Ch-2 (Practical Risk Assessment) and Ch-3 (Managing Control of Loss)

(I-S-M-E-C): Identification of Work, Standards for Work, Measurement of Performance to Standards, Evaluation of Results, and Commendation and Constructive Correction.

5 progressive steps

• Industry studies revealed that over 80% of all major incidents linked to operational and physical change. • Change: Any alternation or variation in a position, behavior, function, property or distinguishing characteristic over a given time interval. Change is measured relative to some initial state. • Physical Plant Change • Operational Change • Administrative Change • Organizational Change • Emergency Change • In-Kind Replacement: Replacement of an instrument with a part meeting same specifications. • Known Operating Envelope • Area Operations Team • Change Control Process 1)Identify Change: If an activity is not recognized as a change, then entire process will be bypassed, allowing potential risks. 2)Evaluate Change: Evaluate change by asking and answering fundamental change questions. 3)Review Change with Area Leadership: These persons may be members of an Area Operations Team, Area Production Maintenance Team, Area Supervisor, Team Leaders etc. 4)Assign Proposed Change for Follow-up: Area managers will determine appropriate person to assign proposed change to for further investigation. • Assigned person will generate a file and change number 5)Risk Assessment: Assigned person(s) must conduct a risk assessment as part of follow-up to proposed change. • Risk assessments may be Informal or Formal based on nature of change. 6)Obtain Approval: Once proposed change has had its associated risks and viability assessed it will be returned to area management personnel with a recommendation to either proceed or not to proceed. 7)Communicate Change: Management personnel of area making change are responsible for ensuring that this communication has taken place prior to implementation of change. 8)Implement Change: Part of implementation is incorporating it into "organizational memory". • It must be reflected in related work instructions, purchasing specifications, inspection and maintenance schedules, operating parameters, and training programs etc. 9)Follow Up on Change: All changes implemented via this procedure must be followed up within a reasonable length of time, to determine if effects of change were as planned. Change Documentation: Organizations may develop a variety of forms to initiate, approve, communicate, and track change. • Change is mother of both problems and progress.

Change Management

Hazard: A condition, device or substance that can directly cause injury to people or damage to property. Risk: a measure of potential loss that considers both magnitude of a loss and its likelihood of occurring. Impact: A measure of magnitude of a loss (severity, consequence, and seriousness). Probability: likelihood that a specific event or outcome will have an identified effect, often expressed as "high," "moderate," or "low", or as a percentage. Frequency: A measure of rate of occurrence of an event expressed as number of occurrences of event in a given time period or potential number of trials. Risk Assessment: process used to identify, quantify, or rank risks.

Def 1

Risk Analysis: A systematic use of available information to determine how often specified events may occur and magnitude of their consequences. Residual Risk: level of risk remaining after all risk control measures have been implemented. Acceptable Risk: level of risk deemed acceptable to a group of people based on industry practices, previous loss experience, and other existing risk. Risk Controls: Measures that reduce or control risks that have been identified through risk assessment. 4 types of risk control are: Terminate: An informed decision to either discontinue an activity or to not initiate it. This is sometimes called risk avoidance.

Definitions 2

• An aircraft collision in midair would unarguably be classified as a Category-I mishap (catastrophic), hazard probability would fall into Level-D (remote) classification based upon statistical history of midair collision occurrence. • System safety effort in this case would require specific, but relatively minimal controls to prevent such an occurrence.

Example- Aircraft Collision

• GRA is an effective middle ground when a SRA is not systematic enough. • Risk assessment is sharing of experience and ideas among qualified persons.

Group Risk Assessment

• Some studies were done by governmental agencies, e.g. National Institute of Occupational Safety and Health, Industrial Accident Prevention Association of Ontario, Canada and others by major universities e.g. University of Nebraska and Stanford University. • These studies, and practical experience they reflect, provide best guide for identifying activities which get desired results. • One such guide is list of 20 program elements. • Many start with a 10 point program and gradually build up to full-grown program of leaders. • These work responsibilities may be spelled out in job descriptions, procedures manuals and/or standard practices.

