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Learning from Experience – Barriers and Opportunities
“…Those who were operating…did not have knowledge of the dangers associated with loss of lean oil flow…Nor did those charged with supervision of the operations have the necessary knowledge…”
“…Key individuals…displayed lack of applied skills and knowledge and there was a lack of supervisory presence and oversight…”
The above where taken from the public domain official investigations into two major incidents, both resulting in loss of life and major plant damage, and both involving oil majors. The incidents whilst separated by 7 years had within their root causes worrying similar factors.
In 2015, 7 offshore workers were killed and 45 injured in an explosion and fire on an offshore hub platform. Investigations showed that remote platforms feeding hydrocarbons to the damaged platform failed to stop flow, significantly increasing the flammable inventory, and escalating the incident. In 1988, on the Piper Alpha platform, the tragic loss of 167 lives was without doubt escalated by the failure of other platforms to stop their flow of hydrocarbon to Piper Alpha.
Why do we continue to see the same root causes with incidents, with the examples above all within the same oil & gas sector and in both cases the first incident received global publicity and benefit from a high quality public investigation?
In this Hazards Forum event – sponsored by the IChemE, we have the pleasure of three esteemed speakers, who will consider this question of our apparent inability to learn, but more importantly offer solutions from different but complementing perspectives.
Dr Nancy Leveson will recognise that we could learn so much more from events if we were willing to change practices that inhibit such learning. In her presentation she will describe the inhibitors to learning and how a systems approach to accident analysis could greatly enhance the learning process.
Faith Wainwright, will consider the challenges of how an organisation can create a sustained learning culture. Using Arup as a case study, Faith will discuss the cultural and organizational aspects of fostering a connected organization where colleagues freely share their expertise, and how communities of practice generate both the vision for future capabilities and the infrastructure for capturing and re-using knowledge gained particularly lessons learned. The talk will provide insights into the tangible benefit and some of the challenges of managing the rather intangible concept of communities, from her experience in leading Arup’s Skills Networks.
Robert Robinson, will consider the question from the perspective of the Oil & Gas Insurance sector, with examples of major incidents presented where the lessons were not learned and the same mistakes subsequently repeated elsewhere at great cost. Suggestions are to be given as to what might have been the barriers to the lessons being learned, and what could be done to reduce the risk of being condemned to repeat the failures of the past.
The evening will conclude with a drinks reception staring at 19:30 which is open to all attendees.
Professor of Aeronautics and Astronautics at MIT
Dr Nancy Leveson is an elected member of the National Academy of Engineering (NAE). Prof. Leveson conducts research on the topics of system safety, software safety, software and system engineering, and human-computer interaction. She has published over 200 research papers and is author of two books, "Safeware: System Safety and Computers" published in 1995 by Addison-Wesley and "Engineering a Safer World" published in 2012 by MIT Press. Both books have been translated into Japanese and Chinese.
She consults extensively in many industries on the ways to prevent accidents and has served on numerous national and international committees and participated in accident investigations including the Columbia Accident Investigation Board, the Presidential Commission on Deepwater Horizon, and the Baker Panel on the Texas City accident.
Fatih Wainwright has contributed to many award-winning engineering projects, including Tate Modern and the American Air Museum in Duxford. Faith has a particular interest in fostering technical communities which share and develop expertise across team and organisational boundaries, and has guided the development of Arup’s ‘Skills Networks’. These are recognised well beyond the boundaries of the firm for delivering an agile, motivating and effective environment in order to deliver the highest quality of work.
Her vision contributed to the setting up of Arup University, which enables learning, sharing and research to be seen holistically, and integrated with project activities. Faith has strong links with academia, and has served on the Joint Board of Moderators, and REF panels in 2008 and 2014. In Arup, she developed a successful programme of masters-level teaching focussing on emerging business challenges, delivered jointly with academic partners.
Faith is the current President of IStructE, is a Fellow of the Royal Academy of Engineering, was awarded an MBE for services to the Built Environment and Engineering Professions, and holds an Honorary Doctorate from the University of Bath.
Global Head of Energy Risk Engineering, Aon
Robert is responsible for the delivery of risk engineering services to clients in the oil, gas and petrochemical sector to support them in achieving their insurance and risk management objectives.
Robert is a chartered chemical engineer and started his career as a process engineer with Exxon at the Fawley manufacturing site. He then joined Sedgwick as a risk engineer and upon the merger with Marsh led the Energy risk engineering team globally for 14 years. During this time, Robert travelled extensively worldwide and worked with clients in all sectors of the hydrocarbon industry, both upstream and downstream. He has worked with a diverse range of companies including integrated multinationals, national oil companies and both small and large independents.
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