Transcript Risk Tolerance - Aviation Human Factors

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
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10 Factors Influencing Risk Tolerance
Strategies for Reducing Risk Tolerance
Actions to Address Risk Tolerance at Your Worksite
Dave Fennell, Imperial Oil Resources
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Risk Perception and Tolerance Model
Maturity of Supporting Tools at ExxonMobil
Hazard Identification “See it”
Risk Perception “Understand it”
Risk Tolerance “Accept or Reject it”
Dave Fennell, Imperial Oil Resources
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.
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Dave Fennell, Imperial Oil Resources
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Root Cause Analysis Flow Chart
Incident, Near Miss or Questionable Item Occurs – Why?
Personal Factors
Job Factors
1. Lack of skill or knowledge
2. Doing the job according to procedure
8. External Factors
5. Lack of or inadequate procedures
6. Inadequate communication of expectations
regarding procedures or standards
or standards takes more time and effort
7. Inadequate tools or equipment (availability,
condition & use; workplace design)
3. Short-cutting the procedure or
standards has been tolerated
Develop follow up actions
4. In past, not following procedure or
standards did not result in an incident
Implement follow up actions
Verify and validate follow up actions
Dave Fennell, Imperial Oil Resources
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Conventional Operations (Sept 3 2009)
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
42%
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
Dave Fennell, Imperial Oil Resources
1366
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Cold Lake Operations (Sept 3 2009)
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
40%
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
Dave Fennell, Imperial Oil Resources
1597
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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
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Hazardrecognitionandrisktolerance
Hazard Recognition and Risk Tolerance
Hazard Recognition
Dave Fennell, Imperial Oil Resources
=
Risk Tolerance
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Dave Fennell, Imperial Oil Resources
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Dave Fennell, Imperial Oil Resources
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Dave Fennell, Imperial Oil Resources
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January 2009
Dave Fennell, Imperial Oil Resources
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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
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• JSA often identifies the hazard
• Hazard is discounted or no follow
through on the mitigation
Dave Fennell, Imperial Oil Resources
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10 Factors That Influence Risk Tolerance
Dave Fennell, Imperial Oil Resources
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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
↑
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Factors Influencing Risk Tolerance
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.
Dave Fennell, Imperial Oil Resources
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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
↑
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Factors Influencing Risk Tolerance
2) Familiarity with the Task - Complacency
“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”
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?’
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Dave Fennell, Imperial Oil Resources
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
↑
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Factors Influencing Risk Tolerance
3) Seriousness of the Outcome
‘Pinch Point’ ... what about ‘Crush’ or ‘Amputation’ point
“Sweet gas” ??
Cable suddenly tightened and
IP’s hand became trapped between cable and wench
drum.
“Hot Water” ??
Strategies for Reducing Tolerance
• Stop and Think “How bad could it be? No, really ...How bad could it be?”
Dave Fennell, Imperial Oil Resources
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The Event:
Signaler Pinned by Truck
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:
Deckhand pinned here
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.
Dave Fennell, Imperial Oil Resources
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Dave Fennell, Imperial Oil Resources
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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
↑
↑
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Factors Influencing Risk Tolerance
4) Voluntary Actions and Being in Control
Key factor in off the job risk – 28 times more likely to be hurt off the job
Strategies for Reducing Tolerance
• Integrate ‘Stop and Think’ into your personal activities
Dave Fennell, Imperial Oil Resources
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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
↑
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Factors Influencing Risk Tolerance
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?)
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Dave Fennell, Imperial Oil Resources
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
Straps caught here
Draw works guard rail
Dave Fennell, Imperial Oil Resources
Re-enactment of how
straps were caught
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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
↑
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Factors Influencing Risk Tolerance
6) Cost of Non Compliance
Greater cost of non compliance lowers risk tolerance
Aviation industry – Low risk tolerance, strictly regulated, high 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
Dave Fennell, Imperial Oil Resources
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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
↑
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Factors Influencing Risk Tolerance
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?
Dave Fennell, Imperial Oil Resources
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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
↑
↑
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Factors Influencing Risk Tolerance
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
Dave Fennell, Imperial Oil Resources
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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
↑
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Factors Influencing Risk Tolerance
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’
Dave Fennell, Imperial Oil Resources
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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
↑
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Factors Influencing Risk Tolerance
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
Dave Fennell, Imperial Oil Resources
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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
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How Bad Could It 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
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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
LPO’s) 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
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Dave Fennell, Imperial Oil Resources
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“Together with our contractors we can create
the safety culture that lowers Risk Tolerance”
Dave Fennell, Imperial Oil Resources
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