A technique for the retrospective and predictive analysis of cognitive errors for the oil and gas Industry (TRACEr-OGI)

Human error remains a major cause of several accidents in the oil and gas (O&G) industry. While human error has been analysed in several industries and has been at the centre of many debates and commentaries, a detailed, systematic and comprehensive analysis of human error in the O&G industry has not yet been conducted. Hence, this report aims to use the Technique for Retrospective and Predictive Analysis of Cognitive Errors (TRACEr) to analyse historical accidents in the O&G industry. The study has reviewed 163 major and/or fatal O&G industry accidents that occurred between 2000 and 2014. The results obtained have shown that the predominant context for errors was internal communication, mostly influenced by factors of perception. Major accident events were crane accidents and falling objects, relating to the most dominant accident type: ‘Struck by’. The main actors in these events were drillers and operators. Generally, TRACEr proved very useful in identifying major task errors. However, the taxonomy was less useful in identifying both equipment errors and errors due to failures in safety critical control barriers and recovery measures. Therefore, a modified version of the tool named Technique for the Retrospective and Predictive Analysis of Cognitive Errors for the Oil and Gas Industry (TRACEr-OGI) was proposed and used. This modified analytical tool was consequently found to be more effective for accident analysis in the O&G industry

Promoting novelty, rigor, and style in energy social science: towards codes of practice for appropriate methods and research design

A series of weaknesses in creativity, research design, and quality of writing continue to handicap energy social science. Many studies ask uninteresting research questions, make only marginal contributions, and lack innovative methods or application to theory. Many studies also have no explicit research design, lack rigor, or suffer from mangled structure and poor quality of writing. To help remedy these shortcomings, this Review offers suggestions for how to construct research questions; thoughtfully engage with concepts; state objectives; and appropriately select research methods. Then, the Review offers suggestions for enhancing theoretical, methodological, and empirical novelty. In terms of rigor, codes of practice are presented across seven method categories: experiments, literature reviews, data collection, data analysis, quantitative energy modeling, qualitative analysis, and case studies. We also recommend that researchers beware of hierarchies of evidence utilized in some disciplines, and that researchers place more emphasis on balance and appropriateness in research design. In terms of style, we offer tips regarding macro and microstructure and analysis, as well as coherent writing. Our hope is that this Review will inspire more interesting, robust, multi-method, comparative, interdisciplinary and impactful research that will accelerate the contribution that energy social science can make to both theory and practice

Subsea Blowout Preventer (BOP): Design, Reliability, Testing, Deployment, and Operation and Maintenance Challenges

Subsea blowout preventer (BOP) is a safety-related instrumented system that is used in underwater oil drilling to prevent the well to blowout. As oil and gas exploration moves into deeper waters and harsher environments, the setbacks related to reliable functioning of the BOP system and its subsystems remain a major concern for researchers and practitioners. This study aims to systematically review the current state-of-the-art and present a detailed description about some of the recently developed methodologies for through-life management of the BOP system. Challenges associated with the system design, reliability analysis, testing, deployment as well as operability and maintainability are explored, and then the areas requiring further research and development will be identified. A total of 82 documents published since 1980's are critically reviewed and classified according to two proposed frameworks. The first framework categorises the literature based on the depth of water in which the BOP systems operate, with a sub-categorization based on the Macondo disaster. The second framework categorises the literature based on the techniques applied for the reliability analysis of BOP systems, including Failure Mode and Effects Analysis (FMEA), Fault Tree Analysis (FTA), Reliability Block Diagram (RBD), Petri Net (PN), Markov modelling, Bayesian Network (BN), Monte Carlo Simulation (MCS), etc. Our review analysis reveals that the reliability analysis and testing of BOP has received the most attention in the literature, whereas the design, deployment, and operation and maintenance (O&M) of BOPs received the least

Risk management in the oil and gas industry : integration of human, organisational and technical factors

