Feb 3 Dave Walline - Establishing A Risk Centric Culture PDF

Establish
a Risk Centric Culture

It Starts by Defining an
Acceptable Level of Risk (ALOR)
for the Organization

By:
Dave Walline, CSP – Guest Lecturer
Walline Consulting, Ltd
February 3, 2019
Walline Consulting, Ltd. 1

My Background
•  47-Yr. Safety Career
•  Multiple Industry Work Experience
•  BCSP Certified Safety Professional
•  Global EHS Experience
•  Areas of Focus – Risk Assessment, PtD and Fatal &
Serious Injury Prevention, Leadership Training
•  Inaugural Committee Chair, ASSP Risk Assessment
Institute (2013-2015)

What Goes Right?
LEARN FROM SUCCESS

Everyday Success – Life Savers
(What Goes Right Everyday!)
Capacity to Fail Safe – Do No Harm!
Dead-man switch Elevator safeguards
Air Brakes - Trucks Fusible link
Safety Relief Valve Traffic Signal Light -blinking
GFCI Emergency Lights
Safety Interlocks Back-up Generator
Microwave oven door shut off Garage door sensor
Run flat tires Airbags
Magnetic Switches Anti-Two Blocking device

Level of Acceptability
(Something to Be Achieved)

•  Foresight of Risk – Act in
Advance
•  Presence of capacity to
enable things “to go
right” across varying
conditions.
•  Capacity to fail safe!
•  Manage conditions that
create a positive safety
outcome
•  SUCCESS!
Delivery Truck Mishap – Lessons Learned
TRUE STORY

Some Questions – Yes, Yes, Yes
(It’s All About the Risk!)
Is operating a motor vehicle involve taking a risk?
Can one’s risk level change while driving?
Do you believe you are a safe driver?
Have you ever been involved in a motor vehicle crash?
Have you ever witnessed a motor vehicle crash?
Is driving a delivery truck different than driving a car?
Can you be a safe driver and still be killed on the highway while driving?
Can you drive on a safe highway and still be killed on the highway while driving?
Can you operate a safe truck and still be killed on the highway while driving?
“Routine Truck Delivery”
(CY 2005)
New Delivery Truck
Safe Truck Driver – seat belt worn

2-lane highway – excellent condition
Daylight hours – great visibility
Driver Alert – No distractions, well rested
Driving within speed limit – 55 mph
Oncoming vehicle – crossed center line
Collision Occurred – Fatality Resulted (our driver)

•  Age 28, Married w/3 kids
All Rules and Controls Used – Then How Did This Tragedy Happen?

Post Incident Findings
(Traditional View - MV Safety Program = Safe)
Finding – Other driver fell asleep at the wheel
Actions Taken - Post Incident

• Cared for Family
• New Truck Replacement
• Driver Training
• Lessons Learned Shared
• Reviewed Safe Driving Rules
Focused on the other driver/organization ✔

Warning Signs of a Vulnerable Organization
(Classical Response When Things Go Wrong)
Focus on Worker and the Program
Re-trofit Re-write
Re-primand Re-inforce
Re-engineer Re-port
Re-pair Re-view
Re-train Re-communicate
Re-inspect Re-start

Crashworthiness
SAFETY - Capacity for Failure

(FAIL SAFE)
A 3,200 # car traveling at 30mph (44fps) impacts a solid structure = 96,800pds. (48.4 Tons)
(After Impact front of vehicle collapses 1 foot)

Key Aspect of Risk
(Consequence Matters)
Hazard Aspect - Magnitude of Energy
An 18 Wheeler (loaded Semi) moving at 70mph
hitting a concrete wall equates to a 1-ton Pickup truck
hitting a concrete wall at 300 mph.

A 70 mph crash carriers more than twice (2X)
the energy or precisely (or 306%)
as much energy as a 40 mph crash.

