EXPLORING THE NEED FOR A CHECKLIST CULTURE IN THE OILFIELD Authors: Troy Kehoe, VP of Innovation, Check-6 International Inc. Matt Mato, Director of Product Management, Check-6 Training Systems, Inc. Joshua Lewis, PhD, Chief Technology Officer, Check-6 Training Systems, Inc.
What’s Inside: 1. Introduction 2. Key Challenges 3. Solution 4. Key Applications 5. Checklist Culture Structure 6. Checklist Ops with RIGOR 7. Checklist Case Studies 8. Key Benefits 9. Summary
Oil and gas extraction workrelated deaths hit the highest level in 2012 since the government began compiling data in 2003. The statistics cited below are in large part due to new, inexperienced, workers brought in to fill an increase in demand. Total deaths 2005: 27 Total deaths 2012: 138 More than 100% increase
1. Introduction This paper aims to illustrate the crucial importance of developing a checklist culture to identify and eliminate human error for the upstream oil and gas exploration and production industry. It highlights the drivers for checklist development, training, coaching, and execution, as well as case studies from high reliability industries that depend on procedures-based cultures, where precision operations are mandatory. It concludes with a detailed look at how the combined expertise of Check-6 can help the oil and gas industry deliver on its business objectives – ensure drilling and completions crews get the job done right, done safe the first time, every time.
(Source: U.S. Bureau of Labor Statistics)
2. Key Challenges Vertical Perspectives – According to MIT professor of statistics Dr. Arnold Barnett, over the last five years, the death risk for airline passengers in the U.S. has been one in 45 million flights. In other words, a person could fly on a commercial airliner every day for the next 123,000 years and expect to live. What if commercial aviation were only 99.99% reliable? There would be a major airline catastrophe every day. It is estimated that preventable medical errors kill more than 400,000 people per year in the U.S. — number three cause of death behind heart disease and cancer. In oil & gas, a market that drives the world’s economy, procedures and Job Safety Analysis (JSA) serve as the backbone of most organization’s HSE initiatives; but, as the statistics above suggest, they are broken, complicated to administer, and in need of a complementing culture-driven solution. Independent research on reliability, maintainability, and risk in oil & gas quantifies human error rates taking into account environmental factors, intrinsic error, and stress factors. TASKS ERROR RATE Identify discrepancies……………….10% Notice configuration error………..10% Perform non-routine op…………...25% Perform under high stress….……..25% Failure to notice value………..…….50% Failure to respond correctly after 1 min. during emergency….90%
Knowledge is learned. And since humans are not perfect, failing plays an important role in the learning curve. Trial and error exercises, collaboration, brainstorming, and creative endeavors actually encourage and embrace failure, which conversely spawns progress, productivity, and maturation. Tribe building encourages a principle of “Fail Early and Fail Often” because that is how people improve. However, there are industries where failure is not an option and procedural discipline is absolutely essential – in order to save lives. Commercial aviation and nuclear power are the best examples. The upstream oil and gas exploration and production industry should be heralded as such an industry but has woefully fallen short. At the rig site, critical tasks are routinely performed with the mentality of “I think” rather than “I know.” After judiciously learning from a procedures manual, crewmembers have no doubt performed the same tasks a multitude of times with repeatable success. Still, people operate drilling rigs: memories fail and moods swing – Human factors can cause even the most experienced crewmember to have a lapse in judgment or decision making. Supervisors and crewmembers who rely on experience to perform high-risk tasks, during normal operations and in emergency situations, often find themselves, knowingly or unknowingly, in the danger zone and on an island far removed from the complexity of procedures manuals. It is during these moments that critical tasks become susceptible to errors that cause Lost Time Incidents (LTI), Total Reportable Incident Rates (TRIR), downtime, longer flat time, and increased Non-Productive Time (NPT). Senior management is coming to grips with the challenges they face when dealing with human factors – psychological and physiological threats from daily life in and outside of work – that serve as key ingredients to most accidents and productivity losses. Safety has been the target but missing that mark puts organizations closer to an 2
Increased Risks – Operators are pushing new exploration at pressures as high as 20,000 pounds per square inch and temperatures as high as 350 degrees Fahrenheit. Breaking these barriers could add up to 10 billion to 20 billion barrels internationally. These extreme circumstances require tasks to be performed with astute procedural discipline for daily operations to be precise, productive, safe, and reliably consistent.
inevitable accident (unless extremely lucky). Striving for precision is to climb the proverbial performance ladder to where safety is inherent, and farther away from a potential accident. Technological advancements in the new digital oilfield empower companies to drill to extreme depths faster than ever before, and with the ability to go farther faster – exacerbating associated risks in these daunting environments – comes a greater responsibility to seek and adopt proven methods that mitigate human error. Integrity all around, not just for the well. 3. Solution An organization’s absolute best mechanism to prevent human error is to instill a checklist culture. Applied with rigor in various verticals such as medical, commercial aviation, and nuclear power, checklists have proven to be essential to the successful implementation of standards.
