An Intellectual Joust - Challenge - - Are you willing to confront propositions that jolt your safety management comfort zone ?

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An Intellectual Joust - Challenge -- Are you
willing to confront propositions that jolt your
safety management comfort zone ?
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TapRooT Summit 2006 - Gatlinburg, TN Thursday,
April 6    0800    GENERAL SESSION Challenging
the Way North Americans Manage Safety ( the
way you think and talk about safety ) Jim
Whiting Principal Risk Engineer
MD risk_at_workplaces pty ltd, Australia jim_at_workplac
es.com.au
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Challenge 1 All behavior depends upon risk
perception. Agree ? or Disagree ?

• If we label/describe an employees actions as -
• stupid or careless or lazy or negligent
• does that mean all we are saying is that -
• the employees risk perception
• is different to ours?
• And
• Whose problem is that ?
• The employees or ours ?

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ALL behaviour depends on Perception of Risk
Benefits and Costs

• Do your workers and managers have the same
  perceptions of what is tolerable risk as you do
  ?
• How do you know if they do agree with you
  regarding what risks are tolerable and
  what are not ?
• You cannot assume or guess they do !
• The ONLY way of knowing is
  to measure / calculate risk together !

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Challenge 1 (contd) All decisions are risk
management decisions
Risk Management Decision Making choosing an
option that is perceived to have the best
benefit / cost ratio No one takes a risk for the
chance of loss
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Why do men die younger ?
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Risk Perception is Risk Reality !!
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Challenge 2 Is the descriptor at risk
behavior any more helpful and any more
meaningful than unsafe act ?

• Do all behaviors involve risk ? hence are ALL
  behaviors actually at risk behaviors ?
• There are no such concepts as
• SAFE or UNSAFE-
• rather
• TOLERABLE Risk and INTOLERABLE Risk

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Audience participation
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What is the second most common word used in
safety ?

• And isnt defined ?
• unsafe

dont
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Challenge 3Do we confuse ourselves and our
employees by not clearly distinguishing between,
and explaining the differences between zero
incidents and zero risk ?
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Key philosophies of risk management

• Zero risk is unachievable
• as well as being frustrating both to
  individuals and organisations
• Zero risk should never be confused with Zero
  Incidents,
• Zero Incidents is an achievable and worthwhile
  expectation
• Zero risk is not achievable