A 70 mph crash has 4X energy as 35 mph crash

Delivery Truck Fatality
(Risk Based View – Vulnerability)
Findings: No Capacity to Fail Safe
•  No Air Bags in Truck
•  At posted Speed Limit:
•  energy magnitude exceeded the safety limits
of the vehicle – head on collisions
•  Take new look at safety (survivable crash)
•  Airbags in Vehicles
•  2 lane highways - speed limit restrictions – 45
mph (max)
Safe? Fail Safe? How Safe?
(Failing Successfully Matters!)
www.safercar.gov
Should We Not Celebrate This Success!
(“Survivable Crash” – A Loved One)
Capacity to Fail Safe

Making’s of A Survivable Crash- SUCCESS
(Predict Failure, Manage Consequences)
Prevention Management Prediction Management Consequence Management
1. Laws, Rules, Programs 1. Distracted Driver 1. Air Bags
2. Licensed Driver 2. Speeding 2. Crumple Zones- Frame
3. Training 3. Brake Failure 3. Seat Belts & Harness
4. Signs, brake lights, etc. 4. Black Ice, dozens more 4. Padded Steering Wheel
and Dash, Safety Glass, etc.
10%
90%
(Traditional Based)
(Risk Based)
100% = Risk Management
(Do we have the capacity to fail safe?) – SUCCESS!
Hazards - Exposures – Controls
WHAT WE KNOW FOR CERTAIN

Hazards/Exposures
(What We Know - Certainty)
•  Hazard – Potential Source of Harm
–  Absence of hazards, there can be no harm
•  Exposure – That which can be harmed
–  Absence of exposure, there can be no harm
•  Hazard is one type of risk
•  Low level controls permit the hazard to exist!
•  Low level controls often permits the exposure
to exist!
Risk
•  A state of uncertainty
•  Chance for harm
•  Effect of uncertainly on objectives (+/-)
•  Combination of the probability of harm and
the severity of that harm
•  Risk Levels Change


Residual Risk
•  Residual risk should be acceptable
–  As judged by the decision-makers
•  “Absolute Safety” Is Not Attainable
–  Some risk will always remain
–  Nothing can be absolutely free of risk
•  ALARP – As Low as Reasonably Practicable

Organizational & System Risk
•  Major risks are Organizational & System based,
not people based
–  Requires consideration at the very top of the
organization
–  Workers can often be sitting on the most valued risk
based information not otherwise privy to others
–  Part of strategic knowledge, planning & decision-
making
–  Done properly, risk-based thinking brings positive
change in many areas – profits, safety,
communications, quality, etc.

Predictive Management – Work As Done
FREQUENCY OF VULNERABILITY

Deviation is the Norm!


Uncertainty (Risk Factors) Induces Failure
(A typical work task)
(Organizational Risk – Variability/Vulnerability)
•  Time Pressures •  PPE Overloading
•  Poor Lighting •  PPE Interferences
•  Poor Work Space •  Fatigue
•  Extreme Temps •  Distractions
•  Adjacent Work Taking
•  High Winds Place
•  Improper Color Coding •  High Noise
•  Color Blindness •  Alarms/Sirens
•  Reptiles, insects •  Personal Health Issues
•  Radio Traffic
•  Working Alone
•  Prescription Meds
•  Damaged Equipment

Stop Work Conditions – Uncertainty
(Barriers to Safe Work)
(Controls Always Deteriorating - Vulnerability)
•  Human Stressors – Previous •  Unauthorized persons enter
Slide electrical hazard boundary
•  Personnel Not Qualified •  Panel doors cannot be secured
in open position
•  Work outside of scope •  Equipment damaged
•  Slippery or damaged work •  Metal dust on panel
surfaces •  Blocked access
•  Trip Hazards •  Missing labels or data
•  Outdated work procedures •  Improper tools
•  No electrical hazard analysis •  Conductive objects found
within electrical hazard
•  Damaged diagnostic boundary
equipment •  Power outages
•  Uncontrolled Hazards ID
Normalization of Deviation!
Accidents Not Accidents
(Words Come First)
•  Culture Change
–  Most accidents are not accidents
–  Leaders “not surprised” by the incident, event
•  The Surprise is failure to plan (decision-
making) for:
–  Known, Common failure modes
–  Magnitude of the Hazard/Energy
–  Capacity to fail safe – SUCCESS
–  Incompatibilities

