CAKE session no. 11

What is a major accident?

Feedbacks from last CAKE session

• Other activities we can arrange– Team buildings– Onshore seminars– Activities for a stronger team identification– Too much brainstorming and paper work. CAKE need to become more practical and to

be more visible in everyday life

• How can we make CAKE more engaging– Feedback, info letters on CAKE news, on goings and plans – Get a face on persons behind CAKE– Onshore CAKE sessions for offshore personnel– CAKE sessions pauses– Other activities, not only discussions. Films etc.

• How do we create a stringer commitment?– Onshore personnel arranging offshore CAKE sessions– Showing results and measures from previous sessions– More CAKE effects– Possibilities for professional courses

Feedback on feedback

• We will arrange crew specific feedback from CAKE sessions

• This autumn we will introduce further measures designed to enhance CAKE. They are yet to be decided.

• We will involve larger groups of personnel in daily CAKE routines

• CAKE sessions will be introduced onshore

About safety tools; last CAKE sessions

• Why is it that we are not always using these tools?– Too much paper for the job at hand– We have many jobs that don’t need a WP– Experience and routine– We do lots of TNT that we do not document

• What can this situation lead to?– Sometimes a short cut leads to an accident, sometimes it doesn’t– It increases the risk of having an accident– Unpredicted incidents, that are not planned may cause a wrong reaction– Misunderstandings regarding planning of conflicting operations– Reduced confidence in the tools

• How can we identify and control risks in other ways?

– Common sense– Use your colleague actively– SAFEtalk– Stronger focus on practical work not on paper work

What is a major accident?

There are several definitions of major accident. We have chosen

the two most frequently used definitions. The first describes

extent, the second describes cause.

• An accident (an acute incident that involves loss) where more than five persons are exposed

• An accident caused by failure on one or more system safety and preparedness barriers

Texas city-disaster: March, 2005 – 15 fatalities

Baker report after the disaster - a wake-up-call

• There are significant similarities between Texas City and other major accidents

• A decrease in personal injuries where regarded as indicators for controlling major accident risks

• Serious hazard indicators where ignored as not relevant information on major accident risks

• Information regarded as HSE-relevant where limited to personal accidents

• Status on process regularity, process deviations, back log, operational costs, maintenance cost, repair costs, loss, budget deviations etc where labelled as operational and financial concerns

• Poor process regularity and extensive maintenance back log where not associated with technical disintegration, and thereby irrelevant for major accident risks.

It concerns maintenance of technical barriers

• All (safety critical) equipment are to be as good as when they where new – at all time

• Maintenance routines and inspections are our most essential tasks

• Several major accidents involves maintenance in one way or the other

– Missing maintenance– During execution of maintenance

Causes behind personal accidents and major accidents are different

• Individual safety is historically high offshore; both in culture, organisation and management priority

• We have several system allowing us to continuously measure personal safety

• We have several systems and persons continuously taking care of personal safety

”Focusing on statistics of personal injuries and undesirable incidents alone is a waste of time in seeking to avoid major accidents”Magne Ognedal, PSA

Consequences and probabilities

Management/safety delegates focus?Management/Safety delegates focus?

Only for offshore crew“Primarily” for engineers and consultants

Often discussed with rig management in morning meetings

Seldom discussed with rig management in morning meetings

Typical topic in safety meetings“Never” discussed in safety meetings offshore

Low costsHigh cost to compensate

Understandable for everyoneComplicated and complex

High probability and low consequence

Small individual accidents

Low probability and high consequence

Major accident

Work Shop

1. Which major accident risks do we have in our department?

2. Which technical barriers are established to reduced these risks?

3. How can we increase our awareness of major accidents in our everyday life; both on an organisational and personal level?

Work shop key words

• Vessel collision• Helicopter crash• HC leakage• Hydrocarbon fire• Major fire• Explosion• Well kick• Stability loss• Major spill of H2S• Massive Blow-out• Damage on main structure• Oil spill• Sub sea blow out – shallow gas