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SPE 86630

A New, Improved JSA Process Gets Enthusiastic Approval from Field Personnel
Carl Veley and Norman Ritchie, vPSI Group, LLC; E. Alan Coats and Joel Disatell, Halliburton

Copyright 2004, Society of Petroleum Engineers Inc.


enough time with a work crew to gain their confidence find
This paper was prepared for presentation at The Seventh SPE International Conference on people privately confessing they see no benefit in the JSA
Health, Safety, and Environment in Oil and Gas Exploration and Production held in Calgary,
Alberta, Canada, 2931 March 2004. process and generally consider it a required but meaningless
This paper was selected for presentation by an SPE Program Committee following review of
formality. On one location, the noise level was so high that
information contained in a proposal submitted by the author(s). Contents of the paper, as everyone wore hearing protection outside offices and quarters.
presented, have not been reviewed by the Society of Petroleum Engineers and are subject to
correction by the author(s). The material, as presented, does not necessarily reflect any The crews would gather, the supervisor would read a JSA
position of the Society of Petroleum Engineers, its officers, or members. Papers presented at
SPE meetings are subject to publication review by Editorial Committees of the Society of
while everyone stood there unable to hear a single word. The
Petroleum Engineers. Electronic reproduction, distribution, or storage of any part of this paper crew then did the job, and the supervisor filed a report that a
for commercial purposes without the written consent of the Society of Petroleum Engineers is
prohibited. Permission to reproduce in print is restricted to a proposal of not more than 300 JSA was conducted as required by company policy. It was no
words; illustrations may not be copied. The proposal must contain conspicuous surprise to find the crews were privately scoffing at the JSA
acknowledgment of where and by whom the paper was presented. Write Librarian, SPE, P.O.
Box 833836, Richardson, TX 75083-3836, U.S.A., fax 01-972-952-9435. process and viewed it a just bureaucratic harrassment.
This situation seems to be common throughout all
Proposal industry. Management sends out strongly worded orders that a
Many oilfield companies require field crews to systematically JSA will be conducted, and they get back reports that the order
analyze safety aspects of their activities before starting to was obeyed, but what actually happens has little or no effect
work. Commonly, this process is called a Job Safety Analysis, on the probability of accidents occurring. A better way is
or JSA, but other labels are also used. needed for gauging effectiveness of a JSA program.
Recent developments in measuring safety performance A JSA is valuable only to the extent to which it prevents
have changed the JSA process by redefining its objective. This accidents. When JSAs are employed, most jobs do not result
change is definitely for the better, and it is rapidly gaining in an accident. However, accidents are rare, so chances are
acceptance throughout the Gulf of Mexico petroleum industry. good that even without a JSA or other prejob safety analysis,
A survey of Gulf of Mexico offshore production facilities most jobs would still not result in an accident. How can we
and drilling rigs showed that JSAs tend to be a tedious prove any given JSA actually decreased the chances of
formality that crews comply with only because they are accidents occurring? This issue also applies when deciding
required to do so. For a typical jack-up drilling rig, adopting whether a given accident report decreased chances of that
this new JSA process and standard can reduce total time spent particular accident repeating. The problem of determining the
in JSA meetings from approximately 30 man-hours per day to effectiveness of these tools is amplified by official or
less than four man-hours per day. Not only does the new style unofficial programs that encourage people to hide accidents or
of JSA provide significant time savings, but it is considerably distort records.
more effective in reducing the likelihood of accidents, meets The authors believe an effective JSA should produce the
with enthusiastic approval of work crews, and provides a same corrective action that would be produced by a good
powerful tool for onsite management. accident report. The only difference is that the JSA devises the
corrective action before, rather than after, the accident occurs.
Introduction Therefore, effectiveness of a JSA can be measured by exactly
Major oil companies often require their own employees and the same process used to measure the effectiveness of
most contractors to use a JSA process, although the process corrective actions in accident reports.1 That means an effective
occasionally goes by some other name. The crux of the idea is JSA should be a plan, or a pre-arranged schedule of events
that crews hold a meeting before beginning any job, analyze leading to attaining some objective. To meet this definition, a
the job, and decide what they can do to prevent accidents plan must contain actions (events) that will be pre-arranged
during the job. when when they are assigned.
While visiting rigs, production facilities, construction sites,
and other work areas, the authors have frequently noted a vPSI Definitions
considerable difference between perception and reality in JSAs. Suppose someone is replacing an electrical transformer
regard to JSAs. Company HSE departments often believe the on a utility pole. Although electrical hazards are associated
JSA process is being scrupulously followed and is accepted by with the actual job, totally independent hazards associated
work crews. They may point to records and testimonies that with working at heights also exist. Both types of hazards must
support that conclusion. However, outsiders who spend be addressed in an effective JSA.
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Performing the job safely requires job skills and a prejob meeting, carefully read through the entire JSA, then
knowledge of how to remove the old transformer and install started work. Fig. 3 shows the cargo basket that the crew lifted