Incompatibilities – High Risk
(Worker Interviews – YES EVERY TIME!)
Frequency of Vulnerability Data
Hazard Category Source Exposure Majority
Response
(Mismatch) (Ever?)
Fire/Explosion Gasoline Open Flame Burned - Yes
Baseline
1. Electrical Work Energized Parts Conductive Object Shocked - Yes
(Worker)
2. Forklifts FLT Movement Pedestrians Nearly Struck By - Yes
3. Elevated Work Ladder User Fall from Ladder - Yes
4. Confined Space Tank, Manhole, etc. Entrant Alerted by Meter Alarm -
Yes
5. Motor Vehicle Car Driver Crash
Know Someone - Yes
The Context - High Consequence Outcomes
Critical Facts/Information
FSI Prevention Programs!
How Crazy is This!
•  First thing we ask workers to do is remove
primary safeguard or create the hazard:
–  Remove Electrical Panel Cover
–  Remove Access Cover on Confined Space
–  Dig a big hole (trench) to enter it
–  Remove machine guard to make repairs
–  Example -Bring 3 FSI Exposures together
(suspended load, forklift and pedestrian)

Key Point!
•  Frequency of injury:
–  especially for high consequence incidents may be low,
but
•  Frequency of vulnerability is off the charts!
•  Failure Modes related to:
–  Controls – no capacity to withstand failure
–  Organizational Stressors
–  Workplace Stressors
–  Common Errors/Mistakes
•  Key Point - Work takes place in a failure mode
context (conditions, decisions, events) – RISK!
Learn from Failure
(“Prediction Management”)

•  See failure as an opportunity to learn
•  Failure is apart of life
•  Be prepared to have failure or error
•  Failure is what we predict

Failing Successful Matters
•  We cannot prevent all failure, therefore we
must defend and safeguard against it.
•  Fragile systems cannot withstand failure
•  Most systems are normally out of control
•  Manage capacity to fail safe

Failure Simulators
•  Commercial Airline Industry – flight simulators
•  Auto Mftr. Industry – crash testing
•  Product Testing – destructive/non-destructive
•  Earthquake simulators – building designs
•  Nuclear Industry – what-if analysis
•  Military - Ballistic testing
Why Not Work Tasks?

Chief Sustainability Officer
•  “No employee should lose his/her life over a
simple human error or mistake, the same ones
we would all make if given the same
circumstances or events”.
Failing Safe Matters!

(Soft Landing!)

Risk Centric Culture
RISK MATTERS

(Focus on SUCCESS)
•  Work/Process = Some Level of Risk
•  Sense of Vulnerability (Uncertainty)
•  Focus - Capacity to Fail Safe
•  Define ALOR – Acceptable Level of Risk
•  Manage Above the Line

•  See risk equal to the event itself
•  Act on risk, in advance of injury/illness
•  Investigation, RA and PtD – as one system
•  Have an “Exit Strategy” – FSI Exposures
•  Risk Assessment – Core Competency
•  Celebrate “Proven Solution” Implementation

Act on Risk, Not Injury

Big Difference
Uncertainty - Risk Curiosity - ALOR

Safety Statistics
RISK BLINDNESS

USA Today Newspaper ($2.00)
•  Commodity
•  Yesterdays News
•  Not highly valued
•  No action comes
from reading it
•  Information readily
available elsewhere


Safety Statistics
•  Commodity
•  Yesterdays News
•  Not highly valued
•  No action comes from
reading it
•  Information readily
available elsewhere
•  No sense of urgency


I created a Leadership Bias!
•  Low Injury Rates (“STATS”) equaled:
–  Safe
–  Low Risk
–  Effective Controls
–  Almost arrived in safety
–  In Compliance
–  Safety Programs = Safe
–  Safe Work Procedures = Safe

Game Changing Feedback
(Leadership Speak)
•  “We are almost there in safety”
•  “We have arrived in safety”
•  “We have eliminated our major risks, now its
just a matter of getting a remaining few
employees on board”
This Alarmed Me!
I realized I created this Mindset

Mission Control
We Have A PROBLEM!
Organization had:
• An Addiction to the Numbers/Stats

