Question: Discuss the actions, decisions and strategies that were carried out by Stardust to ensure the success of introducing the Living Safety culture. (20 markah)

note: please can you make at least 2 full page of word for the questions. as they carry 20 marks. that will be very helpful.

Stardust Petroleum Sendirian Berhad: How to inculcate the pro-active safety culture? Coming together is a beginning; keeping together is progress; working together is success. - Henry Ford The beginning Stardust was established in 2013 as a subsidiary of Petronas Carigali Sendirian Berhad (subsequently referred to as PCSB) to manage a small, marginal field in Malaysia located under a larger oil and gas field with a reservoir that had expected productivity of four to five years. In the middle of 2014, Stardust was given the opportunity to take over the management of a field located at Anjung Kecil (AJK) to provide support for PCSB and to operate and maintain a newly installed facility. However, in October 2014, during the process of handing over the facility and field from PCSB to Stardust, one of the pumps in the pump room in the tanker caught fire and there was substantial damage as a consequence, including two out of four pumps being completely destroyed. The fire delayed the oil production for more than a month and the total estimated damage caused by the fire incurred was a loss of RM19m and included replacing two new 400 kw pumps, repairing the damaged pump room, including new manifolds and paint, and production shutdown for 40 days. At the end of 2014, investigations were initiated by the field owner and the review team to investigate the causes of the fire. The investigations results revealed that human error, specifically negligence, was one of the major reasons for the fire, along with location, position, equipment and procedure, Kevin Collins, the CEO of Stardust, assigned the task of creating a "Living Safety culture to Tarmizi, the Senior Manager of the Health, Safety and Environment (HSE) Department. Tarmizi found it very challenging to inculcate the "Living Safety' culture with zero failure by the December 2015 deadline given by Collins. Tarmizi came up with a slogan to reflect the safety culture: "Action Today, Perfect Day Tomorrow". He believed bringing zero failure could be possible if all employees and crews were to embrace the safety culture in their daily activities. "Action Today' was created to raise awareness about adopting the "Living Safety culture and practicing it in everyday activities, whereas "Perfect Day Tomorrow was meant to focus on the ultimate outcome (ie. zero failure) by adopting this culture. However, Tarmizi faced some resistance to this safety culture from the marine crews. This resistance was apparent from the conversation between Captain Billy, the marine crew leader, Razman, Operation Supervisor, and Tarmizi. Their conversation went as follows: Tarmizi said: "Captain Billy, in order to bring the safely culture, we need to maintain the do's and don'ts that is stated in this new rule book. There are seven major clauses that we need to strictly follow. Such as no drugs, no alcohol consumption, no smoking. Before he finished his sentence, Captain Billy objected: "understand your concern, but do you think that it would be necessary to be so strict in every aspect?" Mr Tarmizi replied: "Oh yes. Otherwise, se, we can't assure zero hazards." Mr Razman interfered the conversation: "I agree with captain Billy. It won't be so easy to make all staff follow the way it is. They are not used to that in this culture." Mr Tarmizi became bit impatient: "I know that it is not an easy task to do. But no matter what we need to do it." Time was running out fast and PCSB management had emphasized that the situation had to be dealt with urgently to ensure that a similar incident would not happen in the future. If such a thing was to re- occur, it would jeopardize the trustworthy reputation of Stardust. In addition, PCSB might not allow Stardust to operate other facilities, which would put the company at risk when it came to it remaining competitive within the oil and gas industry. Malaysian petroleum industry In Malaysia, Petronas was one of the major players in the petroleum industry and generated MR131.4bn in gross national income during 2013 (Bantillo, 2013). Prior to 1975, petroleum concessions had been granted by the state government where oil companies had exclusive rights to explore and produce resources and the companies would pay tax and royalties to the government. On April 1, 1975, when the Petroleum Development Act was published, Petronas was given rights as a custodian of any petroleum resources found in Malaysia, both on land and at sea. Petronas retained the ownership and management control of resource expenditure and profits were managed under an instrument called a product sharing contract (PSC). In 2014, Malaysia produced about 648,000 barrels of oil per day (bopd) (Isa and Zainul, 2016). It also produced about 5.7 billion cubic meters of gas per day, which made Malaysia the 14th largest gas producer in the world. A total of 494,183 square kilometers of acreage was available and consisted of 54 blocks. This included 337,167 square kilometers located offshore including the continental shelf. The other 63,968 square kilometers were located in the deep-water area of Sabah. "Deep water" is where oil and gas activity start to take place at deep sea, normally more than 1,200 m in depth whereas "shallow water could range from 50 to 300 m deep. From those 54 blocks, Petronas Carigali operated 28 blocks and other multinational companies operated another seven blocks. All this activity contributed about 20 per cent of Malaysia's GDP Petronas Carigali Sendirian Berhad Petronas Carigali Sendirian Berhad (PCSB) was one of the key subsidiaries of Petroliam Nasional Berhad (Petronas). It was engaged in oil and gas exploration and production services and also offered oil and gas well drilling, as well as engineering, constructing and commissioning natural gas pipelines and associated facilities. The company was incorporated in 1978 and based in Kuala Lumpur, Malaysia (Bloomberg, 2017) PCSB mainly focused on larger fields (bigger reservoirs) which had longer production ranges. Small and marginal fields were characterized by fields that contained hydrocarbon with less than 30 million barrels of recoverable oil. The main objective of Petronas was to attract the small and marginal field players to invest in Malaysia and assist in developing the expertise of the local players (Jaipuriyar, 2016). For the investors, the Malaysian government allowed incentives that would reduce taxes between 25 to 38 per cent. The aim was to increase overall oil production in Malaysia to 55,500 bpd of oil by 2020. This required RM13.3 billion and was expected to contribute up to RM5.5 billion per year to the country's GDP (WorldVest Asia Pacific Sdn. Bhd, 2016). In Malaysia, a total of 106 marginal fields that reserved about 580 million barrels of oil were still untapped and it had been estimated that within 15 to 18 years, Malaysia would be out of oil if these marginal fields were not developed Stardust Petroleum Sendirian Berhad Stardust Petroleum Sendirian. Berhad (subsequently referred to as Stardust) employed about 70 permanent and contract staff and its Chief Executive Officer (CEO) was Kevin Collins, a Manchester University graduate. In addition to the CEO, Stardust also appointed one legal counsellor, one secretary and six general managers. The main organization chart of Stardust is shown in Exhibit 1. Stardust's core activity was to bring oil out from underneath the seabed and store it in a floating storage facility before it became the final product . A floating storage vessel was installed at the site to store crude