Safety WorkshopREQUIREMENTS FOR RISK MANAGEMENT

IN 21ST CENTURY OPERATIONSOceaneering Space Systems, Houston, 1 May 2012

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ContentIntroduction to this document 5

Introduction to Space & Energy Safety Workshop 7

The Programme 8

The Participants 9

Requirements for Risk Management in 21st Century

Operations 11

Afterword by Ron Westrum 15

Way Forward 17

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Back to HoustonTHE OFFSHORE TECHNOLOGY CONFERENCE (OTC) in Houston is, together with the Offshore Northern Seas (ONS) in Stavanger, two of the world’s leading meeting places for the global energy industry.

This year Greater Stavanger organized a delegation visit to Houston and OTC for the 22nd time! Lead by the Mayor of Stavanger, nearly 200 delegates from more than 70 companies and institutions visited OTC2012. This Space & Energy workshop was part of the delegation program.

OTC is held annually at Reliant Center in Houston. Each year, OTC attracts more than 70,000 attendees and 2,000 exhibiting companies representing more than 110 countries. The 2012 edition of the Conference ended with a record 89,400 attendees.

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Introduction to this documentSpace & Energy is a network of technology companies, knowledge and research institutions focusing on the parallel challenges and oppor-tunities within the space and energy sectors.

We believe the intersection and interaction between these two large industries will reveal a vast potential for competence and technology transfer that will generate new solutions and new busi-ness opportunities.

This document describes the Space & Energy Safety Workshop: Requirements for Risk Management in 21st Century Operations that we arranged during the OTC in May 2012 in Houston. It is not a scientific paper; it is more for inspiration and energy for further work in this exciting field.

The Space & Energy teamStavanger, June 2012

www.spaceandenergy.no  

SUPPORTED BY :

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SAFETY AND RISK MANAGEMENT is at the core of human development and well-being. It is literally the basement of the pyramid of Maslow, which describes the needs that must be fulfilled to grow and evolve as individuals, groups and society. The same counts for business. The man-agement of risk is an integrated process in all operations, but there are numerous approaches to the subject and even more techniques of implementation resulting in different outcomes and quality. The learning experience across industries is one of the reasons we meet at this work-shop.

NASA Johnson Space Center has the motto “Failure is not an option”. The iconic scene that demonstrates this slogan is from Apollo 13 and the famous quote “Hou-ston, we have a problem.” A combination of competence, training, simulations, 1:1 models, 24/7 work and passionate com-mitment saved the lives of the crew of Apollo 13 that returned safe back to Earth.

Despite the successes, accidents still happen and Challenger and Columbia are both cases to draw a lot of learning from.

The oil and gas industry has worked intensively with risk management for decades, but still serious incidents happen. These last few years we have seen some of the biggest blow-outs; Macondo in the Mexican Gulf (BP), Funiwa Deep-A outside Nigeria (Chevron) and Elgin in the UK part of North Sea (Total). This is the serious background for today’s work-shop.

The presentations today will focus both on a technical approach with advanced and sophisticated software systems along with work process re-design and training, as well as a cultural approach underlining the importance of leader-ship and values that should and must be lived by all employees and vendors. To rephrase a popular quote: “Culture eats

strategies & systems for breakfast.” However, technical systems, context and social factors are all necessary to pursue a successful integrated risk management.

I would also like to mention that the opening of the Arctic regions will strengthen the relations and inter- dependencies between the space and energy sectors because arctic operations will be even more dependent on space services such as satellite communica-tions, earth observation, monitoring, forecasts and technologies for remote operations.

A goal for this workshop is finding oppor-tunities for competence and technology transfer across industries in the approa-ches to safety and risk management.

Brage W. JohansenChairman Space & Energy

Introduction to Space & Energy Safety WorkshopThe Space & Energy Safety Workshop: Requirements for Risk Management in 21st Century Operations was hosted by Oceaneering Space Systems in Houston, close to Johnson Space Center, 1 May 2012. Especially invited were companies and individuals we knew could contribute to a discus-sion in the parallel universes of the space and energy sectors.

