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Control room mentality - the best way to improve safety?

Friday, December 2, 2011

One way to maintain the safety and reliability of a system is to have teams in charge of it, said Dr Emery Roe of the Centre for Catastrophic Risk Management, University of California, Berkeley.

More precisely, to have control room personnel with a legal mandate to keep the system running safely and reliably, who are continually monitoring the system, with the expertise and capability to fix problems in real time and try to keep everything as far from risk as possible,

He was speaking at the 'Integrated Operations' conference in Trondheim, Norway, on September 13-14, organised by the Trondheim Center for Integrated Operations in the Petroleum Industry.

This system could be defined as 'high reliability management'.

This is the approach that has been taken by California Independent System Operator (CAISO), in its task of balancing the transmission grid's supply and demand of electricity, and avoiding blackouts, such as the ones in California during 2000 to 2001. The same approach has been followed by many critical infrastructures in the past, ranging from telecoms to oil and gas exploration.

These control room staff develop the skills of recognizing patterns, formulating action scenarios and understanding the threat level they are under, so they can work out the best way to keep things safe.

'They are looking at system patterns, constantly adding and updating information,' he said. 'They undertake a sophisticated form of risk appraisal.'

A set of real-time indicators were developed for CAISO control room operators to keep track of the resilience of the system, or in other words it knows when and how far the control room staff went out of their comfort zones.

You can track the number of times things get close to going wrong, how long the problems occur and how often.

It should not be surprising to hear that the resilience is lowest (or staff are most out of their comfort zone) in times of change, particularly times of unpredictable weather, and times when new software systems are introduced.

Managing supply and demand of California electricity is more difficult in April-May and September-October, where the weather can be less predictable, which means it is harder to forecast how much electricity people will need and when to repair equipment in light of summer usage.

'In 2006 there was a new piece of software which introduced much uncertainty,' he said. 'We know that hardware and software improvements can challenge the reliability of the service in ways you may not recognise.'

Dr Roe sees many parallels between how reliability of electricity supply is managed in California, and how the oil and gas industry could manage reliability of offshore operations.

At Macondo, many things went wrong at once. How many of those things had gone wrong individually in previous drilling projects (blow out preventer didn't close, staff thought cement had set and it hadn't, rig control systems not performing as expected) and was information about those shared as widely as it should have been? In other words, how often were drilling staff around the world going out of their comfort zone for various reasons? Was anyone keeping track of the frequency of 'saves', and the reasons, and so the overall system resilience?

The number of times control operators, such as drillers, go out of their comfort zone could be an important indication that standards are starting to slip and more care is needed, he said.

The Macondo investigations demonstrate the way that safety standards had drifted over time without anyone noticing, like a frog in slowly heating water. 'What was wrong becomes acceptable,' he said.

A little reported fact is that shortly before the Macondo disaster, the well's designation was changed from an exploration well to a production well, which means 'a whole new protocol came into place,' he said. Could this change have been a contributing factor to the loss of overall system resilience?

After any big changes, 'You know you're risking reliability unless there's been maximum pre-training,' he said.


Management vs control room

It is not uncommon for senior management of a company to view control room staff as both subordinate and reluctant, the people who resist management's more risky ideas to improve the business.

People talk about 'management of change' like it is a task for lieutenants of senior management to compel all staff into changing the way they do things. But in fact, 'change' can be one of the biggest causes of reduced safety.

When senior management want to introduce a higher risk strategy for business reasons, they may well have an agenda completely at odds with what control rooms across the world have learned promotes and ensure high reliability in real time services.

'The evolutionary advantage of control rooms is to reduce the risk of failure in order to ensure the safe and continuous provision of the infrastructure service. They would never increase the risk of failure to increase the change of success. From a control room setting, the CEO who ways we must risk failure is like someone who risks suicide for fear of death. If the CEO and other executives don't understand the demands imposed by having a control room on organizational performance they certainly risk business failure.'

Companies often dismiss these unique organization demands imposed on businesses whose brand is the reliability of their service. 'After years of research, I'm here to tell you that control rooms are a unique organizational formation,' he said. 'You can't ignore them any more than you can ignore a law or government regulation for reliability that affects the business brand of being reliable.'

One 'moral hazard' with control rooms is that the safer they are, the greater the temptation of senior executives and their staff to take risks. 'Every second they are reliable is one more second when a designer will take a wacky decision of how to make it better,' he said.



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