research is just starting to look at this contradiction.

Instead of looking at why things go wrong, researchers are looking at why, for 99.999% of the time things go right but just occasionally something unexpected happens. Rather than regard incidents as unique events, perhaps they are cases where, in the normal variability of our work, we’ve strayed too far from the mean. Because we continually focus on errors, we rarely look at the vast majority of times when things go right and try to understand why they went right. If you audit an operation that went well, you’ll probably find a violation of procedures and maybe evidence of less-than-complete competence – things you would immediately pick out when you have an incident. In the end, we rely on people – the man or woman in the loop who can bridge the gap between what the program says and what the local conditions “in the moment” actually demand. We may have gone as far as we can with the enforcement of procedural compliance. We have to think about safety differently.

Leadership, discipline and sense-making cultivate high-reliability organizations.

Leadership, discipline and sense-making cultivate high-reliability organizations.

Should the drilling industry be regulated on an international level?

The aviation industry has an international regulator that’s part of the United Nations. It oversees national regulators, creates and enforces international standards and conducts audits. Significant changes have taken place in the UK, for example, stemming from an audit by the International Civil Aviation Organization (ICAO). The oil industry doesn’t have an equivalent to create and enforce such standards.

The glimmer of hope is what IADC’s leaders Stephen Colville (President/CEO) and Taf Powell (Executive VP – Policy, Government and Regulatory Affairs) have been suggesting – facilitate a conversation among IADC, IOGP and the International Regulators Forum. In the absence of an international regulator, the best hope we have is a voluntary agreement among the contractors’ organization, the operators’ organization and the international regulators group. It would be self-regulation rather than an international treaty obligation, but the hope is that something can be created that will work almost as well as the ICAO. In terms of process safety and improving this industry’s reputation, I think this is the single most important initiative for 2015.

In the past decade, real-time centers to support drilling and well operations have become more prevalent. What have been the lessons learned?

We knew that real-time operations centers provide huge benefits for large-scale operators, but it was more of a challenge to access those benefits for smaller operators working in areas where communication, infrastructure and security are not the best. In an SPE paper I co-authored with OMV (IADC/SPE 168007 presented at the 2014 IADC/SPE Drilling Conference), we addressed how to set up the infrastructure of communications, network and software tools and then how to position the organization to act as a virtual real-time operation center.

The key message was the importance of engaging people at the rigsite, for which a clear and simple communications protocol was essential. We looked at it in relation to a field trial in Tunisia. Richard Kucs of OMV is co-authoring a paper for the 2015 SPE/IADC Drilling Conference that focuses on the next stage of that story. There are exciting developments happening around the integration of various technical tools from different companies into consistent displays. Rather than having different displays, you can have higher-level data presentations driven by these different tools.

Another important development involves process safety, where we’re looking at capturing process safety-related metrics. Do we want to burden our people with more reporting, or are there smarter ways of capturing key process safety parameters from the daily reporting system? With careful design, a morning reporting system should be capable of logging deviations from the drilling program without imposing a burden on the people at the rig.

These deviations may be leading indicators of possible process safety issues, such as a leak-off test that didn’t come out at the right number, a close approach between two wells, a casing pressure test that failed, a deviation from a technical standard or a management of change event – these are things that can get logged in a daily drilling reporting system. When you design the database, you can make sure that you can query these things so that, over time, you can monitor trends and take action accordingly.

Click here for information about the 2015 IADC Human Factors Conference.

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