Our lessons-learned process

We are continuously seeking room for improvement in our research. Here are a few examples:

• We create workshops and assemble operational learning teams, which get critical areas involved in the work of reflecting on processes and tasks. 
• We work from our industrial complexes to find lessons in our standard operations to analyze possible areas for improvement in in a preventive way through dynamics and cause analysis tools, even involving the operators' own shifts. 
• Through the CCPS (Center for Chemical Process Safety) we're working on a project on "Lessons Learned Years Later" which will help both us and other companies in our sector to learn from studying past incidents. 
• IPSG (International Process Safety Group): this is a forum for sharing information about incidents and exchanging knowledge, experiences, techniques, procedures, and special design characteristics — all with the goal of preventing serious accidents.

Our lessons learned can be shared in different ways:

• By creating reflexion and discussion spaces, which could include our internal software tool for incident management, internal forums, or collaborative communities between different industrial plants.
• Through videos that highlight learning-focused actions and best practices put into place.

Once our lessons have reached their targets, the managers of the business, area, or facility in question must identify preventative action plans. For learning to take place, it is vital to ensure that the actions defined can be implemented as quickly as possible and that both their effectiveness and the learning process itself are assessed regularly, e.g.:

• Our incident management software tool Synergi has a lessons learned module that is used by some of our business and besides, actions can be registered for follow-up. 
• The Industrial area is working on building a process that allows to speed up the incorporation of the good practices identified in the Communities of Practice and areas of collaboration in our operational processes, through the figure of the senior technical advisor, who with a global vision and the reputation of his expertise has the capabilities and recognition to ensure the agility, quality and cross-company coverage of this process.

In our lessons learned process, lessons are captured and prioritized according to the interest group that applies. From there, specific actions, including the effectiveness of each, are proposed for the related centers or activities.

Upstream has created a series of videos to accompany the dissemination of the lessons learned with the aim of sharing everything learned in the past five years, including those lessons that reinforce our basic safety rules.

All the videos contain of a description of the lesson and a section with actions derived from it, for example: *Falling objects: on a sliding drilling rig, the side panel of one of the hydraulic jacks was dislodged. The lesson is available on the database and has been shared with operators and contractors globally and has been checked locally at similar facilities.

Lessons acquired from this event that apply to all business units in Exploration and Production:

• Ensure that preventative maintenance and inspection routines are based on equipment failure modes and that these are well understood with their associated risks. Be especially conscious of those fixed structural elements that are only subject to inspection but which are critical for the correct operation of the equipment.
• Ensure that user manuals and training material are made available and that they include a clear description for the operation of the equipment. This will help the equipment's operator to better understand the risks contained therein.
• Identify and be conscious of the limitations and design loads for all equipment. Make sure that this is taken into consideration in all operational procedures.
• Ensure that the equipment design does not put the operator in danger in any failure mode.

In Downstream, we also apply lessons learned throughout the years. We believe that it is necessary to continue encouraging a culture of transparency that incentivizes communication, consideration for human factors in accidents, and the improvement of mechanisms for implementing improvement actions.

One example of a lesson learned came from the breaking of a purge valve on the body of a pump in the industrial area. Lessons acquired from this event were applied as actions in all centers of Downstream:

• Verify that the material of supplied accessories is of equal or greater quality to the material of the pump casing requested in the purchase order.
• Verify that all documentation (in the various stages of selection, supply, and assembly) reflect those qualities.
• Verify that all existing pumps in the plant do not show signs of corrosion due to the quality of already installed material.
• In maintenance operations on the pump or its accessories, report material failures for their analysis and correction.