Podcast: Challenge the Illusion of Safety

Transcript

Welcome to Process Safety with Trish and Traci, the award-winning podcast that aims to share insights from past incidents to help avoid future events. Please subscribe to this free podcast on your favorite platform so you can continue learning with Trish and me in this series. I'm Traci Purdum, editor-in-chief of Chemical Processing, and joining me as always is Trish Kerin, director of Lead like Kerin, who is also known as the Platypus Lady. Hey, Trish.

Trish: Hey Traci, how are you doing today?

Traci: I'm doing really well, and I am looking forward to today's episode. And as we were planning upcoming episodes, you mentioned a few white papers you read from risk management and research company, Incident Analytics. Before I introduce our guest speakers today, do you want to talk a little bit about why you thought this would be a good subject for us?

Trish: Yeah, so the work that Incident Analytics do, and I'm sure that they will expand on it in this conversation, is really about understanding serious injury and fatality risk, and understanding more what are the controls that have failed or were absent that resulted in an incident occurring, and what are the controls that actually worked that resulted in that incident only being of a lower consequence, when it could have actually been up to a fatality. So, I think their work is really interesting in how they've delved right into that particular detail.

Now, full disclosure, I've known these gentlemen for quite a few years now, and in fact, I do sit on their incident advisory board for Incident Analytics too. But the white papers, there's a lot of really great information in there, so I thought it was really useful for people in the Process Safety world to understand a little bit more about some of the things our OHS friends are doing, but also those that do relate, because there is actually some crossover in that serious injury and fatality area. So, that's why I thought that there was a lot of value in having this conversation.

Traci: And I agree, and I'm very much looking forward to it. And now I'd like to formally introduce our guests from Incident Analytics, Alex Fernando, director of strategy and risk advisory. Alex is a management consultant who has worked in many high-risk industries in Europe, Asia, and Australia. His background spans the petrochemical manufacturing, transport, oil and gas, agriculture, and the utilities and mining sectors. He has led safety improvement initiatives in key areas, including serious injury prevention, leadership and governance, and work development. Also joining us is Warren Smith, director of data science and research. With an extensive background in operations management, organizational development, HR management, leadership and culture development, Warren's expertise includes managing exposure to serious injuries and fatalities, leadership development, behavior change, safety governance, systems alignment, and the exploration of human factors associated with error and reliability. All things that Trish and I talk about all the time. So, welcome gentlemen.

Warren: Thanks Traci.

Alex: Thank you Trish and Traci.

Traci: And I do want to mention to the folks listening, Trish had alluded to it, and I know we're going to be talking about white papers throughout this discussion today. So, I'm going to have links to these white papers in the transcript [Whitepaper 1 and Whitepaper 2] and also in the show notes. So, if you're listening along, don't fear, you can come to the transcript and download those white papers and get a little bit more information. But we're going to delve into a lot of what they've researched and disseminated through those white papers, and I guess we're just going to kick it right off. I want to ask both you, Alex and Warren, a little bit about Incident Analytics and how you came to this research. You analyze data from more than 10,000 incidents, let's talk a little bit about it. The who, what, when, where, why, and how of this research.

Warren: Very happy for you to jump in here, Alex.

Intel From 10,000 Safety Incidents

Alex: Yeah, sure. Absolutely. So, look, it’s a privilege to be on the podcast with you both, and exploring a pretty topical concern for most organizations, and whether you call it process safety or OHS, process safety encompasses such a broad range of things, including the human in the loop, so to speak. We did some founding research many years ago with Federation Uni, and that was really trying to validate an approach that we had started to apply in some of our work, and what that led to was to engage several research partners, client organizations, that span about 12 countries... And these organizations spanned a whole range of industries, from mining to utilities, agriculture, transport, et cetera. And what we did was we tried to have a look at their incident data through a very particular lens, and trying to understand how high-risk work is controlled, how certain controls were absent or ineffective, and really trying to understand how you can strengthen this kind of high-risk work through the analysis techniques that we used.

