SPE-173497-MS

Data Drilling: Changing the Way the Oil and Gas Industry Manages Safety
and Risk
Brian Caldwell, and Jack Hinton, Baker Hughes

Copyright 2015, Society of Petroleum Engineers

This paper was prepared for presentation at the SPE E&P Health, Safety, Security and Environmental Conference-Americas held in Denver, Colorado, USA, 16 –18
March 2015.

This paper was selected for presentation by an SPE program committee following review of information contained in an abstract submitted by the author(s). Contents
of the paper have not been reviewed by the Society of Petroleum Engineers and are subject to correction by the author(s). The material does not necessarily reflect
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Abstract
The oil and gas industry is renowned for its technological advances in the capture and use of data science
to find and release new reserves of hydrocarbons to meet the world’s ever increasing energy demands.
Such uses of the scientific analysis of data and information have enabled hydrocarbons to remain the
primary source of energy, worldwide. Data science unlocks patterns typically unseen in typically available
information, thus allowing the industry to see hydrocarbons where previously they were not able to
confirm their presence. Other industries that specialize in demographic analysis of data, like Google and
Yahoo, use data science to see patterns in human interest, which they then make marketable by selling to
manufacturers of goods to target increased sales.
Baker Hughes has leveraged what it has been doing for years with data science in its Geoscience
expertise, to more completely exploit hydrocarbon reserves; to now better exploit previously untapped
revelations from safety incident data. Building on the work that Behavioral Science Technology undertook
in 2011 with seven global companies (ExxonMobil, Potash Corp, Shell, BHP Billiton, Cargill, Archer
Daniel Midland Company, and Maersk), in their publication “New Findings on Serious Injuries and
Fatalities”; and, the further work that ExxonMobil has undertaking with their “Mining the Diamond”
approach to safety data analysis, as first reported by Neil Duffin, President – ExxonMobil Development
Company, at the 2012 Offshore Technology Conference, Baker Hughes has taken this approach farther.
The use of data science applied to safety is revealing previously unseen trends in existing safety incident
(near miss and where harm was caused) data. We call this application, “Data Drilling”.
The results of Data Drilling are provocative, as they better guide the business to more clearly
understand root cause, which precipitates more accurate intervention strategies and effective management
of risk (in a high risk industry). Additionally, the products of Data Drilling present a clear and compelling
picture of risk management to executives, enabling stronger safety leadership to their organizations. The
results of four retrospective studies, of the industry’s experience with Dropped Objects, Wellbore
Placement During Drilling, Wireline Pressure Control Equipment, and Coil Tubing Operations, are used
as examples of how Data Drilling unlocks meaningful root cause that better targets responsible HSE
management. In each case, business leadership was presented with a more accurate assessment of risk than
traditional oil and gas industry data trending techniques typically reveal. As a result, decisions to support
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program and process upgrades and capital expenditures for risk mitigating engineering controls are better
made.
Introduction
Presented are the significant findings that were unlocked in 4 case studies, which clarify a more complete
picture of the potential risk to the business for high consequence events such as a well bore collision with
a live offset well, or a coiled tubing service failure. Multiple aspects of data analysis, including gathering
of relevant data, techniques for analyzing the data, and processes utilized to reclassify reported incident
impacts are discussed.
Using a simple analogy, a series of similar incidents occur in a warehouse, with no worker resulting
injuries. The business avoided worker injuries, possibly severe injuries or fatal outcomes. In safety
vernacular these types of incidents are referred to as a “near miss”. Ideally, we can learn from near miss
events (that occurred but without direct consequence) to prevent future events in which the outcome could
be harmful. However, our ability to benefit from the insights of near miss reporting is often ineffective
because the focus and corrective action response is localized, too limited to just the single event, or just
the location where the event occurred. Many potentially regional or global safety risks to the business are
missed in our safety incident investigations because of a failure to discern trends more holistically – a
failure to look more broadly for patterns. Through Data Drilling, we uncover and group similar events in
our historical data where risk existed but were not clearly identified to allow dedicated response. Through
a collaboration of safety professionals and subject matter experts in applicable oil field service lines, we
are able to merge data sources together and create visualizations to aid in communicating insights to both
product line teams and non-expert stake holders.
To ensure a comprehensive review, the data is drawn from a variety of sources found outside traditional
safety related databases. Incident data is utilized from safety and quality incident reporting systems,
audits, inspections, checklists, service quality reports, engineer field notes, job ticket notes, customer
concern reports, emails and workspace folders. In many cases, subject matter experts are utilized for data
analysis as they are instrumental in identifying these sources of information.
Application of Data Science
Data Drilling unlocks patterns from complex safety incident data sources to reveal unknown or unrec-
ognized risks to the business. Other industries have specialized in analysis of data, like Google and Yahoo,
who use data science to see patterns in demographics to uncover human interests, which they then make
marketable by selling to manufacturers of goods to target increased sales. Data science techniques are also
associated with recent advances in managing large data bases in a field called “big data”, utilizing
advanced techniques such as uncertainty modeling, data warehousing and high performance computing to
unlock relevant insights not available to traditional data analysis processes. The simpler application, Data
Drilling, is able to process complex datasets to reveal both personal and process safety related insights.
Undertaking Data Drilling
Executing a Data Drilling project requires identification of a target service, acquisition of data, analysis
of data, and reporting of findings. Selected oil and gas services associated with known safety critical
elements such as high pressure, high energy, and high temperature can be evaluated by using historical
incident related data. From our experience using Data Drilling methodology, three key areas are
considered to be essential: the Role of Subject Matter Expertise; Establishment of Common Terminology;
and, having standard Data Drilling Process.
Role of Subject Matter Expertise
early in the scoping phase of a Data Drilling project, identify subject matter experts (SME’s) for the
service and risk elements to be evaluated. The SME will help identify and gather incident or report data,
SPE-173497-MS 3

