NEBOSH INTERNATIONAL DIPLOMA IN OCCUPATIONAL HEALTH AND SAFETY UNIT DNI ASSIGNMENT FAHMI ABDULLAH TAHA May 2018

NEBOSH INTERNATIONAL DIPLOMA IN
OCCUPATIONAL HEALTH AND SAFETY

UNIT DNI
ASSIGNMENT

FAHMI ABDULLAH TAHA

May 2018?
RESEARCH ETHICS DECLARATION

The information contained here is, to the best of my knowledge and belief, accurate. I have read the NEBOSH current Guidance and information for candidates, and accept responsibility for the conduct of the procedures set out in the attached application in accordance with these guidelines, the NEBOSH policy on conflict of interest and any other condition laid down by the NEBOSH Unit DNI ethics Committee or its Sub-Committees. I have attempted to identify all the risks related to this research that may arise in conducting this research, and acknowledge my obligations and the rights of the participants.

Signature: Fahmi A.Taha
Name: Fahmi Abdullah Taha
Student Number: 00392610
Date: 27 May 2018
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Executive Summary
In this study we will review the arrangements for managing health and safety in DNO Peshkabir Site, specifically, we will focus on the Centralized Process Facility(CPF) arrangements. We will evaluate the Peshkabir Health and Safety Management System under six core elements: leadership, management, worker involvement, competency, compliance, and risk profile. Then we will identify any perceived gaps in the DNO Peshkabir site health and safety management system (H&SMS) and identify the main risks which may present a threat to Peshkabir site occupants and visitors’ health and safety (H;S). Based on the result of assessment we will thereafter produce justified, proportionate recommendations to improve health and safety performance in the DNO Peshkabir site.
Analysis of the Peshkabir H;SMS as a whole identified numerous of good practices and several perceived deficiencies in each section. We then further analyzed the top three potentially most problematic area/issues and those where proposed improvements would make the most positive impact on the development of H;S performance at Peshkabir site. These three areas that we identified that need to be improved were leadership, personal profile and lack of control measures in terms of possible exposure to toxic gases.
There are the variety of visible aspects and examples of poor leadership in both the DNO senior management and Peshkabir management team, such as not following basic DNO Peshkabir site rules, not leading as or setting an example. It is obvious that there is a strong relationship between effective leadership and a company’s safety performance. The way senior management lead their team in regard H&S will determine how safe their site is to work on. Therefore, we have recommended that an assessment of to assess the level of leadership in DNO Peshkabir Site be carried out, training needs for below standard leaders be identified and a training programmed be implemented to ensure they are aware of company’s expectation from good leaders and their role and responsibilities in this regard.
Based on the findings from our study, the competency profile of entry level Peshkabir employees is very low. Beside their technical knowledge most employees do not have appropriate communication skills. There is no doubt that creating team comprising competent personnel is a core necessity to improve the organization’s H&S performance. So accordingly, we recommend creating an internal team competency improvement committee to analyse the current level of competency of DNO Peshkabir crew and identify any training needs. Then, based on these recommendations, the company should hire a training coordinator for Peshkabir site to prepare and coordinate the training packages. to get all employees through the required training and assess their competence thereafter.
As a further part of this review, we have also undertaken an analysis of the risk profile of Pehkabir Site and have identified numerous risks and we recommend that the following supplementary control measures need to be in place. Specifically, we analyzed the perceived lack of control measures to mitigate exposure to toxic gases. In addition, it is felt that there are inappropriate arrangements in place in terms of gas detection and dispersion which potentially create serious risk of personnel exposure to high concentration of H2S gas. The main deficiency in terms of controlling H2S dispersion is; the location of CPF control room, which is located close to a potential H2S source. There is no fixed H2S sensor system on the Peshkabir CPF to provide early warning of an H2S release and alert people to take preventive remedial action. This being the case, any sort of high concentration H2S gas leak may result in fatality based on the current control measures in place. To be able have better control we recommend that the following actions be implemented; Relocate the CPF control room from the toxic zone in to a non-hazardous zone, and the installation of ten fixed wireless H2S sensors at critical locations on the CPF, identified as a part of this study, to facilitate early recognition of any H2S hazard and raise an emergency alarm to alert people to act and protect themselves from H2S.
In summary, the current gap in DNO H&SMS is creating a potentially serious threat to the safety and welfare of Peshkabir occupants. This gap may result in a serious or fatal incident which may threaten the sustainability of Peshkabir field due to economic, moral and legal reasons. The approximate direct cost of any incident which results with fatality in Peshkabir is above 12,000,000$ as any fatal accident will require a shutdown of the facility until the initial incident investigation is completed. In addition, there will be additional cost such as lost time, compensation to victims’ families, non-productive time, and moral issues with Peshkabir workers, and to company reputation. The overall cost of these recommendations to rectify current unsafe conditions, and close the perceived gap is around 215,700$. On this basis, it is strongly recommended that DNO review these recommendations as a matter of urgency and consider their immediate implementation.?
CONTENT
PRESENTATION i
RESEARCH ETHICS DECLARATION ii
EXECUTIVE SUMMARY iii
TABLE OF CONTENTS iv
LIST OF ABBREVIATIONS vi
SECTION I
INTRODUCTION

1.1. PURPOSE OF STUDY 1
1.2. FACILITIES DESCRIPTION 1
1.3. METHODOLOGY 2
1.4. THE ROLE OF HEALTH AND SAFETY PRACTITIONER 2
SECTION II
REVIEW AND CRITICAL ANALYSIS OF THE ARRANGEMENTS FOR
MANAGING HEALTH AND SAFETY
2.1. LEADERSHIP 4
2.2. MANAGEMENT 6
2.3. WORKER INVOLVEMENT 9
2.4. COMPETENCE 11
2.5. COMPLIANCE 12
2.6. RISK PROFILE 13
2.6.1. Lack of Toxic Gas Detection 14
2.6.2. Lack of Fire / Flammable Gas Detection System 15
2.6.3. Incomplete Fire Fighting System 15
2.6.4. Location of Occupied Buildings 15
2.6.5. Inappropriate Flaring 16
2.6.6. Access and Egress 16
2.7. SUMMARY OF SECTION TWO 17

SECTION III
EVALUATION OF IMPROVEMENTS REQUIRED
3.1. LEADERSHIP 18
3.2. LACK OF REQUIRED COMPETENCIES AMONGST EXISTING WORKFORCE AND POTENTIAL EMPLOYEES 20
3.3. TOXIC GAS; POTENTIAL FOR EXPOSURE 22
3.3.1 Location of Occupied Building 22
3.3.2 Lack of Toxic Gas Detection System 23
3.3.3. Financial Justification 23
SECTION IV

CONCLUSION AND RECOMMENDATION

4.1. CONCLUSION AND RECOMMENDATION 25
BIBLIOGRAPHY 28
APPENDICES 29
Appendix I: SAFE Card 29

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LIST OF ABBREVIATIONS

CPF: Centralized Production Facilities
H;SMS: Health and Safety Management system
HSE: Health Safety and Environment
KAR: Kurdistan Autonomous Region
Kbopd: Thosan Barrel of Oil Per a Day
RIDDOR: Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