oil and to serve as the workers' accommodation. Once the storage reached 90 per cent of its storage capacity, the crude oil would be transferred to other export tanker vessels (off-take tanker). There were 23 mariners who served as contractors for Stardust that had to follow instructions given from the top- down before carrying out any assigned activity. The marine department usually followed a rigid and fixed organizational structure where rules and regulations were standardized, decision-making processes were centralized formality was maintained and hierarchy of power was very clear. This structure was reflected in the vertical communication system, where employees were not able to make decisions unless they received permission from their direct manager. Marine crews made up roughly 76 per cent of crews (23/31) and other crew members were operations/production staff, about 24 per cent of the total number of crews. As marine crews were the majority, they tended to dominate the work culture while Stardust's employees were more flexible in their approach to work in comparison. Work was decentralized and staff were receptive to any suggestions that could improve the work quality. In Stardust, the CEO emphasized being productive, creative and innovative instead of following a rigid structure. The field located at Sarawak, Anjung Kecil Field (AJK), was roughly 200 kmnorthwest of Bintulu and consisted of a monopod well head platform" (WHP), the Tarpon field. There were 1,900 m of a 6-inch flexible hose on the seabed connecting Tarpon and a floating storage unit (FSU) to store the crude oil. Daily production of this facility was about 8,000 bb\day. The other field Tembikai, located about 120 km east of Kuala Terengganu. The field had similar arrangement with AJK but consisted of a three-legged unmanned platform that had a center processing plant (CPP) installed on it. The CPP was connected to a six-inch seabed-flexible hose to floating operating installation services (FOIS). The FOIS had capacity of storing about 220,000 bbl of oil that was similar to the FSU. As such, a maximum of 30-40 marine crews could be onboard and usually managed marine operations. Stardust established a Health, Safety and Environment (HSE) department to build the fundamentals and processes that would support the execution of the project and deliver it within the required timeframe. HSE's vision was to build "Living Safety as organizational safety culture by embracing self-safety personal values. "Living Safety" was about creating a proactive safety culture within the organization and preventing any incident, mishap, injury, environmental pollution, property damage, fire, explosion and unwanted events that could incur losses, such as loss of life, damage of property and environmental pollution. The logo "Living Safety" appeared at various locations where Stardust operated and embroidered on employees' uniforms to act as a reminder for the staff that "safety' was the company's core value To support the effort to instil the "Living Safety' concept, Stardust initiated a program called the Journey of Excellence". The program took place in every month and all employees participated to set out goals, build teamwork and make plans to understand how to deliver those goals. The primary motive behind the program was to create a clear mindset of everybody involved to mobilize a positive culture to be reflected daily in the spirit of team work, better communication, building a positive collaboration to deliver tasks and reflecting the 'Living Safety culture. Kevin Collins - the chief executive officer of Stardust Kevin Collins was 54 years old and had considerable industry experience in management, drilling, completion and field development activities. As a graduate in Chemical Engineering from Manchester University, he started his career in 1983 working for Conoco as a Drilling Engineer based in the UK. In 1990, he joined Texaco as the team leader for various drilling campaigns and then moved to Hess to lead the subsea completion effort on a major field development. Collins developed his leadership and business skills over 20 years by setting up and running a sub- surface consultancy business in the UK in 1993 that ultimately employed over 100 staff. In 2005, he headed to Malaysia to lead Petrofac's business there. Petrofac was one of the international service providers to oil and gas production and processing industry and, as a Country Manager for Petrofac Malaysia, Collins was responsible for all aspects of Petrofac's investment business and the in-country focal point for all Petrofac services businesses. He played a pivotal role in developing new business within Malaysia that allowed Petrofac to grow and develop considerably, as evidenced by the number of employees increasing from 15 in 2005 to over 1,700 by 2013 In October 2013, he was appointed as the CEO of Stardust and served as a member of the Board of Directors. After the accident in the AJK field, Collins thought the HSE department should take the responsibility to instill the "Living Safety' culture to avoid another accident in the future. He instructed Tarmizi to come up with a proper plan. Tarmizi the head of Health, Safety and Environment Department Tarmizi was 46 years old with 20 years of working experience in various industries. He started his career in 1995 as a Research Officer at the Malaysian Institute for Microelectronic System (MIMOS) after graduating from the University of Bradford (UK) in Chemical Engineering. At the end of 1996, MIMOS was corporatized and Tarmizi was assigned a role as a Gas Facility Engineer for a year for the newly- buit semiconductor research plant at the company's technology park in Malaysia and in charge of handling facility readiness, hook-up and commissioning of the gas systems. Later, he decided to change his career path and became a Safety and Health Engineer. At MIMOS, he had helped to take lead in developing the Safety and Health Systems and Procedures and this exposure helped him to extend his competency and experience. He left MIMOS on early 2000 after four fruitful years. He joined AMOCO Chemical (M) Sendirian Berhad in February 2000 and worked for about one year. AMOCO, ARCO and Castrol merged with British Petroleum (BP) before it changed its name to BP Chemicals (M) Sendirian Berhad. In 2008, the chemical industry was in turmoil when oil-based raw materials' price was skyrocketing which resulted in a lowering chemical demand in the global market. BP went through a significant restructuring and reduced their manpower. During this restructuring period Tarmizi left the company and joined Sarawak Shell Berhad as an HSE Adviser. At Shell (which was based in Miri), he was exposed to an upstream working environment. As an HSE Adviser, he was assigned to look at Asia-Pacific HSE competency management by monitoring their profiling to ensure critical positions were up-to-date with the required competency. Tarmizi served Shell for nearly three years before he decided to return to Peninsular Malaysia to work with Talisman Malaysia Limited (Talisman) in 2010 as HSE System and Assurance Team Leader. At Talisman, he was assigned to lead the implementation of the contractor HSE Management, Behavioral Based Safety, Performance Improvement and HSE Assurance and systems. At the same time, he was also assigned a role to support Talisman's regional leadership in enhancing process safety implementation and assurance. In 2012, he was offered the post to serve as the Regional Senior Specialist EHS at Hess Oil and Gas Sendirian Berhad to assist Thailand, Indonesia, Australia and Malaysia. He was assigned to lead the performance improvement initiatives for the region by enhancing safety performance through safety behavior and data management. Tarmizi also was assigned