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Health and Safety Executive
© Crown Copyright, HSE 2016 HSL: HSE’s Health and Safety Laboratory
Mindful Leadership in Technical Safety
Rosemary Whitbread
HSL: HSE’s Health and Safety Laboratory © Crown Copyright, HSE 2016 © Crown Copyright, HSE 2016
Developing collective mindfulness
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“A company whose employees were all individually
mindful of risks would be a dream come true for
many employers. Mindfulness at the individual level
is arguably the ultimate goal. But …individuals will
only be mindful if there are processes of
mindfulness at the organisational level.”
(Hopkins, 2002)
Developing collective mindfulness
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Safety Culture
• What is safety culture?
• Why should/do organisations care about it?
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A three aspect approach to safety culture
Safety Culture “The product of individual and group values, attitudes, perceptions, competencies and
patterns of behaviour that can determine the commitment to, and the style and
proficiency of an organisation’s health and safety management system”.
ACSNI Human Factors Study Group, HSC (1993)
(Based upon Cooper 2000, HSE RR 367)
Psychological Aspects
‘How people feel’ Can be described as the
‘safety climate’ of the
organisation, which is
concerned with individual
and group values, attitudes
and perceptions.
Behavioural
Aspects
‘What people do’ Safety-related
actions and
behaviours
Situational Aspects
‘What the organisation
has’ Policies, procedures,
regulation,
organisational structures,
and the management
systems
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ASCENT: A framework for safety culture excellence
Focus groups
Interventions
SMART action plans
Intervention impact
evaluation
Senior management commitment
Project plan
Steering group
Communication strategy Foundation
Focus
Interviews Workshops
Act
Evaluate
Process evaluation
Data analysis
Analyse
Leading indicators
Lagging indicators
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Leadership
Demonstrated senior
management
commitment and
involvement are vital for
successful health and
safety performance.
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Role and responsibilities of leaders
• Stated in regulatory UK legal systems and guidance: – Hazardous Installations Directorate (HID)
Regulatory Model: Safety Management in Major Hazard Industries (2012/13)
– HSG254: Developing process safety indicators: A step-by-step guide for chemical and major hazard industries
• Other: Corporate Governance for Process Safety: Organisation for Economic Co-operation & Development (OECD) guidance for Senior Leaders in High Hazard Industries.
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Motivating and
developing
individuals
Upholding group
unity
Manage group
task to achieve
progress and
results
Leadership four dimensions
Shared purpose
Scouller, 2011
Too often most of the effort is on this
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Leadership styles
• Why is it important?
•Transformational (lead to worker participation)
•Transactional (lead to worker compliance)
•Other theories:
•Authentic; Resonant; Servant leadership
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Transformational leadership defined
• Idealised influence: articulate a vision; act as role models; inspiring trust and respect
• Intellectual stimulation: challenge assumptions and traditional ways of doing things, invite new ideas
• Inspirational motivation: articulate a clear vision that people can aspire to and seek to attain
• Individualised consideration: attention to people needs and development; create a supportive climate promoting learning opportunities
(Bass and Avolio, 1990)
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Transactional leadership defined
• Contingent reward: Leader agrees with workers the tasks to be completed and clearly articulates performance expectations in exchange for rewards
• Management by exception – active: actively monitor people behaviour to ensure it complies with expected standards of performance and intervene before problems arise
• Management by exception – passive: intervene only after problems have occurred.
Different from Laissez-faire leadership: Complete avoidance of responsibilities whereby the leader avoids making decisions, ignores people problems or needs and provides neither feedback nor rewards.
(Bass and Avolio, 1990)
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Team leaders safety leadership predicting safety performance
Griffin et al 2013 Safety Science
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What did workers report doing ?