SECTION I
INTRODUCTION

1.1. PURPOSE OF STUDY
The main purpose of this study is to carry out a review of the arrangements for managing H;SMS in the DNO Peshkabir facilities comprising the Loading Station and Centralized Process Facility(CPF). Within this assessment, we will evaluate the good and bad safety performance elements and identify the principal underlying reasons behind unsafe acts or conditions through a gap analysis process. Based on the result of assessment we will produce justified and proportionate recommendations to improve H;SMS performance in DNO Peshkabir Site.
Also, we will demonstrate the role and responsibilities for all DNO Peshkabir employees within the scope of the DNO H;SMS. More specifically, we will focus on the roles and responsibilities of dedicated HSE practitioners in minimizing the potential for harm or injury at DNO Peshkabir Site through education, setting procedures and building a positive safety culture in workplace.
1.2. FACILITIES DESCRIPTION
DNO is the operator for the Tawke and Peshkabir oil site development in the Kurdistan Autonomous Region (KAR), northern Iraq. The Tawke and Peshkabir Sites currently produce 130 thousand barrels of oil per day (kbopd) in total from both Centralized Production Facilities(CPF).
Tawke facilities are located approximately 150km north-west of the city of Erbil, and approximately 8km east of the town of Zakho.
Peshkabir site located approximately 38km north-west of the Tawke field. Peshkabir Site is a newly explored filed. Peshkabir Site currently produces 48kbopd in total from Centralized Production Facility (CPF). The Cretaceous wells producing crude oil, flow to Peshkabir CPF via flow-lines for separation and processing. Crude from the well sites reaches through flow-lines to the CPF for processing and refining. 30kbopd Oil produced at the CPF is exported to Fishkhabour storage by 10″ Stainless-steel export pipeline and 18kbopd is transferring to Fiskhabor storage via crude oil tanker Trucks. The tanker is loading via Peskhabir loading station which has capacity of 20kbopd per a day. It can load more than 46 crude oil tankers in 24hrs from six loading gantries.
Peshkabir CPF is capable to separate and process 65 kbopd. It has been managed by field superintendent, with the support of 4 team leaders, 1 HSE advisor, 6 production operators and 10 CPF helpers.
Peshkabir Loading Facility is located 100m west of Peshkabir CPF. It has been operated by two production loading station team leaders, four loading station operator, and 8 loading station helpers.
Peshkabir Site workers are working 12 hrs (from 7:00 am to 7:00 pm) and the work rotation is 2 week on 2 weeks off.
1.3. METHODOLOGY
Many scholars have stressed the importance of data collection instruments in undertaking studies such as this one. In addition, a considerable number of studies have been conducted to clarify why specific data collection instruments should be used for certain research theses. There are various instruments of data collection such as questionnaires, interviews, reading, and observation, and researchers should ensure that the instrument selected is valid for his/her research. This research aims to review the arrangements for managing health and safety in the DNO Peshkabir CPF and to evaluate good or bad elements of recorded safety performance, and thereafter to identify any perceived gaps in the DNO Peshkabir site health and safety management system (H&SMS) and identify the main risks which may present a threat to Peshkabir site occupants and visitors’ health and safety.
Thus, the researcher has decided to use interviews to collect the required data and critically analyse this data against best practice to identify gaps in the current arrangements. The employees interviewed will be from different departments and varying levels of authority and responsibility within the company. The main perceived risks which the interviewer has identified will be discussed with them and a combination of brainstorming and discussion will take place to agree on adequate control measures to eliminate or minimize the risks. Following these discussions a subsequent site review will be conducted by both parties to observe the actual site activities and ergonomics and collect further data for analysis regarding the present risk and control measures in place to support and reinforce the improvement identification process.
1.4. THE ROLE OF HEALTH AND SAFETY PRACTITIONER
Health and safety practitioners are those who have the critical duty in term of helping the employer to manage health and safety in the organization. Peshkabir HSE (Health Safety and Environment) representative has crucial rule and responsibility for managing health and safety in Peshkabir site. He is the one who formulating and improving health and safety procedures, policies and plans. He is assessing ad profiling the risk for the Peshkabir Site based on DNO risk matrix and risk assessment procedure. Also, he is planning and arranging remedial actions to eliminate or minimize the level of the risk. One another duty of the Peshkabir HSE advisor is measuring and site health and safety performance by the way of assessing how well the risk are being controlled and investigation the rote and immediate causes of near misses, incidents, and accident. He also responsible for coordinating the permit to work. ?
SECTION II
REVIEW AND CRITICAL ANALYSIS OF THE ARRANGEMENTS FOR MANAGING HEALTH AND SAFETY

