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7 REDIRECTION OF INSPECTOR ACTIVITY TO ENHANCE THE INSPECTION PROGRAM An integral element of the modified OCS inspection program recommended by the committee is enhanced collection and analysis of safety-related data. The data collection effort must go considerably beyond the present Minerals Management Service (MMS) Offshore Information System in a three-fold purpose: 1. to support the development and implementation of sampling plans for potential incidents of non-compliance (PINCs) (and later perhaps, OCS facilities), 2. to permit systematic targeting of spot inspections, and 3. to support a variety of continuing safety analyses to be used to improve safety and environmental protection on the OCS. All three activities are essential to an ongoing "risk assessment and management" program. Data and analytic tools used for sampling plans and spot inspection purposes will center around the identification of safety trends, while those used for the ongoing safety analyses will be more varied. Carrying out this safety analysis program should not require additional resources; it can be accomplished by reprogramming of existing inspector resources that will be released through the increased inspection efficiency inherent in the recommended alternative inspection program. Given the available work force, how should the inspector activity be redirected? The answer requires an evaluation of the tasks that would effectively serve safety and environmental protection needs on the OCS. The tasks described below could and should be carried out as an integral part of any OCS inspection program. Indeed, the committee believes that one major deficiency of the present inspection program is that it does not incorporate these functions. TASK REDIRECTION For the short term, the redirection of tasks should focus on the following objectives: determining the acceptability of safety performance of all operators, improving the verification of the effectiveness of regulatory requirements, and improving the process by which emerging risks are identified. 75

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76 Determining the Acceptability of Operator Safety Performance Iwo aspects of this objective must be addressed: (1) currently less-than-acceptable operations,' and (2) currently acceptable but deteriorating operations.2 First, the focusing of inspection resources on operators who are not conforming to regulations or lease requirementseither in general or in particular aspects of their operationsand who have less than adequate safety and environmental risk control programs is and should continue to be a priority concern of the MMS. These marginal or unsatisfactory operations should be subjected to MMS surveillance on a priority basis, since deficiencies in risk controls clearly increase the probability and potential consequences of accidents leading to fatalities, personal injuries, property damage, and/or environmental harm. (These are but a few of the more obvious consequences that affect public confidence regarding OCS operations.) Next, deteriorating operations need to be identified and corrected before they deteriorate to the point that they create unacceptable safety or environmental risks. Identifying Less~than-Acceptable Operators The current process by which less-than-acceptable operators are identified is unclear. The committee was given no documentation or inspection results that identified less-than-acceptable operators. The design and implementation of a system using modern statistical data analytic sampling techniques to uniformly identify these operators is essential. An appropriate system would incorporate a variety of records, in addition to inspectors' opinions. This would require periodic records monitoring and review of a type that would shift a greater portion of the inspector's work hours to records inspections in the operators office. Real cost saving could result, because travel costs to management locations ashore, where records are maintained, would be lower and could be scheduled more efficiently than travel to and from the offshore facilities. There would be the further advantage that the inspectors could observe the development and implementation of the operators' safety and environmental risk control systems at the management level, from a perspective that is not now observed directly by inspectors. Identifying Deteriorating Operations This aspect is more difficult to address. There was no evidence that MMS regions and field offices presently are using operator inspection histories systematically to address this problem. Given the present inspection schedules for inspectors, especially in the Gulf of Mexico area, only occasionally will inspectors note deteriorating performance or get general impressions that indicate it is occurring. In the absence of formal guidelines, the MMS inspection system at best can rely only on the unstructured judgments of individual inspection personnel, with the inconsistency and subjectivity that individual judgments entail. An operator may have acceptable operations in one area and poor operations in another area due to varying operational environments or different personnel, for example. 2"Deleriorating operations" refers to the deterioration (notably piping systems) of older platforms due to age or due to the fact that depletion of the wells has made standard maintenance practices uneconomical. It also refers to deterioration of operating procedures and management attitudes affecting safety.

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77 A demonstrably more effective approach could be achieved through analysis. The records monitoring system can and should be designed to detect degradation of safety and environmental risk control systems. Data Collection and Review The inspection data system design should not be limited to scheduled inspection of operator records at operators' operations centers. Spot requests by MMS for operational, inspection, or test data, by telephone or radio communications with manned facilities should be provided for. These unannounced data requests as well as interviews of key individuals who work on the facilities would provide important information on the actual state of safety systems. The selection of key persons to be interviewed has to be carefully considered to enhance the probability of receiving reliable information. At present, there is no established mechanism by which MMS can obtain data or talk to individuals other than during the highly structured onsite inspections. Where data from an individual operator suggest there has been a deterioration of safety systems, the inspection activity could be expanded to include onshore interviews with responsible operating employees. While such information would be used primarily to identify specific deficiencies in existing safety and environmental risk control systems (and thus provide an additional data source), it also would provide a basis for shaping future inspection tactics regarding that operator. These and other indications of deteriorating safety operations would then lead to unannounced inspections of the kind now performed by MMS inspectors; but those inspections would be guided by the new safety analysis program toward specific ameliorating actions. Verifying the Effectiveness of Regulatory Requirements Efforts need to be devoted to verifying the effectiveness, (i.e., appropriateness and adequacy) of the MMS permit approval process for drilling, production, workover, and well shut-in activities, as well as the related regulations and training requirements. More feedback from actual operational conditions and experience is needed. Conceptually, the permit approval process is based in part on postulated failure modes and the installation of equipment and procedures to deal with them. However, the committee observed no evidence that this information was documented in a form that could be used by MMS inspectors to perform system evaluations during platform inspections, rather it was useful only for go/no-go compliance observations of hardware. Some kind of real-world feedback is needed to verify that regulations and training requirements are effective in controlling safety and environmental risks. Opportunities for Acquiring Verification Data Inspections should be used to provide MMS with feedback data in all the foregoing areas. The present PINC list encourages inspectors to look for specific items of noncompliance rather than accident-producing conditions or conditions promoting human error. The committee could find no clear relationship (and certainly not one that was documented) between accident prevention-on which approval, regulatory, and training requirements should be basedand the check items on the PINC list. Further, if inspectors were provided with documentation of the basis for the approvals, as well as for regulatory and training requirements, they could make more informed observations of safety-related activities and procedures on platforms. The information would allow them to identity conditions, activities, and attitudes that might degrade safety and determine how well they were

