Accidents, Incidents and the Human Factor/Decision-Making in the Oilfield
Recorded on July 27, 2011 (90 minutes)

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This topic concerns how people and human nature contribute to major accidents, specifically in the context of drilling operations.  The session will commence with a description of a number of incidents that occurred outside the oil industry and draw parallels with what can happen in drilling operations.  Some common themes of incidents that took place between September 2010 and April 2011 will be highlighted.  Professor James Reason identified a set of characteristics that he labelled the “Vulnerable System Syndrome”, some of which we can see in our own operations, and which will be described, in particular the matter of risk denial.  The talk will consider the effects of hindsight bias on the assessment of incidents and the complexity of the systems in which operators are faced with in the field.  Whether the problem can be solved by the implementation of more rules, regulations, procedures and competency is a debatable question, because at the sharp end there will always be a gap between the written procedure and the hand on the drawworks brake.  In the short term there are certain things we can do to formalise how we plan and then control remote operations.  But in the longer term, we will need to undertake research to evaluate the working environment to identify how the incentives, opportunities and demands influence behaviour in terms of goal conflict, improvisations and adaptations to produce both good and bad outcomes.  With the insights so gained, we may be able to devise training interventions that will people to recognise the domain-specific traps that we set for ourselves.  We can then ensure that our management systems, risk assessment methods, planning procedures and protocols for operational control are designed with the resilience needed to avoid the pitfalls.

Decision-Making in the Oilfield – Dr. Patrick Hudson, Hudson Global Consulting, Delft University of Technology

This presentation will cover the bases for decision making in operational practice. While many decisions are captured in a drilling program, these are always based on incomplete information and an important part of the drilling engineer’s task is the continuous updating of what has to be done in the circumstances as they appear. This is often referred to as Situational Awareness and covers not only the real-time diagnosis of the situation, evaluation of current data against the assumptions and expectations built into the drilling program, but also a projection into the immediate future. A number of biases in thinking and decision making, such as the availability and confirmation biases, have to be understood to ensure that situation awareness is accurate and appropriate.

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John Thorogood is an independent technical advisor to operators, service companies and research institutes in the areas of technology, technical policies, drilling automation, remote area exploration projects and arctic operations.  He has researched human factors issues associated with the command and control of drilling operations.  He worked in operations and technology for BP and heritage companies from 1973 until 2007 in many parts of the world, including deep-water and frontier exploration operations in Sakhalin, the Faroe Islands, UK sector, and in Norway.  He is the author of more than 40 papers and has BA and PhD degrees from the University of Cambridge.  He has served on the Board of Directors of the Society of Petroleum Engineers, is a member of the Editorial Review Committee and a member of the SPE/IADC Drilling Conference Programme Committee.

Patrick Hudson is one of the world’s leading authorities on the human factor in the management of safety, in the oil and gas industry, in commercial aviation and in medicine. He was the Project Leader of the Tripod Research program for Shell International since 1987, was closely involved in developing Shell’s approach to safety management systems after the Piper Alpha disaster and led Shell Group’s Hearts and Minds program on the development of safety culture in the Oil and Gas industry and is now leading a new program for Shell on high consequence low probability accidents. He also advises Total, British Gas, ENI-Agip and BP.

His involvement with aviation has included working with companies such as British Airways, Swissair, Cathay Pacific, Emirates, KLM, Malaysian and Singapore Airlines, Boeing and Airbus. He often advises the United Nations International Civil Aviation Organization (ICAO) based in Montreal and is regularly engaged by the Dutch, US, Singaporean, Australian and Canadian aviation regulatory authorities.

He is increasingly asked to advise other industries, including the steel and mining industries. In 2005 was also appointed to the International Safety Expert Team overseeing the European Union’s main nuclear research reactor. He was one of the authors of the report on patient safety in the Netherlands for the Minister of Health in 2005.