Presented by Peter Wilkinson, Notetic Group

1. TASMANIAN SAFETY SYMPOSIUM
Hobart 18 May 2017
Peter Wilkinson
GM – Risk
Noetic Group

2. Montara
Critical Controls 2

3. What will I talk about?
 No new accidents…?
 How do incidents occur?
 Managing Safety via a focus on Critical Controls
 Culture – Is there any such thing as Safety Culture?
 Discuss some international developments in managing critical controls
 Critical Control Approach is no more than a more rigorous application of what
we already do! Critical Controls 3

4. We know how most bad things happen….!
Most incidents
result from failure
to apply and not a
failure to know
The types of
incidents are
well known
The Causes of
incidents are
also well
known
Good Practice on
how to control
the causes is also
known
Critical Controls 4

5. Risk Causation – A Failure to Implement?
 Most risk events involve:
 Failure to implement well known controls for well known risks
 Examples:
 Barings Bank (1792 – 1992) Nick Leeson – A “rogue” trader?
 Societe General (2008) $7.5bn loss…another “rogue” trader?
 Montara blow out – Australia 2009
 BP Macondo/Deepwater Horizon 2010 $60bn loss
 And many more…!
 Causation
 Each incident is unique in fine detail – but fundamentally the same failures are evident
across all risk domains – from safety in oil and gas to the finance sector to not for profit to
health care
Critical Controls 5

6. Measuring Safety and Safety Myths eg
80% of all incidents are caused by human error
• Over Focus on LTIFR/TRIFR
• Lagging indicators - Looking in the rear view mirror and routinely gamed – slip on step example
• Over – focus on front line worker behaviour
• Little relevance to occupational health or process safety
• Can lead to blame rather than explanation
• Temptation to manage the measure
• Behavioural Based Safety systems – “The magic bullet or a shot in the dark?
Critical Controls 6

7. How do incidents occur?
Critical Controls 7
Human errors
System,
process,
procedural
issues
Engineering,
Technology
and software

8. Managing Safety
 We usually assume that accidents involve:
 Mistakes or errors by individuals
 Procedures
 Engineering
 The prevailing view on accident prevention (and what the law requires) is that
we :
 Assess the risks
 identify controls
 Implement the controls
 Having identified the controls – what do we do next?
 Prepare a bow tie?
 Provide instruction and training?
 Write a procedure?
Critical Controls 8

9. A CRITICAL CONTROL APPROACH?
Or a focus on what really matters….
9Critical Controls

10. CRITICAL CONTROL APPROACH
Some underpinning assumptions :
+ Not new approach and uses Swiss Cheese analogy
+ Most Hazards, Risk and Controls are known
+ Implementation of controls more difficult 24/7 than identifying what the controls could or should be
+ Some controls are more important than others
Active Monitoring is essential
Volume of hazard management documentation is of itself a barrier - Less can be
more/better
Critical Controls 10

11. Typical Situation
 Strong focus on personal safety especially fatality risk
 Often have a variety of systems, procedures, policies, practices
 Procedures, SOPs and Risk Assessments used to manage risks - Quality often
good but ease of use varies due:
 length,
 Complexity
 Clarity
 Usually a gap between Policy and Practice (Work as Imagined vs Work as Done)
 Is it clear which are the risk controls that really matter?
 Monitoring how well controls are implemented in practice frequently weak
Critical Controls 11

12. Complex Bowties
12Critical Controls

13. Critical Controls 13
Large no.
of controls
Processes &
procedures
Complex
bowties “shelf-ware”
What really matters?
Simplified
Bowtie
Critical control
summary sheet
SME

14. Simplified Model of Monitoring
Critical Controls 14
Managers
Ensure Supervisors have systems
for monitoring critical controls and
carry out some monitoring
themselves.
Supervisors
Monitor implementation of critical
controls by operators
Front line workers
Do the work! Carry out their own
monitoring – including each other
Audit

15. The Critical Control Approach
15
Critical Control Information Summary – Steam Plant
Risk Owner…………….
Control Owner…………
1. Title of the critical control
2. What are its specific objectives
3. What are the critical control
performance requirements to
meet the objectives?
4. What are the activities that
support or enable the critical
control?
5. What activities can be checked
to verify the control is working as
implemented?
Critical Controls

16. Critical Controls 16
Process Safety Hazard: Loss of Containment of Sulphuric Acid
Threat: Overfilling a Storage Tank
Critical Control: Unloading Operator Competency
Control Definition: Training and competency of unloading personnel
Control Owner: Warehouse Superintendent
Key Control Activity Desired Outcomes of Key
Control Activity
Validation of Effectiveness
Ensure that the delivery drivers have
completed a specific acid area induction.
All drivers know exactly where to go,
what the unloading arrangements
are and what their responsibilities
are in relation to safe transfer of acid
Verify that drivers have
completed the inductions
(training records) and talk to a
sample of drivers to assess their
level of knowledge.
Ensure delivery drivers have received
specified training
All delivery drivers are trained,
competent and authorised to unload
as per PRO XYZ 056
As above
Ensure delivery drivers are included in
D&A testing
All drivers are free of drugs and
alcohol
Verify the D&A testing
programme includes all drivers
and that all results are negative

17. 17
Risk : Steam Boiler Explosion
Risk Owner: Mill Manager
Control Owner: Production and Maintenance Superintendent
1. Title of the critical control: Low Water level control
2. What are its specific objectives: Maintain boiler feed level within OEM specified limits
3. What are the critical control
performance requirements?
4. What activities are needed to
support the critical control?
5. What checks are needed to
verify the control is working?
+ Low water condition is
automatically detected
+ Heat source is cut off
+ Audible and visual alarm
operates
MMS generates PM routines
for each part of low water
level control
Quarterly Report to Mill
Manager
Critical Controls

18. What does good look like?
 “What really matters” in terms of risk controls is known
+ Purpose, Scope, Objectives are clear
+ Performance standards specified
 There are clear accountabilities for:
+ control implementation
+ control monitoring
 The “health” of controls is routinely and honestly monitored
 Control “health” is used to measure the likelihood of a risk eventuating
 Weak controls are seen as early warning signs - bad news about controls is welcomed, rewarded
and actioned
 Reporting is based on control “health”
 Strategic (or material) risks are a routine part of Executive Meetings
Critical Controls 18

19. And a word on Culture
 Culture: “…remains a confusing and ambiguous concept…little evidence of a relationship between
safety culture and safety performance…”
 Values + Practices = Culture (John Coleman, Harvard Business Review); Andrew Hopkins and Edgar
Schein say much the same.
 Values can be faked – Practices are visible. In good cultures; Values and Practices are in synch
 To improve culture as applied to safety – a focus on practices is likely to be more successful.
Practices repeated are “How we do things round here.”
Putting Safety Critical Controls at the heart of the prevention (and mitigation)
strategy for process safety is good for the culture!
Critical Controls 19

20. Critical controls
Critical Controls 20

21. References
http://www.icmm.com/en-gb/publications/critical-control-management-implementation-
guide
Critical Controls 21

22. The End!
Critical Controls 22