Monday, February 26, 2007

Too much training

Scotland were heavily defeated by Italy in the six nations rugby union on Saturday. Scotland had a disastrous start with Italy intercepting three times (a chip-over kick, pop-pass and long pass) in the first 7 minutes, scoring tries each time.

I'm no expert on rugby, but it looked to me that Scotland had been practicing the maneuvers, but in training had no opposition. This was later said by one of the commentators at the BBC.

I think parallels can be made with industrial settings. We know training is important, but often fail to provide the right training. This case highlights that whilst skills are important, the training programme can back fire if people are not able to make the correct decisions about which skills to use and when. In at least two of the three cases (chip kick and long pass) it is an obvious risk that an interception is possible. What Scotland failed to do was consider whether the risk was worthwhile. If they were close to Italy's try, it probably would be as they had a good chance of scoring points and would have more chance of recovering from an interception before Italy scored. As they were close to their own, the benefit was much less and risk much higher.

This is one area where companies get it wrong with simulators. They ask for 'high fidelity' versions that allow people to gain skills in operating the plant. Unfortunately the complexity and cost of these simulators means that more time is spent gaining skill, leaving relatively little time to practice decision making. Conversely 'low fidelity' simulators do not provide the opportunity to gain skills in operating plant, but this leaves a lot more time on practicing decision making, problem solving etc.

Andy Brazier

Friday, February 16, 2007


Jeremy Clarkson's article in the InGear section of the Sunday Times on 11 February 2007 discussed how some Three Letter Acronyms take longer to say than the full versions. Given that communication can be critical to safety, these examples may be useful to illustrate scenarios.

www = 9 syllables whereas world wide web = 3

From the army

IED= Improvised explosive device = bomb
ACV = armoured combat vehicle = tank
ADW = air defence warning = siren

In business China becomes PRC

And Jeremy adds one that is probably libelous IFA = thief.

Leading indicators of safety performance part 2

Following a comment I received on my previous post on the topic, I have given some further thought to leading indicators.

When you talk about performance indicators people often say they need to be S.M.A.R.T - Simple/sensible; measurable; attainable; realistic; time-based.

But there is a counter argument (I am sure I read this as a quote somewhere once) that says 'all that is important cannot be measured and things that can be measured are not always important.'

The comment made to my earlier post says that lagging indicators need to be based on actual consequences rather so that they are precise, accurate, difficult to manipulate and easily understood. Therefore near misses and high potential incidents cannot be used as indicators. This is an interesting point, and now I have time to think about it I am pretty sure it is correct. I still maintain that a huge amount can be learnt from near misses, but agree that this is not the same as using them to provide performance indicators.

The comment also said that leading indicators are certainly more difficult than lagging ones, but if we ask the people who are close to the risk and working with it every day, we will very quickly get a good indication of which of our systems are weak. Then we can hang indicators on those systems to drive improvement.

So from this I conclude that

1. Our traditional lagging indicators are useful, and there but there is probably no need to look for many new ones.
2. Leading indicators can be identified, but they need to be fluid in order to reflect the issues most relevant to an organisation at any time.
3. Near misses are an excellent source of important information but do not provide data that we can use to measure performance.

Wednesday, February 14, 2007

Behavoural safety - IOSH branch presentation

Presentation by Nick Wharton of JMOC at the IOSH Manchester Branch 13 February 2007

Nick gave a very good presentation covering the basics of behavioural safety. He is a good and entertaining presenter, and clearly very experienced. I think that, although he is obviously quite evangelical about behavioural safety, he was also very honest that it is impossible to create a direct link between introducing a behavioural programme and improving safety performance. This is quite a contrast to some presentations I have seen where it is claimed behaviour modification is The answer to safety.

I am fairly ambivalent to behavioural safety. I consider it to be a useful tool in the safety toolbox but have concerns that companies often put all their effort and resources into it, at the expense of other approaches. In fact some of Nick's figures showed how much continued effort is required. It is not just a case of keeping up a level of effort, but it seems you need to keep increasing effort otherwise safety performance starts to drop. I wonder how sustainable this can be.

Nick suggested that behaviour modification is applicable to process safety as well as personal safety. I am far from convinced about this. However, Nick did say that behavioural safety should not be used until good systems are in place. Perhaps it is the case that the process safety systems are not yet well enough developed, and so there is more to do before we can try behavioural safety. I guess my question is whether systems will every be good enough, and I feel effort spent on systems may always be more beneficial than that spent on behaviours.

The role of motivation

I was rather horrified at comments made by someone at the IOSH Hazardous Industries specialist group meeting on 13 Feb 2007.

This person is very senior in an organisation and ex-HSE. He said that the number of slip/trip/fall accidents on site suddenly started to increase. There had been talk about changes to company ownership and pension arrangements, and so morale was low. This was considered to be the cause of increased accident rate. Departmental managers went to speak to their staff to "explain what is expected of them." He reported that the number of accidents then fell.

