studies show that human factors are responsible for nearly 60-80% of mishaps and near- miss...
TRANSCRIPT
Studies show that human factors are responsible for nearly 60-80% of mishaps and near-miss incidents. These human errors can be identified and controlled using a continuous integrated management system.
Understanding the frequency and severity of human errors as well as the root cause helps
business determine which innovations are needed to reduce risk. Oftentimes, business has not developed a risk register to identify all of the ergonomic issues, especially those related to psychosocial disorders. Our research has found that shift changes, fatigue, work stress, poor planning, and other factors lead individuals to make decisions that put them at risk of injury or illness. These decisions may also result in catastrophic property damage, interruption in business continuity, damage to business reputation, brand, and image, as well as loss of production and profitability. Occurrence of the human factor issues can be reduced or eliminated by changing the safety culture and behavior at all levels within the organization. This includes, but is not limited to setting policy, developing written programs and procedures, identifying hazards, communicating the hazards and associated risk with stakeholders, engaging employee participation, monitoring the work or project, collaborating on systematic changes to improve human performance and ensuring continued improvement.
Practical recommendations and conclusions:
• Integrate risk governance with techniques applied in the human factors to improve the safety management of process hazards
• Review best practices in similar industry around the world and other industries • Hold industry workshops to present and review the proposed approach and seek stakeholder input
on human factors content • Balance prescriptive and goal setting approach and predictive solutions to deliver a more human
approach to industry • Use predictive analytic data to determine how human factors concerns can be applied to hazard
identification and risk control • Industry needs to raise the bar using predictive analytic data to improve human performance,
reduce risk, limit liability, sustain productivity, and meet regulatory obligations • Focus on managing process major hazards through the design and incorporation of more complex
equipment and systems • Challenges of industry continue and require multi-disciplinary and cross functional collaboration
(internal/external) to the organizations even when manpower and resources are stretched • Industry has made great progress managing process related hazards and preventive strategies to
protect workers, property, and environment. • Accidents continue to happen and the majority of them can be linked to a human error or
inadequate human performance.
References
The Human Factors Analysis and Classification System—HFACS; Shappell, S.A., and Wiegmann, (2000) D.A., Report DOT/FAA/AM-00/7, Federal Aviation Administration, 800 Independence Ave., S.W. Washington, DC 20591
Health and Safety Executive (HSE) Offshore Division, Human Factors and Organizational Factors Strategy (2009 – 2012)
Human Factors, WorkSafeBC, 2014
OPNAV Instruction 3500.39C, Operational Risk Management, Department of the Navy Office of the Chief of Naval Operations (2010)
National Institute of Standards and Technology Special Publication 800-30 Natl. Inst. Stand.Technol. Spec. Publ. 800-30, (2002)
Miccolis, Jerry, and Samir Shah. Enterprise Risk Management, an Analytic Approach.Tillinghast - Towers Perrin. A Tillinghast - Towers Perrin Monograph. 1-36. 18 Apr. 2008.
Presented by:Presented by:Bernard L. Fontaine, Jr., CIH, CSP, AIHA FellowBernard L. Fontaine, Jr., CIH, CSP, AIHA FellowThe Windsor Consulting Group, Inc.The Windsor Consulting Group, Inc.
Courtesy of Patrick O Connor and Ken ArnoldHazard Management and the Importance of Human FactorsPresentation to the Marine Board
Error s
Violatio ns
Development of an Organizational Accident (developed from J. Reason)
PersonPerson
Human Factors in Incidents
Baker report on Texas City: “[BP’s] employees were not empowered with a positive, trusting, and open environment with effective lines of communication between management and the workforce.”
Kansai Electric Power Company incident (which killed 5 people) in Mihama, Japan in August 2004 was attributed to ‘a demise in safety culture’.
Lord Cullen in his report on the causes of Piper Alpha: “it is essential to create a corporate atmosphere or culture in which safety is understood to be and accepted as, the number one priority.”
““80-85% of accidents over a reporting 80-85% of accidents over a reporting period of 1999 to 2001 involved human period of 1999 to 2001 involved human
error (USCG) error (USCG)
50% of these initiated by human error, 50% of these initiated by human error, another 30% of these associated with another 30% of these associated with
human errorhuman error”
Hazard, Risk and Safety Hazard, Risk and Safety ManagementManagement
Setting policy
Organizing
Identification & assessment
Procedures
Communication
Employee participation
Acceptance monitoring
Active monitoring
Reactive monitoring
Review
Continual improvement
Planning phase
Performance phase
Assessment phase
Improvement phase
Hazard, Risk and Safety Hazard, Risk and Safety ManagementManagement
Safety Management System Safety Management System (SMS)(SMS)Using national and international standards, guidelines, and
practices, safety management systems provide widespread benefits in productivity, financial, human performance, quality and other business objectives.
