Book: Offshore Safety Management
Chapter 2 - Major Events

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Overview

In principle companies implement Safety Management Systems because it is the right thing to do: they save lives, protect the environment and reduce losses of equipment and production. In fact, of course, it is human nature to respond to events after they have happened. The closing of stable doors invariably follows the bolting of horses. So it is with the offshore oil and gas industry. Safety management systems, and the matching regulations, are developed in the aftermath of catastrophic events. And companies tend to be more thorough and rigorous in the application of existing systems in the months following a catastrophe.

This chapter describes eight of the most important events that have occurred in the process industries over the last forty years. Three of the incidents occurred onshore but their impact was so profound that they affected the entire energy-related business — regardless of its location. (One of the offshore incidents — Blackbeard — was actually a non-event, but it offers profound lessons to managers at all levels.)

The importance of these events is not just to do with the loss of life and the environmental damage that was caused, but also in the lessons that can be learned from them. In particular, this chapter examines the lessons that can be learned by those designing and running offshore Safety Management Systems.

Contents

Chapter 2 - Major Events
Introduction
Santa Barbara (1969)
   The Event
   Incident Analysis
   Long-Term Impact
   Lessons for the Offshore Oil and Gas Industry
      Follow the Rules
      Public Response
      Economic Loss
   Elements of SEMS
      Operating Procedures
      Safe Work Practices
Flixborough (1974)
   The Event
   Incident Analysis
   Long-Term Impact
   Elements of SEMS
      Hazards Analysis
      Mechanical Integrity
      Management of Change
      Emergency Response and Control
Three Mile Island (1979)
   The Event
   Incident Analysis
      Follow the Rules
      Troubleshooting
      Fixation
      Critical Information Missing
      Operator-Instrumentation Interface   
      Inherent Safety
   Long-Term Impact
   Elements of SEMS
      Safety and Environmental Information
      Safe Work Practices
      Emergency Response and Control
Piper Alpha (1988)
   The Event
   Incident Analysis
   Long-Term Impact
   Elements of SEMS
      Pre-Startup Safety Review
      Safe Work Practices
      Investigation of Incidents
      Records and Documentation
Valdez (1989)
   The Event
   Incident Analysis
   Long-Term Impact
   Elements of SEMS
      Pre-Startup Review
      Safe Work Practices
Blackbeard (2006)
   The (Non)-Event
   Incident Analysis
   Long-Term Impact
   Elements of SEMS
      Safety and Environmental Information
      Safe Work Practices
Montara (2009)
   The Event
   Incident Analysis
   Long-Term Impact
   Elements of SEMS
      Hazards Analysis
      Training
Deepwater Horizon (2010)
   The Event
   Incident Analysis
   Long-Term Impact
   Lessons Learned
      Rules Should Be Followed
      Not "Taking a Risk for Safety"
   Elements of SEMS
Fukushima-Daiichi (2011)
   The Event
   Incident Analysis
   Long-Term Impact
   Elements of SEMS
      Hazards Analysis
      Emergency Response and Control
Report of the President's Commission
   Root Causes
      Management of Change
      Intervention
      Communication
      Lessons Learned
      Balancing Risk and Profitability
      Regulatory Failures
   Recommendations
      A1: Risk Management
      A2: "Safety Case" Approach
      A3: International Forum
      A4: Independent Agency
      A5: Regulatory Funding
      B1: Strengthen NEPA
      B2: Interagency Activities
      C1: Oil Spill Planning
      C2: District Plans
      C3: State and Local Involvement
      C4: Increased Research
      C5: Dispersants
      C6: Offshore Barrier Berms
      D1: Oversee Source-Control Efforts
      D2: Source Control Plans
      D3: Accurate Estimates
      D4: Proposed Well Design
   INPO
Management and Leadership
   Leadership
   Following the Rules
   Taking a Risk for Safety
   Technical Expertise
Need for New Standards