This document discusses the concept of "perfect process safety" and how organizations can work towards it. It argues that compliance with regulations alone is not enough, and that learning from incidents internally and externally is critical. The document outlines characteristics of effective learning organizations and barriers to learning in "learning-disabled" companies. It also discusses lessons learned from major incidents like the Deepwater Horizon and Baker Panel reports. The document advocates for a safety culture with ongoing improvement and a focus on truly understanding and reducing risks.
Carrot or stick is a whitepaper exploring safety management issues in the workplace for the APAC region.
In this paper, we examine the reasons why every organization should:
- Build a safety culture, that´s relevant to them;
- Understand how core values relate to safety; and
- Know what kind of leadership drives safety performance
Improving Safety and Health Management in the Construction Industry.
A safety culture helps to ensure wider adoption of safety practices and allows companies to better reap the benefits of their safety investments. The new findings on the influence of a safety culture at a construction company, along with striking differences from the findings in 2012, demonstrate that encouraging a safety culture is critical, that safety investments in the industry are clearly paying off and that jobsite workers are increasingly recognized as playing a critical role in ensuring high safety performance at construction companies. Procore considers safety to be of utmost importance in the construction industry. To learn more please visit https://www.procore.com/.
Carrot or stick is a whitepaper exploring safety management issues in the workplace for the APAC region.
In this paper, we examine the reasons why every organization should:
- Build a safety culture, that´s relevant to them;
- Understand how core values relate to safety; and
- Know what kind of leadership drives safety performance
Improving Safety and Health Management in the Construction Industry.
A safety culture helps to ensure wider adoption of safety practices and allows companies to better reap the benefits of their safety investments. The new findings on the influence of a safety culture at a construction company, along with striking differences from the findings in 2012, demonstrate that encouraging a safety culture is critical, that safety investments in the industry are clearly paying off and that jobsite workers are increasingly recognized as playing a critical role in ensuring high safety performance at construction companies. Procore considers safety to be of utmost importance in the construction industry. To learn more please visit https://www.procore.com/.
Factoring the human into Patient Safety. Rhona Flin. IV Internacional Conference on Patient Safety (Madrid, Ministry of Health and Consumer Affairs, 2008)
The Knowledge Management Role In Mitigating Operational RiskEduardo Longo
Paper presented by Eduardo C. F. Longo at the European Conference on Intellectual Capital, INHolland University of Applied Sciences, Haarlem, The Netherlands, 28-29 April 2009.
Behaviour-Based Safety by BIS Training SolutionsBIS Safety
Behavior-Based Safety (BBS) is the process that creates a safety partnership between management and workers, focuses on people’s behaviour related to how they work, and encourages all workers to be safe and to work safely all time. To know more visit site.
Presents the core features of how to create a Behavioral Safety process. The process is customizable to suit any type of industry / location and is based on a 20 year track record of success on 5 continents.
Factoring the human into Patient Safety. Rhona Flin. IV Internacional Conference on Patient Safety (Madrid, Ministry of Health and Consumer Affairs, 2008)
The Knowledge Management Role In Mitigating Operational RiskEduardo Longo
Paper presented by Eduardo C. F. Longo at the European Conference on Intellectual Capital, INHolland University of Applied Sciences, Haarlem, The Netherlands, 28-29 April 2009.
Behaviour-Based Safety by BIS Training SolutionsBIS Safety
Behavior-Based Safety (BBS) is the process that creates a safety partnership between management and workers, focuses on people’s behaviour related to how they work, and encourages all workers to be safe and to work safely all time. To know more visit site.
Presents the core features of how to create a Behavioral Safety process. The process is customizable to suit any type of industry / location and is based on a 20 year track record of success on 5 continents.
Serious Incident Prevention (SIP) provides critical training designed to reduce catastrophic events.
Participants will learn how to:
Identify risks and work practices critical to addressing those risks
Measure and track those work practices
Encourage conversations around those critical work practices
Identify improvement targets and creates action plans
Include an effective Process Safety Leadership
Develop a Team that involves representative engineers, management, operators, and maintenance
Measure behaviors that are critical to serious incidents:
Maintenance of instrumentation and controls
Completion of hazard analysis, inspection, and testing
Compliance with work permits and procedures
Completion of process upset logs and review at shift change
TESTIMONIALS
“Best workshop I have ever been to. I have been struggling for a while as to how I could engage in our safety program in a meaningful way. You have given me the keys.”
“This is exactly what we needed. And it comes at a great time in the development of our safety program”
For full details, download the PDF brochure today OR contact kris@360bsi.com.
Operational Leadership and Critical Risk Managementmyosh team
Presented by Mark Cooper, Principal Consultant, Sentis
Whats covered?
High hazard activities rely on rules, procedures and standards to specify ‘safe operation’. While these standards are usually written by experts, they may not universally apply to every situation or operational context. A recent review of over 160 serious incidents across multiple industry sectors, identified that 49% of control failures involved intentional ‘workarounds’. This is not to suggest that workers are defiantly flouting rules or expectations. In fact, often workaround behaviours can be linked back to operational leadership and organisational factors.
Operational leaders set the tone and help shape the environment within which critical controls are managed. They act as role models, define what’s expected and influence behaviours and attitudes through their actions and words. In this webinar we’ll target the role of leadership in critical control management processes.
In this webinar, Sentis Principal Consultant Mark Cooper will explore:
• The psychology of risk, risk taking and risk management
• Strategies for leaders to promote, influence and reinforce the importance of critical control management
• The benefits of examining the ways your work is affected by latent operational and corporate influences.