Management leadership and commitment – manpower and resources
Employee participation and engagement – surveys, training, meetings
Planning – written rules, SOPs, and JSAs
Implementation – surveys, inspections, audits, and safety committee
Operation – written safety program, leading and lagging indicators
Evaluation – annual self assessment and mishap investigations
Corrective action – relative to outcome of lagging/leading indicators
Management review – annual program evaluation for improvement
Human Factors and
Safety TopicsProcedures
Inspections, Audits,
Workplace Surveys
TrainingOrganizational
Culture
Relevant human factors to worker
health, safety, and risk governance
Written, technically correct, maintained and accessible, and easy to understand.
Hazard identification and quantitative or qualitative
risk assessment of workers in critical roles
Competence in job function, knowledge of
hazard and control measures
Leadership support of compliant workers and
workers seeking improvement
Associated health and safety
outcomes from performance
Applied, tested, and re-evaluated for valid human
performance. Evaluate personnel decision-making needs. Right tools for job
and used correctly. Evaluate fitness for duty
Measurement of worker exposure, monitor of work
performance, and evaluation of competence. Consider human factors and ergonomic issues. Evaluate proficiency of completing work tasks.
Training applicable to specific hazards and risk,
and capability for each worker. Matched skills
and aptitude. Know how to use right tools or
equipment and report deficiency gap in safety.
Evaluate safety climate and culture Construct of safety
policy, program, and operating procedures Provide right tools and
equipment for job. Report deficiencies.
Critical Elements
Procedures reviewed and relevant to current
operations/process. Critical tasks identified
and analyzed. Work aligns with hiring process
Evaluation of mishaps, near-miss events, levels of exposure, and safety
controls. Workers capable of completing job tasks/assignments
Formal and practical training provided for
identified hazards and/or training to use
and operate equipment and machinery.
Training objectives commensurate with safety hazards/risk. Workers selected
based on capability and experience.
Performance Indicator(s)
Percent (%) of operating procedures based on
recent self-assessment of human performance(Leading indicator)
Percent (%) of facility inspections, audits,
surveys both planned vs performed annually(Leading indicator)
Number of workers or % of staff provided safety training and determined
to be competent(Leading indicator
Health and safety climate measurement
and evaluation of psychosocial issues (Leading indicator)
Human Factors and SafetyHuman Factors and Safety
Commitment: In the face of ever-increasing commercial and economic pressures, does the organization have the will to make SMS tools work effectively?
Cognizance: Does the organization understand the financial and social impact of safety relative to the involvement of human and organizational factors?
Competence: Neither of the other two drivers is sufficient without the necessary practical skills. Does the organization’s SMS possess the right tools, and are they properly understood and utilized appropriately by leadership and the workforce?
Predictive analysis and solutions can be applied to properly manage human factors issue related to safety management and risk.
Drivers for Human Factors Drivers for Human Factors in Safety Management and Riskin Safety Management and Risk
Commitment Cognizance Competence
Principles
Safety management is an integral part of the business
process. Past events are carefully reviewed; novel
scenarios are imagined. Top management is actively
engaged in safety-related issues.
No final victories in the safetywar. Human fallibility and natural
hazards will never be eliminated, only moderated. Organization understands:
person, engineering and system models of safety management It
expects its workforce to make errors and trains them to detect and recover. ‘Upstream’ systemic factors are easier to manage than fleeting psychological states like inattention or forgetfulness.
Organization recognizes that the effective management of safety. It involves the regular sampling of a
variety of organizational parameters (scheduling, planning, resource allocation, procedures,
defenses, training, communication, production conflicts, and the like), identify which of these ‘vital signs’ is most in need of attention, and
carrying out remedial actions
Policy
Company policy to remind all levels of leadership that
safety is everyone’s responsibility. Resolve short-
term production and protection issues safely.
Policies should be in place to encourage safety
messengers.
Organization should publically recognize critical dependence of
effective SMS upon the trust of the workforce. A safe culture is the
product of a reporting culture that, in turn, can only arise from a just culture.