PhD thesis in Risk management and societal safetyThis thesis is based on the following papers, not available in UiS Brage due to copyright:Article 1: Skogdalen, J.E., Vinnem, J.E., (2011). Quantitative risk analysis offshore--Human and organizational factors. Reliability Engineering & System Safety, 96: 468–479. DOI: http://dx.doi.org/10.1016/j.ress.2010.12.013Article 2: Skogdalen J.E., Vinnem J.E., (2011). Quantitative Risk Analysis of drilling, using Deepwater Horizon as case. Submitted for Reliability Engineering & System Safety. 10 May 2011Article 3: Skogdalen J.E, Khorsandi J., Vinnem JE., (2011). Evacuation, escape and rescue experiences from offshore accidents including the Deepwater Horizon. Journal of Loss Prevention in the Process Industries, Accepted manuscript. DOI: 10.1016/j.jlp.2011.08.005Article 4: Skogdalen J.E. and Tveiten C. (2011). Safety perceptions and comprehensions among offshore installation managers on the Norwegian Continental Shelf. Invited to publication in special issue based on paper delivered to The 5th International Conference Workingonsafety.net. Røros, Norway 2010. Submitted for Safety Science, 12 November 2010. Accepted with revisions 24 May 2011. Resubmitted 09 August 2011Article 5: Skogdalen, J.E., Utne, I.B., Vinnem, J.E., (2011). Developing safety indicators for preventing offshore oil and gas deepwater drilling blowouts. Safety Science, 49: 1187–1199. DOI: http://dx.doi.org/10.1016/j.ssci.2011.03.012Article 6: Skogdalen JE., (2010) Safety engineering and different approaches. Safety Science Monitor, 14. URL: http://ssmon.chb.kth.se/vol14/issue2/2_Skogdalen.pdfArticle 7: Skogdalen J.E., Vinnem J.E., (2011). Combining precursor incidents investigations and QRA in oil and gas industry. Reliability Engineering & System Safety, 101(2012), 45-58. DOI: http://dx.doi.org/10.1016/j.ress.2011.12.009The overall objective of this thesis is to provide knowledge and tools for the major hazard risk assessment for offshore installations (and onshore plants) based on an improved understanding of the influence of organisational, human and technical (OMT) factors. This extensive objective was further described by the following sub-goals: 1. Identify and describe human and organisational barriers in risk analysis, 2. Provide knowledge regarding human, organisational and technical factors that influence safety barriers, 3. Define indicators that are suitable for the measurement of barrier performance, 4. Develop models for barrier performance reflecting human, organisational and technical factors These four sub-goals formed the basis for the more specific objectives in the articles. The Deepwater Horizon accident and Macondo blowout were important inputs for several of the articles. One important acknowledgement is that risk management of major hazards differs from managing occupational safety. Another is that managing risks in the oil and gas (O&G) industry demands a high level due to the potential severe consequences. Quantitative risk analyses/assessments (QRAs) are used for risk control in the O&G industry. An important part of the QRA process is to identify and describe barriers in risk analysis. A study of offshore QRAs (Skogdalen and Vinnem, 2011b) showed that there were large differences between the analyses regarding incorporation of human and organisational factors (HOFs). The study divided the QRAs into a four-level classification system. Level 1 QRAs did not describe or comment on HOFs at all. By contrast, relevant research projects were conducted to fulfil the requirements of level 3 analyses. At this level, there was a systematic collection of data related to HOFs. The methods for analyzing the data were systematic and documented, and the QRAs were adjusted according to the status of the HOFs. A second study of QRAs (Skogdalen and Vinnem, 2011a) revealed that the analyses largely only calculated the frequency of blowouts based on the number of drilling operations. The QRAs did not include HOFs related to drilling hazards. As seen in the Macondo blowout, most of the findings were related to HOFs such as work practice, competence, communication, procedures and management. Drilling is an iterative process where changes are made constantly. These changes add, remove or change human, organisational and technical risk influencing factors (RIFs) in order to mitigate hazards and control risks. QRAs have traditionally been focused on technical systems and capabilities. Much less attention has been given to HOFs. Revealing and understanding HOFs are of great importance for ensuring the intended safety barriers when conducting drilling operations. When a major hazard occurs on an installation, evacuation, escape and rescue (EER) operations play a vital role in safeguarding the lives of personnel. In a study (Skogdalen et al., 2011a), EER operations were divided into three categories depending on the hazard, time pressure and RIFs. The study contributes to an improved understanding of safety barriers during EER operations. Surveys are often used to measure the opinions about how organisational, human and technical factors influence safety barriers. A study (Skogdalen and Tveiten, 2011) showed that the