The Power of Collaboration To Improve Process Safety and Workplace Safety

Hart Solutions LLC
The Power of Collaboration
To Improve Process Safety and
Workplace Safety
(While Also Improving Productivity)
Christopher A. Hart
Presentation to
University of Pennsylvania
School of Engineering
February 28, 2019
February 28, 2019 Hart Solutions LLC 1

The Contrast
⎼ Conventional wisdom:
Improvements that improve safety usually
also reduce productivity
⎼ Lesson learned from
proactive aviation safety programs:
Safety can be improved in a way
that also results in
immediate productivity improvements

Improved
Safety
Process Plus Fuel
Creates a Win-Win
Information From
Front Lines
Improved
Safety
System Think
Process AND
Improved
Productivity

Outline
- Why Collaboration Works
- Aviation Success Story
- Improving Process Safety
- Improving Workplace Safety

Two Types of Safety Challenges
February 28, 2019 Hart Solutions LLC
⎼ Process Safety
• Uncontrolled release of energy and/or product,
often into the surrounding environment
• Examples – airplane crash, plant explosion
⎼ Workplace Safety
• Often referred to as “slips, trips, and falls”
• Injury to an employee while working
• Often just one employee in a given event
• Usually little or no effect outside the facility
5

⎼ More System
interdependencies
• Large, complex,
interactive system
• Often tightly coupled
• Hi-tech components
• Continuous innovation
• Ongoing evolution
The Challenge: Increasing Complexity
INVESTIGATOR
AIRLINES
PILOTS
REGULATOR
CONTROLLERS
MECHANICS MANUFACTURERS
The System
⎼ Safety issues are more
likely to Involve
interactions between
parts of the system

Effects of Increasing Complexity:
More “Human Error” because
⎼ The System is more likely to be error prone
⎼ Operators are more likely to encounter
unanticipated situations
⎼ Operators are more likely to encounter
situations in which “by the book” may not be
optimal (“workarounds”)
February 28, 2019
Hart Solutions LLC 7

The Result:
Front-line staff who are
- Highly trained
- Competent
- Experienced,
-Trying to do the right thing, and
- Proud of doing it well
. . . Yet they still commit
Inadvertent
human errors

The Solution: System Think
Understanding how an
improvement in one subsystem
of a complex system may
affect other subsystems
within that system
9

“System Think” via Collaboration
Bringing all parts of a complex system together
to collaboratively
⎼ Identify potential issues
⎼ PRIORITIZE the issues
⎼ Develop solutions for the prioritized issues
⎼ Evaluate whether the solutions are
• Accomplishing the desired result, and
• Not creating unintended consequences
10

When Things Go Wrong
How It Is Now . . . How It Should Be . . .
You are human
and
Humans make mistakes
so
Let’s also explore why the
system allowed, or failed to
accommodate, your mistake
and
Let’s IMPROVE THE SYSTEM!
You are highly trained
and
If you did as trained, you
would not make mistakes
so
You weren’t careful enough
so
You should be PUNISHED!

Fix the Person or the System?
Is the person
clumsy?
Or is the
problem . . .
The step???

Enhance Understanding of
Person/System Interactions By:
- Collecting,
- Analyzing, and
- Sharing
Information

Objectives:
Make the System
(a) less
error prone
and
(b) more
error tolerant

To Err Is Human:
Building a Safer Health System
“The focus must shift from blaming
individuals for past errors to a focus
on preventing future errors by
designing safety into the system.”
Institute of Medicine, Committee on Quality of
Health Care in America, 1999
The Health Care Industry

“We knew about
that problem”
Major Source of Information:
Hands-On Front-Line Employees
(and we knew it might hurt
someone sooner or later)

Next Challenge
Legal/cultural issues
Improved analytical tools
As we begin to get over the first hurdle, we
are challenged by the next one . . .

