Operational excellence: Eight lines of enquiry
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.”