Safety participation: I put in extra effort to improve the safety of the workplace
I help my co-workers when they are working under risky or hazardous
conditions
I voluntarily carry out tasks or activities that help improve workplace safety
Safety compliance: I carry out work in a safe manner
I use all necessary safety equipment to do my job
I use the correct safety procedures for carrying out my job
I ensure the highest level of safety when I carry out my job
Griffin et al 2013 Safety Science
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What did workers see the leader doing?
Safety inspiring: My team leader…
Places a high personal value on the team’s safety
Inspires team members to support safety at work
Presents a positive vision of safety for the team
Safety monitoring: My team leader…
Is alert to safety behaviour in the team
Scans the environment for unsafe actions by the team
Lets me know if I am working unsafely
Safety learning: My team leader…
Encourages new ways of thinking about safety
Sees unsafe behaviour as an opportunity for learning Griffin et al 2013 Safety Science
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The effects of transformational leadership on
employees’ absenteeism in four UK public sector
organisations. Mellor, N. et al., 2009
RR846 Research Report – HSE. (www.hse.gov.uk)
A review of the literature on effective leadership
behaviours for safety. Lekka, C. & Healey, N. 2012
RR952 Research Report – HSE. (www.hse.gov.uk)
HSL research on leadership
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Risk Appetite v Risk Tolerance
• Risk Appetite – the pursuit of risk (taking risks)
• Risk Tolerance – what risk the organisation is able to deal with (exercise control)
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Risk
Concepts
“Risk Assessment can be like the captured spy:
if you torture it long enough it will tell you
anything you want to know.”
W.D. Ruckelshaus, 1st Administrator of US EPA, 1984
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Risk Management Process
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TOR and ALARP
Establish Context
Incr
easi
ng
ind
ivid
ua
l ris
ks a
nd
so
ciet
al c
on
cern
s
Unacceptable region
Tolerable Region (if ALARP)
Broadly acceptable region
Intolerable risk
Broadly acceptable risk
TOR = Tolerability Of Risk ALARP = As Low As Reasonably Practicable
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TOR and ALARP
Establish Context
Incr
easi
ng
ind
ivid
ua
l ris
ks a
nd
so
ciet
al c
on
cern
s
Unacceptable region
Tolerable Region (if ALARP)
Broadly acceptable region
Intolerable risk
Broadly acceptable risk
TOR = Tolerability Of Risk ALARP = As Low As Reasonably Practicable
risk = likelihood × consequence
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Assessing risk
Establish Context
Like
liho
od
Very High
High
Medium
Low
Very Low
Minimal Appreciable Major Severe Catastrophic
Consequence
risk = likelihood × consequence
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Business Risk Dimensions
Establish Context HSL Business risks
Failure to deliver
business as usual Failure to
deliver long term
strategy
Financial
Health and Safety
Legal and Compliance
Reputation
Security
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Minor?
Security Reputation Legal and
Compliance Financial
Failure to deliver long
term strategy
Failure to deliver
business as usual
Health and Safety
Assessing TOR
Establish Context
Major?
Severe?
Catastrophic?
Appreciable?
Chance? Likelihood? Frequency?