Use crisis emergency and recovery planning to test business.
Policies relating to near-miss and incident reporting should make
clear the company’s stance. Disciplinary policies should be
predicated on distinction between acceptable/unacceptable behavior.
Key determinant is not so much the act — error or violation—as the nature of the embedded behavior.
Excerpts taken from unpublished paper entitled “Human Factors Aspects of Safety Management Systems” written by James Reason
Drivers for Human Factors Drivers for Human Factors in Safety Management and Riskin Safety Management and Risk
Commitment Cognizance Competence
Procedures
Organization should establish written operating procedures for each work
task based on hazard identification using a job safety analysis and risk
assessment. Controls should be identified to include
engineering, administrative, and finally the use of personal protective
equipment suited for the individual work tasks.
Procedures, i.e., maintenance, should not only explain how the job be done, but also identify the likely error-prone
steps in the task. Training in the recognition/recovery of errors should
support appropriate procedures. Inform by data on recurrent error traps
derived from safety information reporting systems. Procedures should
be well written in cooperation with those actually experienced doing the
job.
Procedures should be appropriate, accessible, intelligible and
workable. Write procedures with the understanding that people hardly ever read and do at the
same time. Such a balance is very important in relation to intrinsically
error-provoking activities like repairs and maintenance activities.
Practice
Routine audits, inspections, and surveys along with
interviews of the workforce are needed to understand what gets done and how it
gets done. Errors and omissions can be detected
and corrections made before a crisis develops.
The ‘safety health’ of the organization should be continuously monitored
using both reactive outcome data and proactive process measures. The
former help to identify recurrent error traps, while the latter focus attentionupon current systemic weaknesses.
Use rapid, useful and intelligible feedback channels to communicate the lessons learned and the actions
needed.
Visible top-level involvement in safety practices. Management should not only walk the talk,
but also talk the walk. Each level of management should understand the hazards and risks associated
with the work and the need to have established policy, programs, and operating procedures to the work.
Excerpts taken from unpublished paper entitled “Human Factors Aspects of Safety Management Systems” written by James Reason
Operators setting up the process made an error and tank outlet inadvertently closed causing the phenol to overflow
No one was injured, but the direct cost in loss of materials, lost production and recovery of the phenol was £39,800. Indirect cost not calculated.
Investigations found the system for controlling pumps and valves was badly designed and prone to human error.
Phenol is a systemic poison from exposure by inhalation and direct skin contact and absorption
Source: HSE website www.hse.gov.uk/comah/index.htmT
Engineering
Safety management
Human factors
Time
Accident rate
Human Factors in Safety Management and Risk Governance
Engineering
Safety management
Human factors
Better design More procedures!
Time
Accident rate
Human Factors in Safety Management and Risk Governance
Engineering
Safety management
Human factors
Need to designbetter engineering
More procedures!
Behavioural modificationwill fix it…
Time
Accident rate
Human Factors in Safety Management and Risk Governance
Engineering
Safety management
Human factors
Better design More procedures!
Behavioural modificationwill fix it…
Time
Accident rate
Continuous improvement
Human Factors in Safety Management and Risk Governance
Engineering
Safety management
Human factors
Better design More procedures
Behavioural modificationwill fix it…
Time
Accident rate
The “Engineers Graph” or why I don’t need to do anything...
Continuous improvement
Workforceinvolvement
Human Factors in Safety Management and Risk Governance
Is there a way to establish a true and measure effective safety culture within the industry that ensures how people recognize risks and act upon them decisively?
Does the current leadership and organizational structure adequately manage the health or safety risks in the industry?
Does leadership understand the hard and soft aspects of the human element and direct/indirect cost associated with errors?
Are global occupational health and safety policy, programs, and procedures too rigid/complicated or inadequate to manage risks?
Is risk communication used to affect safety culture and change management as a driver for the continuous improvement of the safety management system?