• Organizational Blindness to Risk
• Lost sense of Vulnerability
• Illusion of Control
• Ignorance of the Facts (reality)
• No longer curious – Stopped Questioning!
What Leaders Want
MAKE SAFETY TANGIBLE
(DEFINE SUCCESS)
“See the Zebra”

Leadership Requests?
•  Define what SAFE looks like –
Make it tangible as a Zebra!
•  Provide us with critical
information, not stats
•  Provide us facts to act on in
advance of mishaps/incidents
•  Give us reality in safety
•  Tell us what to do next. We
are waiting for YOUR
direction! – If not YOU, then
who? Me

OSH Professional – Raising our Value
REBRANDING REQUIRED

Value of OSH Pro
(One-On-One Leadership Feedback)
•  Become the Change you want to see in the
organization
•  It’s in the Thinking – forward thinking
•  Build organizational Confidence
•  Critical facts, information – we thrive on this

Gift – Forward Accountability
•  I was empowered to define the future state of
organizational safety going forward
•  I had the capacity to increase my value to the
organization 100 fold
•  I had the opportunity to define what Safe
Work looked like (Risk Based)

New View of OSH Pro
(Rebranding)
Thought Leadership, Change Agent, Value Creator,

Foresight of Risk & Solutions Provider
OSH Pro= Source of Intellectual Property

What Goes Into The Safety Gift Box!
Builds Competency
Critical Information
Act in Advance
Highly Valuable
Make it Tangible
Many Benefits
Builds Confidence
Creates Certainty

Quest for Critical Information
EXPOSE REALITY - VULNERABILITY

Historical Data
(Honor the Injured)
•  Keep historical incident data fresh and
relevant – evidence based!
•  Do not forget the injured or fallen workers
•  Ultimate Safety Sin – Finding wrong solutions
to wrong problem

WHY?
•  Why does it always take a tragedy or serious
injury or illness to learn what is not
acceptable?
•  Reactive thinking and action not acceptable!

Fatal/Serious Incident (FSI) Potential
Organization % Incidents with FSI

Potential
Chevron 28%
DuPont 21%
Alcoa 20%
BST Data 21% (10-36% range)
ORC/MERCER 20% (12-37% range)
Global Organizations 20-50%
One in Five Incidents (mishaps) have potential to be Life Ending or Life Altering!

Key Findings – Risk Based Incident Analysis
(Top 10 – Risk-Based Events/Situations)
(400+ Mishaps) – Realistic View on State of Safety
Key Findings % (Percentage)
No Risk Assessment (RA) or Gaps in RA (Risk Not Seen In Work) 95%
Hazard controls did not match the level of risk in the work 90% (1)
Multiple risk factors/hazards present at same time 90%
High Energy Present (Gravity, Thermal, Vehicle, Mechanical) 80% (2)
Abnormal Conditions & Situations elevated risk in work 70%
Worker(s) directly interfacing with hazard(s) 65% (3)
Errors and failures induced by human factor stressors – 65%
(e.g. fatigue, high noise, poor work space, extreme ambient
conditions, exceed physical capabilities, etc.)
Work methods outdated, not valued, not available or “risky” 60%
Design Related Gaps 37% (4)
Tools & Ladders 25%
(1)  - Above the Line Controls Installed Post Incident

(2)  - Fatal Prevention Programs Required
(3)  - Powered Machinery, Mobile Equipment & Heavy load/object
(4) - 43% for FSI Potential Events Walline Consulting, Ltd. 56
Success Rating of Controls
CONSEQUENCE MANAGEMENT

