The Weekly Reflektion Week 36 / 2020

In last week’s Reflektion we discussed the scope of the investigation into an incident and the flexibility of an investigation team should have to broaden the terms if required. This week we will discuss the learning potential from incidents and what you should consider on how to prevent the incident happening again, anywhere.

What criteria do you use to communicate the details of an incident and the potential learning from the incident? Do you try to put yourself into the recipient’s shoes and consider, ‘what could others learn from this’?

The scope of the investigation into any incident and accident is mostly driven by the consequences and the potential consequences from the event. The potential consequences are often related to the judgement of what could have happened under slightly different (realistic) circumstances. It seems sensible to focus on incidents and accidents that have the most serious consequences whether these be actual or potential. In addition, we have limited resources available and cannot investigate every incident, so prevention of the most serious ones seems a reasonable goal.

The requirements for communicating the incident both internally and externally, for example authority reporting, and safety flashes, are normally related to the categorisation of the consequences. This again seems sensible since it seems more important to focus on prevention of incidents with high potential. There is however a challenge in this approach that is relevant for incidents during critical work where precautions have been taken in advance. The prerequisite for such a judgement is of course, that failure to carry out the identified precautions does not fall under the category ‘slightly different circumstances’. This means that many incidents are not considered serious and hence not reported. The potential learning from these is restricted to the people that actually experienced the incident.

During the skidding of the drilling rig on an integrated production/drilling installation a protection panel on the hydraulic jack used to skid the rig came loose and fell down. The panel weighed 480 kgs and was secured by retaining bolts. The panel was located above the skid control system and three people were working under the panel including the operator of the system. The panel hit the operator’s shoulder and he fell 1.5 meters to the deck below. Luckily, his injuries were not serious.  The two other people managed to move clear of the panel as it bounced down and came to rest. The cause of the incident was wear on the skid beam. The gripper designed to hold the hydraulic jack in place on the skid beam was secured with 345 barg hydraulic pressure. The wear on the skid beam caused a misalignment of the gripper that put excessive forces on the hydraulic jack and the protection panel. The bolts fractured under the forces and flew off and were later found 14 and 18 meters respectively from the skid beam. The incident was classified as serious and investigated and reported in accordance with the company’s procedure. This included information in a safety alert to other companies.

It soon emerged that an almost identical incident had occurred on another installation six months before. On the other installation the control system for the skid hydraulic system was located in a different area and the operator was not standing under the panel. The area had been barriered off to prevent any exposure to hazards, in particular falling objects, that were relevant to the skidding operation. The incident was not classified as an incident with high potential since precautions were in place, and hence was not reported outside the company. Awareness of the first incident would undoubtably have changed the way in which the work was carried out in the second incident. The skid beams could have been inspected to determine whether there was similar wear to the first incident. Additional precautions could have been taken to keep people from being under the panel when the skidding was ongoing.

Don’t just consider the consequences and potential consequences of an incident when assessing the investigation and reporting. Consider the learning potential and how likely it is that a similar incident could occur on another installation/site. Use both formal and informal channels to let people know about the incident. Utilise manufacturers’ systems for experience transfer if this is an appropriate way to facilitate learning. An email with a simple presentation including a description, a few pictures and a figure could save someone’s life.

Reflekt AS