HCR Prevention Guidance 2018

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PREVENTION
GUIDANCE DOCUMENT
Improving safety
and effecting change
through collaboration
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Contents
PREVENTION GUIDANCE DOCUMENT
Contents
Foreword from Health and Safety Executive 05
Introduction 06
- Historical Perspective 07
- Peer Assessments 08
- How to Use This Guide 09
1 Performance
- 1.1 Performance Measures 10
- 1.2 Leading and Lagging Measures 11
- 1.3 Developing Performance Measures 12
- 1.4 Management of Measures 15
2 Operational Activities
- 2.1 Operational Integrity 18
- 2.2 Key Vulnerabilities 18
- 2.3 Design, Commissioning and Pre-Start 19
- 2.4 Operating Plant within Safe Limits 19
- 2.5 Process Operating Procedures 19
- 2.6 Safety Critical Tasks 20
- 2.7 Process Operating Handovers 21
- 2.8 Process Operations Supervision 22
- 2.9 Instrumented Protection Systems 22
- 2.10 Alarm Management 22
- 2.11 Relief, Blowdown, Vent and Flare Systems 22
- 2.12 Process Isolations 23
- 2.13 Permit to Work 24
- 2.14 Small Bore Tubing and Piping Systems 25
- 2.15 Flexible Hose Assemblies 26
- 2.16 Bolted Joints 27
- 2.17 Vibration 28
- 2.18 Valves 28
- 2.19 Management of Change 29
- 2.20 Operational Risk Assessment 30
- 2.21 Sand Management 31
- 2.22 Sampling 31
- 2.23 Leak Management 32
- 2.24 Plant Reinstatement 33
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Contents
Contents
3 Investigation & Learning
- 3.1 Investigation 39
- 3.2 Human Factors 43
- 3.3 Analysis 44
- 3.4 Learning and Sharing 45
4 Competence
- 4.1 Competence Management & Assurance 48
- 4.2 Factors Affecting Competence 49
- 4.3 Competencies Impacting HCR Prevention 50
5 Integrity Management
- 5.1 Main Integrity Threats 56
- 5.2 Key Areas of an Integrity Management 57
- 5.3 Inspection Management System 58
- 5.4 Corrosion Management 60
- 5.5 Fabric Maintenance Management 61
6 Leadership, Communications & Engagement

- 6.1 Leadership 65
- 6.2 Process Safety Culture 66
- 6.3 Communication 67
- 6.4 Engagement 68
- 6.4.1 Workforce Engagement 68
- 6.4.2 Industry Engagement 69
7 HCR Prevention Plans

- 7.1 Plan Content 71
- 7.2 Plan Management 72
Acronyms 77
Appendix 78
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Foreword
Contents
Foreword from The collection of HCR data was one of Lord Cullen’s recommendations arising from the
Piper Alpha Inquiry, and the number of HCRs has rightly been regarded as a key safety
the Health and metric for the offshore oil and gas industry since that time.
Safety Executive
Since 2005 the total number of HCRs has substantially reduced, and a focus on improving
asset integrity, and applying the learning from investigation of HCRs, has undoubtedly been
instrumental in this success. There have been dramatic falls in minor and significant releases,
however major releases, although small in number, have varied significantly over the period
with no discernible trend.
150 10
Minor Major
Significant 8
120
90 6
60 4
30 2
0 0
2005 2008 2011 2014 2005 2008 2011 2014
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HSE’s investigations of major HCRs over the last five years have typically found a loss of
operational control as a key immediate or underlying cause. These incidents have typically
been associated with multiple barrier failures, including failures to follow operational
procedures or a failure to properly manage change. Such releases have typically had a
significant ‘human factors’ or ‘software’ element to them.
HSE’s view is that continued reliance on investigation and learning from reported HCRs,
and a dominant focus on asset integrity, are not enough to fully address the ongoing risk of
major releases. This is because major releases occur only infrequently, and have a different
balance of underlying causes compared with minor releases, for which poor asset condition
is typically more significant.
The key to reducing HCR risk therefore is to support development of a positive process
safety culture within an organisation through which both asset integrity and operational
integrity are well managed. As part of this, it is critical that effective monitoring and audit
systems are in place to proactively identify and act upon any weaknesses in the risk controls,
before they can lead to an incident. And finally, every opportunity should be taken to learn
from the successes and experience of others, such as is captured within this guidance.
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Introduction
Introduction Effective asset integrity management is vital in preventing hydrocarbon

releases (HCRs).
HCRs are a key indicator of how well installation operators are managing
asset integrity on their offshore installations, so preventing them should be a
primary objective.
This guide provides a pragmatic framework for those seeking to prevent HCRs. It is
equally applicable to those looking to establish an HCR prevention programme, as it
is to those looking to improve ones already in place.
The framework comprises several key areas which, if managed effectively, have a
significant impact on preventing HCRs.
These are:
• Performance management
• Operational activities
• Investigations and learning
• Competency
• Integrity management
• Leadership, communication and engagement
• Plans
This guide builds upon existing industry guidance by incorporating the insights
from recent assessments of HCR prevention practices across a range of installation
operators. These peer assessments provided an invaluable view of the main
issues currently facing installation operators, and the various approaches taken
to resolve these.
Step Change in Safety recommends that all installation operators adopt this guide
as the current consolidated good practice on HCR prevention. (See Appendix). Full
commitment to the various elements of the guide will ensure a significant reduction
in overall Major Accident Hazard (MAH) risk exposure, and bring the ambition of the
UK having the safest offshore industry in the world one step closer.
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Introduction
Contents
Historical Offshore HCRs have been an area of on-going concern and industry focus for some time.
Perspective In 2000 the HSE launched a HCR reduction campaign (KP1) aimed at delivering a 50%
reduction in the number of offshore releases by 2004. This involved analysing the size, type
and causes of releases to provide useful insights to industry.
Findings from this campaign led to the production of various guidance documents1 aimed
at bringing about improvements to areas that were found to be significant contributors to
offshore HCRs. These included piping, flanges, valves and small bore tubing systems (SBTs).
The following years saw subsequent reductions in the numbers of HCRs, but numbers
soon plateaued and the planned reduction targets were exceeded in 2006 and 2007. This
led to further investigations and analysis by the HSE into the underlying causes of HCRs.
This found:
• Piping systems (including flanges and valves) continued to be a major source of

HCRs, with piping being the single largest contributor
• SBT contributed the second largest single source of HCRs2
• SBT failures saw a noticeable decline following the issue of industry guidance and a
raised awareness among installation operators of their significance
• Over a quarter of fittings on SBT systems were found to contain faults (e.g. under-
tightness, incorrect or mismatched components, leaks, incorrect or poor installation,
etc.), and that this rate has remained fairly constant
• Incorrectly fitted equipment, improper operation and non-compliance with procedure

(i.e. human factors) were the most widespread operational causes
• Gas compression was the operating system having the highest number of HCRs
1
These included Guidelines for the Management, Design, Installation and Maintenance of Small Bore Tubing Systems and Guidelines
for the Management of the Integrity of Bolted Joints for Pressurised Systems, both developed by Oil & Gas UK.
2
Instruments were in fact the largest single contributor of HCRs greater than 25kg.
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Introduction
In 2010, Step Change in Safety launched an initiative to cut the number of HCRs
from offshore installations in the UKCS by half by 2013. The board of Oil & Gas
UK endorsed the initiative and subsequently requested installation operators to
develop their respective HCR reduction plans.
The following year, the HSE requested all operating companies to submit a copy
of their plans. They noticed marked differences in both approach and content.
A Step Change in Safety working group was then set up to further examine
company HCR plans to identify and ultimately share good practice. The work lead
to the development of two pivotal guides: the Hydrocarbon Release Toolkit and
Guidance on Hydrocarbon Release Reduction Plans.
Industry narrowly missed the 2013 target and delivered a 48% reduction in HCRs
over three years. A further 50% reduction target was proposed from the period
2013 to 2016. To support this, the Step Change working group developed a peer
assessment approach to capture the practices that underpinned the reduction
success. It was also designed to identify ongoing vulnerabilities that would drive
further improvements. This approach can be found in Appendix 1. Although there
has been a marked reduction in the total number of HCRs over the last twenty
years or so, Major HCRs3 – those that represent the highest major accident
potential – continue to happen with ongoing regularity. Installation operators
should continue striving for proactive improvements in their programmes –
building upon and sustaining previous successes – and ultimately moving from a
position of HCR reduction to one of prevention.
Peer Assessments In 2015, the Step Change HCR working group – made up of representatives from
operators, service providers and the HSE – developed a peer assessment template
(see Appendix). The template focused on several key areas that play a fundamental
role in HCR prevention. These included those that have a direct bearing on HCR
prevention – such as operations, integrity management and competency – and
those that are more indirect, but play an equally critical role – such as leadership,
investigations and planning.
Each of these areas was then expanded into a series of subtopics e.g. operations
included control of work, change management, safe operating limits, etc. These
then formed the basis for one-day, face-to-face assessments held at installation
operator locations. Each assessment involved a minimum of two assessors from the
working group, and the audit-style discussions covered each key area in turn.
Installation operators were responsible for making appropriate people available

from within their organisations. These spanned the length and breadth of their
organisations, including those from onshore and offshore teams, senior leaders and
safety representatives.
At the end of the assessment, installation operators were informed of any good
practices that were identified – some of which were identified as best-in-class
practices worth replicating elsewhere – and key opportunities for improvement
(including insights and suggestions shared from other assessments).
At the time of writing this guide, eleven operator peer assessments were undertaken,
with several more scheduled.
3
The HSE’s classification of HCR severity can be found on their website.
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Introduction
Contents
How to Use This guide is broken down into several sections. Each section represents one key area of HCR
vulnerability that should be managed effectively to prevent releases.
This Guide
Each section includes:
• Why the topic is important

• Key elements and subtopics
• Good practice (from the peer assessments)
• Best-in-class examples (from the peer assessments)
• Opportunities for improvement and consideration
• Suggested performance measures
• Key competencies
• A checklist of aspects that should be in place
• References to pertinent documents and further information
Each section represents stand-alone guidance that can be used either in isolation – to
improve a particular aspect of HCR prevention performance – or alongside other sections as
part of a wider improvement exercise.
The guide was developed with a widespread readership in mind. It is designed to be as

relevant to an offshore technician as a senior manager, an inspection engineer or a spills
focal point.
References 1. Guidelines for the Management, Design, Installation

and Maintenance of Small Bore Tubing Systems
Published by the Energy Institute and available via their website
2. Guidelines for the Management of the Integrity of Bolted Joints

for Pressurised Systems
Published by the Energy Institute and available via their website
3. Hydrocarbon Release Reduction Toolkit

Published by Step Change in Safety and available via their website
4. Guidance on Hydrocarbon Release Plans

Published by Step Change in Safety and available via their website
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1. Performance
Why is it
important?
Performance is about how well an organisation is doing in preventing HCRs.
The more an organisation understands its performance – across a range of
activities that aim to prevent HCRs – the more effective any interventions will
be in delivering performance improvements.
Knowing where the shortfalls in performance are, and their extent, allows
organisations to prioritise resources and management focus to best effect.
Performance measures provide an agreed, consistent and scaled approach to
understanding the various aspects of HCR prevention performance.
1.1 Performance The ultimate measure of an organisation’s HCR prevention performance is

undoubtedly the number of HCRs the organisation has had.
Measures
Across many operators, the number of HCRs has become a key measure on
the company scorecard. Where previously organisations had adopted HCR
reduction targets4 , it is now commonplace to find HCR targets of zero,
signalling an overall shift in aspirations from reduction to prevention.
It is a mandatory requirement of all UK operators of offshore oil and gas

installations to report certain HCRs to the Offshore Safety Directive Regulator
(OSDR) as Dangerous Occurrencs 5. These reporting requirements are detailed
within the Oil & Gas UK document, Supplementary Guidance on the
Reporting of Hydrocarbon Releases.
A summary of reported HCRs – including the quantity released, type and

severity – is made available quarterly via the Oil & Gas UK website, and
provides an excellent opportunity for operators to benchmark their overall
HCR performance against peers.
4
Driven in part by the 50% reduction ambitions agreed by UK offshore operators during the periods 2010 to 2013 and subsequently from 2013 to 2016.
5
Under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (often referred to as RIDDOR) of 2013.
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1. Performance
Contents
1.2 Leading Whilst the number of HCRs is the key measure of HCR performance, it is a historical –
or lagging – measure, and provides few insights into how well the various activities and
& Lagging processes that are seeking to prevent future HCRs are performing.
Measures
To better understand these, we need to consider more forward looking – or leading – measures.
Leading measures Represent proactive monitoring i.e. forward looking

Ensure the continued effectiveness of controls that aim
to prevent HCRs
Require routine checks that activities are undertaken
as intended
Lagging measures Represent reactive monitoring i.e. backward looking

Require reporting and investigation of historical events
and activities
Represent a failure of one or more controls in preventing HCRs
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1. Performance
1.3 Developing There is a wealth of guidance available to organisations seeking to develop their
leading and lagging HCR performance measures, along with numerous examples.
Performance The Step Change in Safety publication, Leading Performance Indicators: Guidance
Measures for Effective Use, provides simple guidance on the development and use of leading
performance measures within the wider safety arena.
The HSE’s Developing Process Safety Indicators: a Step-by-Step Guide for Chemical and
Major Hazard Industries offers a dual-assurance approach to performance measures,
with each risk control area having complementary leading and lagging measures.
In addition, the OGP’s Process Safety – Recommended Practice on KPIs proposes a

hierarchical, four-tiered approach to performance measures in which the balance
of measures move from primarily lagging, through combinations of leading and
lagging, to primarily leading.
Tier 1 HCRs of greatest severity Lagging