Hierarchy of Controls (Seek Above the Line Controls)
Note: Every control has a success rating!
Priority Hazard Control Effectiveness Long Term Influence on Risk (B11.0) Examples
Control Burden
Costs
Most Risk Avoidance 100% - Prevents Hazards None Prevent Entry of Hazards No Confined Spaces
into workplace No Elevated Work
Preferred No Risk No Forklift Traffic
No Portable Ladders
Elimination 100% - Hazard Removed None Eliminate Hazard Design Space For Human
Occupancy,
Design Out Need For Entry,
Move elevated work to ground level
Substitution Very High – if hazard/exposure Low Severity & Replace flammable acetone with
eliminated Probability water based solvent,
Substitute manual handling system
(human interaction) with automated
handling system (no human
interaction)
Engineering High – System Control Limited Minimal Impact on Severity, Passive Control: Interlocked
Controls (Passive Controls Impact on Probability Ventilation, Safety railings, Presence
Preferred over Sensing Devices
Active Controls) Active Control:
Local Electrical Disconnect, Portable
Lift Assist
Warning Systems Moderate - People Control Moderate No Severity Impact, Strobes, Beacons, Signs, Labels,
Partial Impact on Probability Horns, Sirens, Back-Up Alarms
Administrative Controls Limited - Soft Control High No Impact on Severity, Written Procedures, Training, Audits,
(Training, Procedures, etc.) Partial Impact on Probability Supervision, Permit Systems,
Inspections, Buddy Systems
Least
Personal Protective Very Low Major No Impact on Severity, Safety Glasses, Face Shields, Work
Preferred Equipment (PPE) Partial Impact on Probability Gloves, Hearing Protection,
Respiratory Protection, Voltage Rated
Walline Consulting, Ltd. Gloves, Safety Footwear 58

Risk Based Incident Analysis
One of the most PRO-ACTIVE Measures
you can take!

It will reveal what you don’t know today and
need to know to act on tomorrow.

“Exposes New Reality”

What’s Acceptable?
SEE RISK IN WORK

Does This Statement Make Sense?
Stop any work that

places you or others
at an unacceptable
level of risk!
What is Unacceptable Risk?
We first have to
define acceptable risk,
then everything else
becomes
unacceptable

Risk Perception
•  Everyone has their own risk thermostat
•  Risk perception decreases the closer you get
to the work
•  Risk becomes (more acceptable) closer to the
work/danger
•  Risk perception changes with levels of
information

ALL WORK TASKS – Act on Risk, Not Injury
(Making Safety Tangible - SUCCESS)
(Evidence Based)
TO ACHEIVE “ACCEPTABLE LEVEL OF RISK” (ALOR)
DOCUMENTED RISK ASSESSMENT (RA)
(readily available and kept current)
HAZARD CONTROLS ARE APPROPRIATE FOR THE RISK
(Above the Line Controls – Documented Exception Rule)
EXPOSED WORKERS ARE TRAINED & COMPETENT
HAZARD CONTROLS ARE BEING MAINTAINED
STOP WORK CONDITIONS
When Faced with Uncertainty (Uncontrolled Hazards/Risk)
ALL HAZARD CONTROLS INSPECTED & USED
WORKERS - CONTINUOUS IMPUT & FEEDBACK
(Hazards, Failure Modes, Control Effectiveness)
Can be verified, measured and acted upon 64

Hierarchy of Controls (Seek Above the Line Controls)
Huge Gap Seen in Understanding HOC
Priority Hazard Control Effectiveness Long Term Influence on Risk (B11.0) Examples
Control Burden
Costs
Most Risk Avoidance 100% - Prevents Hazards None Prevent Entry of Hazards No Confined Spaces
Preferred Start into workplace
No Risk
No Elevated Work
No Forklift Traffic
Here No Portable Ladders
Elimination 100% - Hazard Removed None Eliminate Hazard Design Space For Human
Occupancy,
Design Out Need For Entry,
Move elevated work to ground level
Substitution Very High – if hazard/exposure Low Severity & Replace flammable acetone with
eliminated Probability water based solvent,
Substitute manual handling system
(human interaction) with automated
handling system (no human
interaction)
Engineering High – System Control Limited Minimal Impact on Severity, Passive Control: Interlocked
Controls (Passive Controls Impact on Probability Ventilation, Safety railings, Presence
Preferred over Sensing Devices
Active Controls) Active Control:
Local Electrical Disconnect, Portable
Lift Assist
Warning Systems Moderate - People Control Moderate No Severity Impact, Strobes, Beacons, Signs, Labels,
Partial Impact on Probability Horns, Sirens, Back-Up Alarms
Administrative Controls Limited - Soft Control High No Impact on Severity, Written Procedures, Training, Audits,
(Training, Procedures, etc.) Partial Impact on Probability Supervision, Permit Systems,
Inspections, Buddy Systems
Least
Personal Protective Very Low Major No Impact on Severity, Safety Glasses, Face Shields, Work
Preferred Equipment (PPE) Partial Impact on Probability Gloves, Hearing Protection,
Respiratory Protection, Voltage Rated
Walline Consulting, Ltd. Gloves, Safety Footwear 65

