Corporate Memory - Collective Intelligence

May 2014

and the Struggle against Amnesia

John Evans, Risk and Safety Manager,
g3baxi partnership
Gordon Martin, BSTS Consultancy

Knowledge within a Corporation

Source: CSB interim report Richmond Refinery Accident of August 2012

What are Corporate Knowledge and Collective

Intelligence?
Trevor Kletz said Organisations have no memory
Corporate Knowledge and Collective Intelligence are most evident when
they are done badly or not at all.
Some management failures can defeat a safety management system
and its barriers.
Maintenance, Integrity and MoCs

People

Assessments of Fitness for

Purpose, Engineering Standards,
Risk Assessments

Processes

Design Information the plant

dossier

Plant

In addition each part of the organisation must recognise and

communicate the importance and status of its data to other parts.

Judith Hackitt at the OPERA Seminar 2012

Few operators create effective corporate memory.

Increased contractorisation and outsourcing of operation mean knowledge often
exists outside of the company having responsibility for the assets.
[In] change of ownership ... design information and records might not be passed
on. Purchasers often do not understand the condition of the assets nor how it
was inspected, maintained and modified. Effective due diligence strategies are
essential.
Sites using 3rd parties for plant management / inspection services deliver
significantly poorer performance in management of plant ageing.
3rd parties have a responsibility to ensure that they are competent and capable
of providing the service they are being contracted to do.
The greatest weakness of all is the widespread inability or unwillingness to learn.
Companies fail to learn even from their own internal sources of learning
opportunities - whether across the same site or between sites.
The failure or inability to learn from other types of industry accidents is even
greater.

Company Interfaces North Sea O+G Contracting

Future /
Previous
Client

Future /
Previous
Contractor

Client /
Expectations
Incident
Learnings

Live Plant
Information

Plant Design
Information

Contractor
Assessments
Engineering
Practices /
KPIs
Safety
Barriers

Contractor
Competences

Developing
Standards

Plant
Condition

Succession
Planning

EPSC
HSE

Maintenance

Asset
Integrity

OGP

Normalisation of Deviance

The chart shows the number of dings greater than 1 inch in size. Max on y is 300.

Symptoms of normalisation of deviance include:

Misdiagnosis of the hazard;

Extended turnaround or inspection intervals;
Reduced maintenance;
Operation above design flow rates or pressures;
Ignoring or demotivating staff who identify new hazards.

Loss of staff to retirement is not as significant a source of loss of

corporate memory as renormalising them.

Learning from Losses (Marsh, 2011)

($ Million)

Is Normalisation of Deviance a growing problem for insurers?

Even with the above data, the accident frequency per site is low enough to
deceive them (and even their insurers!) into being complacent.

Industry Changing Events / Improvements to

Engineering Practices
Accidents that have changed
legislation
Flixborough (1974)
Seveso (1976)
Bhopal (1984)
Mexico City (1984)
Piper Alpha (1988)
Toulouse (2001)
Buncefield (2005)
Texas City (2005)
Macondo (2010)
Average once in 4 years

Accidents that have not changed

legislation with (year) & fatalities
Feyzin (1966) 18
Alexander Kielland (1980) 123
Ocean Ranger (1982) 84
Cubatao (1984) 500+
Tenghiz blowout (1986-7) 0
Guadalajara (1992) - 252
Vishakpatnam (1997) 150+
Ufa (1989) - 575
Gaoqiao (2003) 243
Snorre (2004) + Elgin (2012)

Corporations need to learn from outside themselves as well as from their

own experience their structures must be inherently adaptive.

Learning from Accidents Unexpected Consequences

The pipe rupture at Richmond led to a drifting cloud of heavy hot
hydrocarbon. 17,000 local residents sought hospital treatment.
(API states it will form a pool no more than 6 m from the leak)

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Transforming Individual Intelligence to the Collective

Most management systems are hierarchical, top down and
are designed to ensure people work to a competent
standard;
A system that promotes collective intelligence would
explicitly recognise the need for:

Up to date design and plant data;

Communication to create the organisations nervous system;
Appreciation and organisation of the criticality of information;
Synthesising indicators based on the above (i.e. KPIs);
Diagnosing delays in information transmission - schlerosis;
Developing its learning and new ways of synthesising and
communicating information;
Referencing central technical standards;
Learning from others incidents.

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Collective Working within a Systematic Risk Structure

Hazard

Barrier

Alteration to instrument
settings

Operating
Windows concept /
MoC

Incorrect drawings

Changes to design basis

Knowledge of explosions
from FABIG, EPSC, etc.
Behaviour of pressurised
liquid releases

Audit / Survey / MoC

Technical authority
reference

Rotating machinery
problems

Data historian, MTBF

as a KPI

Corrosion

Inspection /
reference to TA

Structural integrity

Inspection /
reference to TA

Competence

Resulting Accident

Training,
recertification

Emergency preparedness
drills, learnings
Corporate
Amnesia
leading to
accident

Latest environmental
requirements for dealing with
fire fighting effluent.

Condition and coverage of

gas detectors

Testing regime for fire

pumps

All work done and all information should have a place within the overall system

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Visualisation - Example
Inspected 1998

Inspection and Pipe age Data

Process Conditions

P = 50barg, T = 20C

Underground Services
Historical Incidents
Nearest Safety Shower
Local Gas Detector Readings
Permits to Work

Electricity 4kV

Electrical Feed Status

These are views of the same location on the same plant.

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Improve Visualisation Data in Context

Cont. 1 - 1.0e-03
Cont. 2 - 1.0e-05

4000

Cont. 3 - 1.0e-07
3800
Cont. 4 - 0.0e+00
3600

Cont. 5 - 0.0e+00
Cont. 6 - 0.0e+00

3400

3200

3000

2800

2600

2400

2200

400

600

800

1000

1200

1400

1600

1800

2000

2200

2400

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Areas Addressed by Visualisation, et al.

Future /
Previous
Client

Future /
Previous
Contractor

Client /
Expectations
Incident
Learnings

Live Plant
Information

Plant Design
Information

Contractor
Assessments
Engineering
Practices /
KPIs
Safety
Barriers

Contractor
Competences

Developing
Standards

Plant
Condition

Succession
Planning

EPSC
HSE

Maintenance

Asset
Integrity

OGP

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Conclusions
Corporate knowledge, collective intelligence and learning are
seriously undervalued by organisations;
Failings are a cause of many accidents, and raise risk at many
other sites;
Live risk bow ties and visualisation vastly improve knowledge
and identify management system failures in real time;
Organisations must learn from incidents;
Independent industry bodies need to formalise the
standards and methods, using: Corporate Knowledge expectations;
Positive collective intelligence case studies;
Model Architectures for Co-working.

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Extras

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Data Visualisation Potential of New Technology

Visualisation of Buried Information;
Collates information together to promote cross discipline
working;
Platform for further development;
All data becomes value added and can be viewed in
context;
It can be linked to standards, data sheets and guidelines;
It takes advantage of current technology, and if Ex rated can
be used on plant, via tablets, etc.