System for Managing Control

• Variety of constructive ____________ measures may be used: • Better communication of goals, objectives and standards to be sure they are understood. • More effective training. • Increased and improved performance feedback so people won't have to guess where they stand. • Improved work instructions and work methods which help to remove frustration, hazards and meaningless activity. • Improved recognition for desired behavior to communicate that it really matters. • Rule enforcement as a last resort, but done in a way that communicates your genuine concern.

corrective

• Potential __________ Analysis: potential problems are listed and then more serious and more probable ones are selected for further analysis. • Likely causes are considered and then preventive and contingent actions are developed to address problems, their causes, and their effects. • Hazard and Operability Analysis (HAZOP): used to speculate possible failures resulting from deviations. • It is very thorough and helps to identify design or procedural deficiencies. • It is used principally in basic engineering packages, engineering design specifications, and operating plants.

problem

1) Identify a facilitator: skill of facilitating is quite different than of group speaking. • Facilitator must: Be unbiased, Be familiar with process or problem being considered, Manage group's process, not create problem under consideration, ensure integrity of process. 2) Assemble a group of 2 to 6 participants: Larger numbers lead to difficulty in reaching consensus. • It is especially important to include those who will be most immediately affected by change. • Ensure that personal bias is minimized. • 3) Establish Low, Medium & High parameters for probability and impact/severity: have a low probability of occurring and a low impact it occur, issue can be appropriately discarded. • A higher probability and impact concern will necessarily be regarded as having a higher risk level and, therefore, deserving of more stringent control measures. • Probability Parameters: Estimating probability is an inexact science, and even most rigorous risk assessment methods cannot accurately establish meaningful probabilities for all risk situations. • Impact/Severity Parameters: develop a universally applicable set of impact parameters. 4) Establish Risk acceptance criteria: reach agreement regarding extent of risk that is acceptable and unacceptable for situation being considered. 5) Obtain records and information for system being evaluated: Such records might include: • Designs, drawings, Investigation records, Employee concern logs, Joint safety and health committee findings, Inspection records, Problem solving team reports, Quality specifications, Training need analysis, PPE analysis, Maintenance records, Manufacturer recommendations etc. 6) Conduct GRA: Use progressively systematic methods if necessary. 7) Record data and follow-up: Accurate and complete records must be maintained.

7 steps of GRA

Treat: Use various loss control tools and techniques to minimize chances of loss occurring and/or magnitude of consequences if it does occur. Tolerate: If a risk cannot be eliminated and reduction measures have been optimally applied, then organization must decide how much of residual threat it will retain and how to do it. Transfer: financial responsibility or burden for a loss can be shared with responsible third parties through leases, partnerships, contracts, holdharmless agreements, and insurance.

Def 3

3) _________ a plan: • Try first to "terminate" (prevent or get rid of) loss exposure. • Often this is not economically or administratively feasible. • When it is, it's a complete and permanent control. • Then "treat" remaining exposures through appropriate loss control activities. • Because it is not practical or economically feasible to create a risk-free environment, it will be necessary to "tolerate" some loss exposures, to operate at an acceptable level of risk. • Another part of plan may be to "transfer" some of risk to others (e.g. insurance and business agreements). • Plan in most cases includes a combination of these strategies. 4)____________ plan: • A plan yields results when it is converted into action and put to work. • Work instructions have to be written, equipment bought, people trained, resources allocated. 5)__________ system: • To measure, evaluate, commend and correct individual and organizational performance.