to lead the Operability Assurance Review (CAR) for the Sinphuhorm gas processing plant in Khon Kean, Thailand. Later on, he was offered the role of leading the department of Stardust owned by PCSB which was focused on small and marginal fields in Malaysia. In May 2014, Tarmizi was offered the Senior Manager post to lead the HSE department at Stardust. His task was to lead and set up the HSEQ wants and needs for the company and was assigned three large rapid projects to manage: Kapal's decommissioning, AJK's infil project and Berantai takeover. At the end of 2014, the CEO of Stardust suggested Tarmizi coach the crews in the company's "Living Safety' culture. He tried but found it very difficult to bring a change in the present culture. In the process of implementing the safety culture The field located at AJK was producing crude oil from two wells and the existing production rate per day could fill approximately 90 per cent of the overall tank's capacity within two to three weeks. The crude oil needed to be unloaded to other off-take tankers almost by two to three weeks rotation to meet the customer demand During the process of handing over the facility and field to Stardust, one of the crude oil pumps (COP#2) caught fire due to leakage of crude oil that was in contact with the nearby source of ignition. It caused significant damage to the pump room which resulted in a loss of RM19m. In November 2014, two investigations were initiated to understand the reason behind this accident one by the field owner and the other by Stardust's review team. It was meant for investigating the main 4Ps factors: people, part (equipment), position (location) and paper (document/procedure) that resulted in a major fire safety process being created. The team performed a root cause analysis to identify the system using Comprehensive List of Cause (CLC) method which looked at the system errors/failures, personal factors (if any) and job factors. From the health, safety and environmental aspect, the intention of the investigation was not to allocate any blame or fault with an individual but was mainly focused on preventing the reoccurrence of a similar incidence in the future. However, if any person were to be found responsible, they would be sent for training or could even be discharged from their duty. In their investigation, the team found out that the root causes of the incident were mainly due to human error as shown in Table 1 Based on the review report, Stardust was looking to establish a way to create a positive safety culture within the organization. One of the programs was designed for contractors and partners to be "self- regulated where the contractors/partners could decide what they wanted to do to create a positive safety environment One of the simple tools Stardust used was a yearly HSE plan for the contractor and partner to deliver at the end of each calendar year. Previously, clients had informed the contractor/partner what to do and contractor followed the instructions. This created dissatisfaction among contractors as the given plan did not belong to the contractor but belonged to the client instead. This resulted in poor execution and implementation of the HSE plan. Considering this, the CEO of Stardust, Kevin Collins, opted to change the company's culture to a new safety culture. Stardust gave authority to their partners/contractors to instruct Stardust what safely measures they wanted Stardust to take. Once a yearly plan had been established, discussions between company and contractor took place about the readiness, funding and commitment taken by management. At the end of the process, the company and the contractor (senior management) signed the plan to agree conditions for the upcoming year Table 1 Immediate and System Causes (behavior-related root causes) Causes Sub-Condition Description Immediate Use of defective equipment, although Aware of pump defect still in service to transfer staff are aware of the defects the crude oil Lack of knowledge of hazards present Improper decision-making or lack of Crew aware of the hazards but do nothing to judgement stop or rectify them Failure to warn Lack of judgement of hazards and decisions made to operate defective equipment Routine activity without thought No warning was given to alert staff in the control room to stop the pump from running Since the activities were being carried out for a long time, it had become the norm on board to accept the defects System Poor judgement Mentioned above Poor co-ordination or reaction time Reaction to the incident was to either shut down or stay operating during the fire Confusing directions/demands Not sure which came first fighting the fire or shutting down production Inadequate identification of critical Behavior did not exist at that time to recognize behavior hazards or priorities Supervisor implied haste Supervisor instructing crew to tackle the fire without coordination or emergency response plan Employee perceived haste Haste from supervisor to order action, e.g. fight the fire instead of gathering in the control room to strategize tactics so appropriate action to tackle the incident is more appropriate Inadequate assessment of required Skills of the crew on board the vessel were below the line of an operating facility as an offshore working environment, not as a sailing tanker Inadequate practice of skills Skills that were available had not been practised according to general competence levels skills Another effort of Stardust was to create a positive safety culture by introducing the "Action Today, Perfect Day Tomorrow' concept which was based on the behavioral ABC model. The ABC model was introduced by prominent psychologist Dr Albert Ellis in an effort to understand the meaning of human reactions to situations or events (adversity) (McLeod, 2008). This model suggested that antecedents or stimulus (A) could create desired behavior (B) which consequently could lead to certain desired consequences (C). Tarmizi believed that the use of this model could assist Stardust to trigger employees and crews' pro- active behavior and eventually could lead to zero failure. Stardust used this ABC approach to drive the required behavior of employees as an ultimate vision of "Living Safety. Following this approach, Stardust set the 'Living Safety culture as the journey of regarding safety as a personal value, not only at the workplace but also in daily activities. Stardust came up with several programs and activities (stimulus - A) to create pro-active behavior among crews (desired behavior - B) in a bid to achieve the excellent HSE performance consequences - C). In brief, Tarmizi planned to apply the ABC model as shown in Figure 1 Figure 1 Implementation of the ABC Model Anticipate (Doing it Consistently) Behavior Safe Habit) Consequences End in Mind) No recordable cases - No serious accidents No environmental pollution Safety is my values -Living safety is a vision -Being proactive -Intervene if unsafe Strong team work Buddy system - watch out for each other's safety Enhance engagement break communication barrier between workers and management Improve trust - embrace CARE values -Walk the talk -break communication barriers -Enhance skills -Raise safety desires - Perform emergency drills/exercise -Conduct safety meetings Perform audits/inspections - Perform site visits before approval of working permits -Holding handrail while ascending or descending the stairs Perform risk assessment for routine or non-routine activities -Close-out the action items assigned -Identify gaps in existing systems for enhancement and improvement -Wearing seat belts while operating vehicles -Perform assessments/health checks of processes to ensure what being stated in the procedure is implemented -Checking isolation property in order to approve the permit -Delivering safety commitments -MySafety Commitment Based on this model, the ultimate end result expected by Stardust, was to attain a perfect day. A perfect day' indicated a day without injuries, serious incidents or environmental pollution. Tarmizi thought that a perfect day would come if Stardust stopped experiencing such incidents in daily operation. The approach was to create proactive actions among the employees and crews of Stardust to prevent any incidents from happening. In other words, it was meant to create a safety culture among employees and crews for their personal affairs in daily activities, and encouraged employees to think before they even left for work, "I want to have perfect driving to work today'. The meaning of perfect driving to work could be, "I want to make sure I follow the speed limit, if someone overtake me recklessly, I will not react; I will wear my seat belt; I will follow the safest route to arrive at work safely and so on. Stardust wanted to inculcate a proactive mentality and actions among its employees and crews so that they could take ownership of their safety in whatever they do. Another effort Stardust wanted to incorporate was to have a "My Safety Leadership Commitment", where a manager would be required to make a personal commitment towards safety. This commitment was to drive the positive safety environment by showing everyone within the organization that the leader had made this commitment. Individual commitment would be displayed or posted in front of every leader in the organization so that the person could see his/her commitment every day. The other purpose to display such commitment was to show employees that their leaders had made a commitment towards enhancing positive safety culture. Tarmizi expected that, it would prove that "The boss is doing it, so I need to do it too. My boss can do it, so do However, Tarmizi knew that, without proper monitoring, such commitments would not be effective. As such, Stardust set four to six monthly reviews of commitments to make employees feel a responsibility to deliver their work. During monthly HSE performance meetings, the forum would show and discuss a few examples of leadership commitment to instigate a good discussion amongst leaders by helping out those who were having problems implementing their commitment by giving suggestions. Such discussions created the CARE values (commitment, agile, rapid and entrustment) (see Table Il and Figure 2) within the organization to create a positive working environment for everybody to work within. Tarmizi's dilemma Tarmizi knew that instilling a different work culture was not easy and chose to follow the three main steps of implementation: pre-execution, execution and post-execution. Pre-execution was mainly to set up the HSE department fundamentals as the basis of HSE framework, such as by developing an HSE policy and initiating relevant contracts that could help the department to execute the plan with minimum resources. Execution was related to training and baseline survey. And the post- execution plan was to assess the impact at the end of the year. The implementation plan catered to relevant stakeholders, such as company employees (Stardust's own employees), contractoripartners (marine crews) and the regulator (Petronas). Pre-execution was time- consuming but not that difficult for Tarmizi. He received full support from the CEO for preparing the whole blue-print of the program. He chose to keep the option to have outside organizations (who were specialized in handling safety issues) as partners, but with limited use. He opted to take their help only when things could not be handled by Stardust's own initiative. He wanted to reduce costs by utilizing the available resources when handling safety issues. This was because Stardust previously bought very expensive safety materials and kept them in storage. Most cases of the materials were not used and were kept locked as outside specialized companies (such as firefighters) were called in to handle safety situations. Both cases incurred costs for Stardust: first, for hiring highly specialized outside companies every time an incidence occurred; and second, for purchasing very expensive safety materials but not Agile using them. Collins supported al Tarmizi's ideas and had given him the green signal to proceed as planned Table II CARE value CARE value Description Commitment where people of organization are committed and accountable In exploring and deciding on new and creative methods Rapid In delivering a set of goals Entrustment where people within the organization are considered trusted partners to work with Figure 2 Example of the CARE values to results Intention Commitment Action Results I want to prevent I am writing my intervene if I see Rectify unsafe Commitment accidents own safety pledge unsafe behaviors acts. Reduce number of acts I want to apply I'll stop the work if Pick my safety Safety buddy and Agile see unsafe buddy I will look after appropriately to behavior each other different I want to be I will not take Plan action well in Safety efficient but safe shortcuts advance performance best in class I trust people who I will make safety Challenge staus Build a safe Entrustment treat safety one of my quo, ie, do not be working seriously behavior values complacent and environment challenge 'green' together status HSE Rapid Once Tarmizi initiated the implementation of the new culture, he started facing some resistance from Stardust's own employees and contractors. Many of them resisted following the seven clauses that Stardust wanted to implement (Table III, detailed information is given in Exhibit 2). Stardust had about 30 permanent crews who worked in the flowing vessels, 23 marine and seven operation, all of whom were contractors. The main resistance came from Captain Billy, who led the marine crews, and operation supervisor Razman, who led the operation crews. In a meeting with Captain Billy and Razman, Tarmizi mentioned that they needed to always stay alert but he found it difficult to make Captain Billy and Razman understand the necessity of adopting the safety culture the way Tarmizi wanted it to be. At the beginning, Tarmizi could not understand the marine crews' reluctance to follow the safety culture. However, when he went for an unannounced inspection, he realized that the crews were not maintaining the habit of wearing of safety attire, such as specific jackets, caps, shoes and gloves, and he spotted cigarette butts all over the ship which was dangerous as smoking was allowed only in designated places. He also noticed that marine crews allowed fishermen to sail small boats near to the ship; to make the situation even more hazardous, the fishermen made fires to cook near to the ship which could cause accidents Slowly, Tarmizi realized that there was a great difference between the Stardust culture and the marine crew contractors. As marine crews contributed to 80 per cent of the total man hours' whereas Stardust's own employees contributed only 20 per cent of an hours (the amount of work performed by the average worker in one hour). It was crucial for Stardust to consider changing the work culture among the marine crews, who were used to following orders only given by their captain Clear power distances were the norm, similar to other national forces, such as the army and air force. Contrary to this culture. Stardust followed a more flexible work culture, whereby employees had the freedom to actively take part in the decision-making processes as Collins focused on maintaining a friendly environment within Stardust to encourage the innovative ideas for the success of the company Tarmizi realized that Stardust's employees were reluctant to change and preferred the traditional way of doing things because they felt that the