Manage Above the Line
•  Higher level controls brings reliability to the
organization
•  Reliability is the ability to succeed under
varying situations and circumstances
•  Has direct impact on energy/severity of harm
levels

Pocket Cards
(Prove Me Wrong)
•  Acceptable Level Of Control •  Safe Work- Tangible
Expose Reality, New Thinking, Act in Advance, Critical Information

Push on Controls
(When things go right - capacity to fail safe)
Energy & CONTROLS

Failure Modes Level of Success
Consequence Matters!
Show Me the Zebra!
•  SAFE WORK - Tangible •  Return Home to Your Family
My Forward Accountability
(CHANGE AGENT)

“RCO” - Risk Competency
(Highly Valued Skill Set)
•  Leadership – Champions
•  Site Managers/Leaders – Enablers
•  Risk Assessors – Certified
•  Risk Assessor Trainers - Certified

Above the Line Controls
•  Certified Risk Assessor to Verify Control Effectiveness
•  Acceptable Level of Risk Achieved
•  Any Exception – Certified Assessor Approval
•  Acceptable Risk may be:

–  Very High Risk, or
–  High Risk

Integration Required
New View – See them all as One!
INV RA PtD Prevention

Risk Centric
Organization
Incident Investigation Risk Assessment
through
Design
Risk Aspect Findings - Gaps found in one system will show up in the others as well!

Portable Ladder Use – Lessons Learned About Failure
TRUE STORY

Falls from Portable Ladders
•  There are no fall from portable ladder
accidents! – No Surprises!
•  What we have is no capacity to fail safe!
•  The critical facts point this out
•  Falling from a portable ladder should be an
anticipated event!
•  What we have are “incompatibility” events

Portable Ladder Story
(Critical Information – Reality)
•  200# person falls:
–  6 feet – 2,400# impact force
–  9 feet – 3,600# impact force Magnitude of Energy!
–  16 feet – 6,400# impact force
•  OSHA – Top 10 Most Violated
•  Last Decade – 43% Workplace Fatal Falls
•  Every Ladder User – Has a fall from ladder story
•  Ladder mishaps have increased by 50%
•  Ladder Safety Program ≠ Safe
•  No capacity to fail safe!
•  25+ Failure Modes Identified (Vulnerability)
•  High Burden Costs

Culture – Portable Ladders
Compliance Based Thinking Risk Based Thinking
(Ladder Safety Program ≠ Safe) (Exit Strategy)
•  Ladder User Training •  No Portable Ladders
•  Ladder User Rules •  No Capacity to Fail Safe
•  Ladder Specifications •  Portable Ladder Exit
•  Ladder Inspections Strategy
•  Ladder User Observations •  Design out portable ladder
•  Ladder Storage Practices use
•  Ladder Selection •  Proven Solutions to
Eliminate Ladder Use
•  Elimination of burden costs

Safety Programs
(Long -Term Burden Costs)
New Reality!
People
Equipment Methods
Training Purchase Scheduling/Planning
Buddy Systems Rental Written Program
PPE Repair/Maintain Safe Work Procedures
Supervision Clean Audits/Inspection
Injuries Retrofit Permits
Claims Storage Observations
Citations-Penalties Transport Device Investigations
Complexity and Uncertainty
All Weak Signals!

Manage Above the Line
(To Achieve ALOR)
•  2 years – all portable ladder tasks will be
identified & eliminated within the company
•  All new designs/redesigns will not permit
portable ladder use – Avoidance!
•  Proven Solutions will be identified and shared
•  Portable Ladder Burden Costs - eliminated
What SUCCESS Looks like

No Ladder Work - Proven Solution
79
(No Fall Hazard = No Harm)
Stop Something Old Start Something New
What
Else Do
You See?
Walline Consulting, Ltd.