But what we found was that a lot of those incidents, and this is really the first finding, was that a lot of time is spent investigating, reporting incidents and they're not done very well. And so, when we looked at these 10,000, we found that there was only about 5000 of those incidents, 5,091, that was actually had enough data in there to really unearth and make sense of. And we then subsequently found there was about 680 of those incidents that were actually worthwhile investigating far deeper, because they were of a serious injury fatality potential. So, that's kind of where the research started, Traci, and obviously we then started to delve into our findings and start sharing that with everyone, both the research partners, but also industry in general, just with the view of trying to help organizations understand that if you look at these incidents through the lens that we take, you're actually going to be better set up for learning from those unplanned events, to identify controls that can be strengthened, understand the antecedent factors, and then also prioritize learnings that help reduce exposure in the field ultimately.

Traci: As I was reading it, the research suggests that facilities investigate why there's a difference between planned work and actual practice. I wanted to ask you both, maybe Warren, you can weigh in on this. Let's talk a little bit about the importance of accurately classifying serious incidents. How does misclassification impact an organization's ability to truly learn from the incidents and mitigate future harm that Alex alluded to a little bit there?

Warren: Yeah, great question, Traci. Thanks for asking that because it really does cut to the core of, I think, why we started out asking some pretty simple questions. A great source of information that could feed a safety strategy, perhaps more effectively than the usual safety metrics that were being used by the organizations that we were actually working with at the time? And we quickly established the fact that their sense of security around some of their risks, there were certainly a number of risks that were almost being treated in a very complacent fashion because they actually weren't seeing the events as we would, they weren't looking through the lens of potential, they were tending to look through the lens of actual. So, when actual events happened where some people could be seriously hurt, that would generate a tremendous amount of response and reaction.

But so many more events were happening with these organizations that we were working with, and that they weren't even having a significant line of sight to. And they were mostly potential events, and we were seeing very, very high potential for a serious injury or fatality in many of these events, barely any information about them, in many cases, treated as near misses, and near misses to go under the radar. So, the problem we were seeing is that the first problem was a sense of complacency around how well these critical risks were being managed, and we are seeing a completely different picture in a lot of cases. What that does lead to, of course, is that those organizations in terms of their safety strategy, their focus on their initiatives in the business, were probably heading into the wrong direction, and we felt that we, well, were quite certain we could actually shine a light on things that would actually provide a much more accurate targeting of their effort, their investment, around safety initiatives to try and control risk. Have you got anything to add to that, Alex?

Alex: No, I think you nailed it on the head. I think for a lot of leaders in organizations, and I feel for executives, if you like, and operational leaders, where you're really relying on the data that's given to you to help provide the necessary resources to make decisions around where you put your limited resources and effort into. And of course, what we're uncovering was that, at that governance level, you're not seeing necessarily reliable data that gives you a really good sense of the risk profile. So, if near misses, all those potential events are going under the radar are classified as inconsequential or negligible or whatever the risk categories are, or classification categories are, you're actually only seeing half the picture. So, I think that's what drove us to spend more time trying to come up with an approach that actually elevates the visibility of those new misses.

Warren: I'd say there's one more thing that was fairly critical for us is that we were really, in a broad sense, we actually focused very much in the early days around the missed learning opportunity, and when it came to controls, that were really probably quite weak, in fact, they weren't being identified by the organization in these critical risk contexts as being weak, as weak as they were, and they certainly weren't seeing the erosion factors around those. Because investigations weren't even being done on many of these events. If they're considered to be fairly inconsequential in terms of the negative outcome, then naturally, you probably wouldn't throw a lot of effort into trying to understand them, and so much learning was being missed, in fact.

Classification System for Control Implementation Issues

Traci: And I think that's key, and you both talked about looking through a lens, and being able to see things that they didn't see. And so, analyzing controls through this lens and providing deeper insights beyond just compliance. In one of the white papers that you wrote, you talked about a three-category classification system for control implementation issues: easy, difficult, and unworkable. Let's talk a little bit about that, and what steps facilities can take based on these distinctions, and then Trish, I'm going to circle back with you and talk a little bit about what they've discussed with us. Warren, you want to take that one?

Warren: Sure, absolutely. Thanks, Traci. We know, because Alex and I've worked with high hazard industry organizations for many, many years before we started this business, so we've been across control verification programs, we've been out in the field, I've done my fair share of coaching supervisors and leaders in how to interact with workers at the front line so that they can actually elicit good practical information about how work is actually being done in the field. And there's always this gap between work as imagined and work as done. And I think we certainly saw it when, you only have to go out in the field and have a chat with some frontline workers who are working at height, or working with kind of things that are under pressure, and you'll quickly establish the fact that they will try to implement the relevant controls, but often there'll be a physical context that just couldn't be imagined by the procedure or the performance standards, the expected performance standards of that control implementation.