Tier 2 HCRs of lesser severity Lagging / Leading
Tier 3 Challenges to key HCR prevention Leading / Lagging
controls and processes
Tier 4 Operational controls and Leading
management system performance
The HSE’s HID Inspection Guide Offshore: Inspection of Loss of Containment

(LOC), provides comprehensive guidance – and numerous useful examples –
across several key risk areas:
• Plant design, construction and commissioning

• Plant operation within safe limits
• Instrumented protected systems
• Relief, blow-down and flare systems
• Isolation standards
• Permit to work
• Small bore tubing, piping and flexible hoses
• Management of change
• Other offshore hazards e.g. sand management, leak management,
plant re-instatement, etc.
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1. Performance
Contents
1.3 Developing
Performance
Measures • Ensure the measures reflect your key areas of HCR risk – or aspects of poor HCR
prevention performance – in which you are seeking to understand and improve
continued...
• Ensure that the total number of measures you adopt is manageable
Good Practice... • Consider regular disscussions on broader integrety threats that would
not necessarily be apparent when reviewing KPIs e.g. SBT or increasing
mechanical failures.
• Recognise that your risks may be external to your organisation e.g. contractor
critical skills competence
• If you are just embarking on your improvement journey, focus initially on only
a handful of key, high-level measures
• Conversely, if you are more established on this journey, adopt lower-level

measures, across a range of activities associated with preventing HCRs
(see the various sections of this guide)
• Develop a complementary balance of both leading and lagging HCR

prevention performance measures
• Ensure that your measures are meaningful to the people within your business
• Ensure that they are easily definable and lend themselves to clear targets and limits
• Ensure that your targets are achievable, understood and supported
• Use KPIs to generate quality conversations during assest integrity reviews,

HCR prevention discussions or similar. These conversations should not just be
focussed on scores or trends but also the risk to people and asset.
Opportunities...
• If you have little or no HCR data of your own, look initially to wider industry
data for guidance on acknowledged problem areas and key vulnerabilities
• Consider using insights from weeps, seeps and non-reportable HCRs to

further improve your overall HCR prevention performance
• Consider regular discussions on broader integrity threats that would

not necessarily be apparent when reviewing KPIs, e.g. SBT or increasing
mechanical failures.
• Use KPIs to generate quality conversations during assest integrity reviews,

HCR prevention discussions or similar. These conversations should not just
focus on scores or trends but also the risk to people and asset.
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1. Performance
The following is a compilation of suggested HCR prevention performance measures

across the various aspects of HCR prevention. The list is not exhaustive – you may
add your own as you become more sophisticated in your needs – but it should
represent a satisfactory starting point for organisations wishing to introduce HCR
prevention performance measures, or those looking at revisiting existing ones.
The measures are organised as per the OGP’s four-tiered, hierarchical approach
mentioned earlier.
Suggested Tier 1 High consequence Lagging Number of HCRs – HSE reportable

Performance Number of HCRs – HSE reportable
Measures (Major / Significant)
Number of PON1s
Number of LOPCs – Tier 1
Tier 2 Lower consequence Lagging / Number of HCRs – all
Leading Number of HCRs –
HSE reportable (Minor)
Number of LOPCs – Tier 2
Number of HCRs –
high RAM potential
Tier 3 Risk controls – Leading / Number of process containment -
challenges Lagging inspection findings
Number of process containment -
audit findings
Number of process containment -
verification findings
Number of HCRs –
medium RAM potential
Number of HCRs – near misses
Number of integrity management
system – audit findings
Number of HCR prevention plan –
audit findings
Number of contractor competence
– audit findings
Tier 4 Risk controls – Leading Refer to each section of this guide
performance for relevant performance measures
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1. Performance
Contents
1.4 Management Many organisations have adopted the use of online models and dashboards to assist in the
improvement of their HCR prevention performance.
of Measures
These allow:
• Complex data to be presented in a more understandable form e.g. heat maps, traffic
lights, graphs, etc.
• Visibility of the measures to be maximised across the organisation, particularly by the
offshore workforce, as part of the continuous improvement dialogue
• Better access to those who need the information
• The data to be managed more effectively and consistently e.g. the application of
weighting factors, adoption of new measures, refining of limits, etc.
• The data to be easily summarised and equated to a single score
• More efficient formal reporting
Many of these models and dashboards are based on the standard barrier concept 6 of:
• Process containment • Protection systems • Emergency response
• Ignition control • Shutdown systems • Life saving
• Detection systems
Good Practice...
• Make high-level HCR prevention measures (and targets) part of your
organisation’s scorecard or business plan
• Set HCR prevention targets for individual assets and installations to promote
internal competition and drive improvement
• Assign an owner to each performance measure, responsible for its collection,
analysis, communication, etc.
• Ensure that the data associated with each measure is readily available and based
on reliable, consistent sources
• Once particular performance aspirations are met, you can retire their measures
in favour of measures associated with new focus areas
• Ensure your performance data is readily available in time for your various weekly
and monthly discussions that they are part of
• Don’t underestimate the effort in introducing new performance measures to
your business, including data collection, storage, reporting, etc.
• Develop a process that defines how your performance measures and associated
data are managed
• Include in this process how the information from the measures is utilised in your
organisation e.g. which meetings, attendees, action parties, etc.
Opportunities...
• Look within your organisational peer groups for inspiration if your own
performance begins to plateau
• Assurance was an area identified in the peer assists that offered significant
opportunity for improvement; ensure that your performance measures
management process is subject to appropriate assurance, review and audit
6
A series of controls that together aim to prevent and limit the impact of Major Accident Hazards.
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1. Performance
Management
of Measures
Best-in-Class Example:
Barrier Model Approach to Dashboard Measures Barrier7
Barrier System Performance Measure

Process Containment People Mechanical isolations
Mechanical joint integrity
PtW training
SBT make-up
Process Breaking of containment

Isolation confirmation certificate number
of audits
Isolation confirmation certificate non
conformances
MAH audit execution
MAH audit level of compliance
PS near miss events
PS events with potential for multiple
fatalities
PS failure process containment
Plant Defined life repairs exceeding
compliance criteria
Number of ‘live’ hydrocarbon seeps
% safety critical PM and CM backlog
non-compliance
Safety critical CM backlog
Safety critical PM backlog
Topside system integrity engineering
assessment
Verification findings level 2/3
Ignition Control People Ex competence
Process MAH audit execution

MAH audit level of compliance
PS failure ignition control
Plant % safety critical PM and CM

backlog non-compliance
Safety critical CM backlog
Safety critical PM backlog
Verification findings level 2/3
7
Note that only the first two barriers of Process Containment and Ignition Control are detailed.
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1. Performance
Contents
Checklist
1. Do you understand your performance across all aspects
of HCR prevention?
2. Have you set realistic performance improvement targets?
3. Do you benchmark your HCR prevention performance

with your peers?
4. Do you have a balance or leading and lagging indicators covering

your key risk areas?
5. Do you consider your non-reportable

HCRs in improving your prevention performance?
6. Are your key performance measures

part of your business scorecard?
7. Do you have installation-specific performance targets in place?
8. Do your performance measures have owners?
9. Is your process for managing performance measures documented?
10. Do you undertake the necessary assurance, review and audit on

this process?
11. Do you have a HCR prevention dashboard in place?
References 1. Supplementary Guidance on the Reporting of Hydrocarbon Releases

Issue 3, December 2015, published by Oil & Gas UK (Reference HS095)
and available via the Oil & Gas UK website
6. Leading Performance Indicators: Guidance for Effective Use

July 2015, produced by Step Change in Safety and available via the Step Change
in Safety website
7. Developing Process Safety Indicators: a Step-by-Step Guide for Chemical

and Major Hazard Industries
November 2015, published by the HSE (Reference HSG254) and available via the
HSE website
8. Process Safety – Recommended Practice on KPIs

November 2011, produced by the International Association of Oil & Gas Producers
(Report No. 456) and available via the International Association of Oil & Gas
Producers website
9. HID Inspection Guide Offshore: Inspection of Loss of Containment (LOC)

Operational guide, produced by the HSE and available via the HSE website
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HYDROCARBON RELEASE 2. Operational
PREVENTION GUIDANCE DOCUMENT Activities
Why is it Body Text here
important?
Industry data tells us that most HCRs occur during normal operations, with
human factors being the root cause of many of these.
It is essential that installation operators understand the HCR risks associated

with the various operational activities undertaken on offshore installations, and
that they have robust measures in place to manage them.
2.1 Operational Operational integrity is about ensuring that effective procedural and managerial
controls are in place to control the risk of HCRs.
Integrity
It is concerned with:
• How people interact with the process plant and how this impacts risk
• The process safety culture, leadership and management on the installation
• The effectiveness of operational procedures (e.g. PtW, isolations, over-rides,
etc.), training, competence assurance, risk assessments, management of
change etc.
It is distinct from asset integrity, which is concerned with ensuring that process
equipment is sufficiently robust to prevent HCRs or other potential major accidents
(e.g. structural collapse).
2.2 Key The HSE’s HID Inspection Guide Offshore: Inspection of Loss of Containment
(LoC) and Loss of Containment Manual detail a number of key areas in which
Vulnerabilities high standards of operation are vital in preventing HCRs.
These include:
• Design, commissioning and pre-start

• Operating plant within safe limits
• Instrumented protection systems (IPS)
• Process isolations
• Permit to work (PtW)
• Small bore tubing and piping systems (SBT)
• Flexible hose assemblies (FHA)
• Bolted joints
• Vibration
• Management of change (MoC)
• Operational risk assessment (ORA)
• Sand management
• Sampling
• Leak management
• Plant reinstatement
Invariably, these high standards of operation should comprise:
• Clear operational procedures and instructions that are adhered to

• Adoption of recognised good practice
• Competent people
• Effective task supervision and offshore leadership
• Major Accident Hazard (MAH) understanding in offshore personnel
• HCR prevention awareness in offshore personnel
• Human factors understanding
• Effective monitoring, review and audit
• Culture of learning and continuous improvement
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Contents
2.3 Design, The design phase of an installation has the greatest potential to reduce HCR risks by adopting
inherently safe designs principles, and by following current industry standards and guidelines.
Commissioning Incorrect design is a prominent root cause of many HCRs.
and Pre-Start
A well-designed and well-constructed installation, with correctly manufactured and assembled
equipment, provides a firm foundation for high standards of operation and maintenance.
It is important that operations personnel received appropriate training, and gain familiarity
with plant and equipment prior to start-up.
It is essential that safe operating limits are specified and adhered to.
Key aspects in this include:

2.4 Operating • Up-to-date technical documentation (e.g. PFDs, P&IDs, equipment data sheets, locked
Plant within valve registers, etc.) should be accessible to operators, TAs and engineers
Safe Limits • Limits should be readily available (e.g. within written instructions, DCS, operating
procedures, etc.) as controlled documentation, and understood
• Excursions from the limits should be recorded, root causes understood and acted upon
• Instructions should be provided that reference the limits, explain the reasons for them,
consequences of exceeding them, and detail corrective actions to restore them
• These instructions should be reviewed regularly and reassessed in the light of any
modifications to the process
• A monitoring and review process to ensure that the limits are adhered to, and operating
procedures are followed
Operating plant within safe limits helps control H2S and CO2 levels, and prevents the
formation of hydrates, further reducing the risk of HCRs.
Personnel required to operate process plant and equipment should have clear operating
procedures, and be competent to do so. They should be adequately supervised, and
information about the associated hazards should be provided. Handovers from one shift to
another should be effective.
Process operating procedures should:

2.5 Process • Be informed by risk assessment of the associated task
Operating • Be clearly written and based on good practice
Procedures
• Specify which procedures apply to which work tasks, and when they should
be performed
• Describe the work equipment, operating conditions and required work methods
• Identify the hazards and controls applicable (including where there is reliance
upon people)
• Describe the actions to take during abnormal conditions

(including all MAH scenarios)
• Be readily available and understandable
• Be regularly reviewed and updated (involving users of the procedures)
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2.6 Safety Many operational activities undertaken on offshore installations are considered
safety critical. These are tasks associated with Major Accident Hazards (MAHs),
Critical Tasks including those that play a role in loss of containment and HCR prevention.
It is crucial that these safety critical tasks are identified and analysed to determine the
potential for human failure. This includes considering those operational Performance
Influencing Factors (PIFs) that make it more or less likely for human error. These PIFs
include the following.
Job factors Clarity of signs, signals, instructions

and other information
System / equipment interface (e.g. labelling, alarms,
error tolerance, etc.)
Difficulty / complexity of task
Routine or unusual
Divided attention
Procedures inadequate or inappropriate
Preparation for task (e.g. permits, risk assessments,
checking, etc.)
Time available / required
Tools appropriate for task
Communication (with colleagues, supervision,
contractor and others)
Working environment (e.g. noise, heat, space,
lighting, ventilation, etc.)
Person factors Physical capability and condition
Fatigue (acute from temporary situation or chronic)
Stress / morale
Work overload / underload
Competence to deal with circumstances
Motivation vs. other priorities
Organisation factors Work pressures e.g. production vs. safety
Level and nature of supervision / leadership
Communication
Manning levels
Peer pressure
Clarity of roles and responsibilities
Consequences of failure to follow rules / procedures
Effectiveness of organisational learning
(learning from experiences)
Organisational or safety culture (e.g. everyone breaks
the rules)
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Contents
The HSE’s ‘A Human Factors Roadmap for the Management of Major Accident Hazards’
guidance for installation operators to ensure that their safety-critical operational tasks are
managed effectively.
The roadmap includes the following steps to assure the performance of people
undertaking safety critical tasks:
• Identify MAH scenarios
• Identify associated safety critical tasks
• Analyse operational task and human errors
• Consider the impact of operational PIFs
• Develop engineering and automated controls
• Develop inspection, testing and maintenance tasks
• Analyse maintenance task and human errors
• Consider the impact of maintenance PIFs
• Develop supporting procedures and checklists
• Provide necessary training for safety critical tasks
• Assure competences
• Monitor, review and verification
2.7 Process Installation operators should ensure that effective operator handovers occur,
including:
Operating
Handovers • A procedure which specifies the requirements for handover
• Sufficient time allocation for individuals to prepare and deliver handovers
• Specification of the information that must be handed over, including:
o Summary of current operational status
o Planned work activities
o Changes in procedures (temporary or permanent)
o New operational risk assessments
o Changes in equipment in / out of service
• Written logs, to support verbal communication

