Summary Tripod Delta (diagnostic evaluation tool for accident prevention) is a checklist-based approach to carrying out safety "health checks." This paper describes the theoretical background of the approach, which is based on a model for understanding the role of human error in accidents. The method for constructing databases from which to make checklists and use of the system to generate remedial safety plans are described. Finally, the implementation is discussed and the status is reviewed. Introduction Tripod is an approach to safety developed by the U. of Leiden and the U. of Manchester in close cooperation with the Shell Intl. Petroleum Mij. B.V.E&P function. Tripod attacks underlying safety problems with special reference to human error, which is seen in failures at both individual and organization levels. A central concept in Tripod is the "latent failure," the potential cause of future accidents. Tripod Delta is a diagnostic tool developed to help identify such underlying problems before latent failures generate active failures (the immediate causes of accidents).This paper describes the background of Tripod Delta, how it operates, and the current status of the system. Accidents, Unsafe Acts, and Underlying Causes. Accidents have a number of immediate causes, many of which have a human origin. For an accident to take place, unsafe human acts must interact with triggering events, such as a breaking cable or a well kick. When the combination circumvents available defenses, the result may be an accident or a near miss. All too often, investigation of an incident focuses on the immediate events and human failures. This concentration on the direct causes (active failures) also often applies to proposals for prevention of future incidents. However, the events leading to accidents do not arise spontaneously. The shortcomings that can be identified after an accident are often present long before as latent failures. The general Tripod model (Fig. 1) in cludes three basic components of the accident process.Accidents happen when defenses are breached.The unfortunate sequence of events involves the combination of one or more unsafe acts in the context of specific triggering conditions (which may themselves be technical or human in origin).Behind the unsafe acts and conditions is a history of causes, classified into a limited set of general failure types (GFT's) shown in Table 1. This restricted set of 11 GFT's has been identified in field studies and from analyses of major accidents. The list was defined by providing a general set of terms adequate to describe latent failures and by distinct ways to remedy the problems identified. The communication GFT, for instance, covers both technical failures (e.g., a poor or nonexistent telephone system or difficult radio communication) and human failures (inability to pass on or to understand messages). The important factor in a potential accident is that the vital information may not be available to the proper people at the right time. Similarly, the hardware GFT refers to the quality and availability of components, tools, and equipment. Problems in any of these areas may lead people to create situations that can lead to hardware failures later, such as accepting corrosion, installing in correct material, or using the wrong tools. The view taken in Tripod is that it is more effective to concentrate on the conditions defined by the GFT's rather than to attempt to stop the unsafe acts as they occur. The GFT's behind the large numbers of unsafe acts and triggering events form a natural and more limited set of targets for improvement. Safety Management and Proactive Approaches. An important starting point in safety management involves identifying the necessary components of good management practice. Shell's Enhanced Safety Management Principles embody such an approach, stressing such factors as the necessity for a firm commitment to safety, line responsibility for safety, and regular audits. Once management systems meet such principles, it generally becomes necessary to determine where attention must be directed. P. 58^
Th!s paper was sebded for presentation bj an SPE Prcgram Commtfee following review of mformatmn c.mtamed m an Astract submitted w the author(s) Controls of the paper as presented have rid ken rewewod by {he Society of Petrobum Engmws and are subject to correctmn h the author(s) Tfw mater{al, as presented does not nu=essardy reflect any postt!on 01the %mty of Petroleum Engineers ifs offrmrs or nwmbecs Papers presented at SPE n-metmgs are subpcf to pubhcatlon revmw by Ed!torial Ccinmctfoas of the Soaety of Petroleum Engineers Permcmon to mpy IS restricted to an abstract of nof more than TWO words Illustrations may not be mpmd Tlw abstract should mntam conspicuous acknowdedgenwnt of where and by whom the pap+r was presented Write Lbrar! an, SPE P O km 8338%, 11.hardwafi, TX 75C83.35% U S A lax 01-214-952-9435Shell cowantas have therr own saparate tdenltms h Ih!s paper the mllecttve expfesswns 'SheH and 'Group' and 'Royal Dulchkhell Group of (%qmmes may be used tor mnven!ance where reference IS made to the compan!es of the Royal Outch/Shell Group m general Three exprasscms are also used where no useful PUVSB IS *wed by ukmfiying the parhcu far ccmpmy or cowanles Abstract This paper sets out the necessary strategic issues that must be dealt with when setting