2.1. LEADERSHIP
Leadership defines as a process carried out within an organizational role that assumes responsibility for the needs of those who decide to follow the leader in accomplishing the project. There are various types and styles of leadership such as senior leadership, executive leadership, and strategic leadership.
In all organizations, leadership has a great effect on HSE culture of the organization. According to many studies, individuals are more likely to be committed to safety and to engage in open communication regarding safety when they believe that their organization demonstrates supportive actions and their leadership visibly follow the organisation HSE rules/standards and support people who commit themselves to organisation’s safety policies. Similarly, it is posited that trust in management and perceived safety climate facilitates the relationship between a high-performance work system and safety performance measured in terms of personal-safety orientation. These instances are pointers to the positive impact of leadership towards ensuring safety.
There is a strong relationship between effective leadership and company’s safety performance. The way senior management lead their team on health and safety will determine how safe their site is to work on. The number of accidents, incidents, ill-health, and unplanned event that happen are, in many cases, directly related the effective or poor safety leadership that you have in the organisation. Always, positive safety culture and climate lead to a decrease in the number of near misses, accidents, incidents or unplanned events while on the other hand, company health and safety performance will be seen to improve correspondingly.
DNO ASA is an international oil and gas company which operates in the variety of countries. Nowadays, DNO pays specific attention to their operation in Kurdistan region of Iraq and shape their HSE strategy based on their field in Kurdistan.
Peshkabir Site produces 48 kbopd crude oil per a day, which equates to 40% of DNO’s production in Kurdistan. The most senior person in charge in PSK is the Peshkabir Site Superintendent. Site Superintendent also has the responsibility as the most senior person in terms of health and safety as well. The role and function of the Peskabir HSE advisor is advising and assisting the Site Superintendent in term of H&S issues. Site superintendent has ownership of all health and safety risks. He is the one who must identify, prioritize and manage these risks, considering the consequences of the worst possible occurrence and the knock-on effects for field operations. The Site HSE Advisor will assist and support him to ensure that risk assessments are carried out, all hazards have been identified, risks have been assessed and appropriate control measures are in place to eliminate risk or minimize the risk into acceptable level. The Site Superintendent will also identify who will be responsible for implementing risk controls and over what timescale.
The Site Superintendent is the focal point for all staff on health and safety issues and his behaviors are a role model for his team. He will strictly adhere to the basic site rules, such as no smoking policy, vehicle speed policy or mandatory personal protective equipment policy at all times as a visible example to his staff. However, when it comes to high level critical decision making, for instance if there is a scenario where he may have to take the decision to halt production operations due to a safety issue, this potential loss of production will weigh his decision-making process and he will, in most instances, allow production to continue whilst a solution to the safety issue is sought. For example, during a pre-startup safety review assessment for Peshkabir Loading Station, the Peshkabir HSE Advisor identified the issue that there was no drainage system and adequate spill kits in loading station to protect the environment in the event of an oil spillage. The Field Superintendent made the decision to start up the operation and to write a deviation procedure for this issue and notify senior management to get remedial action rather than delay the initial start-up. The loading station operated for 6 months without an oil drainage system or spill kits and during this time several oil spillage incidents occurred and lead to minor environmental implications and effects.
According to DNO policies, the senior management from Dubai needs to visit each field/site at least once a quarter each year. Also, the senior management from country office need visit the field once a month. They need to prepare a report known as a site visit report and share five positive improvements and five negative areas which need to be improved. The visibility of senior management varies from department to department or person to person. Some senior managers from the Dubai office visit Peshkabir Site once a year, some do not visit at all. The senior management in-country office pay visits to Peshkabir at least once a quarter. During their visit, the majority of senior managers prefer to stay in the office and hold meetings with Peshkabir management teams rather than visiting the actual process facilities and the general workforce. During their visit, some of them do not follow basic site rules. For instance, bypass, the T-card system and do not fully wear mandatory personal protective equipment while they visit hydrocarbon process facilities and as a result of these failures to adhere to basic site safety rules show poor leadership performance.
DNO Peshkabir facility has SAFE card system which is simple and effective reporting tool. In most oil companies they known as stop cards. SAFE Card submissions help improve the safety of the working environment and show workforce commitment to Putting Safety First. SAFE Cards also provide individuals the opportunity to communicate with Senior Management. Review of HSE records held in PSK for this study shows that in 2017 only two SAFE Cards had been raised by Dubai, Oslo and Erbil senior managers during their visits. It indicates the very low rate of senior management participation in DNO SAFE card program. This is again an indication of poor leadership and engagement from senior management.
During senior management visits, usually, they place the utmost emphasis on the importance of safety, almost all of them stating that safety comes first and they claim the organization’s first priority is people and environment. However, when it comes to take a critical decision making between stopping the operation for sake of a safety or environmental issue, they are not consistent or confident to stop the operation and rectify the issue due to lost production implications. Even, some of most senior managers do not obey simple mandatory site rules, such as no smoking, taking photos inside of hydrocarbon facilities and operating vehicles inside prohibited areas within the facilities. This effect overall health and safety performance of Peshkabir Site. So, the Peshkabir Site managers and leaders lose their motivation to lead as an example corresponds.
However, there are some senior managers who show a genuine interest and concern in the health and safety issues that the Peshkabir Site has, if these are highlighted to them during their visits and they will subsequently communicate these problems through appropriate channels to be addressed following their departure from the site.
2.2. MANAGEMENT
Management can be defined as “the organization and coordination of the activities of a business in order to achieve defined objectives”. It keeps the organization functioning and involves planning, budgeting, staffing, defining responsibilities, measuring performance. They need to consider safety-related issues for economic, social and moral reasons. Therefore, Management must identify the organization’s safety risk profile and prioritize them. Decide whether control measures in place are adhered to legal and international standards or not. Ensure the health and safety roles and responsibilities allocated. Moreover, management needs to plan to allocate resources when it’s required. They need to monitor the organization safety performance and provide competent advice when it needed. They need to provide clear policies to third-party companies regarding the organization expectation and operational standards. Management need monitor risk control performance on a regular basis and review organization’s risk profile.
The Management of Health and Safety at Work Regulations 1999 require employers to put in place arrangements to control health and safety risks. As a minimum, you should have the processes and procedures required to meet the legal requirements, including:
• A written health and safety policy
• Assessments of the risks to employees, contractors, customers, partners, and any other people who could be affected by your activities
• record the significant findings in writing
• Suitable and sufficient risk assessment
• Arrangements for the effective planning, organisation, control, monitoring and review of the preventive and protective measures that come from risk assessment;
• Ensuring there is adequate and appropriate supervision in place;
The DNO Peshkabir Site management team is very small and they are running the whole field from two offices with additional support from the DNO Tawke field and Kurdistan in-country office. DNO aim to implement their organizational standard in all their operational assets which operate in Kurdistan. Accordingly the DNO Peshkabir Site management invested a great deal of time and effort to consider health and safety priorities while they are managing the required arrangements for the organizational activities.
According to international HSE standards, employers must explain clearly the procedure for any worker to follow in serious danger or emergency. Employees, visitors or contractors and others need to know when they should stop work and how they should move to a place of safety in any emergency case. To manage any emergency, DNO Peshkabir has a developed emergency response procedure to be followed in various emergency situations. This procedure is implemented and overseen by a dedicated emergency response team(ERT), led by Field Superintendent, as most senior production authority in Peshkabir Site, in the ER Team Leader role. In the ERT organization chart vital roles are assigned to production team members and their responsibilities in the role have been clearly identified. Moreover, all emergency escape routes and assembly points have been communicated to all site personnel and visitors through the mandatory Peshkabir Site HSE induction. Also, DNO Peshkabir ER plan is supported by the Peshkabir Medical Emergency Plan which makes provision for various arrangements and plans specifically related to medical injuries and emergencies.