the new one. Although these skills are very important, a JSA is off the boat immediately after reviewing this JSA. It contained
not the vehicle for teaching them. The JSA should be used to the load line cable drum, a headache ball, and the main block
make certain that the power is positively isolated, heavy items a total weight of over two tons. The bottom of that basket was
are hoisted properly, and so forth, but it should not address severely corroded, and the bottom angle iron support bent and
how to connect wires, check fluid levels, or secure the nearly failed just as the crane operator set the basket on the
transformer to the pole. Likewise, the JSA should not provide platform deck. If a failure had occurred just seconds earlier,
instructions about how to use ladders, operate man-lifts, or use the basket could have dropped its contents onto the workboat
fall arrest systems; rather, JSAs are the ideal system for from a height of about 85 ft.
ensuring someone makes the appropriate inspections to be As Fig. 3 shows, this basket was obviously in very poor
certain those things are in place and properly used. The JSA condition and should never have been used, but the JSA did
process should be able to detect if someone needs training, but not prevent it from being picked up and exposing a boat, a
it should not be that training. platform, several wellheads, and 11 men to very serious
unnecessary danger. No actual accident occurred, at least
Accidents and Corrective Actions. An accident is an according to conventional definitions, because the basket
unplanned event that has the potential for causing harm. bottom did not fail, nothing fell, no one was injured, and no
People often confuse an accident with its consequences. A damage resulted. Several unsafe acts were performed though,
broken leg is not an accident; it is the result of an accident. when various people chose to use that basket, loaded heavy
Near misses or incidents are commonly used misnomers items into it, transported it to the dock, put it on the boat, and
for accident. An accident does not have to result in harm to finally dynamically lifted it off the boat.
qualify as an accident.1 Accidents can be further described as If the bottom had fallen out of this basket, the event would
having the following four components (Fig. 1): have been an accident, whether it happened just as the basket
Harm (injury or damage) was setting down on the platform, or a few seconds earlier
An unplanned event (with potential for causing when the basket was suspended 85 feet above the deck of a
significant harm, whether harm occurred or not) work boat. The accident would have been exactly the same,
Unsafe acts of people (unsafe conditions can always be but the consequences would have been very different.
attributed to one or more unsafe acts of people) Whatever corrective action is appropriate for preventing
Root causes (the reason(s) for unsafe acts) unsafe baskets from being used is independent of the
accidents consequences. Preventing the bottom from falling
The authors believe that 100% of root causes can be linked out of the next basket has nothing to do with whether a
to acts of people. Typically, faulty valve may be listed as the previous basket failure sank a workboat, snapped off a
root cause of an accident, but that valve was designed, created, wellhead and started a major fire, or simply made a little
and inspected by a person, delivered by a person, installed by noise. The role of the JSA is to take that corrective action,
a person, and should have been checked and maintained by a even though the accident never occurred at all. The same
person. The faulty valve can easily be traced back to the corrective action would have been required if a basket failure
actions, or lack of actions, of a personthe true source of the had resulted in catastrophy, and like any other corrective
accident. action, its probable effectiveness can be classified and
Reasons why people do not anticipate consequences of evaluated (Fig. 1).
their actions can be reduced to four general explanations, The JSA in Fig. 2 had been reviewed and approved by
namely that someone, somewhere didnt Know, Understand, both contractor and oil company safety representatives. It
Believe, or Observe. Treating these as the four root causes of looked normal to them, just as, to the authors of this paper, it
all accidents makes analysis and prevention easier through the looks like a JSA typical of those generally used across all
KUBO-TEPA matrix.1,2,3 One element of the TEPA acronym industry. But remember, this JSA did not work. It did not
for basic corrective actions (Teach, Educate, Persuade, and prevent the crew from doing something extremely dangerous
Assign) is best handled through the JSA process: the Assign and unnecessary.
element. Unfortunately, as they are typically done, It follows that JSAs that look normal are not working
conventional JSAs are weak in that regard, just as typical because they do not contain corrective actions, as previously
accident reports do not specify effective corrective actions. defined.1,2 Notes and good advice are abundant, but no
specific actions are included that will become plans when
Function of JSAs assigned. These JSAs include no evidence of a pre-arranged
In typical JSA programs, crews are instructed to review a job schedule of events leading to attaining the objective of safely
in detail before starting work, think carefully about what offloading a boat.
accidents could happen during each step, and decide what they When a JSAs objective is to produce corrective actions
need to do to prevent those accidents. Thats fine, in principle, that meet our definition of plan then the conventional JSA in
but take a look at how that gets put into practice. Fig. 2 must be modified to be more like the one in Fig. 4. In
When the authors first encountered the JSA in Fig. 2, a this form, the JSA becomes a checklist to help the supervisor
crew of five men was getting ready to offload components of a supervise. Notice that Assignment D in the revised JSA would
temporary crane being set up on the platform. The crew called have greatly increased the probability of the severely corroded
cargo basket being rejected.
SPE 86630 3

