The basis for our investigation was the incident on West Epsilon in 2007 and the incident on Statfjord C in 2005. The audit was conducted as a review and included interviews of key personnel, a review of relevant governing documents and the investigation reports from the two incidents.
Background for the audit
The background for the audit was, in part, our objective of obtaining an overview of the HSE level on the Norwegian shelf. The regulations stipulate the operator's responsibility to ensure that any occurring hazard and accident situations are recorded and investigated, and followed-up to prevent them from happening again.
Purpose of the audit
The purpose of the audit was to clarify which requirements and routines had been established in SH to follow up results from investigation of incidents, both locally and across the company. We also concentrated on clarifying how the company ensures that the weaknesses and defects identified in an investigation are communicated to other parts of the company as lessons learned.
Furthermore, it is was our intention to review how lessons learned from the various investigations were followed-up and implemented throughout the organisation.
In order to obtain a good picture of the company's follow-up of these types of incidents, two incidents relating to drilling and well activities in different units were selected, and relevant personnel both locally and centrally were interviewed for follow-up.
Result of the audit
Although we identified one nonconformity and two issues for improvement during the audit, the audit reveals that SH takes the follow-up of incidents seriously. The recently established system for follow-up of safety flashes and increased use of verifications to ensure satisfactory implementation, compliance and closing of actions can contribute to better quality and follow-up of incidents.
The company's system for following up and closing actions after incidents does not sufficiently safeguard the regulatory requirements; nor does it take into account SH's own requirements for ensuring improvement and preventing reoccurrence of incidents. We have also pointed out potential improvements relating to analyses conducted of incidents and the established system for lessons learned in the company.