Helping to Frame the Board’s Risk Conversation - A Profession in Transformation
by AIRMIC John Hurrell and Julia Graham
This session presented on October 04, 2016 during the FERMA European Risk Seminar in Malta, set out some of the issues involved for risk managers making this professional journey and offer practical ideas and suggestions on how risk managers can seize these professional opportunities.
Reinforcing FERMA’s vision of “a world where risk management is embedded in the business model and culture of organisations”, this session will focus on how risk management can be embedded in the business model of the organisation and the importance of risk culture and the profiling of risk culture as part of this process.
The session introduced models, tools and techniques designed for the risk manager developed in partnership with colleagues from other professions and in consultation with those who have a seat at the boardroom table.
Serious Incident PreventionSM(SIP) provides critical training designed to reduce catastrophic events.
Participants will learn how to:
Identify risks and work practices critical to addressing those risks
Measure and track those work practices
Encourage conversations around those critical work practices
Identify improvement targets and creates action plans
Include an effective Process Safety Leadership
Develop a Team that involves representative engineers, management, operators, and maintenance
Measure behaviors that are critical to serious incidents:
Maintenance of instrumentation and controls
Completion of hazard analysis, inspection, and testing
Compliance with work permits and procedures
Completion of process upset logs and review at shift change
TESTIMONIALS
“Best workshop I have ever been to. I have been struggling for a while as to how I could engage in our safety program in a meaningful way. You have given me the keys.”
“This is exactly what we needed. And it comes at a great time in the development of our safety program”
For full details, download the PDF brochure today OR contact kris@360bsi.com.
The Security Practitioner of the FutureResolver Inc.
In the face of changing business needs and threat environments, companies, organizations and individuals will continue to encounter increasingly diverse and sophisticated risks from an equally broad range of adversaries. These adversaries are equipped as never before supported by education, experience, publicly available critical information and the technology to bring their efforts to realization. Tomorrow’s security practitioner will need an array of integrated tools to effectively prepare for and counter tomorrow’s adversary. These “tools” will always include some traditional tried and proven practices; however, the need for practitioners to think critically, make risk-based decisions, implement leading practice solutions and define security optimization is required.
Presentation by:
Dennis Shepp, MBA, CPP, CFE, Consultant, Security Expert
Phillip Banks, P. Eng, CPP. Director, The Banks Group
Tier 4 Events - Operational Discipline - Do you know how are you performing i...Process Safety Culture
Operational Discipline, as we define it and most others would agree, is “doing the right thing, the right way, every time.” That is a pretty simple definition, but when you start thinking through the implications of what it takes for employees to be properly equipped and have the motivation to do that, things get more complicated. If you break down the definition, you see there are three areas of focus needed to drive the right behaviors of Operational Discipline:
1. Know what the right thing to do is
2. Be willing to always do the right thing
3. Ensure others also always do the right thing
10 ways to ensure your safety leadership journey towards vision zeroConsultivo
This presentation on Safety Leadership Journey towards Vision Zero is about the path ahead - the ten major ways of establishing a culture of proactive leadership ensuring a safety culture for everyone.
Identifying and Managing Waste in Complex Product Development EnvironmentsKen Power
Product Development can be viewed as a Complex Adaptive System. Different people, groups, organizations and systems collaborate in a complex network of relationships and dependencies to produce something of value - generally a product or service. Identifying waste in this value network is a critical step towards creating a truly lean organization.
These slides are from an interactive, hands-on workshop that I ran at the Agile India 2012 conference in Bengaluru, India.
There is a corresponding Blog entry here:
http://wp.me/pSOIL-fE
Essentials of Automations: Optimizing FME Workflows with ParametersSafe Software
Are you looking to streamline your workflows and boost your projects’ efficiency? Do you find yourself searching for ways to add flexibility and control over your FME workflows? If so, you’re in the right place.
Join us for an insightful dive into the world of FME parameters, a critical element in optimizing workflow efficiency. This webinar marks the beginning of our three-part “Essentials of Automation” series. This first webinar is designed to equip you with the knowledge and skills to utilize parameters effectively: enhancing the flexibility, maintainability, and user control of your FME projects.
Here’s what you’ll gain:
- Essentials of FME Parameters: Understand the pivotal role of parameters, including Reader/Writer, Transformer, User, and FME Flow categories. Discover how they are the key to unlocking automation and optimization within your workflows.
- Practical Applications in FME Form: Delve into key user parameter types including choice, connections, and file URLs. Allow users to control how a workflow runs, making your workflows more reusable. Learn to import values and deliver the best user experience for your workflows while enhancing accuracy.
- Optimization Strategies in FME Flow: Explore the creation and strategic deployment of parameters in FME Flow, including the use of deployment and geometry parameters, to maximize workflow efficiency.
- Pro Tips for Success: Gain insights on parameterizing connections and leveraging new features like Conditional Visibility for clarity and simplicity.
We’ll wrap up with a glimpse into future webinars, followed by a Q&A session to address your specific questions surrounding this topic.
Don’t miss this opportunity to elevate your FME expertise and drive your projects to new heights of efficiency.
Transcript: Selling digital books in 2024: Insights from industry leaders - T...BookNet Canada
The publishing industry has been selling digital audiobooks and ebooks for over a decade and has found its groove. What’s changed? What has stayed the same? Where do we go from here? Join a group of leading sales peers from across the industry for a conversation about the lessons learned since the popularization of digital books, best practices, digital book supply chain management, and more.
Link to video recording: https://bnctechforum.ca/sessions/selling-digital-books-in-2024-insights-from-industry-leaders/
Presented by BookNet Canada on May 28, 2024, with support from the Department of Canadian Heritage.
UiPath Test Automation using UiPath Test Suite series, part 4DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 4. In this session, we will cover Test Manager overview along with SAP heatmap.