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Program of the workshop09:00 Registration and coffee

09:15 Welcome and introduction (Michael Bloomfield, Vice President and General Manager Oceaneering Space Systems and Brage W Johansen, Chairman of the Board Space & Energy)

09:30 Setting the scene • Finishing the Space Shuttle Program – Safety and Leadership (Bob Doremus, Associate Director, Safety and Mission Assurance NASA Lyndon B. Johnson Space Center) • Enterprise Resilience (Idar G. Voldnes, President and CEO Intrapoint)

10:00 Mismatch between skills and technology (Prof. Ron Westrum, University of Stavanger) • Man Unlimited: Technology’s Challenge to Human Endurance • Human Envelope: What is it, and how adequate is it? • Contemporary Examples of High Reliability Systems

10:30 Risk Management and Corporate Governance (Hermann S Wiencke and Richard Heyerdahl, co-founders Proactima AS) • Barriers • Management of technical and organizational changes • Handling uncertainty

11:00 Coffee break

11:30 Brainwork and dialogue (facilitated by Kenneth A. Pettersen, PhD and prof. Ole A. H. Engen, SEROS, University of Stavanger) • Based on the above; what projects and opportunities could be designed across the Space & Energy sectors?

12:30 Summary and way forward (SEROS, University of Stavanger)

13:00 Lunch

14:00 Presentation of Oceaneering Space Systems  (Michael Bloomfield, Vice President and General Manager)

14:20 Guided tour

Participants

Links to the main presenters

Oceaneering Space Systems  www.oceaneering.com

NASA www.jsc.nasa.gov

SEROS UiS seros.uis.no

Proactimawww.proactima.no

Intrapoint www.intrapoint.com

IRISwww.iris.no

THE WORKSHOP WAS SPONSORED BY :

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Brage W Johansen IRISPreben Strøm Oceaneering ASBirger Haraldseid Greater StavangerKatrine Vetlesen Prekubator TTOKenneth A Pettersen University of StavangerOle Andreas Engen University of StavangerHermann Wiencke ProactimaRichard Heyerdahl ProactimaRon Westrum University of StavangerMichael Bloomfield Oceaneering Space SystemsMichael Whitey Oceaneering Space SystemsBrian Krolczyk Oceaneering Space SystemsMark Gittleman Oceaneering Intervention EngineeringRobert Doremus NASAChristopher Hoftun Mars InstituteDavid Alexander Rice Space InstituteIdar G Voldnes IntrapointBill Nelson DNVBjørn Tore Bjørsvik Petro Media News

Rune H Rosnes Oceaneering ASAina M Berg IRISVegard Gunnarson IRISEgil Hagir Bitmap ASEyolf Bakke-Erichsen Offshore Media GroupKristoffer Skjelbred Royal Norwegian ConsulateTrygve Brekke Greater StavangerMayor Stanley Wirak City of Sandnes Mayor Ole Ueland Sola municipalityDeputy Mayor Bjørg Tysdal Moe City of StavangerCity Counselor Jon Peter Hernes City of StavangerCity Counselor Anja Berggård Endresen Sola municipalityIngrid Nordbø Sola municipalityNina Othilie Høiland City of Sandnes Anne Berit Berge Ims Randaberg municipalityStein Racin Grødem Forus Næringspark

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PresentationsBOB DOREMUS is Associate Director for Safety and Mission Assurance at NASA. He joined the Space Shuttle Program in 2004 and served several years as Manager of the Space Shuttle Program Safety Office. Prior to that he was in-volved in the Orbital Space Plane Project and worked 19 years as flight controller in Mission

Operations in the Mechanical Systems Group, supporting more than 50 missions as a flight controller.

