gent coach training march 2004

8/11/2019 Gent Coach Training March 2004

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SEOP Distribution 30 xxxx2004

HSSE training

Gent

March 30-31th 2004


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Agenda :

09 00 : Introduction

09 10 : Introduction & background Coachable HSSE moments

09 20 : Syndicate: Management commitment

09 50 :Bradley curve

10 00: Syndicate: Case study & Coffee Break

10 45 : Safety culture

11 00 : Syndicate: Identifying the root causes

12 00 : Just culture decision making process

12 15 : Syndicate: Just culture decisions

13 00 : Courage

13 15: Conclusion

13.30: End


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Coachable HSSE moments

At the conclusion of this session, you will have anunderstanding of:

Why a culture change is required

Which elements are required for the change

What you can do for the change


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TRCs 2003 General Failure Type

%

LEGEND of GFT

HW- Hardware

DE - Design

MM- Maint.Mgt.PR - Procedures

EC- Error Enfor.Cond.

HK- Housekeeping

IG- Incompat. Goals

OR- Organisation

CO- Communication

TR- Training

DF - Defences

0

5

10

15

20

25

3035

40

45

50

HW DE MM PR EC HK IG OR CO TR DF

TRCs - GFT%


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TRCs - % by employees and location

0

10

20

30

40

50

60

70

80

90

100

Emp Cont Fac Gant Ret Com Road Oth

LEGEND

EmpShell Staff

ContContractors Staff

Fac- Facilities

Gant- Gantry

RetRetail Stations

ComCommercial Customers

RoadTraffic Road Incident

Oth - Others


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Safety is in the Head !

Unsafe Conditions

4%

96%

Unsafe Acts

THE CAUSE OF INJURIES


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Medical Treatment

Fatalities Lost Time In juries

First-Aid Cases

Procedures

DocumentationTechnical

Measures

Peoples Behaviour

and

Unsafe Acts

THE ICE-BERG


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1 fatality

30 Major injuries

300 Minor injuries

3000 Incidents which did notcause harm

30 000 at-risk behaviours

Environment where leadershipand peers condone at-riskbehaviours

3

36

HSSE Performance xxxx 2003

30.000275

1


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Demonstrated Management Commitment

To say it starts at the top is a clich.

But

it starts there, or it does not start at all.


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Syndicate exercise

In table groups Describe leadership actions and/or behaviours which

clearly demonstrate to your organization yourvisible commitment to safety

List these actions and/or behaviours

Select a spokesperson; be prepared to review

PS: What you do today not what you should be doing.


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Syndicate exercise

In table groups

Describe leadership actions and/or behaviourswhich destroy the image of your commitment to

safety in the eyes of your employees. List these actions and/or behaviours

Select a spokesperson; be prepared to review


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DEMONSTRATED MANAGEMENT COMMITMENT

Signaling the organization that HSE excellence is a high corporate

priority. Set an expectation of immediate reporting of serious incidents

Integrating HSE considerations in all business and personal evaluations.

Holding management and supervision accountable for their leadership insafety,

Getting personally involved in high potential and serious incidentinvestigations.

Demonstrate a sincere interest in safety through the manner in whichyou conduct your walks through operations in your area ofresponsibility.

Chairing the HSE steering committee. Attendance at HSE meetingsshould be considered a high priority.

Learning how to conduct HSE audits and participating regularly.

Develop an audit schedule which exposes you regularly to all areas overtime.


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ManagementCommitment

Condition ofEmployment

Fear/Discipline Rules/Procedures Supervisor

Control, Emphasis,and Goals

Value All People Training

Personal Knowledge,Commitment, andStandards

Internalization Personal Value Care for Self Practice, Habits Individual Recognition

Help Others Conform Care for each other Networking Contributor Organizational Pride

InjuryRates

NaturalInstincts

Management

Self

Teams

The Bradley Curve

DependentSafety Culture

IndependentSafety Culture

InterdependentSafety Culture

0


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What is a safety culture ?

A safe culture = an informed culture

An informed culture is one that knows where the

edge is without having to fall over it first.

An informed culture is preoccupied with thepossibility of failure and works continuously tobecome more resilient to its operational hazards.


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But an informed culture can only grow froma just culture

An informed culture depends on people reporting

near misses, errors and incidents.

But they wont do that if they dont trust thesystem.

And they certainly wont do it if they aredisciplined because of what they report.


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Reporting

culture

Informedculture

Just

culture

A safe culture has many interlocking elements


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Building a just culture

A just culture depends on: the trust of the workforce

knowing the difference between acceptable andunacceptable behaviour.

A just culture is a culture of accountability, wherepeople know what is expected from them

A just culture ensures that people involved aretreated fairly


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Just

culture

Reportingculture

Informedculture

The elements must work in harmony


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Errors vs violations?

Should all unintended actions (errors) beexempt from disciplinary action?

Should all deliberate violations bepunished?

Unfortunately, its not as simple asthat.


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Scenario 1

A maintainer is assigned to inspect forcracks in an aircrafts fuselage standing onthe tarmac at night.

In accordance with procedures, he/shegets the appropriate work stand and lightsthen carries out a close inspection

Despite this, he/she misses a crack thatcould have seriously endangered theaircraft.


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Scenario 2

As before, a maintainer is assigned to check forcracks in the fuselage at night.

This time, however, he/she doesnt bother to

fetch the stand and lights.

He/she merely walks beneath the aircraft using ahand-held flashlight.

Once again, a dangerous crack is missed.


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Comparison 1 and 2

Both maintainers committed the same unintendederror: missing the crack.

But, in scenario 2, the maintainers actions madethis error far more likely.

