12th AnnualFPSOCongress September2011,Singapore

IndustryandFPSO Health&SafetyPerformance
SimonSchubach RegulatoryOperationsGeneralManager

BackgroundtoNOPSA FPSOhealth&safetyperformance Lessonsfrominspections Lessonsfromincidents

Vision

AsafeAustralianoffshore petroleumindustry

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NOPSAslegislatedfunctions

Promote

Advise

Monitor& Enforce

Cooperate Report Investigate

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Legalframework AGeneralDuties regime:reduceriskALARP Performancebased,withprescriptiveelements Anacceptedsafetycaseisrequiredinorderto undertakeactivities Theprimaryresponsibilityforensuringhealth andsafetylieswiththeoperator

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Whatdoestheregulatordo? ChallengetheOperator
ThoroughSafetyCaseassessments targeted Rigorousfacilityinspections sampledverification Comprehensiveincidentinvestigation depending onseverity PrincipledEnforcement verbal/writtenand prosecutions

Independentassurance
Facilityhealthandsafetyrisksareproperly controlledbyOperatorsoffacilitiesthroughsecuring compliancewithOHSlaw
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INDUSTRYPERFORMANCE

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201011Activities
INDUSTRY
33Operators 210Facilities 286Assessmentssubmitted 365IncidentsNotified 43Accidents 322DangerousOccurrences

NOPSA
33OHSInspectors 20Supportstaff 218AssessmentsNotified 152FacilitiesInspections 1MajorInvestigations 31MinorInvestigations 333Incidentreviews 78Enforcementactions

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Facilities
FacilityGroup Platforms FPSOs/FSOs MODUs Vessels Pipelines TOTAL: No.ofFacilities
BasedonCurrent(2011)data*

60 14 15 10 110 210

* Numbers fluctuate slightly as MODUs and vessels enter the regime and become facilities or leave the regime and cease to be facilities.
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FPSOAgeDistribution
AgedistributionofFPSO/FSOs
(allactiveFPSOs 20052011)
8

FPSO
6

FSO

Number

05years

510years

1015years

1520years

2025years

2530years

>30years

FacilityAgeGroup

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StatisticsforFPSOs
forthefinancialyear201011

Activity FacilitiesInspected Incidents reported Assessments notified Enforcement Actionsissued

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ALLFacilities FPSO/FSO 152 365 218 78 23(15%) 83(23%) 25(11%) 32(41%)

11

11

IncidentCategories
120

NumberIncidentsNotified 201011
ALLFacilityTypes FPSO/FSOs

80

40

0
Unplanned Damage to Accident - Could have Other kind Could have Fire or Event - safety-crit ical Incapacitation caused needing caused Death Explosion Implement equipment >=3 days LTI Incapacity ( immediate or Serious ERP LTI>3) investigation Injury Uncontrolled Uncontrolled Collision Accident HC gas PL release marine vessel Death or release >1- >80-12 500L and facility Serious Injury 300 kg Pipelines kind needing immediate investigation

Morethanhalfofallunplannedevents(alarms,medivacsetc.)occuronFPSOs

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IncidentsperFacilityType
%Incidents Platforms
75% 75%

%Incidents FPSO/FSOs

50%

50%

25%

25%

0% 2005 2006 2007 2008 2009 2010 JanJun 2011

0% 2005 2006 2007 2008 2009 2010 JanJun 2011

%Incidents MODUs
75% 75%

%Incidents Vessels

1/3ofall incidents reportedto NOPSAoccur onFPSO/FSOs

50%

50%

25%

25%

0% 2005 2006 2007 2008 2009 2010 JanJun 2011

0% 2005 2006 2007 2008 2009 2010 JanJun 2011

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Injuries
TRCRates
20

permillion hoursworked

ALLFPSO/FSOOperators ALLOperators

15

Rate

10

TRC = LTI + ADI + MTI

0 2005 2006 2007 2008 2009 2010 Q22011

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HydrocarbonReleases
HCRRates
AllFacilityTypesvsFPSO/FSOs
10 8 6
AllFacilityTypes FPSO/FSOs

Rate
4 2 0 2005 2006 2007 2008 2009 2010 toQ22011

NB: Rates are per milion hours worked

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HydrocarbonReleases
AlmosthalfofallHCRsinvolveeitherValves/VentsorPipes/Tubes

Whatisthistellingus?
EquipmentinvolvedinFPSOHydrocarbonReleases
25%

20%

15%

10%

5%

0%
Valves/ Pipes/Tubes Gaskets/ Vents Seals Joints/ Flanges Other Pumps/ Compressors Tank Instruments Unspecified Engines

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SafetyCriticalElements
Controlmeasuresreliedontoreducetheriskofoneor moreMAEstoALARP
DamagetosafetycriticalequipmentRates
AllFacilityTypesvsFPSO/FSOs
25 20
Rate
AllFacilityTypes FPSO/FSOs

15 10 5 0 2005 2006 2007 2008 2009 2010 toQ22011

WARNING Whatisthis tellingus?