Certainly the supervisor should tell the crew what they are Spotting New Hazards
about to do, but that should be a matter of a few seconds in First drafts of JSAs must rely on experience. That is, people
familiar jobs. Changes in the routines or special circumstances who have done that particular job recall things they know have
should of course be explained, and if it is something the crew gone wrong in the past and rely on their personal experiences.
has never done before, special training may be required; but Its a different matter to look for things that are not so familiar
training is not the function of a JSA. The sole function of an or things that could happen that no one has thought about
effective JSA is to implement corrective actions before an before. Crew members need some sort of guidance for what to
accident occurs. look for when they are trying to spot unfamiliar dangers.
Fig. 5 shows another typical JSA that was designed to be One commonly used system assumes that ultimately,
pulled from a file and reviewed before bleeding off gases from anything with a potential for causing injury or physical
high-pressure gas wells and process equipment. When this damage must involve energy. This idea means crew members
JSA was actually used, the job supervisor read it to his crew, can look for energy sources then reflect on ways that energy
then the crew performed the job, venting high-pressure gas could cause unexpected harm. It may not satisfy rigorous
upwind from a diesel engine with a nonfunctional emergency physics definitions, but energy can be arranged into a small
air shutoff, creating a risk of an engine explosion. (That point number of generalized sources. One such arrangement uses six
was on the companys work permit checklist, which was not energy sources,4 but other people have identified eight
completed.) sources, as shown in Fig. 7. This identification of these
Clearly, this example is another case of a JSA that did not sources has proved valuable in giving ordinary crew members
work. No accident occurred, at least not in the usual sense of a practical guide for spotting hazards as they go about their
the word, but an unsafe act created a major danger and was not jobs. It is particularly useful in debriefings after a nonroutine
prevented. A revised JSA for this job is shown in Fig. 6. job, and it leads to important modifications to existing or
Assignment 3 on the list would almost certainly have caused generic JSAs.
the unsafe engine to be detected. However a hazard or potential accident is identified, the
The principal shortcoming of conventional JSAs is that real secret to a successful JSA is making sure it contains actual
they tend to list what should happen with no provision for corrective actions and not just good advice. It is essential that
ensuring that those things happen. the end result of a JSA is a pre-arranged (i.e. assigned)
sequence of events (i.e. actions) that will ensure a job is done
New JSA Process safely.
Hot work permit forms may involve many man-hours or even
man-weeks in development, but they generally only take a Case History
minute or two to implement. Properly issuing a hot-work The authors reviewed JSAs used by a variety of operators and
permit requires a qualified person to visit the site and review a service companies in the Gulf of Mexico. Most of the JSAs
list to confirm that appropriate assignments are made. The hot were similar to Fig. 2, taken from an offshore production
work permit does not need to be redesigned each time it is platform of a major oil company. This JSA is best described as
used, and special circumstances can easily be penciled in a list of good advice or points that people should keep in mind,
when needed. That same process can be applied to JSAs. but it includes no provisions for ensuring any actions take
A hot work permit does not contain instructions on how to place. Closer inspection shows this JSA does not present
weld, and a JSA should not include training instructions on events that can be prearranged through assignments.
