An Intellectual Joust - Challenge -- Are you willing to confront propositions that jolt your safety management comfort zone ?

TapRooT® Summit 2006 - Gatlinburg, TNThursday, 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, Australiajim@workplaces.com.au

Challenge # 1 All behavior depends upon risk perception.

Agree ? or Disagree ?

If we label/describe an employee’s actions as :-• stupid or careless or lazy or negligent does that mean all we are saying is that :- the employee’s risk perception is different to ours?And

Whose problem is that ? The employee’s 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 (cont’d) All decisions are risk management decisions

Why do men die younger ?

Risk Perception

is

Risk Reality !!

RiskPerception ??

workplacesrisk @ pty ltd

RiskPerception ??

workplacesrisk @ pty ltd

Looking into people’s minds !What makesintolerablerisk -takers ?

workplacesrisk@ pty ltd

All behaviourdepends onris k perception

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”

Audience participation

What is the second most common word used in safety ?

And isn’t defined ?

“unsafe”What is first ? – the most common?

“don’t”

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 # 4Which 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 incidentORWe 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 ?

We won’t do anything around here, unless it is Safe !!

Two faced ?Double talk ?

workplacesrisk @ pty ltd

ACN 082 987 675

Zero injuriesnot

Zero risk

and we only TOLERATEfully managed risks !!

workplacesrisk @ pty ltd

ACN 082 987 675

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.

Table 4: Risk Ranking Matrix

Consequence

1 2 3 4 5 6

6 7 8 9 10 11 12

5 6 7 8 9 10 11

4 5 6 7 8 9 10

3 4 5 6 7 8 9

2 3 4 5 6 7 8

1 2 3 4 5 6 7

Key: 11-12 =Extreme risk 8-10 = High risk 5-7 = Moderate risk 2-4 = Low risk

Lik

elih

oo

d

On track OTMaintenancerequests info

TCmakes

paper record

TCperformance

impaired

TCInattentive

Train / OTVehicle

hits workers

length ofmessage

Frequency ofRequests

radio

Oralprocess

mobilephone

TC does notfollow correct

process

OT workersexposed tosafety risk

OT safetyproceduressucceed

WorkerInjury

NearMiss

Workerfatality

PropertyDamage

only

audiotaperecord

Time ofday

PersonalFactors

Workfactors

ExcessiveStress

Fatigue

RosterStructure

No ofconsecutive

shifts

excessiveovertime

time of day

insufficientbreak between

shifts

insufficientrest breaks

during the shift

externalpressures

internalpersonality

domesticfinancial

socialpressures

Train TrafficDensity

Stage of Shift

Safe workingsystem &corridor

length of"on-the-board"time - 6 or 8

TC issuesincorrect info

OT workersnot advised

Train Diagramproblems

TC does notcheck repeat

back info

TC allows train or OTvehicle to depart

before time

TC does notelectronicallyBlock Section

TC does notmark diagram

TC does notcheck diagram

TC marksdiagram

incorrectly

OT worker does notget to "safe" position

speed of train/ OT vehicle

Vigilance ofworker

5 secondprotection

Visibilityproblems

lookoutsdo not work

Visibilityproblems

Representative Risk Scenario Mapwith risk factors and significant events

OT protectionsystems fail

Set / Choose P Probability of WHOLE scenario completing to chosen Consequence

PScore

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 000to 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

How to calculate risk ?

Use R3 Risk Calculator©

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(cont’d)

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

ALARPRegion

Increasing Individual Risk

and Societal Concerns

Risks cannot be justifiedIntolerable

RegionX

Negligible Risk

BroadlyTolerableRegion

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 FrameworkRisk

ScoreRisk

DescriptorAll categories of

Risk except safety or environment

Safetyand

Environmental Risks12

Extreme Board Approval

Required for Risk Intolerable11

10

High

Senior Executive Approval Required

9 Level 2 Manager Approval Required

8Risk must be

managed in line with the ALARP Principle

Risk must be managed in line with the ALARP Principle ( Note 1 )

7

ModerateRisk must be managed in line with

the ALARP Principle6

5

4

LowNo approval required

but ongoing monitoring and management is required3

2Note 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 ?

Advantagesof the“ Manual ” Approach

Confidence - Assurance Demonstration of :-

CorporateStandardisationConsistencyDue DiligenceDifferent Users &Training Needs

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 ACTChoiceIntent

- Could have- Should have- Wanted to- Needed to- Supposed to--Tried to

Error ? or Substandard Act ? ( Both have Good Reasons )

Challenge # 9Why 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

- don’t take shortcuts - always choose the standard way

Challenge # 10

Why do safety people like the word DON’T ? Does such negative thinking / perceptions actually marginalize safety people from the real business world ?

Do people come to work to DO or to DON’T ?

Do we want to be told what we CAN do or always be told what we CAN”T 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 can’t 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 are predictableHence ALL are manageable / controllable !

Philosophy of Causal / Risk Analysis

* ALL rational behaviour is done(by definition) for “good” reasons

* The Onus on the Investigator / Analyst isto get people to share their“good” reasons

* The best Investigations / Analyses occur within “fair and just” cultures

workplacesrisk @ pty ltd

* The Causal Factors of today’s incident are the Risk Factors of tomorrow’s !

Better risk understanding NOT more risk taking

workplacesrisk @ pty ltd

Wiseworkplacesrisk @ pty ltd

Risk Makers

Risk Takers

need to bea Teamof

Risk Managers

&

workplacesrisk @ pty ltd

ACN 082 987 675

Reachfor theachievable !

workplacesrisk@ pty ltd