Human Factors evaluation of Drilling and Completions equipment Abstract Sam Ranasinghe, Vikki Sanders Atkins, 920 Memorial City Way, Suite 700, Houston, TX 77024, USA A proactive approach to identify and mitigate hazards to personnel from offshore Drilling and Completions equipment was developed and implemented throughout for a major oil and gas operator in the Gulf of Mexico. Hazards were investigated in Hazard Identification (HAZID) workshops that involved a multidisciplinary team comprising of Human Factors (HF), Health, Safety and Environment (HSE), Engineering and Operations representatives. A structured task based assessment of equipment was utilized. HAZIDs were conducted at the vendor yards and on offshore Drilling rigs. All equipment was assessed and any interaction between personnel and equipment was identified. This approach identified design and operational hazards that were overlooked in previous assessments. The deliverables from the assessments included practical and actionable recommendations to mitigate the hazards. Over 635 recommendations were made. A causal and trends analysis was undertaken to identify the key causes for injuries occurring when interacting with equipment. Pinch / Crush injuries were identified as the most prevalent type of hazard and Situational Awareness was identified as the most prevalent potential cause of injuries. This paper discusses the major findings of this analysis. Introduction Safety within the Gulf of Mexico Oil and Gas industry became the focus of attention around the world after the Macondo Incident in April, 2010. Preceding this incident Safety was cited as a priority throughout the industry. Industry safety statistics show that the recordable and lost time incidents in US waters have been lowering slightly but constantly over the past 5 years (IADC, 2008). Total recordable incidence rates for US Offshore workers improved 7% between 2007 and 2008 (IADC 2008). The focus on safety had multiple drivers; regulatory; financial, including insurance premium reduction and the cost of lost time; and corporate responsibility, which highlights the importance of employee well being. Recent drivers include the now mandated API RP 75 which applies to all offshore operations in US Federal waters. This legislation requires more focus on hazard management in operations with a more proactive approach to be taken. One major oil and gas Drilling Operator recognized that their recordable incidents in the Gulf of Mexico region primarily involved third party contractors and their equipment. To reduce these incidents, they initiated a proactive multi disciplinary, safety program involving personnel from Human Factors (HF), Health, Safety and Environment (HSE), Engineering and Operations from within their own staff and third party contractors. This program involved thorough assessments of all Drilling and Completions equipment across the vendor supply chain with the aim of identifying and eliminating hazards to personnel. Initially finger and hand pinch points were the focus but the scope quickly expanded to include any hazard and any potential safety issue. A detailed approach utilized a task based Hazard Identification (HAZID) process in which the input from operations staff was integral to the process. This was to ensure that the issues raised were relevant and pertinent to the operators using the equipment and that the interaction between the operator and equipment remained in focus. This process complemented other HSE initiatives such as offshore hazard hunts and Job Risk Assessments. However this systematic approach identified many equipment and procedural hazards that were not raised previously.