Types of Checklists Normal checklists avoid error altogether while abnormal/ emergency checklists trap error from escalating, mitigating the consequences of human error.
There are many types of checklists based on particular styles that are in turn based on specific sets of circumstances and needs. However, keep in mind the tangible checklists so often energetically engaged as the end all are merely the beginning, as they are inanimate tools waiting to be implemented. The heartbeat of any mature checklist culture is the disciplined human behavior motivated by management’s ability to verify compliance that overtime instills trust among colleagues. Furthermore, trust is key as communal discipline allows supervisors and their subordinates to follow an unwavering set of companybased procedures, written by boots-on-the-ground with real world experiences, rather than a chain-of-command hierarchy based on experience learned 20 years ago from a manual, or worse, the previous supervisor. Teamwork is a bi-product of reliability and consistency, and thus the result of a checklist culture is a reliably consistent team of individuals who communicate with each other across the enterprise in familiar language and operate in near perfect rhythm to complete assigned tasks – precisely, safely, and calmly. 4. Key Applications Clearly stated, the goal of a checklist culture is not to outdo procedures or eradicate the Job Safety Analysis (JSA) altogether. Checklists complement these stalwarts, differentiated by bringing tasks into the present rather than past tense; the latter normally associated with a JSA report. Procedures contain great detail and are good for training, planning, and reference materials for specific data and techniques, whereas JSAs pinpoint safety analyses of the overall job to include hazards, risk, and mitigation actions. The basis of checklists is to assist users while executing tasks derived from approved procedures. They include the minimum essential steps and link specific hazards and mitigation actions directly to a job’s actual 3
steps. Checklists act as a crosscheck to prevent common sources of human error [forgetting procedural steps, steps out of order, failure to recognize risk associated with actions, direct mutual support or external quality assurance (QA) for critical steps, etc.]. Additionally, successful checklist development includes specific notes, cautions, and warnings that alert users prior to performing individual steps. Notes should highlight an operating or maintenance procedure, technique, condition, or statement considered essential to emphasize. Information contained in notes may also be safety related. Cautions should highlight an essential operating or maintenance procedure, practice, condition, statement, etc., which, if not strictly observed, could result in damage to or destruction of equipment or loss of data. Warnings should highlight an essential operating or maintenance procedure, practice, condition, statement, etc., which, if not strictly observed, could result in injury to or death of personnel or long-term health hazards.
Would a checklist culture save this derrick hand from falling? Absolutely. By implementing a simple checklist step that embodies mutual support and crosschecks (as the graphic below details). Derrick Man, “Radio to confirm hooked in and ready.” Derrick Hand, “Roger, good to go boss.”
It is important to remember that checklists should only be written to mitigate human error for an operation’s most critical, high-risk tasks, where failure is not an option. Meaning, they should not be written for every single job task on the rig. Aviation-quality checklists have proven the most reliable form. Unlike the typical grocery store list, where a person checks off items as they walk the aisles, aviation-quality checklists use a challenge and response mechanism from users to ensure each task is executed with diligence, in a pre-determined sequence. The noun-verb relationship is critical to the rhythmic nature that spawns compliance among individual teams. And with a digital platform, management is able to put in play a second set of eyes by establishing a secondary QA authorization step to ensure proper step completion, before proceeding. 5. Checklist Culture Structure In order for an organization to build a sustained checklist culture, case studies from high reliability organizations reveal that systemically implementing a two-phased approach works best. Phase I: Development Development should begin with an introduction for senior leadership to establish a common understanding of checklist theory, design, usage and discipline. Checklist development coaches then work with an organization’s Subject Matter Experts (boots-on-the-ground with intimate real world experiences) to determine applicable high-risk tasks, facilitate checklist writing and propagation into a digital checklist system.