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78 being controlled by the operator's safeW programs and personnel. The observations could cover procedures and their execution as well as hardware and its performance. Information Flow and Access Considerations Information flow channels were not examined extensively, but it appeared to the committee that utilization of information from inspections was not effective due to the lack of formal criteria for its incorporation into the regional data base. Criteria and procedures for documentation and distribution of inspectors' data either verifying or raising questions about approvals, as well as regulatory or training requirements, are needed within MMS as a part of a redirected inspection effort. Also, provisions need to be made to encourage inspectors to report candidly their subjective observations and interpretations. Identification of Emerging Safety Risks Redirection of Inspection Activity Use of the inspection staff to detect emerging safety risks is another area requiring greater emphasis by MMS. As noted earlier (see Chapter 3), the current compliance inspection program is focused on detection of single-point hardware failures addressed by specific regulations. The practical effect of this "compliance" emphasis is that inspectors limit their inspection to the PINC list, the detection of non-compliance with items on it, and the enforcement actions specified in it. This approach provides little or no room or incentive for inspectors to uncover and define risks that may not be addressed in the approvals, regulations, training, or PINC list requirements. It is not clear how MMS identifies emerging risks. In any case, this function is not included in the current position description for inspectors (see Appendix E). The inspectors, who are in daily contact with current operations on the OCS, should be ~lookouts" for emerging risks, and would have the time to so act if their activity devoted to PINC list compliance were reduced; they will need retraining to be effective in this role, however. The detection of emerging risks and potential accident or mishap scenarios should be made a specifically defined function of the inspection effort. Broadening of Reporting and Investigation Criteria Additionally, the scope of the MMS investigations of certain events (accidents) should be extended. First, the definition of a mishap in MMS regulations should be changed to include: "near misses," any drilling or production disruption, and events which prompt an MMS inspector to shut down operations, such as the failure of a mud level gauge in a drilling operation. Second, operators should be required to record and investigate all mishaps, and to keep a log of the mishaps and the investigations, which would be made available to inspectors on request. This procedure would permit MMS to learn about risks on a broader basis than just major events (accidents) and mishaps that happen to occur on the platform when an inspector is present. Inspectors would thus be in a position to review with the operator while onsite any prior occurrence in which safety-critical or single-point-of-failure components or procedures broke down or failed, and also to identify the likely consequences of a similar event or mishap and how to correct the problem, i.e., any changes made by the operator as a result of the investigation.

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79 Dissemination of Investigation Results Information obtained in an event or mishap investigation should be disseminated to MMS units with a need to act, and to operators, in a manner similar to the safety alerts now used for a narrower purpose. The event and mishap data should be more descriptive, relating the event or mishap to risks, and the reports should be issued frequently. Since additional information would benefit both MMS and the operators, the change should be well received by the operators. From the standpoint of MMS, this flow of information should also be beneficial in helping to eliminate "compliance mentality and in developing a cooperative "safety attitude" among OCS operators. Action on Reports of Emerging Safety Risks Action on the information developed by these redirections of the inspection staff activity might be reflected in changes in approvals, regulations, or training requirements. To ensure that the information is utilized, a process should be established to provide inspectors with feedback about the action taken on their reports. INSPECTION FORCE CAPABILITIES Observation of MMS inspectors in the field indicates that redirection of their efforts described above would require some retraining. To accomplish records review using statistical methods, for example, inspectors would require training regarding effective procedures and analytical methods to achieve the desired results. To gather information for validating MMS requirements, retraining would be necessary to incubate an understanding of the concepts underlying the hypothetical or real accident scenarios on which regulatory requirements are based. Most of the MMS staff have had accident investigation training that is sufficient to deal with an expanded investigative function. The committee believes that with a manageable training effort the current inspectors would be for the most part responsive to and capable of adapting to the new tasks. As noted in Chapter 6, it may be necessary to recruit some inspectors over time to address the analytical needs of the enhanced program. PERFORMANCE MEASUREMENT SYSTEMS The committee was not able to obtain a clear picture of the measures used to assess performance of inspection program managers, supervisors, and inspectors. Apparently, the number of inspections completed is the primary criterion for assessing managers' and supervisors' performance. For individual inspectors, it appears that performance assessment methods and criteria may differ from region to region and district to district. The criteria for inspection force performance measurement criteria should be better delineated. Expansion of the scope of inspection activity, as described above would provide measurable benchmarks for assessing inspectors' and managers' performance. The identification of less-than-adequate operator compliance using data analysis also would enable the MMS to measure the effectiveness of the districts and regions in detecting unacceptable operations and fashioning corrective programs for operators to undertake. While measuring the number of violations cited is not important for its own sake, what is measured gets attention. Thus it is important to place a positive focus on improvements brought by inspector intervention. Accordingly, the introduction of means of measuring the work produced under the redirected efforts should be implemented by MMS before the changes are placed in effect.