Doremus highlighted political, fiscal, scheduling and human capital challenges the industry has to deal with when working towards safety. Morover, in order to safely complete space mis-sions, he underlined four key points:• Maintaining a mission focus – how do you achieve this?• Perseverance • Integration. Large part of job nurturing communication• Look for negative trends

The safety foundation of the mission builds on:• Technical excellence • Leadership • Process rigor

SSP SAFETY CULTURE LEGACY • Engage the entire community in risk assessment• Assess risk thoroughly & utilize full set of tools• Balance compliance with engineering judgment• Encourage Dissenting opinions• Support a challenging schedule

When the risk is understood – be willing to:• Proceed with acceptable risk or• Stand down and mitigate unacceptable or poorly

understood risk

QUESTIONS A MANAGER CAN ASK TO DETERMINE EFFECTIVE-NESS OF SAFETY PROCESSESAre issues being debated in the Program? Is there a healthy tension?• Is there trust across the Technical Organizations?• Do the Technical Authority organizations have sufficient

resources and a sufficient voice?• When decisions are made, who does the talking?

Are lines of authority and communication clear and well under-stood across the program?

Requirements for Risk Management in 21st Century OperationsThe aim of the workshop was bringing together professionals from the energy and space sectors with a mindset on safety and managing risk. The two sectors have comparable challenges working with autonomous systems and remote operations in harsh environments. Are there opportunities for competence and technology transfer in the approaches to safety and risk management?

SUMMARY BY Kenneth Pettersen and Ole Andreas Engen, University of Stavanger, Norway

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1) Tour of Oceaneering Space Systems2) Vice President and General Manager Michael Bloomfield 3) Mayors and politicians from Rogaland on tour of OSS4) Michael Whitey demonstrating OSS technology

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• Are there debates on technical and risk issues or debates over authority, roles, responsibilities?

• Are people communicating?

Are we using a good combination of Process/Compliance and Engineering Judgment?• Is there an unhealthy focus of one over the other?• Are we trying to develop Flight Rationale before we have

sufficient technical understanding?• Are we testing and analyzing to anchor our rationale in physics?

Are we framing risks effectively and understandably? Do I under- stand the bottom line, fundamental risk associated with decisions? • Are different risk assessment methods being utilized?• Do I understand where my margins are?

How do my highest risks, as identified through my risk assessment tools (Top Risk review, PRA, Reliability, Hazard analysis)compare?• Are they the same in each case? Why or why not?• Do I understand the assessment tools and their strengths

and weaknesses?• Is there commonality and communication across the program

in risk assessment?• Am I allocating resources appropriately in accordance with

my risk assessment?

How are In Flight Anomalies and Process escapes perceived?• Are they viewed as opportunities to improve the System and

Learn or opportunities for punishment?• Are they viewed as black marks and do projects oppose

accepting them?

• Are we resolving issues rigorously and thoroughly and learn-ing from them?

Am I trending effectively?• What are my trends in non conformances/Processes/Escapes?

Why?• What are my trends in the safety of my personnel? Why?• Are my trending and Non Conformance systems useful for

my projects and contractors?

Are my requirements clear and effective?• Are there debates over what the requirements mean?• Am I being asked to waive requirements frequently? – Why,

technical issue or requirements issue?

IDAR G. VOLDNES is President and Chief Executive Officer Intrapoint. He held positions of President and Senior Vice President of the Wireline and Emerging Markets division at Convergys Corpo-ration, he was President of Geneva Technology, Inc., Vice President at American Management Systems, Inc., and Chief Engineer at Telenor,

Norway’s largest telecommunications provider. Voldnes is also a board member of Wise Online Services, Inc.

Voldnes talked about the experiences of Intrapoint from work-ing with approaches to risk and safety within the oil and gas industry and aviation. His presentation focused on the potential for enterprise resilience and supportive software delivering crisis management solutions.