“More Than 1 in Red, Your Dead”
(Frequency of Vulnerability Data)
Incompatibility Not Acceptable
Pedestrian
(Shipping Yard)
No Exposure to FSI Level Energy!
(ALOR) Yard
Tractors
Powered
Fork Lift
Trucks
NO EXPOSURE = NO HARM
(“NO HARM DECISION-MAKING”)

Confined Space Entry – Lessons Learned About Failure
TRUE STORY

Confined Space Entry – “Risk Profile”
•  300 Entry Supervisors - 15 Countries
–  Daily to Six Month Task
–  “Fully Competent” to “Not Competent”
–  Different Languages & Cultures
•  100 - 150 Entry Permits Issued Monthly
•  2,000 Permitted Spaces
•  Have All The Programs (The Stuff)
–  þ
“Critical Facts”

Confined Space Entry Work
(Leaders Want Reality) – Risk Profile
(Capacity to Fail Safe?)
•  Turnover •  Critical controls not
•  Manpower issues maintained
•  Loss of job competency •  Lack of resources
•  Budget cuts •  Controls ≠ Risk
•  Unauthorized changes •  Time Constraints
•  Acceptable deviations •  Growing Complexity
•  Short cuts – out of •  No confidence
sequence •  Job Scope Creep
•  Don’t see risk in work •  Incompatibility
•  No critical facts •  “Stop” – not valued
Organizational and System Risk - Vulnerability
CSE Supervisor Feedback – Context
(Risk Factors) – 90% Responses – Not Acceptable
Question Yes No
Competent in CSE Supervisor Role? X
Do You Know What a SAFE Entry Looks Like? X
Are You Confident in Your CSE Supervisor Role? X
Is this full time job? X
Have you experienced near miss events in CSE Work? X
Do you like performing this job duty? X
Do you view CSE high risk work? X
Do you know conditions that would trigger STOP Work? X
Do you have concerns or fears about stopping work? X
Does this activity place you into direct conflict with your boss’s X
performance expectations?
“Critical Risk Based Information”

300 Entry Supervisors! (No Confidence or Competence)
Key Learning’s – Risk Factors
(High Degree of Vulnerability is Common)
•  Permitting Process:
–  Identified 85 Common Failure Modes – WOW!
–  Observed or identified 5 + risk factors per entry
•  It’s the weak signals (risk in work) that can
lead to catastrophes

Not Acceptable?

Confined Spaces – New View
–  “Exit strategy” to get out of confined space entry
tasks.
–  Examples – (2 years) – Manage Above the Line!
•  10% of spaces – work performed outside space
•  10% of spaces - redesigned for human occupancy
•  New designs – Just Say No!

Proven Solutions grow out of this New Thinking!

Design above the Line
PREVENTION THROUGH DESIGN

New China Plant Site - 2009

New China Plant - 2011
Risk Based Design Safety Review Avoidance Examples

•  No Portable Ladders
•  No Forklift Trucks in
Production Areas
•  No Elevated Piping system
isolation valves
•  No manual handling or lifting
of production product (45
pounds)
•  No Energized Work – Energy
Isolation
•  No restricted or congested
work spaces

Risk Based Metrics
MEASURE WHAT MATTERS

Impact Metrics – Examples
(Sustainable Risk Reduction)
•  % Fatal/Serious Incident (FSI) Rate
•  Risk Competency:
–  Certified Trainers
–  Certified Risk Assessors
•  Top 5 Risks – Turnover Rate
•  FSI Risk Scorecard – Exit Strategy
•  Heat Map – Risk Category Rating
•  Burden Costs eliminated

Heat Map – 100 Tasks – Example
(RISK = Event)
Risk Assessment Findings Risk Category
(Evaluated Tasks)
Using “ZEBRA” Method
5 UR - STOP
20 VHR - Urgent 50% (1)
25 HR – 60 Days
35 MR
15 LR
Risk Profile of Work Activities

(Single Location)
(1)  – Controls not effective, Failure Modes Not ID, High Energy Present
50% of Work Tasks Do Not Meet the Zebra Test

