Scapa Energy has been busy…

The last year has been an exciting period with heads down and shoulder to the wheel to meet client demand

This effort has resulted in a steady increase in the range of clients we have, the diversity of projects we are managing, and enhanced capability from our growing team of consultants. With a swing to a positive sentiment in the energy industry, we are looking forward to continuing this path whilst consolidating our core services with existing clients.

With our unique mix of experience and by taking a holistic systems approach, we strongly believe we can make a real difference to risk management and asset performance in upstream and high hazard industries.

In what ways do we achieve this?

  • Major Accident Hazard independent audit and assurance, focussing on front line operations.
  • Independent regulatory advice for operators including management of the Well and Installation Operator approval process.
  • Process Safety leadership, coaching and competency assessment.
  • Transition Management and Operational Readiness Reviews.
  • Independent Incident Investigation.

How do we deliver this?

  • Our team of consultants is a unique combination of senior operational managers and ex-regulators.
  • We have a hands-on approach to engagement, we know which stones to look under and who to talk to.
  • Our advice is always impartial and evidence-based.
  • We take a systems view, avoiding the trap of ‘wood and trees’ and understand the wider business context.

What assignments have we been working on? Here are some examples of ongoing or recently completed work;

  • Managing and delivering EnQuest’s Major Accident Hazard Audit and Assurance programme, operational Readiness Review process and provision of Transition Management support.
  • Provision of HSE Audit and Assurance Services for Chevron UK North Sea operations.
  • Led a successful Well Operator approval process for a newly formed Independent Operator in the UK.
  • Led Operational Readiness Reviews for new FPSO operations in the UK and Internationally, including the Kraken project.
  • Completed a number of Process Safety related investigations and provided advice to manage regulatory compliance challenges.
  • Delivered a programme of Process Safety Leadership and Competence Assessment for Spirit Energy, including operations in Norway, Netherlands and the East Irish Sea.
  • Completed Safety culture assessments for a variety of European high hazard sites, engaging with front-line and senior management personnel.
  • Leaning on our regulatory experience, provided Fatal accident Expert Witness services for a UK high hazard operation.
  • Designed and implemented an HSE Management system for an Independent UK E&P Company.
  • Completed an Asset Transfer Due Diligence exercise for HSE and Operational areas.

Scapa Energy is committed to efficient and effective delivery of our services with the goal of always increasing client value by working together to; reduce risk, enhance organisational learning and improvement, and achieve regulatory compliance. This is what motivates us as we look forward to an exciting new year.

If you are interested in discussing in more detail what we do, how we can help you, or if you are interested in working for us, we would be delighted to hear from you. Please contact,, or have a look at our website



Playing Jenga with Risk



I caught up with an industry colleague recently who wanted to share with me the success his company, Risktec, have had with the introduction of simple game-based scenarios to encourage the workforce to think about major accident hazards and risk in a more engaging way. We talked about Jenga.

This reminded me how effective a Game Metaphor can be as a systems thinking tool to generate new ways of thinking, and in this example, about how we manage risk.

Jenga is not a game of chance, it is a game of choice. When managing risk, and when making risk based decisions we are also choosing what steps to take to make sure the benefits of decisions, and the remaining risk is acceptable to the organisation. We choose which blocks (or safeguards) to keep in play, and which ones may be acceptable to adjust, modify or live without.

Thinking about risk management in terms of a Game Metaphor creates some general features for us to think about;

  • There is a set of defined rules which all the players agree to follow, and from time to time the rules may change
  • The players of the Game recognise what it means to do well (win the Game), or do badly (and lose) and each player adopts his strategy based on their own perspective
  • There will be competition between the players, but all must co-operate sufficiently to ‘stay in the Game’

In our upstream industry, we are overwhelmed with internal rules and external regulation. The new Safety Case Regulations are an obvious example of a rule change, but within organisations, we are on a continuous iterative loop of new or revised internal procedures and processes. Sometimes the rule change allows more Jenga blocks to be removed than previously thought safe to so, think ‘fitness for purpose’ calculations versus more conservative design codes. In other cases, we put so many rules in place, you may get only a few moves in before the game stops, you might think of a few examples from your own experience.

