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Engineers Australia Qld Division – Risk
Management Concepts
21 July 2014
Contents
• My own journey – some navigation aids and
axioms
• Downer Mining – current examples
• Effective Operational Risk Management
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SOME NAVIGATION AIDS
Google names or start with:
Charles Perrow, http://press.princeton.edu/titles/6596.html
Erik Hollnagel http://erikhollnagel.com/
Ralph Staceyhttp://en.wikipedia.org/wiki/Ralph_Douglas_Stacey
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Operational Risk Management must:
Dan Petersen’s axioms adapted
1. Force frontline leader action
2. Involve middle management
3. Have visible senior management support
4. Engage the workforce
5. Positively contribute to how work is done
6. Be flexible
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5
Far from Agreement
Close to Agreement
Far from Certainty Close to Certainty
Chaos
Ordinary Management
Social an
d Peo
ple Fixes
Technical Problem Solving
Middle Ground Extra-ordinary Management
Ralph Stacey Agreement and Certainty Matrix (Adapted)
Adapted from the Ralph Stacey Matrix –
Domain of Interest
Extraordinary Management
Ordinary Management
Safety Transformation - Ralph Stacey Matrix Perspective
Perrow and Hollnagel
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PRACTICE IN DOWNER MINING
About DEM – UG, Otraco, DBS, ReGen, Open Cut
Mar 13 Jun 13 Sep 14
Operational Steering Group - oversight
Ongoing Project Health Support and Promotion – four campaigns, climate surveys etc.
Occupational Physician pre employment medical oversight and Workers Compensation focus and ongoing active complex case management
Downer Group Zero Harm Framework and Assurance Processes
Intent and Requirements Standard framework established
Maintenance Excellence Project - Task Instruction documents
Refresh ZH audit/review
Downer Group – ZH Critical Risk Process
Ongoing Business Level Risk Management
Ongoing ZH Leadership course with clear operational integration and support and aligned with Supervisor Capability Framework
Downer Mining operational standards working group
Downer Mining FY15 Zero Harm (Health & Safety) Plan Overview Working – May 2014
Critical Risk Dialogue
Mental Health Management Awareness
DBS Mental Health Peer Support Pilots
Large Site Project Pilot
Critical Risk collate in ARM and STI
Business unit projects
Periodic Health Process - Pilots
Goal 2 Employee Resilience Supporting employees and living our values
Goal 3 Critical Risk Line of sight risk management
Goal 4 Fit for Purpose Systems Value adding framework and components
Jun 14 Mar 14 Dec 14
Downer Mining Values, Congruent Senior Manager messages and visible actions Goal 1 HSE Leadership Building commitment and capability
Leadership and Critical Risk - Project Role of Senior Managers
Resilient Employee – Commercialisation
Maintenance Excellence Project
Alignment & Standardisation - control centric critical risk management Alignment & Standardisation
Process ready to implement for all project types
Align IMS content and refresh PMP process
Goal 5 ZH Function Improving business support
Diagnostic Critical Risk Dialogue
Options
Next Steps Role definition
Integrate key ZH processes with how work is done – JHA, Take 5, Hazard ID etc.
Key questions for all employees
• What specifically in what you do can kill you or
others?
• What specific controls stop this happening?
• What is your role in maintaining the controls?
• What will you do if you think the controls are not
in place?
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What will be delivered • Consistent delivery of maintenance excellence (working the right way) improves how Downer Mining runs and you get better risk management
for free • Maintenance Supervision based on knowledge-based leadership where supervisors remain credible and develop relationships with their crews
and have the time to develop a shared vision of outcomes with maintainers • Each day competent and fit for duty maintenance staff are allocated their work by capable supervisors with
- ‘how to’ task information that is visual, fit for purpose, identifies hazards and controls to support and supplements their knowledge and knowhow
- The specific tools, equipment, components, and consumables required to complete the work safely and efficiently - The skills and experience to carry out a hazard review of the environment in which they are working - An understanding of change thresholds
• This combination of leadership, monitoring, support and well designed approaches delivers reliable and consistent control of maintenance critical risks
S F
Execute work
1. What other hazards do I have to
consider in the broader work
environment? What are the controls?