The UiPath Test Manager overview with SAP heatmap webinar offers a concise yet comprehensive exploration of the role of a Test Manager within SAP environments, coupled with the utilization of heatmaps for effective testing strategies.
Participants will gain insights into the responsibilities, challenges, and best practices associated with test management in SAP projects. Additionally, the webinar delves into the significance of heatmaps as a visual aid for identifying testing priorities, areas of risk, and resource allocation within SAP landscapes. Through this session, attendees can expect to enhance their understanding of test management principles while learning practical approaches to optimize testing processes in SAP environments using heatmap visualization techniques
What will you get from this session?
1. Insights into SAP testing best practices
2. Heatmap utilization for testing
3. Optimization of testing processes
4. Demo
Topics covered:
Execution from the test manager
Orchestrator execution result
Defect reporting
SAP heatmap example with demo
Speaker:
Deepak Rai, Automation Practice Lead, Boundaryless Group and UiPath MVP
Software Delivery At the Speed of AI: Inflectra Invests In AI-Powered QualityInflectra
In this insightful webinar, Inflectra explores how artificial intelligence (AI) is transforming software development and testing. Discover how AI-powered tools are revolutionizing every stage of the software development lifecycle (SDLC), from design and prototyping to testing, deployment, and monitoring.
Learn about:
• The Future of Testing: How AI is shifting testing towards verification, analysis, and higher-level skills, while reducing repetitive tasks.
• Test Automation: How AI-powered test case generation, optimization, and self-healing tests are making testing more efficient and effective.
• Visual Testing: Explore the emerging capabilities of AI in visual testing and how it's set to revolutionize UI verification.
• Inflectra's AI Solutions: See demonstrations of Inflectra's cutting-edge AI tools like the ChatGPT plugin and Azure Open AI platform, designed to streamline your testing process.
Whether you're a developer, tester, or QA professional, this webinar will give you valuable insights into how AI is shaping the future of software delivery.
GDG Cloud Southlake #33: Boule & Rebala: Effective AppSec in SDLC using Deplo...James Anderson
Effective Application Security in Software Delivery lifecycle using Deployment Firewall and DBOM
The modern software delivery process (or the CI/CD process) includes many tools, distributed teams, open-source code, and cloud platforms. Constant focus on speed to release software to market, along with the traditional slow and manual security checks has caused gaps in continuous security as an important piece in the software supply chain. Today organizations feel more susceptible to external and internal cyber threats due to the vast attack surface in their applications supply chain and the lack of end-to-end governance and risk management.
The software team must secure its software delivery process to avoid vulnerability and security breaches. This needs to be achieved with existing tool chains and without extensive rework of the delivery processes. This talk will present strategies and techniques for providing visibility into the true risk of the existing vulnerabilities, preventing the introduction of security issues in the software, resolving vulnerabilities in production environments quickly, and capturing the deployment bill of materials (DBOM).
Speakers:
Bob Boule
Robert Boule is a technology enthusiast with PASSION for technology and making things work along with a knack for helping others understand how things work. He comes with around 20 years of solution engineering experience in application security, software continuous delivery, and SaaS platforms. He is known for his dynamic presentations in CI/CD and application security integrated in software delivery lifecycle.
Gopinath Rebala
Gopinath Rebala is the CTO of OpsMx, where he has overall responsibility for the machine learning and data processing architectures for Secure Software Delivery. Gopi also has a strong connection with our customers, leading design and architecture for strategic implementations. Gopi is a frequent speaker and well-known leader in continuous delivery and integrating security into software delivery.
Key Trends Shaping the Future of Infrastructure.pdfCheryl Hung
Keynote at DIGIT West Expo, Glasgow on 29 May 2024.
Cheryl Hung, ochery.com
Sr Director, Infrastructure Ecosystem, Arm.
The key trends across hardware, cloud and open-source; exploring how these areas are likely to mature and develop over the short and long-term, and then considering how organisations can position themselves to adapt and thrive.
Builder.ai Founder Sachin Dev Duggal's Strategic Approach to Create an Innova...Ramesh Iyer
In today's fast-changing business world, Companies that adapt and embrace new ideas often need help to keep up with the competition. However, fostering a culture of innovation takes much work. It takes vision, leadership and willingness to take risks in the right proportion. Sachin Dev Duggal, co-founder of Builder.ai, has perfected the art of this balance, creating a company culture where creativity and growth are nurtured at each stage.
DevOps and Testing slides at DASA ConnectKari Kakkonen
My and Rik Marselis slides at 30.5.2024 DASA Connect conference. We discuss about what is testing, then what is agile testing and finally what is Testing in DevOps. Finally we had lovely workshop with the participants trying to find out different ways to think about quality and testing in different parts of the DevOps infinity loop.
Epistemic Interaction - tuning interfaces to provide information for AI supportAlan Dix
Paper presented at SYNERGY workshop at AVI 2024, Genoa, Italy. 3rd June 2024
https://alandix.com/academic/papers/synergy2024-epistemic/
As machine learning integrates deeper into human-computer interactions, the concept of epistemic interaction emerges, aiming to refine these interactions to enhance system adaptability. This approach encourages minor, intentional adjustments in user behaviour to enrich the data available for system learning. This paper introduces epistemic interaction within the context of human-system communication, illustrating how deliberate interaction design can improve system understanding and adaptation. Through concrete examples, we demonstrate the potential of epistemic interaction to significantly advance human-computer interaction by leveraging intuitive human communication strategies to inform system design and functionality, offering a novel pathway for enriching user-system engagements.