Approximately 40 HAZIDs were conducted with 25 different vendors across the Gulf of Mexico supply chain. The equipment assessed ranged from complex machinery such as Casing Tongs and Bucking Machines to simple equipment such as transportation baskets and pipe wrenches. Engaging with vendors across the supply chain demonstrated the Operator s commitment to offshore safety and safety leadership. In light of the initiative s success in the Gulf of Mexico, the operator has extended the program to other locations around the world. Methodology A systematic task-based approach was utilized. A task analysis was undertaken to gain an overview of the equipment being analyzed and to increase understanding of the key steps involved, particularly those tasks which are hands on and carried out most frequently. This task analysis encompassed all aspects of equipment use including: Transportation to the rig Rig up Operations Rig down Maintenance Storage. This task analysis was deliberately kept to a high level so the focus remained on the key tasks being analyzed. Task information was collated prior to each HAZID with input from the vendor and Operator engineers. This early engagement with the vendor ensured they clearly understood the objectives of the HAZID and obtained their commitment into the process from the start. Each of the HAZIDs were conducted at the vendor site. They were facilitated by Human Factors engineers and involved a multidisciplinary team with representation from, HSE, Engineering and Operations personnel who were familiar with the equipment. Input from operations staff was vital to each HAZID. This provided the team with the necessary operational understanding of equipment use that may have been missing during earlier engineering design activities. Having floorhands present in the HAZID allowed them to explain in detail how the equipment is used in reality rather than what may be described in procedures. During the HAZID the previously prepared task analysis was used as a template for discussion and as a tool to ensure the attendees considered the different tasks involved with the equipment and where potential hazards might occur. As the HAZID was conducted at the vendor site, the equipment was available to be examined. It also provided an opportunity for the operators to show how the equipment would be loaded out from the shop, how it is used in practice and where the potential hazards would lie. During each HAZID a bespoke guidewords list was used to stimulate discussion and to ensure that a wide range of hazards (from dropped objects and finger pinches through to chemical and ergonomic risks) were considered. To ensure more emphasis was placed on Human Factors issues, more HF related guidewords were used (e.g. Reach, Access / Egress, Controls, Displays) compared to conventional HAZID guidewords lists. When a hazard was identified, it was risk ranked in line with the operator s Risk Ranking matrix as shown below in Figure 1.
Figure 1 Risk Ranking matrix Very Unlikely 1 Unlikely 2 Likelihood Possible 3 Likely 4 Very Likely 5 Multiple Fatalities 5 15 19 22 24 25 Consequence Fatality 4 10 14 18 21 23 Lost Time Injury 3 6 9 13 17 20 Medical Treatment Injury 2 3 5 8 12 16 First Aid Injury 1 1 2 4 7 11 Hazards were recorded and risk ranked based on the severity of the consequence and likelihood of occurrence. The risk ranking color determined the classification of the hazard which then supported the discussion and decision making on whether extra mitigations needed to be applied for the identified hazard. The higher the risk ranking number the more severe the risk was deemed. Mitigations to hazards were discussed within the team and were recorded as recommendations. Ideally, these recommendations would entirely eliminate the hazards, as this was the preference of the Operator and was in line with their hierarchy of controls for hazards. The mitigations ideally would rely less on the human being, therefore safeguards such as procedural changes and PPE were seen as the last line of defense and least effective. The discussion of proposed recommendations was thorough and required agreement from both the Operator and the vendor. Each recommendation was carefully made so it was pragmatic, practical and did not introduce new hazards into the operation. Many recommendations were proposed during discussions, but were subsequently discarded as it was felt that the recommendations would overcomplicate the process and lead to extra hazards with the operation. Having a collaborative approach in proposing recommendations helped to ensure that the vendor was committed to follow through and implement them. Results Hazards In total, from the 40 HAZIDs conducted, 647 hazards were identified with 635 recommendations made. Given the variety of equipment, numerous types of hazards were identified. They varied from those that could cause a First Aid Injury to those that could cause Multiple Fatalities. After analyzing the data it could be seen that most hazards could be grouped under dedicated categories as similar hazard types were recurring in the assessments. In order to better structure the analysis, the hazards were rationalized under 7 key categories: Pinch / crush Muscle / back strain Lacerations Slips / trips / falls
Dropped object Impact Other The data were independently judged and rationalized into categories. These were subsequently assessed by other study team members to ensure integrity of given categories. The Pinch / crush hazard category refers to hazards where fingers, foot or body could be pinched or crushed by equipment. Examples include pinch points due to a basket lid closing inadvertently or crush points due to moving equipment. The Muscle / back strain category primarily refers to manual handling related hazards. The Lacerations category refers to hazards where an operator may be cut from handling or brushing past equipment. An example includes cuts from sharp edges on cotter pins. The Dropped object hazard category refers to hazards caused by dropped objects falling from equipment and hitting an operator. This type of hazard was particularly pertinent for mechanically lifted loads. The Slips / trips / falls hazard category refers to situations where an operator may slip, trip or fall when using equipment, e.g. falling from a work platform or trip hazards from cables. The Impact hazard category refers to where an operator could be hit or impacted by equipment, e.g. swinging loads or whipping hoses. The Other hazard category refers to those hazards which had only a few occurrences and therefore did not warrant having a dedicated category, e.g. chemical or electrical exposure or burns. Figure 2 below details the % breakdown of identified hazards. Figure 2 % breakdown of hazard type Other Lacerations 4% 7% Slips / trips / falls 9% Pinch / crush 42% Impact 11% Muscle / back 11% Dropped object 16% As can be seen from Figure 2, Pinch / crush is identified as the hazard type with the highest frequency (42%). This is followed by Dropped object (16 %) with Muscle / back strain and Impact being the 3 rd most frequent categories (11%). Consequences As was mentioned in the Methodology section, each identified hazard was risk ranked using the Operator s Risk Ranking matrix. The risk matrix was based on Consequence and Likelihood. Figure 3 below shows the % breakdown for the Consequence as defined by type of injury for the identified hazards.