Peshkabir is a new field; therefore there is high volume construction and civil activities carried out by third-party contractors. Any organization engaging contractors have a duty to communicate health and safety responsibilities and expectations. Therefore, DNO needs to make sure everyone understands the part they need to play in ensuring health and safety standards are met. Use of contractors in itself does not result in poor health and safety standards, but poor management can lead to injuries, ill health, additional costs, and delays.
To be able to manage contractor needs and control the risks involved in their activities, and to minimize work-related incidents, the DNO Peshkabir site has various managerial procedures in place. For instance, any non-routine, corrective maintenance and repair activities undertaken in The Peshkhabir Site will require an authorized permit which issued by Peshkabir Permit Office. To allow contractors to operate within the system DNO provides full training to those who will prepare permits or act as performing authorities. Any permit requires being raised by the performing authority 48hrs in advance for planning purposes and work coordination to prevent conflicting activities. The permit content comprises Job description, starting date and estimated the duration of operation, the number of people involved, risk assessment, method statement, identified control measures that need to be implemented and the signature of all parties who take responsibilities to accomplish the work in a safe manner. The permit is effective only as long as people follow the instructions in an appropriate way. To be able to monitor this, DNO has put a permit auditing system in place. As a result, a high percentage of permits are audited by DNO employees from different departments, the statistic of auditing held on a register on the online software, and any audit findings reviewed for purposes of improving work practices and permit preparation in future where corrective actions have been identified.
According to the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR), all employees or employers must report certain work-related injuries, cases of ill health and dangerous occurrences. DNO Peshkabir site has a reporting policy which clearly states that any near miss or incident occurring in the Peshkabir Site needs to be reported under ‘DNO Initial Incident Report’ within 24hrs. The HSE Manager will then assess the actual and potential consequences of the incident and categories same as a low profile or high profile. Accordingly, an investigation team may, in the case of any high-profile categorization, be allocated to investigate the root and immediate causes of the incident and thereafter will prepare a detailed report along with a supporting lesson learned flash. This lesson learned flash will then be communicated to all parties through the HSE bulletin board, Safety stand-down meetings and daily meetings to ensure the message has been distributed and new control measures have been communicated.
The DNO Peshkabir Site is growing very fast with two drilling rig in situ, drilling the well pads and, on average, every three months one new wellhead is commissioned. As a result, the DNO Peshkabir Site continuously requires new employees to be hired in order to be able to run all construction and production activities in a safe manner. But the human resources procedure is very long to advertise, identify and hire some new personnel. For instance, Peshkabir site needs to hire 10 access controllers to be able to provide safe access and egress to the new CPF facility. The procedure will take 9 months to hire the required manpower from first personnel request. Moreover, DNO requires hiring new employees to provide adequate supervision as they are short manpower competent for supervisory roles. Further to this, most DNO employees are working 25 days per month whilst they should be working a 2 week on 2 weeks off rote according to their contract of employment. This has not been possible due to lack of manpower. Accordingly, DNO need to improve and streamline their system and procedures in terms of analyzing personnel needs and manning levels in order to plan ahead to ensure enough experienced, competent employees to maintain safe operations and welfare of personnel.
2.3. WORKER INVOLVEMENT
According to The Management of Health and Safety at Work Regulations 1999 requirement, employer required to ensure his/her company have the procedures to meet the Legal requirements, such as:
• access to competent health and safety advice.
• providing employees with information about the risks in your workplace and
• how they are protected;
• instruction and training for employees in how to deal with the risks;
• consulting with employees about their risks at work
• engaging in consultation with employees, and especially trade unions where
they are recognized.
Beyond the required legal minimum standard, worker involvement is crucial in order to maintain the management of health and safety of organization standard at a high level. Worker involvement facilitates creating a positive safety culture and improves health and safety performance of an organization. The more employees’ involvement into health and safety management the greater their sense of ownership and job satisfaction and the more likely that health and safety performance will improve.
In DNO Peshkabir site there are some arrangements which facilitate worker or contractor involvement into health and safety system, for instance, SAFE Cards. SAFE Card is a simple and effective reporting tool. SAFE cards are raised to report any unsafe acts or conditions, such as spills, incidents or accidents. Also, SAFE card can be raised to encourage those around to act safely or highlight positive action and attitude from workforce. SAFE Card submissions help improve the safety of the working environment and show workforce commitment to Putting Safety First. SAFE Cards also provide individuals the opportunity to communicate with Senior Management.
The safe cards collected by Peshkabir HSE team are submitted to management on a weekly basis to highlight unsafe conditions for action by management and for analysis of trending of safe/unsafe acts or condition. At the end of each week, several of the best SAFE cards are selected by management and various awards and certificates of recognition are presented to winners to encourage workforce participation. So, it gives the opportunity to workers to be involved in decision making on some types of simple health and safety issues. It is an important tool to integrate health and safety as part of everyday business for all levels of the workforce rather than being viewed as something done solely by management.
Another initiative which facilitates worker or contractor involvement into the DNO Peshkabir site health and safety management process is the daily HSE meeting. This is used to communicate the status of daily activities, ongoing operations, current health, and safety performance and any other pertinent information. The HSE meeting is chaired by site HSE advisor on a daily basis.
DNO employees do not have any sort of formal health and safety forums or committees which may be appointed to negotiate or consult with regard to workers problems with management. The safety committees facilitate worker involvement with regard to health and safety management in the workplace by raising individual’s concerns on current health and safety standards of organization and consult with management on workers’ behalf with regard to issues related to health and safety. Contractors or DNO Company workers communicate their problems or concerns through their line manager or informal personal relationship with management. There are no clear lines of communication to report concerns or work-related health and safety issues. All in all, DNO doesn’t have any sort of formal management process to consult with their employees or assess employees performance.
The training need for employee personal development plans are dictated by line managers without consulting with the employee himself. Moreover, there is no form of placement or aptitude test to determine employee level to attend the designated training program. For instance, some of the employees attended to training which was delivered in English actually could not understand written or spoken English. This highlights a huge failing in the process.
There is no kick off meeting prior to the start of a new project to Communicate and co-ordinate that DNO expectation for employees and contractors. There is no pre-job safety meeting to communicate the specific rules and responsibilities each individual in term of safety prior to the start of a new operation. These types of meetings are very important in order to ensure co-ordination and communication of risk involved from the outset of any activity and to allocate the roles and responsibilities of team members to control and mitigate these risks. Prestart meeting is an essential tool to ensure safe operation from the outset.
Moreover, performing authorities (DNO employees or contractor employees who in charge of the work party for completion of the task) are not involved in the level 2 risk assessment when planning new site works or activities. The risk assessment is usually prepared by company HSE representatives and approved by the DNO site superintendent. This method of planning and risk assessment takes key personnel, who will actually carry out the operation, out of the key safety procedure to identify the hazards related to the task and to put control measures in place. It makes level two risk assessments more like tabletop exercise and thus reduces the effectiveness of the risk assessment with the key input being bypassed.
2.4. COMPETENCE
According to most of the scholars, to create strong and effective health and safety management system you need to have competent members through every level of the organization’s workforce. Competency is the combination of theatricals knowledge and practical skills. It is undertaking responsibilities and perform activities to an acceptable standard. Creating a team from the competent member will increase the organization health and safety performance as well.
