Key Programme 2 Deck and Drilling Operations

Final Report

1  Background

HSE's Offshore Division (OSD) initiated Key Programme 2 (KP2) in 2003 in response to unacceptable accident statistics from deck and drilling operations offshore. A programme review in 2005 resulted in a closer focus on the management of lifting operations offshore within these two areas of activity, lifting operations having been seen to contribute significantly to fatalities and major injuries.

This revised programme, known as KP2 Phase 2, ran from December 2005 to March 2007. Its targets were: zero fatalities and a 20% reduction, from 2001/2002 statistics, of incidents and injuries related to deck and drilling operations.

This report presents the programme findings, with guidance to industry on how these may be addressed.

2  Executive Summary

The issues arising from the HSE and STEP Change fatality reviews remain.

The recommendations of the STEP Change Fatality report are still valid.

Deck and drilling lifting related accidents are rising and this is not simply linked to increased offshore activity.

The leading management failure was that of a lack of effective auditing of the management of deck and drilling lifting operations offshore.

The leading failures subsequent to the lack of auditing were: Planning and Control; and Training and Competence.

Failures were significantly greater on MODUs than on fixed installations in regard to the drilling related topics and greater than fixed installations for all other topics.

The leading root causes of deck and drilling lifting dangerous occurrences were: Mechanical failure; dropped objects; and rigging competency.

Conclusions for HSE

Lifting during deck and drilling operations will remain an important area of work although no longer under a programme.

All programme reds have been addressed and inspectors will follow this by onshore inspections of dutyholder audit arrangements for lifting operations.

The programme templates will remain the inspection tool for the topic of lifting operations.

OSD will be writing to all dutyholders to advise them of the programme findings and directing them to review their management of lifting operations focussing on the key areas of audit, planning and control, and training and competence.

The programme manager has drawn up guidance on the auditing of lifting operations.

3  KP2 Phase 1

3.1  The genesis of the KP2 programme was an HSE workshop held in 2002 to review the investigations of five fatal accidents that had occurred offshore in the UKCS in relatively quick succession. The workshop identified three common root causes: Poor risk assessment; procedures; and supervision. It was agreed that these should become a high priority for HSE, commencing in the 2003/2004 work-year.

3.2  The industry had come to a similar position following the STEP Change Fatality Review of 11 fatalities offshore in the North Sea. A comparison of the findings of these two separate activities underlines the main root causes:

3.3  Key Programme 2 began in 2003 with an initial plan to run to 2005. The programme's objectives were:

"To permanently eliminate fatalities and to reduce accidents by 15% during offshore deck and drilling operations",

with the 2001/2002 deck and drilling statistics being taken as the benchmark. The programme objectives would be met by:

1. Targeted inspections of dutyholders engaged in deck and drilling operations when handling heavy loads, concentrating on: 
   • Risk assessment
   • Procedures and job design
   • Supervision and monitoring
2. Mandatory investigation of all deck and drilling operation related major injuries.
3. Working in partnership with industry to significantly reduce risks in these activities.

3.4 In the two years of KP2 Phase 1 (from 2003 to 2005);

• 40 drilling installations and 22 production installations were inspected and presentations given to the workforce on deck and drilling operation safety issues. Good practices were identified but there was clear management variance across the industry. No formal enforcement action was made.
  
• 28 major injuries were investigated. Root causes remained unchanged from the reviewed fatalities - risk assessment, procedures and job design and supervision.
  
• there were four main activities of the partnership working;
  • an HSE mechanical specialist working with STEP Change to produce lifting and mechanical handling guidance;
  • HSE worked with OMHEC in developing best practice training and competence guidance [PDF 150KB] for offshore crane drivers, banksmen and slingers;
  • an HSE human factor specialist working with STEP Change to develop personal responsibility for safety guidance; and
  • HSE well operations specialists involved with industry on drill floor mechanisation and developing research proposals on drill floor supervision.

4  KP2 – Phase 2

4.1 In April 2005 OSD reviewed progress with KP2. Although the accident statistics during deck and drilling operations showed a reduction of around 20% over the period of the programme, and a significant amount of programme work had been done, there were concerns that the programme had not fully tackled the key issues behind drilling and deck operation accidents. There was concern that any initial improvements in accident/incident performance would not continue in the light of the increasing drilling activity during 2005/06. As a result, the decision was taken to:

1. Continue the KP2 Programme to 2006/07 as KP2 Phase 2.
2. Amend the objectives to "permanently eliminate fatalities and to reduce accidents by 20% during offshore deck and drilling operations", to reflect the extension of KP2 by another year [with the 2001/2002 deck and drilling statistics still being taken as the benchmark].
3. Appoint a full-time KP2 Programme Manager (Dave Forsyth).
4. Seek to revitalise all aspects of the programme, with a closer link to STEP Change guidance and standards. Targeted inspections would continue but with a more consistent approach, building on lessons learned in Phase 1 and focussing in-depth on a wider range of key areas. It was agreed that all dutyholders would receive at least one full KP2 Phase 2 inspection.
5. Priority investigation of deck and drilling operation incidents would continue.

