View
218
Download
0
Category
Preview:
Citation preview
8/11/2019 Gent Coach Training March 2004
1/37
SEOP Distribution 30 xxxx2004
HSSE training
Gent
March 30-31th 2004
8/11/2019 Gent Coach Training March 2004
2/37
SEOP Distribution 30 xxxx2004
Agenda :
09 00 : Introduction
09 10 : Introduction & background Coachable HSSE moments
09 20 : Syndicate: Management commitment
09 50 :Bradley curve
10 00: Syndicate: Case study & Coffee Break
10 45 : Safety culture
11 00 : Syndicate: Identifying the root causes
12 00 : Just culture decision making process
12 15 : Syndicate: Just culture decisions
13 00 : Courage
13 15: Conclusion
13.30: End
8/11/2019 Gent Coach Training March 2004
3/37
SEOP Distribution 30 xxxx2004
Coachable HSSE moments
At the conclusion of this session, you will have anunderstanding of:
Why a culture change is required
Which elements are required for the change
What you can do for the change
8/11/2019 Gent Coach Training March 2004
4/37
SEOP Distribution 30 xxxx2004
TRCs 2003 General Failure Type
%
LEGEND of GFT
HW- Hardware
DE - Design
MM- Maint.Mgt.PR - Procedures
EC- Error Enfor.Cond.
HK- Housekeeping
IG- Incompat. Goals
OR- Organisation
CO- Communication
TR- Training
DF - Defences
0
5
10
15
20
25
3035
40
45
50
HW DE MM PR EC HK IG OR CO TR DF
TRCs - GFT%
8/11/2019 Gent Coach Training March 2004
5/37
SEOP Distribution 30 xxxx2004
TRCs - % by employees and location
0
10
20
30
40
50
60
70
80
90
100
Emp Cont Fac Gant Ret Com Road Oth
LEGEND
EmpShell Staff
ContContractors Staff
Fac- Facilities
Gant- Gantry
RetRetail Stations
ComCommercial Customers
RoadTraffic Road Incident
Oth - Others
8/11/2019 Gent Coach Training March 2004
6/37
SEOP Distribution 30 xxxx2004
Safety is in the Head !
Unsafe Conditions
4%
96%
Unsafe Acts
THE CAUSE OF INJURIES
8/11/2019 Gent Coach Training March 2004
7/37
SEOP Distribution 30 xxxx2004
Medical Treatment
Fatalities Lost Time In juries
First-Aid Cases
Procedures
DocumentationTechnical
Measures
Peoples Behaviour
and
Unsafe Acts
THE ICE-BERG
8/11/2019 Gent Coach Training March 2004
8/37
SEOP Distribution 30 xxxx2004
1 fatality
30 Major injuries
300 Minor injuries
3000 Incidents which did notcause harm
30 000 at-risk behaviours
Environment where leadershipand peers condone at-riskbehaviours
3
36
HSSE Performance xxxx 2003
30.000275
1
8/11/2019 Gent Coach Training March 2004
9/37
SEOP Distribution 30 xxxx2004
8/11/2019 Gent Coach Training March 2004
10/37
SEOP Distribution 30 xxxx2004
Demonstrated Management Commitment
To say it starts at the top is a clich.
But
it starts there, or it does not start at all.
8/11/2019 Gent Coach Training March 2004
11/37
SEOP Distribution 30 xxxx2004
Syndicate exercise
In table groups Describe leadership actions and/or behaviours which
clearly demonstrate to your organization yourvisible commitment to safety
List these actions and/or behaviours
Select a spokesperson; be prepared to review
PS: What you do today not what you should be doing.
8/11/2019 Gent Coach Training March 2004
12/37
SEOP Distribution 30 xxxx2004
Syndicate exercise
In table groups
Describe leadership actions and/or behaviourswhich destroy the image of your commitment to
safety in the eyes of your employees. List these actions and/or behaviours
Select a spokesperson; be prepared to review
8/11/2019 Gent Coach Training March 2004
13/37
SEOP Distribution 30 xxxx2004
DEMONSTRATED MANAGEMENT COMMITMENT
Signaling the organization that HSE excellence is a high corporate
priority. Set an expectation of immediate reporting of serious incidents
Integrating HSE considerations in all business and personal evaluations.
Holding management and supervision accountable for their leadership insafety,
Getting personally involved in high potential and serious incidentinvestigations.
Demonstrate a sincere interest in safety through the manner in whichyou conduct your walks through operations in your area ofresponsibility.
Chairing the HSE steering committee. Attendance at HSE meetingsshould be considered a high priority.
Learning how to conduct HSE audits and participating regularly.
Develop an audit schedule which exposes you regularly to all areas overtime.