Devlope implement Monitor

• It starts with an assumed failure or loss (top event) and works backwards to establish how and why such a failure might occur. • Fault tree recognizes conditional relationship between a causal factors and displays relationship in graphical form. • Logic gates depict whether any single condition (gate) or set of conditions (gate) are required to trigger a loss. • Highly hazardous substances/equipment or complex operating systems can be physically simulated (________ Modeling) to determine effects of failure or release. • Techniques as finite element analysis and fire/explosion modeling can help to establish magnitude of potential losses as well as to identify measures to reduce probability of loss. • These methods are generally used at detail design stage or for addressing existing plant problems.

EVENT

• A minor collision between two automobiles in a congested parking lot might be classified as a Category-IV mishap (negligible) with a hazard probability of Level-A (frequent) or Level B (probable). • Effort here would focus on implementing low-cost, effective controls because of high probability of occurrence. • Signs indicating right-of-way, wide parking spaces, low speed limits, placement of speed bumps, and so on, are some examples of such controls.

Example- Minor Collision Between Two Automobiles

(1)A man cleaning a bird feeder on balcony of his condominium apartment in a Toronto suburb slipped and fell 23 stories to his death. He was standing on a wheeled chair when incident occurred. It appears chair moved and he went over balcony. (2) A lawyer demonstrating safety of windows in a downtown skyscraper, crashed through a window with his shoulder and plunged 24 floors to his death. A police spokesman said he fell as he was explaining strength of building's windows to visiting law students. He previously had conducted demonstration of building's window, strength, according to police reports. (3) Four people, including 3 paramedics, died in a confined space incident. First was a teenage boy who, while emptying grass clippings into abandoned cistern, dropped an attachment through opening and apparently went down into cistern to relieve it. When his sister discovered him she called paramedics. One at a time they descended into cistern and promptly lost consciousness. They should have known better from their training; however being members of a small community they all knew the boy and his family. • Incident investigation files found that industry are full of tragic examples that are similar, and that could have been avoided if SRA questions had been and appropriately answered.

Example- SRA

• Henri Fayol (1841-1925) defined functions of management in 1916 as: Forecasting and Planning, Organizing, Commanding, Coordinating and Controlling. • Commanding has been replaced with directing or leading. • Today functions of management are listed by many organizations as: • Planning • Organizing • Leading/Directing • Controlling • Controlling is not treating people as puppets, it is something we do to work process.

Functions of Management for Control

• Any completed risk assessments with significant implications must be reviewed by a person who has authority over area or item affected. • A checklist is provided to assist with this review process. • A system is required to ensure effective follow-up on risk mitigation measures.

GRA Quality

• MIL-STD-882 represent a qualitative judgment on relative likelihood of occurrence of a mishap caused by uncorrected or uncontrolled hazard. • If evaluation of a potential for mishap reveals a Category-I occurrence (catastrophic) with a Level-A probability (frequent), system safety effort would undoubtedly require elimination of hazard through design or provide for implementation of redundant hazard controls prior to system or project activation. • Probability of a hazard risk is inversely proportional to its severity. • However, since some risk of hazard or accident exists even when certain systems or tasks operate as intended and designed (pressure systems, foundry operations, oil refinement etc.), total hazard level must be evaluated, and not just that associated with system or subsystem failures.

Hazard Probability

• By establishing an alphanumeric weighting system for risk occurrence in each severity category and level of probability, one can further classify and assess risk by degree of acceptance. • 4 categories of severity and 5 categories of probability, is often referred to as a "4 × 5 Risk Matrix". • Organizations may add a 5th severity value e.g. "insignificant" or "slight" or "no loss." Then it would be referred to as a "5 × 5 Risk Matrix." • Exact parameters and/or categories assigned are not concrete. • Dark gray, medium gray, light gray, and white shade scheme for black and white print, has been applied for hazard. Color can be used too.

Hazard Risk Matrix

• MIL-STD-882 establishes to determine hazard severity, initially established for DOD. • Hazard severity categories provide a qualitative indication of relative severity of possible consequences of hazardous condition(s). • Criticality of addressing a Category-I (catastrophic hazard), is much more important than a Category-IV (negligible) hazard.

