Safeguarding Process Plants through Higher Reliability › sites › default › files › ... · Safeguarding Process Plants through Higher Reliability Dr Agwu Emele Agwu Husky Energy

Safeguarding Process Plants through Higher Reliability

Dr Agwu Emele Agwu Husky Energy Inc.

Prof Ashraf Labib University of Portsmouth, UK

September 26th, 2018

Bio: Dr Agwu Emele Agwu Husky Energy Inc

• Over 22 years experience in petroleum and manufacturing asset management across Africa, Europe, Asia and Canada.

• PhD in Operations and Systems Management from the University of Portsmouth UK. Research interests in organisational reliability and performance improvement, strategic management, multi criteria decision support systems, and maintenance management.

• A Planner in Husky Energy's Heavy Oil Group. 16 years with Shell Petroleum. Served as Director of Operations for Total Technology Consultants and Vater Integrated Services.

• A founding board member and former Vice President of the Project Management Institute (PMI) Nigeria Chapter.

• A Certified Maintenance and Reliability Professional (CMRP), a Project Management Professional (PMP) and a Facility Management Professional (FMP)

• Volunteers as a football coach for the Battlefords Youth Soccer Inc. Recently took to golfing and fishing.

Bio: Prof Ashraf Labib The University of Portsmouth, UK.

• A professor of operations and decision analysis. Former Associate Dean of the Portsmouth Business School and the Director of DBA

• Research interests in strategic management, manufacturing, reliability engineering, maintenance systems, multiple criteria decision analysis and applications of artificial intelligence.

• Formerly a Senior Lecturer in the Manufacturing Division of the Department of Mechanical, Aerospace and Manufacturing Engineering at UMIST (University of Manchester Institute of Science and Technology). He holds a PhD and MSc from University of Birmingham.

• Attracted several research-funded projects from EPSRC, ESRC, European Commission and the industry. Taught at EDF, HP, Royal Mail, Qatar Gas, SABEC, the University of Manchester, the University of Glasgow Caledonian, and the NSF funded research centre IMS in the USA.

• He has published over 200 papers and books.

Agenda

Disasters

• Preventing “natural” disasters through mindfulness

• “Natural” disasters as “man-made” disasters

Disasters - trends

Disasters - examples

Disasters - examples

15 fatalities, 180 injuries, $ damage, reputation

BP Texas City2005

Piper Alpha 1988

187 fatalities, $ damage, reputation

11 fatalities, 17 injuries, 4.9 mmb spill, aquatic damage, wildlife damage, $ damage, reputation

Perspectives on causationNormal accident theory (NAT) - Perrow

Source: Etkin & Timmerman (2013)

Perspectives - Man-made disaster model - Turner

• Actions & inactions of organizations

• Type 1, type 2, and type 3 error models

• 6 stages of disaster causation– Starting point

– Incubation period

– Precipitating event

– Rescue and salvage

– Readjustment

• “Natural disasters” as “man-made disasters”

CCO 1.0

Perspectives – Inherently safer design

• Reduce or eliminate the conditions that creates hazards

• “What you don’t have, can’t leak”

• “Common sense” design

Perspectives – Defense-in-depth

• Multiple layers

• Overlapping provisions

• Failure of one activates the next

• Common in Nuclear and IT

• Criticized for “safety blind spots”

Perspectives – Energy-Barrier Model

Energy SourceBarrier Vulnerable Target

Prevent build-up of energy

Reduce the amount of energy

Prevent uncontrolled release of energyModify rate or distribution of the released

energy Limit the development of damage

Modify the qualities of the energy Rehabilitate the victims

Separate in space and time, the victims from

the energy being released

Separate the victims from the energy by

physical barriers

Make the vulnerable target more resistant to

damage from the energy flow

Perspectives – Conflicting objectives

Perspectives – Resilience Engineering

• Focus on both what could go right and what could go wrong• Use safety improvement actions to enhance productivity

Perspectives – High Reliability Organizations (HRO)

• Countered NAT

• Began at Berkeley in the 1980s

• High coupling and complexity– Nuclear Power plants

– Navy Aircraft carriers

– Air traffic control

• High potential for catastrophe

• Near errors free and harms free

• Mindfulness as the key

Organizational Mindfulness• Progressed from Budhism

• Introspection – focus

• Situational awareness– Situated in the present

– Context & perspectives sensitive

– Guided, not governed by rules/routines

• Big picture, discriminatory details

• Comprehension of emerging threats

• Keeps “mind” of organizations from “wandering off”

Organizational Mindfulness

• Early failure detection

• Generalizations & oversimplification

• Collective purpose & ownership

• Clear communication

• Interdependent processes

• Quick intervention/Recovery

• Round pegs in round holes

• 5 principles

Mindfulness – High Reliability Organizations

Probability of organizations to perform their defined functions, within defined envelops and boundaries, and within defined time

HROs Principles: Preoccupation with failure

• Paralyzed by worries of failure?