Developing tools and processes to convert
large quantities of data into useful information
Analysts
DATA
USEFUL
INFORMATION
Data Sources
Info from
front
line
staff
and
other
sources
Tools Processes
Smart Decisions
• Identify
issues
• PRIORITIZE!
• Develop
solutions
• Evaluate
effectiveness
From Data to Useful Information

83% decrease in fatal accident rate
in less than ten years
largely because of
System Think
fueled by
proactive safety information programs
Aviation Success: Commercial
Aviation Safety Team (CAST)
19

Success Beyond Expectations
⎼ When CAST began, many safety experts
believed that aviation was already very
safe and unlikely to improve
⎼ Collaboration also
• Generated sustainable safety improvements
by also improving productivity
• Reduced the likelihood of unintended
consequences
• Enabled significant improvement without
generating any new regulations

CAST engaged all participants in identifying problems
and developing and evaluating remedies
⎼ Airlines
⎼ Manufacturers
• With the systemwide effort
• With their own end users
⎼ Air Traffic Organizations
⎼ Labor
• Pilots
• Mechanics
• Air traffic controllers
⎼ Regulator(s)
INVESTIGATOR
AIRLINES
PILOTS
REGULATOR
CONTROLLERS
MECHANICS MANUFACTURERS
The System
Aviation “System Think” Success
21

⎼ Ground Proximity Warning System
• S: Reduced warning system complacency
• P: Reduced unnecessary missed approaches,
saved workload, time, and fuel
Improved Not Only Safety,
But Also Productivity
⎼ Flap overspeed
• S: No more potentially compromised airplanes
• P: Significantly reduced need to take airplanes
off line for VERY EXPENSIVE (!!) disassembly,
inspection, repair, and reassembly

Aircraft manufacturers seek input,
beginning very early in the design
process, from
Manufacturer “System Think” Success
- Pilots
- Mechanics
- Air Traffic Services
(User friendly)
(Maintenance friendly)
(System friendly)

Moral of the Story
Anyone who is
involved in the problem
should be
involved in the solution
24

– Old: The regulator identifies a problem, develops
solutions
• Industry skeptical of regulator’s understanding of the
problem
• Industry fights regulator’s solution and/or implements it
begrudgingly
– New: Collaborative “System Think”
• Industry involved in identifying problem
• Industry “buy-in” re interventions because everyone had
input, everyone’s interests considered
• Prompt and willing implementation
• Interventions evaluated . . . and tweaked as needed
• Solutions probably more effective and efficient
• Safety improvements are sustainable by also improving
productivity
• Unintended consequences much less likely
Major Paradigm Shift
25

– Human nature: “I’m doing great . . . the problem is
everyone else”
– Participants may have competing interests, e.g.,
• Labor/management issues
• May be potential co-defendants
– Regulator probably not welcome
– Not a democracy
• Regulator must regulate
– Requires all to be willing, in their enlightened self-
interest, to leave their “comfort zone” and think of the
System
Challenges of Collaboration
26

Safety Well Done Safety Poorly Done
Benefit$ of Collaborative Safety Improvements
1. Look beyond operator, also
consider system issues - Poor workforce morale
- Poor labor-management relations
- Labor reluctant to report issues to
management
- Retraining costs for new employee
if “perpetrator” is moved or fired
- Adverse impacts of equipment
design ignored, problem may recur
because manufacturers are not
involved in improvement process
- Adverse impacts of procedures
ignored, problem may recur
because procedure originators
(management and/or regulator) are
not involved in improvement
process
27
1. Punish/re-train operator
- Workforce more engaged
- Improved labor-management
collaboration
- Labor more likely to report issues
- Little or no retraining because
employee retains position
- Problem solved because
manufacturers are involved to
address equipment design issues
- Problem solved because procedure
originators (management and/or
regulator) are involved to address
adverse effects of procedures

Benefit$ (con’t)
2. Management decides remedies
unilaterally
- Problem may not be fixed
- Remedy may not be most
effective, may generate
other problems
- Remedy may reduce
productivity or generate
other problems
- Employees reluctant to
implement remedies due to
failure of previous remedies
- Remedies less likely to
address multiple problems
28
2. Apply “System Think,”
with workers, to identify
and solve problems
- Problem more likely to be fixed
- Remedy likely to be more
effective, less likely to generate
other problems
- Remedy more likely to improve
productivity
- Employees eager to implement
remedies due to success of
previous remedies
- Remedies more likely to
address multiple problems

3. Remedies based upon
instinct, gut feeling
Same costly results as No. 2,
above
3. Remedies based upon
evidence (including info
from front-line workers)
Benefit$ (con’t)
Same positive results as No.
2, above

4. Implementation is
last step
- No measure of how well remedy
worked (until next mishap)
- No measure of unintended
consequences (until something
else goes wrong)
Benefit$ (con’t)
30
4. Evaluation after
implementation
- Well-defined metrics provide
input on whether remedy is
effective
- Tracking of unintended
consequences provides data for
continuous improvement