No one of course wants to lose, that is, creating a situation that leads to an unplanned event, whether it affects major accident risks, personal safety, or operational impact. But what does it mean to win? Obviously not to have unplanned events, but depending on your perspective that will also mean no unplanned events and meeting production targets, or meeting a stretch budget target, or to maintain strong regulatory relationships, or to improve operational culture. These goals are not always mutually aligned; a balance must be struck to ensure the right judgements are made to control risk. In ‘Game Playing’ mode, there is a clear advantage to try different scenarios to safely test the impact of removing the next block from the Jenga tower….

However, in daily operations, how aware are we there are many little nudges to the blocks being made, which in isolation, do not appear to have any material significance; but add up all those little moves and adjustments, and you might only be one step away from losing the game. Think cumulative risk, organisational change, a growing trend of deferrals, a tendency to drift towards lower standards, or a complacent culture, as some examples which can weaken the overall resilience of the structure.

If we turn the rules of the game on their head, we can conjure a different approach to risk management. Rather than gradually, and often unintentionally, removing blocks to weaken an originally sound structure without it falling, let’s assume the starting point is a degraded structure with hidden weaknesses and imbalances. From here, the rule could be to add blocks. Over time, and by looking at the Jenga tower from different angles, you gradually build a strong, robust structure which is resilient from knocks and pushes. Now liken this to a strong organisation, management system and workforce moving towards best practice – a winning strategy!

Game-based scenarios can be used in a safe environment to test strategies and decision-making. When we make decisions, we must properly test them in every sense, and every possible consequence before they are implemented. We can change the rules and test the impact, we can see how much better outcomes can be by collaborating between players, and we can recognise the trade-offs between risk, cost and performance.

If we weaken the organisational and systemic structure too far, the consequences are irreversible, the blocks come crashing to the ground. We all lose.


Organisational Learning – room for improvement?

In our oil and gas industry, we have many arrangements in place to assure, audit, learn lessons etc. and continuously improve our operations. Many of these arrangements are driven by regulation or to meet Company standards, as well as improve operational and HSE performance. Unplanned events do occur and we investigate to ensure ‘lessons are learned’. But how effective are all these activities as a means of organisational learning and what more can be done to make sustainable improvements to control risk in our hazardous operations?

Three perspectives which I think offer some insight are;

  • What do we say we do through our processes and procedures
  • What do we actually do in practice
  • What more can be done to improve organisational learning

Taking the first, as an industry we create many procedures, standards, policies, processes, swimlanes, excel registers, databases etc. Each time a new requirement emerges, an incident occurs, or new assets are added, we add to the already burgeoning collection of management system documents. At some point, we all end up moving to a ‘de-cluttering’ exercise!

These are essential tools to manage our business. However, when we undertake creating these documents, how much time and effort do we put in to understanding the perspectives of the end user, the usability of the document, the logical soundness of the processes, the clarity and style of language, and making effective use of graphics and icons. My experience shows a mixed bag; there are some excellent examples out there, matched by procedures that are well in excess of 150 pages, or with flowcharts so complex, you need an algorithm to work out all the possible combinations!

However well or otherwise we capture ‘what we say we do’, what actually happens in practice? Given that the stated purpose of any procedure is well intended, the expectation must be that well intended actions follow. Given any improvement to a procedure or process, equally we should expect improved performance. And given that we audit, verify and assure these processes to check they are effective, we should, after identifying gaps to close, have effective processes that work in practice.

But there are many situations where a gap persists between procedures and practice. Following an incident, how often do we see the root cause of ‘procedure not followed. Or, during an audit, in answer to the question ‘are you aware of this procedure’, the answer is often in the negative.

Whether the activity is proactive assurance, or investigation, the findings from these must be the kernel to organisational learning and improvement. This raises two other questions – are the findings robust, and how well are these findings implemented?

Too often, findings and recommendations are ambiguous, open ended, or confusing. Increased rigour, competence and governance to create targeted, value adding SMART actions is essential.

When actions are entered into the organisation’s action-tracking system, is there clear accountability through the life of these actions, all the way through to checking if the action has actually made a difference? Is the learning loop being closed?

When organisations adopt ISO standards, they are couched in PDCA models, ‘non-conformances’, and other such quality oriented terms. This can add to the theory-practice gap because the language of Quality is often incongruent with day to day oil and gas operations. This does not make for an effective ‘learning system’.

