The Weekly Reflektion 32/2022

A management system describes the processes and procedures that should be followed to carry out all activities in a safe and effective manner. The management system should include a learning process that ensures that these processes and procedures are continually reviewed and updated from experience in their application and changes in regulations and standards.

Gas in the sea surrounding the Snorre A platform

Who complies with the management system in your company and how do you know?

On 28th November 2004 during a workover on well 34/7-P31A on the Snorre field offshore Norway, there was a gas blowout. The Snorre ‘A’ platform is a tension leg platform (TLP) and is tethered by cables to four subsea foundations on the seabed. As well as the inherent hazard of fire and explosion from the leaking gas there was also the possibility of erosion of the seabed around one of the subsea foundations and the very real danger of loss of stability and capsize of the platform. The cause of the blowout was swabbing of the well while pulling a scab liner and leaks in the casing strings that gave the gas a route to the seabed. Swabbing is the term used for reducing pressure exerted on the reservoir when pulling out with equipment. The blowout was one of the most serious that has occurred in Norway and has been the subject of previous Reflektions. 

The Petroleum Safety Authority investigated the incident and identified serious failures and deficiencies in all phases of the operator’s planning and implementation of the workover on the well. These were related to:

– Failure to comply with governing documentation

– Deficient understanding and implementation of risk assessments

– Deficient involvement of management

– Breach of well barrier requirements.

In effect the operator had not followed the processes and procedures described in the management system. As in mostMajor Accidents, the company knew how to do it, but for various reasons did not apply this knowledge.

In most organisations today the management system is available online and can be accessed through PCs, tablets and mobile phones. There are normally links set up to make it easy for the user to navigate within the system and find relevant information. There are routines to ensure only the latest version of any document can be accessed and information on document revisions and why the documentation was revised. There is usually a learning process that describes how experience from ongoing activities, including investigations into incidents and accidents, should be used to review and update the processes and procedures. The management system should contain ‘best practices’ and make the accumulated knowledge of the company available to everyone that uses the system. 

The modern management system also includes indicators for who is using the system and how often. This information is of course anonymised however it can often reveal interesting statistics. One company in Norway carried out an analysis of this information and revealed that the people that use the management system least are the management themselves. Perhaps they feel that they know the processes and procedures so well they don’t need to use the system. Perhaps they feel that compliance with the system is for the rest of the organisation and doesn’t apply to them. Perhaps they feel constrained and want to be able to innovate and find new ways of doing things. Perhaps they have never taken the time to familiarise themselves with the system.

Reflekt AS