how to operate cranes or any other regular job. An effective Therefore, this conventional JSA does not meet the definition
JSA will be predesigned, just as a hot work permit is, but it of a plan and is ineffective at preventing accidents.
will be flexible enough to adapt to unusual conditions, and it The authors have traveled to various locations teaching
will lend itself to easy modification as additional hazards are crews and management how to change the previously used
exposed. methods of creating corrective actions. These crews have
In practice, supervisors use this new style of JSA simply as rewritten numerous JSAs and have found them to be easier
a checklist of assignments that need to be made before starting and more thorough, resulting in a significantly better accident-
work. Some supervisors may want to put a crew members prevention tool. So far, all of these crews have enthusiastically
name or initials in the blank when making the assignment. approved the changes that are being made to the JSA process
Others simply use a checkmark to indicate that the assignment and other safety measurement systems used in this industry.3
was made or the action was comleted. For example, one
assignment might be: ___ will inspect fall protection gear. Conclusions
The supervisor might personally handle that task or delegate it Because 100% of the root causes of accidents can be attributed
to someone else. It doesnt really matter if the name in the to acts of people, the most logical way to prevent accidents is
blank shows who accepted that assignment. In the unhappy to correct the actions of people. The corrective actions that
event that serious injury occurs because fall protection was not result from a JSA should be specific plans that are assigned to
inspected, the supervisor will ultimately be held responsible specific people. This method of assigning responsibilities
anyway. Having that item on the checklist will help the produces true corrective actions that help ensure a prearranged
supervisor avoid that liability by helping make sure the plan takes place, effectively preventing accidents. A JSA is
inspection does occur. valuable only to the extent to which it prevents accidents.
The new JSA process is simpler, faster, and something
crewmembers can understand, look forward to, and put into
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practice. It can provide significant time savings, and it is 2. Veley, C.D. et al.: Derivation, Application, and Evaluation of
considerably more effective in reducing the likelihood of the KUBO-TEPA Matrix for Generating Corrective Actions,
accidents. paper SPE 86736 presented at The Seventh SPE International
Conference on Health, Safety, and Environment in Oil and Gas
Exploration and Production, Calgary, Alberta, Canada, 29-31
Acknowledgements March.
The authors thank Halliburton for their support and assistance 3. Veley, C.D. et al.: A New Method of Measuring Safety
in publishing this paper. Performance Will Soon Affect the Whole Industry, paper SPE
86741 presented at The Seventh SPE International Conference
References on Health, Safety, and Environment in Oil and Gas Exploration
1. Veley, C.D.: Applying a New HSE Measurement System, and Production, Calgary, Alberta, Canada, 29-31 March.
paper SPE 74050 presented at the 2002 SPE International 4. Safety Alert 01-20: International Association of Drilling
Conference on Health, Safety, and Environment in Oil and Gas Contractors, http://iadc.org/alerts/2001%20Alerts/sa01-20.PDF.
Exploration and Production, Kuala Lumpur, Malaysia, 20-22
March.

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Fig. 1Accident components and prevention tools.
SPE 86630 5

Fig. 2Old style JSA case history example.

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Fig. 3Cargo basket with reel used in case history.


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Fig. 4New style JSA case history example.


SPE 86630 7

Fig. 5Old style JSA concerning bleeding off gas.

Fig. 6New style JSA concerning bleeding off gas.


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DN004347
Fig. 7List of hazards.