The Self-Designing High- Reliability Organization

Recent studies of large, formal organizations that perform complex, inherently hazardous, and highly technical task under conditions of tight coupling and severe time pressure have generally concluded that most will fail spectaculatory at some point, with attendant human and social const of great severity. The notion that accidents in these systems are normal, that is, to be expected given the coditions and risks of operations and risk of operation, appears to be as well grounded in experience as in theory

The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea

Of all activities studied by our research group, flight operations at sea is the closest to the edge of the envelope -operating under the most extreme conditions in the least stable environment, and with the greatest tension between preserving safety and reliability and attaining maximum operational efficiency

The blameworthiness of health and safety rule violations

Man-made disasters usually lead to the tightening of safety regulations, because rule breaking is seen as a major cause of them. This reaction is based on the presumptions that the safety rules are good and that the rule-breakers are wrong. The reasons the personnel of a coke factory gave for breaking rules raise doubt about the tenability of these presumptions. It is unlikely that this result would have been achieved on the basis of a disaster evaluation or High-Reliability Theory. In both approaches, knowledge of the consequences of human conduct hinders an unprejudiced judgement about the blameworthiness of rule breaking

Application of remote real-time monitoring to offshore oil and gas operations

The U.S. outer continental shelf is a major source of energy for the United States, and over the past 25 years, deepwater oil and gas production in the Gulf of Mexico has increased significantly. With the move into greater water depths, industry is drilling deeper wells, where operations can experience higher pressures, higher temperatures, and greater uncertainty. Remote monitoring of drilling operations could help operators and regulators enhance the safety of these operations. This study advises the Bureau of Safety and Environmental Enforcement (BSEE) on the application and use of remote real-time monitoring (RRTM) to improve management of the safety and environmental risks of offshore oil and gas operations. As a central part of the charge (see Box 1 -1 in Chapter 1), BSEE asked the committee to conduct a workshop that addressed the critical operations and parameters to be monitored in real time, the role RRTM could play in automation and predictive software and condition-based maintenance (CBM), and how RRTM could be leveraged by BSEE and incorporated into its regulatory framework. Drillers have monitored drilling operations offshore in real time for decades; more recently, a few operators have also transmitted some of these data onshore to improve efficiency and risk management. During its information gathering, the committee was told that RRTM\u27s benefits include increased efficiency, decreased downtime and operational disruptions, reduced equipment damage, improved safety, and overall reduction in risk. Whereas RRTM can provide the rig with technical support and access to onshore expertise, during the committee\u27s workshop the U.S. industry expressed a belief that responsibility and authority for operational decision making should remain offshore. Situational awareness on the offshore facility is important, and RRTM data do not always provide the necessary context. The use of RRTM is variable across the offshore oil and gas industry, and diverse RRTM technologies are available. No RRTM industry standard or standard practice exists, and the industry exhibits varying levels of maturity in its use of RRTM. Thus, a standard approach is not likely to work or to be needed for every company or every well. The committee views RRTM as a best available and safest technology (BAST), when such technologies are consistent with the principles of ALARP (as low as reasonably practicable). The director of BSEE estab-lishes BAST through a documented process, but determining RRTM as BAST in some contexts would not mandate its use across the board. The decision to use RRTM occurs when such technologies are available and economically feasible. BSEE could use existing regulatory requirements, such as the Application for Permit to Drill (APD) and the Safety and Environmental Management System (SEMS) plan, to advance appropriate use of RRTM. By encouraging offshore operators to address RRTM in their APD or SEMS plans, BSEE could allow operators to determine the circumstances under which RRTM should be used and challenge them to do so when BSEE believes that RRTM is necessary for managing risk. RRTM information-whether in real time or archived-could also benefit BSEE in its inspection activities and support inspectors\u27 review of safety-related information before they visit offshore facilities. Preparation, prioritized by risk, could allow for more efficient scheduling and effective execution of BSEE inspections. The committee is not in a position to recommend or validate a definitive list of critical operations and parameters for RRTM. In the committee\u27s judgment, a single standard list for all operations is not practical in view of the variability in operating conditions, geology, and scope and scale of facilities; the evolution of technology; consideration of human factors; and the incorporation of RRTM in a risk-based approach to regulating offshore operations. However, companies using RRTM appear to monitor some of the same critical operations and parameters (see Chapter 2). As sensor technology advances and the ability to transmit that data improves, issues with regard to the management of massive volumes of real-time data will grow. Likewise, as more RRTM of offshore operations is introduced, cybersecurity risks associated with the increased use of technology will rise. Control systems for critical rig-based equipment, not originally designed for connectivity to Internet-facing systems, are likely be at risk. RRTM could contribute to achieving a longer-term goal of offshore systems CBM. Blowout preventers (BOPs) provide a promising case. However, before CBM can go forward, BOP operational data and maintenance history will need to be collected and stored continually over the lifetime of the equipment to allow development of predictive models. Retroactive analysis of BOP performance data may not be adequate due to the complexity and variability of offshore operations and incomplete BOP maintenance history. The committee\u27s consensus recommendations, which are listed below and elaborated in Chapter 4, provide guidance to BSEE and stakeholders in addressing the issues associated with the application of RRTM to offshore oil and gas operations. Recommendation 1. BSEE should pursue a more performance-based regulatory framework by focusing on a risk-based regime that allows industry to determine relevant uses of RRTM on the basis of assessed levels of risk and complexity. BSEE could assess decisions about the monitoring of well parameters or the application of RRTM through the review of a company\u27s APD or SEMS plans and challenge the company to apply RRTM to manage the risk of complex operations. Recommendation 2. The committee views RRTM as BAST when justified by the risk of particular wells. BSEE should monitor the spectrum of RRTM technologies and best practices by using either an internal BSEE group, such as the agency\u27s proposed Engineering Technology Assessment Center, or an external organization, such as the Ocean Energy Safety Institute. Recommendation 3. Consistent with recommendations of previous committees of the National Academies (NAE and NRC 2012; NAE and NRC 2013), BSEE should encourage involvement of all stakeholders in the development of risk-based goals and standards governing offshore oil and gas processes. Specifically, BSEE should work with the American Petroleum Institute (API), the International Association of Drilling Contractors, and other relevant stakeholders to form an API standing technical committee (as opposed to an ad hoc committee) that would establish minimum requirements for which critical operations (and parameters) are monitored and for which data are collected and monitored in real time. In addition, BSEE, along with this technical committee, should propose standards for communication protocols between onshore and offshore facilities when RRTM is used. Recommendation 4. BSEE should encourage API to work with original equipment manufacturers, drilling contractors, and industry trade associations to establish a BOP CBM pilot project, with the goal of an API publication

