Latest / Safe As Podcast / E46: The Stuff That Kills People and weaknesses in Critical Control Programs

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E46: The Stuff That Kills People and weaknesses in Critical Control Programs · Safe As Podcast

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  Do our critical control verification processes operate
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  as intended? Are they actually geared towards
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  the stuff that kills people or well intended but superficial
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  fluff? Let's find out.
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  Good everyone. I'm Ben Hutchinson and This is
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  Safe as a podcast dedicated to the thrifty analysis of safety,
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  risk and performance research. Visit safetyinsights.org for
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  more research. Today I'm covering 2 industry
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  reports, an interim and final report from Left's Read ET al
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  2025 titled Building Resilience into Safety Management Systems,
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  Precursors and Controls to Reduce Serious Injuries and
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  Fatalities. SIFTS The research was motivated
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  and funded by a creative sentence for the death of
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  Patrick, a contractor who drowned when his bulldozer fell
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  through ice on a frozen tailings pond at the Suncorp Base mine in
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  2021. The overarching objective of
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  this creative sentencing research is to to understand the
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  hazards that result in SIFTS, serious incidents and fatalities
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  within mining and any causal and contributing factors and the
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  most effective controls to prevent fatalities.
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  Another goal is to ensure that there are layers for protection
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  so that work fails safely rather than failing lucky or worse,
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  failing unlucky or unsafely. The project engaged in three
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  complementary research activities.
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  There were workshops, there was data analysis of critical
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  control assurance verifications, and it was matched against SIF
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  events or the potential or actual SIF events.
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  And then there were surveys and interviews of the hazard
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  identification and human and organisational performance
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  factors with people. So just upfront, some
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  definitions. So I've mentioned SIF before,
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  I'll use that a bit more. Serious incidents and
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  fatalities. These reports also adopt the
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  Icmm's definition. So controlled by that source is
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  an act, object engineered or system, a combination of act or
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  object intended to prevent or mitigate an unwanted event.
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  Also, I'll be talking about critical controls.
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  So critical control is a control that's crucial to prevent the
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  event or mitigating the consequences of the event.
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  The absence or failure of a critical control would
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  significantly increase the risk despite the existence of other
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  controls. Now, I can't do these two
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  reports just as that. There's just too much detailed
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  findings. So I'll just cover a few key
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  points that I found interesting. So what did they find?
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  So some of the insights from the workshops around building
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  resilience. So first a focus on high energy
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  hazards or what they call stuff that kills you.
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  The workshops with over 200 subject matter experts, they
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  repurpose some bow tie diagrams that they said really helped
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  workers see the high energy hazards and sort of the
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  contributing causal factors and the layered system of controls.
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  So I've skipped a lot of these findings, but the report
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  strongly recommends that companies should consider when
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  they're identifying their stuff that kills you and developing
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  layer controls for these hazards and ensure that these controls
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  are in place and functional. Nothing new there.
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  They said that to use these sorts of bow tie visualisations
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  really help show the hazards and the layers of control.
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  It might just be bow ties or it could be critical task
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  infographics, start work, check diagrams and whatever.
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  But they talk about sharing these visualisations with
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  workers so they can better see, monitor and manage their
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  workplace hazards. And importantly, as the work is
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  really done, you know, work is done versus work is planned or
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  work is imagined. They argue that visualisations
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  also trigger curiosity and curiosity eliminates fear.
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  So these tools are now being used for pre task planning and
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  training and critical control assurance.
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  Some of the other findings is that checking the efficacy of
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  critical controls by comparing or contrasting against our
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  actual incidents. So enhancing the critical
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  control assurance questions or processes, evaluating work and
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  perceptions of risk versus the hazards they're exposed to and
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  whether there's any fear of repercussions that can suppress
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  hazard reporting or overconfidence that could lead
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  to perhaps shortcutting safeguards and the
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  verifications. They also unpack some of their
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  psychological safety discussions.
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  So these workshops were aimed to create a psychologically safe
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  space to discuss human dynamics, leadership, organisational
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  factors potentially related to the SIF incidents.
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  Psychological safety is defined as a belief that one will not be
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  punished or humiliated for speaking out with ideas,
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  questions, concerns or mistakes and that the team is safe for
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  interpersonal risk taking. Interestingly, on this point,
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  when participants were asked to rate the level of psychological
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  safety that they perceived at a recent site visit, the average
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  score was just 3.8 out of seven. So less than a 50% score, which
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  is quite concerning that most people didn't perceive there to
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  be a high level of psychological safety.
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  It wasn't a safe environment for interpersonal risk taking.
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  Next, we'll move into things that I found a bit more
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  interesting around the the data analytical side.
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  You know, when they compared the critical control verification
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  activities versus the actual reported SIF events, like the
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  potential or actual SIF events. And they leveraged machine
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  learning and natural language processing across 5 mining
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  operations. Giving a bit of background, they
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  say Sifs have complex precursors that are not easily visible in
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  companies, physical environments or in their reports or even what
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  workers say. Hence many SIFT recursors are
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  only visible watching the work is done and how it differs from
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  work is intended. And this applies even to routine
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  work where they say controls may be insufficient, bypassed or non
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  functional. They believe that bow ties are
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  useful for visualising the presence of safety capacities.
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  Bow ties demonstrate that safety is the presence of layered
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  controls rather than an absence of serious consequences.
