Examining closely the responses, the information collected could supplement the lack of data that was not available directly from the safety management system when implemented. The implementation of the Company’s HSE management system (HSEMS) has already begun (February 2014) in the upstream branch (Exploration and Production) by a training program for the steering committees where the researcher is involved. Actually, the program content has been based on resilience engineering concepts according to the researcher’s orientation. This has been found a great opportunity to introduce these concepts and make them embedded in the culture of the organisation.
93% 78% 77% 75% 67%
Been interrupted part-way through a task to perform another more urgent task Felt that managers or supervisors had unfairly
blamed a colleague for an error Been given wrong information about a task Not been aware of maintenance activities done
previously, when you needed to know Found that somebody else had already started
a task you were about to do
83% 78% 69% 54% 39%
Been asked to hurry a task Had to rush an inspection Not had enough time to adequately read the documentation before you started a task
Had to cut short a functional check Certified that someone’s work was correct
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If the analysis of the results was stuck to the underlying theory on which MEQ has been developed, then the result would be oriented towards looking up what may lead to maintenance “errors” and consequently towards accidents and undesired outcomes. Accordingly, items that received the most frequent rating resulted in the identification a priori of such issues. The results would be as follows.
Respondents highlighted enormous problems of equipment, time pressure, and supervision/coordination issues. For example, more than 93% reported they were interrupted partway through a task to perform a more urgent task. More than 90% said they had been delayed on a task because they could not obtain a consumable part. Procedures were underlined too. About 75% of respondents said they had used informal source of maintenance (e.g. personal notebook) and 67.23 % of them had difficulty understanding a maintenance document. More than 66 % of respondents reported they found an error in a maintenance document at least once in six months or more frequently. On the other hand, the MEQ questionnaire did not focus on the blame factor. Only one question dealt with this issue. 71.3 % of respondents felt that “managers or supervisors had unfairly blamed a colleague for an error” at least once in six months. According to this approach, factors such as lack or poor supervision, equipment issues, absence of or unworkable procedures, and time pressure/fatigue might push workers to find an easier and/or quicker way to perform tasks than the formal one. Moreover, mistakes might stem from coordination issues, inadequate training and supervision, procedures, time pressure/fatigue, and equipment deficiencies. This might be linked to parts damaged during repair, equipment or part of it wrongly installed, etc. Slips/lapses might derive from time pressure/fatigue and management pressure. Memory lapses such as leaving tasks incomplete might come from workers being under pressure or fatigue. As a result, maintenance working environment might generate conditions giving rise to accidents and causing harm. For the traditional approach, such behaviours are reprehensible or to some extent blameworthy for some managers. It is not the case in resilience engineering.
Analysing the results from a resilience engineering perspective helped find out and understand why things actually go right. As discussed in Chapter three (section 3.4), when things go right, two situations may exist. First, one that may lead to a drift toward hazardous states that necessitates barriers and the other that leads to positive outcomes that needs to be boosted. The MEQ gave a snapshot of work as performed daily by individuals under conditions that were characterised by finite resources, time, and knowledge. When people were asked about accident/incidents occurrences in their facilities (see examples given in section 5.4), the answer
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was generally no incident/accident, most accidents concern road accidents that happen out of the facilities. This meant that the human intervention actually prevented accidents occurrences most of the time. A study of the maintenance system based on resilience engineering is given in Chapter seven. Three significant factors identified by means of MEQ (resources, time pressure, and supervision/coordination) were studied by means of MASRAT.
Another interesting aspect of MEQ was that it allowed benchmarking profiles with other industries. Data from three other industries (electronic equipment maintenance, railway train mechanics, and airline) have been provided by Dr Allan Hobbs the designer of MEQ. The result of the SONATRACH MEQ profile was then compared to the profiles of these industries as shown in figure 5.7. The profiles showed that results were comparable even with different cultures and stage of country development. When drawing the profile, the scale ranges from zero to four where zero stands for never, and four for every day. From this benchmark, majority of items were comparable with some slight differences however. Especially, airlines and oil and gas industries gave quite the same frequency ratings on questions dealing with procedures, time-pressure, supervision/coordination, knowledge and defences whereas rail industry showed a slight higher frequency score regarding procedures and supervision. At the same time, rail and petroleum showed a slight higher frequency scores given by respondents to equipment item. On the other hand, all industries presented quite the same scoring for knowledge whereas electronic industry displayed a lower frequency score for quite all items except fatigue and time pressure where rail reported the lowest score.
Figure 1-17: MEQ profile of SONATRACH compared with other industries
This comparison shows that for complex socio-technical systems, even with different cultures or different levels of country development, the results are comparable.
0.0 0.5 1.0 1.5 Procedures Equipment Supervision Knowledge Time pressure Coordination Fatigue Defences
Average problem score
Factor Scores
Electronic equipment maintenance Railway train mechanics Airline normOil & Gas data
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