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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Page R4
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Page R6
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Page R8
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
×
Page R9
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.
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Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Prepublication Copy Uncorrected Proofs THE HUMAN FACTORS OF PROCESS SAFETY AND WORKER EMPOWERMENT IN THE OFFSHORE OIL INDUSTRY PROCEEDINGS OF A WORKSHOP Steve Olson, Heather Kreidler, Rapporteurs Steering Committee on the Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: A Workshop Board on Human Systems-Integration Division of Behavioral and Social Sciences and Education ADVANCE COPY NOT FOR PUBLIC RELEASE BEFORE Thursday, April 26, 2018 9:00 am. EDT

PREPUBLICATION COPY- UNCORRECTED PROOFS THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 This activity was funded by the Gulf Research Program Fund. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization that or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/25047 Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2018 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. The Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/25047.

PREPUBLICATION COPY- UNCORRECTED PROOFS The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president. The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine. Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

PREPUBLICATION COPY- UNCORRECTED PROOFS Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

PREPUBLICATION COPY- UNCORRECTED PROOFS STEERING COMMITTEE ON THE HUMAN FACTORS OF PROCESS SAFETY AND WORKER EMPOWERMENT IN THE OFFSHORE OIL INDUSTRY: A WORKSHOP DAVID REMPEL (Chair), Professor of Medicine Emeritus, Department of Medicine, University of California, San Francisco LILLIAN ESPINOZA-GALA, Owner, LEG Exploration Education LLC; Secretary for SPE Evangeline Section; Director at Large on SPE International Human Factors; and Member, American Association of Drilling Engineers RHONA FLIN, Professor of Industrial Psychology, Aberdeen Business School, Robert Gordon University PHILIP (PHIL) J. GROSSWEILER, Chair, Human Factors Technical Section, Society of Petroleum Engineers; and Principal Consultant for Risk Management, LNG Projects, M&H Energy Services LAUTRICE (MAC) MCLENDON, General Manager – Safety and Environmental Gulf of Mexico, Shell Oil Company NAJMEDIN (NAJM) MESHKATI, Professor of Civil/Environmental Engineering, Industrial & Systems Engineering, and International Relations, University of Southern California STEVEN (STEVE) RAE, Former President, Global Transition; Independent Business Consultant; and Member, Society of Petroleum Engineers and International Association of Drilling RANDALL (RANDY) L. SAWYER, Chief Environmental Health and Hazardous Materials Officer, Contra Costa County, California Health Services Department National Academies of Sciences, Engineering, and Medicine Staff HEATHER KREIDLER, Study Director TOBY WARDEN, Board Director TINA LATIMER, Program Coordinator v

PREPUBLICATION COPY- UNCORRECTED PROOFS BOARD ON HUMAN-SYSTEMS INTEGRATION PASCALE CARAYON, Chair, University of Wisconsin, Madison JAMES BAGIAN (NAE/NAM), University of Michigan, Ann Arbor ELLEN BASS, Drexel University DIANA BURLEY, George Washington University SARA J. CZAJA, University of Miami, Florida BARBARA DOSHER (NAS), University of California, Irvine FRANCIS (FRANK), T. DURSO, Georgia Institute of Technology ANDREW S. IMADA, A.S. Imada and Associates, Carmichael, California EDMOND ISRAELSKI, AbbVie, North Chicago, Illinois NAJMEDIN MESHKATI, University of Southern California, Los Angeles FREDERICK OSWALD, Department of Psychology, Rice University KARL S. PISTER (NAE), University of California, Berkeley DAVID REMPEL, University of California, San Francisco EMILIE ROTH, Roth Cognitive Engineering, Stanford, California WILLIAM J. STRICKLAND, HumRRO, Alexandria, Virginia MATTHEW WEINGER, Vanderbilt, University TOBY M. WARDEN, Board Director vi

PREPUBLICATION COPY- UNCORRECTED PROOFS Preface Since the 2010 Deepwater Horizon blowout and oil spill, efforts to improve safety in the offshore oil industry have resulted in the adoption of new technological controls, increased promotion of safety culture, and the adoption of new data collection systems to improve both safety and performance. As an essential element of a positive safety culture, operators and regulators are increasingly integrating strategies that empower workers to participate in process safety decisions that reduce hazards and improve safety. According to a report released jointly in 2016 by the Transportation Research Board and the Board on Human-Systems Integration of the National Academies of Sciences, Engineering, and Medicine titled Strengthening the Safety Culture of the Offshore Oil and Gas Industry, such safety advances are part of a gradual process as the industry changes “from one with a risk-taking attitude to one in which anyone can raise a safety concern or stop work on a job because of safety issues.” While the human factors of personal safety (e.g., ensuring that workers wear appropriate personal protective equipment) have been studied and widely adopted in many high-risk industries, process safety—the application of engineering, design, and operative practices to address major hazard concerns—is less well understood from a human factors perspective, particularly in the offshore oil industry. Progress in advancing such process safety improvements in the offshore oil industry will require identifying, researching, developing, refining, and applying current scientific findings from the social and engineering sciences to ensure that workers are best prepared to recognize and act appropriately to mitigate hazards—in particular, actualizing the ability for a worker to report probelsm to supervisors or regulators to prevent a dangerous outcome. The workshop that is the subject of this proceedings was designed to synthesize scientific knowledge and explore best practices and lessons learned from other high-risk, high-reliability industries for the benefit of the research community and of citizens, industry practitioners, decision makers, and officials addressing safety in the offshore oil industry. The workshop location of Houston, Texas, allowed the workshop steering committee to structure the agenda to ensure a diversity of perspectives from both academics and industry participation via panels and audience participation. The committee hopes these proceedings and the engaging experience among participants contributes to strengthening the community of stakeholders with a vested interest in offshore safety while leading to additional knowledge building activities and subsequent positive progress in the area. There is future opportunity to consider additional workshops or consensus studies to advance research agendas for worker empowerment and process safety that both draw upon and advance the application of the social and behavioral sciences in working toward safer operations in the industry. vii