NB: Rates are per milion hours worked

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Fires
FireorExplosionRates
AllFacilityTypesvsFPSO/FSOs
3
AllFacilityTypes FPSO/FSOs

Rate
1 0 2005 2006 2007 2008 2009 2010 toQ22011

NB: Rates are per milion hours worked

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FPSO/FSOs IncidentRootCauses
Top TapRoot Root Causes for FPSO/FSOs
2005 2006 2007 2008 2009 2010 ytd 2011

Work Direction 9.2% Procedures Not Followed 8.2%

Human Engineering 12.1% Work Direction 10.1% Mgmt System - Human 10.1% Preventive Maintenance 10.1% Procedures Not Followed 9.1%

Design Specs 13.7% Equipment Parts / Defects 10.3% Preventive Maintenance 9.7% Procedures Not Followed 8.0% Human Engineering 5.7%

Equipment Parts / Defects 14.2% Procedures Not Followed 13.0%

Procedures Not Followed 20.0% Equipment Parts / Defects 15.3% Design Specs 14.2%

Design Specs 17.2%

Design Specs 15.3 % Equipment Parts / Defects 11.9% Procedures Not Followed 11.0% Mgmt System - Human 9.3% Mgmt System - Equipment 8.5%

Procedures Not Followed 10.5% Preventive Maintenance 9.6% Equipment Parts / Defects 8.8% Training 6.7%

Training 5.1%

Design Specs 12.3%

Preventive Maintenance 5.1% Equipment Parts / Defects 5.1%

Preventive Maintenance 11.7% Tolerable Failure 5.2%

Preventive Maintenance 11.6%

Training 6.3%

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FPSOCASESTUDY

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FPSOCasestudy Incident:Fireandexplosion Issues:

FacilityDesign Commissioning,QA/QC,carryoverintooperations Competencyandtraining Controlroomalarmflooding Maintenancemanagement

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FPSOCasestudy Regulatoryintervention:Inspections Majordeficienciesidentifiedin:

Maintenancebacklogmanagement Effectivenessofoperationalcontrol SCEsnotmeetingperformancestandards Reportableincidents Housekeeping

Enforcementactionincluded:
ImprovementNotices ProhibitionNotice
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FPSOCasestudy Initialresponsetointervention:
Delegationtocontractor Completiondatesnotfullymet OverrelianceonNOPSAtoidentifyhealthandsafetyissues

Interventionoptions:
Inspections Potentialescalationofenforcement
noticeofintenttowithdrawsafetycase requestrevisedsafetycase

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LESSONSFROMINSPECTIONS

Design Commissioning Operations

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DesignIssues Alarmmanagement
Addressduringdesign/commissioning

Materialselection
Souringofthereservoirisacommonoutcomeof facilitiesthatconductproducedwaterreinjection. Thisgenerallyresultsinahigherthananticipated H2Scontentinwell,process&rundownstreams

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DesignIssues CriticalFunctionTesting(CFT)
SCEsnotmeetingperformancestandards SCEoftenrequiresaproductionshutdowntoCFT withfrequencyimplications Systemsshouldallowforperformancetracking/ reportingofSCEduringunscheduledshutdowns.

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CommissioningIssues Safetycriticalelements:performancenon compliance:BDVs/SDVs Incompletecommissioning

constructiondebris excessivepunchlistitems lackofQualityAssurance/QualityControl

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OperationalIssues Inadequaciesincompetency/training
Restartofplantandprocesses:cyclone disconnectionisacomplextaskrequiringtechnical skillsandexperience

Operatorsmustensuresufficienttimefor requiredcompetenciestobeacquired

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OperationalIssues ProceduresIncorrect/NotFollowed
Procedurestaketimetoachieveandshouldbe consideredasdynamic. Proceduresshouldbevalidatedorreviewedto reflectthecurrent,bestpractice. UseManagementofChange(MOC),otherwise procedurescanbeundermined,resultingin shortcutsandrisktaking.