Connector Corner: Automate dynamic content and events by pushing a buttonDianaGray10
Here is something new! In our next Connector Corner webinar, we will demonstrate how you can use a single workflow to:
Create a campaign using Mailchimp with merge tags/fields
Send an interactive Slack channel message (using buttons)
Have the message received by managers and peers along with a test email for review
But there’s more:
In a second workflow supporting the same use case, you’ll see:
Your campaign sent to target colleagues for approval
If the “Approve” button is clicked, a Jira/Zendesk ticket is created for the marketing design team
But—if the “Reject” button is pushed, colleagues will be alerted via Slack message
Join us to learn more about this new, human-in-the-loop capability, brought to you by Integration Service connectors.
And...
Speakers:
Akshay Agnihotri, Product Manager
Charlie Greenberg, Host
Neuro-symbolic is not enough, we need neuro-*semantic*Frank van Harmelen
Neuro-symbolic (NeSy) AI is on the rise. However, simply machine learning on just any symbolic structure is not sufficient to really harvest the gains of NeSy. These will only be gained when the symbolic structures have an actual semantics. I give an operational definition of semantics as “predictable inference”.
All of this illustrated with link prediction over knowledge graphs, but the argument is general.
UiPath Test Automation using UiPath Test Suite series, part 3DianaGray10
Welcome to UiPath Test Automation using UiPath Test Suite series part 3. In this session, we will cover desktop automation along with UI automation.
Topics covered:
UI automation Introduction,
UI automation Sample
Desktop automation flow
Pradeep Chinnala, Senior Consultant Automation Developer @WonderBotz and UiPath MVP
Deepak Rai, Automation Practice Lead, Boundaryless Group and UiPath MVP
UiPath Test Automation using UiPath Test Suite series, part 3
Steve Arendt runcorn uk presentation 8 21-12 final
1. sponsored by
In Search of “Perfect Process Safety”
How to Ensure Sustainable Continuous Improvement
Learning from the M
L i f th Macondo D
d Deepwater H i
t Horizon Bl
Blow O t
Out
August 21, 2012 Runcorn, UK
Steve Arendt, Vice President, P.E.
North America Process Industries
Organizational Performance Assurance Center
sarendt@absconsulting.com
Steve Arendt, P.E.
30+ years in process safety and risk assessment
Vice President, ABS Consulting, NA Process Sector and
Organizational Performance Assurance Center
ABSC project manager for the Baker Panel PSM reviews
Conducted 100s of PSM audits, incident investigations, and best
practice reviews, including 20+ offshore facilities
60+ articles and books on PSM and risk management
Guidelines for Risk-Based Process Safety
Guidelines for Management of Change
A Compliance Guide for EPA’s Risk Management Program Rule
Manager's Guide to Quantitative Risk Assessment
Resource Guide to the Process Safety Code of Management Practices
y g
Guidelines for Hazard Evaluation Procedures, Second Edition
A Manager's Guide to Implementing and Improving MOC Systems
Risk Communication Guide, Chemical Educational Foundation
ProSmart - CCPS PSM Performance Metrics System
Center for Chemical Process Safety Fellow
Recipient of Mary Kay O’Conner PSC Merit Award
Center for Offshore Safety work group member
2
1
2. “Perfect Process Safety”
What is it?
Is it possible?
What are the barriers?
3
A Vision For “Perfect Process Safety”
A culture based on proper ownership of HSE
Risk-informed sensitivity that g
y guides everything
y g
Effective, fit-for-purpose management systems
PS practices embraced and followed with good
operational discipline at ALL levels
Learning from ALL sources – internal, external and
outside industry group
Well-formed/visible performance pyramid; metrics
at every level that drive intended behaviors
Goals and actual performance that improves
4
2
4. Seems to Be Four Types of Companies
In theory, requirements and enforcement practices
should be matched to these various “needs”
needs
Know what to do and do a pretty good job
Know what to do, but don't do a consistent job
Know what to do and "intentionally" don't do a good job
Don't really know what to do – ignorant or confused
Difficult to make happen. Seems like we want “one
happen one
paint brush” and the “same type of painter” no
matter what the need
7
Learning from Experience
Outside your industry
Inside your industry
Inside your company
One BIG problem in industry is that we get taught
the same lesson over and over, but don’t truly
LEARN so that the problems don’t repeat
p p
A critical skill is to find something relevant to learn
and improve on out of EVERY significant incident
8
4
5. Simple Lessons Baker Panel-CSB Reports
Panel-
Ineffective PSM system with weak performance
evaluation, corrective action, and corporate oversight
Lack of follow-up in ALL areas
p
Huge backlogs in inspections and corrective actions
Not following consensus standards – nor their own
Poor risk awareness and assessment
Superficial audits
Inadequate metrics
Poor management review at local level
Not focused on process safety at corporate level
Inadequate corporate safety culture – had symptoms
in every PS culture problem area
Blind spots
Arrogant
Complacent
Superficial
Glacial, non-agile
In denial
9
Macondo – Lessons and Potential Impacts
Classes of root causes - plenty to go around
Inadequate process safety culture for DH
adequate p ocess sa ety cu tu e o
Inadequate GOM operating environment culture
Complex offshore operating environment
Process safety management system failures
Inadequate GOM regulatory environment
Potential influences for onshore regulations
g
Enhanced reporting and third-party audits
Prescriptive independent verification of safety critical
elements
QRA and safety case
10
5
6. Lessons from Major Learning Sources
Failure to execute – primary lesson
We are not taking advantage of all “internal”
internal
sources of learning opportunities
In the U.S., we have incomplete value generation from
20 years of regulatory PSM incidents - inadequate
collective analysis, trending, sharing, and learning
Failure to learn from other types of industry
accidents
Will process safety leading indicators suffer the
same fate?