• Actively seek vulnerabilities

• Identify anomalies

• Cues of evolving failure

• Normalization – redefinition of risks

• Institutionalized wariness

• Doubt as a mindset

CC-BY-SA-2.0

HROs Principles: Preoccupation with failure

• Identify near misses/incidents

• Identify/resolve root causes

• No blames approach, rewards

• Feedback lessons into process

• Clear and open communication

• Worst case scenarios

• Continuous review/improvement

CC-BY-SA-2.0

HROs Principles: Reluctance to simplify

• Standardization vs over-simplification

• Skepticism refines processes

• Think outside the box

• Every problem is unique

• No Hasty generalizations

• Take nothing for granted

• Don’t enter a door without a window

• We know that we do not know, but we do not even know what we do not knowCC-BY-SA-2.0

HROs Principles: Sensitivity to operations

• Details of operations

• Process inter-relationships

• Monitor and react to variations

• Encourage frontline decisions

• Staff Trainings & Competencies

• Effective communication/feedback

• Work load management

• Clear roles and easy interactions

• Rewards and recognitionCC-BY-SA-2.0

HROs Principles: Commitment to resilience

• Anticipate unexpected errors

• Robust emergency response process

• Contain unanticipated failures

• Robust contingency process

• Recover from effects of failure

• Apply learning rom failures

• Shared responsibilities and trust

Greiner (2018) – Graydon.law

HROs Principles: Deference to expertise

• Hierarchical structure during Normal operations

• Expertise during emergencies

• Emphasis on “yield”, not submission

• Mutual respect for others’ jobs

• Expertise for all jobs available

• Use case study

Greiner (2018) – Graydon.law

HROs perspectives on disasters - Titanic

Preoccupation with Failure Reluctance to Simplify Sensitivity to Operations Commitment to Resilience Deference to Expertise

Consideration of arriving on

schedule over safety.

Failure to report haze within

the horizon.

Organisational practice to

move at maximum speed

Oversimplifying the effects

of maximum speed

Ignored saveral warnings

Maximum speed despite

weather and visibility

Poor crew training and

passenger instructions

Poor comprehension of

impending disaster

Ineffective leadership

Ineffective communication

Leadership indecision

Inadequate emergency

management procedures


management training

Inadequate lifeboats

Inadequte emergency drills

Partially provisioned lifeboats

No defined orderfor lifeboat

boarding

Excessive bureaucracy

impeded actions to

stear away from the

iceberg/reduce speed

Mapping the causative factors of the Titanic disaster in terms the 5 HRO Principles

HROs perspectives on disasters - Bhopal


Diminished design specs.

Poor design of flare tower.

Choice of cost over quality.

Replaced stainless steel

with cheaper less durable

carbon steel.

Wrong plant location.

Increased capacity with no

corresponding hazard

assessment.

Manual safety devices

instead of automatic.

Reduced quality standards.

No unit storage system.

Ineffective water system.

No computerized early

waring systems/Impaired

capability of safety devices.

Poor incident reporting.

Poor maintenance

procedures.

Revised processes to

enable operation outside

design parameters.

Ignored warning cues.

Similar incidents in the

past not learned from.

Ignored warnings from

experts.

Ineffective workforce.

Inexperienced workforce.

Operating outside design

parameters/envelopes.

Used emergency MIC

tank in normal operations.

Shut down refrigeration

unit and redirected freon

gas.

Ineffective maintenance

practices.

Poor health and safety

awareness.

Deficient emergency

response procedures.

Poor coordination with civil

authorities.

Alarm turned off after 5

minutes.

Late reporting to authorities.

Poor coordination with

neighbouring communities.

Mapping the causative factors of the Bhopal disaster in terms the 5 HRO Principles

HROs perspectives on disasters - Chernobyl


Design error.

Construction error.

Inadequate procedures

Disabling of automatic

shutdown systems.

Inadequate training.

Violating existing

procedures.

Negligence. Inadequate

competencies.

Ineffective communication

Mapping the causative factors of the Chernobyl disaster in terms the 5 HRO Principles

HROs perspectives on disasters - Challenger


Disregarded warnings

about O-ring flaws.

Oversimplified flaws

Accepted risks on flaws

Waived 6 launch

constraints.

Ignored expert warning

not to launch at low

temperature

Weak decision making

Safety rules violations

Communication failure

Mapping the causative factors of the NASA Challenger disaster in terms the 5 HRO Principles

HROs perspectives on disasters - Columbia


Poor risk management

process

Poor organisation structure:

one person holding three

conflicting positions.

Insufficient time to prepare

for launch

Inadequate supply of basic

personal protective devices.

Disregarded cues from

previous similar

occurences.