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OperationalIssues FailuretocompleteCorrectiveActions
"CasetoOperate","Deviations,"Temporary OperatingProcedures,andsuchareusedtojustify continuedoperations Suchpermissionstooperateshouldbetimelimited andtrackedtoensurepermanentrectificationis appliedandmaintained

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Atopicalissue

LIFEBOATLOADING

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LifeboatLoading
IMOSOLAS,Lifeboatsaredesignedfor75kg/person OffshoreNOPSAfoundaverage=92kg100kg/person

= somelifeboats25%30%overloadedbasedontheirSWL
NOPSAhasmadeOperatorsawareof theproblemoflifeboatsexceeding theirSWLandhaverequiredthemto takeaction. SomeOperatorshave: reducedthenumberofPOBper lifeboat; changedthelifeboatsanddavits biggerboats&increasedSWL addedextralifeboats;
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SeealsoNOPSA SafetyAlertNo.47
32

PROCESSSAFETYCULTURE

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Opportunitiesforimprovement
SafetyCultureSurveyTOPICAREA Areasofconcern FPSOs Pressuretoworkovertime loyaltytotheir ownworkunit SafetyValues/Commitment Processsafetyprogrammesdon'thave adequatefunding Reporting Hazardidentification,controlandreporting trainingnotadequate Contractorsdon'treceiveadequatetraining todotheirjobsafely Workersdon'tactivelyparticipatein incidentinvestigations
34

Training

WorkerProfessionalism/Empowerment

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TOPICBASEDINSPECTIONS

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Maintenancemanagement
Variationbetweendocumentedmaintenancesystem andhowmaintenanceisactuallyconducted Formaldeferralsprocessnotused risksnotassessed 3rdpartycompetency EHSassessedbutnottechnical competencies Auditing inadequate

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EmergencyManagement
Drillsbeingundertakenwithlimitednumberof scenarios PAsystemsineffective,emergencyescaperoutesnot clearlymarkedorobstructed Responsetimes notsubjecttoperformancestandards andnottested Inadequatedebriefs Auditing inadequate

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ReasonsAccidentCausation

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Blindoperations
Wherethoseoperatingequipmentwereunawareof theactualsituationstheywerein
Tendencytointerpreteventsincontextofprevious experiencedespiteevidencetothecontrary(mindset) Management'sfailuretoensurethatmembersofthe workforcehavethe abilitytoidentify,diagnoseandrespond toabnormalconditions

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Macondo,2010
11fatalities Commissionfindingsinclude:
failuretoproperlyconductandinterpret thenegativepressuretest WRONGLYASSUMEDwellcouldnotbe flowing Keptrunningtestsandcomingupwith variousexplanationsuntiltheyconvinced themselvestheirassumptionwascorrect

Commissionidentifiedanumberof potentialfactorsthatmayhave contributedtothefailuretoproperly conductandinterpretthenegative pressuretest:

noproceduresforrunningorinterpreting thetests lackingfullappreciationofcontextin whichthetestwasperformed
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Montara,2009
Nofatalities,wellblowout. Returnoffluidindicatedfloat valveproblem Commissionfindingsinclude:
majorshortcomingsinprocedures werewidespreadandsystemic circumstanceswerenot recognisedorunderstoodby seniorpersonnelatthetime

Commissionrecommended:
existingwellcontroltraining programsshouldbereviewed, withafocusonwellcontrol accidentsthathaveoccurred
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TexasCity,2005
15fatalities Overfillingofatowerduringstartup releasingflammableliquidto atmosphericvent CSBfindingsincluded:
lackofsupervisoryoversightand technicallytrainedpersonnelduring startup Operatortrainingprogramwas inadequate Outdatedandineffectiveproceduresdid notaddressrecurringproblems

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Longford,1998
2fatalities,8injuries lossofhotleanoilflowwith subsequentflowcausingbrittle fractureandhydrocarbons release Commissionfindingsincluded:
Lackofknowledge wasdirectly attributabletoadeficiencyininitial orsubsequenttraining

Commissionrecommendations included:
Operatortodemonstratethatits trainingprogramsandtechniques impartknowledgeofallidentifiable hazardsandtheprocedurestodeal withthem
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ThreeMileIsland,1979
Nofatalitiesorinjuries
Coolantpumpsfailed,reliefvalvestuckopen withapartialmeltdownofreactorcore inappropriateoperatoraction deficienciesintrainingandoperating procedures failureoforganisationtolearnlessons frompreviousincidents Commissionrecommended: Emphasismustbeplacedondiagnosing andcontrollingcomplextransientsand onthefundamentalunderstandingof reactorsafety.

Commissionconcluded:

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Whatcanyoudo? Ensurestaffarecompetent,andsupportedby effectiveprocedurestodiagnoseandrespondto abnormalconditions Shareandlearnlessonsfrompastincidents bothwithinandoutsidetheindustry Organise yourselvesinsuchawaythatyouare betterabletonoticetheunexpected inthe makingandhaltitsdevelopment
(paraphraseofHopkins,2009fromWeickandSutcliffe,2001)

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Thankyou

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