4.2 The industry was informed of the KP2 Phase 2 programme via a launch workshop in November 2005 hosted by the British Rig Owners Association. The programme concluded in the same manner in March 2007. At the launch HSE made it clear that there needed to be an open and shared agenda if any significant reductions were to be made on lifting incidents.

The inspection programme

4.3 The KP2 Phase 2 inspections were broken down into eleven inspection topics, following a review of all relevant material and sources. The topics were:

• Management of Lifting Operations
• Risk Assessment
• Training and Competence
• Planning, Selection and Control of Equipment
• Supervision
• Communications
• Violations and Procedures Ignored
• Monitoring of LOLER on the Drill Floor
• Handling Tubular's on the Drill Floor
• Man Riding
• Learning from Incidents and Near Misses

Inspection templates for each topic were developed, and these gave the background to each topic, the inspection objective and mandatory/guidance inspection questions. These templates can be found in KP2 Phase 2 Inspection Templates [PDF 190KB]. The inspector's remit was to carry out a full KP2 inspection on each of their allocated companies and to provide companies with copies of the templates.

4.4 During KP2 Phase 2, 74 inspections were carried out across all types of installations:

Number of Inspections by Installation Type

• Fixed - 37
• MODU - 18
• FPSO - 7
• Jackups - 3
• FSU - 1
• NUI - 1
• MSV - 3
• Heavy - 1
• Lift - 1
• Flotel - 2
• Dock-side - 1

Following each inspection, inspectors used a traffic-light based reporting system for every inspection topic to ensure that a comprehensive overview could be maintained of both that dutyholder's KP2 performance, and the industry overall. This was similar to that being used by OSD's sister Key Programme, KP3, which covered integrity issues. With this traffic light:

• A red signified that formal enforcement action was taken or seriously considered during the inspection.
• An amber showed that a written request for action had been made following the inspection.
• A green indicated that no significant issues had been found with that particular topic during the inspection.

4.5 Report findings were collated in a spreadsheet Matrix. Samples of these are provided in the Annex to this report.

4.6 The completed matrix was used to compare performance across the eleven KP2 inspection topics, within and across dutyholders and types of installations. The table below identifies the inspection failure rate of each topic.

The "Times Failed" refers to sum of red and ambers and "% Failed" as the percentage of this sum against the total number of inspections. For example, in the first column, the "Times Failed" is 38 (2 reds and 36 ambers) or 60% of the 63 times the topic was inspected. The failure breakdown is graphically represented in the chart below, with further, more detailed, breakdown of the failures under each topic being described in the Annex to this report.

4.7  Comparison across installation types

Only fixed and MODU installations were compared as there was insufficient numbers of other installation types to make a sensible comparison.

Fixed Installations

If the drilling related only subjects are compared (tubular handling, monitoring LOLER on the drill floor and manriding) the failure to inspection rate is: 11/57 = 19.3 %
If all other subjects are compared the failure to inspection rate is: 74/249 = 29.7%

MODUs

If the Drilling related only subjects are compared the failure to inspection rate is: 18/40 = 45% 

If all other subjects are compared the failure to inspection rate is: 41/108 = 38%

Therefore it can be seen that in respect of the drilling related topics MODUs had a 25.7% higher failure rate than fixed installations and in all other subjects an 8.3% higher failure rate.

4.8 Comparison across dutyholders

When company specific inspection results were reviewed against each other no company was found to have a single comprehensive management oversight of lifting operations. Therefore, almost all companies of more than two installations presented uneven results across the topics, as the subject in general was being left solely to offshore management to deal with. A consistent management approach to any industrial subject across several installations can only be achieved by effective management oversight of those installations. In respect of lifting operations this was not happening. This also meant that where good management was being applied, and there were many instances of this, the dutyholder was ignorant of the fact and the company and the industry lacked the benefit of such knowledge.

4.9 Enforcement during KP2

The formal enforcement action taken during KP2 Phase 2 comprised 9 Improvement Notices and 1 Prohibition Notice.