According to The Management of Health and Safety at Work Regulations 1999, an employer needs to appoint one or more competent people to help them implement the measures they need to take to comply with the legal requirements.
DNO is an international organization so accordingly, the most of management team consist of competent people in their chosen profession. DNO Peshkabir management team also contain from competent people with high-level professional qualifications and more than 10 years’ experience in their current position. For instance, the PSK Site Superintendent has more than 10 years’ experience in similar roles within DNO Kurdistan on different projects. Further, he also worked for more than five years in different oil and gas companies before joining DNO. He also holds a BA degree in Oil and Gas engineering to underpin these years of experience. The DNO Peshkabir HSE Advisor also has more than 10 years’ experience in various international companies and holds a master degree in environmental science and NEBOSH IGC international in health and safety. As a result, the most member of Peshkabir management team consists of competent, professional people, and it is this team which is overseeing DNO’s daily work activities. 3rd party contractors and DNO entry-level employees(Production team leaders, operators, and technicians), however, do not always have the same level of competency. For instance, at this time, none of the DNO or 3rd party electric & instrument technicians hold international high voltage certification to carry out work on high voltages devices. Moreover, most of the DNO Peshkabir first aid team or firefighting team members, both of which have critical role in emergency response, do not have appropriate first aid or firefighting training. Also, the majority of DNO production operators or trainee operators English language ability is very low and this is the preferred business language in the oil field so there are potential communication issues as a result. In addition to this, none of the contractor’s personnel have appropriate training/knowledge and language ability to complete any sort of risk assessment or follow up permit to work system leaving the workload to be put upon limited contractor personnel and also DNO personnel who support contractor operations.
As we mentioned previously, DNO Peshkabir management team contain people who have competency in their current role. In addition to their normal role and responsibilities, they have supplementary critical roles and responsibilities in health and safety organizational structure. However, most of these managers and supervisors don’t have any specific training in terms of health and safety such as health and safety leadership training, emergency response training or level two risk assessment training. So, this has created an organizational gap in the management structure of the Peshkabir site in terms of health and safety needs.
There are some key considerations while selecting new employees for the company in terms of their competency. First of all human resources (HR) are looking for their criminal clearance and then their skills and abilities. Other abilities HR look for is applicant certifications, experience and language skills. In interview questions or assessment there is no question which refers to the candidate’s general health and safety knowledge. The focus more on their knowledge of the profession that they are going to work. If Health and Safety is the key priority stated in company policy, this gap in knowledge is one that needs to be addressed in the recruitment process going forward.
2.5. COMPLIANCE
Occupational safety and health compliance can be simply defined as complying with companies, national or international occupational safety and health regulation, policy, standard or law. Basically Occupational safety and health compliance aim to reduce the number of accidents occurring in the workplace, protects the employees, reduces workers compensation claims, and maintains employee safety, morale and productivity.
DNO Peshkabir Site adheres to DNO policies and safety standards which get their fundamental content from international regulation and standards, such as OSHA, NEBOSH, and C155. For instance, in all DNO assets, basic PPE has been provided to DNO employees for free. An appropriate range of sizes, quantities, and types of PPE are always available for DNO employees. Also, basic welfare facilities are provided to Peshkabir employees to support their daily needs such as resting and sleeping accommodation, hygienic mess facilities and adequate supplies of fresh drinking water as well other facilities such as toilet and showers to ensure their comfort and well-being.
Also, DNO Peshkabir Site is following the Governmental law as well. For instance, any person who has been authorized to drive in DNO facilities need to have an appropriate government approved driving license and drive in country speed limit. Prior to giving them the authorization to drive on the site, the Peshkabir HSE Advisor will further assess them and confirm and copy their legal documents then issue them a DNO Peshkabir Driving Badge which indicates they can drive DNO vehicles.
DNO Peshkabir site also follows other international standards such as ACGIH(Association Advancing Occupational and Environmental Health) standards. For instance, the ACGIH standard for hydrogen sul?de based on an eight-hour time-weighted average (TWA) exposure limit is a concentration of 10 parts per million and the 15minute short-term exposure limit (STEL) was 15 ppm. To be able to implement this standard in Peshkabir CPF, DNO is doing regular H2S test every two hours by using multiple gas detector and record the result. Hence, DNO does not have fixed H2S detector which is more reliable to detect and alert people in case of an H2S gas release.
The main aim of HSE Management is to ensure the wellbeing of the workforce, and that there is no harm to environment or damage to the asset but a key consideration alongside that is to reduce the company’s risk of litigation. This is achieved by making sure the company complies with relevant regulations and policies. The good examples of safe practice are highlighted and used as benchmarks for other sites that need improvement in this domain.
2.6. Risk profile
Risk profiling is an integrated and systematic approach to risk management which should provide organizations with a clear picture of all present risks elements of its operations, the effectiveness of the control measures in place to eliminate or minimize the risks.
Every organization may have a specific risk profile based on their size, sector or the employee profile. In some organizations, the risk profile will consist of genuine and instant safety hazards, while in others the risks may be long-term health-related risks. In general, in oil and gas industry both acute and chronic hazards are very common.
Overall, a risk profile must contain;
• The major or strategic operational health and safety risk for the organization
• The likeliness, nature, and level of adverse effect may arise from identify risks
• Identification of who or what will be affected from potential risks
• Identification of effectiveness of current control measure in place and any other control measures which are not in place yet
The outcome of risk profiling must present the actual risks have been identified and prioritized for action and the minor risks simply noted to be kept under review for further consideration.
To be able to form a risk profile for DNO Peshkabir Site we need to consider a variety of risks and a wide range of control measures as it is producing and transporting 48 kbopd of crude oil. The crude processing, storage, and export facilities present a high level of potential risk from possible hydrocarbon loss of containment events. The facilities have been in continuous operation for more than one year without any major accident reported.
The Oil process in the Peshkabir CPF first stage separator (Cretaceous separator) contains a high volume of H2S (mole12%) and high volume of GOR(gas and oil ratio). Hydrogen sulfide is a profoundly flammable, toxic and corrosive gas, for this reason, any potential exposure at anything below very low levels could be life-threatening if appropriate control measures are not in place. Apart from a toxic gas such as H2S, there are high concentration of flammable (LEL) gases which could ignite and burn or explode. In general, the main risk at the Peshkabir CPF and Loading station are:
• Potential jet fire or pool fire from crude oil or explosive gases if ignition source introduced
• Potential for storage tank top fire/bund fire or vapor cloud explosion if ignition source introduced
• Toxic gas dispersion following unplanned release and exposure of personnel to high volume, potentially fatal, levels of H2S
• Environmental damage due to crude oil spillage
• Chronic hearing loss due to prolonged exposure to excessive sound from equipment and generators.
• Potential vehicle collision/accident due to inappropriate access/egress arrangements and heavy vehicle movement
We are going to analyze each of these risks in detail and identify the perceived gaps in control and the areas for potential improvement. As the likelihood of adverse effects occurring and the level of potential consequence is very high as the location of occupied buildings are inappropriate, thus leading to increased levels of exposure to site staff, and the system of flaring gases is poorly designed and managed and there is a general lack of control measures in Peshkabir. We can analyze these issues in detail within the subsection summaries below;
2.6.1. Lack of Toxic Gas Detection
Lack of systematic Toxic gas detection at the CPF is a major concern, as there is no continuous fixed monitoring system currently configured for confirmed gas detection (H2S), reliance being solely on multiple gas monitors, which, in a tiered detection system are usually last level control (fixed; portable; personal)
Other major hazards of toxic gas identified include;
• Storage Tank volatile hydrocarbon containing H2S is discharged through cold vent could potentially, through dispersion reach the CPF control room. The CPF control room, which is very close to the cold vent, is open and there have been instances of low-level toxic gas presence detected in poor weather conditions.
• No Fire & H2S gas detectors located in the loading areas of CPF where the loading operator and truck drivers are constantly present. If off-spec product or product with higher H2S mole% is being loaded, there is potential for toxic gas exposure to operators.