And so, the workers will naturally, they'll still try to get the job done, they're very motivated to get the work performed within a reasonable boundary of risk. Sometimes their assessment of risk and their treatment of that, of course, can go a little bit astray, but they will still try and get the job done with the right motivation in mind. The problem is when we sidle up to these guys who are performing this task and it doesn't quite look right, you can have one reaction, which is, you guys aren't following rules, let's have a conversation about that and your behavior, versus trying to understand what's different about this situation that we didn't foresee when we actually formulated and mandated how a particular task should be performed. So, this gap's quite significant in some cases, and we certainly, when we look through the lens of control enablement with these potential incidents, these series of fatal potential events, we very quickly saw that there was quite a high proportion of difficult or completely unworkable control implementation contexts.

And what happens, of course, is the worker will actually still try to get the job done, they'll assess the risk, they'll try to implement a suitable control situation, and sometimes, unfortunately, they get it wrong. And those incidents, of course, are when they did actually seriously get it wrong. And it's always a bit of an eye-opener when we debrief the organizations that we partner with around this research, and they go, we cannot believe that we have 30 to 40% of our control implementation situations being difficult or unworkable, we never imagined it would be like that. But if you go out there and do control verification, in a proactive sense, as accurately as you can with a real desire to learn from frontline workers, you'll find the same information; it's just that control verification often isn't done with that intent, it's done as a more of a policing exercise. Alex, have you got more to say about that? I've probably gone on a bit too long.

Alex: No, look, I think in that lies probably the kernel of gold in all of this is that we found that there was a disconnect between investigations and control frameworks. And so, quite often there's an over-investigation into incidents that would only be, at worst, for example, a twisted ankle or a broken ankle, and so as opposed to something that if one of two things had changed, something would've been far more sinister in terms of outcomes. So, we're finding that organizations are over-investigating the low severity incidents and not spending enough time on the high severity potential incidents, and of course, then your ability to learn and things that you do for controlling instances are very different from the low severity. And so, there is a disproportionate level of effort, I think is the other piece there. And of course, control verification is a great way of trying to better understand how work's done, but what we did find is that organizations don't tie the two data strings, if you like, together to build a more robust understanding of what's going on, so that's probably the other piece on that there.

Operational Expectations Vs. Operational Reality

Traci: Trish, I want your insights on this and the gap between operational reality and operators who modify or skip safety controls. Can you talk a little bit about that?

Trish:  Yeah, so I think here it's important to also tie it back to where process safety is in this, because Alex and Warren are talking about risks that are often more apparent to see. So, working at height, using vehicles, those sorts of things, in their research, and they've discovered that we have unworkable or very difficult controls when doing control verification that they're really missing. And it's not, as Warren said, it's not that the workers don't want to follow the rules or do it right, it's that they're trying to achieve the task you've set them, in the best way they can, in the circumstances they have. And we often have those circumstances are not optimal for what we're after. And when we think about process safety, the next challenge we have is that the hazard might not be obvious, and then the overall risk and the consequence might not be obvious at all.

It could be something that is really, really quite removed from the particular activity that the worker is doing. And so, if it's hard to tie together and see the controls that are needed, and the lack of their availability in something as straightforward as working from height, it's pretty obvious what the hazards are. Imagine how difficult it is in process safety. And I don't think that in process safety, we are getting it any better when we talk about control verification. We do control verification in process safety, but it is that worker interface part that I think we're missing, that Warren talked about and that you've asked about, Traci. Because when we look at that particular task, it can be very tempting to say they just need to follow the procedure. We've got the procedure here; they just need to follow it. It has to happen in these steps.

