D.J. (Dave) Fennell Senior safety Advisor, Imperial Oil Resources Senior Technical Professional -Safety, exxonMobil. 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.
D.J. (Dave) Fennell Senior safety Advisor, Imperial Oil Resources Senior Technical Professional -Safety, exxonMobil. 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.
D.J. (Dave) Fennell Senior safety Advisor, Imperial Oil Resources Senior Technical Professional -Safety, exxonMobil. 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.
Strategies for Understanding and Addressing Risk Tolerance January 2011 Presented by: D.J. (Dave) Fennell Senior Safety Advisor, Imperial Oil Resources Senior Technical Professional Safety, ExxonMobil Production Company On behalf of: ExxonMobil Human Factors Center of Excellence Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors Influencing Risk Tolerance Strategies for Reducing Risk Tolerance Actions to Address Risk Tolerance at Your Worksite Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 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 being used, effectiveness may lack in some areas Mature safety culture will be functional on this topic, some areas will require more effort to understand the consequences of hazards. Approaches for addressing tolerance are general weak across the company, this is the focus of this presentation. Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
Incident, Near Miss or Questionable Item Occurs Why?
Personal Factors 8. External Factors Job 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 Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 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 (Sept 3 2009) 42% Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 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 (Sept 3 2009) 40% Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Hazardrecognitionandrisktolerance
Hazard Recognition and Risk Tolerance
Hazard Recognition Risk Tolerance = Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com January 2009 Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com IOR Employees are generally quite good at Hazard Recognition 2008 Safety Perception Survey Do employees understand the hazards of the operations they perform? - 92%
Do you initiate action to correct hazards? - 99%
Did you receive adequate safety training? - 92%
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com JSA often identifies the hazard Hazard is discounted or no follow through on the mitigation Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 1) Overestimating Capability/Experience 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 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 Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 2) Familiarity with the Task - 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? Factors Influencing Risk Tolerance He had done this task 500 times without hurting himself We had stack about 200 of them when ... I do it about 10 times every day Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 3) Seriousness of the Outcome Pinch 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? Factors Influencing Risk Tolerance Cable suddenly tightened and IPs hand became trapped between cable and wench drum. Sweet gas ?? Hot Water ?? Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 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 Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 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 28 times more likely to be hurt off the job Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 5) Personal Experience with an Outcome If you have seen a serious outcome, you will be less tolerant of the risk Problem: As Incident Rates improve, fewer people will have had personal experience and leads to Scepticism Strategies for Reducing Tolerance Expert observers, supervisors, keepers of the corporate memory have the obligation to ensure workers know : a) Incidents have occurred because of not following that standard (i.e. What could go wrong?) b) Demonstrate that there have been serious consequences (i.e. How bad could it be?) Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 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 rail Re-enactment of how straps were caught Straps caught here Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 6) Cost of Non Compliance Strategies for Reducing Tolerance 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 tolerance Aviation industry Low risk tolerance, strictly regulated, high cost of non-compliance. Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 7) Confidence in the Equipment Ladder is twice as stable, therefore ... 1995 US Study Cars with ABS have more accidents, no safety gain with airbags because drivers became more aggressive. Parachuting 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? Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 8) Confidence in Protection and Rescue British study workers with back belts tend to lift greater weights
Strategies for Reducing Tolerance 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 Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 9) Potential Profit and Gain from Action US Highways Study deaths on highways tracks directly with the economy Alberta WHS fatalities and lost time incidents in the oil patch increase and decrease with the price of oil. Strategies for Reducing Tolerance Remove rewards for risk taking Eliminate barriers to doing it the right way Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10 Factors That Influence Risk Tolerance 1. Overestimating Capability/Experience 2. Familiarity with the Task 3. Seriousness of Outcome 4. Voluntary Actions and Being in Control 5. Personal Experience with an Outcome 6. Cost of Non-Compliance 7. Confidence in the Equipment 8. Confidence in Protection and Rescue 9. Potential Profit & Gain from Actions 10. Role Models Accepting Risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com 10) Role Models Accepting Risk 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. Strategies for Reducing Tolerance Identify and address the risk takers immediately (including yourself where are you on the risk-taking scale?) Recognize Erosion of Standards and address immediately Factors Influencing Risk Tolerance Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com What Could Go Wrong? 1) Review the serious incidents that have happened in the past and learn from these incidents Coach workers on how to recognize new hazards Recognize potential consequences of those hazards Reduce the tolerable level of risk Calibrate others so their judgement is at the same lowest acceptable level of risk Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com How Bad Could I t Be? 2) Use safety conversations (LPO, Stop and Think, Safety Meetings) to increase awareness on potential outcomes. Keep the corporate memory alive Risk is impacted by the number of Barriers between actions and outcomes Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com What can I do about this? 2) Follow up on the Personal Risk Behaviours identified at Fresh Start: a) Hold safety meeting discussions (or one on one during LPOs) on what they identified and their progress b) Ask workers to share their identified personal risks and commitments to change at safety meetings. (Start by sharing yours). c) Continue to use the Personal Risk Stop and Think cards with the expectation of identifying another personal at risk behaviour Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Together with our contractors we can create the safety culture that lowers Risk Tolerance