An Intellectual Joust - Challenge - - Are you willing to confront propositions that jolt your safety management comfort zone ?
TapRooT® Summit 2006 - Gatlinburg, TN Thursday, April 6 08:00 GENERAL SESSION Challenging the Way North Americans Manage Safety ( the way you think and talk about safety ) Jim Whiting Principal Risk Engineer & MD risk@workplaces pty ltd, Australia firstname.lastname@example.org
Challenge # 1 All behavior depends upon risk perception. Agree ? or Disagree ? If we label/describe an employees actions as :- stupid or careless or lazy or negligent does that mean all we are saying is that :- the employees risk perception is different to ours? And Whose problem is that ? The employees or ours ?
ALL behaviour depends on : Perception of Risk Benefits and Costs Do your workers and managers have the same perceptions of what is tolerable risk as you do ? How do you know if they do agree with you regarding what risks are tolerable and what are not ? You cannot assume or guess they do ! The ONLY way of knowing is : to measure / calculate risk together !
Risk Management = Decision Making = choosing an option that is perceived to have the best benefit / cost ratio No one takes a risk for the chance of loss Option A Perceived Costs Perceived Benefits Option B Perceived Costs Perceived Benefits Challenge 1 (contd) All decisions are risk management decisions
Challenge # 2 Is the descriptor at risk behavior any more helpful and any more meaningful than unsafe act ? Do all behaviors involve risk ? hence are ALL behaviors actually at risk behaviors ? There are no such concepts as – SAFE or UNSAFE- rather TOLERABLE Risk and INTOLERABLE Risk
What is the second most common word used in safety ? And isnt defined ? unsafe What is first ? – the most common? dont
Challenge # 3 Do we confuse ourselves and our employees by not clearly distinguishing between, and explaining the differences between zero incidents and zero risk ?
Key philosophies of risk management Zero risk is unachievable – as well as being frustrating both to individuals and organisations Zero risk should never be confused with Zero Incidents, Zero Incidents is an achievable and worthwhile expectation Zero risk is not achievable
Challenge # 4 Which of the 2 expressions below provides a more meaningful indication of the real world ? and which one does / does not give us false confidence ? We will develop a Corrective Action that will prevent recurrence of an incident OR We will develop a Risk Control that will reduce the risk of recurrence to ALARP –As Low As Reasonably Practicable
Challenge # 5 Is risk tolerance a better term than risk acceptance ? Does tolerating a risk mean we are not happy with the situation and tolerate implies we are only living with the risk and need to keep vigilant and revisit how well the our risk control measures continue to be appropriate ? Whereas accept is fatalistic or defeatist ? with the implication of passive acceptance ?
Zero injuries not Zero risk and we only TOLERATE fully managed risks !! We will never ACCEPT any Injuries/ Deaths anywhere ! anytime !
Challenge # 6 Every organisation should have a process of quantifying risk levels and then defining what risk levels are tolerable and which levels are intolerable. Employees need to be able to calculate risk levels quantitatively to be able to adequately perceive risk as tolerable or not.
Train Traffic Density Stage of Shift Safe working system & corridor length of "on-the-board" time - 6 or 8 TC issues incorrect info OT workers not advised Train Diagram problems TC does not check repeat back info TC allows train or OT vehicle to depart before time TC does not electronically Block Section TC does not mark diagram TC does not check diagram TC marks diagram incorrectly OT worker does not get to "safe" position speed of train / OT vehicle Vigilance of worker 5 second protection Visibility problems lookouts do not work Visibility problems Representative Risk Scenario Map with risk factors and significant events OT protection systems fail
Set / Choose P Probability of WHOLE scenario completing to chosen Consequence P Score Description of Probability Likelihood OR Estimated Chances 6 Almost certain the sequence can and does happen because all risk events / risk factors are very likely to occur or be present Up to 1 chance in 10 5 Quite possible and not unusual that the sequence can and does happen because most risk events / risk factors are likely to occur or be present 1 chance in 10 t o 1 chance in 100 4 Would be possible but unusual that the sequence can and does happen because many risk events / risk factors are likely to occur or be present 1 chance in 100 to 1 chance in 1 000 3 Would be a remotely possible that the sequence can and does happen because only a few risk events / risk factors are likely to occur or be present 1 chance in 1 000 to 1 chance in 10 000 2 Conceivably possible but very unlikely that the sequence can happen but is unlikely because many of the risk events / risk factors are very unlikely to occur or be present 1 chance in 10 000 to 1 chance in 100 000 1 Almost impossible that the sequence can and does happen because most of the risk events / risk factors are unlikely to occur or be present 1 chance in 100 000 or lower
To be confident that employees at all levels understand and may possibly want to or need to change their risk taking behaviors at work, we need to be confident that they can understand & evaluate the risks adequately, AND perceive the risks adequately AND assess the risks adequately AND calculate the risks adequately.