Hazard Severity

"Any substance that jumps out of its container when something goes wrong and hurts or harms the things it touches".

Hazard Substance

Identification of ______: • Effective leaders know from training and experience, what they and others must do to get job done in proper way. • Not having this knowledge, or not applying it, results in frustration, waste and confusion for all concerned. • Broad outlines of an Occupational Health and Safety Management System are found in OHSAS 18001:1999. Standards for _______: • Without adequate standards, there can be no meaningful measurement, evaluation or correction or commendation of performance. • You should have specific, clear, demanding standards for all program elements.

Identification of Work Standards for Work

1)________ all loss exposures: • Make a continuous contribution to identification of loss exposures, including planned inspections, investigations, task analyses, performance observations, safety data sheets, preventive maintenance logs, and damage inventories. 2) _________ risk in each exposure: • Determining the criticality of loss exposures and setting priorities for action. • 3 variables used in this evaluation: Severity: how big or bad is the loss likely to be? Frequency: how often does the exposure occur? Probability: considering people, equipment, materials, environment, process factors, how likely is the loss to occur during each exposure?

Identify Evaluate

• 3 major reasons for loss control are: 1) good leaders are responsible for safety and health of others as well as protection of environment (HSE). 2) HSE provides opportunities for managing costs, 3) provides an operational strategy to improve overall management, including property damage, process loss, and quality. • Cost items obvious to everyone include workers' compensation, medical insurance, damage to equipment and product, downtime, repairs, replacements, lawsuits and liability. • Other costs include investigation time, costs of hiring and/or training replacements, lost productivity, overtime, extra front-line leaders' time, clerical time and loss of business and goodwill. • Traditionally, incident costs have been considered as an expense, as a cost of doing business. • However, many modem managers see and treat preventing incidents as an investment with significant returns, both humane and economic. • People have tendency to rationalize incident causes, to focus on "careless" or "unsafe" acts of others to avoid blaming themselves. • But, Dr. W. Deming (renowned quality consultant) and others discovered, only 15% of a company's problems can be controlled by individual employees, while 85% can be controlled by management system. • Most loss control problems are management system problems. • A well-managed loss control system provides an operational strategy to improve overall management. • H. W. Heinrich in his book "industrial Accident Prevention" wrote, "Methods of most value in accident prevention are analogous with methods required for control of quality, cost, and quantity of production".

Intro for chpt 3

7)Principal of Critical/Vital Few: majority (80%) of any group of effects is produced by a relatively small (20%) number of causes. • Management professional tries to identify critical factors and to concentrate. • This gives greatest return on investment of time, money and other resources. 8)Principal of ____ Advocate: It is easier to persuade a group of people when at least one person within their own circle believes in proposal well enough to champion cause. • This is known as "lobbying" in political circles. 9) Principle of Goals and Objectives: Results tends to increase when people have meaningful goals and objectives toward which to work.• They relate to vision, mission and generic results. • For maximum motivational power, goals must be broken down into specific objectives.

Key

Loss: avoidable waste of any resource Control: compliance with standards or requirements Safety: control of incident loss Occupational Health: Control of work-related illness. Environmental Protection: control of harm or damage to anything (living and non-living) in environment. Loss Control: anything done to reduce loss from risks of business: 1)prevention or reduction of loss producing events 2)minimizing of loss when loss-producing events occur 3) termination or avoidance of risk Loss Control Management: application of effective management skills to loss control from risks of business. • Effective leader keeps up with current, functional meanings of terms in pertinent field, use them properly and helps others to understand and use them correctly

Loss Control Vocabulary

: 1) Identify all loss exposures. 2)Evaluate risk in each exposure. 3)Develop a plan. 4) Implement plan. 5) Monitor system.

Managing risk involves following 5 steps (IEDIM)

Measurement of __________ to Standards: • Leader must know and be able to measure inputs required to get results. • E.g. front-line leader may be conducting only 60% of team meetings required by organization's standards or doing 75% of required job instruction. • Employees may be complying with protective equipment requirements only 80% of time or adjusting a machine to correct tolerance only 92% of time.