• Key information transmitted both verbally and in writing
• Minimum distraction during handovers
• Crosschecking of information via others within the team
• Face-to-face communication where practicable
• Developing and maintaining staff communication and non-technical
competences
• Monitoring, audit and review of handover arrangements
21
2.8 Process Supervisors need to understand the specific hazards of the equipment and
processes that their team operates, and the procedures, controls and arrangements
Operations which are required to control the associated risks.
Supervision
They need to understand their team capabilities, attitudes and motivations in
order to lead them effectively.
The role must be designed to allow sufficient resources, time and opportunity to
interact with others to fulfil their supervisory responsibilities. They should take the
lead during unusual or higher risk activities, and emergency events.
Installation operators should have arrangements in place that describe the role of
supervisors in meeting the above.
These should include:
• Management philosophy and strategy

• Job descriptions
• Training and competency arrangements for supervisors
• Mentoring arrangements for new supervisors
• Emergency response
Arrangements should be in place to measure, audit and review all aspects of

supervisory performance.
2.9 Instrumented Instrumented protection systems (IPS) are typically used to protect processes from
over-pressures.
Protection
Systems Installation operators should have proof-test procedures in place for their IPS, evidence
that they are routinely carried out and ensure that they are being adhered to.
They should also have systems in place for:
• Managing IPS overrides, inhibits and bypasses, that includes appropriate risk
assessment i.e. ORAs.
• Controlling changes to IPS software and configuration settings e.g. trip settings
2.10 Alarm Process alarms provide the opportunity for operators to make corrections to the
operation of the plant before an IPS trip level is reached, but are not subject to
Management the same requirements as an IPS. Installation operators should have an alarm
design and management strategy in line with EEMUA’s Alarm Systems: a
Guide to Design, Management and Procurement.
Good alarm management helps reduce the demand on IPS and thereby reduces
the risk of a HCR should the IPS not function as expected.
2.11 Relief, Blowdown, Installation operators should have systems and arrangements in place to prevent
the over-pressure and under-pressure of process plant and equipment, thereby
Vent and Flare avoiding potentially large, rapid and uncontrolled HCRs.
Systems
It is vital that these systems are suitably designed, operated, maintained and
managed.
22
Contents
2.12 Process A system should be in place to manage the isolation of process plant and equipment to
prevent any uncontrolled HCRs.
Isolations
This should include the following aspects.
Planning and Preparation Isolation standards and procedures

Training and competence requirements
Monitoring, audit and review
Hazard identification
Consequence assessment
Isolation methodology and instructions
Effective communication and
documentation
Higher risk isolations receive greater
scrutiny
Installation Use of approved standard of blanks, spades,
blinds, etc.
Full labelling of isolation schemes
Locked valve management
Proving, Control and Monitoring Initial proving of isolation
Routine checks to ensure the effectiveness
of isolation
Isolation integrity monitoring
Register of long-term isolations, including
routine checks
Reinstatement Isolation removal instructions
Reinstatement hazard assessment
Start-up risk assessment
Visual checks
Leak testing
The HSE’s The Safe Isolation of Plant and Equipment provides more detailed guidance in
these areas.
Good Practice
• Follow the HSE’s guidelines on the safe isolation of plant and equipment
• Use leak detection cameras during reinstatements to detect fugitive emissions
• Recognise leak testing as a distinct competence
23
2.13 Permit to Work Any work involving breaking containment (or the potential to do so e.g. grit-blasting)
on hydrocarbon containment systems should be controlled via a PtW system.
PtW is a key part of an overall control of work system, and plays a significant role in
HCR prevention.
It should include the following elements.
Policy and procedure Defined roles and responsibilities
Training and competence requirements

Task risk assessment Understanding of hazards and controls
Worksite visit and tagging

DRA
Effective communication to relevant parties
SAFE
WORKING
Task approval Formal permission to proceed
ESSENTIALS
Task management Clear overview of all live tasks
OBS TBT and SIMOPS to determine interactions
Breaking containment register
Up-to-date status information
Close out activities
A means of cancelling, suspending

and handing-back permits
Supervision and monitoring

Monitoring and review Ensure the continued effectiveness
of the PtW system
Recognising the impact of any changes

Ensure compliance
Installation operators should be particularly mindful of the following PtW

vulnerabilities:
• Wrong type of work permit

• Incorrect information about the work required
• Failure to recognise worksite hazards
• Permit terms not adhered to e.g. failure to isolate plant or equipment
• Insufficient supervision of the work
• Failure to hand-over plant in a safe condition
• Unauthorised staff performing PtW functions
• Poor management of the PtW system (including SIMOPS)
• Insufficient monitoring and review of the PtW system
• ‘Cut-and-copy’ issues on electronic systems
• Permits covering excessive scopes
24
Contents
2.14 Small Bore SBT are a main source of HCRs, with underlying root causes including poor design, under-
tight fittings, use of incorrect components, corrosion, etc.
Tubing and
Piping Systems Installation operators should ensure those working on SBT are competent to do so and
that the technical management of these systems is robust.
The Energy Institute’s Guidelines for the Design, Installation and Management of Small
Bore Tubing Assemblies provides good practice on their design, installation, inspection
and repair. It also covers the required skill levels, training and competency of the various
personnel involved with SBT.
Good operational practices include:
• A formal competence scheme that includes contractors

• Overall integrity checks, including supports
• Visual inspection of fittings
• Sampled disassembly
• Vibration control
• Leak testing after disconnection
• Not working on pressurised systems
• Use of standardised types and fittings
• Following manufacturer instructions
• Inspection of completed assemblies
• Use of proper tools
• Proper storage techniques
Step Change in Safety’s Mechanical Joint Integrity: Route to Competence Guidance

also provides guidance on how to develop SBT competence.
Good practice…
• Follow the Energy Institute’s guidelines on SBT
• Follow Step Change in Safety’s competence guidelines
• Adopt your flange-break management process for your SBT
• Ensure that your people (including contractors, third parties and especially
transient staff) are fully competent to undertake work on your SBT
25
2.15 Flexible Hose FHA are used extensively in a wide range of offshore applications. They are integral
to many hydrocarbon-carrying systems, and widely used in bulk loading and
Assemblies unloading operations. As such they pose a significant HCR risk.
As with SBT, installation operators should ensure those working on FHA are
competent to so, and that the technical management of them is robust.
FHA carrying hydrocarbons should be subject to routine inspection, with the

frequency and criteria determined via risk assessment.
Visual checks for damage should include:
• Blisters and bulges

• Looseness of the outer cover
• Softening or hardening of the hose
• Kinks or twists
• Abrasion and cuts
• Elongation under load
• End coupling integrity
The Energy Institute’s Guidelines for Management of Flexible Hose

Assemblies provides a good practice, lifecycle approach to the management
of FHA and covers:
• Skill levels, awareness, training and competency requirements

• Conceptual and detailed design
• Risk assessment and risk reduction
• Construction, installation and commissioning
• Operations, maintenance, inspection and testing
• Modification
• Decommissioning
Good practice…
• Follow the Energy Institute’s guidelines on FHA
• Establish a FHA focal point on every shift
• Ensure that contractors and third parties – especially transient staff –

are fully competent to undertake work on your FHA
26
Contents
2.16 Bolted Joints

Bolted joints are safety critical components of pressurised hydrocarbon systems, so it is
essential that Installation operators correctly manage their technical integrity.
The Energy Institute’s Guidelines for the Management of Integrity of Bolted Pipe Joints
for Pressurised Systems describes good practice for managing bolted joints during the
construction and commissioning phases, and over their entire operational life. A key part of
this is training and competency requirements.
In addition, Mechanical Joint Integrity: Route to Competence Guidance, by Step Change in

Safety, provides a pragmatic approach to developing competence.
Good practice…
• Follow the Energy Institute’s guidelines on bolted joints
• Follow Step Change in Safety’s guidelines on mechanical joint competence
• Establish a process that systematically documents flange breaks
• Use a specialist third party for bolted joint management during periods
of high activity e.g. during TARs
MECHANICAL JOINT INTEGRITY
ROUTE TO COMPETENCE
GUIDANCE DOCUMENT
Improving safety and
effecting change through
• Use independent flange make-up witnessing for joints that cannot
be leak tested
collaboration
• Use leak detection cameras during leak testing and ad hoc sweeps
for fugitive emissions
27
2.17 Vibration Fatigue failure from vibration in piping systems is a common source of HCRs.
Three types of vibration impact the offshore industry as a whole: continuous

vibration, transient vibration, and vibration in flexible risers.
Continuous vibration is from steady-state plant operation, and is the most

common. Guidelines for the Avoidance of Vibration Induced Fatigue Failure
in Process Pipework provides good practice on how to manage this.
Transient vibration is caused by the shock or impact loading from rapid valve
closure etc. Transient Vibration Guidelines for Fast Acting Valves Screening
Assessment provides good practice on how to manage this.
Vortex-shedding in gas export risers causes vibration in flexible risers. An industry

project was established to develop guidance8. API 17B - Recommended Practice
for Flexible Pipe and API 17J - Specification for Unbonded Flexible Pipe
consolidate the findings into good practice on how to manage this.
Specific guidance on managing vibration in SBT, FHA and bolted joints systems is
provided in the respective Energy Institute guidelines mentioned earlier.
Good practice…
• Proactively search for vibrations and encourage personnel to report
vibration issues
Valves are widely used in offshore processes, and are a significant contributor of HCRs.
Data tells us that valves that are operated frequently (e.g. control valves) tend to
develop leaks more quickly than those that don’t. And valves with rising stems (i.e.
2.18 Valves gate and globe valves) are more likely to leak than quarter-turn valves such as ball
and plug valves.
The main leak sources from valves are: stem (packing and gland), body (internal,
external and screwed fitting) and bonnet.
Common causes of releases include:

• Design related e.g. incorrect specification, wrong materials, type, etc.
• Fabrication, assembly or installation issues
• Incorrect operation and lack of proper maintenance
Unfortunately, there is limited industry guidance currently published on valve

integrity management9, however current practice suggests that Installation
operators should adopt a valve management system that includes:
• Guidance on required maintenance and inspection activities

• Performance standards for valves that are safety critical
• Training and competency requirements
• Storage requirements
• Testing requirements for valves called from stock
• Learnings from failures, including those from wider industry
• Considerations over each phase of the valve lifecycle,
from design to decommissioning
8
Additional guidance can be found in the Oil & Gas UK’s Guideline on Ageing and Life Extension of Subsea Pipelines and Risers.
9
The Energy Institute recognized this and launched a recent project (S1619 Guidelines for the Integrity Management of Valves for the
Upstream and Downstream Industries, May 2016) to develop such guidelines.
28
Contents
2.19 Management A root cause of many HCRs is the failure to manage change adequately.
of Change Examples include:
• Major plant modifications

• Changes in process operating parameters e.g. control points, alarm settings, trip settings, etc.
• Changes in the mode of operation e.g. from dry gas to wet gas
• Non-identical replacement of equipment
• Changes outside the original design intent
• Organisational changes
• Temporary changes
• Changes to procedures, instructions and practices
• Installation operators should have a process in place to ensure that changes (to process,
equipment and management systems) are properly evaluated and effectively managed.
This should cover:
• Scope of application
• Roles and responsibilities
• Risk analysis requirements
• Training and competency
• Implementation
• Monitor and review arrangements
Change can happen gradually in a way that is difficult to recognise. Installation

operators should periodically review process-related hazards, and identify changes
that have occurred and which may have been missed.
An important part of the implementation is ensuring that all relevant key

documentation is updated and communicated back to the workforce. The
maintenance management system should also be updated.
Changes that impact the performance of safety critical elements require

independent verification. Material changes
Opportunities...
• Creeping change is widely recognised as a vulnerability that should be more
rigorously addressed
29
Contents
Activities
2.20 Operational ORAs are essentially deviations from an installation’s original design intent e.g.
impairment of a safety critical element. They provide an indication of where the
Risk design may be flawed, and where plant is not adequately maintained or is used
Assessment outside of its normal operating envelope.
It is therefore vital that installation operators have a process in place to produce,

verify, control, apply, monitor, audit and liquidate ORAs to the highest standards.
This process should include:
• Levels of risk assessments based on consequences

