SEMS Element – Utilizing Lessons Learned

 

If you have been in the offshore oil and gas industry for anytime, then you know one recommended practice that we have deficiencies in is recording and sharing lessons learned. This SEMSinar™ #4 blog series has been devoted to hazard analysis methodology and safety and environmental information that must be used in your evaluation. If you ask me, SEMS falls short in laying out the ground work and importance of collecting lessons learned information, how that information should be shared and when at key points in your SEMS program that information should be utilized, MOC for example.

30CFR 250.1919 mentions lessons learned briefly;

§ 250.1919   What criteria for investigation of incidents must be in my SEMS program?

To learn from incidents and help prevent similar incidents, your SEMS program must establish procedures for investigation of all incidents with serious safety or environmental consequences and require investigation of incidents that are determined by facility management or BSEE to have possessed the potential for serious safety or environmental consequences.

A quick look at The Safety Directory website reveals well over a million entries related to various quality, health, safety and environmental lessons learned, guidelines, safety alerts, etc related to numerous industries including petrochemical and so on. However, there are only 4 entries into the oil and gas section of this well utilized website.

Now obviously there are other websites like the IADC which list quite a few more Safety Alerts in relation to the oil and gas industry. They have a page with numerous opportunities to gather industry specific information.

The Safety Culture Policystatement issued by BSEE on 09 May 2013 states in item #5 Continuous Improvement ‘that opportunities to learn ways of ensuring safety and environmental stewardship are sought out and implemented.’ BSEE has posted their Safety Alerts on their website as well. They go back to 1972 if you click on the for previous years Safety Alerts.

BSEE is a member of the International Regulator’s Forum for Global Offshore Safety and according to that organizations objectives item 2(b)(iii) the sharing of lessons learned will be required of the government agency members. I recommend a look at their link page. As BSEE has not laid out any framework for recording of lessons learned and how you should communicate that valuable information to the rest of the industry, it is unclear how they will gather that documentation.

However, recently the Center of Offshore Safety (COS) held a meeting to discuss lessons learned and audit improvement opportunities. One of the stipulations of being a member of the COS is that your audit results will be anonymously published along with all of the other members. This is vital for the industry to address areas that contain opportunity for improvement. Also, Black Elk Energy recently held a conference for operational safety and environmental performance on the OCS where lessons learned from the West Delta 32 Incident Investigation and the findings from their I3P audit were major topics of discussion. BSEE has worked closely with Black Elk since the incident at West Deltas 32 last year.

I feel as an industry we should focus more on the prevention in lieu of the reaction. Audits conducted with the mind set of locating opportunities for improvement in lieu of the standard audit mind set of just get it done, will benefit the company the most. You should not be leery to share your audit findings and corrective actions as that is a sign of success.

Recording and reporting of near misses is of vital importance. By definition a near miss is an event that did not result in an injury, fatality or damage only by a fortunate break in the chain of events. Although human error is commonly applied to the initiating event, a faulty process or procedure invariably permits the near miss to occur, and should seriously be considered as an opportunity for improvement. I will refer to the API RP 14J again as section 7.4.3 states that near misses should be part of your standard design practices. Additionally, section 7.4.1 states that compliance with standards, recommended practices and regulatory requirements represents a good practice as all of these have been developed based on lessons learned.