Organizational ChallengesOrganizational Challenges
10 Human Factor Intervention
20 and 30 Human Factor Interventions
Lagging IndicatorsLagging Indicators Leading IndicatorsLeading Indicators
Total lost work days Restricted work days Number of fatalities Injuries/illness rate Asset/property damage Vehicle mishaps Near-miss incidents Chemical releases WC trends and amount Experience modification
Safety/health meetings Supervisor training Employee training Number of inspections No. of audits/surveys No. of self-inspections Reward/recognition Employee turnover rate Observations/accidents Risk/hazard assessment
Improper work procedure Misdiagnosed situation Wrong response action Exceeded ability/authority Inappropriate maneuver Poor decision making Adverse mental state Haste or task saturation Situational awareness Failed to use resources Hiring the wrong person Fail to track performance
Breakdown in visual scan Failed to prioritize focus Inadvertent use of controls Omitted step in procedure Omitted checklist item Poor technique or ethic Over reaction to controls Inexperience or capability Adverse physiological state Physical or mental limitations Inadequate safety training Lack of intelligence/aptitude Lack skills or qualifications
Misapplied skill set Spatial disorientation Visual illusion Misunderstood task Misunderstood rules Poor work environment Miscommunication Tight time constraints Personal readiness Work/home distraction Mental complacency Inadequate reaction time Inadequate rest breaks Time pressures
Failed job requirements Failed to follow direction Lack of worker training Breakdown communication No supervisor oversight Hazard not identified Controls in-place not used Substandard work practices Pre-existing illness or injury Failure of leadership to act Failure to correct problem Failed to enforce the rules Failed to report unsafe acts Lack of funding Excessive cost cutting No formal accountability Poor equipment design
Unauthorized work Exceeded authority Over reaction Lack of capability Lack of qualification Except very high risk Poor planning Lack of objectives Unrealistic goals Under manned/resourced
Organizational ChallengesOrganizational Challenges
Things we know:
Process hazards are understood but human risks vary in uncertaintyThe value of managing hazards/controlling risk robustly is acceptedPrinciples of inherent safety are clear but sometimes ignoredRisk assessment techniques are available and proven within industry
However:
Major hazards, other than process and production; human factors do not always receive the same level of attention in the initial phase of design and fabricationPreventing major accidents tends to focus heavily on the hardware, less on the outcome of the human experience or performanceDesigns continue to increase in complexity but the human element remains unchanged or not considered a critical factorChange management does not always consider human factors in final equation since it is considered inherent to the organization
Hazard ID, Risk Assessment & Prioritization
Triggers Tools-New Projects
-Renew al of Facilities
-New Standards
-Incident Response
-Periodic Review s
-Audits
-Regulatory
-Employee Concerns
-Excursions
-M AR
-HAZID
-HAZOP
-LOPA
-FM EA
-QRA
-ESSA
-EERS
-Blast Study
Major Hazard& Risk Register
Common Risk Matrix
Risk Mitigation Planning & ControlsOptions DecisionsPlan-Engineering Studies, FEL
-Non Engineering Options, e.g.
Administrative Controls
-Evaluation by Risk Ow ner
Execute Plan•Priority•Resources•Progress Tracking and Review s
Emergency Response Plan•Update
Communicate Hazards & PlanText Description
Profile & Score Cards-Text
-Text
-Text
-Text
Evaluation
-Text
-Text
-Text
-Text
Corrective Action-Text
-Text
-Text
-Text
KPIMeasurement
-Action Tracking
-Leading Indicators
-Lagging Indicators
Measurement, Evaluation & Corrective Action
Management Review s
-Text
-Text
-Text
-Text
Improvement
Thru Strategic
Direction
-Text
-Text
-Text
-Text
RiskManagement
System
-Text
-Text
-Text
-Text
Management Review & Improvement
Continuous Hazard Assessment and Risk Reduction
-Partner Approval -Roles &
-Residual Risk Responsibilities
-Business Decision Process -M milestones/
-Commercial Decisions Dates
-Action TrackingLevels of authority based
on level of risk -Progress
Integrated Engineering and Business Plan
Review s
Evaluate the Human Element
Most Common Issues…
Organizational change
Staffing levels/workload
Training and competence
Operating procedures
Managing human failure
Correct hard/soft skills
Fatigue and shift change
Organizational culture
Human factors in design
Communications/interfaces
Integration of human factors into risk
Assessment and investigations
Behavioural safety = Human factors/
Balance of Hard and Soft Skills
Hard Skills
Calculate to solve problem
Operate machinery
Speak a foreign language
Following directions
Demonstrate competence
Previous work experience
Soft Skills
Good manners and trustworthy
Time management
Accept suggestions or criticism
Ability to ask for help or support
Integrity and leadership
Teamwork and adaptability
Failure to correctly specify behaviour
Individual involved not informed of issue or incompetent Task personnel engaged in at the time not discussed/informedWhat they did (or did not do) – human error related to knowing the operating procedure and understanding the processCommunicating risk and outcome if rules are not followed
Making early decisions and sticking to them
As new information becomes available, a critical decision may result in violation of safe operating proceduresFailure to identify the multiple individual and/or organizational behaviours contributing to a mishap or near-miss incidentTimeline critical and sensitive to process or operation
Company Understanding The reality is… Management should…
Personnel will follow established written rules for occupational health
and safety while at work. Workers will ask questions about unfamiliar assigned work tasks or when operating new equipment.