perception and comprehension of safety differed significantly on Norwegian offshore installations between offshore installation managers (OIMs) and the rest of the organisation. The basis for the analysis was a safety climate survey completed by offshore petroleum employees on the Norwegian Continental Shelf. The OIMs had the most positive perception of the following factors: safety prioritisation, safety management and involvement, safety versus production, individual motivation and system comprehension. The different safety perception and comprehension may be influenced by group identity, different knowledge and control and issues of power and conflict. The phenomenon of different safety perception and comprehension between these groups is important to bear in mind when planning surveys as well as planning and implementing risk treatment measures. An important question with respect to the Macondo blowout is whether the accident is a symptom of systemic safety problems in the deepwater drilling industry. An answer to such a question is hard to obtain unless the risk level in the O&G industry is monitored and evaluated over time. The number of kicks is an important indicator of the whole drilling industry, because it is an incident with the potential to cause a blowout. Currently, the development and monitoring of safety indicators in the O&G industry seems to be limited to a short list of ―accepted‖ indicators, but there is a need for more extensive monitoring and understanding of correlation between indicators. Based on the experience of the Macondo blowout, possible indicators for drilling can be related to the subject areas: schedule and cost, well planning, operational aspects, well incidents, operators‘ well responses and the status of safety critical equipment. These indicators can be important inputs for QRAs as well as providing knowledge regarding how organisational, human and technical factors influence safety barriers (Skogdalen et al., 2011b). Accident investigation is the collection and examination of facts related to a specific incident. QRA is the systematic use of the available information to identify hazards and probabilities, and to predict the possible consequences to individuals or populations, property or the environment. Traditionally, QRA and accident investigation have been used separately; however, both methods describe hazards in a systematic way. The research related to including HOFs in QRA brings accident investigation and QRA closer together (Skogdalen and Vinnem, 2011). Over one hundred precursor incidents with the potential to cause major accidents in the North Sea O&G industry, are recorded every year. It is possible to combine accident investigation and QRA to develop new or improved models. This by using the available information from a precursor incident as input into the QRA methodology to identify hazards, probabilities, safety barriers and possible consequences (Skogdalen and Vinnem, 2011). This thesis argues for extended and multidisciplinary investigations of precursor incidents. Risk is managed at all levels of an organisation and in a socio-technical system. Communication between the stakeholders is essential, and unfortunately it often fails. More extensive analyses of precursor incidents can be the basis for improving the communication, management of change and understanding of potential accidents. There seems to be agreement among the stakeholders involved in the O&G industry that safety culture, operational aspects, technical conditions and the number of precursor incidents are influencing each other, but there is a lack of understanding on how and why. This understanding can be achieved by combining and improving existing methods within the framework and process of risk management. Examples of existing methods are: QRA, safety monitoring through the use of indicators, the investigation of precursor incidents and accident investigations. Integration of human, organisational and technical factors in risk assessments is a challenge that adds complexity to the existing models, but also can reduce the uncertainty. The more extensive use of indicators can support the monitoring and review process. This is important to ensure that a greater diversity of risk analysis tools actually support the improved management of risk. There is a need for extensive gathering of data across the O&G industry worldwide. Examples of data are unwanted events, precursor incidents, operational aspects and the technical conditions of safety critical equipment. Knowledge about the factors that influence risk as well as their interaction and status, is essential for managing risk and needs to be supported by data. The suggestions made in this thesis are only small steps in the process, and further research is necessary to: Improve methods for precursor incident reporting, Improve methods for precursor investigation, Extend the collection of safety indicators, Analyse the correlation among safety indicators, Improve the understanding of the correlation and possible use of safety indicators, Improve the data sets used in QRAs, and Establish an industry standard for how HOFs should be incorporated into QRAs

