HF Integration Pty Ltd

Companies spend significant resources on auditing their systems. But how useful are these audits - and are they looking in the right places? Here, we ask whether your audits are giving you a false sense of security. #processsafety #humanfactors #safety #safetyleadership #oilandgas #mining

Can personal safety "golden rules" or life-saving rules be applied to process safety? #processsafety #humanfactors #safety #oilandgas #safetyleadership

A Final Report into the fatal naphtha release and fire at the BP-Husky Toledo Refinery was published by the CSB in June 2024. This article summarises key safety issues. #processsafety #humanfactors #safety #safetyleadership #oilandgas

A Final Report into the fatal naphtha release and fire at the BP-Husky Toledo Refinery was published by the CSB in June 2024. This article summarises key safety issues. #processsafety #humanfactors #safety #safetyleadership #oilandgas

A recent report from the IOGP (International Association of Oil and Gas Producers) outlines various workforce challenges faced by the industry. Is the oil and gas industry heading for a talent shortage? #processsafety #humanfactors #safety #offshore #oilandgas #energy

Since the recommendation for Safety Cases following Piper Alpha, they have been adopted in other industries and sectors. But how useful are they? And are they meeting the original intent? #processsafety #humanfactors #safety #safetyleadership

In this article, we explore whether any industry can learn from an incident that occurred on a nuclear power plant over 45 years ago. We question the focus on human error and outline four key lessons. #humanfactors #processsafety #safety #safetyleadership #HOP

After reflecting on the anniversary of Piper Alpha, and reviewing the latest CSB report into the Husky Toledo Refinery event, I've outlined a few thoughts on the effective handover of critical information. As Wilkinson and Lardner noted when reviewing handover arrangements in the Buncefield incident, there is plenty of guidance available on this topic, but it remains a contributory factor in many events. #processsafety #humanfactors #safety #healthandsafety

The problem with alarms Alarm management was a key topic in my previous role inspecting high-hazard facilities, and the UK HSE team provided input into a detailed publication by EEMUA (Engineering Equipment & Materials Users Association), published in 1999. This document, known as EEMUA Publication 191, became the authoritative reference, and I used this document in my inspections of alarm systems. HSE provided a summary information sheet in 2000 (“Better Alarm Handling”, CHIS6). When interfaces are designed, there may be an assumption that control room operators will always detect an alarm, know what action to take, and respond in a timely manner. However, we know from several incidents around the world that this is not always the case. For those industries that have a safety case or a safety report, it’s important not to make significant claims for operator response to alarms, unless you can demonstrate a high level of human reliability. Despite the fact that clear, detailed guidance has been available for over 25 years, this still remains a key factor in major events. I’ve just been reviewing the latest CSB investigation report into the naphtha release and fire at the Husky Toledo refinery in Ohio. On 20 September 2022, flammable liquid naphtha was released from a pressure vessel, and the vapour cloud ignited causing a flash fire. This incident fatally injured two employees, who were brothers. The incident also caused $597 million in property damage. One of the key findings of the CSB report relates to the management of alarms. It is commonly accepted that more than 10 alarms in 10 minutes is considered an “alarm flood”, when more alarms are presented than can be addressed by a single person. This target was documented in the company’s own guidance on alarms. The impact of an alarm flood is that operators are more likely to miss critical alarms or misdiagnose the situation. At the Husky Toledo incident, control room operators were almost certainly overwhelmed by alarms. On the day of the incident, between 0650am and 1849pm, a total of 3,712 alarms were recorded. In other words, the operators experienced alarm flood for a continuous 12 hours. At a critical time during the event, the six most frequent alarms accounted for nearly half of the alarm annunciations. “The high extent and duration of alarm flood contributed to the incident by overloading the board operators, contributing to miscommunication, errors, and missed alarms, ultimately leading to the fatal incident” (CSB, June 2024, p.102). If you have an alarm system, the EEMUA and HSE guidance provide an approach to help understand if you have a problem - and how to address it. Martin Anderson is a Principal Consultant, working at the intersection of human factors and process safety. #humanfactors #safety #safetyleadership #processsafety  https://lnkd.in/gCDnHHmq

The day when almost nothing went right...... As we approach the anniversary of the explosion and fires on the Piper Alpha platform (6 July 1988), I wonder what can be said about this disaster that hasn’t been said previously. One of the recommendations from the Piper Alpha Inquiry was the need to share lessons, and a huge amount has been written about this event in the past 36 years. Of course, there’s a difference between sharing and learning . . . I’d like to reflect on what this disaster can teach us about our approaches to safety. Brian Appleton, a Technical Assessor who contributed to the Public Inquiry, stated that: “Safety is not an intellectual exercise designed to keep us in work. It is a matter of life or death. It is the sum of our contributions to safety management that determines whether the people we work with live or die”. From reading the Public Inquiry into the disaster, it’s clear that the company put considerable effort into safety. The problem was both the nature and quality of these activities. For example, many design modifications had been made to the Piper platform, most notably the conversion to process gas for production. However, there was no systematic identification and assessment of the potential hazards, or adequate measures for controlling them. Lord Cullen describes the approach to safety as superficial and merely relying on qualitative opinion. It’s not widely known that nine months before the disaster, a contractor was killed in an accident on Piper Alpha. This earlier accident highlighted inadequacies in two systems that played major roles in the disaster: the permit to work system and the shift handover procedures. Unfortunately, these inadequacies were not addressed. The Inquiry heard that the company had a policy of severely restricting the circulation of accident investigation reports, severely reducing the ability to learn lessons. The company was not proactively looking for issues and didn’t effectively respond to concerns when they were raised. Systems that were meant to assure safety had been allowed to decay. The assumption was that “everything is fine” - perhaps due to high production rates (at one point it was the most productive platform in the world). However, the safety arrangements were clearly not fine. Reflection questions: What kind of safety are you doing? And are your safety systems working in practice? Martin Anderson is a Principal Consultant, working at the intersection of human factors and process safety. #processsafety #humanfactors #safety #piperalpha #oilandgas #offshore #safetyleadership