8/11/2019 Gent Coach Training March 2004
14/37
SEOP Distribution 30 xxxx2004
ManagementCommitment
Condition ofEmployment
Fear/Discipline Rules/Procedures Supervisor
Control, Emphasis,and Goals
Value All People Training
Personal Knowledge,Commitment, andStandards
Internalization Personal Value Care for Self Practice, Habits Individual Recognition
Help Others Conform Care for each other Networking Contributor Organizational Pride
InjuryRates
NaturalInstincts
Management
Self
Teams
The Bradley Curve
DependentSafety Culture
IndependentSafety Culture
InterdependentSafety Culture
0
8/11/2019 Gent Coach Training March 2004
15/37
8/11/2019 Gent Coach Training March 2004
16/37
SEOP Distribution 30 xxxx2004
What is a safety culture ?
A safe culture = an informed culture
An informed culture is one that knows where the
edge is without having to fall over it first.
An informed culture is preoccupied with thepossibility of failure and works continuously tobecome more resilient to its operational hazards.
8/11/2019 Gent Coach Training March 2004
17/37
SEOP Distribution 30 xxxx2004
But an informed culture can only grow froma just culture
An informed culture depends on people reporting
near misses, errors and incidents.
But they wont do that if they dont trust thesystem.
And they certainly wont do it if they aredisciplined because of what they report.
8/11/2019 Gent Coach Training March 2004
18/37
SEOP Distribution 30 xxxx2004
Reporting
culture
Informedculture
Just
culture
A safe culture has many interlocking elements
8/11/2019 Gent Coach Training March 2004
19/37
SEOP Distribution 30 xxxx2004
Building a just culture
A just culture depends on: the trust of the workforce
knowing the difference between acceptable andunacceptable behaviour.
A just culture is a culture of accountability, wherepeople know what is expected from them
A just culture ensures that people involved aretreated fairly
8/11/2019 Gent Coach Training March 2004
20/37
SEOP Distribution 30 xxxx2004
Just
culture
Reportingculture
Informedculture
The elements must work in harmony
8/11/2019 Gent Coach Training March 2004
21/37
SEOP Distribution 30 xxxx2004
Errors vs violations?
Should all unintended actions (errors) beexempt from disciplinary action?
Should all deliberate violations bepunished?
Unfortunately, its not as simple asthat.
8/11/2019 Gent Coach Training March 2004
22/37
SEOP Distribution 30 xxxx2004
Scenario 1
A maintainer is assigned to inspect forcracks in an aircrafts fuselage standing onthe tarmac at night.
In accordance with procedures, he/shegets the appropriate work stand and lightsthen carries out a close inspection
Despite this, he/she misses a crack thatcould have seriously endangered theaircraft.
8/11/2019 Gent Coach Training March 2004
23/37
SEOP Distribution 30 xxxx2004
Scenario 2
As before, a maintainer is assigned to check forcracks in the fuselage at night.
This time, however, he/she doesnt bother to
fetch the stand and lights.
He/she merely walks beneath the aircraft using ahand-held flashlight.
Once again, a dangerous crack is missed.
8/11/2019 Gent Coach Training March 2004
24/37
SEOP Distribution 30 xxxx2004
Comparison 1 and 2
Both maintainers committed the same unintendederror: missing the crack.
But, in scenario 2, the maintainers actions madethis error far more likely.
He/she deliberately engaged in behaviour thatsignificantly and unjustifiably increased the risk oferror (recklessness).
8/11/2019 Gent Coach Training March 2004
25/37
SEOP Distribution 30 xxxx2004
Compliance versus non-compliance?
It could be said that the main difference was that oneperson complied with procedures and the other did not.
In other words, the issue of blame could hinge oncompliance or non-compliance.
But even that is too simple. Consider Scenario 3.
8/11/2019 Gent Coach Training March 2004
26/37
SEOP Distribution 30 xxxx2004
Scenario 3
The situation is basically as before.
But this time the maintainer discovers that theproper work stand is broken and there are nostrong lights available.
Pressed for time, the maintainer does a walk-under inspection using a flashlight.
As before, a dangerous crack is missed.
8/11/2019 Gent Coach Training March 2004
27/37
SEOP Distribution 30 xxxx2004
Differences between Scenarios 2 and 3
In Scenario 2, the maintainer deliberatelydecides to short-cut the appropriate procedures
re: work stand and lights.
In Scenario 3, the maintainer is forced to commita situational violation because the appropriate
equipment is either unserviceable or missing.
8/11/2019 Gent Coach Training March 2004
28/37
SEOP Distribution 30 xxxx2004
Where should the line be drawn?
SabotageSubstance abuse
Reckless
violations
System-induced violationsNegligent errors
System-induced errors
etc.
Culpable Blameless
?
8/11/2019 Gent Coach Training March 2004
29/37
SEOP Distribution 30 xxxx2004
Coachable HSSE moments Workshop
Role playSplit up into groups of 4-5 people.
Appoint role players: Person 1, Person 2, ObserversPlay the roles
Feedback from observers
Change the roles for next scenario
General presentation (3 minutes each group)
Scenario 1:
Peter has to visit a construction site with Paul (contractor).
Paul has suggested to use his car for the visit.
When Peter wants to sit down on the passenger seat,
he notices that the seatbelt is broken.Peter gets out of the car and
checks what the problem is.