But if you can't follow that procedure for a range of reasons, or if it's actually just really, really difficult to do, or it's going to take you a lot longer, and this is a task that you have to do multiple times a day, if what is perceived in your own mind as a valid shortcut, you're going to take it. And I don't care how diligent you are, I don't care how much you love the procedures, I'll guarantee at some point you are going to realize there's a faster, simpler, easier way to do that task, and you're going to do it that way, no matter how good you think you are. I investigated an incident where I looked at the sequence that the operator had to do, and I just kept looking at it going, if I was the operator, I'd do it the way he did it, not the way the procedure said, there's no way I'd do it the way the procedure says, that's ridiculous.

It was just so many excessive steps, going back and forth and back and forth and back and forth, over quite some distance, for no perceived value in the task. There's no way I would've followed the procedure. And that's me talking, and I love getting things right, because I know that it's an important safety thing. So, if someone like me is going, yeah, I wouldn't have followed that procedure either. Imagine what our everyday workers are doing, and imagine the situation we're putting them in.

Warren: So, can I just add to that because I think you've brought it to life almost in a real context there. And what we find also is that it's not just the procedures that sometimes feel clunky, or just don't feel suitable for the work context, to the worker, sometimes we actually just don't set them up for success with the right kind of equipment, either. The organization can sometimes take shortcuts around having perfectly fit for purpose equipment, like the electronic work platform, an EWP that I'm required to take some cladding off the side of a building, and I suddenly find that this hasn't been maintained properly, that it's leaking oil, I'm a bit worried about it, there isn't a second one around the place for me to use, I'm just going to get a ladder. Because I've got to get this job done. Now, all of a sudden, I've elevated my risk substantially in a way that I know I probably shouldn't have done, but I'm far more motivated to get the job done, and the organization hasn't really set me up perfectly to be able to do it by the book anyway.

And this kind of situation happens all the time, very surprisingly often to leaders and to senior safety professionals, and they're shaking their head. We're not shaking our head because we're going, we understand completely how this happened, and of course, the challenge for organizations is to get out there and actually try to understand themselves with a different mindset, with more of a curious mindset rather than one that says, well, we are out here, and my job is to police and find problems and solve them, which is a completely different attitude, and not a very particularly helpful one in a lot of circumstances.

Trish: Yeah, absolutely, Warren, I agree.

High-Pressure Training

Traci: Now, hearing all of this, and Trish, I want to ask you this question: Is it obvious that people might be taking shortcuts out there, and they have these controls in place, and they have these processes in place, and they go through them in a calm environment? But when incidents happen, it's no longer a calm environment; there are time constraints, there's pressure, and there is real danger. Is there a benefit to having operators being trained in these types of conditions, in emergency-type conditions, and if so, how do you do that effectively?

Trish: I think there are two parts to that. So, first of all, it's always useful to have people trained in what to do when the unexpected happens because the unexpected, you're right, will happen. The unexpected should be expected because it's always going to happen in some way. So, training people, making sure that it becomes second nature, is how you want them to respond. So, emergency drills, those sorts of things, are really, really useful. Unfortunately, I'm not sure we can train our operators for every possible eventuality, so we need to make sure we're training people on how to respond during complex events because we may not necessarily be able to predict every single type of event or sequence that may happen, but we can train them in how to think and how to stop and how to respond appropriately before they just jump in to try and do something.

So, I think that's one point. The other point is, let's involve the operators in actually developing the procedures because they're the people that know what actually goes on, as opposed to the engineer or the manager, sitting in a room thinking about what should go on, and what happens in a perfect world. Because also, when an incident happens, it's never just one thing; it's never only one control that's at fault in an incident. That's why we have multiple layers of defense. There are always multiple things that have gone wrong. And our procedures generally don't focus on understanding that multiple aspects of it when they're written by someone who's not doing the task. If you've got someone that's actually doing the job, they'll go, Oh yeah, those two things usually do happen together, yeah, so we do need to manage that. So, getting them involved. And when you do go out for that control verification as well, it's not a policing check about whether you’re following the procedure? It actually should be, how's this procedure working for us? Let's talk about that.

Let's talk about how the procedure actually works or doesn't. So, there's an old concept that, way back in the ICI days, they called it a job cycle check, and it was actually a procedure verification in the field. And obviously, as Warren said, controls are much bigger than procedures as well, but I'm just focusing on that one for the moment. And the job cycle check was all about understanding whether the procedure was still correct. Is the procedure still adequate? It was not just the operator following it, but was it the right procedure? Should we be redrafting that? Is there a change or an improvement we need to make? And it really was going in with that curiosity of, is the procedure still working for us, not are you following the procedure? Very different question.

