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Platform ZERO Incidents

Blame and Just Culture: (The importance of transparency and trust in

achieving Zero Incidents)

10th December 2015

Ed Barsingerhorn GM Europe / Africa

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30 Minutes

• Show believe/Support in PZI

• Culture (and the just part)

• Leadership (a role within the culture?)

• Partners in Safety

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(Safety) Culture

• How the organisation behaves when no one is watching

• Refers to the way that safety issues are addressed in a workplace

• The attitudes, beliefs, perceptions and values that employees

share in relation to safety

• The way ‘we do safety around here’

• That assembly of characteristics and attitudes in organizations and

individuals which establishes that as an overriding priority safety

issues receive the attention warranted by their significance

• Culture: that complex whole which includes knowledge, belief, art

morals, law, customs and any other capabilities and habits by man

as a member of (society)……..

• Those aspects of the organizational culture which will impact on

attitudes and behavior related to increasing or decreasing risk

• Forms the environment within which individual safety attitudes

develop and persist and safety behaviors are promoted

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1. Maintain Sense Of Vulnerability

2. Combat Normalization Of Deviance

3. Establish an Imperative for Safety

4. Perform Valid/Timely Hazard/Risk Assessments

5. Ensure Open and Frank Communications

6. Learn and Advance the Culture

ORGANIZATIONAL CULTURE: WHAT NASA DID NOT DO

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Group Golden Rules

You and I

• Comply with the Law, Standards and Procedures

• Intervene in unsafe and non-compliant situations

• Respect our neighbours

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Consequence Management

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WHY LIFE SAVING RULES?

Aim is to prevent harm to people

12 high-risk operations at work

Consistent set of rules > culture of compliance

Not new. Most staff adhere already every day

Mandatory Compliance for work-related activities

Applicable to all operations under Shell’s

operational and/or governance control

JVs encouraged to participate

Each reported non-compliance will be investigated

Failure to comply will result in disciplinary action,

up to and including termination of employment for

Shell employees or, for employees of contractors or

sub-contractors, removal from site and

disqualification from future Shell work.

Supervisors are held accountable to

communicate and ensure compliance 6

Life-Saving Rules

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12 Life Saving Rules

Life-Saving Rules – what are they?

Work with a valid work

permit when required

Conduct gas tests when required

Verify isolation before work

begins and use the specified life

protecting equipment

Obtainauthorisation

before entering a confined

space

Obtainauthorisation before

overriding or disabling safety

critical equipment

Protect yourself against a fall when working at height

Do not walk under a

suspended load

Do not smoke outside

designated smoking areas

No alcohol or drugs while working or

driving

Wear your seat belt

While driving, do not use your phone and do not exceed

speed limits

Follow prescribed Journey

Management Plan

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7

2

8

3 5

11

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129 10

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Note: Commuting, alcohol in social settings and smoking in office environments are out of scope

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Reporting

Reporting is not about blame. It’s about collecting information to help us understand why rules are being broken and what we need to do to make sure it doesn’t happen again.

When you see someone break a Life-Saving Rule:

1. STOP IT

2. REPORT IT

3.CORRECT IT

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Since the Life-Saving Rules were introduced in 2009…

LOST TIME INJURIES HAVE REDUCED BY

42%

FATAL INCIDENTS HAVE REDUCED BY

75% THIS MEANS OVER

30 LIVES MAY HAVE BEEN SAVED (per annum) SINCE THE LIFE-SAVING RULES WERE IMPLEMENTED

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Just Culture Consequences for the Individual

Descriptions of rule related behaviour

Consequences for their Supervisor/Manager

I thought it was better for me

personally to do it that way

I thought it was better for the

company to do it that way

I can’t follow the procedure

and still get the job done

Other people here do it

the same way

Did they think they were

doing it the correct way?

Did they follow all procedures

and best practices?

I meant to do it my way and

thought I would get away with it

Aware of this happening before?