Performance

4)Principle of __________ of Action: Management efforts are most effective when focus at point where work is actually done. • Most of day-to-day action takes place on floor, shop, field where people provide service or make product. • Thus, front line leaders are point of management control for safety, quality, production and costs. 5)Principle of __________ Example: People tend to use their leaders as models. • Most people want to please their leaders, and do so by following their behavioral example. 6)Principle of ________ Causes: Solutions to problems are more effective when they treat basic or root causes. • We relate this to items detected during planned inspections, to causes of any loss during investigations, or to quality and production problems. • We can't cure disease by treating only symptoms.

Point Leadership Basic

• Most of the principles continue as a leader strives for continual improvement. 1)Principle of Reaction to Change 2)Principle of Behavior Reinforcement 3)Principle of Mutual Interest 4)Principle of Point of Action 5)Principle of Leadership Example 6)Principle of Basic Causes 7)Principal of Critical/Vital Few 8)Principal of Key Advocate 9)Principle of Goals and Objectives 10) Principle of System Integration 11) Principle of Involvement 12) Principle of Multiple Causes

Principles on Risk Control

1)Principle of ___________ to Change: People accept change more readily when it is presented in relatively small amounts. • Be sure to plan for handling likely resistance to change. • Keep people well informed of pending changes and reasons for them, emphasize benefits of change for people involved, get people to participate in planning as much as is feasible and build from known to new. 2) Principle of __________ Reinforcement: Behavior with positive effects tends to continue or increase that individual will have less desire to take substandard or unsafe way. • Give repeated immediate positive recognition when their performance is recognized. • When that need is not met, people will tend to stop trying as hard or attempt to get recognition through unacceptable means (horseplay, rule violations, showing off etc.). 3)Principle of _________ Interest: Programs, projects and ideas are best sold when they bridge wants and desires of both parties.

Reaction Behavior Mutual

Evaluation of ________: • It determines to what degree standards have been met. • If actions are not happening as they should or not being accomplished at desired level evaluation should determine why and what needs to be done to reach it. • Involvement and feedback from people doing work are essential to craft corrective action necessary for success. Commendation and Constructive ___________: • Top executives should set tone for positive behavior reinforcement throughout organization.

Results correction

• Small organizations experience a large number of risk situations regarding processes, materials, equipment, procedures, personnel, and work environment in relatively short periods of time. • A formal risk assessment for many of these situations would neither be feasible or appropriate, yet some form of risk assessment remains necessary. • SRA is a critical thinking process that can be effectively used to meet many of needs described above. • SRA technique is an exceptional tool for all employees to effectively address common risk situations. • It can be performed by anyone, anywhere and does not require any documentation.

SRA (Simple Risk Assessment)

• SRA technique is quick easy to apply and usually requires little training. • Educating all employees about SRA is only first step. • Further and continuous reinforcement is required. • General new hire orientation • Job specific/workplace orientation • Team safety meeting topics • Planned safety contacts topics • Critical topic promotion • Bulletin board postings • Contests • Pocket cards • Mailings.

SRA Training, Reinforcement and Leadership Example

• Documentation should indicate names of participants, dates performed, conclusions and follow-up actions. • Define System/Scope • Use Item Classifications • List Concerns • Explain Impacts • Record Impact Rating • Explain probability • Record probability Rating • Record Risk Level • Establish Risk Controls • Record Residual Risk

Steps for Conducting GRA

10)Principle of __________ Integration: better new activities are integrated into existing systems higher chance of acceptance and success. • Probability of acceptance is greatly increased when new is incorporated into or linked with an existing program or system. 11) Principle of _____________: Meaningful involvement increases motivation and support. • Frontline leaders ask their people for suggestions, recommendations and advice in matters that affect their work. • People tend to develop a feeling of ownership and support of what they helped to create. • Front-line leaders who use this principle effectively develop mutual interest, mutual motivation and mutual respect. 12) Principle of _____________ Causes: Incidents and other problems are seldom, if ever, result of a single cause. • Most incidents involve both immediate causes (substandard acts/practices and substandard conditions) and basic causes (personal factors and job factors). • Management professional tries to identify all possible causes of problem at hand, then gives greatest attention to those with most potential to control problem.