• Clearly defined roles and responsibilities
• ORA team selection criteria
• Process for hazard identification
• Process for assessing initial and cumulative risks
• Process for defining controls and assessing if residual risk is ALARP
• ORA approval process
• Clear communication of the ORA
• Monitoring and closeout
Good practice…
• Ensure your ORAs are communicated effectively e.g. in morning
reports, shift handovers, heli-briefings, etc.
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Contents
2.21 Sand Produced sand can lead to HCRs in the following ways:
Management • Sand plugging causing valves to seize

• Accumulated sand requiring operator intervention to remove it e.g.
digging-out, dismantling of equipment, sand-washing, etc.
• Accumulated sand impeding the effectiveness of corrosion inhibitor
• Sand accumulation in instruments leading to incorrect readings
and compromised operational control
• Erosion of internal surfaces
Installation operators should have a sand management process in place to manage

these risks.
This should contain:
• Sand management strategy describing how sand hazards

are assessed and controlled
• Sand monitoring philosophy
• Flowline inspection findings
• Optimised operations e.g. fluid velocities, production restrictions,
choke settings, etc.
• Wall thickness checks
• Intervention procedures e.g. removal of sand from vessels
• Independent verification of the effectiveness of the process
2.22 Sampling Sampling involves breaking into the hydrocarbon containment envelope, so
poses a real HCR threat.
The hazards associated with sampling should be addressed in operating

procedures and include:
• Techniques for sampling

• Sample connections to use10
• Precautions to be taken during sampling and contingency procedures
10
The HSE report that the taking of samples from unofficial sampling points has been the root cause of several serious HCRs.
31
2.23 Leak All process plant has a potential for loss of containment and therefore HCRs.
Installation operators should have a process in place to manage these.
Management
Key elements of this should include: identification, assessment, management,
recording and reporting.
To correctly assess the leak, the following should be understood:
• Condition of the associated equipment

• Cause of the leak
• How the situation deteriorates with time
• Consequences of the leak
• How to classify the leak
The leak should then be managed accordingly so that the risks are ALARP. This
may mean removing equipment from service, or remaining in service but with
additional controls e.g. regular monitoring, secondary containment measures,
limiting access, etc.
Leak data should be recorded in an up-to-date leak register, and reported in line
with regulatory and corporate stipulations.
A leak that is sufficiently small – a weep or seep – may not necessarily require
immediate remedial action, however this should be planned at the first opportunity.
Weeps and seeps should be recorded in a register and be regularly monitored to
ensure they do not escalate.
Good practice…
• Routinely and proactively search for leaks using cross-disciplined teams
• Develop a strong culture of leak awareness and reporting amongst
your offshore personnel
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Contents
2.24 Plant Installation operators should have effective arrangements in place to manage
the reinstatement of plant following a maintenance period, to ensure that
Reinstatement the HCRs don’t occur. They should ensure that the following aspects are addressed.
Mechanical completion checks Use of a flange-break register for

tracking disturbed joints
Use of disturbed joint/ flange tags
Visual confirmation checks:
- Maintenance activities have been
completed
- Equipment is in place as per design
- All isolations have been removed
- Critical valves are returned to their
normal positions
- All vents / drains are in their correct
position
- Bleed points are capped / blanked
- All instrumented protective devices
are lined-up
Pressure testing Pressure testing procedure in place
for return-to-service
- Specific leak test procedures and
marked-up drawings
- Assessment process should be in place
Start-up and monitoring Plant line-out checks prior to restart
Plant checks to ensure:
- Emergency systems are ready
- Trip inhibits have been removed
- Confirm that there are no outstanding
actions that may impact
- Equipment and plant start-up
procedures in place
- Appropriate start-up crew in place
- Adequate communication to other
impacted parties
- Post start-up monitoring
arrangements until steady state
33
Performance Body Text here
Measures - % key documents updated against plan

- Number of process limit excursions
- % human factors roadmap complete
- Number of demands on safety critical alarms
- Number of process operating procedures beyond their due review date
- Number of safety critical tasks identified but not assessed
- % operating technicians identified as fully competent
- % completion technician refresher training programme
- Number of supervisory hours spent ‘on plant’
- Number of live IPS overrides, inhibits and bypasses
- Number of demands on mechanical relief devices
- Number of control loops operated in manual mode
- Number of isolation standards monitoring audit findings
- Number of live non-compliant isolation schemes
- Number of long-term isolations
- Number of PtW monitoring and audit findings
- Number of SBT inspection findings
- Number of SBT management system monitoring and audit findings
- Number of FHA inspection findings
- Number of FHA management system monitoring and audit findings
- Number of bolted joint inspection findings
- Number of bolted joint process monitoring and audit findings
- Number of vibration concerns identified
- Number of control valves physically bypassed
- Number of problem valves
- Number of outstanding HAZOP review actions
- Number of live ORAs
- % progress sand management plan
- Number of live leaks, weeps and seeps being monitored
- Number of reinstatement mechanical completion check exceptions
- Number of reinstatement start-up check exceptions
Key Competencies
- Process operators / control room operators / field operators
- Process isolations
- Leak testing
- Leak detection camera and US leak detector usage
- PtW process
- SBT
- FHA
- Bolted joints making and breaking
- Valves
- ORA process
- Sample taking
34
Contents
Checklist
Operating Plant Within Safe Limits
1. Is your key documentation up-to-date and accessible?
2. Are your limits readily available and understood?
3. Do you record and investigate excursions?
4. Are consequences of exceeding them understood, along with
corrective actions?
5. Do you undertake regular reviews to ensure procedures are adhered to?
6. Have you implemented the HSE’s human factors roadmap for
safety critical tasks?
7. Do you have clear, understandable and accessible operating procedures?
8. Do they identify hazards and associated controls, and include
abnormal conditions?
9. Are they regularly reviewed and updated?
10. Do you have effective operator handover arrangements in place?
11. Do you monitor, audit and review these arrangements?
12. Do you have effective process operations supervisory arrangements
in place?
Instrumented Protection Systems

13. Do you have proof-test procedures in place for your IPS?
14. Do you ensure they are carried out correctly?
15. Do you have a system in place for managing IPS overrides,
inhibits and bypasses?
16. Do you ensure they the procedures are adhered to?
17. Do you control changes to your IPS software and configuration settings?
Process Isolations
18. Do you follow the HSE’s guidelines on safe isolation?
19. Are your isolation standards and procedures adhered to?
20. Are your staff fully competent to undertake isolations?
21. Do your higher risk isolations receive greater scrutiny?
22. Do you ensure that your isolation schemes are fully labelled?
21. Do you have a procedure in place for managing locked valves
and is it followed?
23. Do you maintain a register of long-term isolations
and are they routinely checked?
24. Do you recognise leak testing as a competence?
25. Do you have a formal process for reinstatement?
26. Do you use leak detection cameras during reinstatement?
35
Checklist
Permit to Work
28. Are your personnel trained and competent in your PtW system?
29. Do you regularly ensure that your PtW procedures are adhered to?
30. Do you check the continued effectiveness of your PtW system?
Small Bore Tubing and Piping Systems

31. Do you follow the Energy Institute’s guidelines on managing SBT?
32. Do you have a formal competency system for SBT, and does it extend
to third parties?
33. Do you ensure that your SBT management process is adhered to
and remains effective?
34. Do you use a flange-break process for your SBT?
Flexible Hose Assemblies

35. Do you follow the Energy Institute’s guidelines on managing FHA?
36. Do you have a formal competency system for FHA, and does it extend
to third parties?
37. Do you ensure that your FHA management process is adhered to
Bolted Joints
38. Do you follow the Energy Institute’s guidelines on managing
bolted joints?
39. Do you have a formal competency system for bolted joints?
40. Do you ensure that third party personnel are competent to work
on your bolted joints?
41. Do you ensure that your bolted joints process is adhered to
Vibration
42. Do you follow the Energy Institute, HSE and API guidelines
on vibration management?
43. Do you ensure that the procedures are adhered to and are effective?
44. Do you undertake vibration searches and encourage personnel
to report vibrations?
36
Contents
Checklist
Valves
45. Do you have a valve management process in place based
on industry good practice?
46. Are your staff trained and competent to work with valves,
including third parties?
47. Do you ensure that your valve process is adhered to
Management of Change
48. Do you have a robust MoC procedure in place and does it cover
creeping change?
49. Are your staff trained and competent in your MoC process?
50. Do you ensure that your MoC process is adhered to
Operational Risk Assessment

51. Do you have a robust ORA process in place?
52. Are your people trained and competent in how to use this process?
53. Do you ensure that your ORA process is adhered to
Sand Management
54. Do you have a sand management process in place?
55. Do your operating procedures take account of the impact
of sand on operations?
56. Do you ensure that your procedures are followed and the process
remains effective?
Sampling
57. Do you have a process in place for sampling?
58. Are your people trained and competent to take samples?
remains effective?
Leak Management
60. Do you have a risk-based approach to leak management?
61. Do you have a process in place to manage weeps and seeps?
62. Do you maintain an up-to-date leak register?
63. Do you routinely and proactively search for leaks?
remains effective?
65. Have you developed a strong culture of leak awareness
and reporting?
37
Checklist
Reinstatement
66. Do you use a flange-break register and disturbed joint / flange tags?
67. Do you have effective pressure testing arrangements in place
for reinstatement?
68. Do you have effective start-up and monitoring arrangements in place?
References 1. HID Inspection Guide Offshore: Inspection of Loss of Containment (LOC)

Produced by the HSE and available via the HSE website
2. Loss of Containment Manual

3. A Human Factors Roadmap for the Management of Major Accident Hazards

4. Alarm Systems: a Guide to Design, Management and Procurement

3rd edition, EEMUA publication 191, publish by the Engineering Equipment
and Materials Users Association (EEMUA) and available via their website
5. The Safe Isolation of Plant and Equipment

2nd edition, 2006, HSG253, published by the HSE
and available via their website
6. Guidelines for the Design, Installation and Management

of Small Bore Tubing Assemblies
2nd edition, May 2013, published by the Energy Institute
7. Guidelines for Management of Flexible Hose Assemblies

2nd edition, February 2011, published by the Energy Institute
8. Guidelines for the Management of Integrity of Bolted Pipe Joints

for Pressurised Systems
2nd edition, June 2007, published by the Energy Institute and available via their website
9. Mechanical Joint Integrity: Route to Competence Guidance

Revision 2, June 2013, published by Step Change in Safety and available via their website
10. Guidelines for the Avoidance of Vibration Induced Fatigue

Failure in Process Pipework
2nd edition, January 2008, published by the Energy Institute
11. Transient Vibration Guidelines for Fast Acting Valves Screening Assessment
OTR 2002/28, produced by the HSE and available via their website
12. API 17B - Recommended Practice for Flexible Pipe

5th edition, May 2014, published by API and available via their website
13. API 17J - Specification for Unbonded Flexible Pipe

3rd edition, July 2008, published by API and available via their website
14. Guideline on Ageing and Life Extension of Subsea Pipelines and Risers
Issue 1, January 2016, HS096, published by Oil & Gas UK
38
HYDROCARBON RELEASE 3. Investigation
Contents
PREVENTION GUIDANCE DOCUMENT & Learning
Why is it
important?
Investigation and learning is concerned with how organisations investigate HCRs
to identify the immediate and underlying root causes, ensure that remedial action
is taken and that lessons are learnt to avoid future occurrences.
Insights gained from analysing historical HCR incidents should also help
organisations focus where improvement effort is required.
Investigation is an essential part of the monitoring process within installation

operators and is required under the 1999 Management of Health and Safety at
Work Regulations (MHSWR)11.
Installation operators are required to report certain HCR events, including

underlying causes, to the Offshore Safety Directive (OSDR).
3.1 Investigation To be most effective, investigations require a structured, methodical approach to

information gathering, collation, analysis and review. Quality investigations unearth the
root causes of HCRs and maximise learning opportunities.
The process can be broken down into reporting, classification, investigation and follow-up.
Reporting Report the HCR incident

Conduct an initial assessment of actual and potential
severity of the release
Gather and preserve evidence
Register the release
Classification Quantify release parameters
e.g. quantity, duration,
phase, etc.
Determine if RIDDOR reportable or not
Classify as leak, weep or seep
Sub-classify as appropriate e.g. Major,
Significant or Minor
Investigation Form the investigate team
Determine root causes using a structured
approach e.g. root cause analysis (RCA)
Agree remedial actions and owners
Identify key learnings for sharing
Review the incident, enter in
the management system and
communicate outcomes
Follow-up Monitor progress of the action items
Close out the incident
Monitor, review, audit and assurance
11
MHSWR Reg 5 requires employers to make arrangements for the effective planning, organization, control, monitoring and review of the preventive
and protective measures defined in Reg 1. Paragraph 36 of the ACOP to the regulations indicates that monitoring includes investigation.
39
Good practice… Body Text here
• Scale your investigations so that they are proportionate to the actual

and potential severity of the release – the higher the severity the greater
the investigation effort
• Assume the worse credible potential consequence of the release when
evaluating it
• Include your near-miss releases – these provide invaluable insights into
what could have happened
• Have in place a clear process that details how your releases are reported,
classified, investigated and followed-up
• Involve and engage with your workforce, Safety Reps and specialists
e.g. contractors and vendors in investigations
• Use formal incident review panels for your higher severity releases to
involve leaders, ensure consistency, promote SMART, fit-for-purpose
actions, and endorse sharing
• Use process engineers and technical safety engineers to quantify and
validate your release metrics
• Adopt Oil & Gas UK guidance12 on categorising and reporting your HCRs
• Recognise RCA and incident investigation as key competences and
train and develop your staff accordingly
• Involve your senior leaders in release investigations, both as team
members and as investigation leaders
• Consider creating a duty investigator role to provide initial front line
support and ensure robust initial assessments
• Develop a simple, clear investigation matrix that is visible and well
understood throughout your organisation (see Best-in-Class Example 1)
• Consider categorising your HCRs according to the 7Cs of Joined-up
Thinking material13 to promote better understanding and maximise
learning opportunities
• Implement a quality checking process for your investigations to ensure
consistently high standards are maintained (see Best-in-Class Example 2)
Opportunities...
• Installation operators are still seeing repeat incidents, suggesting
that investigations are not identifying root cause, remedial actions
are not effective or lessons-learned are not being taken on board
• The overall quality of low severity, but more numerous, HCR
investigations could be improved
• Near-miss data seems to suggest that the greatest threat to
installation operators is posed by medium severity releases, as they
are far more numerous than high severity incidents
12
Supplementary Guidance on the Reporting of Hydrocarbon Releases by Oil & Gas UK
13
Step Change’s 2015/16 HCR prevention themes of Change management, Communication, Complacency, Control of
work, Competence, Culture and Commitment. Each is available as a downloadable workforce engagement pack.
40
Contents
Best-in-Class Example 1:
Summary Investigation Matrix
Risk Severity Investigation Owner RCA Report Timeline Approver

