Page 63 - Well Control for Completions and Interventions

54 Well Control for Completions and Interventions

• Alert the operating company supervisor.
• Where a hydrocarbon release could trigger gas alarms at the facility,
the control room operator will need to be informed immediately.

1.1.12 Human and organizational factors
Human rather than technical failure now represents the greatest threat to
complex and potentially hazardous systems 8

Between the 1960s and the 1990s, it has been estimated that the con-
tribution of human error to accidents in hazardous technologies under-
9
went a fourfold increase. This is not because people are becoming more
accident prone, but more a reflection of the way accidents are analyzed
and the improved understanding of human factors. By the 1990s, the oil
industry was beginning to realize that human and organizational factors
were important considerations in accident cause and analysis. Following
the Piper Alpha disaster, and the publishing of the Cullen report
(November 1990), Robert Gordon University were commissioned by the
UK’s Health and Safety Executive to investigate and report on “Human
and Organisational Factors in Offshore Safety”. The findings, published
in 1997, made several observations and recommendations. These included
a recommendation that “Crew Resource Management training should be used
to teach ‘human factor skills such as leadership, team working, decision making,
assertiveness and communication, with the aim of reducing human error”. 10 The
review also noted that most of the industry used a coding system for acci-
dent reporting that was limited in terms of human and organizational fac-
tors. They recommended using a wider range of human factor codes,
more in line with those used by the marine and aviation industries.
Nevertheless, oil industry progress towards Crew Resource Management
(CRM) training remained limited, and human factors barely featured in
formal well control training, where the emphasis remained on kill sheets
and equipment. The Macondo disaster (April 2010) dramatically changed
attitudes to the importance of human factors in well control training.
The Macondo blowout killed 11 workers. It caused enormous envi-
ronmental damage along the Gulf coast, and has had a serious adverse
effect on the livelihood of the local people. As of July 2016, Macondo is
estimated to have cost BP almost $62,000,000,000. 11 A report by the
Chief Counsel to the National Commission on the BP Deepwater
Horizon Oil Spill and Offshore Drilling concluded that “all of the technical
failures at Macondo can be traced back to management errors by the companies