System Involvement Multiple

• Managing can be predictive and proactive rather than reactive and after-the-loss. • As leading management consultants have emphasized: you cannot manage what you cannot measure. • Loss control measurements they know about are incident consequences such as frequency rates and severity rates. • These measurements may enable meaningful comparisons between incident performance of an organization for a given period of time. • Their greatest weakness is that they are after fact. • In effect they are reactive measurements that tell you nothing about nature of your problems or what to do about them. • Measurements reflect accomplishments as a percentage of standard. • E.g. if your standard requires that you do weekly inspections, but you conduct only three in a given month, you are a 75% performer regarding that specific standard. • Periodically, entire loss control program should be measured for compliance to standards. • There is also a need for more frequent measurements of certain aspects of critical activities. • e.g. quantity and quality of planned inspections, quantity and quality of investigations conducted etc. • Results of these measurements can be a source of pride on performance or they can motivate corrective action to get a critical activity back on target.

System for Managing Control

• This methods require team participation and results should be documented. • '______ if?' Analysis: can be used to screen out unintended deviations and associated hazards. • This method requires experience and imagination in identifying things that could go wrong. • Group Risk Assessment (GRA): used to identify and rank prevalent loss scenarios. • GRA requires that a scale of potential impacts and associated probabilities be defined (H-M-L) prior to conducting exercise. • Method is highly adaptable to all systems and situations and is commonly applied.

What

• Commonly used: SRA and GRA (semi-quantitative). • Simple Risk Assessment (SRA): used by individual workers to identify hazards and risks in workplace. • This technique is prompted by simple questions, quick and easy to apply with minimum training. • SRA can be performed informally during daily routine tasks. • SRA will often trigger a formal risk assessment when significant hazards or risks are encountered. • Checklist and Round Table discussions: are easy methods to adopt. • Standardized checklists are generally category specific and are based on accumulated experience. • They are unfortunately not quantifiable and they are seldom available for unique situations.

What Assessments are Available?

• Time to begin risk assessment is during conceptual phase/stage of a new facility/proposed change, as well as ongoing risk assessment during life cycle. • It is a prerequisite to introducing changes to work environment: physical, procedural, or organizational. • It is also an essential component of standard work practices to develops an awareness of job hazards, equipment failure modes, and things that could go wrong even in a stable operating environment. • Typical applications for risk assessment include: 1) Pre-work, job, or task risk assessment as an integral part of daily activities. 2) Safety and operability reviews for all capital and expense projects to ensure that all significant design considerations have been satisfied. 3) Hazard identification and analysis to accompany development and execution of safe operating procedures. 4) Risk and hazard reviews of existing instructions and work practices for critical tasks to determine their adequacy. 5)Pre-startup safety reviews to ensure that facilities and conditions are suitable for operation. 6)Risk assessment of an operation to ensure current or proposed conditions do not compromise safety, reliability, industrial hygiene, commodity balance, fire protection, and environmental considerations. 7)Risk assessment of all planned changes to facilities, procedures, systems, organization etc.

When to Use PRA

• Failure Modes and Effects Analysis (FMEA): When a system is well defined, this method may be conducted to determine what possible losses might occur as a result of failures. • FMEA method attempts to quantify and rank system risks by utilizing numerical data from previous failures and established plant values. • FMEA is readily adaptable to most mechanical systems. • Fault Tree Analysis (FTA): is used to define failure logic and to establish probability of total system failure for highly complex systems where interacting failures occur

FMEA and FTA