2.6.2. Lack of Fire / Flammable Gas Detection Systems
In case of flammable hydrocarbon release leading to fire (if ignited), there is no automatic mechanism in the CPF/Loading Station that will detect the flammable gas or flame/fire, other than operators at the field who could spot and activate MAC, which will alarm shut down the plant. This sole reliance of human intervention is not felt adequate in terms of the potential risk.
2.6.3. Incomplete Fire Fighting Systems
The firewater network is incomplete in Peshkabir. No foam pourers or water spray facility are in place on the storage tank to extinguish any conflagration in case of a tank top fire. No cooling of nearby tank/hydrocarbon equipment is considered at the moment, and this gives a potential for escalation. The existing water monitors provided per tank are not capable of extinguishing a tank top fire or bund fire without supplementary foam suppression systems in support. The ERT complement comprises no trained / competent personnel or equipment and resources available at the plant to fight fire in a major incident.
2.6.4. Location of Occupied Buildings
According to the analysis, most losses of containment events were classified as MAH due to the fact that the severity rating of a hydrocarbon containing H2S release has been identified as 4 or above (more than one fatality / major injury) on the BU RAM matrix. The severity rating is higher because the proximity of occupied buildings in the plant which buildings are too close to the process operating units. The CPF control rooms are open in nature, have no electrical circuit integrity maintained (ignition source), no HVAC system to prevent gas ingress, and are located in the middle of the plant and thus, due to these factors are at high risk of toxic gas ingress and fire in the event of any significant release.
2.6.5. Inappropriate Flaring
The current CPF flare is a ground flare and toxic gas will not disperse high up in the air. Therefore, in the event of any flaring failure and gas release, the high relative density of H2S gives the potential for higher concentrations forming around occupied buildings in CPF. In addition to the CPF flares, there is the Cold vent for storage tanks A, B, C and D in Peshkabir which are also located very close to CPF control rooms. This fact significantly increases the potential for exposing the CPF occupants to H2S in the event of any unplanned release.
It is therefore recommended to optimize flaring operations in Peshkabir with a single high capacity HP flare which could cater for all needs for HP (high pressure) / LP flaring in Peshkabir. According to this study, a properly designed HP flare correctly and remotely located will decrease the current detectable H2S concentrations at the CPF to an acceptable level and significantly reduce the potential for personnel exposure.
2.6.6. Access and Egress
Access to CPF/EPF plant facilities, segregated Roads and Pathways and barriers for vehicles and operator movement inside the plant are not maintained. This might lead to a potential vehicle on vehicle collision or vehicle/pedestrian incident. In the case of fatal accident, the company will be faced with enforcement actions and potential prosecution, as it is a clear breach of legislation and law, such as ILO C167 – Safety and Health in Construction Convention, 1988 article 13, which states that “safe means of access to and egress from all workplaces shall be provided and maintained.”
The risks that arise from these hazards can be controlled by:
• Construction of segregated routes of access for pedestrian and vehicles.
• Provision of designated pedestrian crossing points
• Installation of proper traffic signs and imposition of speed limits
• Provision information and instruction for all site personnel in regard to the above controls and close supervision to ensure these controls are adhered to.