We have a culture challenge
11
Six Characteristics of a Learning Organization
(Harvard Professor David Garvin)
Supports discussion and evaluation of divergent opinions
and data
Provides timely feedback and flexibility in the means
used to conduct work activities
Stimulates new ideas to promote a step change in risk
understanding and operational performance
Maintains an external focus by not automatically
discounted outside ideas and ways
Treats errors/mistakes as investments. Learns from
them. Encourages proper risk-taking
Routinely updates a learning plan to increase
competencies
12
6
7. Characteristics of a Learning-Disabled Company
(Steve Arendt, Armchair Process Safety Psychologist)
Dysfunctional safety culture
People hide things and kill messengers
p g g
Fail to question; procedures not followed without
accountability
Mixed/improper safety/production messages
Complacency, low trust, silo mentality
Misplaced safety ownership, invisible/ineffective
leadership
Superficial causal analysis of problems
Things don't get fixed
No company memory
Add in your own…
13
Characteristics of Good Risk Management
Necessary, but Not Sufficient for Perfect PS
Pervasive understanding of what risk is
Consistent practices driven using fit-for-purpose
g
HSE management system
Life-cycle wide and enterprise deep risk visibility
Flexible tool set and relevant data sources
Competent practitioners
Appropriate risk tolerance concepts/tools employed
Effective risk reduction issue management
Regular executive review of risk register top issues
Risk ownership throughout the organization
14
7
8. Definition of the Perfect PS Leading Indicator
The Perfect Risk Model Or…a “Live Risk” Model
Evaluates the risk impact of day-to-day
facility changes and circumstances:
User d fi
U defines equipment th t i f il d
i t that is failed,
disabled, degraded etc.
Operational adjustments
External circumstances
Evaluates the increase in risk from
these changes
Requires input from risk models
(HAZOPsHAZIDs, LOPAs, BTs,
QRAs) into risk model
Operator identifies
equipment that is
failed or out of
service
LIVERISK shows you the
increase in risk due to the known
equipment failures/outages or
operational circumstances
15
LIVERISK Features
Dashboards for
Different levels within the organization (
g (facility, Business Unit,
y
Corporate etc.)
Different departments (production, safety, inspection etc.)
Accounts for the impact of changes in management systems
Mechanical integrity: testing & maintenance programs; Project Quality
Management (PQM), etc.
Health, Safety and Environmental: results of HSE audits, Class
surveys, etc.
surveys etc
Integrate HSE/process safety metrics (leading indicators)
Integrate safety culture issues
Others
Accounts for operational profile and external events
16
8
9. Improvements in Process Safety/HSE
Technology
and standards
HSE management Culture
ate
systems • Organizational and
Risk/Incident Ra
individual behaviour
aligned with goals
Standards
• “Felt” leadership
• Engineering improvements
• Personal accountability
• Hardware improvements
• Shared purpose & belief
• Design review
• Compliance Management Systems Improved
• Integrated HSE MS culture
• R
Reporting
ti
• Assurance
• Competence
• Risk Management
Time
Adapted from Kiel Centre 17
Overview of U.S. Industry Process Safety
Performance Improvement Activities
Center for Chemical Process Safety
Risk Based Process Safety Guidelines emphasis on Learning from
Experience
Leading indicator work in late 90’s culminating in new PS metrics
guidelines
Member benchmarking project and Vision 2020
API
RP 754
API/AFPM Advancing Process Safety Initiative
Center for Offshore Safety
Lessons from industry accidents and investigations
Industry is refocusing attention and leadership
away from PSM compliance to PS Performance
18
9
10. Current PSM/HSE Auditing and RCA
Practices Don’t Go Far Enough
PSM/HSE audits generally issue findings and areas
for improvement “at the element level” even though
the evidence used may point to deeper problems
Incident investigations identify PSM elements as root
causes but don’t address safety culture factors
Use of PSM leading indicators are just becoming
broadly accepted, but their use for performance
management is in the “infant stage”
Plenty of learning opportunities; need to adjust our
learning and performance improvement approaches
19
Center for Chemical Process Safety
Made Culture an Official SMS Element
Evaluated major organizational
accidents and prepared Safety
Culture Awareness tool
ABSC included Process Safety
Culture as an element in CCPS
Guidelines for Risk Based
Process Safety
Defined the twelve essential
features of a good culture
Created structure for a culture
management practice
20
10
11. 21
What Is Safety Culture?
Our Company and Individual DNA
Cu tu e is t e te de cy in a o us – a d ou
Culture s the tendency all of and our
organization - to want to do the right thing in the right
way at the right time, ALL the time – even when/if no
one is looking – ABS Group definition
Culture is the result of all the actions - and inactions -
in institutional/workforce memory
Individual and organizational safety culture is affected
by ethnic culture and off-the-job behavior
Culture is hard to measure and more difficult to change;
it will be the “root cause of the decade”
22
11
12. To Address Unsafe Acts, Some Companies
Have Implemented BBS Programs
Industry experience has varied
Worked for some; did not work for others
Worked for a while, but then floundered
Some have not tried it because of the resource commitment and
negative feedback
Problems with BBS programs
LTA management commitment; LTA resources
Perceived to be a program for employees to “fix themselves”
p g p y
Management not viewed as a part of the problem/solution
Lack of employee ownership
Trivial/ineffective observations - quotas, improper reward systems,
program gets stale, gets nit-picky
Employees unable to provide/accept constructive peer feedback
23
Organizational Accidents and Culture
Challenger & Columbia
Piper Alpha
L f d
Longford
Chernobyl
Flixborough
Texas City
Macondo
24
12
13. Process Safety Culture – Essential Features
1. Establish safety as a core 7. Defer to expertise
value
l 8. Ensure open and effective
2. Provide strong leadership communications
3. Establish and enforce high 9. Establish a
standards of performance questioning/learning
environment
4. Formalize the safety culture
emphasis/approach 10. Foster mutual trust
5. Maintain a sense of 11. Provide timely response to
vulnerability safety issues and concerns
6. Empower individuals to 12. Provide continuous
successfully fulfill their monitoring of performance
safety responsibilities
25
1. HSE/Process Safety As a Core Value
Deeply ingrained sense of value for HSE/safety
At all levels of the organization
Promoted to an ethical imperative in really strong
cultures
Awareness of responsibility to:
Self
Co-workers
Company
Society
Individual and group intolerance of those in
violation of the norm
26
13
14. 2. Strong Leadership
Visible, active, consistent support from all levels
of company management
Through communications, actions, priorities,
provision of resources, etc.
