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The eight lines are divided into two groups of four. The first group is about routine operations and the second about non-routine operations. |
Asking the right questions is right in many jobs - teachers, scientists and lawyers among them. However, in some occupations, it can actually be a matter of life and death. Lives can be put at risk if doctors or detectives ask the wrong questions. And experience shows the same is true for people who lead high-hazard operations in the energy industry, such as oil rigs, refineries and chemical plants.
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John Sieg, BP’s group head of
operations, has studied industrial
accidents closely and says many can
be traced back to one of eight specific
defects in process safety. If managers had
asked the right questions at the right time,
he says, they may have had a chance to
intervene and correct potential defects
before an accident occurred.
This is why BP’s operational leaders
have begun using a technique called the
‘eight lines of inquiry’ when they observe
work and talk with frontline staff. The
‘eight lines of inquiry’ mirror the eight
defects and are a set of specific questions
designed to help leaders identify potential
problems.
Examples cross the industry, for instance,
the Piper Alpha accident in the UK North
Sea in 1988 was largely a result of operators
failing to spot the hazard involved in
starting up a pump when its relief valve had
been removed for maintenance. In the ‘eight
lines’ tool, this is covered by line of inquiry
number three – ‘hazard recognition and
response capability’.
A refinery fire in California in 1999 was
primarily caused by opening a naphtha
line that had a leaking block valve when
the unit was in operation, resulting in an
uncontrolled hydrocarbon release – this
could have been covered by line number
six on ‘breaking containment’.
The 2005 Buncefield fuel depot
explosion in the UK followed the
overfilling of a tank when a switch failed to
work – covered by line of inquiry number
seven, relating to overfilling equipment.
Sieg is a mechanical engineer by
training who spent more than 30 years
leading operations for chemicals giant
DuPont, and at one time responsible for
more than 30 major plants worldwide. He
says: “All of my experience told me that
some combination of these eight defects
contributed to most accidents and, so, it
was important to find a simple way for line
leaders to ask the right questions to make
sure that the relevant risks are managed.”
A few years ago, Sieg discussed the eight
defects at BP’s Operations Academy –
located at the Massachusetts Institute of
Technology. One of the attendees, Curt
Bakle, now an operations leader at BP’s
petrochemicals plant in Hull, UK, recalls
how delegates at the Operations Academy
meeting conceived the idea of ‘eight lines
of inquiry’ to match the eight defects.
“We sat down and discussed how we
could work with the information John had
provided to create something very simple
and useful that we could take to the field.”
Sieg says: “We kept it simple – fewer
than the fingers on both hands – but made
sure it covered the really critical areas. The
principle is that if the answers that a leader
gets indicate that any of these defects
might be present to the smallest degree,
then he or she has an obligation to stop the
work until it is investigated and resolved.”
BP’s executive vice president for safety
and operational risk (S&OR), Mark Bly,
emphasises the importance of leaders
engaging with the organisation in
observing the conduct of work to
understand if it is achieving the expected
conditions. “The eight lines of inquiry is a
great tool that provides a systematic
approach to help leaders do this,” he says.
“When I am in the field doing inspections, I
carry a card describing the eight lines of
inquiry in my shirt pocket.”
The eight lines are divided into two
groups of four. The first group is about
routine operations. They relate to layers of
protection; safety-critical equipment and
instruments; the capability of people
performing work; and following procedures.
The second group is about non-routine
operations. They relate to preparedness for
abnormal operations; breaking
containment; avoiding overfilling or overpressurising
vessels or containers; and
‘right material, right place’. Right material,
right place, for example, is about avoiding
hazardous materials getting into the wrong
part of a system.
The eight lines tool is part of the wider
network of checks and balances that BP has
intensified since the 2010 Deepwater
Horizon tragedy, including the creation of
its S&OR organisation, which has deployed
teams working with each business to help
drive safe and compliant operations.
BP’s senior safety experts stress that
primary responsibility for safety lies not with S&OR, but with the line management
at platforms, refineries, ships or chemical
plants. They prefer to talk of ‘assurance’
rather than inspection – putting the focus
onto the conduct of operations, not the
inspectors – and describing assurance as
“making sure that what is supposed to be
happening actually is happening.”
In BP, this process of assurance takes
place within the context of the operating
management system (OMS). Sieg and his
team were instrumental in the development
of the OMS, which provides a single set of
operating procedures for every operating
site in the company. It’s designed to be
relevant to every BP site and has been
benchmarked against best practice in the
energy industry and beyond.
“Simply put, OMS is the way we
operate,” Bly says. “OMS defines the
operating conditions we expect in a holistic
way. It addresses systems and processes but
also equally the leadership and
organisational factors required to deliver
safe, compliant and reliable operations.”
As well as using the eight lines, when
Bly inspects operations, he is looking for
consistency in what he hears. “My schedule
varies from site to site, but, generally, I start
off with the senior site leadership,” he says.
“I want to hear what they are working on,
what their major risks are and what steps
they are taking to mitigate those risks.
Then I go and see the frontline leaders and
test if they see the world the same way.
“Finally, I get out onto the floor or into
the field and speak to the folks actually
doing the work and see how what I have
heard from the leadership is showing up in
our operations.
“If any of that points to a gap in the
management system, or any disconnect
between the leaders and the frontline on
safety and systematic operating, it is
important that we take the opportunity to
understand how that may have happened
and what needs to be done to improve the
system.”
Sieg concludes: “It’s very easy to write
operating expectations such as procedures
and standards. What is important is how
that material is actually applied to work,
day in and day out. S&OR provides vital
checks and balances, but the first priority is
for line managers to be the safety leaders.
So, they need the right tools to enable them
to observe and ask questions
systematically. This is what the eight lines
framework helps to provide.”
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