and review and analyze the collected data. They also will be able to read incident notes and reports more
effectively than non-experts, and understand the nuances of the service line such as jargon, technical
terminology and engineering specifications and formulas. In addition, the SME will recognize certain
types of operating conditions and circumstances in which risk was present, but that may or may not have
been identified in the incident narrative or report. Subject matter experts are found in operations,
technology, engineering, HSE function, products and services support functions, and typically have
multiple years of field experience. It is critical to the validity of the project final results that safety
professionals do not attempt to single handedly obtain and analyze the data, as the effort will not carry
the same effect or respect with stakeholders whom
Establish Common Terminology
bridge the vocabulary where overlap of personal and process safety (operational safety management), are
used. Use simple classification of terminology, such as:
Catastrophic; Worker fatality, multiple worker hospitalizations, explosion, serious fire, uncontrolled
loss of primary containment with regional impacts (disruption to adjacent land or water use), loss of
major infrastructure.
Major; Days away from work injury, multiple worker injuries, and uncontrolled loss of primary
containment with localized impacts, fire with local impacts, and damage to infrastructure, loss of
multi-barrier event.
Serious; Medical treatment beyond first aid, controlled loss of primary containment at the work
location, equipment damage, loss of single-barrier event.
High Potential Near Miss; An incident in which actual injury, damage or environmental impact was
not observed, however if circumstances had been slightly different, higher serious or higher conse-
quence event could have occurred
Near Miss; Similar to HIPO NM, however consequences likely would not have resulted in a serious
or higher event, for example first aid or minor spill.
Failure to Deliver Services as Planned; Service provided did not deliver expected results, for
example failure to meet timing requirements, failure to utilized resources as planned, failure to reach
goals set in project objectives. Safety impact may or may not be present.
The Data Drilling Process
use as wide a dataset as possible (company records, industry shared events, etc.). Once compiled, the SME
team reviews incident and report data collaboratively, discussing the incident details. A project facilitator
is useful to ensure alignment of the SME team with the project objectives, and to ensure the process moves
along in a timely fashion. There is a tendency with technical personnel to focus on details of the data to
the exclusion of the higher level goal of identifying hidden risks. In some cases, what was detailed in the
incident report will have been appropriate and sufficient to describe the full extent of risk that was present
in the incident (using the described classification strategy above). In other cases, it becomes clear that
circumstances of a near miss or high potential near miss event carried significantly more risk if
circumstances had been slightly different. For these events the SME team agrees on the probability of
higher consequence, based on their experience in the field, frequency of similar historical events, and
frequency of exposure. In the case studies to follow, we paid special attention to incidents that
demonstrated potential for loss of primary containment (well blow-out, fire or explosions) as the
opportunity for loss of life and catastrophic environmental damage increase significantly under these
scenarios.
Once all relevant incidents have been reviewed by the SME team, sort out those incidents where the
classification as reported matched the agreement of the SME team; these were utilized again in a final step
in which underlying causes were identified. At this point the incidents left in the data set are reviewed for
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classification escalation based on SME input (example for example near miss is upgraded to a serious
incident).
At this point it is possible to judge the relative shift across the data set for incident classifications,
comparing what was originally reported with the upgraded consequence of the elevated incidents. The
comparison provides insight into the relative hidden risk the business may have been operating under.
Further in this paper, case studies will be used to better illustrate this.
Additionally the teams should review the entire data set looking for underlying causes that contributed
to the incidents such as failure to follow procedures, failure to execute stop work authority or failure of
leadership. And, it should be noted that some incidents will have multiple contributing factors.
Other useful insights will be discovered during the process of reviewing incidents in Data Drilling. For
example, multiple case studies may reveal that parties external to your company may have a significant
role to play in the contributing factors for many incidents experienced by service companies. In some
cases, a stop work point may have been identified by your workers, yet overridden by others who did not
agree that stop work should be called, and press for continuation of operations. Shortcuts to save time or
other violations to safety policies and procedures may be uncovered. There is a wealth of collateral
information that is uncovered through Data Drilling that is all useful in better understanding risks and
controls.

