MANAGING RISKS THAT MATTER MOST Intellectual Property of ASA. Not - - PowerPoint PPT Presentation
MANAGING RISKS THAT MATTER MOST Intellectual Property of ASA. Not for use without our permission. What is the most important goal of SHE training? a. Communicate b. Educate c. Motivate d. All of the above e. None of the above f. Keep
MANAGING RISKS THAT MATTER MOST
a. Communicate b. Educate c. Motivate d. All of the above e. None of the above f. Keep them awake
What is the most important goal of SHE training?
PRINCIPLES of
People are not perfect and are going to make mistakes. Error-likely situations can be predicted and risks can be controlled. Organizational values strongly influence performance. Positive and negative reinforcement determine behavior. Learning from the past will stop future events. Every response to failure creates a reaction.
The core of ASA HOP is PEOPLE
Human Error 80%
Equipment 20%
Individual 10%
Organizational Weakness 90%
EVENTS/FAILURES CAUSES of HUMAN ERROR Don’t try to fix people. Fix bad systems and set workers up for success.
and contain those errors at their early stages.
fair culture never blames human error.
performance cannot be expected.
SITUATIONAL TRAPS
ACTIVITY/ WORK
TOOLS
DRIFT TRAPS
Decision Making Brilliantly simple… profoundly impactful!
a Questioning Attitude b 10 Situational Error Traps c 10 Normalized Drift (LOWs) Error Traps d OP Tools - 10 e Human Behavior f Situational Awareness / Dynamic Risk Assessment g Risk Ranking Process h Components of Risk a Job Plan Analysis b New Projects c Work Flow and Design d MOC e Contractor Engagement a Pre-Task Review b Self Check c Procedures d Place Keeping e Peer Check f Stop Work Authority a Job Skills b Operating Experience c Performance Modes d Post-Job Review e Root Cause Analysis f Observations and Audits g Process Improvement h Sustainability
A Holistic Approach to Safety
1. Risk Assessment and Control
a Coaching b Plus/Delta c Three-Part Communication d Phonetic Alphabet e Turnover a 12 Steps b RRRI c EE Engagement d Plus/Delta Calls e Performance Appraisals a Safety Away from Work b Safe Lifestyles a Value of Safety (Culture) b Regulatory Compliance c Champions/SME d Executive Engagement e Supervisory Support f Alignment across Organization
Accountability
and Leadership
A Holistic Approach to Safety
1. Risk Assessment and Control
A Holistic Approach to Safety
a Questioning Attitude b 10 Situational Error Traps c 10 Normalized Drift (LOWs) Error Traps d OP Tools - 10 e Human Behavior f Situational Awareness / Dynamic Risk Assessment g Risk Ranking Process h Components of Risk
Mental and Emotional State/ Consciousness/ Situational Awareness
Accountability/ Expectations/ Performance Criteria Empowerment / Autonomy/ Authority Perceptions of Risk/ Risk Taking/Risk Aversion Leadership Organizational Culture – Integrity/Ethics/ Value of Safety Task Design/ Management of Change Workgroup Dynamics – Participation/Peer Pressure/ Conflict Resolution Interpersonal Dynamics – Heredity/Culture/ Personality/ Attitudes/Habits Communication Education/ Training/ Aptitude
Probability Severity Severity Correctability
Assessing
and
Controlling RISK
High Low Hazards & Traps Safe Unsafe Employee Actions DANGEROUS SAFE
Risk Level
Controlling Risks
∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧
HOP Tools HOP Error Traps
Assessing
and
Controlling
Strong Weak Organizational Factors Risk Factors
Situational Factors are traps that exist at a given point in
time and affect individuals while performing a task, which can increase the chance of making an error.
Normalized Drift (Latent Organizational Weaknesses – LOWs)
are traps in the form of weakness and breakdowns in organizational and personal defenses that become accepted over time, resulting in sub-standard performance, increased risks, and adverse events. cause high-risk, error-likely situations. HOP teaches how to recognize and eliminate these traps, and to not create them for yourself or others.
Overconfidence Overestimation of one’s performance, ability, level of control, or rate of work
Vague Guidance Unclear instructions, whether written, demonstrated, or spoken Multiple Tasks Too many activities going on at the same time Distractions / Interruptions Being physically or mentally separated from the task Time Pressure Pressure exerted, whether perceived or real, to accomplish a task within a set period of time
First Shift/ Late Shift Early/late in one’s work schedule, or last day before or first day back from holidays/vacation/illness
Physical Environment The work space where you will be performing a task Scope Change Conditions outside of routine or expected patterns Peer Pressure Influence exerted by a peer, or peer group, in encouraging a person to change his or her attitudes, values, or behavior Mental Fatigue/ Stress The consequence of the failure to respond adequately to mental, emotional, or physical demands
that put you in…
6 I am following a procedure that I have used dozens
and valves that are new and different since the shutdown last month. What is Scope Change?
