12 PIPELINE TECHNOLOGY JOURNAL ptc 2019 KEYNOTE Figure 7: Reducing failures and root causes ment systems focussed only on the (engineering) threats to a pipeline (Table 1) will miss key barriers (and deficien- cies) in the integrity management system (Figure 3). Other industries are looking closely at safety culture, organisational structure, competence, knowledge/data management, etc., to reduce future failures, and their expe- riences can be used by the pipeline industry. We prevent pipeline failures by having effective pipeline integrity management systems [34], but we can do more, and experience in other industries show us how to reduce failures further, by broadening the pipeline integrity man- agement system considerations (Figure 3), and determin- ing the true/root cause of failure, and not simply the failure cause, Figure 7. These root causes could be grouped into: • • • • • safety culture (e.g., staff put safety second); staff/corporate competency (e.g., incompetent staff); data management (e.g., incorrect or insufficient data); knowledge management (e.g., loss of experienced staff); organisational error (e.g., contracting error);system error (e.g., errors in procedures); system error (e.g., errors in procedures); human error (e.g., poor judgement); near miss (e.g., low consequence event ignored); • • • • malicious act (e.g., theft). Footnotes 1 ‘Safety culture’ is part of the overall culture of an organisation and reflects the collective attitudes and values which the operator’s employees share with respect to risk and safety. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. http://primis.phmsa.dot.gov/comm/reports/safety/SigPSIDet_1994_2013_US.html#_ngtrans A D Livingston, G Jackson, K Priestley, ‘Root causes analysis: Literature review’, UK’s HSE. Contract Research Report No. 325/2001. 2001. Anon., ‘Deep Water - The Gulf Oil Disaster and the Future of Offshore Drilling: Recommendations’, National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling. January 2011. https://www.govinfo.gov/content/pkg/GPO-OILCOMMISSION/pdf/GPO-OILCOMMISSION-1.pdf Anon., ‘Human factors: Organisational change’. UK Health and Safety Executive. http://www.hse. gov.uk/humanfactors/topics/orgchange.htm A M Collins, ‘Safety Culture: A review of the literature’, Health and Safety Laboratory, UK. Report HSL/2002/25. Crown copyright. 2002. Anon., ‘The San Bruno Catastrophe and Its Aftermath’, California Public Utilities Commission. May, 2012. https://www.in.gov/iurc/files/Zeller_-_San_Bruno_Catastrophe_Aftermath.pdf Anon., ‘An independent review into the broader issues surrounding the loss of the RAF Nimrod MR2 aircraft XV230 in Afghanistan in 2006’. Charles Haddon-Cave QC. October 2009. HC 1025 London: The Stationery Office. UK. J T Reason, ‘The Contribution of Latent Human Failures to the Breakdown of Complex Systems’, Philosophical Transactions of the Royal Society (London), series B.327:475- 484, 1990. Anon., ‘Pipeline systems Part 4: Steel pipelines on land and subsea pipelines – Code of practice for integrity management’, BSI PD 8010-4:2012. British Standards Institution. UK. 2012. Anon., ‘Managing System Integrity for Hazardous Liquid Pipelines’, American Petroleum Institute. API Recommended Practice 1160. Second Edition. America Petroleum Institute. September, 2013. Anon., ‘Integrity Management of Submarine Pipeline Systems’, Recommended Practice. DNV- RP-F116. Det Norske Veritas. Norway. October 2017. Anon., ‘Managing System Integrity of Gas Pipelines’, ASME B31.8S-2018. American Society of Mechanical Engineers. New York, USA. 2018. https://www.phmsa.dot.gov/faqs/phmsa-and-pipelines-faqs Anon., ‘Pipeline Safety Management System Requirements’, API Recommended Practice 1173. America Petroleum Institute, June 2015. Anon., ‘Pipeline Risk Modelling Overview of Methods and Tools for Improved Implementation’, Pipeline and Hazardous Materials Safety Administration, USA. Draft 1. May 9, 2018. Anon., ‘PABIAC Strategic Objective 2: Safety Management Systems. A self-assessment tool for SMEs’. http://www.hse.gov.uk/paper/safetymanagement.pdf Anon., ‘Managing for health and safety’, HSG65. Published by the UK’s Health and Safety Executive. http://www.hse.gov.uk/pUbns/priced/hsg65.pdf S Shappell, ‘Human Error and Commercial Aviation Accidents: A Comprehensive, Fine- Grained Analysis Using HFACS’, Federal Aviation Administration. DOT/FAA/AM-06/18. Office of Aerospace Medicine Washington, DC 20591July, 2006. https://www.faa.gov/data_research/research/med_hu- manfacs/oamtechreports/2000s/media/200618.pdf D L DeMott. ‘Human Reliability and the Cost of Doing Business’. https://ntrs.nasa.gov/archive/ nasa/casi.ntrs.nasa.gov/20140008715.pdf http://www.boeing.com/commercial/aeromagazine/articles/qtr_2_07/article_03_2.html https://www.agcs.allianz.com/insights/expert-risk-articles/how-aviation-safety-has-improved/ Anon., ‘Competency Based Training and Assessment in the Aviation Environment’, Civil Aviation Safety Authority. Australian Government. CAAP 5.59A-1(0). July 2009. M A Makary, M Daniel, ‘Medical error - the third leading cause of death in the US’, BMJ. 2016. iacld.ir/ DL/elm/95/medicalerrorthethirdleadingcauseofdeathintheus.pdf Anon., ‘Reducing error and influencing behaviour’, UK Health and Safety Executive Report HSG 48. 2009. http://www.hse.gov.uk/pUbns/priced/hsg48.pdf J Philley, ‘Potential Impacts to Process Safety Management from Mergers, Acquisitions, Downsizing and Re-engineering’, Process Safety Progress, Vol 21, No. 2, pp 153-160. 2002. B Sampson, ‘Safety First’, Professional Engineering, 8 July 2009. pp 19-20. http://www.boeing.com/commercial/aeromagazine/articles/qtr_2_07/article_03_5.html M Wright, D Turner, C Horbury, ‘Competence assessment for the hazardous industries’, Health and Safety Executive Research Report 086. UK. 2003. Anon., ‘Competency Assessments for Nuclear Industry Personnel’, International Atomic Energy Agency. Vienna, STI/PUB/1236. ISBN 92–0–110105–8. 2006. P. Körvers, ‘Accident precursors; pro-active identification of safety risks in the chemical process industry’, Dissertation. TUE. Eindhoven, Netherlands. 2004. P E D Love et al, ‘What Goes up, Shouldn’t Come down: Learning from Construction and Enginee- ring Failures’, The Twelfth East Asia-Pacific Conference on Structural Engineering and Construction. Elsevier. Science Direct. Procedia Engineering 14 (2011) 844–850. 2011. A Anderson, ‘Making a success out of a museum of failure’, New Scientist. 8 June, 1991. T Kletz, ‘Lessons from Disaster: How Organisations Have No Memory and Accidents Recur’, IChemE. Rugby, UK. 1993. https://www.aboutpipelines.com/en/preventing-incidents/ Author Phil Hopkins Phil Hopkins Ltd. Independent Consultant phil@philhopkinsltd.com