The audit was directed toward Statoil's compliance with requirements stipulated in the Major Accident Regulations, safeguarding safety-critical elements (barriers), follow-up of measures following the loading arm incident and verification of systematic work to prevent incidents, including the transfer of experience following international incidents.
The audit activity was carried out with a basis in the Temporary regulations relating to safety and working environment for certain petroleum facilities on land and associated pipeline systems and the Major Accident Regulations. The activity was also connected to the PSA's main priorities for 2010; ”Management and major accident risk”, including learning from serious incidents, and ”Technical and operational barriers”.
On the basis of these main priorities, we performed a follow-up activity directed toward measures following the loading arm incident on 20 August 2009.
The objective of the activities was to verify that the Sture terminal fulfils the requirements stipulated in the Major Accident Regulations, verify that selected safety-critical barriers are safeguarded in a comprehensive and consistent manner, and also to verify that management is involved in and contributes to systematic work as regards learning from and preventing incidents.
In general, we noted a considerable improvement as regards training and measures following the loading arm incident. However, we did identify several improvement items, especially in connection with learning from external incidents and in connection with resources and competence as regards inspection of barriers.
No nonconformities were identified.
Improvement items in relation to the Major Accident Regulations
Safety report and emergency preparedness plan are not updated
The safety report and emergency preparedness plan do not reflect the current situation. A revision is planned for both documents during the summer/early fall of 2010.
Changes to the facility are not reflected in the safety report, and the emergency preparedness plan is not up to date as regards names and telephone numbers.
Classification of equipment as regards criticality must be reviewed. Implementing this requires new criteria from the system owner (TNE). This takes time due to a lack of resources, which in turn affects the amount of outstanding maintenance work (back-log).
During interviews and presentations of maintenance work, we discovered a large number of outstanding maintenance tasks at the Sture terminal.
Improvement items in relation to learning from incidents
Learning from incidents
Learning and implementation of measures following internal incidents (at the Sture terminal) seems sufficient. For other relevant incidents, international and national, learning and possible implementation of measures seems random.
Based on interviews, the flow of information seems to mostly take place through discipline networks, and is thus dependent on personal initiative to implement possible measures. This seems to be true for all of Statoil's land facilities.
Measuring the effect of implemented measures
A system seems to be lacking for measuring the effect of implemented measures.
During interviews, we learned that a system had not been established to measure whether implemented measures have the desired effect.
Improvement items relating to follow-up of the loading arm incident
Measures following the incident
Significant improvement work has been carried out following the incident. Several key issues still remain.
During the presentation of the loading arm incident, we discovered that several of the long-term measures had not been implemented and completed. During interviews and review of documentation, we also learned that there was deficient documentation of competence and training of operators. We observed that signage in the control cabinet was poorly fastened (the glue does not hold) and that there were several signs in the cabinet that had already come loose and been set aside. Placement, securing and tagging of the pin preventing unintended emergency disconnection does not seem appropriate.
Improvement item related to safety-critical elements (barriers)
Ignition source control
There seems to be an inadequate system for follow-up and inspection of barriers to prevent ignition.
During interviews and inspections we discovered that responsibility and inspection of barriers to prevent ignition were dispersed among different organisational units and personnel. Those responsible for securing electric ignition sources had limited familiarity with how mechanical sources of ignition were secured and there was not a clear description of who should have a complete overview and overall responsibility.
It was suggested that TNE had an important responsibility without this being clearly described and very few personnel present at Sture were organisationally attached to TNE. Uncertainties were expressed concerning the boiler, which were substantiated with the fact that the boiler could be difficult to fire up, and also the number of safety systems and familiarity with these. Concern was expressed regarding possible hidden faults that could also lead to the boiler constituting a possible ignition source. Vehicle transport was also pointed out as an area needing improvement.
During interviews and review of documentation, we learned there was limited familiarity with internal company performance requirements (performance standards) for key safety barriers.