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Assessing risk
Establish Context
Like
liho
od
Very High
High
Medium
Low
Very Low
Minimal Appreciable Major Severe Catastrophic
Consequence
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Assessing risk
Establish Context
Like
liho
od
Very High
High
Medium
Low
Very Low
Minimal Appreciable Major Severe Catastrophic
Consequence
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Application and governance
Establish Context
Business risks
Risk dimensions
Family A Family B Family C Family D
Family E Family F Family G Family H
Business risk families
Senior managers
Board level
Workforce
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Business risk families
Identify Risks
Business risk family A
Business as usual Long term strategy Health and Safety Financial
Legal and Compliance Reputation Security
e.g. Supporting the HSE mission
A
A
A
A
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Analysing business risks
Analyse Risks
Supporting the HSE mission
UK business
Worldwide business
Infrastructure & Asset management
Capability
Health and Safety
HSL Risk Families HSL Risk Dimension
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Organisational risk evaluation
Evaluate Risks
Like
liho
od
V High
High
Med A
Low
V Low
Min Appr Maj Sevr Cat
Consequence
Like
liho
od
V High
High
Med B
Low
V Low
Min Appr Maj Sevr Cat
Consequence
Like
liho
od
V High
High C
Med
Low
V Low
Min Appr Maj Sevr Cat
Consequence
Risk Families
A
B
C Li
kelih
oo
d
V High
High C
Med A B
Low
V Low
Min Appr Maj Sevr Cat
Consequence
Risk Dimension
Risk Dimension 1: close to ‘intolerable’
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Organisational risk evaluation
Evaluate Risks
Like
liho
od
V High
High
Med
Low A
V Low
Min Appr Maj Sevr Cat
Consequence
Like
liho
od
V High
High
Med B
Low
V Low
Min Appr Maj Sevr Cat
Consequence
Like
liho
od
V High
High
Med C
Low
V Low
Min Appr Maj Sevr Cat
Consequence
Risk Families
A
B
C Li
kelih
oo
d
V High
High
Med B C
Low A
V Low
Min Appr Maj Sevr Cat
Consequence
Risk Dimension
Risk Dimension 2: ‘broadly acceptable’
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Risk management and register
Controlling risks
Business risks
Risk dimensions
Family A Family B Family C Family D
Family E Family F Family G Family H
Business risk families
Senior managers
Board level
Workforce
Risk register
Risk management
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ASCENT: Analyse
Focus groups
Interventions
SMART action plans
Intervention impact
evaluation
Senior management commitment
Project plan
Steering group
Communication strategy Foundation
Focus
Interviews Workshops
Act
Evaluate
Process evaluation
Data analysis
Analyse
Leading indicators
Lagging indicators
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Key Performance Indicators
• Managing process safety requires a systematic approach
• KPIs can help measure process safety (and other) performance, aid decision making, and thus proactively prevent problems from occurring
• How KPIs change with time can provide more sophisticated management information by helping you anticipate the future
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Key Performance Indicators (continued)
• Provides senior management, the regulator and the public with assurance of industry’s safety performance and management
• Provide an early warning that critical safeguards have deteriorated or will deteriorate so timely actions/decisions can be taken to drive change
• Enable planning of resources
• Enable benchmarking, both within and between comparable sites
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Key Performance Indicators (continued)
• Reactive Lagging Indicators – recording consequences • Loss of containment incident rate • Vessel/pipe degradation % metal loss • Numbers of high level alarms activated
• Proactive Leading Indicators – strength of barriers • Safety training percent complete • Isolations completed to required standard • % of alarm systems inspected/maintained to schedule
• KPIs often split into: • People • Process • Plant Integrity
• KPIs needed for different management levels
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Guidance – lots!!!
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Reason’s “Swiss cheese” model of accident causation
Some holes due
to active failures
Other holes due to
latent conditions
Hazards
Losses
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Six steps to KPIs: HSG 254
STEP 1:
Establish KPI team
and support
STEP 2:
Decide what can go
wrong and where
STEP 3:
Set lagging indicators
STEP 4:
Set leading indicators
STEP 5:
Establish data collecting
and reporting system
STEP 6:
Use – and Review!
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What we have learnt since HSG 254 was first published in 2005?
• Major accidents continue to occur
• Inquiries repeatedly point to failings in Process Safety Management and Leadership that could have been detected by an effective KPI programme
• The case for having KPIs has never been clearer or stronger
• But, many organisations are still having difficulty in implementing KPIs
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So what’s the problem?
• Poor understanding of factors that need to be taken into account when establishing a KPI programme
• Absence of effective leadership to drive forward a KPI programme
• Over emphasis on the difference between leading & lagging indicators to the detriment of acting on information
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So what’s the problem?
