human factors in barrier management - …...ptw review/ ifs technical preventive maintenance system...

Human Factors in Barrier Management

05 May 2017, Søren Claudius Hansen & Lars Bagger Hviid

Themes

1 Barrier Management in Maersk Drilling – principles and components

2 Establishing the Barriers Elements in Drilling Operations

3 Thinking Human Factors into Barrier Management

4 Self-verification and Activity Assurance – Leadership and Culture

5 HF in Well Control Situations

6 Case – does this actually work?

Building blocks to developing our BMS

Hazid & MAH analysis (BowTie

analysis)

Technical barriers

elements

Operational barriers

elements

Organizational barrier elements

BMS

✓ Performance standards

✓ Safety functions✓ SECE

✓ Key safety critical operational activities

✓ Supporting documentation

✓ Key role identification✓ Key capabilities✓ Competency

assessment process

Safety Critical (sub)functions to ensure well control

Mud system

Casing/ Cement

HP RiserTop Drive/

Draw works

Kick detection system

BOP incl. Control

Choke and Kill

system

Diverter system

Mud gas separator

Barrier ManagementEquipment, procedures and competent personnel in place to ensure the barrier integrity

Title of presentation | page 4

Control HC flowIdentify and control HC kickPrevent influx

TECHNICAL BARRIER ELEMENTS

ORGANISATIONAL BARRIER

ELEMENTS

OPERATIONAL BARRIER

ELEMENTS

1. Key Activities

2. Required information

(Input, Manuals, Sup. Docs etc.)

1. Roles

2. Required competency

3. Assurance Activity/ Comp. assessment

Barrier Element

Assurance ActivityVerification Criteria (What does good look

like)

Monitor

Framework for maintaining the barriers on the rigs(Developed to be tested on Maersk Invincible)

page 5

OrganizationalOn the Job Training (OJT)

Operational

Process self-verification

Work Execution Process

Drills and scenario

training (well control)

Audits

100% compliance. w. drills

80% Overall compliance w. OJT training matrix.

100% compliance. w. WEP

100% compliance. w. self-verification matrix

PoBCO

SIRIUS

Self verification matrix/ Synergi

PTW review/ IFS

Technical Preventive Maintenance System100% compliance w.

performance standards

Technical Barrier Status Workbench

(IFS)

Safe

ty C

ritical Function

Organizational barriers

Technical barriers

Operational barriers

CAP

PobCO Certifications

Minimum hiring requirements

Self Verification & Activity Assurance

Management system

Work Execution Process

After Action Review

Developing a culture where people keep on being developed to fulfil their roles in the safety critical activities

✓ Control performance shaping factors✓ Increase situational awareness✓ Detect/ Comprehend/ Project

Creating the right environment for the people to operate safely

✓ focusing on Human Machine Interactions

✓ HF considerations in the design phase of our rigs

Designing clear procedures with strong links between equipment and operations

✓ Control performance shaping factors ✓ Pattern recognition✓ Trending and thresholds✓ Situational awareness

ISO11064 and NORSOK 002

Preventive maintenance

SECE

Performance standards

Drills and Training

DWOP

Enablers to strengthen the barrier elements and interlink them

Self Verification ProcessAssurance activity in place

page 7

To reach Zero Incidents

• Self-verification is one of the best tools to drive active visible leadership, management accountability and procedural compliance

Testing and ensuring that the right barriers are in place

• Self-verification is a management audit & inspection tool for specific operations

• Self-verification is an coaching and learning process

Self-verification follows a simple flow• Practical and easy to embed in daily operations• Follows our PDSA approach and philosophy

PlanningConductin

gFollow-up

Activity Assurance

• SV activities as per weekly matrix

• Evaluate current operations for high criticality and safety risks

• Agree which jobs to SV during work permit meeting

• Announce SV to be conducted to crew (pre-tour)

• Prepare (review procedures and OCL)

• Conduct SV at worksite with crew

• Provide feedback to verified crew

• Enter SV into Synergi

• Ensure non-conformance actions are closed

• Discuss SVs conducted during morning call

• Monitor trends and compliance with matrix schedule

• Verify and participate during rig visits

OIM and Heads of Departments Rig Manager and HSE advisor

HOW:Visual leadership – Heads of Departments and OIMs on the worksite

10 processes to be self-verified in 2017• Shift handover• Well control• Work with pressure• Toolbox Talk• Work Execution Process

Processes are chosen based on criticality as well as incidents and safety issues seen• 8 of the processes are specific• 2 are non-specific and can be applied on all jobs (TBT & Work

Execution Process)

• After initial implementation when our own crew are comfortable with SV, we will review if SV should be expanded in scope, for instance by including verification of service companies

• Red/Restricted zones• Lifting operations• Pipe handling• Fluid and Bulk transfer• Marine barriers (floaters only)

Human Factors in Well Control

WHY:

• Well control often has multiple complex interfaces

• Frequently not properly understood

• Often caused or exacerbated by people making mistakes under pressure

• Decisions made under pressure often determines the outcome

WHAT and HOW:

• Setting up the individual and the group for success

• Utilizing the strengths and mitigating the weaknesses

• Performance shaping factors and Dynamics associated with cognitive/social biases

Endsley’s model for Situational Awareness

In well control terms HF..