Alex: Yeah. And Traci, if I may, Trish, you've just triggered a thought for me around industries that do it really well in emergency management, so offshore oil and gas, I spent a few years there, getting exposed to training of OIMs in offshore, and the rigor in which they test and train and support the OIMs and their teams in offshore, it's all about making decisions under duress, and it's extraordinary the level to which I've seen that work, from the first on scene, to the incident controller, to the OIM on the platform, all the way up to incident coordination onshore, and then up to crisis management. So, the testing and drilling are extraordinary in terms of how they set people up for success, as best they can, to manage those high-pressure environments. Where I have seen it kind of... And then you've got this long tail, right?

So, when you look at industry onshore, so we did a lot of work in mining and utilities and things like that, and what we find is that the emergency response elements are probably less of a focus as distinct from... Now, I think typically there's a lot of prevention controls, and then there's mitigation controls, and there's those emergency response kind of controls, and we don't see as much emphasis on the emergency response capability within organizations, as a generalization. So, I think there's work to be done to elevate controls and those specific controls that are really necessary to fail safely.

Trish: Yeah, no, that is interesting, because I wonder if it's something as simple as when you're on land, part of the emergency response is get out of there. But when you're on a platform, there's limited options to get out of there.

Alex: Yeah, absolutely.

Safety Strategies

Traci: Alex and Warren, I want to talk a little bit more about the initial research that you did, and through reading it, I noticed that you came up with several key strategies for organizations. Can we talk about those?

Alex: Okay, sure. So, look, I think the first takeaway, and we've kind of foreshadowed this in the early conversation, was around leveraging your incident investigations to get deeper insights around how you can strengthen controls. And so, one of the things we find is that investigations, and there's a lot of really good investigation, accident causation tools that are out there that help organizations test the hypothesis of what we could have done differently had we done it in a different way, and so I think what we're finding though is that many organizations don't take a controls lens to their investigations, and in doing so, get a better sense of, well, how do we set up people for success? How do we enable those controls to be more effective and help people fail safely, so to speak? So, I think that's probably the first takeaway.

And also, within that, spend more time focusing on the high severity of potential incidents, because I think the resourcing construct that we have is that we've got limited resources to investigate everything, and the things that you do in response to low severity incidents are different from the things that you do for high severity incidents. And so, the first takeaway really is around leveraging your incidents using a controls-based approach, and spending more time focusing on strengthening those controls of high-severity incidents. I'll throw to you for the next one, Warren, if you're okay-

Warren: Can I just add to that a little bit?

Alex: Please.

Warren: Because I think this just flows into what people would be interested in, perhaps, is what we find out when we actually shine a lens on all of these incidents that perhaps were being missed? In fact, our research suggests that up to five in six [inaudible 00:29:35] potential events are probably not even noticed. Not noticed as a major or a critical risk event. So, in those situations, what we're trying to understand is why the control was not implemented, or was absent or ineffectively implemented? And there's a whole raft of upstream factors that tend to contribute to that. What we noticed out of the investigations, we looked at a lot of investigations, as you can imagine, Traci, is that rarely are those upstream factors ever identified. We'll see the people issue, the guy forgot to do something, he was distracted, or there was probably a low level of skill; therefore, the work didn't get done properly. There's a whole raft of things that can happen at the personal level, and they're usually picked up quite well.

But anything beyond that gets very, very flimsy, and sometimes completely missing in any investigation that we look at. Sure, we see some good ones, but they're definitely in a minority. And what it means is that we are not routinely picking up the issues that tend to perpetuate this exposure over time; there's a lot more that needs to be done in terms of strengthening and deepening investigations on incidents that are really necessary to do that deep dive on. Alex and I get quite frustrated when we see people using quite good tools and good approaches for investigations, well-known methodologies, but the investigation itself is still very ordinary, in fact, quite poor in a lot of cases. So, the method is actually not necessarily the problem; it's actually the willingness to ask more questions. And a simplified, wise approach when done properly is actually quite good, but when it's done badly, it's pretty useless. So, I just wanted to add that, Alex, because I think you've touched on something that's really important.