Presentation of Data and Results

The following case studies highlight the application of Data Drilling for personal safety in Case Study 1,
and Upstream Process Safety in Case Studies 2, 3 and 4. For purposes of the analysis, data was generally
obtained through company experience, industry shared incidents and cooperation with companies with
whom we work.

Case Study 1-Dropped Objects, Potential for Worker Injury

Within the oil and gas service industry infrastructure at manufacturing, repair and overhaul shops, many
types of lifts are conducted daily using mechanical aids such as forklifts, overhead trolley cranes and
pendant cranes. Dropped objects from these mechanical aids are classified as either static drops which are
purely gravity induced, and dynamic drops due to momentum, collisions and failures in mechanical lifting
components. The majority of drops related incidents observed were dynamic and included 43 dropped
objects resulting in 1 major (for days away from work case), and 42 near miss events as initially reported
in the incident description. To assist in further evaluation, we employed a DROPS calculator which plots
the mass of the dropped object against the distance traveled to determine the maximum potential
consequence (source DROPS Online, Global Resource Center). Based on where the calculated factor for
each incident fell on the calculator graph, it was possible to quickly characterize the potential consequence
using reference points for the level of injury sustained ranging from first aid to fatality.
From the initial set of 43 incidents, 27 were upgraded to a more severe classification when the subject
matter team evaluated the potential impact of the incident using the DROPS calculator to gauge the
severity of personal injury, see Table 1 below.

