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.
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.
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 and the management of rigging lofts.
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:| Main Findings of STEP Change review of eleven fatalities | Main findings of HSE Review of five fatal investigations |
|---|---|
| Routine risks underestimated Risk not perceived or deemed acceptable Risk assessment not “live” |
Risk Assessment |
| Procedural violations routine and tolerated | Job design, procedures and control of handovers |
| Supervisors spending insufficient time on site | Job supervision and monitoring |
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:
3.4 In the two years of KP2 Phase 1 (from 2003 to 2005);
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:
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.
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:
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:
| Installation Type | Number of Inspections |
|---|---|
| Fixed | 37 |
| MODU | 18 |
| FPSO | 7 |
| Jackups | 3 |
| FSU | 1 |
| NUI | 1 |
| MSV | 3 |
| Heavy 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:
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.| Topic | Management | Plan & Control | Train & Comp | LOLER on Drill Floor | Handling Tubular's | Violations | Risk Assessment | Manriding | Supervision | Communications | Learning |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Score | Times Inspected | ||||||||||
| Red | 2 | 6 | 2 | 1 | 0 | 1 | 2 | 0 | 1 | 0 | 0 |
| Amber | 36 | 24 | 26 | 12 | 10 | 14 | 14 | 9 | 10 | 10 | 8 |
| Green | 25 | 41 | 40 | 21 | 26 | 44 | 50 | 30 | 53 | 52 | 45 |
| Times Inspected Total | 63 | 71 | 68 | 34 | 36 | 59 | 66 | 39 | 64 | 62 | 53 |
| Times “Failed” | 38 | 30 | 28 | 13 | 10 | 15 | 16 | 9 | 11 | 10 | 8 |
| % Failed | 60% | 42% | 41% | 38% | 28% | 25% | 24% | 23% | 17% | 16% | 15% |
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.
Only fixed and MODU installations were compared as there was insufficient numbers of other installation types to make a sensible comparison.
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%
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.
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.
The formal enforcement action taken during KP2 Phase 2 comprised 9 Improvement Notices and 1 Prohibition Notice.
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.
Two Improvement Notices were served in regard to failure to train.
One Improvement Notice was served in regard to management of lifting equipment.
One Improvement Notice was served in regard of failing to follow PTW procedures during a major lifting operation.
Two Improvement Notices were served; both related to inadequate risk assessments for lifting operations.
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.
6.1 The programme’s targets were: Zero fatalities and a 20% reduction, from 2001/2002 statistics, of all other lifting related incidents and injuries.
| Fatal | Major | Over3Day | |
|---|---|---|---|
| 2001/2002 Totals | 2 | 28 | 83 |
| KP2 Target (-20%) All incidents | Nil | 22 | 66 |
6.2 Statistics from 2001/2002:
| Deck and drilling - All accidents | |||
|---|---|---|---|
| Fatal | Major | Over 3-day | |
| 2001/02 | 2 | 28 | 83 |
| 2002/03 | 0 | 30 | 57 |
| 2003/04 | 1 | 20 | 49 |
| 2004/05 | 0 | 27 | 44 |
| 2005/06 | 1 | 28 | 54 |
| 2006/07 | 0 | 11 | 55 |
6.3 Set against the programme targets the end of programme data means that these targets have been met.
| Fatal | Major | Over 3-day | |
|---|---|---|---|
| 2001/2002 totals | 2 | 28 | 83 |
| KP2 Target (-20%) all incidents | Nil | 22 | 66 |
| 2006/2007 figures | Nil | 11 | 55 |
| All accident percentage reduction from 2001/2002 | -200% | -39% | -66% |
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.
| Deck and drilling - Lift related | |||
|---|---|---|---|
| Fatal | Major | Over 3 day | |
| 2001/02 | 1 | 5 | 5 |
| 2002/03 | 0 | 4 | 4 |
| 2003/04 | 0 | 5 | 6 |
| 2004/05 | 0 | 5 | 6 |
| 2005/06 | 1 | 8 | 12 |
| 2006/07 | 0 | 6 | 18 |
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.
| Offshore Activity for Period of KP2 Statistics | |
|---|---|
| Period | Million Man Hours |
| 2001/2002 | 54.49 |
| 2002/2003 | 47.53 |
| 2003/2004 | 43.32 |
| 2004/2005 | 40.0 (estimation) |
| 2005/2006 | 47.39 |
| 2006/2007 | 56.35 |
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.
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.
7.4.1 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 and the management of rigging lofts.
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.
Of the 38 failed inspections there were 41 subject failures within the topic. Of which:
No formal enforcement action was taken but notices were considered on two occasions.
Of the 30 failed inspections there were 34 subject failures within the topic. Of which:
Five enforcement notices were served:
Three Improvement Notices in regard to control of portable lifting equipment and lifting accessories;
Of the 28 failed inspection there were 36 subject failures within the topic. Of which:
Two Improvement Notices were served in regard to failure to train.
Of the 13 failed inspections there were 13 subject failures within the topic. Of which:
One Improvement Notice was served in regard to management of lifting equipment.
Of the 10 failed inspections there were 10 subject failures within the topic. Of which:
No formal enforcement action was taken.
Of the 15 failed inspections there were 15 subject failures within the topic. Of Which:
One Improvement Notice was served in regard to failing to follow PTW procedures during a major lifting operation.
Of the 15 failed inspections there were 16 subject failures within the topic. Of which:
Two improvement notices were served; both related to inadequate risk assessments for lifting operations.
Of the 9 failed inspections there were 10 subject failures within the topic. Of which:
No formal enforcement action was taken.
Of the 11 failed inspections there were 11 subject failures within the topic. Of which:
No formal enforcement action was taken but a notice was considered in regard to inadequate supervision of a lifting operation.
Of the 10 failed inspections there were 10 subject failures. Of which:
No formal enforcement action was taken.
Of the 8 failed inspections there were 8 subject failures. Of which:
No formal enforcement action was taken.
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