Committed to what is right
Visionary and inspiring
Open and honest
Firm b t fl ibl
Fi but flexible
Alert and responsive to modify strategies to
meet safety goals
HSE/safety as line responsibility
27
3. Consistent Accountability to High
Performance Standards
Individual d
I di id l and organizational
i ti l
Standards established, reinforced, and updated in
a controlled fashion
Consistency in accountability and transparency at
all organizational strata – no “double standards”
Avoidance of normalization of deviance
Zero tolerance for willful violations of safety
standards, rules, or procedures
28
14
15. 4. Formalize a Culture Approach
Culture cannot be designed or manufactured, but ...
Document key principles or activities that support or
maintain its safety culture
Record basic safety tenants, such as in a company
policy or mission statement
Formalize a culture evaluation, monitoring, and
learning activities that are expected to be carried
out by someone or some group on a periodic basis
29
5. Sense of Vulnerability
Preoccupation with failure
Constant vigilance for indications of system
weaknesses
Attention to “weak signals”
Avoidance of complacency
“Past performance not a guarantee of future success”
Avoidance of putting excessive reliance on
safety systems
Awareness of need for resilience (multiple lines of
defense)
Burden of proof for safety rather than "un-safety
30
15
16. 6. Individual Empowerment
Clear delegation of, and accountability for,
responsibilities
Provision of requisite authority and resources to
staff to allow success in assigned roles
Management expectation and tolerance of
disparate opinions
Personal responsibility for safety
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7. Deference to Expertise
High value placed upon training and
development of individuals and groups
Authority for decisions migrates to proper people
based upon their knowledge and expertise
Rather than rank or position
Independent and unassailable role for safety
experts
Imperative for maintaining the “critical mass” of
expertise required for safe operations
32
16
17. 8. Open and Effective Communications
Vertical communications (both up and down)
Management hearing as well as speaking
Horizontal communications
All have the information they need to identify and
respond to the unexpected
Emphasis on observation and reporting
Redundant and/or non traditional
non-traditional
communications channels
Monitoring of communications for effectiveness
33
9. Questioning/Learning Environment
Enhancing risk awareness and understanding as
means to continuous safety improvement
Appropriate and timely hazard/risk assessments
Thorough and timely incident investigations
Looking beyond site or company for applicable
learnings
Reluctance to simplify interpretations or seek the
p y p
simple solutions
34
17
18. 10. Mutual Trust
Employees for managers
Trust that managers will do the right thing in support
of safety
Managers for employees
Trust that employees will shoulder their share of
responsibility for safety performance
Peers for peers
p
Confidence in a just system where honest errors
can be reported without fear of reprisals
35
11. Responsiveness to Safety Concerns
Awareness of safety as a dynamic non-event
A “properly tuned controller”
properly controller
Rapid, but not reckless, response to the unexpected
in order to maintain the safety setpoint
Timely response to implement learnings from
audits and investigations
Timely resolution of mismatches between
practice and procedure t prevent normalization
ti d d to t li ti
of deviance
Timely reporting of, and response to, employee
safety concerns
36
18
19. 12. Continuous Monitoring of
Performance
Curiosity/anxiety for ”How are we doing?
How doing?”
Sensitivity to operations
Process
Management system
Interpersonal
Pertinent, clear metrics addressing both leading
, g g
and lagging indicators
Defined
Created
Tracked
37
Examples of Culture Influencing Events
A co-worker does not object when an operator writes an
“armchair permit”
Supervisors consistently support workers who shut down a
process they believe to be unsafe – even if they were
wrong
An operations manager extends a unit shutdown to await
definitive evidence that a thin-walled vessel is safe to
operate
A plant manager does not wear appropriate PPE when
walking to the control room to eat lunch with a unit crew
A corporate EHS Director persists in her efforts to justify
staffing resource commitments to support process safety
in spite of company cost-cutting edicts
Red = Negative Green = Positive
38
19
21. PAR Process Safety Performance vs. Culture Map
Culture survey results and other sources
are sorted into the 12 essential features
Analysis of all process safety
performance data (e.g., audit actions)
is sorted into the 12 essential features
41
Ranking of Cultural Causal Factors Present – Summary
of Study Results
Cultural Causal Factor – Decreasing Frequency
1. Normalization of deviance
2. Non-responsiveness to safety concerns
3. Lack of a questioning/learning environment
4. No performance monitoring/pursuit of
improvement
5. Lack of sense of vulnerability
6. Lack of trust – unsafe reporting environment
42
21
22. How to Change PS/HSE Culture
Embracing the idea that YOU affect culture
Understanding potential root causes
Determining ways to improve culture weaknesses
Follow-thru throughout an organization
43
How Leaders Influence Beliefs/Values
What leaders pay attention to, measure, or
control
Reactions to critical incidents or crisis
Criteria used to allocate scarce resources
Deliberate attempts at role modeling, teaching,
and coaching
Criteria for reinforcement and discipline
Criteria used to select, promote, or terminate
employees
44
22
23. Small Group/Individual Mentoring and Coaching
Workshops and role play
Examples of accidents that occurred due to safety culture problems
CCPS 12 essential features of a good safety culture
Taking personal responsibility for evolving your Process Safety and
Occupational Safety (Total Safety) behavior and culture
Understanding potential historical root causes for culture problems
Soliciting ideas for improving culture
