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Strategies for Understanding and AddressingStrategies for Understanding and Addressing

Risk ToleranceRisk Tolerance

January 2011January 2011

Presented by:Presented by:

D.J. (Dave) FennellSenior Safety Advisor, Imperial Oil Resources

Senior Technical Professional –Safety, ExxonMobil Production Company

On behalf of:On behalf of:

ExxonMobil Human Factors Center of ExcellenceExxonMobil Human Factors Center of Excellence


10 Factors Influencing Risk Tolerance10 Factors Influencing Risk Tolerance

Strategies for Reducing Risk ToleranceStrategies for Reducing Risk Tolerance

Actions to Address Risk Tolerance at Your WorksiteActions to Address Risk Tolerance at Your Worksite


Risk Perception and Tolerance Model

Hazard Identification “See it”

Risk Perception “Understand it”

Risk Tolerance “Accept or Reject it”

Maturity of Supporting Tools at ExxonMobil

Tools in place and Tools in place and being used, being used, effectiveness may effectiveness may lack in some areaslack in some areas

Mature safety culture will be Mature safety culture will be functional on this topic, functional on this topic, some areas will require more some areas will require more effort to understand the effort to understand the consequences of hazards. consequences of hazards.

Approaches for addressing Approaches for addressing tolerance are general weak tolerance are general weak across the company, this is across the company, this is the focus of this the focus of this presentation. presentation.


Incident, Near Miss or Questionable Item Occurs – Why?Incident, Near Miss or Questionable Item Occurs – Why?

Personal FactorsPersonal Factors 8. External Factors8. External FactorsJob FactorsJob Factors

Root Cause Analysis Flow Chart

5. Lack of or inadequate procedures

6. Inadequate communication of expectations regarding procedures or standards

7. Inadequate tools or equipment (availability, condition & use; workplace design)

Develop follow up actions

Implement follow up actions

Verify and validate follow up actions

1. Lack of skill or knowledge

2. Doing the job according to procedure or standards takes more time and effort

3. Short-cutting the procedure or standards has been tolerated

4. In past, not following procedure or standards did not result in an incident


RCAF Category Category Count

7. Inadequate Tools or Equipment 301

4. In the Past, No incident occurred 282

1. Lack of Skill or Knowledge 253

6. Inadequate Communication 191

3. Short-Cutting the standard has been Tolerated 148

2. Correct Way Takes More Time/Effort 137

5. Lack of or Inadequate Procedures 30

8. External Factors 24

Grand Total 1366

Conventional Operations Conventional Operations (Sept 3 2009)(Sept 3 2009)

42%42%


RCAF Category Category Count

7. Inadequate Tools or Equipment 349

1. Lack of Skill or Knowledge 330

4. In the past, no incident occurred 288

6. Inadequate Communication 244

2. Correct Way Takes More Time/Effort 177

3. Short-Cutting the standard has been Tolerated 152

5. Lack of or Inadequate Procedures 44

8. External Factors 13

Grand Total 1597

Cold Lake Operations Cold Lake Operations (Sept 3 2009)(Sept 3 2009)

40%40%


10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance

1.1. Overestimating Capability/ExperienceOverestimating Capability/Experience ↑↑

2.2. Familiarity with the TaskFamiliarity with the Task ↑↑

3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓

4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑

5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓

6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓

7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑

8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑

9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑

10.10. Role Models Accepting RiskRole Models Accepting Risk ↑↑


Hazardrecognitionandrisktolerance Hazardrecognitionandrisktolerance

Hazard Recognition and Risk ToleranceHazard Recognition and Risk Tolerance

Hazard RecognitionHazard Recognition Risk ToleranceRisk Tolerance==


January 2009


IOR Employees are generally quite good at Hazard IOR Employees are generally quite good at Hazard RecognitionRecognition

2008 Safety Perception Survey2008 Safety Perception Survey

• “ “Do employees understand the hazards of the Do employees understand the hazards of the operations they perform?” - operations they perform?” - 92%92%

• “ “Do you initiate action to correct hazards?” - Do you initiate action to correct hazards?” - 99%99%

• “ “Did you receive adequate safety training?” - Did you receive adequate safety training?” - 92%92%


• JSA often identifies the hazardJSA often identifies the hazard

• Hazard is discounted or no follow Hazard is discounted or no follow through on the mitigationthrough on the mitigation



1. Overestimating Capability/Experience ↑2.2. Familiarity with the TaskFamiliarity with the Task ↑↑










1) Overestimating Capability/Experience ““I can lift 75 kg in the gym ... I can lift this nitrogen bottle”I can lift 75 kg in the gym ... I can lift this nitrogen bottle”

““I have driven in worse conditions than this and did just fine”I have driven in worse conditions than this and did just fine”

Strategies for Reducing Tolerance• Reflect on your role as a mentor – the person who is watching may not have the same skill, experience or capability.