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RON  WESTRUM  is an Emeritus Professor of Sociology at Eastern Michigan University and Adjunct Professor at the University of Stavanger, Norway. He is a recognized expert on organiza-tional dynamics in the aviation field. He has made many presentations to international scien-tific groups such as NATO Advanced Research

Institutes, FAA and NTSB-sponsored seminars, the World Bank seminar on Systems Safety, etc. He also served for two years on a National Research Council panel to evaluate NASA’s program on Engineering Complex Systems, and on an advisory council to Human and Organizational Risk Management activities in NASA.

Westrum highlighted that although high-risk industries are overall doing better there are still gaps. We keep doing things we shouldn’t do:• Cutting safety resources • Putting undertrained people in charge• Failing to learn from experience• Taking risks we shouldn’t

Westrum also highlighted three areas that are a challenge across industries and which may be further developed through space-energy:• Requisite imagination• Hearing faint signals• Follow through and fix problems

How can industries learn from each other? Westrum pointed at four possible mechanisms:• Transfer people• Transfer principles• Transfer key techniques• Joint conferences

Can you have the same accident twice?• Challenger (1986) and Columbia (2003) shuttle explosions• Columbia: “Eerie echoes of Challenger” (Dr. Sally Ride)• Different Accidents, similar causes?• Similar cutbacks to safety staff• Similar confusion of authority• Similar “groupthink” about safety issues

RICHARD HEYERDAHL is co-founder and chair-man of the board of Proactima AS. Richard has more than 20 years of experience with risk man-agement and HSE management in a variety of activities. He has through his career held a num-ber of management positions including Head of Safety and environmental advisory services and

Risk Management Director. Richard is lecturing in areas of risk analysis, risk management, audit, accident investigations and emergency response.

HERMANN S. WIENCKE is co-founder and man-aging director of Proactima AS. He is engaged in several R&D projects related to the area of risk management and societal safety and he also lectures at the University of Stavanger (UiS) in courses related to risk management methods and tools. Hermann has more than 20 years of

experience as consultant and manager and has been engaged in projects within the oil and gas industry, transportation and health sector.

Richard and Hermann talked about how we can improve the way we manage risk. A large number of risk assessments are being performed to understand the risk, but the interaction between the technical and organization factors are often poorly understood. Key messages from their presentation were:• Experience from major accidents shows that root causes often

are a combination of technical and organization factors. Inter-action between these must be evaluated in risk assessments.

• Managers are making decisions without fully understanding the effect these decisions have on i.e. major accidents risk.

• Managers state that they are using Key Performance Indictors to monitor the major accidents risk (such as ”zero outstand-ing maintenance on safety critical equipment”), but experi-ence from accidents show us that major accidents are also caused by technical issues outside the teem “safety critical”. Do we have good enough KPI’s?

• Managing risk should be as important for a manager than managing budget.

SAFETY MATURITY?

Avia

tion

Med

ical

Nuc

lear

Offs

hore

Spca

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WHERE ARE THE LESSONS THAT INDUSTRIES NEED TO LEARN?If other industries have lessons we need, what are the mechanisms by which our own industry can learn from them?

CONCLUSIONS1. Our safety science is pretty good. 2. Our safety practice leaves a lot to be desired.3. We need to learn from other industries by listening

so we don’t have to learn by experience.

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1) ONE OF THE THINGS THAT I NOTICED was that each of the industries that has developed a safety science needs a good history of its own efforts in developing safer operations. I thought I knew some-thing of the history of aviation and medi-cal safety, but actually I found that my own knowledge had huge gaps, and was even less adequate in regard to nuclear, offshore and space operations. It might be useful to gather such histories using graduate students, a conference, and putting together a basic bibliography. These histories in turn could prove inter-esting for the other industries.