PERFECT PRECISION EFFICIENT EFFECTIVE SAFE VIOLATION INCIDENT ACCIDENT
Initial focus is placed on issues deemed most important and then systematically broadened to build checklists for all other critical phases of operations. Checklists are sorted into normal operations, abnormal operations and emergency operations. Warnings, cautions and notes are considered best practices in commercial aviation and provide “just-in-time” hazard identification and awareness. Equipment limitations are also included for ready reference and pre-job planning and preparation. The development phase ends with coaches deployed to the work site to validate checklists for content, accuracy, and final operational approval. Phase II: Training
The concept of mitigating human error is to move organizations up the performance ladder while reducing the frequency and magnitude of performance deviations. Once a culture of procedural discipline and compliance is established using checklists as an effective crosscheck, organizations experience a higher level of safety, efficiency, and reliability; a reduction in rework; and increased precision that moves the organization toward optimization.
Once an organization’s leadership team buys into the methodology, checklist coaches then introduce the program to designated stakeholders to explain checklist theory, design, usage, discipline and continuous improvement processes. Coaches then travel to the work sites in order to teach the philosophies of and reinforce checklist discipline and further verify design. These coaches are empowered to actively instruct each team member on proper checklist utilization, procedures and discipline, as well as teach a continuous improvement process whereby crews take ownership in the quality of the checklists they use. Perpetual Reinforcement Transitioning to a culture of procedural discipline designed around checklists is not going to happen overnight. Perpetual leadership and sustainment coaching is essential to overcome the effects of turnover, complacency, and a “flavor of the month” mentality. Without proper oversight, leadership and perpetual reinforcement, the disciplined use of checklists will degrade over time. For this reason, checklist experts recommend follow-on sustainment coaching to safeguard the value proposition of the initial role out. The frequency of sustainment coaching should be tailored to meet an organization’s needs. 6. Checklist Ops with RIGOR Checklist Ops with RIGOR is culture-driven initiative with an intuitive checklist-based mobile app that puts procedural discipline and verifiable compliance literally in the palm of the user’s hand. Checklist Ops with RIGOR seamlessly integrates into Check-6’s Crew Resource Management strategy, giving end users an even higher level of reliability and human error mitigation. Developed and written as aviation-style checklists, Checklist Ops with RIGOR allows crewmembers to perform with step-by-step precision, so that supervisors and workers find the reliable and consistent workflow during high-risk operations.
Checklist Ops Checklist Ops is a scalable consulting service representing the adopting organization’s first step in moving towards an enterprise-wide checklist culture via training, coaching and checklist development. Secondary, the suite-to-service leverages the coaches’ wisdom by helping operators and drilling contractors identify and develop checklists for critical tasks. The developers and coaches are former military and commercial aviation pilots who have decades of experience in building checklist cultures and high performance teams. √ A checklist culture helps crews do it right the first time, every time √ A checklist culture ensures safe, repeatable and verifiable behavior √ A checklist culture improves productivity RIGOR software is currently operated on either a full-size Apple iPad tablet or Apple iPad Mini tablet, and offered with a Class I Division II intrinsically safe cover to meet equipment safety requirements at the rig site.
RIGOR Complementing Checklist Ops is RIGOR, a digital checklist and compliance system consisting of hardware and software-as-a-service products that give crews the tools to respond with methodical actions and reactions in both normal and emergency situations. With RIGOR, critical steps are simplified, actions are deliberate, and all checklist execution data is captured and tracked for reporting purposes. √ √ √ √ √
RIGOR proves procedural compliance RIGOR provides automated place keeping RIGOR makes enterprise-wide updates easy RIGOR embeds images and links to reference materials RIGOR allows accurate data capture every time a job is performed (who, what, and when)
For crewmembers, the pressure to memorize complex procedures is minimized, while management’s confidence in crew performance is maximized. Checklists are electronically executed in a pre-determined, step-by-step sequence with a deliberate swipe from a stylus pen or finger. Why digital? Studies show that paper checklists have a 1 in 150 error rate, whereas digital checklists have a 1 in 3000 error rate.