E X A M P L E S
acceptable, over time
are not right
D E F I N E D
When variations in accepted standards, processes, and practices don’t result in serious consequences and , over time, become the new norm, allowing risk to increase.
The distinction between “likelihood” and “consequences”
How do you make decisions?
Drift and Risk grow proportionately.
1.Conflicting Values – when stated organizational principles and values do not match actual performance 2.Condoning – tacit approval of unacceptable deviations – NO PASS! 3.Bad Habits – short cuts, complacency, wrong perceptions of risk, thrill seeking 4.Vague Policies – misunderstood and inconsistently applied 5.Ineffective Training – improved job performance not realized
Normalized Drift
Traps in the form of weakness and breakdowns in
personal defenses that become accepted over time, resulting in sub- standard performance, increased risks, and adverse events.
6.Flawed Procedures – needed but missing, incorrect, unclear 7.Faulty Equipment – broken, out of date, inaccurate 8.Technology – failure to take advantage of technology 9.Design/Engineering – inaccurate drawings, component labeling, unapproved modifications 10.Lack of Accountability – Focus is on results rather than how achieved; expectations not clear
Normalized Drift
Traps in the form of weakness and breakdowns in
personal defenses that become accepted over time, resulting in sub- standard performance, increased risks, and adverse events.
and
List examples of hidden hazards and dangers you have at HOME and WORK and how you will correct them.
Normalized Drift How to Correct
Questioning Attitude A mindset that promotes good decision-making and proper actions. Pre-Task REVIEW Discussions of an activity right before it is performed to manage risks. Self-Check
Conscious and deliberate focus of attention
just before and while performing the task.
Effective Communication Communicating effectively by using a set of methods and techniques to reduce error potential. Job Planning Analysis Big picture planning tool that specifies steps, error traps, and defenses.
Procedure Usage Understanding the procedure’s intent and purpose, and following all actions as written in the sequence specified. Peer Checking A 2nd person checks the correctness of another person’s actions prior to the action being implemented. Performance Coaching Being ready, willing and able to give and accept constructive feedback. Post-Job Review What was planned? What happened? Why did it happen? How can we do better next time? Place-Keeping Clearly marking instructional steps being used to control a task to indicate the completion status of the step.
ELEMENTS a Pre-Task Review b Self Check c Procedures d Place Keeping e Peer Check f Stop Work Authority
Policies and procedures that make sense are in place, properly administered, and consistently followed. Stakeholders optimize human and organizational performance (HOP) principles, tools, error traps, and methods.
ELEMENTS a 12 Steps b RRRI c EE Engagement d Plus/Delta Calls e Performance Appraisals 1. Understanding – what is accountability 2. Process – how does it work here 3. Communication – so everyone knows 4. Responsibilities and Duties – what am I expected to do 5. Acceptance – do I agree 6. Authority – do I have the power to control my destiny 7. Consequences – what happens if I do or if I don’t 8. Performance Reviews – when, who, how 9. Candor – open, direct, honest ALWAYS
violation; organizational weakness
process work Accountability systems are rigorous to ensure expectations are clear, authority is appropriate, and consequences reinforce objectives. Auditing activities proactively assess how employees are influenced by organizational behavior.
Demonstrated Leadership Accountability
ELEMENTS a Job Skills b Operating Experience c Performance Modes d Post-Job Review e Root Cause Analysis f Observations and Audits g Process Improvement h Sustainability
Training and Learning
Training is robust; adults learn, and perform
experience (OE). Process-focused innovations grow the safety culture.
Use the HOPER Form to analyze all events
Which Normalized Drift Traps were present? Which Situational Traps were present?
Tools
ELEMENTS a Safety Away from Work b Safe Lifestyles
Family-Driven Safety Values
Why is safety away from work critically important?
In 2017, 169,936 accidental/uninten- tional deaths occurred (CDC, 2019). Just 3% (5,147) of the deaths were work- related (BLS, 2018). Accidents are the number-one cause of death for the majority of the U.S. population (ages 1 to 45) (CDC, 2019).
Focus on means, not end result Never condone Give and Accept Safety Feedback Coaching
CALL to ACTION
Learn, grow and help others make safe decisions HOP Tools Learn Them Live Them Share Them Internalize WII-FM! Self Accountability Team Accountability
Focus on “Systems” proactively and reactively Identify and correct “Normalized Drift” Mindset of “vulnerability” “what if” and “it can happen to me” Reward safe, not unsafe, actions Nip bad habits in the bud Deal with risk takers, authority resisters, and mental states
CALL to ACTION
Manage Risks Live Safe Focus Away From Work