Creating circumstances for:

• Detecting “something is wrong in the well”

• Comprehension

• forward projection – and foundation for correct forward decision making

• good planning - what does “good” look like? And what is outside safety envelope?

• Disciplined execution – staying inside the safety envelope

• Continuous evaluation and trending against “what “good” looks like”

How do we do this..?

• Team Based Well Control Training

• Detection skills and pattern recognition

• Non-technical skills (leadership, communication, team work, decision making- and planning strategies, handling stress and fatigue)

• Application of technical skills for well control

• Performance enhancement training – new start-ups

• New team integration and Non-technical skills

• Offshore Simulators Exercises

• Detection, pattern recognition and application of technical skills (+some non-technical skills)

Offshore simulator training offered quarterly to key personnel on our rigs

page 14

Training consist of two elements:

A theoretical questionnaire;Provides the opportunity to practice e.g. calculations and theoretical knowledge around well control

A practical scenario training on simulator; Provides the opportunity to practice detection of and response to well control situations

1

2

After completion of exercises a feedback report will be created; Provides knowledge about areas that can be improved and is an unique opportunity to discuss personal development plans

IWCF well

control

Team based well control

IWCF well

control

Team based well control

• Maersk Drilling Management Team priority:It is important to develop our competencies to improve our high standard in safe well control management – even more so in tough times.

• Focus on personal development: Crew members have a learning tool to continuously maintain and improve well control competencies.

• Offers onboard training: The training is flexible and easily accessible offshore. This fosters a “learning culture” and gives the opportunity of discussion with peers and supervisors on board. – a knowledge to be used for development and promotions.

Why is the training offered?

• Create awareness of skill level: Supervisors will have a better understanding of the skill level on board.

• Key element in Surface Well Control Manual:The training is a key element in assurance and is in compliance with the new Well Control Manual.

On board simulation

On board simulation

On board simulation

On board simulation

• Main objective - remain within safety envelope at all times

• Well control process designed to:

• Mitigate plans “drifting” in critical situations

• Help combat mental traps and human errors

• Facilitate non-technical skills and help maintain correct decision making

• Facilitate good team resource use

• Facilitate better communication (onboard and rig/shore)

• Increase ability to identify deviations from expected outcomes or trends

• Must be rig friendly and ensure buy in of all – including clients and other third parties

Human Factor focus in WCM

Well closed in

Instruct driller to contact WCT if SICP approaches MAASP

Instruct Driller and Mud loggers to

report anomalies

Ensure no other activity in active

system

Consider withdrawing other

work permits

Gather logs and other relevant

information

Call HQ duty phone

Call for meeting:· Company man· Mud Engineer· OIM· DSL· Drilling Engineer· Geologist· Mud loggers· Other relevant personnel

Study and review situation

Call town (both local and HQ)

Unconventional includes:· HPHT· String not on bottom· MPD· Underground blowout· Plugged string /

washout· Black out· Adverse weather· etc.

Confirm the following:· BOP holding pressure· Line up correct to monitor

pressures · Driller monitoring correct

details· Trip tank circulating over

well· Content of choke & kill

lines (if applicable)

Conventional well control

Handle on board Prepare all details for discussion

N

Well Control Management Flowchart 1

Step 1

Step 2

Step 3

Step 4

Step 5

Action Who Comments

Shut in Driller

Confirm BOP holding pressure and no leaks

Driller / Assistant Driller / Mud logger

Confirm: · valve status· pit status· All

instrumentation working correctly

· Closed loop communication

· Driller to document

· Mud logger to document

Each rig to generate own detailed checklist

Confirm line up correct and pressures

being monitored Driller

Confirm Trip Tank circulating over well

Driller

Confirm contents of choke & kill lines (if

applicable)Driller

Step 1 Establish baselines, confirm shut-in & verify pressures and volumes

Focus area Strategy / Plan

Does it work?

Summary

• We have developed an operational barrier management framework for our rigs

• Human factors are considered for each elements and for interlinking the elements

• For well control human factors are reflected in the procedures and in the training

• Self verification process support management in driving the safety culture

• It is proven to work in real life.