2) ONE OF THE QUESTIONS my talk posed was how one industry learns from an-other. Since I was directly involved in the process of aviation safety teaching medi-cine some of its “lessons learned” it may be useful to reflect on that experience. Much of the transfer of ideas was affect-ed by scholars or practitioners from one area who deeply immersed themselves in the culture of another industry. For instance, Jan Davies, MD, an anesthesiol-ogist, actually was given an office in the building that housed the Australian accident investigations bureau. Davies then became a kind of ambassador be-

tween the two industries. Bob Helmreich (aviation psychology) took his “crew resource management” training from aviation to medicine, and directly taught people working on this in (for instance) the Bern Kantonsspital in anesthesiology and elsewhere. James Reason spent time talking to Lucien Leape and others involved in medical safety, as well as ana-lyzing 200 incidents for the National Institute of Medicine, then wrote an interdisciplinary textbook setting forth his results. I personally was involved in two of the meetings of the United States Committee on Blood Safety and Availa-

Afterword by Ron WestrumIn the process of putting together the presentation “Ready for Prime Time? – 21st Century Safety Science” I had a number of thoughts, many of which were reinforced by the experience of the workshop itself. So here they are:

• Business performance management is a “top-down” approach, risk management is a “bottom-up”. The entire organization must be involved

• Need a holistic approach to barrier management and be able to identify changes and manage these efficiently

Risk management in 21st century operations requires the ability to:• Go from visions and goals to safe operations• Have an holistic approach to barrier management and be

able to handle management of change.

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HOLISTIC APPROACH TO BARRIER MANAGEMENT

STEP I

Identify all hazards and accident situations

STEP III

• What is the relationship between minor accidents/incidents and major accident?

• What gets measured get’s done. We have not been assess-ing major accident risks which is something different from workplace health and safety

• KPI are used for financial objectives not for safety management• The oil and gas industry has a lot to learn from the NASA

processes on • Integrating new technologies• Facilitating communication• Simulating technologies

• Higher level mistakes can be said to have dominated both sectors

• How much emersion into another industry does it take in order to achieve a level of maturity?

• Space systems safety analysis (mission assurance – that all systems are to succeed) failure mode effects analysis) the same mode of logic applies to both.

• Organizational redundancy may be a prerequisite for trans-fer of knowledge and people. How do the market conditions affect these possibilities?.

• The setting up of across industrial board of directors for companies responsible for safety critical systems.

• There seems to be an increasing tendency also to recruit personnel into oil and gas industry from other technical do-mains. One example is Halliburton Technology Centre, Hou-ston who now has recruited two of their senior leaders from outside the oil and gas industry.

• The space & energy network is aiming for an annual intern-ship for Norwegian students visiting NASA.

Loss of control

MAIN STEPS/ASSESSMENTS AND EVALUATIONS TO PERFORM GOOD BARRIER MANAGEMENTSTEP I: Assess and evaluate the overall barrier strategy for each defined situtions of hazardas accidents.STEP II: Assess and evaluate the robustness, functionality and integrety for each barrier (barrier elements and barrier functions).STEP III: Assess the technical integrity/conditions of the barriers elements

Key points from the discussions

STEP II

Barrier element 1 Barrier element 2 Barrier element 3 Barrier element 4

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bility, under the Surgeon General, to help transfer some of the key findings and introduce the key aviation safety person-nel to the medical community. A similar presentation was done by three of us from the aviation safety community to the National Association of Blood Banks. Eventually, under David Gaba, MD (UC Berkeley?) was developed a “clinical re-source management” program in anes-thesiology and I seem to remember a textbook in this was written. This was obviously the analogue to “cockpit re-source management “ from aviation.

These intensive efforts may represent the kind of cross-disciplinary sharing that one needs to do, since there is a common tendency to see one’s own industry in some way as “unique” and therefore other industries’ experiences may not be seen as relevant. Prof. Rhona Flin (Univ. of Aberdeen) told me that mostly oil-oriented safety people were not interested in, e.g. Crew Resource Management, and that she had had little success in selling CRM ideas to them. I also feel that energy and space them-selves need not limit their search for good safety ideas to each other, but should open themselves up to lessons from other industries.