• Seeking a quick solution or simplistic measure of major hazard risk
• A need for a better understanding of the difference between Sector Indicators and site-based indicators
• An over focus on benchmarking
• Demand for absolute proof that KPIs reduce the risk of a major accident
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Factors to take into account
• Engagement with the workforce
• The need for everyone to understand and agree on the ‘risks’,
• How negative results will be treated
• The accuracy with which the KPI reflects the condition and status of a control measure
• How easily and reliably data can be captured
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The Importance of Leadership
• Persuade me vs I insist
• Most senior executives need to be strongly persuaded why a KPI programme is needed rather than expecting or demanding that such a programme is implemented
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Sector vs Site-specific KPIs
• No ‘one size fits all’ solution
• KPIs need to be tailored to the risks present at each facility or installation
• Generic indicators will be less focused
• Sector-based indicators can realistically only succeed where they reflect the main risks present in all operations
• Benchmarking is useful but not the main aim of a KPI programme
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Leading vs Lagging
• A leading indicator can never be an incident or a near miss – that’s just good fortune
• The difference is not that important
• Information to act upon is key!
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Are Indicators Predictive of a Major Accident?
• Only where KPIs have been set to measure the control system barrier that is designed to prevent the accident
• You can’t measure what you don’t have
• Deterioration or breakdown of systems will lead to a major accident whether you measure system status or not
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Essential Characteristics of KPIs
• Reflect the consensus of the risk profile of the organisation/ activity
• Tailored to the specific risks
• Focus on vulnerability and provide opportunity for early intervention
• Based on data already available
• What they measure and why the issue is important clearly defined
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Methodology
• Sketch out the process / activities
• Identify and map onto the process diagram the main challenges to integrity
• Identify what systems and barriers exist to prevent those challenges materialising
• Select the most important in terms of criticality and vulnerability
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Safety Critical
System Vulnerable to failure
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Is the control measure critical?
• Relates to controlling process conditions?
– Temperature, pressure, flow, level, corrosion?
• Does it lie on the critical path to a major accident? MA initiator should it fail?
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Is the system Vulnerable? Key words
• Last in line?
• Provides no warning of failure?
• Offers little or no opportunity of recovery?
• Relies heavily on human intervention or correct action?
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KPIs – a systems based method
‘Developing System-Based Leading Indicators for Proactive Risk Management in the Chemical
Process Industry’
Ibrahim A. Khawaji
Massachusetts Institute of Technology
June 2012
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KPIs – a systems based method
GOALS
• Are the safety constraints comprehensive? i.e. covering all the hazards
• Are safety constraints adequate? i.e. using the appropriate controls
• Are safety constraints functional? i.e. ensuring they are implemented and not degraded
• Are safety constraints adaptable?
• i.e. controls address changes in the system
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KPIs – a systems based method
Leading Indicators Development Process
• Detect Flaws (feedback/leading indicators)
• Define factors resulting in the flaws
• Take corrective action to address the factors
• Monitor progress and effectiveness of the process (feedback/leading indicators)
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ASCENT: Focus
Focus groups
Interventions
SMART action plans
Intervention impact
evaluation
Senior management commitment
Project plan
Steering group
Communication strategy Foundation
Focus
Interviews Workshops
Act
Evaluate
Process evaluation
Data analysis
Analyse
Leading indicators
Lagging indicators
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Safety culture excellence assessment
Focus groups & interviews
Leading & lagging
indicators
SMS & documentation
review
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Safety culture excellence levels
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1. What do you have in place in your own organisation that reflects mindful organising principles ?
2. What could be improved?
– Use of diagnosis questionnaires
The infrastructure of mindful organising
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ASCENT: Act
Focus groups
Interventions
SMART action plans
Intervention impact
evaluation
Senior management commitment
Project plan
Steering group
Communication strategy Foundation
Focus
Interviews Workshops
Act
Evaluate
Process evaluation
Data analysis
Analyse
Leading indicators
Lagging indicators
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How to manage mindfully
1. Small wins in the preoccupation with failure
• Define near miss: system’s safeguard or vulnerability?
