Threat-and-Error Management: The Connection Between Process Safety and Practical Action at the Worksite

Abstract

Summary High-reliability organizations have five important characteristics: a preoccupation with failure, a reluctance to simplify, sensitivity to operations, resilience, and a respect for expertise. Experience from recent incidents suggests that these qualities may generally be lacking in organizations that manage drilling operations today. Research sponsored by oil-and-gas producers and others has suggested that creating a sense of “chronic unease” in relation to barrier integrity and operation of safety-critical systems, combined with understanding of the psychological issues that create error-producing conditions, will strengthen defenses against major accidents occurring. The question remains as to the best way to embed the necessary skills through teaching, coaching, and assessment and their integration into routine working practices. Experience from aviation suggests that successful implementation of nontechnical skills needs to be combined with a clearly defined operational framework. Such an operational framework, however, is not widely observed in the drilling community at present. A standardized approach that defines how drilling operations are to be executed, activities monitored, decisions made, or changes managed in a time-constrained environment provides the context in which the necessary individual and organizational skills can be taught. Training needs to address the underlying psychological theory—in particular, cognitive biases—of nontechnical skills to counter threats and errors in the workplace. The paper summarizes the principles of high-reliability organizations and their contribution to process safety in the context of drilling operations. Then, we describe Threat-and-Error Management, which evolved from aviation-based Crew-Resource Management to produce the levels of safety that today we accept as normal. We introduce operational risk management in drilling as the analogous link with aviation. The paper concludes by illustrating how one can use these concepts in drilling operations to enhance routine risk-management activities, and presents a description of the tools and techniques involved. The advantage of this approach is that effective nontechnical skills can be observed, coached, and assessed on a routine basis in the workplace. Active use of these methods in everyday drilling operations promotes the essential characteristics of a high-reliability organization by instilling the sense of chronic unease and concern for barrier integrity, thereby reducing the chance of minor anomalies cascading into major accidental events.