SUCCESS Scorecard – Examples
(FSI Prevention – Exit Strategy)
Corporate Sustainability – Above the Line
•  1 Year
–  100% - Eliminate Energized Work
–  100% - Eliminate Phone Use while driving
•  2 Years
–  100% - Eliminate Portable Ladders
–  20% - Eliminate - Confined Space Entry
•  3 Years
–  25% - Eliminate exposure to energized parts -
diagnostics
–  50% - Eliminate Forklift/Pedestrian Interface
Moving Forward
COURAGE TO CHANGE

Change Agent
Organizational Courage to Act On Risk Not Injury!
•  Predict the Future – Foresight of Risk

–  No surprise – no accident!
–  Fail Safe
•  The secret is seeing and acting in advance!
–  Act on risk, not event
–  See risk = to the event itself
Never Forgetting the 400!

New Language & Expectations
(Become the Change!)
•  Words Come First:
–  Above the Line Controls
–  Acceptable Level of Risk
–  Capacity to Fail Safe
–  Burden Cost Reduction
•  Expectations:
–  See and Act on Risk
–  Exit Strategy
–  Risk Competency
–  Proven Solutions

CELEBRATION!
•  How are you communicating when your
leaders and employees act on risk in advance
of incidents, and:
–  Nothing Happens?
–  No Injury Statistics?
A GAME CHANGER!

How Do Safety Pro’s Greatly Enhance Their Value?
(Safety Leadership)

1  Define Acceptable Level of Risk (ALOR) for Organization
Make it Tangible, only then can unacceptable risk be acted upon
2  Provide Risk Based Critical Facts/Information to
Leadership
Act on Risk, Not Injury – foresight of risk
Strong sense of vulnerability/weak signals (uncertainty)
3  Focus on Predictive and Consequence Management
(90%)
Predict failure, fail safe systems and work
4  Build Confidence (SUCCESS) within your organization
See it, Manage it, Act on it and Measure it
5  Provide Proven Solutions – Above the line controls
Fault Tolerant, consequence management (reduce severity of harm
potential)

Forward Accountability
(Very Empowering!)
•  Own the future – Become the Change
•  Define the Future – Make it Tangible
•  Set the Bar – Level of Acceptability
•  Be the Doctor, not patient
•  Proven Solutions, Exit Strategy
•  Be fully at stake! - Please, prove me wrong!
•  Be Creator of Critical Information
•  Build Organizational Confidence to
–  Act on the risk, not injury/illness
My View of Safety!
“An organizations safety performance will

only advance at the pace the OSH Pro leads
the change. If not us, then who”?

Dave Walline, CSP
Our Leaders Are Waiting on US!

Rest of the Story – CEO/COB

Thank You
Dave Walline, CSP
Walline Consulting, Ltd.
Port St. Lucie, FL
David_walline@yahoo.com
(419)-215-7987

Feb 3 Dave Walline - Establishing A Risk Centric Culture PDF

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Feb 3 Dave Walline - Establishing A Risk Centric Culture PDF

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Establish

a Risk Centric Culture

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Air Brakes - Trucks Fusible link

Safety Relief Valve Traffic Signal Light -blinking

GFCI Emergency Lights

Safety Interlocks Back-up Generator

Microwave oven door shut off Garage door sensor

Run flat tires Airbags

Magnetic Switches Anti-Two Blocking device

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Can one’s risk level change while driving?

Do you believe you are a safe driver?

Have you ever been involved in a motor vehicle crash?

Have you ever witnessed a motor vehicle crash?

Is driving a delivery truck different than driving a car?

Safe Truck Driver – seat belt worn

Daylight hours – great visibility

Driver Alert – No distractions, well rested

Driving within speed limit – 55 mph

Oncoming vehicle – crossed center line

Collision Occurred – Fatality Resulted (our driver)

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Finding – Other driver fell asleep at the wheel

Actions Taken - Post Incident

Focused on the other driver/organization ✔

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SAFETY - Capacity for Failure

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Capacity to Fail Safe

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WHAT WE KNOW FOR CERTAIN

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Why Not Work Tasks?

Failing Safe Matters!

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• An Addiction to the Numbers/Stats

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• An Addiction to the Numbers/Stats

(1)  - Above the Line Controls Installed Post Incident

•  Acceptable Risk may be:

•  Predict the Future – Foresight of Risk