Health and Safety Executive

1. Health and Safety Executive SOME ERGONOMIC ASPECTS OF DP VESSEL CONTROLS meyrick.hadfield@hse.gov.uk Specialist Inspector Maritime Integrity Team, Energy Division

2. Introduction • Health and Safety Executive’s involvement in offshore oil and gas • Bibby Topaz reminder • Drilling rig incident in 2016 • Ergonomic issues • Similar worldwide incidents • Measures taken by the industry and regulators

3. HSE’s Role • Health and Safety Executive • UK Government Department • Regulator for Health and Safety at Work throughout UK • Health and Safety at Work Act 1974 • Plus secondary legislation • Offshore it covers the oil and gas industry • In association with BEIS, as environment regulator

4. Bibby Topaz incident

5. Safety Bulletin OSD 1-2013 • Warning to offshore industry on blocking of data communications in dynamic positioning systems • http://www.hse.gov.uk/safetybulletins/dynamic-positioning-systems.htm

6. Kongsberg Fix Technical Bulletin No DP-02/2012 Kongsberg November 26th 2012 K-Pos class 1,2 & 3 K-Pos I/O Bus malfunction Firmware fix

7. DP Drilling Rig

8. DP Drilling Rig

9. 2016 Incident • INITIAL CONDITIONS • Drilling Rig on DP • Attached to well in 370 metres of water • Warning watch circle 5 metres • Red watch circle 8 metres • Bunkering diesel from a supply vessel

10. Event Sequence

11. Bridge View

12. Riser Management Desk

13. Utility Panel Views

14. Initial Conclusions • Nothing wrong with the equipment • The bridge team messed up.

15. Accidental Switch from DP to Manual • Only protection was double push button Not an approved protections in ABS ‘Guidance Notes on the Application of Ergonomics to Marine Systems 2013’

16. Inadequate Indication of Changed Mode of Control • Different button illuminated • Alarm (popup) message on DP screen:- THRUSTERS NOT READY • No compliance with IMO and ABS guidance • Audible alarms (Did not comply with good practice)

17. Bridge View

18. Guidance Ignored IMO Guidelines for Vessels with Dynamic Positioning Systems - MSC Circular 645 ‘The active (control) mode should be clearly displayed.’ ABS ‘Guidance Notes on the Application of Ergonomics to Marine Systems 2013’ ‘Visual displays should provide a positive indication of the state of the equipment such as: ready, running, not running, etc’

19. Corrective Actions taken By Company • Cover guard fitted to panel buttons • Ban on objects (incl. papers) on DP consoles • More DP Operator emergency drills • Drills to include accidental change from DP to manual.

20. HSE Safety Alert • ‘Some Ergonomic Issues of DP Vessel Controls’, Health and Safety Executive (HSE) • Safety Alert Bulletin ED3 2016] • http://www.hse.gov.uk/safetybulletins/dp-vessel-controls.htm

21. Similar Alerts • ‘Vessel loss of position whilst diving in close proximity to a hydrocarbon facility’ • NOSPEMA (National Offshore Safety and Environmental Management Authority) • Safety Alert 62 June 2016 • https://www.nopsema.gov.au/assets/Safety-alerts/A484748.pdf • ‘Lessons Learned: Dynamic Positioning Ergonomics’ • USCG National Centre of Expertise • ‘Drill Down’ Issue 7-LL October 2017 https://www.dco.uscg.mil/OCSNCOE/The-Drill-Down/ in the listing item 7.

22. Australian IncidentDive Support Vessel

23. US IncidentDrilling Rig

24. IMCA DP Station Keeping Event Bulletin 01/18 • International Marine Contractors Association • ‘unintentional or accidental activation of any button that has influenced the DP control of the vessel’ • 9 incidents in 3 years 2015-18 • 6 with double push buttons • 3 with single push buttons

25. NOPSEMA Findings

26. NOPSEMA REPORT • Https://www.nopsema.gov.au/assets/Safety-resources/A638513.pdf • Error tolerance in dynamic positioning systems November 2018

27. Other Vessels

28. Other Vessels

29. Other Vessels

30. Other Vessels

31. HSE Actions • Issued Safety Alert Bulletin ED3 2016 • Circulated this and the NOPSEMA and USCG alerts to industry associations • Some contact with DP manufacturer • Include the topic in offshore inspections

32. Inspection Findings • Half of vessels have fitted protective covers to switches • Inadequate indication of mode of control. • for equipment of the same manufacturer • message THRUSTERS NOT READY • Lack of places for papers, checklists etc.

33. Other Regulators • International Regulators Forum 2017 • NOPSEMA presentation on risk posed by design-induced human error for DP systems • The Regulators agreed to follow up • NOPSEMA • ‘Regulator’ magazine articles • Requested information from all DP manufacturers

34. Manufacturer’s Letter • One manufacturer’s DP information letter • Double push button, accepted barrier for decades • Recently owners requested a second barrier • Protective cover, or • Software function (requiring confirmation of change of control mode) • Considers it is the owner’s responsibility to decide on need for second barrier

35. Conclusions • Various incidents would not have happened with better protection against accidental deselection of DP. • Double push button is not adequate protection. • Many vessels have now fitted protective covers over the mode selection switches.

36. Conclusions [cont’d] • Effective response was delayed because, there was no clear indication on the DP screen of the current mode of control. • Software modifications are becoming available which require transfer of mode of control to be confirmed before implementation.

37. Conclusions [cont’d] • Inadequate locations for papers and documents clipboards etc • Inadequate Human Factors ergonomic involvement at the design stage. • by manufacturers, customers

38. Summary • Drilling rig incident in 2016 • Ergonomic issues • Similar worldwide incidents • Measures taken by the industry and regulators

39. Don’t spoil the ship for a ha’porth of tar.