new initiative would require more work of them. Stardust was a comparatively young company and, as such, had a lack of resources. Only three people were working in the HSE department and were responsible for handing al required tasks. Tarmizi recalled his conversation with his subordinate Kamal in an informal gathering Kamal asked him "Sir, would it be more complicated if we implement the new safety culture? Do I need to perform more tasks?" Mr Tarmizi smiled, not to make him worry, and replied: "Oh no. We are just going to handle the slution in a different way. But it doesn't mean increasing your workload. Table Ill Stardust's seven major operation control clauses No Operation control clause Policies (HSE, stop work, drug and alcohol, business ethics, audit and quality and security) HSEMS documentations Site-specific procedures Guidelines code of safe working practices 5 Permit to work systems Management of change procedures Maintenance management systems 1 2 3 4 6 Despite their conversation, Tarmizi felt that Kamal was still worried about his workload. The next day when Tarmizi called a meeting to discuss the Living Safety culture, Kamal did not attend. When he contacted Kamal, Kamal informed him that he would be on medical leave for the next two days. During the meeting with his assistant and other staff, Tarmizi had asked them for their input. One of the staff members said, "It seems a good plan, but I am not so sure whether it will work or not. Tarmizi reminded him. But at Stardust we always prefer the innovative way that can bring maximum output. Another staff member replied, "Yes, it is true. But it does not mean that we have to change the existing culture. We just need to be extra conscious for the next time. At this, Tamizi decided to wrap up the meeting and to think deeply about this issue Al efforts were being made to try to build positive safety culture within the organization and the goal was that when everything was in order , hazards could be avoided. When hazards were being eliminated, less safety issues would surface. Tarmizi knew that this was easy to say but difficult to perform The CEO firmly suggested that Tarmizi solve the issue by the end of 2015. Otherwise, Stardust would lose the trust of PCSB which would be the end of Stardust's journey. As the oil and gas producing fields were owned by PCSB, i Stardust was unable to create trust and deliver the services as promised, no more fields would be allocated to Stardust to operate in the future. It could also lead to Stardust losing its competitiveness in the oil and gas industry and the projects would be given to their close competitors such as ENQUEST, Petrotac or Lundin. If this were to happen, it would result in higher costs and more rad procaceas which would make Stardust's lournay very difficult Exhibit 1 Figure E1 me organization structure of Stardust Stardust's Organization Chart CEO Kevin Collins Legal Counsel Mr Faiz (M) Secretary Ms Marina (M) GM - Contract Requirement Mr Zamzari (M) SM-HSE Mr Tarmii (MGM- Development Mr Shamsul (MGM- Production Operating Mr Azman (M) GM- Commercial Strategy Mr Adnan MGM- Finance & Strategy Ms Nur Aligah Notes: M - Malaysian; E-expatriate; GM-general manager; CEO - chief executive officer, SM - senior manager Exhibit 2: Detail description of Stardust's seven major operation control clauses Policies - Health, Safety and Environment, stop work, drug and alcohol, business ethics, audit and quality This is mainly about the company level 1 policy that is set for the purpose as the main intent or what the company ideology/principle of how the company views those items. Let's start with HSE Policy is to ensure it complies with the Occupational Safety and Health Act 1994 that requires a company that falls within those categories are required to create a HSE Policy. The HSE Policy will be signed by the highest management in the organization to ensure staff and contractor that work with the company will fulfill this obligation to ensure they have a safe and healthy working environment. Other policies cover specific needs for certain requirements and stands for allowing any person to stop any unsafe work without fear. This policy gives the ultimatum to the workforce to stop any unsafe acts and conditions that have the potential to loss of life, property, environment and reputation. For drugs and alcohol, it is mainly to ensure that anyone working for the company is not under the influence of drugs or alcohol prior to starting to work for the company. For business ethics, the company has a code of conduct so that the workforce does not fall into the trap of bribery or security threats. On audit, it is mainly about the need of an organization to have an assurance process in place so that practice and implementation is being assessed, audited, and inspected for compliance and good governance processes. Finally, on quality policies where the company stands to ensure work and tasks being carried out are fulfilling the relevant agreed requirements, so the product at the end of the process is meeting the standards of relevant recognized qualities. Health, Safety and Environment Management System documentation This is in relation to the HSE Management System (MS) or management expectations that governor frame how the organization manages their HSE. For the company, the element of HSE MS is 10 which and is comprised of leadership and organization. Those ten elements will be supported by individual procedures and guidelines that set the minimum framework and boundaries within the organization. Site-specific procedures/work instruction This is related the specific procedures that support the work and tasks carried out in the company. Examples of a specific procedure include operating the fire water pump. Guidelines - code of working practices This is similar to above (site-specific procedures), except sometimes refers to the industrial code of practices that provide some guidelines for the industry of what and how to perform the relevant tasks. Examples include the code of conduct when entering the confined space area. Permit to work system This system is related to the control of hazards at the workplace. Normally, in the company, or similar businesses, the working environment will have this system mainly to control hazards at work. This system works through a form to be completed by workers to verify prevention plans and that remedial plans are in place to ensure work is always executed safely. This is one way to ensure any work carried out, as well hazards, are assessed and controlled before being executed. Exhibit 2: Detail description of Stardust's seven major operation control causes Policies Health, Safety and Environment, stop work, drug and alcohol, business ethics, audit and quality This is mainly about the company level 1 policy that is set for the purpose as the main intent or what the company ideology/principle of how the company views those items. Let's start with HSE Policy is to ensure it complies with the Occupational Safety and Health Act 1994 that requires a company that falls within those categories are required to create a HSE Policy. The HSE Policy will be signed by the highest management in the organization to ensure staff and contractor that work with the company will fulfill this obligation to ensure they have a safe and healthy working environment. Other policies cover specific needs for certain requirements and stands for allowing any person to stop any unsafe work without fear. This policy gives the ultimatum to the workforce to stop any unsafe acts and conditions that have the potential to loss of life, property, environment and reputation. For drugs and alcohol, it is mainly to ensure that anyone working for the company is not under the influence of drugs or alcohol prior to starting to work