I have a number of problems with this. The first is, I am not aware of poor morale being a significant cause of slip/trip/fall type accidents. I can see that people may be a bit distracted so it may have some influence, but I would expect this to be minor. However, I am sure that morale has a very big influence on whether people will come to work when injured (if you are fed up at work, any excuse to stay off is welcomed) and report accidents (with an eye to a claim). Also, if morale was the cause how could the managers message that staff are expected to pay attention to what they are doing have an impact on the cause?

Leading indicators of safety performance

Ian Travers of HSE presented at the IOSH Hazardous Industries specialist group, 13 February 2007. He was referencing a new guidance document HSG254 on leading indicators.

A good analogy was presented. If someone arrives late for a meeting you have a lagging indicator of failure. Arriving on time may be a leading indicator. Thinking about this, I would say arriving on time is not a true indicator. However, if we were to know what speed that person had driven on the journey we would know that either they had plenty of time to arrive safely (kept below speed limits) or if they had been in a rush (above speed limits at times) we would have leading indicator of how safe the arrangements really had been, even though success had been achieved.

Unfortunately putting this into practice in an industrial setting seems very difficult. It was notable that Ian did not provide any good examples in his presentation. He did give some idea of how to go about identifying indicators, with a key steer being to have a good idea of "what success looking like." This needs to be considered carefully, because for example it is not a case of saying what a permit-to-work looks like but what is the system intended to deliver.

Ian said there was a need for better indicators because audit is usually too infrequent and compliance focused, whilst work place inspection rarely addresses critical controls. However, before going down the route of developing leading indicators it is important to answer the following 3 questions:
1. Why do it?
2. What will you do with the data?
3. How will it influence safety performance?

It is unlikely that there will be any generic leading indicators. Even company wide are unlikely to be effective as having enough indicators to cover all the requirements is likely to be too many for them to be effective.

At the end of the presentation I concluded that leading indicators may not be the solution we are looking for (at least at this time). Whilst in theory they are exactly what is required, putting it in to to practice is very difficult. We may do better by using lagging indicators better, especially learning from near-misses and process disturbances.

Monday, February 12, 2007

BP's integrity management

From the IChemE's Safety and Loss Prevention Subject Group Newsletter Winter 2007. Report from a seminar on 28 September 2006 titles 'Asset integrity management in the process industry'.

Peter Elliott presented BP's integrity management standard. This is built on the principle that accidents occur because of simultaneous failures of the 3 layers of protection that are plant, processes and people. BP's integrity management standard is part of the company's operating management system and includes the 10 following elements.

1. Accountabilities
2. Competence
3. Hazard evaluation and risk management
4. Facilities and process integrity
5. Protective devices
6. Practices and procedures
7. Management of change
8. Emergency response
9. Incident investigation and learning
10. Performance management

Wednesday, February 07, 2007

Who reads procedures & other safety documents?

I think there is a rule of thumb that says 20% people will never read anything you give them. If we follow that analogy on, of the 80% who read the first page, 20% are unlikely to turn the page. See how this pans out below

Page 1 80%
Page 2 64%
Page 3 51%
Page 4 41%
Page 5 33%
Page 6 26%
Page 7 21%
Page 8 17%
Page 9 13%
Page 10 11%

So if the document you give them is more than 3 pages long, less than 50% are likely to make it to the end.

This is not based on any studies or science, but I think is not a bad representation of reality. It highlights that we need to address the fact that 20% will read nothing. But if we make sure all the most important information is in the first page or two, at least the majority will read it.

Also, this shows that about 10% of people will read everything. If these are the key influencer's for the rest of the population this can be pretty significant.

Andy Brazier

Tuesday, February 06, 2007

Business continuity planning

I atteneded a short talk given by Lynne Hughes of Conwy council yesterday. The Civil Contingencies act 2004 place duties on agencies likely to be involved in dealing with major incidents to assess risks, have plans, warn and inform, share information and co-operate.

North Wales councils have got together to publish a booklet. Conwy council have a website

Andy Brazier

Are good leaders born or created

Article in Sunday Times 4 February 2007 by Mary Braid

Leadership defined as "the ability to inspire others to strive and enable others to accomplish great things." In this case they nurture the talent of others.

The debate is whether it is something you are born with or can be learnt. An alternative view is that leadership has to be "earned" by gaining respect from others.

Whatever the truth, it is pretty clear that one style of leadership does not fit all circumstances. In some cases command and control is appropriate, but in many it is not. Now that a lot of responsibility has been devolved down the chain of command, more people need leadership qualities; using initiative, creativity and innovation.

One problem is that we want more people to take leadership, and this includes taking risks. Unfortunately failure, which is part of risk, still tends to be punished. Also, when people are taught leadership (if it is possible) they are given an idealised view of the world, which often does not have much baring to real life.

In real life it takes one set of skills to work to the top and another to be effective when you get there. "That is why good governance is so important" to ensure talented and effective leaders make it to the top.

Andy Brazier