Figure 3 - % breakdown of Consequence Fatality 12% Multiple Fatalties 1% Medical Treatment Injury 20% Lost Time Injury 38% As can be seen from Figure 3, Lost Time Injuries were identified as being the most frequent type of injury (38%). This is followed by First Aid Injury (29%) and Medical Treatment Injury (20%). Most hazards were deemed to be in the low to medium risk category. Causes The key causes for the hazards were determined. As the majority of hazards had more than one identified cause, the hazard causes were rationalized under key categories: Situational awareness Organizational failures Manual handling Working environment Equipment functionality Equipment design First Aid Injury 29% These rationalized categories were also independently assessed by study team members to ensure reliability of category. The Situational Awareness category refers to causes where an operator does not have full awareness or cognizance during an operation. Examples of causes include poor hand or body placement or poor communication between operators. The Organizational failure category refers to causes where organizational issues were identified as a contributing factor to the hazards. Examples include inadequate training, poor planning or not restricting access to an area. The Manual handling category refers to causes which led to related muscle / back strain related hazards. Examples include heavy loads, improper manual handling technique or repetitive motion. The Working environment category refers to causes where the working environment contributes to the hazards. Examples include weather conditions, rig motion and poor housekeeping. The Equipment functionality category refers to causes where the functionality of the equipment was identified in contributing to the hazard. Examples include over pressuring of equipment and improper securing of equipment. The Equipment design category refers to causes where the design of the equipment contributed to the hazards. Examples include improper marking / labeling and equipment failure. Figure 4 below details the % breakdown of identified hazard causes.
Equipment functionality 13% Figure 4 - % breakdown of hazard causes Manual handling 12% Org failures 4% Situational Awareness 33% Working environment 14% Equipment design 24% As can be seen from Figure 4, Situational Awareness is identified as the most prevalent cause of hazards (33%) followed by Equipment Design (24%). Discussion Value added With 647 hazards identified and 635 recommendations made and with approximately 75 % of the recommendations closed out by the vendors, it can be clearly seen a great deal of value was added from conducting the HAZIDs. Many hazards along with subsequent recommendations were identified that had been missed in previous equipment design reviews. This proactive approach to hazard management where hazards are identified and mitigated before they occur has been very beneficial. It is commendable to the Operator for driving this initiative and committing the resources to proactively address personnel safety on their platforms. Most of the hazards identified were ranked in the amber or green category which were deemed to be low to medium risk. Mitigations were always recommended for those few occurrences where red risk hazards were identified. However even for the low risk ranked hazards recommendations were generally made to make the equipment safer. The philosophy for the HAZIDS was to reduce the risk to as low as reasonably practicable irrespective of how low risk the hazards were deemed to be. Human Factors approach The task based approach adopted was successful in identifying hazards. This approach was different to conventional HAZIDs as it emphasized the Human Factors element in equipment design with focus on the human system interaction. Compiling a task analysis provided invaluable insight of the different tasks being conducted, e.g. whether a particular load was being lifted manually or by mechanical means, or how equipment is made up above the rotary. From conducting this preliminary screening of tasks it could be determined where the potential hazards could lie. During the workshop, discussing the task breakdown ensured the operators considered the different steps involved in the operation. This was particularly poignant for tasks which are undertaken frequently and when hands are laid on the equipment. The task based approach helped to guide the HAZID analysis of the operation