He is getting aware that it is a very old existing problem,
that was never solved.
What does he say to Paul?
8/11/2019 Gent Coach Training March 2004
30/37
SEOP Distribution 30 xxxx2004SEOP-Distribution
Coachable HSSE moments Workshop
Scenario 2
Yesterday a leak (100 kg diesel) was found in a Production unit.
Investigation shows that Vincent has repaired the pump on his own way and thathe hasnt followed the official procedure.
Vincent is a very experienced mechanic and assumes that his way to carry out the work
is the best.
Six months ago he has discussed his better way with his supervisor Eric and informed
Him that the current procedure is not practical; the proposed alternative procedure
was not examined by Eric.
Now Eric realizes that Vincent way is better and the cause of the leakage is not the
deviation from the official procedure.
Eric meets Vincent.
Scenario 3
John is the supervisor of a team of 4 people. Jim is one of this team and he is very
introvert. Jim has noticed a very dangerous situation and has prevented an accident,that could have happened.
John has congratulated Jim for his initiative and wants to reward him. Jim states that
he has just done his normal work and shouldnt be rewarded (hes also afraid that this
reward will create jealousy in his team).
John meets Jim.
8/11/2019 Gent Coach Training March 2004
31/37
SEOP Distribution 30 xxxx2004
Coachable HSSE moments Workshop
Scenario 4
Jeff is the supervisor of Michael. Michael is the supervisor of a team of 10 people.Peter , one of the team of 5 employees, has a safety performance which is not an
example for others.
Michael has problems to tell Peter that his performance is not acceptable and
he is used not to tell him this.
Jeff has just heard, that Peter could have got serious burns, during taking a sample
this morning.Jeff meets Michael.
8/11/2019 Gent Coach Training March 2004
32/37
SEOP Distribution 30 xxxx2004
Coachable HSSE moments Workshop
Items for the discussion:
What are the problems ?
Is the real problem clear ?
Is the standard clear?
What are the actions to be taken?
8/11/2019 Gent Coach Training March 2004
33/37
SEOP Distribution 30 xxxx2004
*Management/Supervision responsibility to correct route
causes of system issues.
#Time Bound
Were the actions
as intended?
Were the results
as intended?
Sabotage or
Malevolent
Act
Reckless
Violation
System*Induced
Violation
Knowingly Violating
Procedures?
Procedures & Standards
Clear and Workable?
Pass Substitution
Test?
Defective
Training, Selection
Experience
Negligent
Error
System*
Produced
Error
NO NOYES
Verbal Warning
Minimum Bonus
Final Warning Letter
Dismissal
Increasing Individual Culpability
Formal Coaching on Issue
History of Violating
procedures
YESYES
YES
YES
YES
YES
NO
NO
NO
NO
Training required
NOO
NO
Unconsciousviolation
No blame errorInadequate awareness
NOYES
First Warning Letter
No Promotion
Sieze Coachable moment
Just Culture Decision Treefor serious near miss / incident
consider reward proactive reporting
8/11/2019 Gent Coach Training March 2004
34/37
SEOP Distribution 30 xxxx2004
Given the circumstances thatexisted at the time of theevent, could you be sure that
you would not have committedthe same or similar breach or
unsafe act?
The Substitution Test
C h bl HSSE t W k h
8/11/2019 Gent Coach Training March 2004
35/37
SEOP Distribution 30 xxxx2004
Coachable HSSE moments Workshop
Make groups of 4-5 people
Examine following 8 scenarios
Define where you end up in the Just Culture decision treeFeedback (each group different scenario)
8/11/2019 Gent Coach Training March 2004
36/37
SEOP Distribution 30 xxxx2004
Coachable HSSE moments Workshop
Discuss in small groups the steps in the decision tree:
1. A subcontractor (scaffolding company) is erecting a scaffold. A scaffolder has not fixed
the rope of his harness to a fixed part of the construction.
2. A Shell employee is driving inside the plant with a speed of 50 km/hr
3. A driver is exceeding the maximum speed on the right lane as he he is afraid that reducing
the speed will result in dangerous situations (e.g. overtaking vehicles)
2. A crane operator lifts piping over the public road without safety signs and
demarcation.5. A (contractor) mechanic is repairing a pump. He is working without a permit to work
and the electrical isolation has not been carried out.
6. Two employees are working together. One of them is new and does not wear the required
personal protection. The other person is his supervisor, who is wearing the required ppe
and he accepts that his colleague does not wear personal protection equipment.
7. An employee is carrying out a modification according the latest PI&D.sThe PI&D is not up to date. The modification results in a leakage.
8. An operator has to isolate a pump, but because of safety reasons this can not be done
(release vent is at 3 meter high)
8/11/2019 Gent Coach Training March 2004
37/37
SEOP Distribution 30 xxxx2004
Summary
A safe culture is an informed culture: onethat knows where the edge is withoutfalling over it.
An informed culture depends on trust. Theworkforce will not report errors and nearmisses if they are punished for it.
Thus a safe culture depends critically uponbuilding a just culture.
Recommended