RIGOR software consists of three main software components: Checklist RIGOR Builder, Checklist RIGOR Cloud, and Checklist RIGOR Application. The Builder is a PC-based program that leverages subject matter experts’ knowledge and experience to create digital checklist from approved procedures. The Cloud, a company-hosted server for centralized storage and synchronizing of client checklists and compliance data, facilitates user management, checklist assignment, status tracking, completion, data capture, and efficiency reporting. Finally, the Application is currently an iOS-based application that allows users to access checklists online or offline and sync updates, changes, and compliance data with the Cloud when online access is available. 6
7. Checklist Case Studies Medical CHECKLIST FOR IVs 1. WASH HANDS WITH SOAP 2. CLEAN SKIN WITH CHLORHEXIDINE 3. FULL BARRIERS OVER PATIENT 4. FULL BARRIERS OVER STAFF 5. AVOID FEMORAL SITE WHEN INSERTING AND REMOVING CATHETERS
“It’s remarkable! We have few examples where we’ve been able to demonstrate sustained success in quality improvement, and what Dr. Peter Pronovost and the Michigan Project truly demonstrated is that there are simple interventions (checklists) that can make a big difference and be sustained if the culture of medicine embraces them.” – Atul Gawande, MD, lead physician of the World Health Organization’s Safe Surgery Saves Lives Initiative
For years, catheter-related bloodstream infections (or infections from central line IVs) were a seemingly unavoidable complication of caring for the sickest patients in intensive care units. The infections kill 17,000 patients annually, and the average cost of caring for an infected patient is $45,000, studies show. But then a stunning thing happened. A group of Michigan hospitals implemented a relatively simple set of interventions, including a checklist of infection-control practices, with an astonishing result: the average infection rate dropped 66 percent after one year. The median central-line infection rate fell to zero per 1,000 catheter days, compared with a national average of 5.2. The achievement was due to a checklist entailing five simple steps: 1) hand washing with soap, 2) cleaning the skin with chlorhexidine, 3) using full-barrier precautions over the patient when inserting central venous catheters, 4) wearing a sterile mask, hat, gown, and gloves, and 5) avoiding the femoral site for inserting and removing unnecessary catheters. Three years after the project began, 85 Michigan ICUs have improved their success. The average infection rate has dropped 86%, while the median rate remains at zero, according to a study published in the British medical journal BMJ. Energy – Oil and Gas Check-6 was tasked to facilitate a project for a major service company. Problem: the service company’s Rotating Control Device (RCD) unit would be assembled, barged to the rig, installed, and then would fail after tripping in a substantial number of stands. The crews would then have to trip out, rig down, and then barge the unit back to shore. Unfortunately, the failure rate was unacceptably high and was happening frequently. Diagnosis: Check-6’s observation proved that during the build up of the Rotating Control Device (RCD) that it was very easy to install the packing gland upside down. After the tool was assembled, the packing gland was not visible, so final inspection could not verify the proper installation. Solution: Check-6 wrote a simple checklist and included a quality assurance step to verify proper installation prior to final assembly. 7
Result: the service company has not had had the failure since implementing the checklist. Given the day rate of offshore operations, what are the time and cost savings as a result of this simple checklist? How much crew exposure to risk did Check-6 eliminate? It is hard to even estimate, but the value of that single checklist improvement has certainly saved millions, if not tens of millions of dollars. And, how long will those cost savings grow over time due to a single checklist? 8. Benefits
Whether rigging up, running tools, preparing or landing a BOP, etc., rig crews spend most of their time preparing to perform tasks. The preparation in between the production can be streamlined with the use of checklists.
Digital checklists are tools that house all the key references to ensure the job is recorded and performed precisely, efficiently, and without incident. √ √ √ √ √ √ √ √ √ √
Simplify complex procedures where tasks require methodical actions Mitigate human factors that cause critical mistakes Prepare for the task with easily searchable and linkable references Communicate clearly so everyone is on the same page Focus on the task at hand by managing the amount of information necessary for good decision-making Preserve information while eliminating unnecessary paperwork Minimize human error Verify compliance and track success metrics demonstrating that checklists are completed accurately and in a timely manner Improve safety and performance KPIs by tracking metrics Stay in control with updates that can be instantly disseminated across the enterprise
9. Summary With the great crew change rapidly approaching, now is an opportune time for the upstream oil and gas exploration and production industry to leverage the experience of its seasoned crewmembers to develop checklists that inspire future generations to become active participants in high reliability organizations. The overarching goal of building a sustained checklist culture for the digital oilfield is to move organizations from mere safety to sound precision operations, make jobs easier while increasing productivity, and create environments where crews return home safely.