for the company. For business ethics, the company has a code of conduct so that the workforce does not fall into the trap of bribery or security threats. On audit, it is mainly about the need of an organization to have an assurance process in place so that practice and implementation is being assessed, audited, and inspected for compliance and good governance processes. Finally, on quality policies where the company stands to ensure work and tasks being carried out are fulfilling the relevant agreed requirements, so the product at the end of the process is meeting the standards of relevant recognized qualities Health, Safety and Environment Management System documentation This is in relation to the HSE Management System (MS) or management expectations that governor frame how the organization manages their HSE. For the company, the element of HSE MS is 10 which and is comprised of leadership and organization. Those ten elements will be supported by individual procedures and guidelines that set the minimum framework and boundaries within the organization. Site-specific procedures/work instruction This is related the specific procedures that support the work and tasks carried out in the company Examples of a specific procedure include operating the fire water pump. Guidelines - code of working practices This is similar to above site-specific procedures), except sometimes refers to the industrial code of practices that provide some guidelines for the industry of what and how to perform the relevant tasks. Examples include the code of conduct when entering the confined space area. Permit to work system This system is related to the control of hazards at the workplace. Normally, in the company, or similar businesses, the working environment will have this system mainly to control hazards at work. This system works through a form to be completed by workers to verify prevention plans and that remedial plans are in place to ensure work is always executed safely. This is one way to ensure any work carried out, as well hazards, are assessed and controlled before being executed. Management of change procedures This procedure is about managing change that has an impact on safety or can or have the potential to result in an incident. Normally changes to processes must be detailed in a document and communicated to relevant staff members that have been impacted by that change. Several catastrophic Incidents are related to poor/lacko changes of management already in place. People have to be informed and educated about any changes that have taken place. Maintenance management system This is normal in any organization to have a maintenance management system to maintain equipment so that it will serve longer and safer. Within maintenance management, all equipment breakdowns and failures that could potentially lead to catastrophic incident are monitored Stardust Petroleum Sendirian Berhad: How to inculcate the pro-active safety culture? Coming together is a beginning; keeping together is progress; working together is success. - Henry Ford The beginning Stardust was established in 2013 as a subsidiary of Petronas Carigali Sendirian Berhad (subsequently referred to as PCSB) to manage a small, marginal field in Malaysia located under a larger oil and gas field with a reservoir that had expected productivity of four to five years. In the middle of 2014, Stardust was given the opportunity to take over the management of a field located at Anjung Kecil (AJK) to provide support for PCSB and to operate and maintain a newly installed facility. However, in October 2014, during the process of handing over the facility and field from PCSB to Stardust, one of the pumps in the pump room in the tanker caught fire and there was substantial damage as a consequence, including two out of four pumps being completely destroyed. The fire delayed the oil production for more than a month and the total estimated damage caused by the fire incurred was a loss of RM19m and included replacing two new 400 kw pumps, repairing the damaged pump room, including new manifolds and paint, and production shutdown for 40 days. At the end of 2014, investigations were initiated by the field owner and the review team to investigate the causes of the fire. The investigations results revealed that human error, specifically negligence, was one of the major reasons for the fire, along with location, position, equipment and procedure, Kevin Collins, the CEO of Stardust, assigned the task of creating a "Living Safety culture to Tarmizi, the Senior Manager of the Health, Safety and Environment (HSE) Department. Tarmizi found it very challenging to inculcate the "Living Safety' culture with zero failure by the December 2015 deadline given by Collins. Tarmizi came up with a slogan to reflect the safety culture: "Action Today, Perfect Day Tomorrow". He believed bringing zero failure could be possible if all employees and crews were to embrace the safety culture in their daily activities. "Action Today' was created to raise awareness about adopting the "Living Safety culture and practicing it in everyday activities, whereas "Perfect Day Tomorrow was meant to focus on the ultimate outcome (ie. zero failure) by adopting this culture. However, Tarmizi faced some resistance to this safety culture from the marine crews. This resistance was apparent from the conversation between Captain Billy, the marine crew leader, Razman, Operation Supervisor, and Tarmizi. Their conversation went as follows: Tarmizi said: "Captain Billy, in order to bring the safely culture, we need to maintain the do's and don'ts that is stated in this new rule book. There are seven major clauses that we need to strictly follow. Such as no drugs, no alcohol consumption, no smoking. Before he finished his sentence, Captain Billy objected: "understand your concern, but do you think that it would be necessary to be so strict in every aspect?" Mr Tarmizi replied: "Oh yes. Otherwise, se, we can't assure zero hazards." Mr Razman interfered the conversation: "I agree with captain Billy. It won't be so easy to make all staff follow the way it is. They are not used to that in this culture." Mr Tarmizi became bit impatient: "I know that it is not an easy task to do. But no matter what we need to do it." Time was running out fast and PCSB management had emphasized that the situation had to be dealt with urgently to ensure that a similar incident would not happen in the future. If such a thing was to re- occur, it would jeopardize the trustworthy reputation of Stardust. In addition, PCSB might not allow Stardust to operate other facilities, which would put the company at risk when it came to it remaining competitive within the oil and gas industry. Malaysian petroleum industry In Malaysia, Petronas was one of the major players in the petroleum industry and generated MR131.4bn in gross national income during 2013 (Bantillo, 2013). Prior to 1975, petroleum concessions had been granted by the state government where oil companies had exclusive rights to explore and produce resources and the companies would pay tax and royalties to the government. On April 1, 1975, when the Petroleum Development Act was published, Petronas was given rights as a custodian of any petroleum resources found in Malaysia, both on land and at sea. Petronas retained the ownership and management control of resource expenditure and profits were managed under an instrument called a product sharing contract (PSC). In 2014, Malaysia produced about 648,000 barrels of oil per day (bopd) (Isa and Zainul, 2016). It also produced about 5.7 billion cubic meters of gas per day, which made Malaysia the 14th largest gas producer in the world. A total of 494,183 square kilometers of acreage was available and consisted of 54 blocks. This included 337,167 square kilometers