1500 - Evans - Corporate Memory Collective Intelligence
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Transcript of 1500 - Evans - Corporate Memory Collective Intelligence
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8/10/2019 1500 - Evans - Corporate Memory Collective Intelligence
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and the Struggle against Amnesia
John Evans, Risk and Safety Manager,
g3baxi partnership
Gordon Martin, BSTS Consultancy
May 2014
Corporate Memory - Collective Intelligence
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Knowledge within a Corporation
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Source: CSB interim reportRichmond Refinery Accident of August 2012
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What are Corporate Knowledge and Collective
Intelligence? Trevor Kletz said Organisations have no memory
Corporate Knowledge and Collective Intelligence are most evident whenthey are done badly or not at all.
Some management failures can defeat a safety management system
and its barriers.
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Design Informationthe plant
dossier
Maintenance, Integrity and MoCs
Assessments of Fitness for
Purpose, Engineering Standards,
Risk Assessments
Plant
Processes
People
In addition each part of the organisation must recognise and
communicate the importance and status of its data to other parts.
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Judith Hackittat the OPERA Seminar 2012
Few operators create effective corporate memory.
Increased contractorisation and outsourcing of operation mean knowledge often
exists outside of the company having responsibilityfor the assets.
[In] change of ownership ... design information and records might not be passed
on. Purchasers often do not understand the condition of the assets nor how it
was inspected, maintained and modified. Effective due diligence strategies are
essential.
Sites using 3rdparties for plant management / inspection services deliversignificantly poorer performance in management of plant ageing.
3rdparties have a responsibility to ensure that they are competent and capable
of providing the service they are being contracted to do.
The greatest weakness of all is the widespread inability or unwillingness to learn.
Companies fail to learn even from their own internal sources of learningopportunities - whether across the same site or between sites.
The failure or inability to learn from other types of industry accidents is even
greater.
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Company InterfacesNorth Sea O+G Contracting
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Contractor
Client /Expectations
Live Plant
Information
Assessments
Developing
StandardsPlant
ConditionEPSC
OGPHSE
Engineering
Practices /
KPIs
Plant DesignInformation
Incident
Learnings
Safety
Barriers Contractor
Competences
Asset
Integrity
Maintenance
Succession
Planning
Future /
Previous
Contractor
Future /
PreviousClient
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Normalisation of Deviance
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Symptoms of normalisation of deviance include:
Misdiagnosis of the hazard;
Extended turnaround or inspection intervals;
Reduced maintenance; Operation above design flow rates or pressures;
Ignoring or demotivating staff who identify new hazards.
Loss of staff to retirement is not as significant a source of loss of
corporate memory as renormalising them.
The chart shows the number of dings greater than 1 inch in size. Max on y is 300.
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Learning from Losses (Marsh, 2011)
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Is Normalisation of Deviance a growing problem for insurers?
Even with the above data, the accident frequency per site is low enough to
deceive them (and even their insurers!) into being complacent.
($ Million)
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Industry Changing Events / Improvements to
Engineering PracticesAccidents that have changed
legislation Flixborough (1974)
Seveso (1976)
Bhopal (1984)
Mexico City (1984)
Piper Alpha (1988)
Toulouse (2001)
Buncefield (2005)
Texas City (2005)
Macondo (2010)Average once in 4 years
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Accidents that have not changed
legislation with (year) & fatalities Feyzin (1966)18
Alexander Kielland (1980)123
Ocean Ranger (1982)84
Cubatao (1984)500+
Tenghiz blowout (1986-7)0
Guadalajara (1992) - 252
Vishakpatnam (1997)150+
Ufa (1989) - 575
Gaoqiao (2003)243 Snorre (2004) + Elgin (2012)
Corporations need to learn from outside themselves as well as from their
own experiencetheir structures must be inherently adaptive.
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Learning from AccidentsUnexpected Consequences
The pipe rupture at Richmond led to a drifting cloud of heavy hot
hydrocarbon. 17,000 local residents sought hospital treatment.
(API states it will form a pool no more than 6 m from the leak)
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Transforming Individual Intelligence to the Collective
Most management systems are hierarchical, top down and
are designed to ensure people work to a competentstandard;
A system that promotes collective intelligence would
explicitly recognise the need for:-
Up to date design and plant data; Communicationto create the organisations nervous system;
Appreciation and organisation of the criticality of information;
Synthesising indicators based on the above (i.e. KPIs);
Diagnosing delays in information transmission - schlerosis;
Developing its learning and new ways of synthesising and
communicating information;
Referencing central technical standards;
Learning from others incidents.
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Collective Working within a Systematic Risk Structure
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Hazard Barrier
Alteration to instrument
settings
Incorrect drawings
Changes to design basis
Rotating machinery
problems
Corrosion
Structural integrity
Competence
OperatingWindows concept /
MoC
Audit / Survey / MoC
Technical authority
reference
Data historian, MTBF
as a KPI
Inspection /
reference to TA
Inspection /
reference to TA
Training,
recertification
Corporate
Amnesia
leading to
accident
Knowledge of explosionsfrom FABIG, EPSC, etc.
Behaviour of pressurised
liquid releases
Resulting Accident
Emergency preparedness
drills, learnings
Latest environmental
requirements for dealing with
fire fighting effluent.
Condition and coverage of
gas detectors
Testing regime for fire
pumps
All work done and all information should have a place within the overall system
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These are views of the samelocation on the sameplant.
Inspected 1998
Inspection and Pipe age Data
Process Conditions
Underground Services
Historical Incidents
Nearest Safety Shower
Local Gas Detector Readings
Electrical Feed Status
Permits to Work
P = 50barg, T = 20C
Electricity4kV
Visualisation - Example
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Improve VisualisationData in Context
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400 600 800 1000 1200 1400 1600 1800 2000 2200 24002200
2400
2600
2800
3000
3200
3400
3600
3800
4000
Cont. 1 - 1.0e-03
Cont. 2 - 1.0e-05
Cont. 3 - 1.0e-07
Cont. 4 - 0.0e+00
Cont. 5 - 0.0e+00
Cont. 6 - 0.0e+00
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Areas Addressed by Visualisation, et al.
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Contractor
Client /Expectations
Live Plant
Information
Assessments
Developing
StandardsPlant
ConditionEPSC
OGPHSE
Engineering
Practices /
KPIs
Plant DesignInformation
Incident
Learnings
Safety
Barriers Contractor
Competences
Asset
Integrity
Maintenance
Succession
Planning
Future /
Previous
ContractorFuture /
PreviousClient
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Conclusions
Corporate knowledge, collective intelligence and learning are
seriously undervalued by organisations;
Failings are a cause of many accidents, and raise risk at many
other sites;
Live risk bow ties and visualisation vastly improve knowledge
and identify management system failures in real time;
Organisations must learn from incidents;
Independent industry bodies need to formalise the
standards and methods, using:-
Corporate Knowledge expectations; Positive collective intelligence case studies;
Model Architectures for Co-working.
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Extras
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Data VisualisationPotential of New Technology
Visualisation of Buried Information;
Collates information together to promote cross disciplineworking;
Platform for further development;
All data becomes value added and can be viewed in
context;
It can be linked to standards, data sheets and guidelines;
It takes advantage of current technology, and if Ex rated can
be used on plant, via tablets, etc.
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