Procedures are often out of date, poorly written, vaguely understood or
ambiguous. Lack of training by supervisor forcing people make up
their own rules to do the work.
Find out why procedures are not followed, Determine if the process or
operation can be improved or become more efficient by engaging stakeholders. Hire competent talent
and training personnel in the hazards, risks, and controls.
Personnel will be competent in everything they do. They have been hired with the skill sets to do the job based on past performance training, and qualifications. Younger hires are more familiar with safety technology because of their education to do the
job right.
Everyone has gaps in their knowledge and understanding of the operation or process, equipment or
machinery used, and requirements to reduce risk and use engineered
control measures.Some companies have lost highly
experienced personnel due to attrition or economic downsizing.
For novices: provide supervision and train on safety procedures
For those whose knowledge is ‘rusty’: reassess capability and gaps and
provide refresher trainingFor those who are leaving: plan to
mentor others to take over by learning from the experience of old
hands before they retire.
Personnel are highly motivated in their work, organization, and career. Personnel demonstrate positive work
ethic, good attitude, and desire to learn or be trained.
Even the person in their ideal job has some ‘off days’; routine tasks are
simply boring and workers become complacent. Workers have social,
religious, or family issues.
Design jobs to stimulate interest; use engineering/administrative controls to reduce risk. ‘Rotate’ in and out of the most boring but necessary jobs.
Consider time-off
Safety Behaviour/Risk at WorkSafety Behaviour/Risk at Work
Company Understanding The reality is… Management should…
Personnel are always wherethey should be
People wander off or are asked to do favors for others that takes them out
of their normal workplace Downsizing stress limitation on
coverage and availability.
Accept that people won’t always be where they should be. Provide radios
and pagers. Arrange for back up cover when someone really does
need to go elsewhere
In an emergency, personnel will make right decisions to ‘save the
day’
Real emergencies are often highlycomplex and stressful. People don’t
react as in the emergency plan
Practice emergencies so everyone is familiar with required routines and
maintains skills for infrequent events. Provide clear
information/instructions. Have contingency plan and ensure
everyone knows role and responsibility
Work highly reliably: be very unlikely to make an error
All tasks are prone to human errors – some more than others. Human
errors are a major cause of accidents and can
occur in all jobs including operations, repairs, maintenance, adjustments, modification and management. Job safety analysis provides insight into the hazards and controls for each
phase of the operation or process.
Consider human and operational error when assessing/evaluating risk. Make safety systems as ‘forgiving’ as
possible (resistant to error; allow time for correcting the error). For
safety critical tasks, make sure key steps are independently checked, and that procedures and other job
aids are clear. Avoid a ‘blame culture’ game.
Safety Behaviour/Risk at WorkSafety Behaviour/Risk at Work
Other key problems we have found from inspection and assessment are:
Too much emphasis being placed on reducing personal accidents (slips, trips, falls etc.) without an equal focus on preventing major accidentsFailing to realize that that safety culture is about everyone in the company, including managers and senior leadership, not just the ‘front line’Not being clear how the safety management system will prevent or reduce human errors which may lead to major accidents
Linear risk problems can be managed using a ‘routine-based’ strategy, such as introducing a law or regulation
Complex risks may be best addressed by accessing and acting on the best available scientific expertise, aiming for a ‘risk-informed’ and ‘robustness-focused’ strategy
Uncertain risks are better managed using ‘precaution-based’ and ‘resilience-focused’ strategies, to ensure the reversibility of critical decisions and to increase a system’s capacity to cope with surprises
Ambiguous risk problems require a ‘dialogue-based’ strategy aiming to create tolerance and mutual understanding of conflicting views and values with a view to eventually reconciling them
Based on both the evidence from the risk appraisal and evaluation of broader value-based choices and the trade-offs involved, decide
whether or not to take on the risk.