step by step. It was commented from various attendees at the HAZIDs, that this level of detail had never been considered previously and was extremely useful. Using a fresh perspective Using Human Factors engineers alternative perspective ( a fresh pair of eyes ) on the equipment was useful in identifying the hazards. The operators regular use of the equipment could lead to complacency and operators becoming immune to hazard identification or knowingly accept them as part of their normal day to day operations. The design of equipment and alternative methods of conducting operations were questioned during the HAZIDs. The this is the way it s always been done attitude is prevalent in the oil and gas industry. Therefore analyzing operations and equipment from a fresh angle and challenging the operators to think outside the box yielded beneficial results. Vendor appreciation Vendors appreciated the detailed approach of the HAZIDs and the collaborative effort with the Operator. The HAZIDs also provided a forum for floorhands to raise previously ignored safety concerns as a formal avenue was provided for issues to be identified and resolved with commercial push from the Operator. Many recommendations particularly concerning handling and pinch points (e.g. loading tool boxes and baskets) also improved the safety of equipment in the shop. All these factors ensured that recommendations were more likely to be implemented with minor push back. In addition a lot of recommendations would be implemented across the whole vendor supply chain. This may mean that the vendors have a commercial advantage over their competitors as they have safety modifications that their competitors may not have implemented. Operator appreciation The Operator provided Drilling and Completions engineers for every HAZID when relevant. Having this attendance at every HAZID meant the awareness of safety was also heightened amongst their operations and allowed them to understand the operational hazards and issues in more detail. The Operator also can use the findings gleaned from the HAZIDs to assess and compare vendor equipment to feed back any equipment safety initiatives to their Drilling rigs. Benefits of multidisciplinary team The HAZID provided a forum bringing Operations, Engineering, HSE and HF personnel together. The different disciplines provided a useful input into the discussions. It was noted that Operations personnel were not always familiar with the engineering aspects of the equipment design. The engineers were asked to explain in detail how the equipment functions. This helped to bridge the gap between Operations and Engineering. However the HAZIDS also provided an avenue for the engineers to understand from Operations how the equipment is used practically on the rigs and any associated operational challenges. This sometimes highlighted that the use of equipment may have deviated over time from the original equipment functionality. Hazards Pinch and crush point hazards were identified as having the highest frequency. This was the initial focus for the HAZIDs and correlates with the Operator s findings that most hazards with 3 rd party equipment are associated with hand / finger injuries. These findings highlight the hands on nature of Drilling and Completions work. Most of the pinch / crush injuries were identified during the rig up and rig down phases of the process. Rig up is the
phase in operations where physical and mental workload for the operators is usually at their highest. This is where potentially concentration for operators could begin to wane leading to poor hand / body placement and subsequent injury. Pinch points were identified as a recurring hazard in the design of Tool Boxes. It was noted that many vendors had Tool Boxes with heavy lids that had insufficient lid securing mechanisms. A Lost Time Injury could easily occur if the lid inadvertently closed on an operators hand. The simple fix for this hazard was to implement a secondary securing device for the lids. This is an example of simple practical fixes which could be easily implemented by the vendors. Dropped objects were identified as being the second most prevalent type of hazard. Given that most equipment transported onto the rig will be lifted overhead, dropped objects were a key focus area. It was identified that much of the equipment, particularly Baskets and Tool Boxes, did not have secondary retaining mechanism on the bolts, e.g. on ratchet strapping mechanisms. In the event of the bolts becoming loose by mechanical damage or being knocked during the lift, the whole mechanism could become loose and become a subsequent dropped object. Applying secondary retention on bolts is another example of a simple fix which could be easily implemented by the vendors. The third most frequent type of hazard was muscle / back strain. These were mainly attributed to manual handling related injuries. Manual handling of equipment is always a frequent task on Drilling rigs and it was well recognized that it could easily lead to a Lost Time Injury. Simple fixes such as ensuring the weights were labeled on the equipment were common recommendations made to vendors. This ensured that if the item was outside the manual handling boundaries, the floorhand would make provisions for mechanical handling or for increased manpower. Other