Backup slides

Title of presentation | page 24

Act Plan

Do Study

MAH

Technical Barrier Elements

Operational Barrier Elements

Organisational Barrier Elements

Human factors

Do Study

Act Plan

page 26

MAH

Operational Checklist to support management executing on the strategy

page 27

Decision flow chart for BM page 29

Planned Activity

Follow normal Work Execution Procedures

Consult Tech Barrier Status Workbench

(IFS)

Consult Qualification

matrix (PoBCO)

Do we have the required competency for the job

Discuss the details of the activity and evaluate the hazard(s) involved and risk of

Hydrocarbon release

Loss of primary well control

Gas release

Fire or Explosion

Structural damage

Helicopter crash

Dropped objects

Risk of causing a

major accident event

Any relevant Deviation Permits or

Active corrective WOs

Do we have procedures/

OCLs in place the activity

Check procedures and checklist in Sirius

Is it safety critical

Have the barrier integrity

been compromised

Make risk assessment on

impact of barrier integrity

Ensure mitigation is in place

Produce the necessary procedures

to ensure safe execution

Follow steps in OCL for verification of Barrier Function

Ensure that task leader is familiar with relevant performance

requirements

Y

?

Y

Y

Y Y YN

N

N N N

N

Ensure mitigation is in place

WHYWHAT

ANDHOW

– SELF-VERIFICATION?

A standard matrix based on unit type defines minimum frequency of SV • Ensures all processes are verified on a regular basis • Allows flexibility based on current operations and specific issues observed• Matrixes for floaters, jack-ups with and without Safety Officers and stacked

units

* matrix for floaters

OCLRole

Shift Handover

Well control

Work with pressure

TBTRed/

Restricted zones

Work Exe. Process

Lifting OpsPipe

handlingMarine

Barriers*Fluid/Bulk Transfer

Total per position

% per position

OIMbi-weekly

Even weeks

weekly weekly weekly 3,5 11%

DSL weekly weeklybi-weekly

Even weeks

bi-weeklyUneven weeks

bi-weeklyUneven weeks

3,5 11%

TP weeklybi-weeklyUneven weeks

weekly weekly weekly weeklybi-weekly

Even weeks

6 19%

TSL weekly weekly weekly 3 10%

Maint. Eng.

weekly weekly weekly 3 10%

MSL/ AMSL

weekly weekly weekly weekly weekly 5 16%

SO 3x weekly weekly 3x weekly 7 23%

Total on weekly basis

3 2 1 8,5 2 7,5 2 1 1 3 31 100%

% split 10% 6% 3% 27% 6% 24% 6% 3% 3% 10% 100%

1. Make the well safe & establish shut in parameters

2. Assemble Well Control Team and gather information about the well (Well control Pull Out Pack)

3. Ensure everything is covered & conclusions are not drawn too early

4. Challenge statements and theories (devils advocate)

5. Agree on kill method

6. Establish parameters and agree on ”what does good look like” during the well kill

7. Communicate to all involved – using verbatim repeat back throughout

8. Start well kill and monitor kill against expected outcomes

Human Factors must be central and not viewed as an “add on”. The process must be designed to incorporate Human Factors from the beginning.

Mapping created the following phases:

Mapping well control31

Continous assessment

Provide user friendly trend sheets for operations

• Volume & pressure control during displacements (mud changes/cement…)

• Ballooning

• Torque, drag and pressure trends

• Cuttings volume vs ROP and cuttings shape and size

• Changes in mud properties

• Volume control (expected mud use vs actual)

• Expected gas expansion

• During HPHT wells various operations are fingerprinted to compare with later readings – why not do similar

32

Mental traps• Well control is stressful and a number of mental traps

(sometimes called cognitive biases) need to be dealt with

• These mental traps have a major influence on individuals and teams to recognise events or deviations from what’s going on around them

• Confirmation bias - is the tendency to interpret information that confirms one’s own observation (which may or may not be flawed)

• Normalization of Deviance - is the gradual process through which unacceptable practices or standards become normal and acceptable

• Groupthink - is the tendency of a decision-making group to strive for consensus that results in avoiding critical examination of alternatives

33

Who

• OIM

• Drill crew – AD and up

• Client and 3rd parties

• Onshore support

34

Human factors strategies embedded in the Well control procedures:

page 35

• Closed loop Communication

• Technique to combat mistakes more likely to occur when individual is under pressure and/or fatigued

• “Devils advocate”

• This strategy is used to minimize the risk of the Well Control Team developing what is called “normalization of deviance” and “Groupthink

• Forward Projection and Trending

• Forward projection is used to predefine what “good” and “bad” looks like. Its important methods to understand what to expect.

human factors in barrier management - …...ptw review/ ifs technical preventive maintenance system...

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