Table 1—Drops Incidents Classifications as Reported, and Post

Data Drilling Analysis
Incident Classification As Reported Post Analysis

Catastrophic / Major 1 27
Serious 0 0
HIPO NM / First Aid 42 15
SPE-173497-MS 5

The upgrading of these incidents to a higher consequence may mean the industry has been very
fortunate to not witness more injuries or fatalities from dropped objects than have been seen to date. While
some the drops incidents fall into an appropriate category of near miss as reported, and do not need further
analysis, others contained clues that indicated a much higher potential consequence was present than what
actually occurred. For example, a 6 foot mandrel weighing 150 pounds fell from a storage rack to the
ground without striking an employee, however a worker was standing next to the rack as the mandrel fell
(while being picked from a rack by a forklift). Due to proximity of an employee most observers would
classify this incident as a HIPO NM. In other words, if the employee had been standing a few inches or
feet to the mandrel, the result could have been a severe injury or worse.
Data Drilling for drops further revealed that 70% of the HIPO drops involved forklift operations,
including lifting or direct transport on forklift forks, collisions and contact with stationary objects such as
“bumps” to racked equipment and materials. Incidents related to loss of load from forks are entirely
preventable if effective load securing systems are employed. The results of this Data Drilling analysis
provided the insight needed to support investment of upgraded forklift securing components.
Data Drilling revealed that 25% of HIPO drops were associated with crane related incidents (both
trolley and pendant style), primarily due to failure of lifting hardware securing loads. Based on these
findings, projects were executed to limit load height lifts to worker shoulder height, provide additional
training and competency demonstration for workers responsible for preparing and securing loads for
lifting, and for reduction of crane function whenever possible.
Finally, 9% of HIPO drops were failures in racking systems for materials and equipment storage, which
required upgrades to racking systems such as securing and banding stacked or stored loads, installation
of anti “push through” barriers on the back of racks. Additionally, the use of conveyors to eliminate the
needs for racks altogether is being implemented where floor space is available.
When the 43 incidents represented in this Data Drilling project were evaluated for underlying factors,
two predominated; failure to follow procedures, and failure to stop work. In other words, workers knew
what process or procedure was preferred and allowed, and in spite of recognition that an unsafe or
non-compliant condition existed, continued with the operation which resulted in a drop incident.
Additionally as a result of this study, manufacturing facilities initiated an aggressive program to
educate first line and facility managers on the expectations of stop work authority, and refresh their
awareness and understanding of policies and procedures about manual handling and storage of heavy
materials. Posters, electronic message boards, emails and other communications were targeted to facility
operations personnel highlighting improvements to engineering controls, and upgrades to processes and
procedures aimed at reducing high risk DROPS incidents.
Case study 2, Well Bore Collision Avoidance
Drilling contractors and operators with drilling crews spend significant amounts of resources and time
planning drilling jobs to ensure avoidance of collisions with off-set wells in proximity of the well being
drilled. In spite of the technology advances, highly sophisticated software and tools, and careful planning
efforts, near misses and actual collisions with offset well bores occurs in the field, and although low
frequency event, it carries high potential consequence for catastrophic outcomes. While many incidents
do not result in loss of life or asset, there are unfortunately incidents in which loss of life, loss of assets
and significant harm to the environment has occurred. Using industry data we evaluated 61 incidents
involving either near misses or actual collisions with well bores during drilling from 2004 to 2014,
applying the Data Drilling process.
Well bore collision data was collected, reviewed and analyzed with multiple drilling services subject
matter experts, including regional and global service coordinators, prior anti-well collision managers,
prior operations managers and upstream process safety specialists. HSE collaborated with the SME’s for
analysis, and facilitated preparation of the data through distilling basic causes and underlying dynamics.
6 SPE-173497-MS

Of the 61 incidents reviewed, there were; 0 catastrophic, 4 major, 16 serious, 6 HIPO NM, 20 NM and
15 failures to deliver against plan. Post Data Drilling process in which the SME’s reviewed the data as
reported, the following upgrades in incident classifications resulted to reflect potential risk of the historic
incidents; 10 incidents from lower classified events were elevated to catastrophic potential, 15 incidents
from lower classified events were elevated to serious or major potential, 7 near miss incidents were
elevated to HIPO near miss and 8 failure to deliver against plan were elevated to near miss, see Table 2
below.

Table 2—Well Bore Collision Incident Classifications, as Reported and Post Data Drilling Analysis
Incident Classification As Reported Post Analysis

Catastrophic 0 10
Major and Serious 20 35
HIPO NM 6 13
NM or Failure to execute to plan 35 3

As in the former case study focusing on personal safety, the shift in the “as reported” risk consequences
to significantly higher classifications may indicate that the industry has been relatively fortunate more
catastrophic or major well bore collision events have not occurred. However, recent high profile oil and
gas industry incidents have shifted the industry practice to more sophisticated planning and preparation
pre-job activities. Data Drilling compliments this effort well in terms of providing focus areas for
improvements to reduce risk based on historical data, rather than more basic programmatic elements.
There were other significant findings brought forward as a result of the Data Drilling analysis on well
bore collision data. An important finding was that operational records of well bore collisions are difficult
to obtain as clearly written reports, and even when available, most operators and service companies are
very reluctant to share the information publically. If we are to get the most insight from these types of
analyses, we will need better cooperation from industry partners to review additional incident details, and
thus appeal to all well bore collision stake holders to consider working collaboratively with groups like
International Oil and Gas Producers (IOGP) and International Association of Drilling Contractors (IADC)
to bring more incident data to the table for review (which can be done without publicizing company
sources). Finally, the well bore collision incident reports in all the formats discovered, were highly
technical and required the help of SME’s to interpret and direct deeper understanding of the incident
narratives.
The team then further accessed the data for underlying factors, with a goal of constructing mitigating
actions to reduce the risks. Two primary causal factors related to well bore collisions were; failure to
follow procedures and policies, and failure to execute work per the written job plan. These are better
explained in light of the underlying dynamic of customer pressure. While service companies and drillers
highly value compliance with policies and procedures, it is apparent from data narratives that drilling time
influences decision-making and is contributing to safety risks. The analysis found customer impacts are
present in 60% of the failures in planning for drilling jobs and 58% of the time in terms of failures in field
execution. These range from inaccurate data submitted to the driller for well planning, to putting the driller
on the wrong slot when arriving at the rig. In the field execution phase, typical customer pressure is seen
by customers “accepting the risk” of a well bore collision and insisting the driller continue on even when
they are aware of the fact that drilling has entered a no-go zone. Additional communication and pre-job
agreement with drillers and customers and operators will be needed to overcome these easily preventable
higher risk conditions.
The complexity of drilling work is increasing as lateral well creation activity increases. Movement
through highly congested vertical zones on complex multi-well pads increases the potential risk of well
SPE-173497-MS 7

