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The HSE year 2008: Lessons learnt could have prevented incidents and accidents

Several incidents could have been avoided if the industry had learnt from their own and others’ mistakes. A lack of experience transfer is one of several recurring themes among the underlying causes of accidents.

“The decline in knowledge about the big tragedies is a grave concern,” said Director General Magne Ognedal at the PSA press conference concerning the HSE year 2008.

The PSA annual report “Safety – status and signals” was also presented at the press conference. The articles sum up the year which has passed and throw light on the most important safety challenges facing the industry. 
Read more

There have been several incidents with a major accident potential in 2008. And the investigations clearly identify recurring themes among the underlying causes.

Knowledge in decline
“Both the leak on Statfjord A in May and the Cracker incident at the Mongstad refinery in August had major accident potential. And in both cases, lessons learnt from previous incidents could have stopped it happening,” says Mr. Ognedal.

He underlines that no lessons learnt must be wasted in the work of preventing new accidents. He also points out the importance of insight into the big tragedies in the North Sea, and finds it worrying that many of today’s players don’t know about the disasters of the 1980s, such as Alexander Kielland and Piper Alpha.

Several features in common
In less than a year there were three incidents leading to oil discharges in the petroleum activity offshore: A loading hose rupturing on Statfjord A in December 2007, a leakage during the loading of a tanker on Draugen one month later, and oil being pumped out in connection with another incident on Statfjord A in May 2008.

These incidents – plus the Ekofisk blowout in 1997 and an oil blowout in the Gulf of Mexico in 1979 – were reviewed by Sintef last year on assignment from the PSA. The review has identified a number of common features, mainly related to weaknesses in management systems such as clear roles and responsibilities, management of competence, experience transfer, learning from previous incidents, and risk assessment of methods and equipment. (Link to relevant article "Learning difficulties")

Deficient knowledge of and respect for one’s own procedures also turned out to be a common denominator.

Experiences from investigation
An investigation is an important tool in obtaining knowledge and shedding light on the causes of serious incidents. The PSA’s summary of the main features in their own as well as international investigations conclude by mentioning several matters that give food for thought: “We see that the company management lacks knowledge of the realities, that the company managements’ own investigations rarely uncover the weaknesses, and that risk is being systematically underestimated,” Magne Ognedal maintains.

The lifeboat issue
Early in the year, all the free-fall lifeboats on Veslefrikk and Kristin (both operated by StatoilHydro) were out of operation because of a fault in the release mechanism, and once again there was uncertainty surrounding the integrity of lifeboats on the Norwegian shelf. The PSA considers this a serious matter and has launched its own investigation, which is currently taking place.

The lifeboat issue has persisted over a number of years: in the summer of 2005, a number of problems were uncovered with regard to the free-fall lifeboats on facilities in the North Sea and the Norwegian Sea. The industry, represented by OLF, has identified a number of weaknesses in design and use of materials.

Safety issues such as G-forces, seats, seatbelts and impacts against the hull have also been assessed. The objective is to arrive at a totally new industry standard for free-fall lifeboats during the first half of this year. (Link to a relevant article: More concerns over evacuation)

Noise – a silent major accident
Noise in the petroleum industry is a continuing working environment risk. Every year, about 350 instances of work-related hearing damage are reported to the PSA. If those figures are to come down, the industry must find a new approach to this challenge.

A continuing high number of hearing damage reports is an indication that personal protective equipment is an inefficient barrier, and that the industry must work much more aggressively to reduce the actual noise from its source. (Link to a relevant article: "A silent disaster)

The integration process following the merger of Statoil and Hydro led to fundamental disagreement between the management of StatoilHydro and their employees on several issues last year. It is not up to the PSA to choose solutions or decide on operating models for the company.

The PSA’s role is to maintain a close dialogue with both parties and challenge the company on all issues that relate to health, safety and the environment. It is the company management’s own responsibility to ensure that the solutions they choose are robust – and that no changes that might raise the risk level are allowed. (See separate article)