up a management system for HSE. It touches on the setting of objectives using a form of risk matrix ,and the establishment of corporate risk tolerability y levels. Such issue management is vital but can lx seen .as yet another corporate HQ initiative. lt must therefore be linked and made relevant to those in middle management tasked with implementing the system and also to those at risk 'at the sharp end of the business.Setting acceptance criteria is aimed at demonstrating a necessary and sufficient level of control or coverage for those hazards considered as being within the objective setting of the Safety or HSE Case.Critical risk ,areas addressed via the Safety Case, within Shell companies at least, must show how this coverage is extended to critical health and environmental issues. Methods of achieving this ,are warious ranging from specific Case deliverables (like the Hazard Register and Accountability Matrices) through to the incorporation of topics from the hazard :malysis in toolbox talks and meetings. Risk analysis techniques 'are increasingly seen as complementary rather than separate with environmental assessments, health risk assessment sand safety risk analyses tahng place together and results being considered jointly.The paper ends with some views on the way ,ahead regarding the linking of risk decisions to target setting at the workplace and views on how Case information may be retrieved and used on a daily basis,
Previous papers given to SPE conferences have described the Shell Group approach to Safety Management Systems and to Safety Cases. Their extension to HSE MS and to HSE Cases has also been addressed. Since 1984 the Enhanced Safety Management (ESM) programme within Shell companies has led to a significant improvement in the management of safety but it was only when structured management systems (based upon an understanding of the business processes) were introduced that true integration of HSE as a line responsibility became a reality. This paper describes the THESIS software package and the way that management systems have been made 'live' and how workforce involvemerU can be demonstrated. The paper starts with the premise that "...work should not start before it is confirmed that essential safety systems are in place and that staff are accountable for this requirement. Where we cannot ensure safety, then operations should be suspended...".Line management needed a way of making this a real part of the job and of providing workplace personnel with an essential understanding of the risks that they face. In Jakarta we stated that "Many of the early Safety Cases reviewed failed to provide a clear message that the operation's safety management system has benefited from the assessments made in preparing a Safety Case. They were regarded as paper exercises and a sterile documentation of what had been done, often by engineers or consultants. Without some form of 'energising' the system becomes just another book on the shelf. Since Jakarta we have been completing wotk on relational database software aimed at changing the Safety Case from being a paper document to a software based 'System' from which on-line reports can be extracted that add value to those managing the risk of the business. Changes to the electronic document can be readily undertaken and whilst still not painless the development and updating of a Safety or HSE Case is now much reduced in terms of time and effort enabling it to remain alive. With the critical HSE activities and tasks specified and related hazards and effects identified and linked via a relational database, it is possible and realistic to provide to the workplace clear reports that describe the necessary controls in terms of the tasks that actually provide those controls.
Th/s paper was seb~ed for presenlatmn by an SPE Programme Commmee following rewew of mformahon ccmtamed m an abstract subimtted bV the authorsContents O! the paper as presented have not been revmwed bv the SOCIaty o! Petrobum Engineers and are sub)ected to carrectton by the authors Ttm mater#al, as presentd, does not necessarily reflect any postmn of the So.Iaty of Petroleum Engineers, fis offtcars, or members Papers presented at SPEnwelmgs aresubject 10pukdgmtm rewew by Ed!tor!al Commttees of the Society of Petrokwm Engineers Perr?lsston to copy IS raslncted to an abstract al not more than 300 words Illuslratlons may not be copbsd Tfw abstract should mnta[n conspicuous acknowledgement of where and by whom the papa! was presented Write I!brar\an, SPE P O 9QK 833E?6 i%hamkm TX 75@33.3636 U S A fax 01.214.9435 Shell compames have their own separate )drmt)tles In thm paper the wlledwe expreswo.s 'ShelV and 'GrQvp' and 'Roval DutchlShell Group o{ Cowan!m' maybe used for cmnvemence where reference IS made 10 the companies 01 the Royal Dutch/Shell Group m general Th@sa expressions are alsomadwhere no useful purpose IS served by !denhfymg the paticula( mmpany or compames .-. .-. Abstract A desire to implement HSE Management Systems including HSE Cases in all Shell companies operations prompted the development of a relational data base softw,arc package (THESIS) to provide a structured way of preparing an HSE Ci~\e. The softw,are includes features which fkilitate the management of "Keeping the Case Alive". enabling the dissemination of taisks
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