Topic:  Planning and Control

Three Improvement Notices in regard to control of lifting accessories;
One Improvement Notice in regard to lift planning; and;
One Prohibition Notice in regard to winch guarding.

Topic: Training and Competence

Two Improvement Notices were served in regard to failure to train.

Topic: LOLER on the Drill Floor

One Improvement Notice was served in regard to management of lifting equipment.

Topic: Violations and Procedures Ignored

One Improvement Notice was served in regard of failing to follow PTW procedures during a major lifting operation.

Topic: Risk Assessment

Two Improvement Notices were served; both related to inadequate risk assessments for lifting operations.

5  Incident investigations

5.1 A key part of KP2 Phase 2 was the continuation of HSE investigations of all lifting related deck and drilling operation accidents and dangerous occurrences. These investigations (for 20005/2006 and 2006/2007 - April to March) were analysed and, as can be seen below, the dominant accident root causes, although mixed in priority of occurrence, remain unchanged from the 2002 fatality review findings, namely planning (which includes risk assessment), supervision, and hazard awareness.

5.2 When analysis was made of deck and drilling dangerous occurrences over the same period the root causes were seen to be very similar year on year.

6  Statistical Results

6.1  The programme's targets were: Zero fatalities and a 20% reduction, from 2001/2002 statistics, of all other lifting related incidents and injuries. 

6.2  Statistics from 2001/2002:

6.3  Set against the programme targets the end of programme data means that these targets have been met.

6.4 However, when lifting only related deck and drilling statistics are reviewed it can be seen that there has been an overall increase in lifting related accidents.

This increase cannot be explained simply by increased work activity offshore, as has been argued by some, as the table below shows there is no such correlation.

7  Conclusions

In considering the programme findings it should be remembered that all dutyholders were provided with a copy of the inspection templates prior to an inspection being carried out. With the majority of companies this was done well in advance of inspection.

Companies could, and should, have found the failures themselves, having been provided with the same inspection tool as the inspectors. Many did take pro-active action, but failures were still found.

These failures were not difficult to uncover. Any competent safety professional, using the templates or a similarly focussed and structured inspection approach would have uncovered them.

Findings:

7.1 The programme has lead to a much more consistent and targeted regulatory approach to the subject of lifting operations offshore. This has helped raise the profile of this area of offshore safety both in the industry and to the offshore workforce.

7.2 The programme approach has been endorsed internationally by regulatory bodies with the adoption of the inspection templates by the North Sea Offshore Authorities Forum (NSOAF) and the International Regulators Forum (IRF) in their work on this subject. This means that via the programme, regulatory consistency in the inspection of lifting operations is now spreading globally.

7.3 From a simple statistical point of view KP2 achieved its objectives, but as the programme progressed it was refocused onto the lifting areas of deck and drilling operations and HSE continues to have concerns about the industry's record of these activities.

7.4 The main findings of the programme are:

7.4.1 The issues arising from the HSE and STEP Change fatality reviews remain.

7.4.2 The recommendations of the STEP Change Fatality report are still valid.

7.4.3 Deck and drilling lifting related accidents are rising and this is not simply linked to increased offshore activity.

7.4.4 The leading management failure was that of a lack of effective auditing of the management of deck and drilling lifting operations offshore.

7.4.5 The leading failures subsequent to the lack of auditing were: Planning and Control; and Training and Competence.

7.4.6 Failures were significantly greater on MODUs than on fixed installations in regard to the drilling related topics and greater than fixed installations for all other topics.

7.4.7 The leading root causes of deck and drilling lifting dangerous occurrences were: mechanical failure, dropped objects; and rigging competency.

In response to the main findings the programme manager has drawn up guidance on the auditing of lifting operations.

7.5 What the programme findings mean for HSE

7.5.1 Lifting during deck and drilling operations will remain an important area of work although no longer under a programme.

7.5.2 All programme reds have been addressed and inspectors will follow this by onshore inspections of dutyholder audit arrangements for lifting operations.

7.5.3 The inspections of audits will feed in to OSD's inspection programme on safety barriers.

7.5.4 The programme templates will remain the inspection tool for the topic of lifting operations.

7.5.5 There are a number of discrete packages of work that have arisen from, or are benefiting from, the KP2 programme, for example, inspection of lifting operations on Dive Support Vessels and work on supply vessel loading.

7.5.6 The programme manager, using the programme findings, is working with a drilling contractor on the revision of its lifting management procedures. Lessons learned will be passed to industry.

7.5.7 OSD will be writing to all dutyholders to advise them of the programme findings and directing them to review their management of lifting operations focussing on the key areas of audit, planning and control, and training and competence.