High Catastrophic Level 1 Director Apollo Extended 2 months VP
Medium Major Level 2 Manager Apollo Full 1 month Director
Low Minor Level 3 OIM 5 Why Short 2 weeks Manager
41
Best-in-Class Example 2:
Incident Investigation Quality Checker
Quality Aspect Enter Findings… Score (1-5) Guidance

Appropriate team composition Team comprised HSE manager 4 Facilitation adequate?
(facilitator), facility manager, HSE Offshore suitably involved?
advisor, and fully supported by Onshore suitably involved?
offshore team Specialists suitably involved?
Appropriate depth of analysis Full investigation report 4 Analysis method suitable?
completed, including timeline of Timeline of events clear?
events and lab analysis. Taken to All “Why…?” questions explored?
review panel.
Causes identified Within both the report and the 4 All probable causes covered?
incident management system Immediate causes identified?
Underlying causes identified?
Human factors considered Considered and 3 “Why did...?” explored?
documented within the report. “Why didn’t…?” explored?
Areas covered included design, Plant design considered?
procedures, training and Supervision considered?
behaviours Competence considered?
Communication considered?
Procedural aspects considered?
Behaviours considered?
SMART actions All entered into the incident 4 Root causes addressed?
addressing causes management system, including Focus on non-root causes?
additional ones identified in the Number of actions appropriate?
review panel Were they SMART?
Appropriate level or urgency Quickly set up and undertaken. 2 Time taken to form team?
Final conclusion reached quickly Time taken to investigate?
but results from outside body Time taken to review panel
took too long and weren’t Time taken to share learnings?
expedited, delaying the review
panel.
Learnings shared Learnings were shared 4 Shared at installation?
throughout the investigation. Shared across other installations?
Shared at installation level, Shared across business?
across the business and entered Shared with other operators?
into the Step Change safety alert Shared with contractors?
database Shared with vendors?
Shared with industry?
Total 25 out of 35
Satisfactory:
Total ≥ 21 and each score ≥ 3
Not satisfactory:
Requires follow-up coaching
42
Contents
3.2 Human Industry HCR statistics14 reveal that almost a third of all HCRs have human factors as
either an immediate or underlying cause. For Major reportable releases, this figure is even
Factors higher. It is essential that installation operators include human factors in the investigate
scope, and consider what people did, as well as what plant was involved
Good practice…
• Ensure investigations go beyond ‘human error’ or ‘procedure not followed’
to understand the underlying root causes of operations integrity issues
• Distinguish between intentional and unintentional acts
• Adopt established guidance on human factors from HSE and Step Change
in Safety
• Provide human factors training for those involved in HCR investigations,

or specialist support
Opportunities...
• Many installation operators admit that they can still do more to consider human
factors in HCR investigations
HUMAN FACTORS
HOW TO TAKE THE NEXT STEPS
GUIDANCE DOCUMENT
Improving safety and
effecting change through
collaboration
14
For example, the HSEs Report on the Hydrocarbon Release Incident Investigation Project.
43
3.3 Analysis Data recorded from HCR investigations should be analysed to identify patterns and
trends. These can then be translated into meaningful improvements. To maximise
these insights, data that is recorded should be standardised and cover the what,
where, when and who of the incident.
What? Hydrocarbon phase, quantity, duration, actual and potential severity,

causes, etc.
Where? Asset, process, system, equipment, etc.
When? Start-up, normal operations, reinstatement, turnaround, shutdown,
day / night shift, etc.
Who? Human factors, behaviours, culture, etc.
Analysis and wider insights can also be gained externally from sources such as the
HSE for reportable releases. This can also help focus any improvement effort.
Good practice…
• Use a single company database to record HCRs data and allow

widespread access
• Analyse and trend weeps and seeps data
• Use external data analyses to provide wider data insights
• Develop a formal process describing what data is captured, analysed

and by whom
Opportunities...
• Many installation operators admit that they can still do more to
consider human factors in HCR investigations
44
Contents
3.4 Learning Installation operators should learn from their previous HCR incidents and from those of
others. They should be able to convert these learnings into improvement activities and
and Sharing fewer HCR incidents.
All installation operators have an obligation to share learnings from HCR incidents, both
internally and externally.
“Almost every aspect
of what went wrong
Arrangements should be in place to:
at Texas City had
gone wrong before, • Actively seek HCR prevention lessons and good practices from others, including
either at Texas City or offshore operators both in the UK and worldwide, as well as onshore major hazard
elsewhere. Some of industries (e.g. refining, oil and gas, nuclear etc.)
these earlier failures
had been extensively • Identify changes to relevant codes and standards and review these in light of existing
documented and operational arrangements
publicised…”
• Share learnings related to HCR prevention, including lessons learned from internal
Failure to Learn: incidents, with peers in industry (e.g. such as via Step Change in Safety or Oil & Gas
the BP Texas City UK), and actively contribute to the revision of related standards and guidance
Refinery Disaster
Andrew Hopkins
Good practice…
• Develop a process that details how lessons are shared internally and externally
• Leaders check that lessons are being acted upon and shared
• Focus on early sharing of insights and follow-up as new information
becomes available
• Actively seek wider industry learnings e.g. safety alerts, from vendors,
peer organisations, etc.
• Share learnings externally e.g. with key contractors, vendors, industry bodies, etc.
• Create dedicated space in existing meetings to discuss learnings
Opportunities...
• Most installation operators recognise that they could learn more, both internally
and externally
• Better sharing of learnings with the offshore teams
• Better sharing of learnings externally
45
Measures - Number of learnings acted upon
- Number of HCR investigation actions overdue
- Number of LFIs / safety alerts issued
- % timely incident investigations
- Overall quality of investigations
- % staff RCA competent
- % staff incident investigation competent
Key Competencies
- RCA practitioner
- Incident investigation leader
- Incident investigation team member
46
Contents
Checklist
1. Do you have a structured, scaled investigation
process in place?
2. Is the actual and potential severity of the release considered?
3. Does your process include near-miss releases?
4. Do you follow the OGUK guidance on reporting releases?
5. Is RCA recognised as a key competence in preventing HCRs?
6. Are your leaders, offshore workforce and specialists involved in

your investigations?
7. Is incident investigation recognised as a key competence in

preventing HCRs?
8. Do you check the quality of your investigations in place?
9. Are human factors considered in your investigations?
10. Do you provide human factors training to those involved

in investigations?
11. Do you have a consistent approach to capture release data?
12. Is historical release data analysed for trends and insights?
13. Are lesson-learned shared effectively within your organisation?
14. Are lessons-learned shared outwith your organisation?
15. Do you actively seek lessons-learned from outwith

your organisation?
16. Do you periodically check relevant codes and standards for

updates and changes?
17. Do you have performance measures in place for

HCR investigations?
References 10. Report on the hydrocarbon release incident investigation project

OSD Hydrocarbon Release Reduction Campaign, Offshore Technology Report
2001/055, produced by the HSE and available via the HSE website.
11. Failure to Learn: the BP Texas City Refinery Disaster

January 2014, ISBN 978 1 921322 44 0, published by CCH Australia Limited.

47
HYDROCARBON RELEASE
4. Competence
important?
Competence is a combination of training, skills, experience and knowledge
that a person has, and their ability to apply these to perform a task or
undertake a role correctly. 15
Competence is a key component of workplace activities. Current legislation

requires that operators can demonstrate the competence of their staff.
It is essential that those undertaking the various tasks and roles associated
with HCR prevention have the necessary competencies to do these safely
and effectively.
Competence is especially important for front-line workers involved directly

with plant and equipment, but also for others such as leaders, technical
authorities and onshore engineers. It is equally applicable to all personnel,
contractors and operator staff.
4.1 Competence Organisations involved in the offshore oil and gas industry must have competent
people to support their operations, and be able to demonstrate this.
Management
& Assurance To manage this, organisations should have in place a competency
management system that:
• Describes what competencies, training and assessments are required for

particular roles and tasks i.e. competence profiles
• Details the current status of individuals against these requirements, including

gaps and how they are being managed
• Includes contractors and other third parties
• Retains all records of assessment and supporting documents (for review and
audit by assessors and verifiers)
Step Change’s The Competence Management Framework describes a simple,

four stage process of competence assurance.
Stage 1 Assessment of Capability Robust recruitment & selection process
Compliance training, further induction

Stage 2 Initial Assessment
and initial assessment
Competence demonstration
Stage 3 Professional Assessment
and professional assessment
Stage 4 Ongoing Verification Individuals maintaining competencies
A key component of any competency management system should be frequent

auditing and management review.
All competencies impacting HCR prevention should be managed in line with

this approach.
15
More detail can be found on the HSE’s website in the section What is Competence?
48
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4. Competence
Contents
4.2 Factors Many factors can impact competence, such as attitude, physical ability and time dilution.
Human factors is a collective term to explain how these and other factors can impact
Affecting competence and the ability of people – at all levels of the organisation – to perform tasks
Competence correctly. Step Change’s Human Factors: How to Take the First Steps… groups human
factors into three key areas, and details the various aspects of each.
Plant & Equipment Should be designed and located to reduce errors during use
and maintenance
The design should consider emergency situations when

errors are more likely
Processes Procedures should be clear and practical
Risk assessment and incident investigation should consider

human factors
Safety critical communication should be clear

and unambiguous
Safety critical change should be managed
Staffing levels and workload should not jeopardise safety
People People need the right training, competence

and supervision
There should be strong safety leadership
Human error and how to manage it should be

well understood
Performance influencing factors such as fatigue should also

be understood 16
Poor practices should be identified, understood and changed

out
Both organisations and individuals should understand the impact of these factors, recognise
when they are present and react accordingly to minimise their impact.
16
These performance-influencing factors are detailed in the HSE’s Performance Influencing Factors (PIPs) information sheet.
49
HYDROCARBON RELEASE
4. Competence
4.3 Competencies There are many activities and processes within an organisation that have a direct and
indirect impact on HCR prevention.
Impacting
HCR Prevention Those that impact directly include:
Plant design
Safe isolation and reinstatement practices
Joint management, including flange management
and bolted mechanical joints
Flexible hose and fittings management
Pressure testing
Small bore tubing and piping management
Permit to Work
Management of Change
Proof testing IPS
Overrides, inhibits and bypasses
Sampling
Leak management
Plant reinstatement
Plant start-up and shutdown
Seal maintenance e.g. on pumps, compressors and valves
Those that impact indirectly include:
Incident investigations
Environmental management
Release reporting
Use of release detection technologies e.g. fugitive leak detection cameras
and ultrasonic detectors
Spill prevention and contingency planning
HCR prevention awareness training e.g. process safety workshops and
live training events 17
17
Such as those held at DNV GL Spadeadam Testing and Research, in Cumbria.
50
HYDROCARBON RELEASE
4. Competence
Contents
4.3 Continued... Good practice competence schemes are available from various industry bodies. Step Change
in Safety’s Mechanical Joint Integrity: Route to Competence Guidance, the Energy Institute’s
Competencies Guidelines for the Design, Installation and Management of Small Bore Tubing Assemblies
Impacting and Guidelines for the Management of Flexible Hose Assemblies all detail respective
HCR competence requirements.
Prevention Many larger organisations have formal in-house competence schemes for process operators
and maintenance technicians, whilst others adopt schemes from lead industry bodies such
as OPITO.
Installation operators should have competency standards for each process operator role
(e.g. supervisor, control room operator (CROs), field operators). These standards should be
installation and role specific, and linked to the Major Accident Hazards on the installation.
Process operator training should be well structured, and be a combination of theory and
practical experience. It should cover all operating modes, including abnormal, emergency
and maintenance conditions.
Trainees should have specific learning objectives, and be allowed sufficient time and
support to progress. Trainers and assessors should be trained in their roles, and have
sufficient knowledge and experience.
Competence should be assessed through a combination of verbal questioning and

written testing. The assessment should be proportionate to the criticality of the tasks
and risks concerned.
Installation operators should have arrangements in place to check and monitor task
performance, reassess competence and provide appropriate refresher training.
51
HYDROCARBON RELEASE 4. Competence
Good Practice...
• Adopt recognised industry competence schemes as good practice
• Treat fugitive leak detection camera and ultrasonic detector usage as