Alex: Yeah. Yeah, I think extending into that second takeaway, I think we could talk about control verifications. And so we're not advocating solely to focus on the rear-view mirror, as it were. We are seeing that focusing on potential events is quite predictive in terms of where your highest exposures are. But I think complementing that with control verifications, I think to Trisha's point, going out there with a learning mindset to understand how could we have set up this work for success using the JCA, the job cycle analysis, kind of process that the ICI in Orica still today continue to use, I think that's a really, really useful lens. And so, leveraging control verifications, understanding how work is actually done in the field is really, really key. So, that's effectively the second takeaway for us in that. And using that data and triangulating that with your incident data is probably the nirvana. We don't see enough organizations using both the learnings from unplanned events, as well as trying to learn from how work is done in the field, and bringing those two data sets together. Anything you want to add to that one, Warren?

Warren: In the early days, we asked ourselves that question: are the organizations that we're working with, they've got great control verification programs, and actually sometimes quite solid investigation processes, when we see good ones, but no cross-referencing of that information. And we're talking about the same thing here, really, we're talking about how work is performed, and why it occasionally goes wrong, and trying to more deeply understand that. One's proactive, the other one’s reactive, and it used to frustrate us enormously that sometimes it was quite difficult to get organizations to see the opportunity that they were missing. I think more and more organizations now do understand that, and they're trying to actually align their processes around both the reactive and the proactive analysis of how work is performed.

Safety Methods Aren’t The Problem

Traci: Trish, I'd like to know your thoughts on some of these strategies. The interesting point of the method is not necessarily the problem, but maybe the investigation is.

Trish: Yeah, so I think it's really important, as Alex and Warren have said, that we need to link these two really valuable pieces of data together, and that is something that I see often missed as well, because we focus on either just the incident results, or we just delve into control verification and we're not actually linking it together to make sure that we truly understand the dynamics of how it fits together. Because it's those dynamics that will then result in an incident when something starts to fail or degrade, so I think that's a really, really important part.

I think it is also, as I've said, the idea of it's not necessarily the investigation tool, absolutely, you can take a great investigation tool and do a terrible investigation in it, if you're not willing to be open, and to be curious, and to be willing to find that if you're a leader in the organization, that maybe you had something to do with it. And I think that's really one of the big challenges, that, to find the deeper organizational issues, and where our controls are not working from that organizational perspective, it's not about the frontline worker, it's about how we set them up to do their job with their equipment, with their training, with their procedures, and with the time that we give them to do the work as well. So, as leaders in an organization, how are we enabling the work, or in fact inhibiting the work?

And I think that is something that, it's a tough question when the answer is going to be that as a leader, I've actually failed in this investigation, and I am responsible for it in some way. It's very hard to look in the mirror and realize that you could have done something different in this instance. And so, I think that's one of the challenges that we have to take. There are a multitude of investigation tools out there, but it's about being genuinely curious and doing that depth of investigation, and not stopping at the worker. We need to understand why the worker did what they did, not necessarily what they did; why they did it is often far more important and offers far more insight than just understanding what it was they did.

Control Implementation Checklists

Traci: And Trish brings up good points of tools, having tools to use. And Alex and Warren, I know that in one of your white papers you talk about control implementation checklists. Can we talk a little bit about that? Can you explain what that is and how it's used?

Warren: There's actually probably half a dozen key points here. We've actually touched on a couple already, and the first one obviously is to get out there proactively and verify the controls are being implemented. And if they're not being implemented as you imagined, have that conversation that we've been talking about, have that curious conversation rather than the policing approach. Obviously, analyze the incidents that happened on the other side of the fence when we've actually had a really negative outcome, and typically that means that our controls regime has failed in some way. Could have failed the worker, the worker may have failed themselves, there's a whole raft of issues there. But it's actually being intent upon trying to extract all of the learning possible around that, without any kind of shielding of leaders, without any protection of the system, because often the system is at fault, and it's important to try and find out which aspects of our safety management system are not actually setting people up for success.

Are procedures really badly written? Do people not understand them? Did the work evolve over the last five to six years, and we never actually really adapted our procedures to how work is actually being performed in the field? There's a whole raft of questions there that have to be asked, and incidents provide a really interesting prompt for that. But one of the fundamental things that we see as a result of that is that we'll see organizations spending quite a bit of time on the people factors, and sometimes they'll deal with issues like poor supervision, maybe even about how leaders are actually communicating their priorities to workers and seeing how that influences urgency and stress, but very rarely do they take a really hardcore look at are the controls themselves adequate for the context?