So maybe we should concentrate on moving people rather than just moving ideas. I noted, in talking to safety-oriented firms at the OTC 2012, that the “Swiss Cheese Model” (for instance) had not even been heard about in Offshore safety discussions. And it was my (superficial

perhaps) impression that offshore safety was a world of its own, with relatively little sharing from other industries.

Now the professors in universities are not similarly limited, and e.g. Reason, Flin, Helmreich, Gaba, Robert Bea, etc. all have interests that are very wide. But how many people not in the nuclear industry have heard of the role of the Institute of Nuclear Power Operations (INPO) and its role in spreading safety knowledge across the nuclear industry in the USA? In my talk I noted an example of how crew resource management (“sterile cockpit”) might well have averted a collision be-tween a US submarine and a Japanese school ship. Where the relevant lessons are may not be obvious.

3) THE SPACE INDUSTRY in particular has unique problems related to safety and mission success, but so far has not at-tracted the stellar intellectual talent de-voted to aviation. So, for instance, while each of the shuttle explosions has led to an intense intellectual ferment (e.g. Vaughan’s The Challenger Launch Deci-sion and Starbuck and Farjoun’s Organi-zation at the Limit), the best discussion of the Hubble Space Telescope fiasco was an investigation by a team from the Hartford Courant, a local newspaper. The government report on Hubble, for in-stance, was far less informative. Yet the Hubble screw-up was a multi-billion dol-lar accident that required a second shut-tle mission. When NASA did a study on the causes of space accidents, for in-stance, the study was kept proprietary

and not published. (I was told I could con-sult a copy out at NASA/Ames, but not take it home) NASA in recent years killed a program that was studying space acci-dents, and which had $50 million funding.

This is not to say that there are not ongo-ing efforts, such as a web magazine and an annual conference on “Space safety and rescue” to focus on safety in space and in space operations. Does the Human Factors and Ergonomics Society have a space section? I don’t know.

What role in space safety could Norway take? Should there be a Scandanavian space safety institute, with Sweden and Denmark as partners? (I don’t know what the Germans or the French are doing. There is, of course, the International Space University, in Strasbourg, France, but I don’t know what they offer in terms of safety courses or programs.) Should one of the Norwegian universities (Stavan-ger?) develop a space safety program? I am pleased to find out there will be NASA interns from Norway. But when they return, will there be a program for them? Should there be a European Union project on space safety, if there is not one now? Should Stavanger have a confer-ence? A course? A professor? Where does this fit in with the Norwegian space center and the Norwegian space pro-gram?

4) ALL THESE THOUGHTS could be further elaborated, through further in-house dis-cussions and mini-conferences.

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SAFETY AND RISK REMAINS A KEY THEMATIC AREA of high importance for both the space sector and the energy industry. Following from the workshop discussion there is no doubt that enhanced competence and technology transfer is an idea that could con-tribute to better risk management and safer practices.

Both industries have immaturities related to their approaches to risk and safety that underlines a need to learn from other industries by listening so we don’t have to learn by experience. The presentations given during the event highlighted generic challenges linked to among other regulatory issues, financial questions, leadership approaches, human capital management and innovations and technological development.

In order to implement learning across industries there is the need to understand the mechanisms by which one industry can learn from the other. The workshop indentified four main categories that may facilitate cross industry learning. These are:• The transfer of people• The transfer of ideas• The transfer of principles and systems and • The transfer of techniques

THE SUCCESS OF ANY ONE OF THESE MECHANISMS depends on dealing with a range of inter-industrial issues, some of which were discussed during the workshop. • To what extent there exists a high degree of common concepts and thinking within

risk and safety across industries• The degree of comparable challenges technologically and organizationally between

the industries• The degree of similarities or difference related to goals and industrial values (eco-

nomically, politically and socially)• The degree of similarity concerning market conditions (e.g. oil and gas highly privat-

ized and a complex landscape of actors with challenging contractual relations, space historically more homogeneous with more stable contractual relationships)

• To what extent there are similarities or differences concerning expectations on how future market conditions will influence implementation and development of risk and safety management systems.

Way forward

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