required competencies
• Ensure that key offshore leadership roles (e.g. OIM, Production Supervisor,
Maintenance Supervisor, etc.) have the necessary competencies and
awareness training
• Include competence in your HCR prevention plan
• Recognise that your offshore leak champions need to be competent
• Make competency mentors available offshore
• Verify competencies as part of any investigation review
• Include competency as a performance measure in your performance

dashboard
• Provide dedicated training for offshore supervisors that includes process

safety and HCR prevention awareness
• Undertake regular competency audits on key contractors
• Involve contractors and other third parties in live awareness events
• Ensure your competence management system is verified, approved or

accredited e.g. by OPITO
• Recognise behaviours as part of your competence assurance scheme
• Ensure that technical authorities are part of your competency assurance

scheme
Opportunities...
An area of particular concern identified was the assurance of third
party competences; organisations with primary responsibility should:
• Ensure that third party competence systems are consistent with their own
• Seek demonstrable evidence to assure the competence of individuals
• Ensure adequate management supervision and support is provided
to contractors
Don’t just audit your larger contractors; work with smaller contractors to
ensure their system aligns.
Overall visibility of status of HCR prevention competencies could be improved

e.g. via a performance dashboard.
Don’t just rely on your supply chain or onshore contract managers to ensure
that third party staff are competent; ensure that you have the necessary
offshore processes in place to assure individual competence.
52
HYDROCARBON RELEASE
4. Competence
Contents
Performance
Measures - % staff completed HCR prevention training
- % staff completed MAH awareness training
- % leaders completed process safety training
- % staff PTW training overdue
- % staff small-bore tubing competent
- % staff flexible hose competent
- % staff bolted flange make / break competent
- % staff trained on new equipment
- % staff isolations competent
- % staff MoC system trained
- % process operators / CROs / field operators competent
- % contractor / service provider competent (key skills)
Key Competencies
- Fugitive leak detector camera and ultrasonic leak detector usage
- Leak champion role
- Competence assessor role
- Offshore competence mentor role
- Process operator / CRO / field operator
53
HYDROCARBON RELEASE
4. Competence
Checklist
1. Do you have a formal, robust and effective competency
management in place?

2. Does it include contractors and third parties?

3. Does it include an effective
competence assurance scheme?

4. Is it regularly audited and reviewed?

5. Do you regularly audit and review third party
competence systems?
6. Are all of your HCR prevention roles and activities included?
7. Do you include TAs and other similar roles

in your competence schemes?
8. Do you recognise leak camera and leak detector

usage as a competence?
9. Do you recognise leak champion

(or similar) as a competence?
10. Are behaviours an integral part of

your competence schemes?
11. Are you aware of the various factors

that can impact competence?
12. Do you understand performance influencing factors,

and how to manage them?
13. Do you recognise all your roles and activities that directly
impact HCR prevention?
14. Do you recognise all your roles and activities that indirectly
impact HCR prevention?
15. Are your competence schemes in line

with good industry practice?
16. Do you have competency standards for all your process

operator roles?
17. Are they linked to your installation MAHs?
18. Does your operator training include all operating modes,

including abnormal conditions?
19. Do you have competence mentors available offshore?
20. Do you include HCR prevention competence

as a performance measure?
21. Do you have a process offshore to verify the

competence of third parties individuals?
54
HYDROCARBON RELEASE
4. Competence
Contents
References
1. The Competency Management Framework
A guidance document produced by Step Change in Safety,
updated March 2016, and available online via their website
2. Human Factors: How to Take the First Steps…

A guidance document produced by Step Change in Safety,
available online via their website
3. Performance Influencing Factors (PIFs)

Information sheet produced by the HSE
and available online from their website
4. Mechanical Joint Integrity: Route to Competence Guidance

Revision 2, June 2013, published by Step Change in Safety
5. Guidelines for the Design, Installation and Management

of Small Bore Tubing Assemblies
A guidance document produced by the Energy Institute,
May 2013, available online via their website
6. Guidelines for the Management of Flexible Hose Assemblies

A guidance document produced by the Energy Institute, February 2011,
available online via their website
55
HYDROCARBON RELEASE 5. Integrity
PREVENTION GUIDANCE DOCUMENT Management
important?
Integrity management covers the systems, processes and activities used
to ensure that equipment degradation – due to fatigue, corrosion or
erosion – does not affect its ability to perform as intended, and ideally
informs of any emerging issues with sufficient time to fix them.18
Data reveals that the degradation of the material properties of equipment

is a significant immediate cause of many HCRs, with inadequate inspection
and condition monitoring proving a common underlying cause.
It is vital that installation operators understand the technical integrity

risks of process containment equipment, and have effective systems in
place to identify and manage these.
5.1 Main Integrity In basic terms integrity management focuses on permanent static equipment,
whereas maintenance management relates to temporary and dynamic equipment.
Threats
Within this context, the main integrity threats facing installation operators are
corrosion degradation and fatigue failure (due to vibration), and primarily
associated with SBT, FHA and bolted joints.19
Step Change in Safety’s Asset Integrity Toolkit provides an oversight of asset

integrity good practices and pragmatic tools to promote good asset integrity
management.
Good Practice...
• Utilise Step Change in Safety’s Asset Integrity Toolkit
• Include your priority integrity threats on your performance dashboard
• Actively search for new technologies to improve how you identify
and manage your integrity threats
Opportunities...
• Temporary repairs with extended deviations are seen as a particular
vulnerability facing installation operators.
18
For the purposes of hydrocarbon containment, integrity management is concerned only with
pressure systems, focusing on the degradation of fixed equipment such as pipework, pipelines,
vessels and valves. Rotating machinery, sensors, electrical, and controls systems are generally
excluded, as are wells.
19
The management of these threats is covered in their respective Energy Institute guides and covered
in the Operational Integrity section of this guide.
56
HYDROCARBON RELEASE 5.Contents
Integrity
5.2 Key Areas of Integrity management uses risk-based processes to:
an Integrity • Assess equipment integrity threats

Management • Understand the consequences of these threats
• Estimate the timescale to failure
This information is then used to determine the extent, frequency and type of inspection
technique that should be employed (to determine if the threat is resulting in degradation).
As the process is risk-based, it does not mean that failures will never occur, but that the
risk of failure has been reduced to an acceptable level.
There are essentially three main areas that an effective integrity management
system should include:
• Inspection management
• Corrosion management
• Fabric maintenance management
It should be noted however, that effective inspection, corrosion and fabric maintenance
management processes do not necessarily constitute an effective integrity management
system. This only occurs when these processes are married-up with an ability to utilise the
data obtained to perform continued suitability-type assessments.
57
5.3 Inspection Inspection management is concerned with the preparation, undertaking, refining
and recording of the various inspection activities.
Management
System Key elements of an effective inspection management system should include the
following.
Accurate P&IDs Identifies the equipment to be incorporated into an inspection scheme

Corrosion circuits20 Groupings of pipework with similar service
Inspection isometrics Uniquely identifies all inspection features e.g. bends, welds, tees, etc.
Risk assessment Corrosion circuits require assessment to determine inspection needs
Follows defined RBI or CRA methodologies
Essential that the RBI methodology is controlled and documented
Looks at both probability and consequence of failure to define risk
RBI assessments require various information including:
- Inspection history
- Known defects
- Process conditions
- Construction materials
- Corrosion threats
- Corrosion rates
Inspection scheme Defines all inspection requirements in the form of a plan
CMMS often used to contain the inspection scheme and frequency
Essential to integrate this with wider plans e.g. TARs
Inspection work packs Provides clear instructions to offshore inspectors
For pipework it defines:
NDT techniques e.g. radiography, ultrasonic testing, visual, etc.
Coverage of inspection e.g. dead-legs on oil export systems
UT scanning patterns
Defect criteria Clear criteria of when a defect report should be raised
Defect management Database to capture details of the anomaly, including remedial actions
Risk-ranking establishes priorities
Remedial actions include:
- Periodic monitoring
- Spool replacement or weld repair
- Installation of a temporary repair e.g. a clamp or composite wrap
- Painting to re-instate coating
- Fitness-for-service assessment
Inspection management Records the completed inspections
Essential in developing inspection work packs
Offshore NDT Resource Ensure that sufficient offshore inspection personnel are available
Inspection personnel should be suitably skilled and qualified
Deferral of work A process is required to risk assess and document inspection deferrals
20
Some inspection management systems don’t use corrosion circuits but assess each unique pipework line separately.
58
Integrity
Good Practice...
• Ensure that your P&IDs and isometrics are accurate, detail all fixed
equipment and have correct insulation demarcations on them
• Ensure that your inspection isometrics and piping corrosion circuits cover
all your hydrocarbon pipework
• Remove redundant equipment from your inspection schemes
• Ensure offshore is involved in your inspection planning process
• Update your risk assessments with current information from your
inspections
• Link your inspection scanning patterns to expected degradation e.g.
closed drains lines can expect internal corrosion at the 6 o’clock position
at any point along a horizontal straight
• Adopt NII technologies to reduce the need to enter your vessels (to
undertake internal inspections)
• Use thermal imaging cameras to routinely look for fugitive emissions on
pipework and vessels
• Use digital detector array radiography to provide quicker results (that
require less exposure time and eliminate the need for dark rooms)
• Adopt phased array over conventional UT to provide higher probability of
detection for small internal pitting
• Adopt grab-line crawler technology to improve the way in which FPSO
moorings are inspected
• Utilise a dedicated defect management database in preference to multiple
spreadsheets
• Use proprietary software to provide single-point control and management of
risk assessments
• Ensure that your inspection reporting requirements and defect criteria are
clear and understood i.e. your defects are actually reported
• Ensure that your process for managing inspection repairs – especially
overdue repairs – is robust
• Remove temporary repairs within their design life
• Ensure that you adhere to recognised industry inspection standards e.g.
API 510 and API 57021
• Ensure that your offshore inspectors are competent and skilled in the use
of the various inspection technologies
• Ensure that your inspection management system addresses corrosion
under pipe supports and within trunnions
21
API 510 and API 570 are Pressure Vessel Inspection Code: In-Service Inspection, Rating, Repair & Alteration and Piping Inspection Code respectively.
59
5.4 Corrosion Corrosion management is concerned with the various activities that control and
monitor corrosion.
Management
Key elements of an effective corrosion management system should include the
following -
Corrosion Activities required to control and monitor

control equipment corrosion
matrices Ensure the matrices are regularly reviewed and updated
Activities may include:
- Chemical treatment e.g. continuous injection of
corrosion inhibitor and periodic application of biocide
- Corrosion monitoring via corrosion coupons and probes
- Chemical monitoring e.g. inhibitor residuals, bacteria
analysis, etc.
- Pipeline pigging
Effective Frequent corrosion management meetings
meetings Review results of inspection and corrosion
management activities
Key stakeholders are:
- Production chemistry
- Corrosion
- Operations
- Inspection personnel
Failure Investigate all HCRs due to material degradation
investigation Understand how and why the inspection management
system failed
Integrate learnings
Performance Ongoing monitoring and review of the corrosion
monitoring management system
Use of performance measures
Ensure overall effectiveness of inspection
and corrosion management
Good Practice...
• Include full periodic insulation strips on hydrocarbon equipment (or
an NDT equivalent) as part of your CUI management strategy
• Inspect operational and design dead legs, including vessel bridle
pipework, for microbial corrosion
• Inspect for corrosion in transits through walls and bulkheads
• Be aware of souring wells increasing the concentration of H2S and
increasing the likelihood of cracking
60
Integrity
5.5 Fabric Fabric maintenance is concerned with the overall approach to painting and coating systems.
Maintenance Key elements of a fabric maintenance management system should include the following.
Management
Fabric Documented approach defining painting work

maintenance Includes assessment criteria and paint-by dates
strategy Describes how PFP and insulation work should be addressed
Paint specification Details coatings systems that can be used
Includes required surface preparation and quality requirements
Live-line-blasting Ensures no loss of containment due to blasting prior
procedure to painting
Painting resource Competent painters required to deliver productivity and quality
Good Practice...
• Use bristle blasters and one-coat systems for spot repairs (to
increase productivity)
• Trial spray coatings (as an alternative to conventional insulation
techniques) on your vessels to manage CUI more effectively
61
Measures - % process containment – SECE PM compliance
- % process containment – SECE CM compliance
- Number of inspection findings – high risk
- Number of vessel inspections and findings
- Number of vessel inspections overdue
- Number of pipework inspections and findings
- Number of pipework inspections overdue
- % fabric maintenance plan progress
- % critical joints failed initial inspection (for new plant)
- Leak detection camera – number of HCRs during routine sweeps
- Number of temporary repairs with extended deviations
- Number of high priority integrity threats
- Number of new technologies trialled and adopted
- % P&ID and isometrics reviewed
- Number of NII vessel inspections
- Number of HCRs due to material degradation
- Corrosion inhibitor usage
- Biocide usage
- Inspection management system reviews and findings
- Corrosion management system review and findings
- Number of RBIs updated after inspections
- Fabric maintenance management system and findings
Key Competencies
- Offshore inspection (including technologies e.g. detection
cameras, NDTs, UT scanning, etc.)
- Offshore corrosion
- Investigation and RCA
- Offshore painting (including technologies)
62
Integrity
Checklist
1. Do you understand your main integrity threats?
2. Do you include your main integrity threats in your

performance dashboard?
3. Do you actively search for new technologies to help you manage

your integrity threats?
4. Do you have an effective inspection management system in place?
5. Do you monitor, review and audit the system to ensure

it remains effective?
6. Are your key drawings accurate enough to develop effective

inspection schemes?
7. Do you regularly review and update risk-based inspection

methodologies?
8. Do your inspection schemes integrate with wider plans e.g.

shutdown plans
9. Are your inspection work packs clear and comprehensive in content?

