Making Safety Real Taking Risk Management to the …...School Of Engineering Safety and Risk...
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School Of Engineering Safety and Risk Management David and Joan Lynch Making Safety Real Taking Risk Management to the Next Level
Transcript of Making Safety Real Taking Risk Management to the …...School Of Engineering Safety and Risk...
School Of Engineering Safety and Risk ManagementDavid and Joan Lynch
Making Safety Real
Taking Risk Managementto the Next Level
It All Comes Back to Culture….
Vision/Values
Principles/Beliefs
Decisions Information
Rewards
Finance
Communication
Safety Production Measures
Audit
Culture
Results
Defines How We Do Things Here
Basis for DecisionMaking (DNA)
Piper Alpha….29 years ago
Critical Activities• Risk Assessment Action Implementation• Permit System Management• Blinding of Piping Under Maintenance• Safety Recovery System Integrity• Training in Emergency Evacuation
Organization Choices…Designed to Get the Results They Get
Critical Activities• Formulation of Cement• Cement Placement for Well Sealing• Monitoring of Pressure Readings for
Well Seal Confirmation• Emergency Diversion Protocols• Blowout Protector Installation and
Maintenance
Organization Choices…Designed to Get the Results They Get
Reflecting Back….….when you go to the Smithsonian and see Discovery there, think how lucky you are to see her whole, intact, and with her crews safely on the ground….
January 28, 1986, the Shuttle Challenger Explodes
Challenger - 1986
Immediate Cause?
Too cold to launch, “O” – rings failed to keep O2 from H2 mixing before the engine
Basic Causes?
Management pressure on cost & schedule
Failure to investigate previous incidents.
Failure to do a risk assessment.
Columbia - 2003
Immediate Cause?
Tiles were damaged
Basic Causes?
Management pressure on cost & schedule
Failure to investigate actual incidents.
Failure to do a risk assessment.
ENGG 406 - January to April, 2012
1. Maintain Sense Of Vulnerability2. Combat Normalization Of Deviance 3. Establish an Imperative for Safety4. Perform Valid/Timely Hazard/Risk Assessments5. Ensure Open and Frank Communications6. Learn and Advance the Culture
Key Organizational Culture FindingsWhat the Organization Did Not Do……..
Culture not Advanced,Failure to Learn
Safety Not An Imperative
Lack of OpenCommunication
Failure to Risk Assess
Normalizationof Deviance
Lacking a Senseof Vulnerability
Making Connections….
Culture not Advanced,Failure to Learn
Safety Not An Imperative
Lack of OpenCommunication
Failure to Risk Assess
Normalizationof Deviance
Lacking a Senseof Vulnerability
Making Connections….
Risk Level not Known to those Affected and/or Leading
Management System Failure
Culture not Advanced,Failure to Learn
Safety Not An Imperative
Lack of OpenCommunication
Failure to Risk Assess
Normalizationof Deviance
Lacking a Senseof Vulnerability
Making Connections….
Risk Level not Known to thoseAffected and/or Leading
Management System Failure
Culture not Advanced,Failure to Learn
Organization Choices…Effectively Learning from Incidents
Incidents Are a Tragedy…
….But the Biggest Tragedy Would Be Not to Learn From
Them
Serious IndustrialIncident
BREAKINGthe INCIDENT CHAIN
Serious IndustrialIncident
Serious IndustrialIncident
Serious IndustrialIncident
Serious IndustrialIncident
Vice President
Latent Causes – Define Culture“Organizations are Designed toGet the Results They Get”.
evaluation of 873 high-consequence incidents at 34 companies over a 12-month period
found that most investigations were fair in terms of quality
most companies took at least one corrective action for high-consequence incidents, but few of these corrective actions were confirmed as having been completed
most corrective actions were secondary interim administrative controls (e.g., having a safety meeting) rather than fair or strong controls (e.g., training, engineering elimination)
Fatalities
Injuries
Fatalities and Serious Incidents are Persisting in Industry
Activity or Program
Leadership Safety Training
Planned Inspections
Work Procedures or Practices
Incident Investigation
Observation of Work Activities
Emergency Preparedness
Work Rules
Codes of Practice
Permits and Isolations (Lock-Outs)
Individual/Team Training and Development
Personal Protective Equipment
Health Control
Risk Management
Change Management
Orientations and Personal Communications
Group Meetings
General Promotions
Hiring and Placement
Materials and Services Management
Chemical Management/Labeling
Wellness and Off-the-Job Safety
Security
Equipment/Tool Condition Checks
Fire Prevention
Housekeeping
Near Miss Reporting
Expenditure of a FiniteEffort to Achieve an Optimized Level of RiskManagement
Process Safety Management Elements
1. Accountability: Objectives and Goals 2. Process Knowledge and Documentation 3. Capital Project Review and Design Procedures 4. Process Risk Management 5. Management of Change 6. Process and Equipment Integrity7. Human Factors8. Training and Performance9. Incident Investigation10. Company Standards, Codes and Regulations11. Audits and Corrective Actions12. Enhancement of Process Safety Knowledge
The System View
Risk Management Effectiveness....
Optimizing Effort and Risk Benefit
Expenditure of a FiniteEffort to Achieve an Optimized Level of RiskManagement
Breaking the Incident ChainSite Selection & Design
Construction
Operation
Decommission/Closing
Major Tailings FacilityImpoundment Failure
Risk
Lev
el
Effort Expended
A
B
FiniteResource
Level
Risk Management Effectiveness....
Auditing for Performance….
0 10080Scored Activities
Curve “A” Curve “B”
Freeboard Insufficient(Water Balance Issue)
Dyke Erosion(Surveillance Issue)
DesignNonconformance
Major Tailings FacilityImpoundment Failure
Risk Ranking….Not All System Requirements are Equal
0 10080
0 105
Scored Activities
Critical Activities0 105
Critical Activities
Curve “A” Curve “B”
Risk Management Effectiveness....
FiniteResource
Level
Risk
Lev
el
Effort Expended
A
B
Safety as a Value
Life Saving Rules
Triggers
Critical Procedures
Critical Field Practice
Reference Procedures
General/Trade/Operator Practices
Qualification Training
Facility/Task Training
General Safety Training
Risk ProfileThe System View
Risk Ranking….Not All System Requirements are Equal
Risk
Lev
el
Effort Expended
Risk Management Effectiveness....
FiniteResource
Level
A
B
Policy
Fatality Risk Standards
Critical Control Management
Procedures, permits, plans and instructions
Assurance Governance
Review
Audit
Verify
Monitor
CEO
COO
RSVPs
GMs
16 Global Fatality Risks• Event in a confined space
• Contact with electricity
• Fall from height
• Uncontrolled release of energy
• Fall of ground – surface
• Fall of ground – underground
• Vehicle/pedestrian interaction – underground
• Vehicle/pedestrian interaction – surface
• Vehicle interaction – offsite
• Vehicle collision (heavy and light) – surface
• Heavy Vehicle event – rollover, over edge
• Uncontrolled load during lifting
• Entanglement in rotating equipment
• Underground fire and explosion
• Incident during tire handling
• Struck by falling object
Critical Controls Identified for Action
Fatality risk management process
EconomicSocietal Demands
Values
Societal Perception…Values
EconomicEnvironment
Societal Demands
Values
Societal Perception…Values
EconomicEnvironmentCommunity
Societal Demands
Values
Societal Perception…Values
EconomicEnvironmentCommunitySafety/Risk
Societal Demands
Values
Societal Perception…Values
design
design
1970 1980 1990 2000 2010 2020
The Journey……
