SPE Human factors safety report and some compelling viewing from the CSB

Neil McNaughton expresses surprise at this year’s SPE/SEG event clash. He then compares the SPE report on human factors in process safety with the ongoing efforts of the Chemical Safety Board. ‘Human factors’ are indeed key but not only in the way the SPE describes them.

Last year the annual conferences and exhibitions of upstream’s two major societies (the Society of Petroleum Engineers and the Society of Exploration Geophysicists) were back to back—one a week after the other causing some consternation in the vendor community which used to have a few weeks to recover before setting up for the other show. This year things are even more interesting as the SPE is holding its ATCE in Amsterdam the same week as the SEG’s event is taking place in Denver. A couple of years back the two societies agreed to ‘formalize an agreement for intersociety cooperation to benefit their global membership through joint events, programs and services.’ I’m not sure the diary clash is a result of this cooperation or despite it. Aren’t we all ‘cooperating’ now as we ‘break down the silo walls?’


The Society of Petroleum Engineers (SPE) Technical Report ‘Process safety: the human factor*’ (see page 11) is interesting. The report results from a two day event that took place in Houston in July 2012. The summit was organized in response to the US national commission on the Deepwater Horizon oil spill which ‘set out the need for sweeping reforms that would accomplish no less than a fundamental transformation of the oil and gas industry’s safety culture.’ The SPE meet focused on such ‘human factors’ in process safety with the aim of creating a ‘common understanding of the strategic challenges for the oil and gas industry, to identify what is known and unknown in the field, and to explore actions required to accomplish the needed change.’

Now this is all very worthy stuff but it raises several questions. The SPE’s initiative merits further investigation. In fact the authors encourage organizations to ‘continually assess safety performance and to be chronically dissatisfied.’ As a chronically dissatisfied sort of a person I thought that I would offer a few ideas.

Firstly we don’t know who the attendees at the summit were and so it is not clear who is authoring the report. It could be that the authors are the top safety experts from oil companies and their safety system providers, managers (who may or may not have safety qualifications), petroleum engineers wanting to learn more or folks interested in having a few days away from the office. There is a problem of the report’s authority here.

Next there is the report’s title. Not so much the ‘human factors’ part (although that is a bit of a mouthful). Rather the ‘process’ side of the equation. The report’s focus is not process control system safety per se. It is not about business process safety per se either. In fact I’m not sure exactly what safety issues are being addressed here, nor what exactly is the petroleum engineer’s role in all this? There may be a little societal scope creep here, I am not sure.

The third thing is that it is much easier to enumerate problems than fix them. What would be good would be to hear some examples of how things go wrong and how safety systems fail. One learning from other safety conferences that we have reported on is that it is a good idea to ‘walk the plant’ i.e. for managers, safety and otherwise, to get out in the field and to see for themselves what is really going on.

The SPE report advises the industry to seek inspiration in the approach to safety as practiced in aviation and nuclear power even though recent developments in aviation and nuclear make one wonder if they are that much better than oil and gas. The report also has resulted in an SPE ‘human factors’ technical section, website and discussion board. These may be doubling up on the existing HSE community, although I had a job navigating the SPE.org website and could not easily evaluate the different communities.

There is another organization that does a great job at ‘walking the plant,’ although unfortunately, it does this after an accident has happened. This is the US Chemical Safety Board (CSB). The CSB considers oil to be a chemical and considers oil and gas incident investigation to be in its remit. The CSB investigates major incidents and has just produced its final report on the 2010 Tesoro refinery fire in Anacortes Washington. The CSB is to produce its final report on Deepwater Horizon next month, and we will of course be providing a summary.

Following its investigations the CSB produces telling videos that use avatars and virtual reality to produce what makes for, I confess, very compelling viewing for the mawkish. But the CSB’s videos are also compelling in a good way, in that they provide exposure to a range of different ‘human factor’ related contributions to different incidents.

From my viewing of a limited number of the CSB’s videos it appears that accidents are not generally caused by esoteric failings that need fancy new technology or a ‘process’ change. They are more likely caused by a failing to apply already well-established minimum industry practices. Sometimes they are caused by a failure to fix what regulators or in-house experts have already flagged as dangerous situations.

The Tesoro report found that the refinery had a ‘long history of frequent leaks and occasional fires during startups.’ The API specs for the steel used and for the risk based inspection technology were both ‘written permissively.’ The CSB found multiple instances in other refineries of steel failing in similar circumstances.

Other CSB videos make it clear that if you walk your plant and it looks rusty and clapped out, it probably is. If you have unfenced installations near centers of population then kids will likely use them as playgrounds and may blow themselves up.

Unfortunately, regulatory capture and pressure from multiple stakeholders to keep old plant running beyond its safe lifetime, and other ‘human’ not to say political factors come into play.

* A free download from the SPE.

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