• Clarify what constitute ‘good news’
• Create awareness of vulnerability
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How to manage mindfully
2. Small wins in resistance to simplification
• Raise doubts to get information
• Handling disagreement or conflicting views
• Treat all unexpected events as information
3. Small wins in sensitivity to operations
• Encourage people to speak up
• Develop sceptics
• Brief people meaningfully
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How to manage mindfully
4. Small wins in commitment to resilience
• Treat your past experience with ambivalence
• Accelerate feedback
• Develop competencies
5. Small wins in deference to expertise
• Create flexible decision structures
• Boost imagination for managing the unexpected
• Enhance experts self-awareness
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Visible Leadership
• Get out and about often enough and at the right time
• Asking the right questions about the right things in the right way
• Find why they are doing it rather than just who’s doing it.
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Setting an Example (Modelling)
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Challenging Unsafe Behaviour
• Challenging is an act of caring
• You see dangers they may not
• If someone challenges you
thank them!
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Discretionary Effort
“Want to Do it”
Minimal Compliance
“Have to Do it”
Reinforcement
Punishment
4 : 1
Recognition
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‘Leadership For Safety’- Fleming, 2001
Looked at the practices of 23 offshore supervisors that were rated as
‘effective’ and ‘ineffective’ by their subordinates:
Effective supervisors:
Valued subordinates more
Visited the worksite more often to check if subordinates needed assistance
Encouraged participation in decision making
Ineffective supervisors:
Abdicated responsibility for subordinate safety
Focussed more on productivity and deadlines
Felt under pressure to get the job done, often at the expense of safety
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Risk Awareness techniques
• Step back five by five
• Mining – SLAM & SMART
• Air force ‘three ways’
• Risk triggered commentary
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Miners: SLAM
• Stop Think through the task
• Look Identify the hazards for each job step
• Analyze Determine if you have the proper knowledge, training, and tools
• Manage Remove or control hazards and use proper equipment
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Mine Operators: SMART
• Stop Isolate each step in a task and identify past and potential accidents, injuries, and violations.
• Measure Evaluate the risks associated with the task and barriers that have allowed hazards to cause injuries
• Act Implement controls to minimize or eliminate any hazards that make the risk unacceptable
• Review Conduct frequent work site visits to observe work practices and audit accidents, injuries, and violations to identify root causes
• Train Develop a human factor-based action plan and then involve and train the miners
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• Esso
“Step back five by five” program
Take five minutes to think about what might go wrong and how this might be avoided.
• Air Force pilots
Risk assessments prior to sorties. Identify three ways in which things might go wrong and steps which will be taken to ensure that these unwanted outcomes do not occur.
(Hopkins, 2002)
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Risk Triggered Commentary
Source: Rail Safety & Standards Board
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Risk Triggered Commentary
• RTC technique: Risk Triggered Commentary - Think it through. RTC involves the person speaking aloud what they usually just think to themselves, when performing an action (driving, signalling, etc).
• RTC allows the person to “sense check” what they should do next.
• It is not just repeating what they see (e.g. The train is
arriving at a junction), but saying the required action they will need to take. E.g. “next signal is a single yellow – brake to notch two, once I pass under the bridge”.
Source: Rail Safety & Standards Board
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© Crown Copyright 2014
HSL ‘Make it Happen’ model for culture and behaviour change
Interactive influences of organisation, job and
individual characteristics on H&S behaviour
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Influences on Behaviour (Physical context)
Organisation
Policies/procedures (e.g. usability, practicality)
Safety Management Systems
Resources (staff, equipment, training)
Health surveillance scheme, etc.