viii PREFACE This Proceedings of a Workshop was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this report: Dave DeJoy, Workplace Health Group, Department of Health Promotion and Behavior, College of Public Health, University of Georgia; Ron McLeod, Independent Consultant; Roland L. Moreau, Independent Consultant; Christiane Spitzmueller, Center for ADVANCING Faculty Success, Office of the Provost, University of Houston. Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the report nor did they see the final draft of the report before its release. The review of this report was overseen by David H. Wegman, School of Health and Environment, University of Massachusetts, Lowell. He was responsible for making certain that an independent examination of this proceedings was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the rapporteurs and the National Academies. I wish to express my deep appreciation to the members of the workshop steering committee for their diligent and dedicated contributions to this workshop within an expedited time frame. The diverse expertise and experience offered by the committee members were indispensable to the development and conduct of the workshop. The committee also benefited greatly from the expertise of Ford Brett, a member of the Gulf Research Program Advisory Board, who acted as a consultant throughout the planning process. I wish to also thank the diverse set of attendees to the workshop whose years of experience, insights and knowledge and active participation in the meeting were critical to producing the workshop report. Finally, on behalf of the entire committee, I wish to recognize the National Academies staff whose expertise and skill were essential to our fulfilling our charge. David Rempel, Chair Steering Committee on the Human Factors of Process Safety and Worker Empowerment in the Offshore Oil Industry: A Workshop PREPUBLICATION COPY- UNCORRECTED PROOFS

PREPUBLICATION COPY- UNCORRECTED PROOFS Contents 1 INTRODUCTION AND THEMES OF THE WORKSHOP 1 The Gulf Research Program and Safety in the Offshore Oil Industry 2 Challenges, Barriers, and Possible Ways Forward 3 Organization of This Proceedings 8 2 THE PIPER ALPHA AND THE DEEPWATER HORIZON 9 The Piper Alpha 9 The Deepwater Horizon 13 3 EFFECTIVE WORKER EMPOWERMENT FOR OFFSHORE SAFETY 17 A Framework for Understanding Empowerment 18 The Path to Empowerment 21 4 THE ROLES OF DIFFERENT STAKEHOLDERS 23 Empowerment throughout the Industry 23 Working across Levels 24 The Role of Middle Management 25 The Role of Regulators 26 5 BARRIERS TO EFFECTIVE WORKER EMPOWERMENT 29 Distinguishing between Personal and Process Safety 29 Four Barriers to Overcome 33 Where Research and Pracrice Meet 34 6 LESSONS FROM OFFSHORE OPERATIONS IN OTHER REGIONS 37 Workers Attitudes Around the World 37 Elected Safety Representatives in the North Sea 38 Lessons from a Safety Program in West Africa 40 Associations for Making the Voices of Gulf Workers Heard 41 7 CURRENT SYSTEMS FOR WORKER RESPONSES TO UNSAFE 43 CONDITIONS, WORKER INTERVENTIONS, AND REPORTING A System for Gathering Industry-Wide Safety Data 43 Adapting a Safety Program for the Aviation Industry 45 Enhancing Worker Empowerment in Refineries in California 48 8 TRAINING FOR EMPOWERMENT 51 Lessons from the Military 51 In Pursuit of “Felt Leadership” 53 Training for Low-Frequency, High-Consequence Events 54 The Importance of Voice 55 ix

x CONTENTS 9 IMPORTANT MESSAGES AND POTENTIAL NEXT STEPS 57 Problems and Potential Lessons Learned from the Workshop 57 Culture and Leadership 58 Lessons from Elsewhere 59 Procedures and Empowerment 60 Generating and Disseminating Data 61 A Multifaceted Approach 62 APPENDIXES A Workshop Agenda 67 B Workshop Participants 71 C Biographical Sketches of Steering Committee Members and 75 Workshop Presenters PREPUBLICATION COPY- UNCORRECTED PROOFS

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Since the 2010 Deepwater Horizon blowout and oil spill, efforts to improve safety in the offshore oil industry have resulted in the adoption of new technological controls, increased promotion of safety culture, and the adoption of new data collection systems to improve both safety and performance. As an essential element of a positive safety culture, operators and regulators are increasingly integrating strategies that empower workers to participate in process safety decisions that reduce hazards and improve safety.

While the human factors of personal safety have been widely studied and widely adopted in many high-risk industries, process safety – the application of engineering, design, and operative practices to address major hazard concerns – is less well understood from a human factors perspective, particularly in the offshore oil industry. The National Academies of Sciences, Engineering, and Medicine organized a workshop in January 2018 to explore best practices and lessons learned from other high-risk, high-reliability industries for the benefit of the research community and of citizens, industry practitioners, decision makers, and officials addressing safety in the offshore oil industry. This publication summarizes the presentations and discussions from the workshop.

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