Rare copy number variants and congenital heart defects in the 22q11.2 deletion syndrome

The 22q11.2 deletion syndrome (22q11DS; velocardiofacial/DiGeorge syndrome; VCFS/DGS; MIM #192430; 188400) is the most common microdeletion syndrome. The phenotypic presentation of 22q11DS is highly variable; approximately 60-75 % of 22q11DS patients have been reported to have a congenital heart defect (CHD), mostly of the conotruncal type, and/or aortic arch defect. The etiology of the cardiac phenotypic variability is not currently known for the majority of patients. We hypothesized that rare copy number variants (CNVs) outside the 22q11.2 deleted region may modify the risk of being born with a CHD in this sensitized population. Rare CNV analysis was performed using Affymetrix SNP Array 6.0 data from 946 22q11DS subjects with CHDs (n = 607) or with normal cardiac anatomy (n = 339). Although there was no significant difference in the overall burden of rare CNVs, an overabundance of CNVs affecting cardiac-related genes was detected in 22q11DS individuals with CHDs. When the rare CNVs were examined with regard to gene interactions, specific cardiac networks, such as Wnt signaling, appear to be overrepresented in 22q11DS CHD cases but not 22q11DS controls with a normal heart. Collectively, these data suggest that CNVs outside the 22q11.2 region may contain genes that modify risk for CHDs in some 22q11DS patients.status: publishe

Copy-number variation of the glucose transporter gene SLC2A3 and congenital heart defects in the 22q11.2 deletion syndrome

The 22q11.2 deletion syndrome (22q11DS; velocardiofacial/DiGeorge syndrome; VCFS/DGS) is the most common microdeletion syndrome and the phenotypic presentation is highly variable. Approximately 65% of individuals with 22q11DS have a congenital heart defect (CHD), mostly of the conotruncal type, and/or an aortic arch defect. The etiology of this phenotypic variability is not currently known. We hypothesized that copy-number variants (CNVs) outside the 22q11.2 deleted region might increase the risk of being born with a CHD in this sensitized population. Genotyping with Affymetrix SNP Array 6.0 was performed on two groups of subjects with 22q11DS separated by time of ascertainment and processing. CNV analysis was completed on a total of 949 subjects (cohort 1, n = 562; cohort 2, n = 387), 603 with CHDs (cohort 1, n = 363; cohort 2, n = 240) and 346 with normal cardiac anatomy (cohort 1, n = 199; cohort 2, n = 147). Our analysis revealed that a duplication of SLC2A3 was the most frequent CNV identified in the first cohort. It was present in 18 subjects with CHDs and 1 subject without (p = 3.12 × 10-3, two-tailed Fisher's exact test). In the second cohort, the SLC2A3 duplication was also significantly enriched in subjects with CHDs (p = 3.30 × 10-2, two-tailed Fisher's exact test). The SLC2A3 duplication was the most frequent CNV detected and the only significant finding in our combined analysis (p = 2.68 × 10-4, two-tailed Fisher's exact test), indicating that the SLC2A3 duplication might serve as a genetic modifier of CHDs and/or aortic arch anomalies in individuals with 22q11DS