bore collisions. As a result of this analysis, one drilling service company held a global operations stand
down to focus on reinforcement of stop work authority, and the expectation that drilling procedures and
anti-collision policies will be honored by all employees in the field.
Finally, it was clear from the amount of effort required to obtain meaningful well bore collision data
that better field reporting of near miss and HIPO near miss events needs to occur to ensure quality data
is available for on-going analysis of the causal factors for incidents, and to aid creation of effective
mitigating strategies. Actions taken as a result of this analysis include; improvements in the planning
phase of drilling work, improvements in the training and competency of field crews along with remote
coaching through real time monitoring of drilling jobs. Additionally we see drillers and operators with
drilling interests pursuing engineering solutions that provide automated monitoring and check points for
drilling activities that will prevent field crews from progressing into no-go zones during drilling
operations.
Case study 3, Wireline Pressure Control Incidents
Wireline services require preventative barriers to manage well bore pressure, and thus reduce the
probability of a serious safety incident. Mechanical integrity of pressure control equipment (PCE) is
paramount to well control to avoid serious consequences that could lead to the loss of primary containment
or loss of well control, which includes the uncontrolled releases of hydrocarbons when connected to the
well to perform essential wireline services.
A critical portion of the operation is the rig up phase. The engineer in charge must supervise the
wireline crew to ensure the well head pressure control equipment (PCE) installation and pre-job testing
is properly executed to safely deploy down-hole tools.
Utilizing the Data Drilling process, a total of 439 wireline quality and safety incidents from 2005 to
2014 were analyzed by Data Drilling to identify incidents associated with pressure control, and brought
forth 46 incidents for additional review. A team of wireline subject matter experts were utilized in both
the data acquisition and data analysis phases. These SME’s include service delivery and quality experts,
field operations and repair and maintenance specialists. The review team was facilitated by a safety
specialist. Post analysis, 5 as reported incidents from lower classifications were upgraded to serious, major
or catastrophic to better reflect potential risk consequence, see Table 3 below.

Table 3—Wireline Service Incident Classifications Involving Pressure Control Equipment as Reported, and Post Data Drilling Analy-
sis
Incident Classification As Reported Post Analysis

Catastrophic 1 2
Major and Serious 6 10
HIPO NM 32 31
Near Miss 7 3

While not as significant a number of incidents upgraded to higher classifications than other case studies
presented, the impact is none the less important to managing primary containment on the well bore and
worker personal safety. Pressures on well bores routinely exceed 10,000 psi, and represent a major risk
to wireline service crews when loss of pressure control incidents occur.
The Data Drilling analysis revealed not only the potential for increased incident severity, but provided
clearer insight into underlying causing of historical events, namely failure to follow procedures, poor job
planning, and equipment assembly failures (for example PCE was assembled as assumed to be in ready
condition, but actually required preventative maintenance prior to use in the field). Pre job planning
8 SPE-173497-MS

failures were typified by arriving at the job site without all required PCE gear present to completely
prepare for rig-up.
As a result of this analysis operations executed a highly focused execution improvement program to
better manage the job cycle, which includes processes to set the correct work flow paperwork, along with
standardized procedures in one central location with access by all workers. Consequently instead of crews
yielding to customer pressure, company man pressure, time pressure, sales pressure, the crews held their
lines on execution and stopped work when their procedures could not be followed.
Additional improvements have seen wireline management leadership realigned all the way to the field
to facilitate improved accountability for operational objectives. Competency and training program
upgrades have included extensive hands on training prior to deployment in the field on inspections, rig-up,
maintenance and operation of pressure control equipment used in wireline operations.
Case Study 4, Coiled Tubing Operations
A total of 115 quality and safety incidents from the years 2012 to 2013 were evaluated to determine if the
reported outcomes hid more severe risk than was apparent from historical data trending reports. Incident
outcomes for 61 incidents were then reclassified in terms of incident potential, both for personal safety
and process safety.
As in prior case studies, a team of coiled tubing subject matter experts partnered with safety,
engineering and technology experts to both obtain and evaluate the incident data as reported. Of the 61
incidents examined, there were 23 incidents elevated to serious, major or catastrophic, which may indicate
a much higher level of potential risk is involved with coil tubing operations than most companies would
expect based on normally reported historical data, see Table 4 below.

