Management Presentation on Phase One findings from your PSMR audit. - PowerPoint PPT Presentation

Management Presentation on Phase One findings from your PSMR audit. Presented by Lead Auditor to Shell Expro Leadership Team on 22nd October, 1999 Shell Expro Sept-Oct 1999

Principal Findings ● Violation in operation of Process plant ● Non-compliance with routine maintenance ● Flawed PFEER verification process ● Operating with intolerable risks ● Constant imbalance Production/Cost vs.. Safety ● Ineffective Audit & Management Review process ● Asset Management checks and balances ● Manning, Planning and Activity Levels not aligned ● Inadequate communication and consultation ● Inappropriate attitude, skills and behaviour Shell Expro Sept-Oct 1999

Violation in Operations Review of handover notes indicate that violation is common the violations varied in severity from procedural non conformance e.g. Permit to Work System - and to operating plant outwith its design and operations envelope Violations of operating procedures were witnessed during the Audits - these violations were known up and accepted by the Asset Manager - Many violations are known about by the workforce Violations included falsification of maintenance records for safety critical equipment Shell Expro Sept-Oct 1999

Examples of Falsified Records BB Oil test separator with passing LCV was being operated with a combination of overrides on low level and continual operation of an XCV downstream of the LCV - the overrides were not being recorded in the control room book - situation had persisted for a number of weeks Main BB gas riser ESDV failed LOT (at least twice performance standard) platform started up immediately - the Work Order indicated that the ‘ESDV had no fault found’ . Oil Mist Detectors on BD remained isolated for over a year - External PFEER inspector had signed off ‘in good faith’ but no action had been subsequently taken Shell Expro Sept-Oct 1999

Brent Bravo et al - Goal Widening Objectives Is the ‘goal widening’ rather than Goal Setting regime a present SAFETY, and future REPUTATION issue ? Safety & Reputation RISK Above Above Above GAS PIPELINE 1 cm/min 4 cm/min 20 cm/min RISER take take ESDV Leak Off immediate immediate replace at Test (LOT) action action next planned CRITERIA to replace to replace shutdown DELUGE 20 seconds 60 seconds 100 seconds RESPONSE CRITERIA Shell Expro Sept-Oct 1999

Overview of Brent Bravo Brent Bravo with 156 person on board Operation of test separator in violation of codes LOS gas detectors were inhibited - outputs isolated Unauthorised overrides in Control Room Skid deck covered by heavy equipment - explosion venting impaired - casual control over same Many Permit to Work violations observed Fire pump ‘only one run left on pump, only use in anger’ Fireman being used to supply cooling water to drilling Two minor gas leaks - valve stems (not reported) Emergency Generator questionable reliability (air in lube oil ) Seawater (PCV) discharge to sea jammed open Low levels of safety critical maintenance compliance (14%) OIM had no overview of the above and many other dispensations/deviations Shell Expro Sept-Oct 1999

Manning and Planning Role combination is enacted prior to competence attainment, competence is developed on the job - safety critical activities can drop out which are not then picked up Manning reduces, but activities remain the same or increase, not at steady state, excess hours worked with no adequate control on this Low numbers leads to reduced flexibility for unexpected workload, training and progression etc. For example young trainee Shell technicians feel trapped with development curtailed Increased use of vertical relieving - no standard for what level of relieving is acceptable for key positions OIM vertical relieving, no consistent Policy - OIM vertical relieving 80 days per year Planning processes across platforms vary from good to chaotic, still high level of planning offshore Equipment can arrive offshore and be worked on prior to ‘design pack arriving’ Shell Expro Sept-Oct 1999

Human Factors A number of individuals in the organisation admitted that they were coping with high levels of stress - teams also indicated concerns for the stress levels inflicted on their supervisors Throughout the organisation people up to Management level are aware of issues, they are concerned, but remain passive In this PSMR Review human factors play a consistent part in the breakdown of essential controls - is inappropriate management ‘style’ driving and shaping team behaviour and attitudes that then results in the breakdown of controls at the workplace? Shell Expro Sept-Oct 1999

In conclusion Objective of PSMR Review was to Assess the adequacy & effectiveness of controls in place to manage safety in platform operations Opinion of PSMR Review Team The sampling process of the organisation has verified that there are significant weaknesses in essential controls. In our opinion the fundamental reason for this is not the absence of structures, systems and processes but rather that inappropriate attitude and behaviour causes non compliance, or deviation from, these control processes. We believe that the key business drivers and messages from corporate level are fostering undesirable behaviour in the organisation both onshore and offshore Shell Expro Sept-Oct 1999

Immediate Recommended Actions Shell Expro should take immediate action to reduce the risks of operation on Brent Bravo specifically and the Brent Field in general - Risks on BB at present - as witnessed during recent visit - are intolerable - we are aware of no remedial action being taken to reduce these risks since the visit to this installation almost two months ago. Weakness and deficiency is apparent in the continued operation of plant and equipment outside design envelope and violation of operating procedures e.g. Permit to work management of changes to plant and operating parameters recording of accurate records for the testing of safeguarding and other SCE * (it was established that false records were entered into databases for oil riser ESD Valve) changes of performance criteria for SCE with no thought to the implications of such change - the goal widening approach * SCE - Safety Critical Equipment chronic deviation from safety critical equipment routines with no prior approval or risk assessment Shell Expro Sept-Oct 1999

Immediate Recommended Actions Shell Expro should take immediate action to reduce the risks of operation on Brent Bravo specifically and the Brent Field in general etc Weakness and deficiency is apparent in the lack of controls in the inhibition/overriding of safeguarding systems failure of the independent external and Shell internal verification process to pick up the weaknesses highlighted by the PSMR failure to ensure that only competent staff who are assessed as such perform safety critical roles Failure to notify and otherwise inform workforce on BB specifically of intolerable risk levels and what is causing same failure to notify HSE (Regulator) of the true circumstances surrounding recent press and media coverage e.g. lack of compliance with SCE maintenance raised by OILC et al ( what OILC was claiming and newspapers/TV were reporting was factual, in fact situation much worse, but recent Shell Press release statements indicate all is well, not to worry etc. This will be a huge REPUTATION issue, if the above PSMR findings leak onto the streets) Other business not related to BB - Failure to correct injustice to CA technicians disciplined in process now known to have been flawed Shell Expro Sept-Oct 1999