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 them awake Intellectual Property of ASA. Not for use without our permission.

Intellectual Property of ASA. Not for use without our permission.

PRINCIPLES of The core of ASA HOP is PEOPLE P eople are not perfect and are going to make mistakes. E rror-likely situations can be predicted and risks can be controlled. O rganizational values strongly influence performance. P ositive and negative reinforcement determine behavior. L earning from the past will stop future events. E very response to failure creates a reaction. Intellectual Property of ASA. Not for use without our permission.

CAUSES of HUMAN EVENTS/FAILURES ERROR Individual 10% Equipment 20% Human Error Organizational 80% Weakness 90% Don’t try to fix people. Fix bad systems and set workers up for success. Intellectual Property of ASA. Not for use without our permission.

Intellectual Property of ASA. Not for use without our permission.

ADVANCED CONCEPTS • Human error is like gravity, weather and terrain, just another foreseeable hazard. James Reason • Error is pervasive... what is not pervasive are well-developed skills to detect and contain those errors at their early stages. • 90% of human error is caused by weak organizational systems. A just and fair culture never blames human error. • Strengthening weak organizational systems defines a Learning Culture. • Psycho-behavioral safety strategies are losing propositions. • Safe living away from work is more critical than workplace safety. • Above all else, family-driven safety values raise performance. • HOP situational and normalized drift error traps increase risk. • HOP prevention tools strengthen decision-making and control risks. • Without Demonstrated Leadership Accountability, high-reliability performance cannot be expected. Intellectual Property of ASA. Not for use without our permission.

ACTIVITY/ SITUATIONAL WORK TRAPS Decision Making DRIFT TOOLS TRAPS Brilliantly simple… profoundly impactful! Intellectual Property of ASA. Not for use without our permission.

1. Risk Assessment and Control Questioning Attitude a 10 Situational Error Traps b 3. Work Practices 10 Normalized Drift (LOWs) Error Traps c OP Tools - 10 Pre-Task Review d a e Human Behavior Self Check b Situational Awareness / Dynamic Risk Procedures c Assessment f Place Keeping d Risk Ranking Process g Peer Check e Components of Risk h Stop Work Authority f 4. Training and Learning Job Skills a Operating Experience b 2. Design/Engineering/Planning Performance Modes c Job Plan Analysis a Post-Job Review d New Projects b Root Cause Analysis e Work Flow and Design c Observations and Audits f MOC d Process Improvement g Contractor Engagement e Sustainability h A Holistic Approach to Safety Intellectual Property of ASA. Not for use without our permission.

5. Effective Communication 6. Demonstrated Leadership Coaching a Accountability Plus/Delta b 12 Steps a Three-Part Communication c RRRI b Phonetic Alphabet d EE Engagement c Turnover e Plus/Delta Calls d Performance Appraisals e 8. Safety Management and Leadership 7. Family-Driven Safety Values Value of Safety (Culture) a Safety Away from Work a Regulatory Compliance b Safe Lifestyles b Champions/SME c Executive Engagement d Supervisory Support e Alignment across Organization f A Holistic Approach to Safety Intellectual Property of ASA. Not for use without our permission.

1. Risk Assessment and Control Questioning Attitude a 10 Situational Error Traps b 10 Normalized Drift (LOWs) Error Traps c OP Tools - 10 d e Human Behavior Situational Awareness / Dynamic Risk Assessment f Risk Ranking Process g Components of Risk h A Holistic Approach to Safety Intellectual Property of ASA. Not for use without our permission.

Interpersonal Dynamics – Perceptions of Risk/ Heredity/Culture/ Risk Taking/Risk Aversion Personality/ DECISION- Attitudes/Habits Task Design/ MAKING Management of Change FACTORS Empowerment / Communication Autonomy/ Authority Education/ Training/ Aptitude Accountability/ Workgroup Dynamics – Expectations/ Leadership Performance Criteria Participation/Peer Pressure/ Conflict Resolution Organizational Culture – Mental and Emotional State/ Integrity/Ethics/ Consciousness/ Value of Safety Situational Awareness Intellectual Property of ASA. Not for use without our permission.

Acceptable Risks? Risk Tolerance? Intellectual Property of ASA. Not for use without our permission.

Intellectual Property of ASA. Not for use without our permission.

Assessing Controlling RISK and Correctability Severity Severity Probability Intellectual Property of ASA. Not for use without our permission.

Assessing RISK and Controlling DANGEROUS Weak High Unsafe ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ ∧ Risk HOP Error Traps Level Controlling Risks HOP Tools ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ ∨ SAFE Strong Safe Low Hazards & Employee Organizational Risk Traps Actions Factors Factors Intellectual Property of ASA. Not for use without our permission.

Error Traps… cause high-risk, error-likely situations. HOP teaches how to recognize and eliminate these traps, and to not create them for yourself or others. 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. Intellectual Property of ASA. Not for use without our permission.

TRAPS SITUATIONAL Time Pressure Pressure exerted, whether perceived or Distractions / real, to accomplish a task within a set Interruptions period of time Being physically or mentally separated from the task Multiple Tasks Too many activities going on at the same time Overconfidence Overestimation of one’s performance, ability, level of control, or rate of work Vague Guidance Unclear instructions, whether written, demonstrated, or spoken Intellectual Property of ASA. Not for use without our permission.

TRAPS SITUATIONAL First Shift/ Late Shift Peer Pressure Early/late in one’s work schedule, or last Influence exerted by a peer, or peer day before or first day back from group, in encouraging a person to holidays/vacation/illness change his or her attitudes, values, or behavior Scope Change Conditions outside of routine or expected patterns Physical Environment The work space where you will be Mental Fatigue/ performing a task Stress The consequence of the failure to respond adequately to mental, emotional, or physical demands Intellectual Property of ASA. Not for use without our permission.

TRAPS that put you in… Intellectual Property of ASA. Not for use without our permission.

6 I am following a procedure that I have used dozens of times in the past. Today, I’m operating pumps and valves that are new and different since the shutdown last month. What is Scope Change? Intellectual Property of ASA. Not for use without our permission.

NORMALIZED DRIFT • Individual – Group – Systemic E • “Temporary” becomes long -term X A • Short Cuts M • Extend PM to cut costs P L • “Learn to live with it” E • Condoning S When variations in accepted standards, D • Unacceptable risks become processes, and practices don’t result in serious consequences and , over time, become the new E acceptable, over time norm, allowing risk to increase. F • Hard to find, easy to ignore I • Growing tolerance for things that N are not right E • Under the radar of audits D Intellectual Property of ASA. Not for use without our permission.

The distinction between “likelihood” and “consequences” How do you make decisions? Drift and Risk grow proportionately. Intellectual Property of ASA. Not for use without our permission.

NORMALIZED DRIFT Intellectual Property of ASA. Not for use without our permission.

Normalized Drift Traps in the form of weakness and breakdowns in organizational and personal defenses that become 1.Conflicting Values – when stated organizational accepted over time, principles and values do not match actual performance resulting in sub- 2.Condoning – tacit approval of unacceptable standard deviations – NO PASS! performance, 3.Bad Habits – short cuts, complacency, wrong increased risks, and perceptions of risk, thrill seeking 4.Vague Policies – misunderstood and inconsistently adverse events. applied 5.Ineffective Training – improved job performance not realized Intellectual Property of ASA. Not for use without our permission.