located offshore including the continental shelf. The other 63,968 square kilometers were located in the deep-water area of Sabah. "Deep water" is where oil and gas activity start to take place at deep sea, normally more than 1,200 m in depth whereas "shallow water could range from 50 to 300 m deep. From those 54 blocks, Petronas Carigali operated 28 blocks and other multinational companies operated another seven blocks. All this activity contributed about 20 per cent of Malaysia's GDP Petronas Carigali Sendirian Berhad Petronas Carigali Sendirian Berhad (PCSB) was one of the key subsidiaries of Petroliam Nasional Berhad (Petronas). It was engaged in oil and gas exploration and production services and also offered oil and gas well drilling, as well as engineering, constructing and commissioning natural gas pipelines and associated facilities. The company was incorporated in 1978 and based in Kuala Lumpur, Malaysia (Bloomberg, 2017) PCSB mainly focused on larger fields (bigger reservoirs) which had longer production ranges. Small and marginal fields were characterized by fields that contained hydrocarbon with less than 30 million barrels of recoverable oil. The main objective of Petronas was to attract the small and marginal field players to invest in Malaysia and assist in developing the expertise of the local players (Jaipuriyar, 2016). For the investors, the Malaysian government allowed incentives that would reduce taxes between 25 to 38 per cent. The aim was to increase overall oil production in Malaysia to 55,500 bpd of oil by 2020. This required RM13.3 billion and was expected to contribute up to RM5.5 billion per year to the country's GDP (WorldVest Asia Pacific Sdn. Bhd, 2016). In Malaysia, a total of 106 marginal fields that reserved about 580 million barrels of oil were still untapped and it had been estimated that within 15 to 18 years, Malaysia would be out of oil if these marginal fields were not developed Stardust Petroleum Sendirian Berhad Stardust Petroleum Sendirian. Berhad (subsequently referred to as Stardust) employed about 70 permanent and contract staff and its Chief Executive Officer (CEO) was Kevin Collins, a Manchester University graduate. In addition to the CEO, Stardust also appointed one legal counsellor, one secretary and six general managers. The main organization chart of Stardust is shown in Exhibit 1. Stardust's core activity was to bring oil out from underneath the seabed and store it in a floating storage facility before it became the final product . A floating storage vessel was installed at the site to store crude oil and to serve as the workers' accommodation. Once the storage reached 90 per cent of its storage capacity, the crude oil would be transferred to other export tanker vessels (off-take tanker). There were 23 mariners who served as contractors for Stardust that had to follow instructions given from the top- down before carrying out any assigned activity. The marine department usually followed a rigid and fixed organizational structure where rules and regulations were standardized, decision-making processes were centralized formality was maintained and hierarchy of power was very clear. This structure was reflected in the vertical communication system, where employees were not able to make decisions unless they received permission from their direct manager. Marine crews made up roughly 76 per cent of crews (23/31) and other crew members were operations/production staff, about 24 per cent of the total number of crews. As marine crews were the majority, they tended to dominate the work culture while Stardust's employees were more flexible in their approach to work in comparison. Work was decentralized and staff were receptive to any suggestions that could improve the work quality. In Stardust, the CEO emphasized being productive, creative and innovative instead of following a rigid structure. The field located at Sarawak, Anjung Kecil Field (AJK), was roughly 200 kmnorthwest of Bintulu and consisted of a monopod well head platform" (WHP), the Tarpon field. There were 1,900 m of a 6-inch flexible hose on the seabed connecting Tarpon and a floating storage unit (FSU) to store the crude oil. Daily production of this facility was about 8,000 bb\day. The other field Tembikai, located about 120 km east of Kuala Terengganu. The field had similar arrangement with AJK but consisted of a three-legged unmanned platform that had a center processing plant (CPP) installed on it. The CPP was connected to a six-inch seabed-flexible hose to floating operating installation services (FOIS). The FOIS had capacity of storing about 220,000 bbl of oil that was similar to the FSU. As such, a maximum of 30-40 marine crews could be onboard and usually managed marine operations. Stardust established a Health, Safety and Environment (HSE) department to build the fundamentals and processes that would support the execution of the project and deliver it within the required timeframe. HSE's vision was to build "Living Safety as organizational safety culture by embracing self-safety personal values. "Living Safety" was about creating a proactive safety culture within the organization and preventing any incident, mishap, injury, environmental pollution, property damage, fire, explosion and unwanted events that could incur losses, such as loss of life, damage of property and environmental pollution. The logo "Living Safety" appeared at various locations where Stardust operated and embroidered on employees' uniforms to act as a reminder for the staff that "safety' was the company's core value To support the effort to instil the "Living Safety' concept, Stardust initiated a program called the Journey of Excellence". The program took place in every month and all employees participated to set out goals, build teamwork and make plans to understand how to deliver those goals. The primary motive behind the program was to create a clear mindset of everybody involved to mobilize a positive culture to be reflected daily in the spirit of team work, better communication, building a positive collaboration to deliver tasks and reflecting the 'Living Safety culture. Kevin Collins - the chief executive officer of Stardust Kevin Collins was 54 years old and had considerable industry experience in management, drilling, completion and field development activities. As a graduate in Chemical Engineering from Manchester University, he started his career in 1983 working for Conoco as a Drilling Engineer based in the UK. In 1990, he joined Texaco as the team leader for various drilling campaigns and then moved to Hess to lead the subsea completion effort on a major field development. Collins developed his leadership and business skills over 20 years by setting up and running a sub- surface consultancy business in the UK in 1993 that ultimately employed over 100 staff. In 2005, he headed to Malaysia to lead Petrofac's business there. Petrofac was one of the international service providers to oil and gas production and processing industry and, as a Country Manager for Petrofac Malaysia, Collins was responsible for all aspects of Petrofac's investment business and the in-country focal point for all Petrofac services businesses. He played a pivotal role in developing new business within Malaysia that allowed Petrofac to grow and develop considerably, as evidenced by the number of employees increasing from 15 in 2005 to over 1,700 by 2013 In October 2013, he was appointed as the CEO of Stardust and served as a member of the Board of Directors. After the accident in the AJK field, Collins thought the HSE department should take the responsibility to instill the "Living Safety' culture to avoid another accident in the future. He instructed Tarmizi to come up with a proper plan. Tarmizi the head of Health, Safety and Environment Department