making business & safety even better: ‘learning from weak ... · and occupational safety....
TRANSCRIPT
Professional Incident Investigation
Making Business & Safety Even Better:
‘Learning from Weak Signals’
Brian McConnell, CEO / Finance Director
George Dyer-Wilson, Global Business Development Manager
Professional Incident Investigation
Kelvin TOP-SET Background
• Improving Incident Investigation Globally
• Investigations
• Training
• Business Improvement
Professional Incident Investigation
What to expect:
• What is a ‘Weak Signal?
• Developing ‘Structured Curiosity’
• Using TOP-SET Indicators to Identify Weak Signals
• The Concept of ‘Organisational Rust’
• Weak Signals during Investigations
• Communication & Sharing Lessons Learned
• Business Improvement
Professional Incident Investigation
What are Weak Signals?
• Indicators of larger problems
• Something out of the ordinary
• Intuition
• What’s Changed?
Professional Incident Investigation
Weak signals example
Professional Incident Investigation
Weak Signals and Indicators
Professional Incident Investigation
Explosives Industry
With explosives, weak
signals can quickly turn to
disaster.
Professional Incident Investigation
Reliance on Procedures
What did the weak signals show us during this investigation?
Someone was killed, but picking up on the ‘weak signals’ could have prevented this.
False belief that
that paper based
rules were
followed…
Not the case.
Professional Incident Investigation
The importance of first impressions
Professional Incident Investigation
Looking at general conditions
Professional Incident Investigation
Looking at general conditions
Professional Incident Investigation
How many indicators?
Rule of
Professional Incident Investigation
Prediction through weak signals
Professional Incident Investigation
Professional Incident Investigation
Thinking in Investigations
15
First – Open Thinking
PLANNING &
INVESTIGATION
Then – Focused Thinking
ANALYSIS
Professional Incident Investigation
Structured Curiosity
• Tripod / TOP-SET Iterative Approach
• Testing Observation / Theories
• Looking outside comfort zones
Professional Incident Investigation
Using TOP-SET Indicators
Professional Incident Investigation
Professional Incident Investigation
Organisational Rust
Professional Incident Investigation
Organisational Rust ©
Operating as designed with all controls in place
DANGER ZONE
Even slight changes can lead to incidents.
Drifting from safe standards
Professional Incident Investigation
Top Eight Examples of Causes 1. Failure of management and or supervisors to walk about and
effectively engage and intervene
2. Going beyond the authority of the permits
3. Working to perceived time pressures
4. Failure to take responsibility
5. Communication failures
6. Errors and violations
7. Not stopping the job
8. Shortcuts.
Professional Incident Investigation
Communication and Sharing Lessons Learned
Professional Incident Investigation
Business Improvement
• Weak Signals are everywhere
• Everyone’s job to look out for them
• Take action
• Share / Communicate
• Evolve processes
Professional Incident Investigation
‘What Can You Do?’
Never forget that a safe workplace requires that
everyone in the facility pay attention to BOTH process
and occupational safety.
Recognize that safety culture and attitude, operating
discipline, safe working practices, and other elements
of a good safety programme are essential to success in
both process and occupational safety...
Professional Incident Investigation
Understand your plant’s process safety AND occupational
safety programmes and your role in making them
successful.
Actively participate in all of your plant’s safety activities
and encourage your co-workers to participate as well.
AIChE March 2014
Professional Incident Investigation
Questions?