Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com Strategies for Understanding and Strategies for Understanding and Addressing Addressing Risk Tolerance Risk Tolerance January 2011 January 2011 Presented by: Presented by: D.J. (Dave) Fennell Senior Safety Advisor, Imperial Oil Resources Senior Technical Professional –Safety, ExxonMobil Production Company On behalf of: On behalf of: ExxonMobil Human Factors Center of Excellence ExxonMobil Human Factors Center of Excellence
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Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
Strategies for Understanding and AddressingStrategies for Understanding and Addressing
Strategies for Reducing Risk ToleranceStrategies for Reducing Risk Tolerance
Actions to Address Risk Tolerance at Your WorksiteActions 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 Tools in place and being used, being used, effectiveness may effectiveness may lack in some areaslack in some areas
Mature safety culture will be Mature safety culture will be functional on this topic, functional on this topic, some areas will require more some areas will require more effort to understand the effort to understand the consequences of hazards. consequences of hazards.
Approaches for addressing Approaches for addressing tolerance are general weak tolerance are general weak across the company, this is across the company, this is the focus of this the focus of this presentation. 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?Incident, Near Miss or Questionable Item Occurs – Why?
Personal FactorsPersonal Factors 8. External Factors8. External FactorsJob FactorsJob Factors
Root Cause Analysis Flow Chart
5. Lack of or inadequate procedures
6. Inadequate communication of expectations regarding procedures or standards
• “ “Do employees understand the hazards of the Do employees understand the hazards of the operations they perform?” - operations they perform?” - 92%92%
• “ “Do you initiate action to correct hazards?” - Do you initiate action to correct hazards?” - 99%99%
• “ “Did you receive adequate safety training?” - Did you receive adequate safety training?” - 92%92%
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
• JSA often identifies the hazardJSA often identifies the hazard
• Hazard is discounted or no follow Hazard is discounted or no follow through on the mitigationthrough on the mitigation
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance
1. Overestimating Capability/Experience ↑2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑
10.10. Role Models Accepting RiskRole 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 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”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.
Cable suddenly tightened andIP’s hand became trapped between cable and wench drum.““Sweet gas” ??Sweet gas” ?? “Hot Water” ??“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 Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4. Voluntary Actions and Being in Control ↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑
10.10. Role Models Accepting RiskRole 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 – Key factor in off the job risk – 28 times more likely to be hurt off the job more likely to be hurt off the job
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5. Personal Experience with an Outcome ↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑
10.10. Role Models Accepting RiskRole 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 riskIf you have seen a serious outcome, you will be less tolerant of the risk
Problem: As Incident Rates improve, fewer people will have had As Incident Rates improve, fewer people will have had personal experience and leads to personal experience and leads to Scepticism
Strategies for Reducing Tolerance• ‘‘Expert observers’, supervisors, ‘keepers of the corporate memory’ have Expert observers’, supervisors, ‘keepers of the corporate memory’ have the obligation to ensure workers know :the obligation to ensure workers know : a) Incidents a) Incidents havehave occurred because of not following that standard (i.e. occurred because of not following that standard (i.e. What could go wrong?)What could go wrong?) b) Demonstrate that there b) Demonstrate that there havehave been serious consequences (i.e. How bad been serious consequences (i.e. How bad could it be?)could it be?)
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 railRe-enactment of how straps were caught
Straps caught here
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6. Cost of Non-Compliance ↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑
10.10. Role Models Accepting RiskRole 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 toleranceGreater cost of non compliance lowers risk tolerance
Aviation industry – Low risk tolerance, strictly regulated, high Aviation industry – Low risk tolerance, strictly regulated, high cost of non-compliance. cost of non-compliance.
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7. Confidence in the Equipment ↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑
10.10. Role Models Accepting RiskRole Models Accepting Risk ↑↑
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
7) Confidence in the Equipment
““Ladder is twice as stable, therefore ... ”Ladder is twice as stable, therefore ... ”
• 1995 US Study – Cars with ABS have more accidents, no safety gain 1995 US Study – Cars with ABS have more accidents, no safety gain with airbags because drivers became more aggressive.with airbags because drivers became more aggressive.
