In January 2010, the International Association of Oil and Gas Producers (OGP) Safety Data Subcommittee sponsored a two-day Fatal Incident and High-Potential Event workshop. Considering the industry plateau in fatal accident rates over the last five years, the main objectives of the workshop were to focus specifically on causes and prevention of fatal incidents in the upstream oil and gas industry and to recommend actions that might be taken to prevent future fatal incidents. An analysis of historical OGP fatality and high-potential incident reports and a review of existing rules developed by OGP member companies were conducted, contributing to the development of OGP Life-Saving Rules. Several member companies have realized the benefits from implementing their own programs, which have been based on their own fatal incident learning. However, there is a larger potential benefit to be realized in learning from a larger OGP member company's data set and standardization of rules across the industry. Many contractors are required to learn new rules and procedures each time they go to work for a different client, even though the operating practices and risks are very similar. Migrating toward a standard set of industry life-saving rules will improve understanding and compliance, especially in multilingual and multicultural settings, with the aim of reducing serious incidents and fatalities. The OGP Life-Saving Rules provide operational workers and supervisors with simple, clear icons and instructions on the actions that they are expected to take to prevent fatalities. In many fatal incidents, the actions of individuals are the last barrier in fatality prevention. A set of eight core rules and ten additional rules were selected. The 8 core rules correspond to 40% of the fatal incidents analysed, and the full set of 18 rules correspond to 70% of the fatal incidents analysed.
Royal Dutch Shell plc. (RDS) and the companies in which it directly or indirectly owns investments are separate and distinct entities. But in this paper the collective expression 'Shell' may be used for convenience where reference is made in general to these companies. Like the other (interim) holding companies in the Shell Group, RDS is not (directly) involved in the operations of Shell companies. Shell companies are independent companies and are autonomously managed. Shell companies do not instruct each other, but are deemed to comply with those "Shell" policy rules that they have adopted themselves. If and to the extent this report contains forward-looking statements these are based on current expectations and assumptions and involve known and unknown risks and uncertainties that could cause actual results, performance or events to differ materially from those expressed or implied in this report. Readers should not place undue reliance on forward-looking statements. For the Life-Saving rule icons used in this publication, Shell International Exploration and Production B
Shell has, over the years, built up a comprehensive suite of HSE tools for incident prevention and analysis. Tools like Bowtie diagrams, Hearts and Minds and Tripod incident analysis have been presented separately at previous SPE conferences (Reference 8–19). Now these tools have matured, approaches will be presented for integrated application of these tools, which results in greatly enhanced benefits. For incident analysis Tripod Beta theory has been used to improve the deep understanding of underlying causes of incidents. The widespread use of Bowtie diagram's to develop management systems with barriers to prevent incidents has made it logical to link failed barriers in the bowtie diagrams for a particular type of hazard to the Tripod Beta analysis of incidents. This leads to a more thorough analysis with more opportunities for learning. Tripod Beta theory has been used for years within Shell International Exploration and Production as investigation method, but in recent years the Tripod Beta incident analysis methodology has been updated to link the underlying causes towards human behaviour models, resulting in more focused approach towards the human error. Therefore the immediate and underlying causes are better understood in relation to human behaviour. This new update of the Tripod beta theory (with the improved human behaviour model) is interesting in a number of areas:What can leaders practically do in preventing incidents on the workplace via leadership behaviour?Where should organizations focus their attention at preventing incidents?How can the Hearts and Minds tools be effectively applied once trends in incidents causation are established in the area of human behaviour elements? This paper describes the thinking process, practical application and the outcome of the integration of Tripod beta and the Hearts and Minds concepts. Introduction Often a lot of time is spent on the investigation and analysis parts of incidents. This process is quite structured. However another essential part in the incident 'review' process is designing the recommendations. In terms of spending efforts effectively, this process to arrive at recommendations is essential. If the wrong recommendations are developed on basis of a sound investigation and analysis, a lot of time is wasted and more importantly reoccurrence is not prevented. The recommendations from these incident 'reviews' should therefore also have a component that influences human behaviour through leadership actions. Research and major accident investigations have shown the importance of focusing on culture and leadership behaviour (references 20 and 21).
