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Authors: Bas Oonk, Beatrijs Ekkers, Coen van Driel, Crhis Williams, André de Rooij
Background
Every day at least one incident or near miss occurs at one of the thousands of sites and companies involved in the oil and petrochemical and process industry. Organizations are urged by regulators to overcome learning disabilities.
What is not so obvious what it takes to organize Cross Site Learning within one organization. It would be helpful to understand the current practice and success factors. To provide organizations with a comprehensive framework to evaluate their maturity on cross site learning and help them to take action to organize Cross Site Learning.
We will focus on sharing of learning between sites in a corporate organization (cross pollination). Onsite learning is important to make cross site learning effective, but it’s not the primary subject of our study.
Goals
- Understand the questions of executives and leaders that are responsible for process safety
- Present current evidence based knowledge in a comprehensive wave
- Present a ‘maturity-model’ for companies to assess their current practice
- What (typical to be in scope/out of scope) / Who / how to select for cross site learning
- Conditions / ways to learn from each other in a network / community
- How to transfer network learning to site learning (learning strategy)
- How to deal with the risk-rule reflex (diminishing returns of more instructions)
- How to go from site learning to a safer practice? (design of corrective actions / learning interventions and follow up)
- How to implement cross site learning and keep it effecitive?
- What is the value of the digitals tools (AI, big data analyses, teams, Learning Management Systems, Learning Experience Platforms, Electronic Perfomance Support System (EPSS)) for cross site learning?
- Investigate the current practice / opinions in the process industry
- Investigate contribution of maturity level (model) to process safety performance
- Investigate the success factors within networks where cross site learning takes place successfully. For example, nuclear power stations within the European Union.
- Share knowledge of this research (article in a peer reviewed journal / congress)
Scope
In scope | Out of scope |
| Cross site learning within a business unit or company | Learning within a production unit, production site / between companies |
| Process Safety (both small LOPC’s as API incidents) | Personal Safety |
| Learning from success & failures (e.g. process safety fundamentals) | Process improvement |
| Cross site learning / Cross company learning | Learning within a production unit or site |
| Process Industry | |
| Performance management (KPI’s) | |
| Leadership | |
| Network / Communities | |
| HRO, Safety 2, Resilience Engineering, Psychological safety |
Participants
- Safety Delta Nederland
- VNCI
- VNPI
- EPSC
- Deltalinqs
- Leading Companies at Holding, BU or Site level
- New Behavior
Project Milestones
| Initiate | Literature Research | Field research part 1 | Field research part 2 | Share learning |
| Project charter Project team Timeline / Research approach / Level of Evidence | Research question Thesaurus terms Longlist / short list articles Hypotheses | Participants Questionnaire for semi-structured interviews Insights from interviews | Sample size Participants Questionnaire for online Statistical analyses model Insights from data | Round table discussion with workgroup Maturity model / learnings Article for journal Seminar with involved associations |
| November | December | May/June | September / Oktober | December |
The project is in the Field research part 1 at the moment
The goal of the literature research is to define the base for cross site learning to be tested in the field research. The hypotheses for the field research and the first ideas what effective cross site learning might be. In summary what is already written about cross site learning and what are the initial elements of the maturity model for cross site learning
In the field research the members of the participating companies will be interviewed to understand their challenges in cross site learning for process safety, the impact on process safety performance, the challenges they encounter, the ideas they have to successfully realize cross site learning, etc. In the second part the outcome will be converted into an online questionnaire to be send out to a wider range of companies to get statistical data.
In the share learning phase the core project team will convert the data into the maturity model and make it presentable to be published.
Constraints, assumptions, risks, dependencies
- Anonymous / data privacy of companies and persons
- Networks / Communities are the primary route for cross site learning
- The culture of companies to share knowledge, insights and incidents
Annex 1: Recommendations of Incident Investigations
| Aanbevelingen ‘Explosies MSPO2 Shell Moerdijk’De Onderzoeksraad voor Veiligheid is van mening dat Shell bewuster om moet gaan met risico’s. Medewerkers moeten continu alert zijn op veiligheidsrisico’s, zeker bij het doorvoeren van wijzigingen in productieprocessen, installaties en van grondstoffen. Ook moet het bedrijf kritisch blijven kijken naar eerder gedane onderzoeken, opgestelde procedures en maatregelen. Zodoende kan voorkomen worden dat het bedrijf jarenlang blijft werken op basis van achterhaalde of onjuiste aannames. Ook moet Shell meer lering trekken uit incidenten, waarbij er expliciete aandacht moet zijn voor achterliggende oorzaken. Als laatste ziet de Onderzoeksraad ook een rol weggelegd voor Shell waar het gaat om het delen van de opgedane kennis en ervaring binnen de petrochemische industrie |
| Brand bij Esso, 21 augustus 2017Zorg voor verspreiding van de opgedane kennis naar aanleiding van het voorval, bij zowel andere fabrieken van ExxonMobil, als bij de gehele (petro)chemische industrie. |
| Meer samenwerking nodig voor veilig Chemelot Overkoepelende visie ontbreektHet werken met gevaarlijke stoffen brengt risico’s met zich mee, zeker wanneer meerdere van zogeheten Brzo-bedrijven op één terrein gevestigd zijn. De risico’s worden nu per bedrijf beheerst, waarbij de aanpak gericht is om te voldoen aan wet- en regelgeving. Een overkoepelende visie op veiligheid van Chemelot als geheel ontbreekt. De Onderzoeksraad concludeert dat de bestaande samenwerkingsverbanden beter benut moeten worden om de veiligheid structureel te verbeteren. |
| Failure to learn, Andrew HopkinsWhat is most striking about the Texas City accident was BP’s failure to have learnt this lesson already. It seems that the organization suffered from a learning disability in this respect. In this, it was not alone. Accidents often repeat themselves, sometimes within the same organization. |
