Mind the Gap. Ian Travers Process Safety Consultant IAN TRAVERS LTD. PROCESS SAFETY CONSULTANCY

Transcription

1 Mind the Gap LEARNING FROM 30 YEARS IN MAJOR HAZARD RISK CONTROL Ian Travers Process Safety Consultant

2 What goes wrong? You are designing for people the way you would like them to be, not for the way they really are. Don Norman, The Psychopathology of Everyday Things People do safety not systems or technology, And, people undo safety just as effectively.

3 Why did it happen to us? The most repeated responses from CEOs and Directors following a major accident. Safety is our number 1 priority we always put safety first I just don t understand how it could happen No one every mentioned we had a problem We have professional safety experts We never skimp on safety We have extensive systems and procedures HSE has regulated us for years and we have never had anything serious wrong We have a comprehensive safety report scrutinised by HSE We have never had an incident before

4 The Challenge

5 Solution process safety management?

6 Process Safety Leadership Challenge What you need to know and understand you can t see. Sometimes the concepts of process safety seem like quantum physics: (you have heard about it, know its complicated but you couldn t explain it to a someone else) Risk has been transformed into equations & numbers: likelihood of 10-6 / year Safety Integrity level 3 Initiating event x likelihood x consequences Giving risk a precise numerical value seems to make it less intangible and acceptable If you are uncertain about risk management you are probably reluctant to ask You probably want simple answers on complex issues

7 Process Safety Leadership Challenge Every decision you make affects safety Do you understand how? Do you take process safety and risk management into consideration when making corporate decisions?

8 Perfection vs Reality Despite: Your best endeavours Meeting legal responsibilities Putting safety first Engaging, influencing & promoting Investing and resourcing Checking & monitoring.. From day 1 systems deteriorate

9 How do things fail? Nicely: Predictably Steadily According to engineering calculations and design lives Provide early warning of failure Allow for recovery Unhelpfully: Erratically Without warning or previous mal-function Early Allowing for no recovery

10 How do People Fail? Unhelpfully: Erratically Without warning or previous mal-function Early Allowing for no recovery

11 People do safety not systems or technology, And, people undo safety just as effectively. Understand human error mechanisms Identify critical tasks and vulnerability Set out and explain what is important and why Engage the workforce in the development of controls Capture the hazards and risk profile Measure human performance

12 So what can you do? Learn from others doesn t really work! Hope it never happens too late Try to get deep into the complexity of risk

13 So what can you do? Focus on what really matters in process safety Get good and meaningful information on performance (of people) Play close attention to what gets raised Engage and go and talk risk reality but most of all listen Be afraid Don t get complacent If you don t understand ask and then ask again Never assume or hope things are right get positive confirmation Remember failure is not a linear process

14 So what can you do? Ask the 49 questions Share your answers Agree on what s important Keep running up the down escalator

15 Engage, Talk Risk Reality and Listen Engage and go and talk risk reality : What shortcuts do people take? What do they find confusing? What do they find conflicting? What could be improved? What s gone wrong recently but has not been reported?

16 Focus on what really matters How could it go catastrophically wrong? Where / when will most likely go wrong? What controls or systems are there to prevent a major incident? Which of these controls are most vulnerable to failure? What information do you have to show those systems continue to operate to the desired performance standard?

17 Thank You Questions? Ian Travers Process Safety Consultant