What more can be done to strengthen the organisation’s learning effectiveness? Perhaps a first step is to look at what the learning process is. Deming’s PDCA continuous improvement cycle has been in use over a long period, driven from a manufacturing viewpoint where we;

  1. Plan a better way of improving a product (or process)
  2. Implement (Do) the improvement
  3. Check if the improvement has worked (Deming called this a Study step)
  4. Take further Act(ion) to improve again, and so on in a cycle

An alternative model is offered, where we;

  1. Engage with end users and observe behaviours in practice, compare these experiences to the expectations defined in company processes.
  2. Reflect on what is driving any differences in practice, what are the underlying themes from a cross section of perspectives, what are the soft issues, are there any feedback loops setting up certain types of behaviour?
  3. Form a clear view on what the essential themes (or models) are that drive practice and what improvement actions might make a difference. Check any assumptions being made.
  4. Validate these key improvement actions with those who will be affected, test how they will add value, and implement through a robust change management process, and we return then to the first step.

This learning process (introduced by Kolb, 1984), takes account of people, their unique perspectives, and the importance of taking time to reflect and identify underlying themes.

Kolb (1984)

Kolb (1984)

How does this translate into our fast-moving dynamic, complex and unpredictable energy industry? This suggested approach, a systems approach, is not complex or time-consuming. It is necessary however to think and plan a little differently. Rather than only getting involved at low levels of detail and looking at component level, also stand back and observe the wider behaviours in the workplace. Rather than think of events in isolation, look at the feedback loops and other inter-relationships which have caused the event. Rather than assume people will comply with a process, engage with the key users, go to their operating space and really understand their perspective. Get them involved in shaping business processes.

Organisational Learning using a Systems Approach such as this is expertly introduced in Peter Senge’s ‘The Fifth Discipline”. A recommended read for an introduction to systems thinking in organisations.

With this approach, more effective interventions are possible, personal ownership for improvement will be more likely, and in the long term, more effective organisational learning, and a safer and more efficient operation!

Has Reason’s Cheese gone stale?

Courtesy of James Reason, the Swiss Cheese Model has advanced thinking considerably in the explanation, and in the prevention, of major accidents in the energy industry. Reason forced us to think in more than one dimension and to consider ‘defences in depth’ to avoid undesirable events happening in our industry. These defences include hardware, people, systems and processes.

Reasons ‘Defences in Depth’, 1997


In recent years, industry has adopted many tools, processes and models based on this barrier model aimed at preventing and minimising the risk of Major Accident Hazards being realised. This has without doubt progressed the understanding of the primary causal factors of these events, but we are still, with an unnerving regularity, having unplanned hydrocarbon releases and major accidents. In the UK North Sea, hydrocarbon leaks have reduced in recent years, however, in the period April 2013 to April 2014 there was a 20% increase in leaks (source HSE). This year alone, four workers were killed and several injured, following a fire and explosion on the Pemex Abkatun platform in the Gulf of Mexico, and six workers were killed on the Cidade de Sao Mateus FPSO in Brazil following a pump room explosion.

Certainly, there will have been in-depth analyses carried out by investigators to understand what barriers have failed and resulted in these tragic events. We have a very effective tool to analyse and present these findings through the barrier model, but, it did not prevent the event. Is this because Reason’s model was not applied, not understood, or limited in some other way?

I think there is a limitation of this model, which is this – it is targeted at avoidance of an undesirable event in isolation. To offer a simple analogy of football, if the only strategy was to avoid conceding goals, we wouldn’t be a very successful team. A holistic approach would have a strong defence, midfield and forwards. We would have clear strategies for developing the performance of the team as a whole, identifying barriers to improving overall performance, not just defending. We would have arrangements in place to reflect on performance and identify what areas require further improvement.

By adjusting our mindset to go beyond barriers to avoiding undesirable events happening, we would open up fresh thinking and new ideas, such as identifying barriers to Best Practice. By understanding the barriers to best practice we could strengthen our prevention safeguards and create a larger gap between daily operations and the risk of a major accident, and at the same time, providing significant leeway when organisational drift reduces performance over time.