He/she deliberately engaged in behaviour thatsignificantly and unjustifiably increased the risk oferror (recklessness).


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Compliance versus non-compliance?

It could be said that the main difference was that oneperson complied with procedures and the other did not.

In other words, the issue of blame could hinge oncompliance or non-compliance.

But even that is too simple. Consider Scenario 3.


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Scenario 3

The situation is basically as before.

But this time the maintainer discovers that theproper work stand is broken and there are nostrong lights available.

Pressed for time, the maintainer does a walk-under inspection using a flashlight.

As before, a dangerous crack is missed.


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Differences between Scenarios 2 and 3

In Scenario 2, the maintainer deliberatelydecides to short-cut the appropriate procedures

re: work stand and lights.

In Scenario 3, the maintainer is forced to commita situational violation because the appropriate

equipment is either unserviceable or missing.


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Where should the line be drawn?

SabotageSubstance abuse

Reckless

violations

System-induced violationsNegligent errors

System-induced errors

etc.

Culpable Blameless

?


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Coachable HSSE moments Workshop

Role playSplit up into groups of 4-5 people.

Appoint role players: Person 1, Person 2, ObserversPlay the roles

Feedback from observers

Change the roles for next scenario

General presentation (3 minutes each group)

Scenario 1:

Peter has to visit a construction site with Paul (contractor).

Paul has suggested to use his car for the visit.

When Peter wants to sit down on the passenger seat,

he notices that the seatbelt is broken.Peter gets out of the car and

checks what the problem is.

He is getting aware that it is a very old existing problem,

that was never solved.

What does he say to Paul?


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SEOP Distribution 30 xxxx2004SEOP-Distribution


Scenario 2

Yesterday a leak (100 kg diesel) was found in a Production unit.

Investigation shows that Vincent has repaired the pump on his own way and thathe hasnt followed the official procedure.

Vincent is a very experienced mechanic and assumes that his way to carry out the work

is the best.

Six months ago he has discussed his better way with his supervisor Eric and informed

Him that the current procedure is not practical; the proposed alternative procedure

was not examined by Eric.

Now Eric realizes that Vincent way is better and the cause of the leakage is not the

deviation from the official procedure.

Eric meets Vincent.

Scenario 3

John is the supervisor of a team of 4 people. Jim is one of this team and he is very

introvert. Jim has noticed a very dangerous situation and has prevented an accident,that could have happened.

John has congratulated Jim for his initiative and wants to reward him. Jim states that

he has just done his normal work and shouldnt be rewarded (hes also afraid that this

reward will create jealousy in his team).

John meets Jim.


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Scenario 4

Jeff is the supervisor of Michael. Michael is the supervisor of a team of 10 people.Peter , one of the team of 5 employees, has a safety performance which is not an

example for others.

Michael has problems to tell Peter that his performance is not acceptable and

he is used not to tell him this.

Jeff has just heard, that Peter could have got serious burns, during taking a sample

this morning.Jeff meets Michael.


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Items for the discussion:

What are the problems ?

Is the real problem clear ?

Is the standard clear?

What are the actions to be taken?


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*Management/Supervision responsibility to correct route

causes of system issues.

#Time Bound

Were the actions

as intended?

Were the results

as intended?

Sabotage or

Malevolent

Act

Reckless

Violation

System*Induced

Violation

Knowingly Violating

Procedures?

Procedures & Standards

Clear and Workable?

Pass Substitution

Test?

Defective

Training, Selection

Experience

Negligent

Error

System*

Produced

Error

NO NOYES

Verbal Warning

Minimum Bonus

Final Warning Letter

Dismissal

Increasing Individual Culpability

Formal Coaching on Issue

History of Violating

procedures

YESYES

YES

YES

YES

YES

NO

NO

NO

NO

Training required

NOO

NO

Unconsciousviolation

No blame errorInadequate awareness

NOYES

First Warning Letter

No Promotion

Sieze Coachable moment

Just Culture Decision Treefor serious near miss / incident

consider reward proactive reporting


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Given the circumstances thatexisted at the time of theevent, could you be sure that

you would not have committedthe same or similar breach or

unsafe act?

The Substitution Test

C h bl HSSE t W k h


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Make groups of 4-5 people

Examine following 8 scenarios

Define where you end up in the Just Culture decision treeFeedback (each group different scenario)


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Discuss in small groups the steps in the decision tree:

1. A subcontractor (scaffolding company) is erecting a scaffold. A scaffolder has not fixed

the rope of his harness to a fixed part of the construction.

2. A Shell employee is driving inside the plant with a speed of 50 km/hr

3. A driver is exceeding the maximum speed on the right lane as he he is afraid that reducing

the speed will result in dangerous situations (e.g. overtaking vehicles)

2. A crane operator lifts piping over the public road without safety signs and

demarcation.5. A (contractor) mechanic is repairing a pump. He is working without a permit to work

and the electrical isolation has not been carried out.

6. Two employees are working together. One of them is new and does not wear the required

personal protection. The other person is his supervisor, who is wearing the required ppe

and he accepts that his colleague does not wear personal protection equipment.

7. An employee is carrying out a modification according the latest PI&D.sThe PI&D is not up to date. The modification results in a leakage.

8. An operator has to isolate a pump, but because of safety reasons this can not be done

(release vent is at 3 meter high)


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Summary

A safe culture is an informed culture: onethat knows where the edge is withoutfalling over it.

An informed culture depends on trust. Theworkforce will not report errors and nearmisses if they are punished for it.

Thus a safe culture depends critically uponbuilding a just culture.

gent coach training march 2004

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