Many companies put a lot of effort into incident investigations to improve their overall HSE performance and to circumvent reoccurrence of the incidents. However embedding the findings from incident investigations is a complex activity in a global company. Often incident alerts are sent around, but are these alerts effective to provide structural learning and does the right information reach the right people at the right time in the right format?In this paper failures and successes in the Learning From Incident (LFI) process over various years are presented, as identified in several mini Learning from Incident reviews. Structural changes recently made in the learning from incidents organization and processes are described to ensure effective learning and feedback. This includes appointment of LFI coordinators and regular review of trends and external incidents by LFI review teams.Furthermore three types of "alerts" to support the LFI process are discussed, Action Alerts to ensure actions are taken, Leadership Alerts to address underlying causes, and Awareness Alerts accompanied by learning packs (interactive exercises) to suit the shop floor target audience.Ongoing efforts focus on reaching the target audience (especially contractors out in the field), better incorporate relevant learning (like history alerts) in existing processes and development of better communications materials and learning exercises.The above should lead to an improved LFI Process through increased mindfulness, increased awareness of direct causes and associated learning, increased awareness of underlying causes and actions to address these, and more embedded learning in the HSE MS and other systems and processes.As long as repeated incidents occur in a company, the HSE management system and the learning from incidents process is apparently flawed. Therefore the significance of this paper is to help companies to review and improve their structure of the "learning from incidents" process.
Shell companies have a systematic approach to health, safety, security and environmental management in order to achieve continuous performance improvement. To this end, Shell companies manage these matters as critical business activities, set standards and targets for improvement, and measure, appraise and report performance externally. We continually look for ways to reduce the environmental impact of our operations, products and services. Shell has, over the years, built up a comprehensive suite of Health, Safety, Security and Environment (HSSE) courses for its employees and contractors. These are mainly classroom courses, managed and delivered by Shell specialists. With the introduction of a new Shell-wide Competence Based Development framework in 2004, the opportunity was taken to rejuvenate the complete HSSE learning portfolio, using the latest learning methods and distribution systems. Two forces drove the design philosophy -To make relevant HSSE training available at the right time in the right place at the right costTo facilitate "real learning" which takes place when the theory is applied in practice. This happens at the workplace Advances in the field of Information and Communication Technology (ICT) and telematics application were applied to the design and delivery of the new HSSE training. Basic HSSE awareness learning is supplied as a set of electronic newspapers, delivered daily by e-mail. They are written in simple language, and contain pictures, cartoons and puzzles. They have embedded links to slidepacks and websites. They have a common "red-thread" case study, and there is a test at the end of each module. These were launched at the start of 2005, and take up has been massive, with excellent feedback. Advanced HSSE knowledge learning is supplied by a blended learning event, which uses combinations of the most effective learning methodologies. The event is delivered through TeleTOP, an electronic course management system. The heart of each module is three assignments - one to prove understanding, one to show workplace application, and one to challenge and discuss. These assignments are assessed and marked by a facilitator. Networking and best practice sharing is stimulated and documented. This paper describes the thinking process around and the outcome of the novel design and delivery of HSSE training at Shell. Introduction Shell has, for some years used Tripod Beta in its investigation and analysis for serious incidents. Tripod Beta is a root cause analysis tool, which identifies the underlying causes of failed barriers that set the events in motion to result in the incident. After reviewing many incident investigations within Shell, it was revealed that the lack of competence of employees at various layers in the organization was one of the major underlying causes of incidents. A comprehensive competence based development framework for all jobs that are critical to HSSE management was set up, and relevant learning modules were developed and implemented. Shell has had a long history of classroom HSSE training in its exploration and production business, which has been taken up by all of the other businesses, and is well regarded. However these are vulnerable to the normal threats to learning uptake or participation - time, distance, budget and competing priorities. These issues have to be considered when designing new learning events. Bringing the Learner to the Learning was clearly not the answer, so the modules were designed to bring the Learning to the Learner. These two drivers - the move to a formal HSSE competence development and assurance system and a wish to apply modern learning research and tools to HSSE learning, resulted in the new suite of HSSE learning events which are described in this paper.
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