Decide which culture elements you are going to address
Decide who in management is needed to support your efforts
Develop a plan for the next month, the next six months, the next
year, and the next three years
Determine what metrics will be used to monitor progress
45
Some Culture Improvement Lessons
If you have poor culture, marked by mistrust or
needs large improvement, the worst thing y can
g p , g you
do is too just start “talking” about it at the top
The “top” needs to first start “behaving” better to
address culture weaknesses
Then, the talk will build up from the bottom
If you survey, do it anonymous and voluntary; you
survey
should commit to sharing the results – quickly
Any education/training, etc. should extend to ALL of
the workforce, including contractors
BUILD OWNERSHIP
46
23
24. Sense, Learn, and Fix at Every Level
Put sensors, not censors, at every level
Develop learnings at every level
Take corrective action at every level
47
Strategy for Process Safety
Performance Management
Monitor PSM health
For ALL PS learning opportunities:
Evaluate PSM failure modes
Determine PSM failure culture causal factors
Ensure sustainable PSM/HSE performance
improvement
Avoid organizational warning signs
Embrace critical success factors for PSM
48
24
25. Evaluating PSM Element Failure Modes
Determine basic element steps
Review element written program
Identify life-cycle activities completed and current
status
• Design and development
• Implementation and rollout
• Operation
• Monitoring and improvement
Develop workflow diagram of element work process
Review relevant incident root causes for element
Review relevant element metrics - leading and
lagging indicators
49
Evaluating PSM Element Failure Modes
Review previous two audit cycle results for element
Assign incident, root causes, audit findings and
observations, and metrics indicator performance to:
• Life cycle phase during which the element performance issue
occurred
• Workflow process point where element breakdown occurred
Highlight element life-cycle phase where
performance issues are greatest
Highlight work process point where most
element performance issues have occurred
50
25
26. Evaluating PSM Element Failure Modes
Determine corrective and preventive actions to
reduce chance of element performance failure
p
occurring again
Implement/redo life-cycle phase in a more reliable fashion
Improve element work process design
Create better leading indicators to monitor element
performance area
Improve use of existing relevant metrics to monitor
element performance
Increase management review scrutiny on element
performance area
All of this may not be enough
51
Evaluating PSM Element Failure
Culture Causal Factors
Map element performance issues to cultural
features
Compare performance to known culture
weaknesses
Identify which culture features appear to be
contributing to element performance lapses
52
26
27. Ensuring Sustainable PSM/HSE
Performance Improvement
Make technical corrections to PSM element
performance
Implement culture improvement activities to
address culture weaknesses
Monitor culture change and improvement
53
Guidelines for
Management of Change for Process Safety
Recognize
Classify
Evaluate hazards and risks
Approve (or not) or modify
Get ready for the change
Communicate/train
Update documentation
200 pages. April 2008, US $95
ISBN: 978-0-470-04309-7
http://www.wiley.com/WileyCDA/WileyTitle/productCd-0470043091.html
54
27
28. MOC Program Life-Cycle Phases
Design and development
Implementation and rollout
Operation
Monitoring and improvement
55
MOC System Design/Development Failure Modes
Inadequate workforce involvement
Inadequate design basis - wrong change types
types,
inadequate review/authorization protocols
MOC use rate not considered when establishing MOC
resources
Inadequate MOC resources designated
MOC protocol complexity inappropriate for change types,
resources, or workforce culture
MOC system roles and responsibilities inadequate
Scope of application of MOC program inadequate
56
28
29. MOC System Rollout Failure Modes
Inadequate workforce involvement
Inadequate awareness training of workforce
workforce,
including contractors
Inadequate detailed training of MOC system
participants
Insufficient MOC system tools/forms/resources
provided
Insufficient pilot-testing
57
MOC System Operation Failure Modes
Failure to identify a proposed change - system circumvented
Change classified as an emergency change when it did not
meet established criteria
Mistakenly included a RIK in the MOC review process
Proposed change improperly classified - type or review path
MOC origination information inadequate
MOC initial review not completed or inadequate
Inadequate MOC reviewers
Wrong MOC review method used
MOC hazard review path step missed, out of order, incomplete
MOC hazard evaluation inadequate - hazards missed or risks
improperly evaluated
58
29
30. MOC System Operation Failure Modes
Emergency MOC review procedure not finished
MOC authorization inadequate - wrong, missing or risks
accepted are inappropriate
PSI not updated based upon change
Personnel not informed of change
Personnel not trained on change
Wrong communication or training provided to personnel
Temporary change left in place too long without further review
Failure to restore system to original condition after a
temporary change
MOC review records inadequate or missing
MOC delayed or lost in the system
59
MOC System Monitoring Failure Modes
MOC metrics not properly developed or used
Inadequate management review/oversight of
MOC system
MOC not addressed sufficiently in PSM audit
60
30
31. Top MOC Operating Phase Failure Modes % of MOC
Issues
Failure to identify a proposed change
61 %
- system circumvented
Temporary change left in place too 43 %
long without further review or failure
to restore system to original
Personnel not informed of change g 35 %
MOC delayed or lost in the system 23 %
MOC hazard evaluation inadequate -
hazards missed or risks improperly 18 %
evaluated
61
MOC Failure Example –
Offshore Gas Compressor Module
62
31
32. Unrecognized Change Led to Release
Original position Modified position
63
Gas Release Resulted in a “Lucky Explosion”
64
32