Table 4 —Coil Tubing Operations Incident Classifications, as Reported and Post Data Drilling Analysis
Incident Classification As Reported Post Analysis

Catastrophic 0 8
Major 13 18
Serious 10 20
HIPO NM / First Aid 38 25

Examples of catastrophic incidents were dropped objects such as bolt and chain block falling from the
injector head, the bottom hole assembly (BHA) ejected from the head due to uncontrolled pressure, a
worker struck from manipulating injector head, and loss of control of the stored energy in the coiled tubing
reel.
Similarly, major and serious events such as loss of containment were loss of control of tubing, an over
pressure event or the BHA ejected from the well. Personal injury due to falls and slips from elevated work
platform were also present.
The analysis also revealed that the rig-up and rig-down phases of workflow represented the work tasks
most likely associated with serious to catastrophic events, followed closely by well services and trailing
were facility and maintenance activities.
Basic causes for the incidents evaluated demonstrated the primary causes were related to failure to
follow procedures, with supervisors not holding their crews accountable to follow procedures. Underlying
dynamics for this condition were related to industry expansion resulting in high worker turn-over, limited
experienced personnel in the market and resulting challenges to maintaining training and competency
standards amount available workers. Additionally variations in coiled tubing unit design and well control
equipment create unnecessary operational complexity for limited experience workers. Finally, the high
SPE-173497-MS 9

pace of work and cultural reluctance to call STOP WORK facilitate high risk conditions on many coil
tubing jobs resulting in incidents.
Mitigating actions to reduce risk in coiled tubing operations focused on improvement in training and
competency management on a dedicated well and coil training unit prior to field deployment, more
effective worker recruiting, reduction of operational complexity through standardizing of procedures and
equipment, and increases in leadership accountability based on flawless and compliant field execution.
Conclusions
Many companies in the oil and gas industry maintain a robust database of safety incident data, which is
assumed to be the cornerstone for managing safety and risks. However, unless this data is effectively
analyzed to reveal hidden risk faced in field operations, along with the underlying causes of incidents, the
true value in these databases remains obscured. Baker Hughes has demonstrated the Data Drilling process
can unlock deeper risk related insights, and better quantify the true risk field operations are facing.
The four case studies presented all exhibited increased risk potential existed when historical reported
data was evaluated by subject matter experts using a “what could have happened” perspective. When
senior leadership teams were presented with this information, the analysis credibility was enhanced
because long service operations experts they knew had collaborated on the findings. The Data Drilling
reports have effectively supported enhanced mitigating strategies, including; capital expenditure for
equipment upgrades, expanded technical and leadership training, additional resources dedicated to
upgrades in procedures and policies, and reaffirmation to their middle management and front line
supervisors on the expectations for compliant operations and support for stop work authority.
Discussions with oil and gas operators and service companies indicate all struggle with a pervasive
underlying cause of not following procedures in both the field and shops. However, the corrective
action(s) needed to revolve these risk factors are not easy to implement, as evidenced by the year on year
trend as a primary finding in incident causal analyses. A basic strategy to mitigate risk from workers not
following procedures, and born from the presented Data Drilling case studies, is as follows:
1. Engineer the risk out of the operation, such that the worker physically cannot continue operation
in an unsafe condition.
2. Ensure high quality technical training coupled with demonstrated competency for critical safety
tasks is completed prior to the commencement of high risk work.
3. Set a consistent leadership expectation (in words and writing) that demands compliance with stop
work authority, procedures and policies, and the highest application of personal integrity in
executing the same.

Acknowledgements
The authors would like to acknowledge the technical support and time provided by the subject matter
experts at Baker Hughes and partnering oil and gas companies in compiling and analyzing the data in the
referenced case studies.

References
“New Findings on Serious Injuries and Fatalities”, (Behavioral Science Technologies, Inc. 2011), 417
Bryant Circle, Ojai, California.
“Understanding and Application of the Diamond to Prevent Fatalities”, (Jack Toellner, P.E., CSP
2012), ExxonMobil, Houston, Texas.