2.7. SUMMARY OF SECTION TWO
Most of these issues have been identified through a variety of internal studies within the organization, such as level two risk assessment and major accident hazard analysis(MAH) but the mitigation recommended for same has yet to be implemented. During our studies on risk assessment and MAH, it was noted that although these procedures included the identification of persons affected (P.E.A.R), this exercise did not make any specific consideration for vulnerable people such as, pregnant women, young people or the disabled, whilst this is unlikely it is not impossible and so any design should make allowance for what is felt to be a credible circumstance.
The critical health and safety risks such as explosions and fires, exposure to H2S, high-pressure line failure, falls from height and vehicle collision was included in the overall business risk management of the organization even where no site-specific controls were subsequently put in place to mitigate for same.
the role of Peshkabir health and safety practitioner in Peshkabir site’ risk management and profiling is crucial. He is profiling and assessing risks and organizing activities to implement the plans. He is the part of risk assessment team when the company needs risk assessed for any specific job or activity. Also, he is the authority who can assess and approve any risk assessment, lifting plan or method stamen when a third-party company applies permit to commence job in DNO Peshkabir site.

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SECTION III
EVALUATION OF IMPROVEMENTS REQUIRED

In this section, we will determine the top three improvements that potentially could make the most substantial impact on improving health and safety performance of Peshkabir Site. We will explain in detail how each targeted improvement would be achieved.
3.1. LEADERSHIP
Based on our assessment and research, the biggest hindrance to Peshkabir health and safety improvement is poor leadership. As we mentioned in a previous section of this study, there is a strong relationship between effective leadership and a company’s safety performance. The way senior management lead their team on health and safety will play a large part in determining how safe their site is to work on. The number of accidents, incidents and ill-health cases that happen can, in many cases, be directly related to the ineffectiveness or poor safety leadership that may be present in an organization.
Moreover, leadership has an effect on all other 5 core elements which we previously analyzed in the ‘review and critical analysis’ section above. So, it follows, in the opinion of the authors, that if you have good leaders and leadership it will have a positive effect on all health and safety systems and the safety culture, morale, and motivation of the workforce.
As we mentioned in our study previously, DNO senior management (Dubai and Oslo) require under company policy to visit Peshkabir site once a quarter every year. But in fact, most of the management visit the Peshkabir site only once a year and some did not visit the site at all. During their visit, they should be aware of the need to listen to site management and employee problems and, where necessary, take these problems to top management in turn, in order that they are seen to be addressed and proper and adequate resources are allowed to support this process. Unfortunately, most senior management when they are visiting Peshkabir site usually interact with the Site Superintendent and his senior personnel and do not spend enough time with other departments or employees such as team leader and operators so they do not provide the general workforce an opportunity to air their problems and concerns.
As we stated previously, some senior managers do not set a good example during their visits, for instance, they do not follow basic site rules, such as PPE, T-card or facial hair policy during their site visit. Most of them don’t contribute to the company’s SAFE card program initiative. They can be overly critical of the current production or the perceived safety status of the site and only focus on negative aspects instead of providing recognition and encouragement to site management, and the workforce in general, for their positive actions and advice for more improvement.
We already mentioned that overall, site management follows all basic site rules and try to set an example, but examples of poor leadership became apparent when the site management or senior management required to give critical decision to either stop an unsafe production operation or write a deviation report and continue the operation under unsafe condition. Most of the time the potential loss of production will weigh his decision-making process and he will, in most instances, allow production to continue whilst a solution to the safety issue is sought. For instance, there is no intrinsically safe lighting pole or electricity distribution panel inside of Peshkabir CPF when they commission it. It has been highlighted by site HSE Advisor but the site management liaised with senior management decide to continue and commission CPF with normal lighting pole and electricity distribution panel.
In the opinion of the authors, to improve effective leadership, first of all, DNO need to identify the areas of poor leadership on the Peshkabir site. This is best achieved through the appointment of a third party management consultant, or, alternatively by appointing an internal committee to assess the level of leadership in DNO Peshkabir Site. The committee or third-party consultants brief will include interviewing people from different departments encompassing all levels of the employee from top management to “shop-floor” worker. They will analyze company statistics, metrics and document to identify trends, such as illness, incidents by type and category, mechanical failures etc. After they identify the perceived core problems and their potential relationship to poor leadership then they will be charged to work with management to develop a training needs matrix encompassing all levels of the company operating structure. The principal aim of the training will be to stress the importance of effective leadership and set out the techniques and principals required for good leadership. After they complete the scope of training, then there will be a requirement for commitment by management to ensure that all those identified as requiring training receive the necessary support and time away from the workplace to complete this training. This display of commitment in itself will go a long way to confirming management buy in to the improvement process.
Part of the rollout of this safety improvement and employee investment process will require arrangements to be made by management and their chosen site representatives to run a campaign to distribute the message and raise awareness of the initiative in Peshkabir site and across DNO. The team will need to nominate different awards for good leaders and encourage and recognize good leadership practices.
After a suitable period of time, the third-party consultant or committee will be invited to revisit and assess any improvement in terms of effective leadership and to further identify does this improvement have a positive effect on company health and safety performance. To track and communicate any identified improvements more systematically, the committee or 3rd party representative will be requested to repeat this review process on an annual basis and to prepare a report of findings for company-wide distribution. Also, at the end of each year areas where recordable improvements have been achieved will be shared with all DNO crew by means of a workshop presented in Peshkabir site conference room by senior management representatives.
This process will require a lot of effort and there will be both direct and indirect costs. The possible estimated direct cost of hiring a 3rd party company or gathering internal committee and delivering required leadership training will be 19,000$ for annually. Other possible direct costs such as stationary, transportation, and awards will be around 4,000$ for two years’ time. The indirect cost will be non-productive time. The non-productive time for managers will be 5% of their yearly working time. For normal workers will be 2% of their yearly working time.
3.2. LACK OF REQUIRED COMPETENCIES AMONGST EXISTING WORKFORCE AND POTENTIAL EMPLOYEES
As we discussed in section two previously, to create a strong and effective health and safety management system you need to have competent members at every level of the organization’s workforce. This fact has been stated by The Management of Health and Safety at Work Regulations 1999. According to this regulation, an employer needs to appoint one or more competent people to help them implement the measures they need to take to comply with the legal requirements.
As we have stated before, the most of Senior DNO management and DNO Peshkabir management team consist of competent people in their profession who has the high-level qualification and longtime experience in their current position. however, the team which is performing the daily work activities such as operators, team leaders or 3rd party contractors do not always have the same level of competency. For instance, none of DNO or 3rd party electric & instrument technician has international high voltage certification to commence work on high voltages devices. Moreover, the most of DNO Peshkabir ERT members don’t have appropriate first aid or firefighting training, or appropriate language ability. Addition to this, none of the contractor’s personnel has appropriate training/knowledge and language ability to complete any sort of risk assessment or follow up permit to work system in an appropriate way.
Most of difficulties and shortages we identified to show that there are several skills gaps within DNO Peshkabir field crew in term of required competency. To figure out this problem DNO Peshkabir management need to invest in improving the skills, ability, and competency of Peshkabir employees overall. To be able to raise the competency level of Peshkabir employees, first of all, DNO Peshkabir site need to appoint a suitably qualified team from their internal staff to analyse the current level of competency across the DNO Peshkabir crew either through placement tests or interview, training record review or observation in the workplace. Then, this committee will identify the training needs for each individual based on their roles and responsibilities.
Finally, a dedicated training coordinator requires being appointed to the Peshkabir Site in order to prepare and coordinate the training packages. The training coordinator will manage the schedule for each employee who requires training and will maintain both records and certifications and the company training matrix.
The initial challenge, unique to the training environment in Peshkabir and KRG in general, is the need for all employees to go through a language competence test then if required they may need to go through language training to achieve a level of comprehension to allow them to complete further skills specific training such as, leadership, firefighting, chemical handling, first aid, high voltage, H2S awareness, defensive driving etc.
From our studies and interviews with Peshkabir management and crew, the time scale for improvement should be targeted over a period of four years to close the gap and get all Peshkabir staff through required training and get them to the desired level of competency.
The First year the focus will be on appointing the team, identifying the training needs and getting the first employees through language training, on a prioritized basis, in order to upgrade their English speaking and comprehension skills. In the second year, following the establishment of communication and comprehension capabilities, the appointed training coordinator will be able start getting people through some basic training such as Safety Golden Rule, Permit to Work System, Personal Protective Equipment, H2S awareness training, SCBA usage training, Defensive Driving training. Then in the 3rd year, it will be possible to start more advanced training such as Process Operations training, Fire Fighting training, Risk Assessment training, first aid training. In the 4th year key personnel, having completed all foundation level training will go through more task-specific training such as Instrumentation & Control, High Voltage, and Gas Processing Training.
The site superintendent will be responsible for implementing the program in liaison with the training coordinator. The financial resource will require being allocated from Norway and Dubai. The cost of in-house training is estimated to be around 7,000$ per year for the first and second years. The Cost of external training such as Instrumentation & Control, high voltage and gas processing will be around 75,000$. External training will be only provided to the supervisor, team leader, and senior operator level. The benefit of delivering all these training courses to DNO Peskabir staff will be the creation of a skilled, competent and safety conscious workforce. As a result, it should improve the production and HSE performance of DNO Peshkabir site. Such an investment in personnel will also ultimately improve the Peshkabir HSE Key Performance Indicators. The company should see a significant decrease in the recording of unsafe acts, incidents, and ill-health while the number of safe acts and condition observed should increase correspondingly.
The effectiveness of the improvements will be measured, monitored by training coordinator and competency improvement committee and the improvement report will be distributed to site superintend and senior management by training coordinator on a monthly basis.
3.3. TOXIC GAS; POTENTIAL FOR EXPOSURE
DNO Peshkabir Central Process Facility is producing and transporting 48 kbopd of crude oil. Peshkabir crude oil contains a high volume of H2S (mole12%) before treatment. Hydrogen sulfide will be a profoundly flammable, hazardous gas, furthermore, could reason could be allowed life-undermining circumstances If appropriate control measures are not in place. This concentration of H2S (mole12%) can cause instant death of people. Therefore we can consider H2S as the major threat and the consequences associated possess high risk to plant personnel.
As we mentioned in our study previously, the potential for exposure to personnel in the event of an unplanned release is unacceptable based on current arrangements as the Location of Occupied buildings are inappropriate and vulnerable, and there is a lack of automatic toxic gas detection over and above the most basic personal detection for workers.
3.3.1. Location of Occupied Buildings
The CPF control rooms are open in nature, no electrical circuit integrity maintained (ignition source), no HVAC system to prevent gas ingress, and are located in the middle of the plant possess high risk of toxic gas ingress and fire impact. In addition, Storage Tank volatile hydrocarbon containing H2S is discharged through cold vent reaches CPF control room. The CPF control room, which is very close to the cold vent, is open and experiences toxic gas presence in worst weather conditions.
Therefor, the location of control room needs to be changed and it needs to be installed into a safe zone according to site H2S /gas disruption model.

3.3.2. Lack of Toxic Gas Detection System
With the relocation of the Control Room and associated offices, the potential for exposure to toxic gas in the event of a release will be fully mitigated based on dispersion pattern modeling. But still, the personnel operate the CPF will be in danger and they might expose to high-level H2S as there is no appropriate arrangement in place to detect H2S release and alert people to react accordingly.
Lack of Redundancy of Toxic gas detection at the CPF is a major concern, as no automatic action is currently configured for confirmed gas detection. Moreover, no fixed wireless H2S gas detectors located in the CPF and CPF loading station area where operators are constantly present. If an off-spec product or product with higher H2S mole% is being loaded, a potential for toxic gas exposure to operators and it may result in fatality if it did not handle in an appropriate way. Therefor installation of automatic, fixed, wireless H2S gas detection sensors will facilitate early recognition of hazard and raising an emergency alarm and alert people to act accordingly and protect them self from H2S exposure by using SCBA or other types of emergency escape sets.
3.3.3. Financial Justification
The estimates cost and benefit analysis for relocating the CPF control room and installation of automatic fixed wireless H2S sensors will require a specific study by DNO Peshkabir facility construction team and it is hoped that part of these mitigation costs can be absorbed into a planned expansion of the facility. However, as a result of our initial investigation, and for the purposes of this report as per current arrangements, and following our liaison and discussions with the facility construction manager, the estimated costs for these modifications are indicated in the cost-benefit tables below.