Job
Job design/environment (e.g. staff movements, crowded, confined space, shift patterns, workload, etc)
Control measure provision (e.g. availability, accessibility, maintenance)
Competence/Training
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Influences on Behaviour (Social context)
Job/Organisation Committed & Supportive Leadership
Safety culture (just, flexible, reporting,
learning)
Vision and value for safety
Supervisor role
Worker involvement/Autonomy
Team cooperation/support
Open communication
Change management
Extra-organisational influences Foresight systems to consider
emerging hazards, new regulations, etc.
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Influences on Behaviour (Individual)
Motivation/Decision Making
Automatic:
Cognitive/perceptual bias
Skills automaticity/Habits
Reflective:
Knowledge-based
Subjective norms (expectations of
others)
Self-efficacy (confidence in skills)
Beliefs about consequences of
performing behaviour (+/-)
Intention; goals
Mindfulness
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Influences on Behaviour/ OSH performance (Individual)
Capability
Knowledge: Information/Update
Education/Training/Refresher
Knowledge sharing
Skills:
Intra & interpersonal skills
(Assertiveness, Situation awareness, Leadership, Decision-making, Teamwork, Resilience in emergency procedures, etc.)
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ASCENT: Evaluate
Focus groups
Interventions
SMART action plans
Intervention impact
evaluation
Senior management commitment
Project plan
Data analysis
Steering group
Communication strategy Foundation
Analyse
Focus
Interviews
Leading indicators
Workshops
Act
Evaluate
Process evaluation
Lagging indicators
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The 5 Whys? - 1
There is a puddle of oil on the shop floor
Mindless response might be: someone to clean it up and this is just a housekeeping issue.
• We need to ask: why there was a puddle of oil on the floor?
• Because the machine was leaking oil.
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The 5 Whys? - 2
• Why was it leaking oil?
• Because the gasket has deteriorated
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The 5 Whys? - 3
• Why ?
• Because we bought gaskets of inferior material
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The 5 Whys? - 4
• Why?
• Because we got a good deal (price) on those gaskets
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The 5 Whys? - 5
• Why?
• Because the purchasing agent gets evaluated on short term cost savings.
In this company, the remuneration/financial policy is leading to cut cost on quality and safety.
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HSL: HSE’s Health and Safety Laboratory © Crown Copyright, HSE 2016
TEETH CLEANING
Setting Key Performance Indicators – a quick reminder
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Teeth cleaning procedure
• Duration: at least two minutes - 30 seconds brushing each section of your mouth (upper right, upper left, lower right and lower left).
• Frequency: morning and night.
• Technique: – Start with outer and inner surfaces, brush at a 45-
degree angle in short, half-tooth-wide strokes against the gum line. Make sure you reach your back teeth.
– Once you get to the inside surfaces of your front teeth, tilt the brush vertically and use gentle up-and-down strokes with the tip of brush.
– Move on to chewing surfaces. Hold the brush flat and brush back and forth along these surfaces.
Source: Oral-B Institute (other toothbrush brands are available)
HSL: HSE’s Health and Safety Laboratory © Crown Copyright, HSE 2016
Teeth cleaning equipment
• Teeth
• Toothbrush
• Toothpaste
• Timer?
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Teeth cleaning outcomes
• What is the desired outcome from the teeth cleaning process?
• Can the outcome be readily detected?
• Can the outcome be measured?
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Teeth cleaning outcomes
• Its very important to select indicators that, in the main, directly show how well the systems are working in practice, i.e. those linked to process controls.
No tooth decay
No fillings Wet toothbrush
Toothpaste used up Fresh breath
Clean teeth
Time spent in the bathroom
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Teeth cleaning KPI (Lagging)
• Lagging indicator – number or percentage of times that teeth are clean when checked (need to agree a performance standard)
IMPORTANT: If teeth aren’t clean we need to investigate to understand why
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Teeth cleaning KPI (Leading)
• Leading indicators
– the number of times that critical equipment (toothbrush etc.) is available and in the right condition
– when checked, the percentage of times the correct teeth cleaning process is followed
IMPORTANT: Checking the procedures are being followed is more useful than checking standard operating procedures are in place.