Moving towards Best Practice

Moving towards Best Practice













Of course, it can be argued that this is just another way of presenting an ‘ALARP’ justification, but there is a difference. In our day to day management of operations, if we think ‘what can I do today that will make a shift towards better practice’, rather than the approach of ‘what do I need to do to meet a minimum standard’ then new opportunities arise. It might be something as simple as focussing on better quality risk assessments for work activities, or investing more effort in integrity management strategies, or looking at opportunities for the team to work more to its strengths.

During the design stage of major developments, how well do we really meet Inherent Safety in Design goals (rather than falling into the reverse ALARP trap)? Testing the design against best practices, and taking into account all the necessary trade-offs, will result in a safer design and a smoother passage through regulatory assessment.

Taking yet another view, Dave Brailsford of Team Sky provides a powerful example of moving towards best practice over a long period of incremental improvements, or as he called it;

the aggregation of marginal gains

To address the question raised in the title of this blog, Reason’s cheese model has been immensely successful in advancing preventive measures, and is perhaps not yet stale! But we need new metaphors to energise our thinking and to move to a different level of performance and we need alternative models to stimulate fresh debate on achieving best practice.







Systems Thinking – a fresh way of looking

Systems Thinking – a fresh way of looking…

Image courtesy of Michael Leunig

In our energy industries, how many thorny issues keep recurring, how do we find it difficult, if not impossible to get to the root of issues and make changes that make a difference in the long term?  Why is there often conflict and surprises when a well-intended intervention is made? Why do procedures get blamed when things go wrong?  There are many examples, but here are two from my own experiences;

  • Electronic Permit to Work Systems (read as a technical system) are intended to simplify maintenance and hazardous activities, whilst improving safety and operating efficiency. Over several years of the energy industry implementing such systems, electronic Permit to Work systems have added complexity, they have not reduced the frequency of failures in Control of Work, and the operating efficiency of the workforce has decreased considerably in recent years, where at best, an offshore installation may achieve 6 to 7 productive hours from any individual worker each shift.
  • Major Capital projects have run extraordinary late, averaging at least one year, and often more, beyond budget completion dates. As an inevitability, costs have also spiralled to orders of magnitude higher than original budgets, where the economic viability of the project itself becomes threatened. These outcomes are real, but the paradox is that every operating company is majoring in ‘Capital Efficiency’, and within the context of a mature industry that has been executing major projects for fifty years. A rational view would expect such a developed industry to be highly efficient at major project delivery, with advanced technology and experienced project teams in abundance.

With these two scenarios, what explanations can be offered to make sense of these puzzling dynamics…?

These examples illuminate the difficulty in dealing with real world complexity. To clarify, this is not scientific, mathematical or engineering complexity. This is the point! Managing real world complexity is to acknowledge that people, organisations, values, goals and behaviours are crucial factors when trying to find explanations for ‘systems’ that are not working. To treat human endeavours as a technical difficulty will result in a messy situation.

This is exactly the world of Systems Thinking. This approach invites a fresh way of looking at problems. The critical distinctions which make this approach different are:

  • It is holistic, rather than reductionist
  • It takes into account multiple perspectives (that all have different goals)
  • Causes and events are interconnected by feedback loops, rather than linear thinking
  • Systems of interest are used to understand interconnections, relationships and purpose

In very simple terms, it means stepping out of the weeds, and appreciating the whole situation, understanding the relationships and interconnections between events, behaviours and the underlying systemic structure.

Systems Thinking embraces these principles and with a range of methods, tools and approaches, allows new ways of looking at problems. For example, a systems approach to Permit to Work would use methods to explore why individuals are driven to populate the system with too much information creating the situation where the worker has a rucksack full of information to read before he can carry out a routine task. Aspects such as leadership behaviours or attitudes to blame would be much more important than the technical system in play.

With the Capital Project example, taking a Systems approach would require a concerted effort to understand the perspectives of supply chain dynamics, it would look at the historical cycles of the skilled labour market, and it would look at how projects are organised and how they collaborate across organisational boundaries.

The proof is in the eating of course. I have adopted a systems approach to a range of issues for many years, both on small and larger interventions. And from my experiences, all I can say is that it works.

Does it need an intensive period of study to put it into practice? My view is not. To acknowledge the principles of stepping back and thinking holistically is already a giant step forward.