Tarmizi was 46 years old with 20 years of working experience in various industries. He started his career in 1995 as a Research Officer at the Malaysian Institute for Microelectronic System (MIMOS) after graduating from the University of Bradford (UK) in Chemical Engineering. At the end of 1996, MIMOS was corporatized and Tarmizi was assigned a role as a Gas Facility Engineer for a year for the newly- buit semiconductor research plant at the company's technology park in Malaysia and in charge of handling facility readiness, hook-up and commissioning of the gas systems. Later, he decided to change his career path and became a Safety and Health Engineer. At MIMOS, he had helped to take lead in developing the Safety and Health Systems and Procedures and this exposure helped him to extend his competency and experience. He left MIMOS on early 2000 after four fruitful years. He joined AMOCO Chemical (M) Sendirian Berhad in February 2000 and worked for about one year. AMOCO, ARCO and Castrol merged with British Petroleum (BP) before it changed its name to BP Chemicals (M) Sendirian Berhad. In 2008, the chemical industry was in turmoil when oil-based raw materials' price was skyrocketing which resulted in a lowering chemical demand in the global market. BP went through a significant restructuring and reduced their manpower. During this restructuring period Tarmizi left the company and joined Sarawak Shell Berhad as an HSE Adviser. At Shell (which was based in Miri), he was exposed to an upstream working environment. As an HSE Adviser, he was assigned to look at Asia-Pacific HSE competency management by monitoring their profiling to ensure critical positions were up-to-date with the required competency. Tarmizi served Shell for nearly three years before he decided to return to Peninsular Malaysia to work with Talisman Malaysia Limited (Talisman) in 2010 as HSE System and Assurance Team Leader. At Talisman, he was assigned to lead the implementation of the contractor HSE Management, Behavioral Based Safety, Performance Improvement and HSE Assurance and systems. At the same time, he was also assigned a role to support Talisman's regional leadership in enhancing process safety implementation and assurance. In 2012, he was offered the post to serve as the Regional Senior Specialist EHS at Hess Oil and Gas Sendirian Berhad to assist Thailand, Indonesia, Australia and Malaysia. He was assigned to lead the performance improvement initiatives for the region by enhancing safety performance through safety behavior and data management. Tarmizi also was assigned to lead the Operability Assurance Review (CAR) for the Sinphuhorm gas processing plant in Khon Kean, Thailand. Later on, he was offered the role of leading the department of Stardust owned by PCSB which was focused on small and marginal fields in Malaysia. In May 2014, Tarmizi was offered the Senior Manager post to lead the HSE department at Stardust. His task was to lead and set up the HSEQ wants and needs for the company and was assigned three large rapid projects to manage: Kapal's decommissioning, AJK's infil project and Berantai takeover. At the end of 2014, the CEO of Stardust suggested Tarmizi coach the crews in the company's "Living Safety' culture. He tried but found it very difficult to bring a change in the present culture. In the process of implementing the safety culture The field located at AJK was producing crude oil from two wells and the existing production rate per day could fill approximately 90 per cent of the overall tank's capacity within two to three weeks. The crude oil needed to be unloaded to other off-take tankers almost by two to three weeks rotation to meet the customer demand During the process of handing over the facility and field to Stardust, one of the crude oil pumps (COP#2) caught fire due to leakage of crude oil that was in contact with the nearby source of ignition. It caused significant damage to the pump room which resulted in a loss of RM19m. In November 2014, two investigations were initiated to understand the reason behind this accident one by the field owner and the other by Stardust's review team. It was meant for investigating the main 4Ps factors: people, part (equipment), position (location) and paper (document/procedure) that resulted in a major fire safety process being created. The team performed a root cause analysis to identify the system using Comprehensive List of Cause (CLC) method which looked at the system errors/failures, personal factors (if any) and job factors. From the health, safety and environmental aspect, the intention of the investigation was not to allocate any blame or fault with an individual but was mainly focused on preventing the reoccurrence of a similar incidence in the future. However, if any person were to be found responsible, they would be sent for training or could even be discharged from their duty. In their investigation, the team found out that the root causes of the incident were mainly due to human error as shown in Table 1 Based on the review report, Stardust was looking to establish a way to create a positive safety culture within the organization. One of the programs was designed for contractors and partners to be "self- regulated where the contractors/partners could decide what they wanted to do to create a positive safety environment One of the simple tools Stardust used was a yearly HSE plan for the contractor and partner to deliver at the end of each calendar year. Previously, clients had informed the contractor/partner what to do and contractor followed the instructions. This created dissatisfaction among contractors as the given plan did not belong to the contractor but belonged to the client instead. This resulted in poor execution and implementation of the HSE plan. Considering this, the CEO of Stardust, Kevin Collins, opted to change the company's culture to a new safety culture. Stardust gave authority to their partners/contractors to instruct Stardust what safely measures they wanted Stardust to take. Once a yearly plan had been established, discussions between company and contractor took place about the readiness, funding and commitment taken by management. At the end of the process, the company and the contractor (senior management) signed the plan to agree conditions for the upcoming year Table 1 Immediate and System Causes (behavior-related root causes) Causes Sub-Condition Description Immediate Use of defective equipment, although Aware of pump defect still in service to transfer staff are aware of the defects the crude oil Lack of knowledge of hazards present Improper decision-making or lack of Crew aware of the hazards but do nothing to judgement stop or rectify them Failure to warn Lack of judgement of hazards and decisions made to operate defective equipment Routine activity without thought No warning was given to alert staff in the control room to stop the pump from running Since the activities were being carried out for a long time, it had become the norm on board to accept the defects System Poor judgement Mentioned above Poor co-ordination or reaction time Reaction to the incident was to either shut down or stay operating during the fire Confusing directions/demands Not sure which came first fighting the fire or shutting down production Inadequate identification of critical Behavior did not exist at that time to recognize behavior hazards or priorities Supervisor implied haste Supervisor instructing crew to tackle the fire without coordination or emergency response plan Employee perceived haste Haste from supervisor to order action, e.g. fight the fire instead of gathering in the control room to strategize tactics so appropriate action to tackle the incident is more appropriate Inadequate assessment of required Skills of the crew on board the vessel were be