☐
10. Are your defect criteria clear and understood?
11. Are your defects effectively managed in a database?
12. Does your inspection management system effectively record

completed inspections?
13. Do your offshore inspectors have the right competencies,

and do you assure this?
14. Do you have an effective system in place for managing deferrals?
15. Are your offshore people involved in the inspection
16. Are your inspection scans linked to expected

degradation mechanisms?
17. Have you adopted NII approaches to vessel inspections?
18. Are you trialling and adopting new technologies to improve

integrity management? ☐
19. Do you have an effective corrosion management system in place?
20. Do you monitor, review and audit the system to ensure it

remains effective?
21. Are your Corrosion Control Matrices regularly reviewed and updated?
22. Do you integrate learnings from incident investigations

into your inspections?
63
Checklist
23. Do you inspect dead legs for microbial corrosion?
24. Do you have an effective fabric maintenance management

system in place?
25. Do you monitor, review and audit the system to ensure it

remains effective?
26. Do you have a live-line blasting procedure in place?
27. Do your offshore painters have the right competencies, and do you
assure this?
References
15. Asset Integrity Toolkit
Developed by Step Change in Safety and available via their website
16. Guidelines for the Design, Installation

and Management of Small Bore Tubing Assemblies
2nd edition, May 2013, published by the Energy Institute
17. Guidelines for Management of Flexible Hose Assemblies

2nd edition, February 2011, published by the Energy Institute
18. Guidelines for the Management of Integrity of Bolted

Pipe Joints for Pressurised Systems
2nd edition, June 2007, published by the Energy Institute
19. API 510 Pressure Vessel Inspection Code: In-Service

Inspection, Rating, Repair & Alteration
10th edition, May 2014, published by the API and available via their website
20. API 570 Piping Inspection Code

4th edition, February 2016, published by the API
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HYDROCARBON RELEASE 6. Leadership,
Communication
Contents
PREVENTION GUIDANCE DOCUMENT & Engagement
Why is it
important?
Leadership, communication and engagement are important because they help
ensure that the appropriate level of attention is focused by installation operators
on their HCR prevention plans, and that their prevention activities remain on-track.
They demonstrate how leadership in your organisation feels ownership for

(and prioritises) HCR prevention, how this is communication throughout your
organisation and how your organisation, and wider industry, is engaged in the
programme of HCR prevention.
Leadership, communication and engagement are key supporting elements of any

HCR prevention programme, along with resourcing, training and competence,
targets and metrics and monitoring and auditing.
6.1 Leadership Leadership is how leaders within an organisation demonstrate ownership, commitment
and overall accountability for HCR prevention as an important company objective.
Examples of demonstrable leadership in HCR prevention may include:
• Exemplifying the right behaviours that should be mirrored

• Making dedicated time available
• Establishing clear priorities and targets
• Senior leadership sponsorship of the programme
• Reviews by senior leaders
• Process safety leadership training
Leadership also plays a key role in driving the cultural change that may be required when
moving an organisation from a position where it is not managing its release to one where
it is more mindful of the consequences, and actively seeks to prevent them. This may
mean the wholesale realignment of values, priorities and knowledge base, in addition to
refocusing attention.
Examples of leadership mindfulness may include:
• Recognising that past success is not a guarantee of future success

• Installing a sense of unease and a desire to change
• Creating a culture of prevention rather than reduction
• Seeking to understand the current problems
• Creating a clear distinction between process and personal safety
• Focusing on wider topic of major accident prevention
Leaders should also play an active role in monitoring and reviewing HCR
prevention arrangements, including:
• Regular monitoring of compliance of arrangements for controlling and

mitigating HCR risks
• Periodic audit of the effectiveness of these arrangements
• Review of monitoring and audit findings
65
Communication
Good Practice... Body Text here
• Move from a reduction to a prevention culture, and develop by

continuous improvement
• Establish clear HCR targets that are widely understood e.g. in
company score cards
• Set clear accountability for releases and release prevention
• Specify release targets within personal performance contracts
Opportunities...
• Improvement programmes not operationalised by a clear plan
6.2 Process Safety Effective leadership is essential in creating a positive process safety and HCR
prevention culture. To be fully effective, this culture needs to exist throughout the
Culture entire organisation, and be driven at board level.
Organisations with a positive process safety culture typically

exhibit the following:
• Effective process safety leadership

• Process safety is a core value of both the organisation and the individual
• Process safety management standards are set, performance is monitored, and
deficiencies are addressed
• There is a chronic sense of unease with respect to major accident hazard
risks, including HCRs
66
Communication
Contents
6.3 Leadership commitment to HCR prevention should be communicated to the organisation

as a whole, along with an understanding of current performance, the risks associated
Communication with releases and what efforts are being undertaken.
Examples of communication may include:
• Dedicated communication plans

• HCR prevention as an element within
- Town-hall meetings
- Safety meetings
- Toolbox talks
- Installation inductions
• Dedicated campaigns; posters, notice boards and leaflets
Good Practice...
• Routinely cascade HCR prevention as a key leadership message
• Regularly communicate your performance, programme and progress
• Undertake regular senior leadership offshore visits, with a clear focus on
release prevention
• Consider using online dashboards to communicate performance
• Use formal incident reviews to communicate learnings from previous releases
• Use videos and animations of incidents to visibly communicate key
messages
• Use intranets and dedicated webpages to promote the programme and
encourage involvement
• Utilise different types of communication to ensure the message reaches
everyone
• Involve the workforce in developing and delivering communication
• Ensure the messaging remains current and relevant to prevent it from
going stale
• Ensure those that deliver the messages (e.g. supervisors, safety advisors or
hydrocarbon release focal points) have the necessary skills and material to
be effective
Opportunities...
• Lack of awareness of release targets and performance offshore

• Poor communication of incident learnings across the organisation
• Plans communicated are out of date
67
Communication
6.4 Engagement Engagement is concerned with how your workforce is involved in your
programme of HCR prevention, and how your organisation is connected with
wider industry in preventing HCRs.
6.4.1 Workforce Workforce involvement is important because people need to understand the role
they play in preventing releases, and they need to be aligned and supportive of the
Engagement programme. They are also the eyes and ears around your installation 22.
Examples of workforce engagement may include:
• Awareness workshops
• Methods of making releases (and their consequences) real for people
• Different approaches for different audiences
• Time-out for safety
• Use of recognised engagement models
The HSE publication Play Your Part! contains many more examples of
workforce involvement.
In addition, Guidance on Effective Workforce Involvement in Health and Safety

details how to improve the effectiveness of workforce involvement via a simple
three-step implementation approach.
Good Practice...
• Engage regularly with your key contractors around HCR
prevention performance
• Appoint HCR prevention champions
• Establish front-line engagement programmes
• Run workshops that focus on key vulnerabilities e.g. flanges
and small-bore tubing
• Implement recognition schemes for releases that are prevented
• Establish release prevention expectations as part of the
offshore arrival briefing
• Tie-in HCR prevention with existing behavioural safety programmes
e.g. Mind Safety
• Arrange live simulation events (e.g. Spadeadam23) to broaden
understanding of releases
Opportunities...
• Poor offshore awareness of programme / plan and progress
22
HSE research suggests that automatic detection systems only detect a proportion of releases. Their data shows that people detect one-third of Major
releases and two-thirds of Significant releases (both HSE definitions of Major and Significant).
23
DNV GL Spadeadam Testing and Research, Cumbria, is designed to carry out full-scale hazardous trials and simulate real-world environments.
68
Communication
Contents
6.4.2 Industry Installation operators should be proactive in seeking broader learnings from industry,
and integrate these into existing practices. They should also play an active part in
Engagement contributing to the wider knowledge base of HCR prevention.
Examples of wider industry engagement may include:
• Involvement in industry workgroups e.g. Oil & Gas UK and Step Change in Safety
• Participation in benchmarking exercises
• Acknowledging industry targets and adopting good practice
• Reaching out to other organisations for good practice
• Proactive sharing of good practice
Good Practice...
• Benchmark against HSE and Oil &Gas UK statistics

• Benchmarking and share information with your peer organisations,
contractors and vendors
• Proactively engage with other operators to discuss issues and share good practice
Opportunities...
• Many installation operators don’t actively seek external learnings and good
practice; industry insights and benchmarking data is often under-utilised
• There is considerably opportunity to involve key contractors and vendors
more in the release prevention dialogue
• Little interaction within other asset groups or partner installation operators
Performance
Measures - Number of leaders completed process safety training
- Number of leadership reviews of HCR prevention arrangements
- Number of offshore visits by senior leaders with HCR prevention focus
- Number of improvement actions arising from senior leader visits
- % attendance at plan progress meetings by senior leaders
- % attendance senior leaders at live awareness events
- Number of offshore visits by HCR prevention programme lead
- % attendance at awareness workshops
- Number of recognitions for HCRs prevented
- Relative company position in reported HCR statistics
- Number of process safety audit scores
- Number of process safety improvement actions
Key Competencies
- None identified
69
Communication
Checklist
1. Are your leaders visible and do they demonstrate a desire to
improve performance?
2. Have clear priorities and targets been set by your leadership?
3. Do leadership performance contracts include release targets?
4. Are your leaders involved in the monitoring / review of HCR

prevention arrangements?
5. Is the HCR prevention message communicated clearly

throughout your organisation?
6. Is your current performance widely understood?
7. Are your communicated plans up-to-date?
8. Are your leaders visible offshore?
9. Do you use your intranet to communicate plans, progress,

updates, etc.?
10. Do you tailor your communications to suit your

different audiences?
11. Is your workforce actively involved in the

communication process?
12. Do your people understand their role in HCR prevention?
13. Do you utilise live simulation events to improve understanding?
14. Is HCR prevention part of your installation induction?
15. Do you recognise releases that are successfully prevented?
16. Do you utilise industry statistics to benchmark

your performance?
17. Do you actively engage with your contractors and vendors

around HCR prevention?
References 1. Hydrocarbon Releases (HCRs) Offshore

HSE Offshore information sheet, 2/2009
2. Play Your Part!

A HSE guidance document available either as a leaflet or via their website
3. Guidance on Effective Workforce Involvement in Health and Safety

A guidance document published by The Energy Institute
and available as either a hard copy or via their website
70
HYDROCARBON RELEASE 7. HCR
Contents
Prevention
PREVENTION GUIDANCE DOCUMENT Plans
Why is it
important?
Plans articulate an installation operator’s policy, strategy and approach to preventing HCRs.
Plans bring together the various HCR prevention activities into one structured, visible place,
and signify a commitment to action.
They are formal, working documents and represent agreements, detail the scope of work and
indicate planning assumptions. They allow the scope, timeline and resources to be optimised.
Plans facilitate communication with stakeholders by identifying ownership, important
milestones, activity dependencies and critical paths. They also enable progress to be
visualised and managed.
7.1 Plan Content Plan content is the scope of HCR prevention activities to be delivered. The focus should be on
managing key HCR risks, and incorporating lessons learnt and wider industry good practices.
Typical scope should encompass the following elements:
• Leadership, awareness and communication

• Human factors and operational practices
• HCR analysis and reporting
• Recognised good practice e.g. bolted joints, flexible hoses, small-bore tubing, etc.
• Integrity management
• Review, audit and assurance
Good Practice...
• Develop prevention plans (rather than reduction plans) that aim to deliver against a
business target of zero HCRs
• Incorporate all asset phases i.e. design, construction, operate and decommissioning
• Ensure that your plan includes key events such as shutdowns, turnarounds,
reinstatements, etc.
• Develop an overarching strategy first and then align plan content with this strategy
• Include both technical and people-based content (see the various sections in this guide)
• Include both onshore and offshore dimensions
• Recognise that supervisor engagement is key
• Develop installation plan content with the installation
• Include activities that are based on the root causes and data trends of your historical HCRs
• Promote HCR prevention awareness events and engagement activities within your plan
• Include monitoring, assurance and audit activities within the plan
• Identify any additional or external resources that may be required
• Resist the temptation to change plan content (out with formal review points)
• Resist the temptation to include activities captured in base-business plans
Opportunities...
• Plan content should be achievable – little is gained by carrying over significant content
to the next iteration of the plan
• Assurance was an area identified in the peer assists that offered significant opportunity
for improvement
71
Prevention
7.2 Plan HCR prevention activities can be managed via either dedicated HCR prevention
plans or as part of wider company improvement plans e.g. safety improvement
Management plans, asset integrity plans, installation plans, etc.
These plans can be either short duration intervention plans or longer term.
Short term Typically 3 – 6 month duration

intervention Aimed at delivering rapid step-change improvement
plans
Useful for addressing immediate shortfalls in
performance
Scope limited to a handful of activities
Short duration means shorter activities
Focus on delivery and pace
Impacted less by new priorities and
resource constraints
Short frequency review cycle e.g. weekly
progress meetings
Requires relatively little planning effort
Allows organisations to quickly move on
to new improvements
Longer duration Typically 1 – 2 year duration
plans Aimed at delivering improvements across many
areas
Useful for campaigned improvement programmes
Extensive scope
Longer duration allows for longer
activities
Focus on sustained plan execution
Impacted more by new priorities and resource
constraints
Typically builds on previous plans
Longer frequency review cycle e.g. monthly
progress meetings
Requires considerably more planning effort
Allows organisations to maintain a prolonged focus
It should also be recognised that many HCR prevention activities can exist out
with a dedicated HCR prevention plan e.g. within integrity plans, competence
plans, installation plans, safety plans, operational excellence plans, etc. In these
instances, the activities are part of core business plans, and come together as a
more virtual HCR prevention plan.
72
Contents
Prevention
Good Practice...
• Have senior leadership sponsorship and involvement in progress meetings

