Improving safety by focusing on critical controls
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Peter Wilkinson, GM of Risk at Noetic Group, gave a presentation at the Tasmanian Safety Symposium on managing safety via a focus on critical controls. He discussed how most incidents occur due to failures to implement known controls, not from lack of knowledge. Wilkinson advocated for a critical control approach that simplifies risk management by identifying the few controls that really matter for each risk and prioritizing active monitoring of their implementation, rather than relying on complex documentation alone. This approach provides clear accountability for critical control implementation and health monitoring to serve as an early warning system and metric for risk management performance.
Improving safety by focusing on critical controls
- 1. TASMANIAN SAFETY SYMPOSIUM Hobart 18 May 2017 Peter Wilkinson GM – Risk Noetic Group
- 3. What will I talk about? No new accidents…? How do incidents occur? Managing Safety via a focus on Critical Controls Culture – Is there any such thing as Safety Culture? Discuss some international developments in managing critical controls Critical Control Approach is no more than a more rigorous application of what we already do! Critical Controls 3
- 4. We know how most bad things happen….! Most incidents result from failure to apply and not a failure to know The types of incidents are well known The Causes of incidents are also well known Good Practice on how to control the causes is also known Critical Controls 4
- 5. Risk Causation – A Failure to Implement? Most risk events involve: Failure to implement well known controls for well known risks Examples: Barings Bank (1792 – 1992) Nick Leeson – A “rogue” trader? Societe General (2008) $7.5bn loss…another “rogue” trader? Montara blow out – Australia 2009 BP Macondo/Deepwater Horizon 2010 $60bn loss And many more…! Causation Each incident is unique in fine detail – but fundamentally the same failures are evident across all risk domains – from safety in oil and gas to the finance sector to not for profit to health care Critical Controls 5
- 6. Measuring Safety and Safety Myths eg 80% of all incidents are caused by human error • Over Focus on LTIFR/TRIFR • Lagging indicators - Looking in the rear view mirror and routinely gamed – slip on step example • Over – focus on front line worker behaviour • Little relevance to occupational health or process safety • Can lead to blame rather than explanation • Temptation to manage the measure • Behavioural Based Safety systems – “The magic bullet or a shot in the dark? Critical Controls 6
- 7. How do incidents occur? Critical Controls 7 Human errors System, process, procedural issues Engineering, Technology and software
- 8. Managing Safety We usually assume that accidents involve: Mistakes or errors by individuals Procedures Engineering The prevailing view on accident prevention (and what the law requires) is that we : Assess the risks identify controls Implement the controls Having identified the controls – what do we do next? Prepare a bow tie? Provide instruction and training? Write a procedure? Critical Controls 8
- 9. A CRITICAL CONTROL APPROACH? Or a focus on what really matters…. 9Critical Controls
- 10. CRITICAL CONTROL APPROACH Some underpinning assumptions : + Not new approach and uses Swiss Cheese analogy + Most Hazards, Risk and Controls are known + Implementation of controls more difficult 24/7 than identifying what the controls could or should be + Some controls are more important than others Active Monitoring is essential Volume of hazard management documentation is of itself a barrier - Less can be more/better Critical Controls 10
- 11. Typical Situation Strong focus on personal safety especially fatality risk Often have a variety of systems, procedures, policies, practices Procedures, SOPs and Risk Assessments used to manage risks - Quality often good but ease of use varies due: length, Complexity Clarity Usually a gap between Policy and Practice (Work as Imagined vs Work as Done) Is it clear which are the risk controls that really matter? Monitoring how well controls are implemented in practice frequently weak Critical Controls 11
- 13. Critical Controls 13 Large no. of controls Processes & procedures Complex bowties “shelf-ware” What really matters? Simplified Bowtie Critical control summary sheet SME
- 14. Simplified Model of Monitoring Critical Controls 14 Managers Ensure Supervisors have systems for monitoring critical controls and carry out some monitoring themselves. Supervisors Monitor implementation of critical controls by operators Front line workers Do the work! Carry out their own monitoring – including each other Audit
- 15. The Critical Control Approach 15 Critical Control Information Summary – Steam Plant Risk Owner……………. Control Owner………… 1. Title of the critical control 2. What are its specific objectives 3. What are the critical control performance requirements to meet the objectives? 4. What are the activities that support or enable the critical control? 5. What activities can be checked to verify the control is working as implemented? Critical Controls
- 16. Critical Controls 16 Process Safety Hazard: Loss of Containment of Sulphuric Acid Threat: Overfilling a Storage Tank Critical Control: Unloading Operator Competency Control Definition: Training and competency of unloading personnel Control Owner: Warehouse Superintendent Key Control Activity Desired Outcomes of Key Control Activity Validation of Effectiveness Ensure that the delivery drivers have completed a specific acid area induction. All drivers know exactly where to go, what the unloading arrangements are and what their responsibilities are in relation to safe transfer of acid Verify that drivers have completed the inductions (training records) and talk to a sample of drivers to assess their level of knowledge. Ensure delivery drivers have received specified training All delivery drivers are trained, competent and authorised to unload as per PRO XYZ 056 As above Ensure delivery drivers are included in D&A testing All drivers are free of drugs and alcohol Verify the D&A testing programme includes all drivers and that all results are negative
- 17. 17 Risk : Steam Boiler Explosion Risk Owner: Mill Manager Control Owner: Production and Maintenance Superintendent 1. Title of the critical control: Low Water level control 2. What are its specific objectives: Maintain boiler feed level within OEM specified limits 3. What are the critical control performance requirements? 4. What activities are needed to support the critical control? 5. What checks are needed to verify the control is working? + Low water condition is automatically detected + Heat source is cut off + Audible and visual alarm operates MMS generates PM routines for each part of low water level control Quarterly Report to Mill Manager Critical Controls
- 18. What does good look like? “What really matters” in terms of risk controls is known + Purpose, Scope, Objectives are clear + Performance standards specified There are clear accountabilities for: + control implementation + control monitoring The “health” of controls is routinely and honestly monitored Control “health” is used to measure the likelihood of a risk eventuating Weak controls are seen as early warning signs - bad news about controls is welcomed, rewarded and actioned Reporting is based on control “health” Strategic (or material) risks are a routine part of Executive Meetings Critical Controls 18
- 19. And a word on Culture Culture: “…remains a confusing and ambiguous concept…little evidence of a relationship between safety culture and safety performance…” Values + Practices = Culture (John Coleman, Harvard Business Review); Andrew Hopkins and Edgar Schein say much the same. Values can be faked – Practices are visible. In good cultures; Values and Practices are in synch To improve culture as applied to safety – a focus on practices is likely to be more successful. Practices repeated are “How we do things round here.” Putting Safety Critical Controls at the heart of the prevention (and mitigation) strategy for process safety is good for the culture! Critical Controls 19
- 22. The End! Critical Controls 22
Editor's Notes
- #5: The types of MAEs are well known The Causes of MAEs are also well known Good Practice on how to control the causes is also known Our Research shows that MAEs result from failure to apply well known barriers effectively and NOT a failure to know what the barriers are.