• Acknowledge that despite your ability, the exposure is still there.

• Acknowledge that the capability or skill may be sufficient and then reinforce the way that it should be done.

Factors Influencing Risk ToleranceFactors Influencing Risk Tolerance


10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑

2. Familiarity with the Task ↑










2) Familiarity with the Task - Complacency - Complacency

Strategies for Reducing Tolerance• ‘Situational Awareness’ – Treat every time like the first time .... ‘Stop and Think’

• ‘What could go wrong this time?’

• ‘How would I teach a new person to do this?’

• ‘Do I still do it by the book? Have I just been luck?’


““He had done this task 500 times He had done this task 500 times without hurting himself”without hurting himself”

““We had stack about 200 of them We had stack about 200 of them when ...”when ...”

““I do it about 10 times every day”I do it about 10 times every day”




3. Seriousness of Outcome ↓









3) Seriousness of the Outcome ‘‘Pinch Point’ ... what about ‘Crush’ or ‘Amputation’ pointPinch Point’ ... what about ‘Crush’ or ‘Amputation’ point

Strategies for Reducing Tolerance

• Stop and Think “How bad could it be? No, really ...How bad could it be?”


Cable suddenly tightened andIP’s hand became trapped between cable and wench drum.““Sweet gas” ??Sweet gas” ?? “Hot Water” ??“Hot Water” ??


The Event:

While backing a truck/trailer onto a barge, the driver lost sight of the deckhand who was providing direction. The driver continued to move the trailer back after losing sight of the signaler - pinning the signaler's legs between the back of the trailer and a toolbox on the deck. The deckhand suffered soft tissue injuries to their legs (luckily, no broken bones)

The Learning:The driver of the truck did not stop when losing sight of their signaler.The signaler put themselves in the line of fire after losing eye contact with the driver. Several fatalities occur in Alberta each year where drivers have backed over their signalers. The standards in the Safety Management System (Section 6 Subject 11 Page 6-91) state:

Drivers must:• stop if they lose sight of a signaler

Actions:Ensure all drivers:

- understand the standards for signalling,

- understand their responsibility to maintain eye contact with their signaler

- understand the consequences of not strictly adhering to this standard.

Signaler Pinned by Truck

Deckhand pinned here





4. Voluntary Actions and Being in Control ↑








4) Voluntary Actions and Being in Control

Strategies for Reducing Tolerance• Integrate ‘Stop and Think’ into your personal activities

Key factor in off the job risk – Key factor in off the job risk – 28 times more likely to be hurt off the job more likely to be hurt off the job







5. Personal Experience with an Outcome ↓







5) Personal Experience with an Outcome If you have seen a serious outcome, you will be less tolerant of the riskIf you have seen a serious outcome, you will be less tolerant of the risk

Problem: As Incident Rates improve, fewer people will have had As Incident Rates improve, fewer people will have had personal experience and leads to personal experience and leads to Scepticism

Strategies for Reducing Tolerance• ‘‘Expert observers’, supervisors, ‘keepers of the corporate memory’ have Expert observers’, supervisors, ‘keepers of the corporate memory’ have the obligation to ensure workers know :the obligation to ensure workers know : a) Incidents a) Incidents havehave occurred because of not following that standard (i.e. occurred because of not following that standard (i.e. What could go wrong?)What could go wrong?) b) Demonstrate that there b) Demonstrate that there havehave been serious consequences (i.e. How bad been serious consequences (i.e. How bad could it be?)could it be?)



Well Servicing Fatality - May 2002

A well servicing worker was fatally injured when he was pulled into the rotating draw works by the strap on his fall arrest harness.