Financial justification/cost benefit table
Item Cost Payback/Benefit Person Responsible /Action by Duration Target Date
Re-location of CPF Control Room The total direct and indirect cost will be around 23,500$. This cost will include ground preparation, sub-base, electricity, transportation, technological update, fiber-optic cable, new sensor and transmitters, water supply and septic drainage system. In addition, there will be cost, such as shut-down the CPF for 8hrs the day transferring and installing PLC(programmable logic control) which cost 48,000$. It means total implementation cost will be 71,500$ The benefit of this corrective action will isolate people from danger zone. Avoid any catastrophic incident such as fatality due to exposing high H2S. According to DNO policy in case of fatality, all the work activity will be seized in the location that incident happen until initial investigation completed. (which may take 3-5 days) The production lose for 3-5 days will be around 5day x 48000bbl x 50$ = 12,000,000$. In addition we will non-monetary benefits such as, avoid loss time and non-productive time, demoralize Peshkabir workers, and damaging company reputation. Production Manager/ Field superintendent/ Facility Construction Manager / HSE Advisor / BU Construction Department 3 months 05.09.2018
Installation of 10 Wireless H2S gas detector and connecting them with CPF control room The total direct cost of installing 1 fixed wireless H2S gas detector will be around 2,500$ and we need to install 10 of them to the critical area in CPF. In addition, we need a control panel and alarm system which cost 11,000. Total cost will be around 38,000$. This cost will include buying materials(gas detectors and a wireless transceiver, control panel) and installation process by DNO CPF maintenance team. Additionally, they need to be calibrated on monthly basis, the cost of calibration device is 1,200$. The total implementation cost for this operation will be 39,200$. The installation of the wireless H2S gas detector will facilitate early recognition of H2S and raise an emergency alarm and alert people to act accordingly and protect them self from H2S exposure by using SCBA or other types of emergency escape sets. In case of high concentration H2S release if you do not have appropriate recognition and alarms system people will not be aware of the danger and it might result with fatality. As we mentioned previously, in case of any fatality or high-potential incident the whole CPF will be shut-down until initial investigation completed. As we calculate in previously, the company will lose 12,000,000$ due to shut down. In addition, they will be more cost such as loss time, compensation to victim family, non-productive time, demoralize Peshkabir workers, and damaging company reputation. Production Manager/ Field superintendent/ Facility Construction Manager / HSE Advisor / BU Construction Department -For ordering/ receiving equipment (3 months)
-For installation and calibration(7 days) 13.09.2018
The Work Order for this project will be raised by site superintendent and detail design will be done by facility engineers. The work will be commencing under the authority of facility construction manager. The resource/cost for these modifications will be allocated by Dubai Business Unit through facility construction department.?
SECTION IV
CONCLUSION AND RECOMMENDATIONS

4.1. CONCLUSION AND RECOMMENDATIONS
The main purpose of this study was to carry out a review of the arrangements for managing health and safety in DNO Peshkabir Site comprising the Loading Station and Centralized Process Facility(CPF). Within section two of the study, we carried out an evaluation of the Peshkabir Management System under six core element (leadership, management, competency, etc. ) and identified ‘where is the Peshkabir site now’ in term of health and safety performance. Based on the result of assessment and gap analysis of perceived weaknesses and shortcomings in current procedures, we then produced a series of justified, proportionate recommendations to improve health and safety performance in DNO Peshkabir H&SMS.
We thereafter analyzed in greater depth the top three perceived areas for attention in detail in order to determine the top three improvements that could make the most positive impact on the potential improvement of health and safety performance at Peshkabir site. These three areas that we identified for improvement were; leadership, lack of required competencies amongst existing workforce and lack of control measure in term of exposing to toxic gases.
As we mentioned in the previous section of this study, there are variety of visible examples of poor leadership within DNO senior management and Peshkabir management team. It is obvious that there is strong relationship between effective leadership and company’s safety performance. The way senior management led their team on health and safety substantially affect how safe their site is to work on. The number of accidents, incidents and ill-health cases that happen are directly related the effective or poor safety leadership that you have in organization.
Therefore, we have recommended;
• Identify the areas of poor leadership on the Peshkabir site
• Identify training need for incompetent leaders
• Appointment of a third party management consultant, or, alternatively by appointing an internal committee to assess the level of leadership in the DNO Peshkabir Site
• Develop a training needs matrix encompassing all levels of the company operating structure
• Requiring training receive the necessary support and time away from the workplace to complete this training
• Run a campaign to distribute the message and raise awareness of the initiative in Peshkabir site and across DNO
We have analyzed in detail the function of competent employee profile in effective health and safety management system. We have state that, most of DNO Peshkabir management member were competent in term of adequate qualification and experience but still they present some aspect of poor leadership. The profile of other employees, such as team leaders, operators, electrical and instrument technician were very low in term of competency. So accordingly we give several recommendations to rectify this gap and ensure all Peshkabir occupant and visitors were working in a safe working environment. These recommendations were:
• appoint a suitably qualified team from their internal staff to analyse the current level of competency across the DNO Peshkabir crew identify the training need for each individual
• identify the training needs for each individual based on their roles and responsibilities.
• Hire a dedicated training coordinator for Peshkabir site in order to prepare and coordinate the training packages
• all employees to go through a language competence test then if required they may need to go through language training to achieve a level of comprehension to allow them to complete further skills specific training
• Then they will be able to attend other training which will be more task-specific, such as, leadership, fire fighting, chemical handling, first aid, high voltage, H2S awareness, defensive driving, oil and gas processing etc.
Moreover, we have analyzed the risk profile of Pehkabir field and we identify numerous risk and suggest for control measures need to be in place. More specifically we analyze the lack of control measure in term of exposing to toxic gases in section two of this study. As we state, there is an inappropriate arrangement in term of gas detection and dispersion which create serious risk of exposing to high concentration of H2S for Peshkabir occupant and visitors. The main deficiency in term of controlling H2S dispersion was the location of CPF control room is very close to the H2S source which we classify as zone one and there is no any sort of fixed H2S sensor in Peshkabir CPF which detect the hazard and alert people to take preventive remedial action. So, any sort of H2S gas leak may result with fatality with current control measure in place.
To be able to have better control we recommend to;
• Change the location of CPF control room from zone one(toxic zone) and installed in to a safe zone(non-hazardous zone) based on Peshkabir CPF site H2S /gas disruption model.
• Installation of ten fixed wireless H2S sensors to the critical location at CPF which will facilitate early recognition of hazard and be raising an emergency alarm and alert people to act accordingly and protect them self from H2S exposure by donning emergency escape sets and move from danger zone to a safe assembly location.
In final summary, as this study has identified and listed, there are various perceived gaps in the DNO Peshkabir health and safety management system. As noted above, these gaps encompass leadership style, safety culture, human factors and engineering controls and so there is a need for a concentrated commitment from management to review and commit resources to action all these recommendations on a prioritized basis. Such a commitment will send a message to the workforce in general and will see an improved and safer workplace for all DNO Peshkabir personnel. At a corporate level, these improvements, once in place, will also be mitigation against any legal, economic or moral consequence as a result of a major incident being realized at the site.
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APPENDICES