• Ensure that installation plans have installation ownership
• Consider centralised plan coordination to ensure that strategic
objectives are managed
• Celebrate milestone success
• Make the plan visible throughout your organisation
• Ensure the plan is current and includes latest updates
• Recognise that effective plan management is a separate activity and
make the necessary resources available for this
• Understand that plan management is more involved than just issuing
regular reports
• Hold activity owners to account for progress
• Make attendance at progress meetings a priority for those involved
• Ensure that your progress meetings are effective and realistic in
managing progress issues
• Recognise that the plan requires regular management review
• Document and communicate the plan management process, including
roles and responsibilities
• Consider tiering your progress meetings for more comprehensive plans
i.e. an installation level review (more frequent across all activities) and
a leadership review (less frequent across priority activities only)
• Subject your plan to appropriate audit and review; consider including
it within your annual assurance plan
• Deep-dive activities on an ad hoc basis to assure progress, compliance, etc.
Opportunities...
• Recognise that short-term intervention plans are intense and can
deliver only limited content
• Recognise that long duration plans can become mundane and need
periodically re-invigorating
73
Prevention
Best-in-Class Example:
HCR Prevention Strategy and Plan
Overview 2 year company HCR prevention programme

containing short-term intervention plans for each
installation, with phased implementations
Many elements of HCR prevention are recognised as

being embedded within core business processes
e.g. SCE management, small-bore tubing
management, competency management, etc.
Individual installation plans aligned to an

overarching company HCR prevention strategy:
- Alignment with the HSEs loss of containment
inspection guide 24
- HCR prevention awareness and engagement
- Visual management via performance indicators
Plan content Strategy:

- Alignment with the HSEs loss of containment
inspection guidelines
- Visible HCR prevention performance management
- Company-wide HCR prevention engagement
Installation plan milestones:
- Onshore engagement event
- Offshore engagement event
- Agreed plan content
- Performance measures in place
- Proactive spills team in place
- Loss of Containment Inspection Guide – detailed
assessment
- Loss of Containment Inspection Guide – gap closure
plan
- Follow-up progress event
- HCR prevention day-to-day in place
Plan management Central programme manager

Installation project managers
Weekly programme progress meetings (with

leadership sponsor)
Weekly installation progress meetings
24
HID Inspection Guide Offshore: Inspection of Loss of Containment (LOC)
74
Contents
Prevention
Performance
Measures - % plan complete
- % plan completion compliance
- Number of plan activities overdue
- % attendance compliance at progress meetings
- % senior leader attendance compliance at progress meetings
- Number of plan activities deep-dives
- Number of plan activities deep-dive issues found
Key
Competencies - None identified
75
Prevention
Checklist
1. Do you have an overarching HCR prevention strategy
or policy in place?
2. Do you have an aligned, agreed and achievable plan of activities

in place?
3. Does it detail the scope in terms of timeframes

and resources?
4. Does it identify key milestones, dependencies

and critical paths?
5. Does it address key HCR risks, and include lessons learned

and industry good practice?
6. Does it consider all phases of the asset life cycle

and important events?
7. Have you incorporate both technical

and people-based content?
8. Have you included both an onshore and offshore dimension,

with local ownership?
9. Does it include monitoring, audit and assurance activities?
10. Do you have senior leader sponsorship and active involvement

for your plan?
11. Do you have well-attended, effective progress review meetings

in place?
12. Do you have effective plan management in place?
13. Are your plans up to date and visible throughout

the organisation?
14. Do you celebrate milestone success?
15. Do you review and audit the plan, and deep-dive activities?
References 12. HID Inspection Guide Offshore:

Inspection of Loss of Containment (LOC)
Operational guide, produced by the HSE
and available via the HSE website
76
HYDROCARBON RELEASE
Acronyms
Contents
Acronyms CM: Corrective Maintenance

CUI: Corrosion Under Insulation
DCS: Distributed Control System
HCR: Hydrocarbon Release
EEMUA: Engineering Equipment and Materials Users Association
FHA: Flexible Hose Assemblies
HAZOP: Hazardous Operations Risk Assessment
HCR: Hydrocarbon Release
HSE: The Health and Safety Executive
IPS: Instrumented Protection Systems
KPI: Key Performance Indicator
LoC: Loss of Containment
LoPC: Loss of Process Containment
MAH: Major Accident Hazard
MoC: Management of Change
NDT: Non-Destructive Testing
NII: Non-Intrusive Inspection
ORA: Operational Risk Assessment
PFD: Process Flow Diagram
P&ID: Piping and Instrument Diagram
PFP: Passive Fireproof Protection
PIF: Performance Influencing Factors
PM: Preventative Maintenance
PS: Performance Standard
PtW: Permit To Work
RBI: Risk Based Inspection
RCA: Root Cause Analysis
SECE: Safety and Environmental Critical Element
SBT: Small Bore Tubing
SIMOPS: Simultaneous Operations
TA: Technical Authority
TAR: Turn Around (Shut Down)
US: Ultrasound
UT: Ultrasonic Testing
77
HYDROCARBON RELEASE Appendix
Peer Assessment Questions
1: Performance
The following questions are designed to determine how organisations measure their hydrocarbon
release performance, the actions they have successfully implemented and how they intend to
overcome current issues to enhance process safety.
Questions
1 What data is regularly collated and reviewed to determine the risk of a

potential hydrocarbon release; are clear, measurable and effective KPIs used?
2 How are acceptable process safety limits selected for each KPI, how are they
benchmarked within the organisation and across the industry?
3 How is KPI data analysed and used to positively impact hydrocarbon release
process safety performance?
4 What have been the most effective interventions to reduce hydrocarbon

releases and why were they so successful?
5 What are the current key issues impacting hydrocarbon release performance
and how can they be overcome?
2: Operation Activities
The following questions are designed to determine what systems and processes organisations
have in place to mitigate and control hydrocarbon releases.
Questions
1 Describe how your control of work system manages your preparation, breaking
containment, management of the isolation over time, and plant reinstatement.
2 How does your organisation’s change management system ensure that the status of all
plant is known and understood by everyone and that adequate measures are in place to
maintain it effectively? e.g. mothballed or redundant equipment, decommissioned plant
and equipment.
3 What processes and procedures do you have in place to manage bolted joints,
flexible hoses and small bore tubing? How does your organisation ensure their
implementation can prevent the likelihood of a HCR in these areas?
4 How do you ensure that you remain within your plant design envelope?
78
HYDROCARBON RELEASE
Appendix
Contents
3: Investigation & Learning
The following questions are designed to determine how organisations measure the quality of
hydrocarbon leak related investigations, analysis and learning.
Questions
1 Describe how hydrocarbon leaks are quantified and validated within your organisation,
and how incident investigations are scaled to reflect the severity of the leak.
2 Describe how your organisation categorises, records, trends and analyses hydrocarbon
leaks, weeps and seeps.
3 Describe how your organisation learns from specific single incidents,

and if this process is formalised.
4 Describe how learning opportunities are converted to improvements

within your organisation.
5 Does your organisation seek learning opportunities from external sources? If so, describe
this process and whether it is formalised in your processes and procedures.
79
4: Competence
The following questions are designed to determine how organisations deal with the competence
of their staff who have some activity connected with hydrocarbon release reduction and monitoring.
he intent is to identify best practice that can lead to improving competence across the UKCS.
Questions
1 What is the overriding process adopted in your company to assess the competency of
staff whose job involves contributing to managing hydrocarbon release reduction?
2 Listed below are some areas of activity which can lead to hydrocarbon containment
issues. In respect of the potential for hydrocarbon releases please explain your
competency management process for staff involved in these and any other topics you
believe to be relevant.
a.) Hydrocarbon isolation systems

b.) Use of 3rd party personnel on your installation who undertake high risk
activities suchas well intervention and other activities with potential
for hydrocarbon releases
c.) Flange assembly on hydrocarbon systems
d.) Small bore connections assembly
e.) Hydrocarbon sampling
f.) Seal maintenance e.g. pump seals, compressor seals, valve stem maintenance
activities
g.) Corrosion management, including corrosion under insulation.
3 Start-up, shutdown and restart of hydrocarbon systems are high risk periods. Please
describe the processes you use to assess the competence of staff and contractors in
respect to hydrocarbon releases during these activities.
4 Please explain how staff and contractor competence is considered in your hydrocarbon
release investigation process.
5 How do you assess the competency of engineering staff and contractors to ensure their
application of process safety in design takes account of the need to minimise
hydrocarbon release potential?.
80
HYDROCARBON RELEASE
Appendix
Contents
5: Integrity Management
The following questions are designed to determine how organisations manage the integrity of
their assets, what their main issues are and how they intend to address them.
Questions
1 Can you describe your integrity management system and how you know this system is
focussed on your integrity threats?
2 What are your main integrity issues on your assets and how are they being managed?
3 How do you know that you have the correct corrosion management and mitigation
process in place and how do you know it is performing?
4 What gaps have you identified in your integrity management strategy and how do you plan to
address them?
5 What new technologies have you investigated, which ones did you adopt and why?
6: Leadership, Communication & Engagement
Questions
1 What are your organisation’s targets with respect to hydrocarbon releases and how
are they set?
2 Describe how hydrocarbon releases are reported, presented and shared across your
organisation. Give an example of this.
3 How high in your organisation do you see positive engagement relating to minimising
reducing hydrocarbon releases.
4 Describe how your organisation benchmarks its performance within its peer group
with respect to hydrocarbon releases.
81
Human Factors associated with these topics
The following questions are designed to determine to what extent human factors are considered
during safety critical tasks, incident investigations and how organisations manage them.
Questions
1 To what extent are human factors considered in HCR incident investigations?
2 To what extent do you understand the role that human factors plays in HCR?
3 To what extent are human factors considered in safety critical tasks?
4 Describe how the organisation is engaged around increasing the awareness of HCRs
5 Describe the role of your various leadership in these engagements
6 To what extent are your HCR reduction efforts connected with other programmes
e.g. behavioural safety programmes, MAH awareness, ‘I am the barrier’, etc.?
82
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HYDROCARBON RELEASE

6 Leadership, Communications & Engagement

7 HCR Prevention Plans

HYDROCARBON RELEASES REPORTED TO HSE

Introduction Effective asset integrity management is vital in preventing hydrocarbon

• Piping systems (including flanges and valves) continued to be a major source of

• SBT contributed the second largest single source of HCRs2

• Incorrectly fitted equipment, improper operation and non-compliance with procedure

Installation operators were responsible for making appropriate people available

• Why the topic is important

The guide was developed with a widespread readership in mind. It is designed to be as

References 1. Guidelines for the Management, Design, Installation

2. Guidelines for the Management of the Integrity of Bolted Joints

3. Hydrocarbon Release Reduction Toolkit

4. Guidance on Hydrocarbon Release Plans

1.1 Performance The ultimate measure of an organisation’s HCR prevention performance is

It is a mandatory requirement of all UK operators of offshore oil and gas

A summary of reported HCRs – including the quantity released, type and

Leading measures Represent proactive monitoring i.e. forward looking

Lagging measures Represent reactive monitoring i.e. backward looking

In addition, the OGP’s Process Safety – Recommended Practice on KPIs proposes a

Tier 1 HCRs of greatest severity Lagging

The HSE’s HID Inspection Guide Offshore: Inspection of Loss of Containment

• Plant design, construction and commissioning

• Conversely, if you are more established on this journey, adopt lower-level

• Develop a complementary balance of both leading and lagging HCR

• Ensure that your targets are achievable, understood and supported

• Use KPIs to generate quality conversations during assest integrity reviews,

• Consider using insights from weeps, seeps and non-reportable HCRs to

• Consider regular discussions on broader integrity threats that would

• Use KPIs to generate quality conversations during assest integrity reviews,

The following is a compilation of suggested HCR prevention performance measures

Suggested Tier 1 High consequence Lagging Number of HCRs – HSE reportable

Barrier System Performance Measure

Process Breaking of containment

Ignition Control People Ex competence

Process MAH audit execution

Plant % safety critical PM and CM

2. Have you set realistic performance improvement targets?

3. Do you benchmark your HCR prevention performance

4. Do you have a balance or leading and lagging indicators covering

5. Do you consider your non-reportable

6. Are your key performance measures

7. Do you have installation-specific performance targets in place?

8. Do your performance measures have owners?

9. Is your process for managing performance measures documented?

10. Do you undertake the necessary assurance, review and audit on

11. Do you have a HCR prevention dashboard in place?

References 1. Supplementary Guidance on the Reporting of Hydrocarbon Releases

6. Leading Performance Indicators: Guidance for Effective Use

7. Developing Process Safety Indicators: a Step-by-Step Guide for Chemical

8. Process Safety – Recommended Practice on KPIs

9. HID Inspection Guide Offshore: Inspection of Loss of Containment (LOC)

Why is it Body Text here

It is essential that installation operators understand the HCR risks associated

• Design, commissioning and pre-start

Invariably, these high standards of operation should comprise:

• Clear operational procedures and instructions that are adhered to

Key aspects in this include:

Process operating procedures should: