Professional Documents
Culture Documents
3
Safety Performance by Industry
Sector
Injuries & illnesses per 200,000 hours worked (2002)
4
Relative risks of fatal accidents in the work
place of selected occupations
Fishers (as an occupation) 35.1
Timber cutters (as an occupation) 29.7
Airplane pilots (as an occupation) 14.9
Garbage collectors 12.9
Roofers 8.4
Taxi drivers 8.2
Farm occupations 6.5
Protective services (fire fighters, police guards, etc.) 2.7
Average job 1.0
Grocery store employees 0.91
Chemical and allied products 0.81
Finance, insurance and real estate 0.23
Sanders, R.E, J. Hazardous Materials 115 (2004) p143, citing Toscano (1997)
5
Chemistry Industry
Association of Canada
Member Performance
CIAC website
www.canadianchemistry.ca
Staff contact: Stephanie Butler
613-237-6215 x 245
6
Incident Pyramid:
1 Serious/ Disabling/ Fatalities
Process hazard
A physical situation with potential to cause
harm to people, property or the environment
Risk (acute)
probability x consequences of an undesired
event occurring
8
They thought they were safe
Good companies can be
lulled into a false sense of
security by their
performance in personal
safety and health
They may not realise how
vulnerable they are to a
major accident until it
happens
Subsequent investigations
typically show that there
were multiple causes, and BP Deepwater Horizon
many of these were known
long before the event
9
Why and how defences fail
People often assume systems work as
intended, despite warning signs
Examples of good performance are cited as
representing the whole, while poor ones are
overlooked or soon forgotten
Analysis of failure modes and effects
should include human and organizational
aspects as well as equipment, physical and
IT systems
10
Process safety management
Recognition of seriousness of consequences
and mechanisms of causation lead to focus
on the process rather than the individual
worker
12
Functions of a management system
Planning
Measurement Direction Organizing
Structure
Leadership
Implementing Controlling
Detailed work plans Performance standards and
Specific milestones for accomplishments measurement methods
Initiating mechanisms Checks and balances
Performance measurement and
reporting
Internal reviews
Variance procedures
Audit mechanisms
Corrective action mechanisms
Procedure renewal and reauthorization
Planning
Planning
Organizing
Planning
Organizing
Implementing
Implementing
Organizing
16
Use of self-assessment tool for
collective progress reporting and action
17
Process-Related Incident Measure (PRIM)
2007 Findings: All Elements
18
Assessing an organizations safety effectiveness
20
Excellent guidance
exists but how is it
being used?
21
The New Product Introduction Curve
adoption
Percent
In E Ea La La
no ar rly gg
va ly te ar
to Ad M M ds
rs o aj aj
pt or or
er ity it y
s
Can be applied to adoption of new ideas
Categories differ by ability and more importantly, motivation
22
Accountability
23
Management of Change
24
Process and Equipment Integrity
Design to handle all anticipated conditions, not just ideal
or typical ones
Make sure what you get is what you designed
(construction, installation)
Test to make sure the design is indeed valid
Make sure it stays that way
Preventative maintenance
Ongoing maintenance
Review
Be especially careful of automatic safeguards
25
Consider operator as
fallible human
performing tasks in
background
Buncefield, UK
26
Realization of significance of sociocultural factors in
human thought processes and hence in behaviours
27
Human behaviour aspects Familiarity to
engineers
People, and most organizations, dont More
intend to get hurt (have accidents)
To understand why they do leads us
eventually into understanding human
behaviour, both at the individual and
organizational level, and involves:
Physical interface
Ergonomics
Psychological interface
Perception, decision-making, control actions
Human thought processes
Basis for reaching decisions
Ideal versus actual behaviour
Social psychology
Relationships with others
Organizational behaviour
Less
28
Human behaviour modes
Instead of looking at the ways in which people can fail, look at how they
function normally:
Skill-based
Rapid responses to internal states with only occasional attention to
external info to check that events are going according to plan
Often starts out as rule-based
Rule-based
IF, THEN
Rules need not make sense they only need to work, and one has
to know the conditions under which a particular rule applies
Knowledge-based
Used when no rules apply but some appropriate action must be
found
Slowest, but most flexible
29
Reasons Cheese Model
James Reason, presentation to Eurocontrol 2004
30
Active and latent failures
Active
Immediately adverse effect
Similar to unsafe act
Latent
Effect may not be noticeable for some time, if at all
Similar to resident pathogen. Unforeseen trigger conditions
could activate the pathogens and defences could be undermined
or unexpectedly outflanked
31
A Classic Example of a Latent
Failure
Hazard of material
known, but lack of
awareness of potential
system failure mode
leads to defective
procedure design
through management
decision
Epichlorhydrin fire,
Avonmouth, UK
32
And another
Hazard of material
not obvious (despite
history)
Latent error allowed
dust to accumulate,
Scottsbluff, NE 1996
creating conditions
for subsequent
events
Finance shows:
Relevance of such factors without technical
distractions
How fast a system can deteriorate once controls are
relaxed
How wrong risk assessments can influence bad policy
decisions
35
Relevance of organizational factors
37
In general, safety gets better as society learns more
Standard
of Safety
Time
38
But the rate of improvement is not steady
Standard
of Safety
x 10
Time
39
In fact, the curve can be one of periodic rapid gains
followed by gradual but increasing declines
x 100
Time
40
Organizational Culture Model
James W. Bayer, Senior VP Mfg, Lyondell Chemical Company
Strong
Tribal Operational
Excellence
People
Chaotic Bureaucratic
Demographic effects
Less staff
Experienced cohort leaving or left
Skills transfer senior > (middle) > junior
Replacements understand the way something is done,
but not why it is done that way, the potential
consequences of doing it differently and how to detect
and recover from undesired actions
42
What does an organizations investigation
of its failures reveal about its:
Culture
Management system?
43
Knowledge
Never realized problem could occur (benchmarking error)
was it treated as a unique deficiency?
was there a broader review of the benchmarking process to find if there are
other areas where knowledge could be deficient?
Policy
Thought situation would be acceptable but didnt realize full implications
until it happened
Does it appear to be acceptable now?
Was review of policy and accountability limited or broad in scope?
System design
Even if everything had been done as intended, problem would still have
occurred
How comprehensive was analysis of system deficiencies and practicality of
solutions?
How effective is action plan and follow through?
Was review of system design limited or broad in scope?
System execution (management system error)
Problem occurred because someone or something did not perform as
intended
Did analysis consider why execution not as intended?
Was corrective action appropriate and balanced?
Was review of system execution limited or broad in scope? 44
Dealing with a Safety (or Engineering) Problem
Finding out who youre dealing with
Where is the organization on the curve? (generally, and re the specific issue or problem)
Where are the people youre dealing with on the curve? (generally, and re the issue or
problem)
Finding out what to do
Benchmark dont try to reinvent the wheel unless youre sure there isnt one already
(or youve time and its fun to do so)
Find out what others are doing about it
Read the instructions
Identify/define the issue
If its likely to be regulated, check with government agencies, trade associations, web,
internet
If not regulated but likely good industry practice, check suppliers, other users of same
material or item, other users of similar items, other industry contacts but test the info!!!
(cross-check, ask if it makes sense)
Check standard reference works, (Lees, CCPS, etc)
Doing it
Try to think of all situations that are likely to occur (process, eqpt, people)
KISS, keep it user-friendly, show basis for decisions if practical to do so
Follow up afterwards to see how its working
45
Questions?
46