Challenge # 6 (contd) Without the certainty of a corporate risk tolerability framework - which defines risk tolerability levels - managers and employees will continue to be confused by lack of corporate guidance and definition of corporate standards re risk tolerance.
Control measures must be introduced for risk in this region to drive residual risk towards the broadly acceptable region. If the residual risk remains in this region, and society desires the benefit of this activity the residual risk is tolerable only if further risk reduction is impracticable or requires action that is grossly disproportionate in time, trouble and effort to the reduction in risk achieved. Risk Evaluation - ALARP Tolerability Principles ALARP Region Increasing Individual Risk and Societal Concerns Risks cannot be justified Intolerable Region X Negligible Risk Broadly Tolerable Region Level of residual risk is not regarded as significant and further effort to reduce risk is not likely to be required as the resources to reduce the risks are likely to be grossly disproportionate to the risk reduction achieved. X Risk Level $
Risk Tolerability Criteria or Framework Risk Score Risk Descriptor All categories of Risk except safety or environment Safety and Environmental Risks 12 Extreme Board Approval Required for Risk Intolerable 11 10 High Senior Executive Approval Required 9 Level 2 Manager Approval Required 8 Risk must be managed in line with the ALARP Principle Risk must be managed in line with the ALARP Principle ( Note 1 ) 7 Moderate Risk must be managed in line with the ALARP Principle 6 5 4 Low No approval required but ongoing monitoring and management is required 3 2 Note 1 As part of the ALARP justification, if the exposed population is a worker, a Job Safety Analysis is required. The methodology for conducting a Job Safety Analysis is described in the Safety Management System.
Challenge # 7 Can the same scenario lead to different consequences ? Why do participants of risk analyses often argue about consequences ?
Is an error a cause? or a consequence ? or ….. ? Challenge # 8
Quick Way to Find Causal Factors Who did what wrong? What equipment failed? If these problems had not occurred, it could have prevented the incident (circle) from occurring or significantly reduced the incident's consequences. ERROR SUBSTANDARD ACT Choice Intent - Could have - Should have - Wanted to - Needed to - Supposed to --Tried to Error ? or Substandard Act ? ( Both have Good Reasons )
Challenge # 9 Why do safety people like - double negatives rather than - double positives ? - reduce / prevent human error - improve human reliability - decrease injury statistics - increase levels of risk control - dont take shortcuts - always choose the standard way
Challenge # 10 Why do safety people like the word DONT ? Does such negative thinking / perceptions actually marginalize safety people from the real business world ? Do people come to work to DO or to DONT ? Do we want to be told what we CAN do or always be told what we CANT do ?
Challenge # 11 Is the term shortcut actually a good descriptive word that is sensibly associated with the needs of a real workplace in the real world - where the day-to-day business challenge is to find smarter better ways of doing our work OR shortcuts ? To give more certainty / confidence to our people, do we need to clarify better the difference between - finding shortcuts which is smart and taking shortcuts without risk assessments which is dumb ?
Challenge # 12 What do we mean when we tell our employees that :- If you follow this procedure you will be SAFE ? Can your people vary from a procedure ? After completing a pre-start job risk assessment, ( whatever your company calls them -Take 5 - STOP - Stepback 5X5 - JSA etc.) are your people clear regarding what they can and cant do ? Do they know clearly if they can - and under what circumstances – actually vary the procedure for the job based on their findings of the pre-start job risk assessment ?
* ALL causes / risks arepredictable Hence ALL are manageable / controllable ! Philosophy of Causal / Risk Analysis * ALLrational behaviour is done (by definition) forgood reasons * The Onus on the Investigator / Analyst is to get people to share theirgood reasons * The best Investigations / Analyses occur within fair and just cultures * The Causal Factors of todays incident are the Risk Factors of tomorrows !