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ANNEX – Detailed breakdown of inspection failures in each of the KP2 topic areas

1  Topic: Management of Lifting Operations

Of the 38 failed inspections there were 41 subject failures within the topic. Of which:

• 28 (68 %) were a lack of an effective audit system;
• 10 (25%) were due to a failure to review existing procedures against the STEP Change Guidelines "Lifting and Mechanical Handling"; and
• 3 (7 %) were due to other management failures. For example: Policy gaps identified by comparison to the inspection template.

No formal enforcement action was taken but notices were considered on two occasions.

2  Topic: Planning and Control

Of the 30 failed inspections there were 34 subject failures within the topic. Of which:

• 16 (46%) were related to control of portable lifting equipment and lifting accessories;
• 12 (35%) were related to the competent (planning) person; and
• 6 (18%) were related to other matters, for example: deck and cargo management.

Five enforcement notices were served:

Three Improvement Notices in regard to control of portable lifting equipment and lifting accessories;

• One Improvement Notice in regard to lift planning; and
• One Prohibition Notice in regard to winch guarding.
• A further notice was considered in regard to control of lifting accessories.

3  Topic: Training and competence

Of the 28 failed inspection there were 36 subject failures within the topic. Of which:

• 23 (64%) related to general lifting training and competence; and
• 13 (36%) related to the LOLER Regulation 8 competent person.

Two Improvement Notices were served in regard to failure to train.

4  Topic: LOLER on the Drill Floor

Of the 13 failed inspections there were 13 subject failures within the topic. Of which:

• 9 (70%) related to deficiencies of the application of LOLER;
• 2 (15%) related to deficiencies in the control of lifting equipment; and
• 2 (15%) related to other matters. That is review of routine tasks in accordance with STEP Change guidance and a manual handling issue.

One Improvement Notice was served in regard to management of lifting equipment.

5  Topic: Handling Tubular's on the Drill Floor

Of the 10 failed inspections there were 10 subject failures within the topic. Of which:

• 4 (40%) related to deficiencies of supervision;
• 3 (30%) related to deficiencies of equipment handling/equipment training;
• 1 (10%) related to deficiencies in competency; and
• 2 (20%) related to procedural deficiencies.

No formal enforcement action was taken.

6  Topic: Violations and Procedures Ignored

Of the 15 failed inspections there were 15 subject failures within the topic. Of Which:

• 6 (40%) were violations observed at the time of the inspection eg Banksman handling load; and
• 9 (60%) were related to violations not identified or addressed by management eg risk assessments not being carried out when this was a company requirement and failure to address known violations within incidents.

One Improvement Notice was served in regard to failing to follow PTW procedures during a major lifting operation.

7  Topic: Risk Assessment

Of the 15 failed inspections there were 16 subject failures within the topic. Of which:

• 12 (75%) related to inadequate risk assessments;
• 3 (19%) related to lack of risk assessment training; and
• 1 (6%) was procedural. That is risk assessment process was not included in company procedures.

Two improvement notices were served; both related to inadequate risk assessments for lifting operations.

8  Topic: Manriding

Of the 9 failed inspections there were 10 subject failures within the topic. Of which:

• 7 (70%) related to the STEP Change guidance eg no register maintained;
• 1 (10%) related to training;
• 1 (10%) related to rescue; and
• 1 (10%) related to procedural violations.

No formal enforcement action was taken.

9  Topic: Supervision

Of the 11 failed inspections there were 11 subject failures within the topic. Of which:

• 7 (64%) related to supervision issues witnessed at the time of the inspection;
• 3 (27%) related to lack of guidance/instruction for supervisors; and
• 1 (9%) related to training.

No formal enforcement action was taken but a notice was considered in regard to inadequate supervision of a lifting operation.

10  Topic: Communications

Of the 10 failed inspections there were 10 subject failures. Of which:

• 5 (50%) were related to pre-task or procedural issues eg lack of risk assessment and other information passed at toolbox talk;
• 3 (30%) were related to radio communications eg predominant use of radios on the installation with no radio use protocol;
• 1 (10%) related to deck noise; and
• 1 (10%) related to banksman not being distinguishable to the crane operator.

No formal enforcement action was taken.

11  Topic: Learning from accidents and incidents

Of the 8 failed inspections there were 8 subject failures. Of which:

• 4 (50%) related to onshore views/findings not being passed offshore;
• 3 (38%) related to improvements required in investigation skills/systems; and
• 1 (12%) related to actions not completed from findings.

No formal enforcement action was taken.