Acceptance
Reduction
Prohibition or Substitution
No formal intervention necessary
Benefit is worth the risk, but risk reduction
measures are necessary
Risk so much greater than benefit that it cannot be taken on
Basic elements of Risk Governance:
Pre-appraisal of industry hazardsHazard identification of all occupational risksAssessment via risk registerMitigation and strategic management planningReview for change and continuous improvement
Two broad approaches to apply these principles
PrescriptiveGoal Setting
Assessment Sphere:Generation of Knowledge
Management Sphere:Decision on & Implementation of Actions
Risk Characterisation• Risk Profile• Judgement of the
Seriousness of Risk• Conclusions & Risk
Reduction Options
Risk Evaluation• Judging the Tolera-
bility & Acceptability• Need for Risk
Reduction Measures
Tolerability & Acceptability Judgement
Pre-Assessment:• Problem Framing• Early Warning• Screening• Determination of Scientific Conventions
Pre-Assessment
Risk Appraisal:Risk Assessment• Hazard Identification & Estimation• Exposure & Vulnerability Assessment• Risk Estimation
Concern Assessment• Risk Perceptions• Social Concerns• Socio-Economic Impacts
Risk AppraisalRisk ManagementImplementation• Option Realisation• Monitoring & Control• Feedback from Risk Mgmt. Practice
Decision Making• Option Identification & Generation• Option Assessment• Option Evaluation & Selection
Risk Management
Communication
1 Knowledge Challenge: Complexity Uncertainty Ambiguity
2 Risk judged: acceptable tolerable intolerable
3 Risk Management Strategy: routine-based risk-informed/robust focus precaution-based resilience-focus discourse-based
Design Fabrication Operations
Asset Lifecycle Integrity and Reliability
Construction
Pre-Assessment Components
Definition Indicators
1 Problem framing Different perspectives of how to conceptualize the issue
dissent/consent on goals of selection rule dissent/consent on relevance of evidence choice of frame (risk, opportunity, fate)
2 Early warning Systematic search for new hazards
unusual events or phenomena systematic comparison between modeled
and observed phenomena novel activities or events
3 Screening (risk assessment and concern assessment policy)
Establishing a procedure for screening hazards and risks and determining assessment and management route
screening in place? criteria for screening: hazard potential,
persistence, ubiquity, etc. criteria for selecting risk assessment
procedures for: known risks, emergencies, etc.
criteria for identifying and measuring social concerns
4 Scientific conventions for risk assessment & concern assessment
Establishing a procedure for screening hazards and risks and determining assessment and management route
definition of NOAEL validity of methods and techniques for
risk assessments methodological rules for assessing
concerns
Risk Assessment Hazard identification and estimation Exposure assessment Risk estimation
Concern Assessment Socio-economic impacts Economic benefits Public concerns (stakeholders and individuals)
Assessment Definition Indicators
1. Generation Identification of potential risk handling options, in particular risk reduction, i.e. prevention, adaptation and mitigation, as well as risk avoidance, transfer and retention
standards, voluntary agreements performance rules restrictions on exposure or vulnerability economic incentives compensation insurance and liability labels, information/education
2. Assessment Investigations of impacts of each option (economic, technical, social, political, cultural)
effectiveness and efficiency minimization of side effects sustainability fairness legal and political implementability ethical acceptability public acceptance
3 Evaluation and Selection
Evaluation of options (multi-criteria analysis)
assignment of trade-offs incorporation of stakeholders & the public
4. Implementation Realization of the most preferred option
accountability consistency effectiveness
5 Monitor and Feedback
Observation of effects of imple-mentation (link to early warning)
Ex-post evaluation
intended impacts non-intended impacts policy impacts
RISK MANAGEMENTDECISION PROCESS
Is MaximumPossible Loss
(MPL) Severe?