⎼ Safety implemented well
• Improves safety more effectively
• Creates benefits greater than the costs
• Is sustainable because of improved
productivity
⎼ Safety implemented poorly
• Does not improve safety as much as
expected
• Probably reduces productivity
• Can be very costly
So . . . Is Safety Good Business?
31

Effects of CAST on Safety
CAST
⎼ Focuses on safety rather than compliance
⎼ Generates the safest result
⎼ Facilitates and encourages development of a
robust safety culture
⎼ Improves labor-management relations
⎼ Not only improves safety, but does it the
most efficient way

Could CAST Improve Process Safety
In Other Industries?
⎼ Other transportation industries
⎼ Nuclear power
⎼ Chemical manufacturing
⎼ Petroleum exploration or refining
⎼ Healthcare
⎼ Banks (financial risk)
⎼ Other
33

Broad (Micro to Macro) Applicability
⎼ Applicable to any System, big or small, that is
having process safety issues
• Entire industry (such as CAST)
• Company (some or all)
• Facility
• Type of activity
⎼ Potential participants in collaboration include
• Operator
• Employees
• Manufacturers
• Regulators
• Other?
34

Could CAST Improve Workplace Safety?
⎼ Similarities to process safety
• Challenges re continued safety improvement as
systems become more complex
• Injury/fatality rates unlikely to continue declining as
current safety improvements approach asymptotic
limit
⎼ Differences from process safety
• Workplace safety focuses on compliance rather than
safety
• Workplace safety collaboration does not typically
include regulator (OSHA) or manufacturers
35

Disconnect Between Process Safety
and Workplace Safety
⎼ BP Horizon
• When explosion occurred in the Gulf, they
were receiving an award for workplace safety
• Meanwhile, process safety clearly not under
control
⎼ Aviation
• Some key participants in CAST are not satisfied
with their workplace safety
36

Focusing on Safety vs. Compliance
⎼ Regulations create a “regulatory floor of compliance”
⎼ Focusing on safety creates a higher level of safety than
the regulatory floor of compliance because
• Regulations generally prescribe a minimum safety level, not
necessarily a desirable safety level
• Regulations don’t fit every situation
• Some situations have no applicable regulations
⎼ The CAST program has not generated any new
regulations because the industry is far above the
regulatory floor of compliance

What If No Applicable Regulations?
⎼ If focus is on compliance – do whatever
works to accomplish the desired result
⎼ If focus is on safety – accomplish the
desired result in the safest way

Suggested Beta Test
to Improve Workplace Safety
– Select problem that has been hurting workers and is
stubbornly resistant to improvement
• Nagging problem for many years
• Many interventions have been tried, not successful
• Likelihood that problems are systemic, not just people
• Collaboration as effort to address the system problems
• Employees more likely to engage because beta test is
focused on improvement rather than punishment
– Create collaborative corrective action beta test group,
include all who are involved in the process
• Management, Labor
• Manufacturers?
• Regulators?
• Others?
39

- Demonstrate safety commitment . . .
The Role of Leadership
- Include “Us” (e.g., system) issues,
Not just “You” (e.g., training) issues
- Make safety a middle management metric
- Engage labor early
- Include the System --
manufacturers, operators, regulator(s), and others
- Encourage and facilitate reporting
- Provide feedback
- Provide adequate resources
- Follow through with action
but acknowledge that mistakes will happen

- Emphasize the importance of System issues in
addition to (not instead of) worker issues
How The Entity in Charge
(Regulator?) Can Help
- Encourage and participate in
industry-wide “System Think”
- Facilitate collection and analysis of information
• Clarify and announce policies for protecting information
and those who provide it
• Encourage other industry participants
to do the same
- Recognize that compliance is very important, but
the mission is
reducing systemic risk

Conclusions
⎼ Safety issues in complex systems usually involve
human/system interface issues
⎼ Collaboration can help address not only the human
issues but also the system issues
⎼ Collaboration can help ensure that safety improvement
programs also improve productivity, which makes the
safety improvements more sustainable
⎼ Aviation industry collaboration success is transferable
to other potentially hazardous industries and to
workplace safety
42

Thank You!!!
Questions?
Christopher A. Hart
Hart Solutions LLC
chris@hartsolutionsllc.com
202-680-4122February 28, 2019 43

The Power of Collaboration To Improve Process Safety and Workplace Safety

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