33. Company PS Metrics Related to Incident
Number of open MOCs
MOC action item aging
Process piping inspection aging
None of these metrics addressed monitoring
the technical performance aspects of MOC
that
th t contributed to the incident
t ib t d t th i id t
65
Top MOC Cultural Causal Factors
1. Establish process safety as a 7. Defer to expertise
core value
l 8. Ensure open and effective
2. Provide strong leadership communications
3. Establish and enforce high 9. Establish a
standards of performance questioning/learning
environment
4. Formalize the process safety
culture emphasis/approach 10. Foster mutual trust
5. Maintain a sense of 11. Provide timely response to
vulnerability safety issues and concerns
6. Empower individuals to 12. Provide continuous
successfully fulfill their safety monitoring of performance
responsibilities
66
33
34. MOC Failure Was a Root Cause
Several MOC failures occurred
Development – failure to account for change type
Rollout – precursors occurred during period
Operation – failure to recognize, failure to evaluate
Several safety culture issues were uncovered
that contributed to the MOC system failures
Lack of a sense of vulnerability
Failure to empower individuals
Lack of a questioning/learning environment
Normalization of deviance
67
Conclusions from Example
MOC is a critical PSM element
MOC performance management (audits) often
don't provide sufficient improvement information
We must examine MOC failure modes to support
continuous improvement
MOC failure prevention must consider "life-cycle
improvements
Culture and behavior issues MUST be addressed
for sustainable improvement
Leading indicators supported by frequent
management review are needed
68
34
35. Strategy for Process Safety
Performance Management
Evaluating PSM failure modes
Determining PSM failure culture causal factors
Ensuring sustainable PSM/HSE performance
improvement
Avoiding organizational warning signs
Critical success factors for PSM
69
How Does a Company Tell If It Is:
In a process safety ditch
On th d
O the edge of a ditch
f dit h
Getting closer to a ditch
Moving away from a ditch
Maintaining proper distance from a ditch
AVOID loss of visibility or fidelity in
performance evidence sources – maintain
a well-shaped and complete pyramid
70
35
36. Example of a Faulty Pyramid
Accidents
Incidents
Precursors
Management System Failures
Unsafe Behaviors and Attitudes
Culture – Individual and Organizational Tendencies
71
Recognizing Catastrophic
Incident Warning Signs in
the Process Industries
ISBN: 978-0-470-76774-0
264 pp
December 2011
US $125.00
$125 00
http://www.wiley.com/WileyCDA/WileyTitle/pro
ductCd-047076774X.html
72
36
38. Process Safety Metrics – Arendt Suggestions
1. Process Safety incidents – ANSI/API RP 754 Tiers 1 and 2
2.
2 Process Safety incident precursors – RP 754 Tier 3
3. Failure to follow procedures/SWPs – BBS at-risk
observation rate
4. Failure to fix identified process safety problems – action
item backlogs or aging, equipment deficiencies backlogs
5. Failure to identify process safety deficiencies– inspection
(all sources) backlog, failure to identify/report incidents or
do adequate RCA
6. Failure to assess risk– MOC circumvention or low quality,
PHA schedule backlog, PHA quality review
7. Safety culture weaknesses – Map RCs of incidents to
cultural causal factors
75
Emerging Challenges with PS Metrics
Don’t pick too many
Make sure they roll up properly
Make sure they add value
Don’t just pick things you can measure; make
certain they affect accident risk
Think through how you will use them; anticipate
unintended behaviors
Make them visible – positive culture influence
76
38
39. Characteristics of Good Process
Safety Companies
Not blind or arrogant – willing to look into the mirror
Safe questioning/learning environment
Proper safety ownership and leadership
Effective, fit-for-purpose management systems
Disciplined in execution - low/decreasing backlogs
Effective action - prevention not just correction
prevention,
Action at multiple levels of the pyramid
Builds better ownership and fosters a better culture
77
Characteristics of Good Process
Safety Companies (cont’d)
Learns lessons cheaply taught from all sources -
py g
avoids repeat teaching
Pursues effective continuous improvement – seeks
out better practices
High quality incident investigations
Proper process safety metrics and discerning
audits
Effective management review
78
39
40. Keys to Future Process Safety Success
To pursue zero or perfect PS – you’ve got to change the
ways you are doing some things that served you okay to
get you to where you are at
Fit-for-purpose PSM/HSE system that is well-executed
Nurture culture and operating discipline
Create an effective learning organization
Apply root cause thinking to everything
Maintain an effective corrective action process
High quality incident investigations
Proper process safety metrics
Discerning audits
Effective management review
79
Teaching, Learning, and Remembering
Go back to your plant, company, or organization
and pick a notable incident and find out:
What was done to keep it from happening again
Do people remember it and the lessons
What have you done to embed it in your "lore"
What effective approaches still exist to prevent it
What do you have to protect against PS Alzheimers
Pick a notable event from another company or
industry - and do the same
Go up your chain-of-command and see how far
the “remembering” goes
80
40
41. “Perfect Process Safety”
Is a worthy and valuable goal
Can only be pursued by highly reliable
organizations that embody effective learning
patterns
Sustainable process safety does not allow
learning to evaporate or “retire”
Should be the stretch goal for all companies and
organizations
81
Swiss Cheese Model for Accident Causation
82
41
42. Time for Questions
sponsored by
In Search of “Perfect Process Safety”
How to Ensure Sustainable Continuous Improvement
Learning from the M
L i f th Macondo D
d Deepwater H i
t Horizon Bl
Blow O t
Out
August 21, 2012 Runcorn, UK
Steve Arendt, Vice President, P.E.
North America Process Industries
Organizational Performance Assurance Center
sarendt@absconsulting.com
42