• Parachuting – Failure to deploy replaced with late deploymentParachuting – 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 Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8. Confidence in Protection and Rescue ↑
9.9. Potential Profit & Gain from ActionsPotential Profit & Gain from Actions ↑↑
10.10. Role Models Accepting RiskRole 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
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9. Potential Profit & Gain from Actions ↑
10.10. Role Models Accepting RiskRole 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 US Highways Study – deaths on highways tracks directly with the economyeconomy
• Alberta WHS – fatalities and lost time incidents in the oil patch increase Alberta WHS – fatalities and lost time incidents in the oil patch increase and decrease with the price of oil. and decrease with the price of oil.
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
10 Factors That Influence Risk Tolerance10 Factors That Influence Risk Tolerance1. Overestimating Capability/Experience ↑
2.2. Familiarity with the TaskFamiliarity with the Task ↑↑
3.3. Seriousness of OutcomeSeriousness of Outcome ↓↓
4.4. Voluntary Actions and Being in ControlVoluntary Actions and Being in Control ↑↑
5.5. Personal Experience with an OutcomePersonal Experience with an Outcome ↓↓
6.6. Cost of Non-ComplianceCost of Non-Compliance ↓↓
7.7. Confidence in the EquipmentConfidence in the Equipment ↑↑
8.8. Confidence in Protection and RescueConfidence in Protection and Rescue ↑↑
9.9. Potential Profit & Gain from ActionsPotential 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 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. influence the decisions to accept risk by other members of the group.
Strategies for Reducing Tolerance
• Identify and address the risk takers immediately address the risk takers immediately (including yourself – where are you on the ‘risk-taking’ scale?)
• Recognize ‘Erosion of Standards’ and address immediatelyRecognize ‘Erosion of Standards’ and address immediately
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
What Could Go Wrong?What Could Go Wrong?
1)1) Review the serious incidents that have happened in the past Review the serious incidents that have happened in the past and learn from these incidentsand learn from these incidents
• Coach workers on how to recognize new hazardsCoach workers on how to recognize new hazards
• Recognize potential consequences of those hazardsRecognize potential consequences of those hazards
• Reduce the tolerable level of risk Reduce the tolerable level of risk
• Calibrate others so their judgement is at the same lowest Calibrate others so their judgement is at the same lowest acceptable level of riskacceptable level of risk
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
How Bad Could It Be?How Bad Could It Be?2)2) Use ‘safety conversations’ (LPO, Stop and Think, Safety Use ‘safety conversations’ (LPO, Stop and Think, Safety
Meetings) to increase awareness on potential outcomes. Meetings) to increase awareness on potential outcomes.
• Keep the ‘corporate memory’ aliveKeep the ‘corporate memory’ alive
• Risk is impacted by the number of ‘Barriers’ between Risk is impacted by the number of ‘Barriers’ between actions and outcomesactions and outcomes
Dave Fennell, Imperial Oil Resources Downloaded from www.avhf.com
What can I do about this?What can I do about this?2)2) Follow up on the ‘Personal Risk Behaviours’ identified at Follow up on the ‘Personal Risk Behaviours’ identified at
Fresh Start:Fresh Start:
a) Hold safety meeting discussions (or one on one a) Hold safety meeting discussions (or one on one during LPO’s) on what they identified and their progressduring LPO’s) on what they identified and their progress
b) Ask workers to share their identified personal risks b) Ask workers to share their identified personal risks and commitments to change at safety and commitments to change at safety meetings. (Start meetings. (Start by sharing yours). by sharing yours).
c) Continue to use the ‘Personal Risk’ Stop and Think c) Continue to use the ‘Personal Risk’ Stop and Think cards with the expectation of identifying cards with the expectation of identifying another personal another personal at risk behaviourat 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 Together with our contractors we can create the safety culture that lowers Risk Tolerance”the safety culture that lowers Risk Tolerance”