examples included replacing handles with pad eyes for equipment which was deemed to be too heavy to be manual handled. Addressing manual handling hazards also denoted a cultural change. It shows that over the years more emphasis has been placed on safe behavior instead of the more traditional mindset of the floorhand completing the job quickly. Causes Situational Awareness was identified as being the key cause for the hazards (76%). This was mainly attributed to factors such as poor hand / body placement, poor communication between operators and inadvertent operation of equipment. These are causes where the operator was not fully aware of their surroundings both from a mental and physical perspective. This lack of awareness could lead to an operator inadvertently placing their hand in the wrong place, communicating incorrectly or insufficiently or inadvertently operating equipment without realizing another operator is in close proximity. All these scenarios could lead to serious hazards occurring. It is documented that Drilling team members recognize that interpersonal skills, such as teamwork, communication, and leadership, contribute to safe and effective task performance. However it also reported that communication and leadership could be improved (Crichton, 2005). The identification of Situational Awareness as a prevalent cause highlights that most hazards are attributed to the behavior of the operators and their understanding of their surroundings. This complements the Human Factors approach taken in the HAZIDs where the equipment was assessed with focus on the human / system interaction. Understanding equipment operation should not solely focus on the equipment. Other issues taken into account during the HAZIDs include how the operator interprets their surroundings, communication between the operators and whether the operators hand and body position are in a safe position when using the equipment.
The lack of awareness can introduce further questions on other factors which affect the operator s ability to keep focused on the job. Complacency was cited as a key factor to why hazards tend to occur. Sometimes steps in the procedures are ignored as the operators feel they already know the process and it is therefore acceptable to take shortcuts. This can lead to a false sense of security where operators believe they are immune to getting injured on the job. Drilling operations are traditionally completed under time pressure. This may mean an operator is more likely to incorrectly conduct a task with safety being compromised in favor of getting the job done. Fatigue can also be an issue, when an operator s concentration is low, he / she is more likely to commit an error, e.g. place their hand in the wrong place. The compromise of safety and fatigue management on a Drilling platform relate back to the culture of the organization they are working in and how serious safety is considered within the organization. When investigating incidents or near misses on rigs, the analysis needs to deeply focus on the root causes why the operator committed the error. Equipment design is only part of the reason incidents occur, organizational and cultural issues are also significant contributing factors. Conclusion From the HAZIDs conducted so far, approximately 647 hazards have been identified with 635 recommendations being made. A wide array of hazards have been identified from mainly pinch / crush to dropped objects to manual handling to impact injuries. Most recommendations have been implemented which highlights the significant added value of undertaking the HAZIDs. It has been highlighted that experience, training and procedures are not always sufficient safeguards to prevent hazards from occurring. Analyzing the equipment, deducing what kinds of hazards can occur and proposing subsequent mitigations is a valuable proactive process. These HAZIDs identified many hazards which were not identified before. The assessments were facilitated by Human Factors personnel who have the mindset and background to analyze the equipment design whilst systematically taking into account the human element. The benefit of the HAZIDs has been well recognized with safety awareness being raised amongst the vendors and within the Operator s own Drilling team. This process is straight forward and under the guidance of Human Factors input can be applied to both offshore and onshore environments and across a range of industries. This initiative highlights the benefits of adopting a proactive approach to hazard management. References 1. IADC ISP Program - Summary of Occupational Incidents, 2008 2. API RP 75 - Recommended Practice for Development of Safety Environmental Management Program for Offshore Operations and Facilities, 2004, American Petroleum Institute 3. Crichton, M., 2005. Attitudes to teamwork, leadership, and stress in oil industry drilling teams