Oversimplified and

accepted the risk from

foam

Weak decision making No contingency plan for such

occurrence.

No emergency response plan

for such occurence

Mapping the causative factors of the NASA Columbia disaster in terms the 5 HRO Principles

HROs perspectives on disasters – Piper Alpha


Inadequate plant design.

Inadequate change

management process.

Inadequate hazard

assessment.

Inadequate maintenance

procedures.

Inadequate safety

procedures.

Inadequate permit to work

system.

Inadequate shift handover

process.

Poor shift handover

Inadequate attention to

permit process

Ineffective emergency

response procedure

Neighbouring plants

waited on hierarchy

for shutdown

instructions,

inadvertently fueling

the explosion.

Mapping the causative factors of the Piper Alpha disaster in terms the 5 HRO Principles

HROs perspectives on disasters – Texas City


Inadequate hazard

identification and

assessment.

Poor plant engineering and

design. There should have

been a shut off or recycle

flow process at high

temperatures.

Plant modification with no

corresponding hazard

assessment.

Disregarded cues of

possible reoccurence

based on similar

occurences in the past.

Deviation from operating

procedures.

Poor supervision.

Unclear chain of command

Ambigous roles and

responsibilities.

Poor communication.

Inadequate training


response practices.

Emergency alarms not

activated in time

Mapping the causative factors of the Texas City disaster in terms the 5 HRO Principles

HROs perspectives on disasters – Deepwater H.


Poorly designed cement

barrier

Poor maintenance

procedures.

No function test of cement

barriers.

No function test of safety

safety systems.

Non functional safety

alarms.

Failure to interprete a

safety test.

Poor communication

Inadequate training

Poor maintenance

practices.

Poor crew coordination.

Delay in reacting to signals


response training.

Inadequate supply of

lifeboats Poor mustering

process

Mapping the causative factors of the Deepwater Horizon disaster in terms the 5 HRO Principles

HROs - Gaps

• Stereotypical concentration

• Single organizations

• Theoretical perspective

• Reactive research

• Reliability measurement

• No standardized roadmap for implementation

CC-BY-SA-2.0

Roadmap – Organizational Reliability Maturity Model (ORM2)

Roadmap – Framework for Organizational Reliability

Maturity (FORM)

P=1-(R-Ri)/R

Roadmap – Framework for Organizational Reliability

Maturity (FORM)

P=1-(R-Ri)/R

Level

Preoccupation with

Failure Pull

Commitment to

Resilience Pull

Average Pull for

all 5 Principles

5 7.56 0.20 5.00 0.12 0.11

4 20.44 0.53 28.33 0.68 0.60

3 38.44 0.00 41.94 0.00 0.00

2 22.22 0.58 17.50 0.42 0.77

1 11.33 0.29 7.22 0.17 0.50

FRAMEWORK FOR ORGANISATIONAL RELIABILITY MATURITY

COMPANY CHARLY

Roadmap – Organizational assessment with FORM

P=1-(R-Ri)/R

Roadmap – Benchmarking with FORM

ORGANIZATIONS SILENT STARTER STABLE SUSTAIN SUMMIT

COMPANY ALPHA

COMPANY BRAVO 0.47 0.68 ML 0.95 0.59

COMPANY CHARLY 0.59 0.77 ML 0.62 0.14

COMPANY DELTA 0.56 0.88 ML 0.77 0.39

COMPANY EECHO 0.77 0.82 ML 0.69 0.22

COMPANY FOXTROT 0.88 ML 0.76 0.49 0.14

COMPANY GULF 0.91 ML 0.69 0.21 0

COMPANY HOTEL 0.94 ML 0.53 0.1 0.01

COMPARING THE MATURITY OF THE ORGANIZATIONS



ORGANIZATIONS SILENT STARTER STABLE SUSTAIN SUMMIT

COMPANY A

Preoccupation with failure 0.00 4.67 9.83 11.33 74.17

Reluctance to Simplify 0.00 0.00 0.00 8.54 91.46

Sensitivity to operations 0.00 1.82 2.27 9.09 86.82

Commitment to resilience 0.00 0.42 1.46 2.50 95.63

Deference to expertise 0.00 0.00 0.00 3.13 96.88

COMPANY B






COMPANY C






COMPANY D







COMPANY E






COMPANY F






COMPANY G






COMPANY H







Roadmap – Predicting with FORM

Roadmap – Improving with FORM

Roadmap – Improving with FORM

Last words

• HROs point the way to process safety

• Application of organizational mindfulness enhance safety

• Could be applied to diverse organizations

• Safeguard processes, safeguard humanity

Documents

Safeguarding Process Plants through Higher Reliability › sites › default › files › ... · Safeguarding Process Plants through Higher Reliability Dr Agwu Emele Agwu Husky Energy