If we see controls routinely failing largely because they've got a very heavy behavioral requirement, in other words, we need a worker to do the perfect thing, at exactly the right time, and exactly the right way every time, which is actually not a reasonable expectation, of course, because we're all prone to error, are we actually standing back from that and asking ourselves the hard question, do we need to fundamentally shift how we're actually expecting this work to be performed? Can we think about a technological solution that will actually lift the bar dramatically on allowing the worker to fail safely, because we've got better mitigation controls that don't require people to do anything, they just work by themselves? So, taking the approach of looking for more robust engineered control solutions, I think, is the real challenge here, and we're seeing more and more organizations starting to think about that rather than just being complacent.

I think about the bow tie work they did three years ago, which is probably out of date now, given the speed at which organizations change their processes. So, there are three items on the checklist. There are a range of other issues there, because you still have to address the system issues, which means that you have to be prepared to own up to the fact that we may not have set everybody up perfectly for success here. We may have made it a little bit difficult to get this work done. We may have fallen behind the curve where workers adapted and adapted and adapted to get the job done and to meet production targets, but we didn't actually explore that and understand that, and we're still out in the field, doing workers on the head for not doing things the right way.

When in actual fact, they're doing things the right way in their minds, unfortunately, probably the risk has been elevated a little, and we didn't pay attention to that over time. So, the system issues are really important. How are we establishing relationships with the right kinds of contractors that have a similar kind of safety culture to our own? Are we actually engaging suppliers and maintenance providers with a view to quality rather than necessarily cost? There are a number of issues there that need to be extracted from incidents and control verifications, if you can ask the right kinds of questions. Sorry, Traci, I could go on and on.

Traci: Hey, that's a good thing, when we're talking process safety, that's a good thing. And Trish, I want to toss it over to you and get your thoughts on that checklist of what we just discussed.

Trish: Yeah, there's some really, really valuable insights and information in there, and it's really just worth taking a look, and then critically going back and comparing it to what you've got in your own organization, and saying, okay, is there something we can improve here? Because with the research findings, I'll guarantee you, your company is probably no different, you will have a significant portion of controls in the process safety area of your business that are either difficult to implement or just unworkable.

And we've been lucky that to date, they haven't all lined up, but at some point in the future they will all line up and we will have a major process safety event from it. So, take a look at those checklists, and critically compare it to what you're doing internally. I think there's real value in that, to figure out not just to do more work, but actually can you refocus your efforts? Because you'll be doing a lot of work in a lot of different areas, and is it adding any value to you? How about you take a look at those checklists and see if you can refocus your effort into a more valuable area.

Making the Mental Flip For Safety

Traci: And Trish, I think the gist of everything that we've talked about, discussed today, seems to require a fundamental shift in how leadership thinks about safety incidents. Instead of asking why didn't they follow the procedure, it's why couldn't they follow the procedure? How do you get the executives, the C-suites, to make that mental flip?

Trish: There are a couple of parts to this. One is that this is where we need to be, really encouraging our leaders to not only be curious but also to be courageous. Because they need to ask some tough questions, and they need to ask some questions that are going to uncover and lay bare some organizational failings, and that is always difficult to see when you're a leader, and difficult to manage because that can feel like a personal attack at times for people. And so, that requires courage as well as that curiosity. The other part of it is that leaders need to challenge the data that they're given, and challenge whether we’re seeing the right information. It's not just about giving us more and more numbers; it's about giving us insight into them. What are we learning? How are we connecting our control verification with our learnings from our incidents? Is there a message here that we are missing? So it is about, again, getting leaders to challenge. So, it's creating that curiosity again.