Legemiddelgjennomganger på sykehjem

Beboere på sykehjem ofte flere og kompliserte medisinske problemer. Dette skyldes at de bruker i gjennomsnitt fem legemidler fast daglig og at alder, organfunksjon, mentalsvikt og ernæringstilstand kan gjøre dem mer følsomme for bivirkninger og interaksjoner. Legemiddelbehandlingen blir derfor kompleks og medfører stor risiko for legemiddelrelaterte problemer. Legemiddelgjennomganger kan være et kvalitetssikrende tiltak for å håndtere legemiddelrelaterte problemer. Formålet med denne oppgaven var å finne en god arbeidsmetode for legemiddelgjennomganger på sykehjem, vurdere screening som metode og NORGEP-kriteriene som inklusjonskriterier. Fire sykehjem ble inkludert i kartleggingen av NORGEP-kriteriene og seks sykehjemsleger ble invitert til å delta i legemiddelgjennomganger. Totalt ble 164 pasienter inkludert i NORGEP-kartleggingen. Syv pasienter fikk sin legemiddelbehandling vurdert i en legemiddelgjennomgang. Blant de 164 inkluderte pasientene, hadde 54 % av pasientene treff på minst ett kriterium. Fem pasienter hadde treff på fire kriterier. Blant de syv pasientene som fikk en legemiddelgjennomgang, hadde seks pasienter treff på NORGEP-kriteriene. Alle disse seks hadde treff på kriterium 36 som førte til endringer i legemiddelbehandlingen. Blant de syv pasientene ble 14 legemidler gitt fast og 18 behovsmedisiner seponert. Det ble utarbeidet en metode for legemiddelgjennomganger, men det må gjøres flere legemiddelgjennomganger, da denne studien inkluderer for få pasienter til å konkludere. NORGEP-kriteriene ble vurdert mer klinisk relevant enn de fleste interaksjonene funnet i interaksjonsdatabaser, som kan tyde på at de er gode inklusjonskriterier

Grafisk profil for Norsk Ynglingklubb

Hovedprosjektet har hatt følgende problemstilling: Gi Norsk Ynglingklubb en ny grafisk profil. Dette vil innbære ny logo, informasjonsbrosjyre for NYK, forslag til nytt tittelhode og design for medlemsbladet Styrbord med tanke på det skandinaviske samarbeidet. Vi la opp arbeidet på følgende måte: 1. Teoristudium 2. Design av ny klubblogo og informasjonsbrosjyre som skal være ferdig til Sjølystmessen «Sjøen for alle» 8.–17. mars 2002. 3. Designe nytt utseende på medlemsbladet Styrbord som også inkluderer nytt tittelhode. Brekke om sesongens første utgave av bladet som skal være ferdig til begynnelsen av mai. Først satte vi oss inn i teorien på områdene merkevarebygging, «branding» og strategisk design slik at vi hadde fakta vi kunne støtte oss på under prosjektet. Basert på dette begynte vi å designe de ulike oppgavene. Fordi vi hadde en tidsfrist å rekke så tidlig som i begynnelsen av mars, startet vi allerede i januar med å designe logo og brosjyre. Etter messen tok vi fatt på medlemsbladet som skulle være ferdig trykt innen prosjektslutt i mai. Problemstillingen ble noe endret underveis. I utgangspunktet skulle vi designe et nytt utseende og sette opp en mal for medlemsbladet, men det utviklet seg til at vi også stod for ombrekking av årets første nummer. Bladet gikk rett fra oss til trykkeriet. Det var en spennende erfaring å operere uten mellomledd. Vi kom i mål i forhold til alle punkter i den endelige problemstillingen og vi er fornøyd med resultatet. Gjennom prosjektets gang har vi lært mye om typografi, design og viktigst av alt, teori og kunnskap bak grafisk profilering. Dessuten har vi fått satt oss enda bedre inn i programvare som kan komme godt med ute i arbeidslivet

Evacuation, escape, and rescue experiences from offshore accidents including the Deepwater Horizon

When a major hazard occurs on an installation, evacuation, escape, and rescue (EER) operations play a vital role in safeguarding the lives of personnel. There have been several major offshore accidents where most of the crew has been killed during EER operations. The major hazards and EER operations can be divided into three categories; depending on the hazard, time pressure and the risk influencing factors (RIFs). The RIFs are categorized into human elements, the installation and hazards. A step by step evacuation sequence is illustrated. The escape and evacuation sequence from the Deepwater Horizon offshore drilling platform is reviewed based on testimonies from the survivors. Although no casualties were reported as a result of the EER operations from the Deepwater Horizon, the number of survivors offers a limited insight into the level of success of the EER operations. Several technical and non-technical improvements are suggested to improve EER operations. There is need for a comprehensive analysis of the systems used for the rescue of personnel at sea, life rafts and lifeboats in the Gulf of Mexico