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Challenge 4Which of the 2 expressions below
provides a more meaningful indication of the
real world ? and which one does / does not give
us false confidence ?
We will develop a Corrective Action that will
prevent recurrence of an incident OR We will
develop a Risk Control that will reduce the risk
of recurrence to ALARP As Low As Reasonably
Practicable
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Challenge 5Is risk tolerance a better term
than risk acceptance ?
Does tolerating a risk mean we are not happy
with the situation and tolerate implies we are
only living with the risk and need to keep
vigilant and revisit how well the our risk
control measures continue to be appropriate
?Whereas accept is fatalistic or defeatist ?
with the implication of passive acceptance ?
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Zero injuries not Zero risk
and we only TOLERATE fully managed risks !!
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Challenge 6 Every organisation should have a
process of quantifying risk levels and then
defining what risk levels are tolerable and which
levels are intolerable. Employees need to be
able to calculate risk levels quantitatively to
be able to adequately perceive risk as tolerable
or not.
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Table 4 Risk Ranking Matrix
Consequence Consequence Consequence Consequence Consequence Consequence
1 2 3 4 5 6
6 7 8 9 10 11 12
5 6 7 8 9 10 11
4 5 6 7 8 9 10
3 4 5 6 7 8 9
2 3 4 5 6 7 8
1 2 3 4 5 6 7
Likelihood
Key 11-12 Extreme risk 8-10 High
risk 5-7 Moderate risk 2-4 Low risk
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Representative Risk Scenario Map
with risk factors and significant events
TC issues
OT workers
incorrect info
not advised
TC does not
check repeat
back info
TC allows train or OT
vehicle to depart
OT worker does not
Visibility
before time
get to "safe" position
problems
TC does not
electronically
Block Section
OT protection
systems fail
Train Diagram
problems
speed of train
/ OT vehicle
Train Traffic
TC does not
Density
Visibility
mark diagram
problems
TC marks
Stage of Shift
lookouts
diagram
do not work
incorrectly
Safe working
system
TC does not
Vigilance of
corridor
check diagram
worker
length of
"on-the-board"
5 second
time - 6 or 8
protection
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Set / Choose P Probability of WHOLE scenario
completing to chosen Consequence
P Score Description of Probability Likelihood OR Estimated Chances
6 Almost certain the sequence can and does happen because all risk events / risk factors are very likely to occur or be present Up to 1 chance in 10
5 Quite possible and not unusual that the sequence can and does happen because most risk events / risk factors are likely to occur or be present 1 chance in 10 t o 1 chance in 100
4 Would be possible but unusual that the sequence can and does happen because many risk events / risk factors are likely to occur or be present 1 chance in 100 to 1 chance in 1 000
3 Would be a remotely possible that the sequence can and does happen because only a few risk events / risk factors are likely to occur or be present 1 chance in 1 000 to 1 chance in 10 000
2 Conceivably possible but very unlikely that the sequence can happen but is unlikely because many of the risk events / risk factors are very unlikely to occur or be present 1 chance in 10 000 to 1 chance in 100 000
1 Almost impossible that the sequence can and does happen because most of the risk events / risk factors are unlikely to occur or be present 1 chance in 100 000 or lower
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How to calculate risk ?
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To be confident that employees at all levels
understand and may possibly want to or need to
change their risk taking behaviors at work,
we need to be confident that they can
understand evaluate the risks adequately,
AND perceive the risks adequately AND assess
the risks adequately AND calculate the risks
adequately.
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Challenge 6(contd) Without the certainty of
a corporate risk tolerability framework - which
defines risk tolerability levels - managers and
employees will continue to be confused by lack of
corporate guidance and definition of corporate
standards re risk tolerance.
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Risk Evaluation - ALARP Tolerability Principles
Risk Level
Control measures must be introduced for risk in
this region to drive residual risk towards the
broadly acceptable region. If the residual risk
remains in this region, and society desires the
benefit of this activity the residual risk is
tolerable only if further risk reduction is
impracticable or requires action that is grossly
disproportionate in time, trouble and effort to
the reduction in risk achieved.
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Risk Tolerability Criteria or Framework
Risk Score Risk Descriptor All categories of Risk except safety or environment Safety and Environmental Risks
12 Extreme Board Approval Required for Risk Intolerable
11 Extreme Board Approval Required for Risk Intolerable
10 High Senior Executive Approval Required Senior Executive Approval Required
9 High Level 2 Manager Approval Required Level 2 Manager Approval Required
8 High Risk must be managed in line with the ALARP Principle Risk must be managed in line with the ALARP Principle ( Note 1 )
7 Moderate Risk must be managed in line with the ALARP Principle Risk must be managed in line with the ALARP Principle
6 Moderate Risk must be managed in line with the ALARP Principle Risk must be managed in line with the ALARP Principle
5 Moderate Risk must be managed in line with the ALARP Principle Risk must be managed in line with the ALARP Principle
4 Low No approval required but ongoing monitoring and management is required No approval required but ongoing monitoring and management is required
3 Low No approval required but ongoing monitoring and management is required No approval required but ongoing monitoring and management is required
2 Low No approval required but ongoing monitoring and management is required No approval required but ongoing monitoring and management is required

Note 1 As part of the ALARP justification, if the
exposed population is a worker, a Job Safety
Analysis is required. The methodology for
conducting a Job Safety Analysis is described in
the Safety Management System.
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Challenge 7Can the same scenario lead to
different consequences ?Why do participants of
risk analyses often argue about consequences ?
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Challenge 8
Is an error a cause? or a consequence ? or
.. ?
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Quick Way to Find Causal Factors
Error ? or Substandard Act ? (
Both have Good Reasons )
What equipment failed?
Who did what wrong?
If these problems had not occurred, it could have
prevented the incident (circle) from occurring
or significantly reduced the incident's
consequences.
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Challenge 9Why do safety people like -
double negatives rather than - double positives
?- reduce / prevent human error - improve
human reliability- decrease injury statistics
- increase levels of risk control- dont take
shortcuts - always choose the standard way
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Challenge 10Why do safety
people like the word DONT ? Does such negative
thinking / perceptions actually marginalize
safety people from the real business world ?Do
people come to work to DO or to DONT ?Do we
want to be told what we CAN do or always be told
what we CANT do ?
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Challenge 11Is the term
shortcut actually a good descriptive word that is
sensibly associated with the needs of a real
workplace in the real world - where the
day-to-day business challenge is to find smarter
better ways of doing our work OR shortcuts ?To
give more certainty / confidence to our people ,
do we need to clarify better the difference
between - finding shortcuts which is smart and
taking shortcuts without risk assessments which
is dumb ?
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Challenge 12What do we mean
when we tell our employees that -If you follow
this procedure you will be SAFE ?Can your
people vary from a procedure ?After completing
a pre-start job risk assessment,( whatever your
company calls them -Take 5 - STOP - Stepback 5X5
- JSA etc.)are your people clear regarding what
they can and cant do ?Do they know clearly if
they can - and under what circumstances
actually vary the procedure for the job based on
their findings of the pre-start job risk
assessment ?
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Philosophy of Causal / Risk Analysis
The Causal Factors of todays incident are
the Risk Factors of tomorrows !
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Fortune favours the Brave
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