1) Loose clothing and personal protective equipment around rotating equipment

2) Equipment guarding

Draw works guard railRe-enactment of how straps were caught

Straps caught here







6. Cost of Non-Compliance ↓






6) Cost of Non Compliance


• Identify the cost of non compliance and increase it where necessary

• Remove barriers and increase reward for compliance

Greater cost of non compliance lowers risk toleranceGreater cost of non compliance lowers risk tolerance

Aviation industry – Low risk tolerance, strictly regulated, high Aviation industry – Low risk tolerance, strictly regulated, high cost of non-compliance. cost of non-compliance.









7. Confidence in the Equipment ↑





7) Confidence in the Equipment

““Ladder is twice as stable, therefore ... ”Ladder is twice as stable, therefore ... ”

• 1995 US Study – Cars with ABS have more accidents, no safety gain 1995 US Study – Cars with ABS have more accidents, no safety gain with airbags because drivers became more aggressive.with airbags because drivers became more aggressive.

• Parachuting – Failure to deploy replaced with late deploymentParachuting – Failure to deploy replaced with late deployment

Strategies for Reducing Tolerance• Training on limitations of the equipment and engineering

• Stop and Think ... What will happen if it does fail?










8. Confidence in Protection and Rescue ↑




8) Confidence in Protection and Rescue •British study – workers with back belts tend to lift greater weights


• Understand the limitations of protection & rescue measures• See them as ‘last lines of defence’, or ‘not to be relied upon’ ?• “Every job should be able to be done safely by a 65 year old with a bad back and ...” Howie Dingle











9. Potential Profit & Gain from Actions ↑



9) Potential Profit and Gain from Action • US Highways Study – deaths on highways tracks directly with the US Highways Study – deaths on highways tracks directly with the economyeconomy

• Alberta WHS – fatalities and lost time incidents in the oil patch increase Alberta WHS – fatalities and lost time incidents in the oil patch increase and decrease with the price of oil. and decrease with the price of oil.


• Remove rewards for risk taking

• Eliminate barriers to doing it the ‘right way’












10. Role Models Accepting Risk ↑↑


10) Role Models Accepting Risk • When Role Models in a work group accept a certain level of risk, they When Role Models in a work group accept a certain level of risk, they influence the decisions to accept risk by other members of the group. influence the decisions to accept risk by other members of the group.


• Identify and address the risk takers immediately address the risk takers immediately (including yourself – where are you on the ‘risk-taking’ scale?)

• Recognize ‘Erosion of Standards’ and address immediatelyRecognize ‘Erosion of Standards’ and address immediately



What Could Go Wrong?What Could Go Wrong?

1)1) Review the serious incidents that have happened in the past Review the serious incidents that have happened in the past and learn from these incidentsand learn from these incidents

• Coach workers on how to recognize new hazardsCoach workers on how to recognize new hazards

• Recognize potential consequences of those hazardsRecognize potential consequences of those hazards

• Reduce the tolerable level of risk Reduce the tolerable level of risk

• Calibrate others so their judgement is at the same lowest Calibrate others so their judgement is at the same lowest acceptable level of riskacceptable level of risk


How Bad Could It Be?How Bad Could It Be?2)2) Use ‘safety conversations’ (LPO, Stop and Think, Safety Use ‘safety conversations’ (LPO, Stop and Think, Safety

Meetings) to increase awareness on potential outcomes. Meetings) to increase awareness on potential outcomes.

• Keep the ‘corporate memory’ aliveKeep the ‘corporate memory’ alive

• Risk is impacted by the number of ‘Barriers’ between Risk is impacted by the number of ‘Barriers’ between actions and outcomesactions and outcomes


What can I do about this?What can I do about this?2)2) Follow up on the ‘Personal Risk Behaviours’ identified at Follow up on the ‘Personal Risk Behaviours’ identified at

Fresh Start:Fresh Start:

a) Hold safety meeting discussions (or one on one a) Hold safety meeting discussions (or one on one during LPO’s) on what they identified and their progressduring LPO’s) on what they identified and their progress

b) Ask workers to share their identified personal risks b) Ask workers to share their identified personal risks and commitments to change at safety and commitments to change at safety meetings. (Start meetings. (Start by sharing yours). by sharing yours).

c) Continue to use the ‘Personal Risk’ Stop and Think c) Continue to use the ‘Personal Risk’ Stop and Think cards with the expectation of identifying cards with the expectation of identifying another personal another personal at risk behaviourat risk behaviour


““Together with our contractors we can create Together with our contractors we can create the safety culture that lowers Risk Tolerance”the safety culture that lowers Risk Tolerance”

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