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  Nicely, they say that bow ties make the invisible visible and
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  the unspeakable discussable. With more resilient capacities,
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  they argue, the system is more likely to fail safe than fail
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  lucky. So what did they find with these
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  gaps in the critical Control assurance versus the actual
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  events? In mining and tailings
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  operations, SIP incidents related to working with or near
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  energised equipment constitute 60% of the incidents.
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  But critically, just 8% of the critical control assurance
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  activities focused on these same scenarios.
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  Also, exposure to toxic materials or hazardous
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  atmospheres constitute 5% of the incidents.
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  Yet the critical control assurance activities focused on
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  just .1% of these hazards. For production and processing,
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  working with or near energised equipment and toxic exposure
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  account for 25, around 25% of the SIF incidents.
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  Yet critical control assurance activities only focused on
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  between 1 and .13% of the hazards.
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  And another one. I've skipped a lot of these, but
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  exploration and drilling dropped objects accounted for the
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  highest number of CIF incidents, 83%, but accounted for just 38%
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  of the control assurance activities.
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  So these findings help identify the potential for enhancements
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  to the quality and attention of critical control assurance.
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  It suggests that much of the stuff we're actually observing
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  during the critical control assurance activities isn't
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  properly calibrated. The things that's actually
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  hurting people or potentially will hurt people.
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  They also unpack some insights from a human and organisational
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  performance perspective. So talk how the surveys revealed
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  that the participants, the participants attitudes generally
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  have the strongest relationships with the proxy safety variables
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  that were measured in this in these reports, which they say
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  emphasise the importance of social psychological factors in
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  shaping safety. It's not just about physical
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  controls, it's about people. People create safety, they
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  create safety capacities. They also found that one of the
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  strongest predictors of safety perceptions accrues.
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  You have positive safety attitudes.
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  For instance, my crew places a great deal of emphasis on safety
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  and beliefs that they can conduct the work safely, like a
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  collective efficacy. So in other words, safety,
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  climate and precursors around climate where the leaders are
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  seen to actually care about safety, whether the environment
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  is conducive to people to be able to work safely, were
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  important. They also covered some of the
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  reasons for the hazards not being identified or reported.
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  Probably nothing really new here for most people, but some of the
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  key areas. The first was worker
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  inexperience. So these sorts of demographics
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  may not have enough knowledge or experience in their role to
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  recognise features of their environment as hazards.
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  The safe career implications was tied up, so participants noted
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  that people may not report hazards due to perceived fear
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  that reporting may have a negative consequence for their
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  current employment or career trajectory.
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  The perception of fear of negative consequences appears to
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  be a strong driving force for why some people might hesitate
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  to report a hazard. There's perhaps a normalisation
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  of some of the hazardous work. So a perception that the very
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  nature of mining and oil and gas work is dangerous and therefore
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  it's just normal or expected to encounter hazards need frequent
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  exposure to these sort of embedded hazards.
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  They also contribute to a desensitisation where the hazard
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  is accepted as part of normal work and therefore employees may
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  assume reporting is unnecessary. And another factor under
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  recognition of hazards is a discrepancy between general fear
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  and specific hazards. So while 15% of respondents
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  feared career repercussions and 11% feared social repercussions
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  if they identified and tried to mitigate a hazard, only around
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  somewhere between 3 to 17% actually feared specific
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  hazards. So most of the fears that
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  resulted from hazards relate to people fearing social
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  repercussions, you know, getting socially outcasted by their crew
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  members or getting penalised by management for reporting things
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  rather than actually having a real sensitivity to the harm
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  that can result from that hazard.
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  So overall, trying to wrap all this together again, I've
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  skipped a lot, but they draw on Conklin's hot principles.
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  So accepting that people make mistakes, accepting that blame
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  won't necessarily fix things, accepting that context tries
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  behaviour. Learning is vital and how we
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  respond to incidents and hazards and people really matters.
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  Also explain the importance that our system should increase the
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  chances of failing safely rather than failing lucky or failing
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  unsafely or unlucky. And specifically for our sift
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  hazards and interactions, they offer some preliminary
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  suggestions. Query in the paper.
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  Create a hazard and inventory of work is done in all mine
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  operations. So how does work actually get
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  done? Describe it, learn about it,
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  detail it Identify or develop indicators for SIFT precursors,
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  controls and insurance and audits.
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  Make sure we're actually inspecting and learning and
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  monitoring the things that really matter Determine which
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  activities are most likely to be completed by contractors and the
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  hazardous work and interactions. Examine how indicators and
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  controls and control and barrier assurance vary across owners and
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  operators, contractors and subcontractors.
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  Not mentioned here, but we know that the principal contractors
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  and the clients often shift the risk down their contracting
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  chain. So they often transfer the more
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  severe risks to contractors that probably had the least resources
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  to properly eliminate those sorts of hazard exposures.
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  They also mentioned in the report surveying prevailing
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  safety climates and beliefs and norms with the owners and
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  contractors, et cetera. Build systems level, multi
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  layered, effective and insured controls at different levels.
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  That's it on safe. As I'm Ben Hutchinson, please
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  help share, rate and review, and check out safetyinsightsorg for
• 12:33
  more research. Finally, feel free to support
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  Safe As by shouting a coffee link in the show notes.