Reckless violation Personal

optimizing violation

Optimizing violation Situational violation Routine violation Unintentional violation Normal compliance

Reckless violation Personal

optimizing violation

Optimizing violation Situational violation Routine violation Unintentional violation Normal compliance

Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes

Yes

Yes Yes

No No No No No No

No

11 Shell Global Solutions PTD/HHSC

A “HIGHLY RELIABLE” SAFETY CULTURE (GENERATIVE)

Ownership of HSSE - HSSE is part of everyone’s job… promotion of high degree of self- sufficiency within the organisation

Wariness – we’re not complacent about good performance, but are constantly uneasy about what could go wrong … for ourselves and our colleagues… we’ve always got HSSE at the front of our minds …..leaders challenge green and red traffic lights

Just - we get recognised and rewarded when we do good things … but we know we will be treated fairly if things go wrong; a ‘no blame’ culture, with a clear line between the acceptable and unacceptable

Learning – we are open to understanding and addressing the root causes of problems, not just treating the symptoms… we recognize that learning requires time for reflection and understanding ... and that ultimately drives changes in behavior

Informed - our leaders are involved and competent …they know what goes on…. they accept bad news, not just the good… information is shared quickly

Willing to intervene - we always speak up when we feel something is not quite right…. no one walks past a problem or unsafe act without taking time to address it

Empowered - we are competent and trusted to do the right thing

Able to walk the talk - we all do what we have committed to do - there is no “say do” Gap

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79.000 hits in Shell System

USING THE DECISION TREE

Were the actions

as intended?

Knowingly breached

procedures?

Pass Peer test?

History of prior

misinterpretations?

Were the results

as intended?

Procedures clear and workable?

Defective training/

experience?

Training needed

Unintentional

Error

Malevolent act

Reckless Violation

System Induced error

System produced

error

Negligent

NO NO

NO NO

NO NO

NO YES YES

YES YES YES

YES

YES

Termination

Disciplinary letters

Counselling/coaching Verbal warning

Were the actions as in tended?

Were the resultsas in tended?

Sabotage orMalevolent

Act

RecklessViolation

SystemInducedViolation

Knowingly Violating Procedures?

Procedures Clearand Workable?

Pass Substitution Test?

DefectiveTraining, Selection

Experience

NegligentError

SystemProduced

Error

NO NO YES

*

*

Verbal Warning

First Warning Letter

Final Warning Letter

Dismissal

Diminishing Individual Culpability

Managemen t/super vis ion respons ibil ityto co rrect root cau se s o f sy stem is su es

Increas ing Individual Culpability

The Rules of Fair PlayDecision Tree

Coaching

TrainingRequired

NO BlameError

History of Violating procedures?

YES YES

YESYES

YES

YES

NO

NO NO

NO

NO

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The Just Culture

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HSSE-SP Leadership

Talking about leaders;

Who is the safest president of the USA?

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Obama,…?

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Or Bush jr .., ?

17 Shell Global Solutions PTD/HHSC

Leadership challenges

Leaders face choices/dilemmas e.g. safety vs. costs vs. schedule

Leaders are role models – whether they choose to be or not

A leader’s behaviour impacts those around them and thus creates the “culture” of the organisation

Leaders are judged by the things they do and say – not by their intent

“ Excelling in HSSE and social performance requires doing the right thing proactively,

before being prompted by events.

It’s about showing care for people and the environment, working together effectively

across functions and with contractors as one integrated team, and making use of

existing tools and processes.

It requires leadership follow-through to ensure that good work is sustainable.”

18 Shell Global Solutions PTD/HHSC

What is “Good HSSE Leadership”

Shell has identified five requirements:

Be mindful of HSSE risks;

Demonstrate visible and felt HSSE leadership through measurable actions;

Motivate, coach and develop personnel in effective HSSE management; and

Hold individuals accountable for their HSSE behaviors and performance.

Engage with stakeholders about HSSE

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JanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFebMarAprMayJun JulAugSepOctNovDecJanFeb

2006 2007 2008 2009 2010 2011

Fre

qu

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mill

ion

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urs

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rs (M

illio

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Total Hrs (Monthly) Total Kms(Monthly)

LTIF (12M) Pearl GTL TRCF (12M)

HSE Performance – 10 times lower LTI than Industry Average

OGP 2009 TRCF 1.75

OGP 2009 LTIF 0.45

Middle Mgt Engaged

Leadership highly visible

Enrolling leadership

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30 minutes further

• Show believe/Support in PZI

• Culture (and the just part)

• Leadership (a role within the culture?)

• Partners in Safety – Recognition / story

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