And I think that curiosity is just something that I think we all need a lot more of, and we all need to be encouraging it not only in our leaders but also in our workers, because we actually want them curious. There may well be that we have procedures or equipment or controls that the workers do know a much better way, and we need to understand that so we can potentially implement that, once we've assessed that it's not going to create any additional risk to us. So, encouraging that curiosity, being courageous about it, and really challenging what, as leaders, we are being told, because depending on how well you receive bad information, that's going to determine what anybody ever tells you. If you don't receive bad information, well, nobody's ever going to give you bad information, which means you're not going to know what's actually going on. You're going to be given a sugar-coated version because everybody's trying to protect themselves from the wrath of your behavior. So, being really open to receiving that bad news is also critically important as leaders.

Big Picture Message on Safety

Traci: Great advice there. Alex and Warren, you've put so much time into this research. What is the big picture message that you hope we're giving to these organizations?

Alex: Yeah, my sense is, and a caller on a webinar yesterday talked about the illusion of safety, and so I think it's a really good call out, that what we're trying to do is shine a light on, and make the unknown known, so to speak, where... All organizations have put a lot of effort into their control frameworks, but what I'll be encouraging and advocating for is to take a fresh look at how susceptible some of those controls are. Because a good proportion of them, in and across, and this is common across all of our high-risk industries that we've partnered with to analyze their frameworks, is that there's a large proportion of those controls that are highly susceptible to system factors that don't set up the worker for success. Or they're highly reliant on the worker doing the right thing at the right time. So, I'd be advocating for a focus on just taking stock of how susceptible your control framework is, and so that's what's driven our work to shine a light on that.

Warren: Yeah, I think there's something about the focus of senior leaders and executives, and board members for that matter, in most organizations that has been driven a lot by some very simplistic metrics, and those metrics have probably become a little more sophisticated over time, but they're still mostly lag metrics. So, we get wound up about the fact that we had a really significant incident this month, and we haul people up in front of the executive to explain what's happened, why it's happened, what you're doing about it, and how we never want to see it happen again, but what they're not really... And that's really the primary focus at that level. So, it does tend toward a greater reactivity at a senior culture level; it also tends to push this green traffic light culture, where we see reporting... And I think Trish sort of alluded to this. We tend to fool ourselves culturally into feeling like everything's got to be okay, so we'll make everything okay somehow, and that's not the case.

People are out there getting the work done in a way that if you looked at it, at first blush, you'd go, Oh, that feels a little bit wrong, and the actual fact they're just trying to get the work done. And our challenge is to help them be better at risk assessing, in that moment, the stress and urgency are building, a habit of just stepping back for a minute and actually rethinking, what's the situation here? How should I be managing this? Rather than just sticking their hand in the machine to grab something, or trying to fix the problem without actually properly considering the nature of the problem in the first place, and then getting themselves hurt.

And these all come from stress and urgency, and stress and urgency comes from somewhere else, which is usually the expectation that you will get the job done within this timeframe, and you'll do it right, because we've told you how to do it right, and that's not exactly how it works. And I think the more senior leaders actually get information that helps them to understand the mechanics of how work is being done, rather than just focusing on lag metrics. Tremendous opportunity for them to lift their sights and actually be more broadly aware of how risk is actually being managed in the business, and I think that's the key, because then their decision making, their communication could be so much more effective in the business.

Traci: Trish, do you have anything to add?

Trish: Just to encourage people to take a look at the white papers, they are free to download, and you'll have links to them in the transcript. But then, really critically, take a look at your own organization, and think long and hard about whether you could be seeing some of these things in your organization? And if you are, you need to think about how you can actually implement better control verification, understand this a little bit more... Because these are the sorts of things that even though as you read the white papers, you might think, oh, this is very OHS-based, it's not really about process safety, think a little bit deeper about it, because it actually is about process safety as well. It covers the fundamental principles that we're talking about here, covering both occupational and process safety. So, I encourage you all to take a look and see what you can learn from it, and how you can improve your own organization in this space.

Traci: Well, I want to thank the three of you for helping us find deeper organizational issues, spurring that curiosity, if we're going to fail, fail safely, and helping us to not rely on the rearview mirror. I appreciate all the time and effort that went into the research and this thoughtful conversation. Unfortunate events happen all over the world, and we will be here to discuss and learn from them. Subscribe to this free award-winning podcast so you can stay on top of best practices, you can also visit us at chemicalprocessing.com for more tools and resources aimed at helping you run efficient and safe facilities. On behalf of Trish, Alex, and Warren, I'm Traci, and this is Process Safety with Trish and Traci. Thanks again.