Analyze Factors Affecting Sizeof Possible Loss
EliminateSource(s) of Loss
Reduce PossibleLoss Size by
Positive Action
Transfer Risk
Does Any SeverePossible Loss
Remain?Assume Risk
TransferRefused
Risk RemainsToo High
DO NOT PROCEED
DISCOUNTINUEOPERATION
PROCEED
CSURMA Self-Insurance Pool
ContractualTransfer
CommercialInsurance
Avoid / Eliminate
CampusDeductible
AssumeCalculated
Severe Risk
Assume LowRisk Exposure
Identify Exposure toPossible Loss
Estimate MaximumPossible Loss / Probability
of LossCSURMA Self-Insurance Pool
ContractualTransfer
CommercialInsurance
CSURMA Self-Insurance Pool
ContractualTransfer
TransferRefused
Risk RemainsToo High
CommercialInsurance
CSURMA Self-Insurance Pool
ContractualTransfer
DO NOT PROCEED
TransferRefused
Risk RemainsToo High
CommercialInsurance
Self-Insurance Pool
ContractualTransfer
Identify Exposure toPossible Loss
Estimate MaximumPossible Loss / Probability
of Loss
Analyze Factors Affecting Sizeof Possible Loss
Identify Exposure toPossible Loss
Estimate MaximumPossible Loss / Probability
of Loss
Reduce PossibleLoss Size by
Positive Action
Avoid / Eliminate DISCOUNTINUEOPERATION
Reduce PossibleLoss Size by
Positive Action
Avoid / Eliminate
EliminateSource(s) of Loss
Assume Risk
AssumeCalculated
Severe Risk
EliminateSource(s) of Loss
Assume Risk
CampusDeductible
AssumeCalculated
Severe Risk
EliminateSource(s) of Loss
Assume Risk Assume LowRisk Exposure
CampusDeductible
AssumeCalculated
Severe Risk
EliminateSource(s) of Loss
Assume Risk
PROCEED
Assume LowRisk Exposure
InsuranceDeductible
AssumeCalculated
Severe Risk
EliminateSource(s) of Loss
Assume Risk
YES
YES
YES
YES
YES
YES
YES
NO
NO
YES
NO
YES
YES
NO
YESYES
YES
NO
NO
YESYES
YES
NO
YES
NO
YESYES
YES
YES
YES
NO
YESYES
YES
YES
YES
YES
NO
YESYES
YES
YES
YES
YES
YES
NO
YESYES
YES
Management
Internal • Involving all affected regulatory or government bodies if risk management measures have
impacts on their mandate
External• Press conferences on selection of management measures (low uncertainty and ambiguity)• Information of stakeholders about regulatory impact review and, if needed, organisation of
hearings (high uncertainty and low ambiguity)• Engaging in formal deliberations with stakeholders and representatives of the public (high
ambiguity)
Risk Communication
Pre-assessmentShaping the process (consensus on frames)Design Discourse
AppraisalGathering information and knowledge Epistemic Discourse
Assessment and EvaluationDeliberating around values/perspectives and assigning trade-offs
Reflective Discourse
ManagementWeighing pros and cons of management measuresPragmatic Discourse (for low ambiguity)
Participative Discourse (for high ambiguity)
Stakeholder Involvement at Different Stages
Complexity
Epistemic
Use experts to find valid,
reliable and relevant
knowledge about the risk
Uncertainty
Reflective
Involve all affected
stakeholders to collectively
decide best way forward
Ambiguity
Participative
Include all actors to expose, accept,
discuss, and resolve
differences
Simple
Instrumental
Find the most cost-effective way to make
the risk acceptable or
tolerable
Management/ Staff
Dominant risk characteristic
Type of participation
Actors
Management/ Staff Management/ Staff Management/ Staff
Scientists/ Researchers
Affected stakeholders
Civil society
Scientists/ Researchers
Scientists/ Researchers
Affected stakeholders
As the level of knowledge changes, so alsowill the type of participation need to change
Integrate risk assessment with techniques applied in the human factors to improve the safety management of process hazards
Some steps to achieve this:
Review best practices from around the world with the industry and other industries
Update best practices, provides more focus on the human element, and addresses non-process related hazards more robustly at the design and fabrication stage
Hold an industry workshops to present and review the proposed approach and seek stakeholder input on human factors content
Balance prescriptive and goal setting approach and predictive solutions to deliver a more human approach to industry
Using predictive analytic data to determine how human factors concerns can be applied to hazard identification and risk control
Industry has made great progress managing process related hazards and preventive strategies to protect workers, property, and environment
Focus on managing process major hazards through the design and incorporation of more complex equipment and systems
Non-process related major hazards are well understood but receive less focus than the process hazards during design and fabrication
Challenges of industry continue and require multi-disciplinary and cross functional collaboration internal/external to the organizations even when manpower and resources are stretched
Accidents continue to happen and the majority can be linked to a human error or inadequate human performance
Industry needs to raise the bar using predictive analytic data to improve human performance, reduce risk, limit liability, sustain productivity, and meet regulatory obligations