2. What are the hazards to others that I
am introducing as I carry out my
work? What are the controls?
3. How much can things change before I
stop and reset how I am approaching
this work?
Target State – Improving the reliability of critical risk management in maintenance
I understand and always apply integrated safety processes
Approve work Plan work Schedule work
Resource work Business Systems - Asset Management
Provide ‘fit for purpose’ Work Instructions that detail key hazards and controls at each task
step
Fit, competent, experienced and
motivated people who are ready to
work
Tools, Equipment Consumables & Components are
available
Provide ‘fit for purpose’ Work Instructions that detail key hazards and controls at each task
step
Fit, competent, experienced and motivated people who are ready to
work
Tools, Equipment Consumables & Components in
place
What other hazards do I have to consider in the broader work environment? What are the controls?
What are the hazards to others that I am introducing as I carry out my work? What are the controls?
How much can things change before I stop and reset how I am approaching this work?
The supervisor’s role is to coordinate the assembly of these parts and then monitor that they remain in place
The maintainer’s role is to ask the questions and get the work done on time and to specification using the resources and information provided
Establishing a standard Interface Model between supervisors and maintainers – Version 1
S
F
Loss of Control vehicle incident causing serious injury and/or
equipment loss
Fit for Purpose Vehicles Equipment suitable for application
Selection -Specify vehicle use requirements -Define minimum vehicle equipment e.g. CAS, chocks, lights, flags etc.
-Consider load weight and how it will be distributed
-Apply Plant vehicle minimum standards; Traction control, ABS etc.
Pre-use checks -Daily fit for purpose checks -Load planned and secured
Maintenance -Equipment faults ranked and corrected to schedule
-Does not operate with defined Category A faults
-Timely quality maintenance
Modification -Speed governors
Fit & Competent Drivers Knowledge, experience and capability to avoid loss of control
Competent -Licenses, training and assessment for vehicle
-Drives to conditions
Fit -Fatigue management -Journey planning -Fit for duty expectations including AOD screens
Culture -Clear operating expectations from supervisors and peers
-Productive safe behaviours are recognised and rewarded, unsafe behaviours are corrected
Operating Conditions & Standards Reducing demands on driver Roads and Ramps -Haul road standards -Controlled application of water -Routine pit inspections -Parking area standards; spoon drains -LV HV separation -Intersection design Operating standards -Pre-start briefing covers driving conditions
-Positive communications re hazards
Road Design -Physical barriers: berms windrows
-Run off ramps
Occupant Protection
OEM provided -ANCAP rating for LV -Seat belts -Air bags -Cargo barriers -Position of ancillary equipment e.g. Radios
After Market -ROPS for special purpose vehicles
Emergency Response Local emergency response
-Vehicle first aid kit -Fire extinguisher
Site emergency response Community emergency response
Insurance Alternative vehicles
Critical Risk Barrier Map - Vehicle Loss of Control (LOC) Resulting in Serious Injury and/or Significant Equipment Loss
Notes for Use:
1. Identify current controls/barriers 2. Consider the practicality of alternative and/or additional barriers 3. Assess the adequacy and reliability of the selected barrier 4. Detail the inputs necessary to maintain and/or improve barrier
adequacy and reliability 5. Ensure that employees understand their role in maintaining barrier
reliability 6. Continue to test and check barriers that are people dependent
Barriers to prevent LOC
Barriers that mitigate LOC
Monitor Ensuring people dependent barriers remain reliable Frequent -Supervision performance monitoring
-Check that pre-start equipment issues are closed out
-GPS tracking (speed and position) -CAS records Periodic -Speed checks -Assurance; competency and licensing
-Hazard and Incident reporting and investigation
Post incident
Effective Operational Risk Management
1. Effective risk management is a contact sport - a
requirement not an invitation
2. Beware of compliance façade and gaming
3. Risk assessment is not risk management
4. Get the thinking off the bookshelf
5. Don’t confuse task level hazard and control
6. Understand the bigger system (socio-technical)
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