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SHV  
#1 Posted : 09 August 2012 02:45:47(UTC)
Rank: Super forum user
SHV

Dear All, We have got a consultant on board, and based on our our Risk Matrix (Blue , Yellow, Red), he is trying to convince us that,during defining incident potential, likelihood of incident should be based on past experience on project site. For example, during car roll over, it will be only be in red category in Risk matrix. if company had experience of fatality or total disability in the past, otherwise it will be categorized in yellow and will not be on TOP Management table to get attention, even though it will be thoroughly investigated by investigation team. He is saying, it is world wide standard practices and we should not over-burn the risk with wrong incident classification. myself and other coworkers believe that any incident which had potential to fatality or permanent disability based on incident investigation and facts should be in red category and on Top Management table to get attention.(regardless of past project experience) I should point out that, the company is Oil and Gas exploration company and working in Middle East with low level of safety culture. Any comment highly appreciated. SHV
Kate  
#2 Posted : 09 August 2012 08:15:11(UTC)
Rank: Super forum user
Kate

We have a criterion for putting an incident in the equivalent of your red category (referred to senior management) that can be described as "If this event happened again, would it be suprising if it was fatal?" (Multinational chemical company.) I agree, "It's never happened to us before" makes no sense as a criterion. You cannot judge the likelihood of rare events just on whether they have happened to you in the past. The sample's too small. You would need to look much more broadly at whether similar incidents have resulted in fatality, not just in your company / site but overall.
SHV  
#3 Posted : 09 August 2012 09:10:46(UTC)
Rank: Super forum user
SHV

Kate, Thanks, in fact we also considered whether that incident happend in other places or not during risk evaluation actual and potential, usually will be fall in yellow or red category category in Risk Assessment Matrix. ..written in our procedure , ""After assessing potential outcome, the likelihood is estimated on the basis of experience and or/ evidence that such outcome has actually occurred" so our consultant judgment is based on these statement. any comment?
jericho  
#4 Posted : 09 August 2012 09:22:36(UTC)
Rank: Forum user
jericho

Estimating the likelihood of an incident can bring in a host of factors; one of which is previous history. However, this must be taken in context. The weight that you give to it depends entirely upon the circumstances. Being struck by lightning on a golf course does not mean that everyone one will, every time they go out, does it? But a high instance of electricians receiving shocks because no one bothers to isolate and test, would indicate that it was pretty likely to happen again - soon. The thing is with history is that high evidence of that event is pretty compelling but no evidence at all actually isn't. Not on its own. If there is lack of history, it only really helps if there is a valid reason as to why there is none. IE you have effective controls. Now, I am not entirely clear in your question if you are talking about the potential for an event to occur, or for the out come of the incident (injury) to be the same again IF the event is repeated. Let's take a car crash."We crashed 100 cars at speed and the results for the occupants were...." This really only works if the crashes are the same. And naturally with driving as an activity being risk assessed you can't actually predict the precise nature of the crash people might have. So, some has to be settled in the assessment itself so that context is clear. Valet parking of cars would be different to business driving mostly on fast road networks. How we approach this is by identifying the general type of incident that could occur - let's say loss of control at speed due to inattention, distraction or other driver's action, resulting in high speed crash. OK? Then we consider not the most common outcome, nor the best we'd hope for, but the reasonable worst. What is not beyond the bounds of credibility? In this case I have to say that fatal injuries of permanent disability would not be unreasonable. This does NOT mean that every crash will result in this, people will walk away at times, but we now understand the potential at its reasonable worst. Whenever there is an incident, we examine what we predicted against what actually happened and analyse why there was a difference, if any and rethink the potential we recorded in the first place. Now to be honest, for high speed driving, unless they make card that turn into massive beach balls on impact, fatal injuries will always be the reasonably foreseeable worst for us. But if you start to look at other tasks then this becomes quite interesting. Let's take a task that could at its reasonable worst result in a fracture to an arm or leg. Typically we experince less that this with only sprains and the like. Periodically we do get a fracture. "Ah hah" we say, "We thought that might happen" But just very occasionally we get something worse. And on examination there are factors that mean the elevated injury outcome were not predictable and in fact quite unique to the outcome on that day. We do record that, but we don't change the injury potential for that risk assessment simply because of that one slightly bizarre event. So in summary. Potential for an incident to occur again can be based on many things not just history unless you can show it occurred because of common control failures still in existence and that nothing has been done to address that Injury outcome can be predicted in advance given what we reasonably know about the universe and can be different to the actual outcome in many cases, but it's worth looking at why they were different. Risk assessment after all is largely about "What do we do?" "How could that go wrong?" and "What are we doing to prevent that from happening?" What isn't helpful though is to confuse likelihood as the likelihood of the INJURY happening again. It should be the likelihood of the incident, which could lead to an injury. In that, I would say the consultant is incorrect. It leads to erroneous conclusions. I have never been killed in a car crash, therefore 'risk' is low. That can't be right. I drive 40k miles per year in all conditions, under pressure, at the ends of the day - the chances of me having as crash are pretty high. And under the sort of conditions that I drive, the type of crash I might have could reasonably result in major injuries or death. That should be enough for my boss to sit up and take notice. He is not going to say, "Ahh but you haven't been killed so I don't buy that" is he? Jericho
chris.packham  
#5 Posted : 09 August 2012 09:26:42(UTC)
Rank: Super forum user
chris.packham

So the possibility of an incident such as Buncefield would not have been considered significant as it had not occurred before? You could have a situation where the risk assessment shows a real potential for someone to be killed, yet because no-one has as yet it would not be something where action would be required? I can see the argument in court: "No my lord, we did not do anything about this as no-one had been killed at that time." Chris
jericho  
#6 Posted : 09 August 2012 09:26:44(UTC)
Rank: Forum user
jericho

unless they make card that turn into massive beach balls Obviously that should have read 'cars'. Can't imagine that card beach balls would really catch on. Where is the edit facility? Jericho
RayRapp  
#7 Posted : 09 August 2012 09:36:40(UTC)
Rank: Super forum user
RayRapp

Risk is an amalgam of the likelihood of the event occurring, which is also inextricably linked to the frequency of the task, plus the potential consequence. Whilst the likelihood can often be ascertained the consequence is more problematic. For example, a minor event can have catastrophic consequences and a catastrophic event can have minor consequences. It is feasible to adjust the risk based on a knowledge of previous incidents - assuming that there are some of course. However, not too much weight should be based on previous outcomes - history is not always an accurate indicator for future events.
SHV  
#8 Posted : 09 August 2012 09:50:21(UTC)
Rank: Super forum user
SHV

Thanks Jricho and chris, i just wanted to add that, in our risk matrix, if the incident fell in Yellow(normally if that incident happened in industry before) will only get middle level management attention and he may do something about it but taking an incident to Top Management table is based on red category and should be happened before or some bad thing like fatality or disability just occurred ..(our consultant view point)
jericho  
#9 Posted : 09 August 2012 09:57:04(UTC)
Rank: Forum user
jericho

I agree Ray. And I think that where people come unglued sometimes is that they try to make risk assessment too 'accurate' if that's the right term. Risk assessment is an estimation of whether we doing stuff well enough or not. And we have to examine the key factors as I said in my summary. A cut could as you say be "ouch' or it could be far worse. But it is both context and reasonableness that allow the elasticity of judgement. Cut in a path lab? Or cut on some paper in a school. Truth is that under bizarre circumstances the school cut could result in septicaemia but in terms of word knowledge that would be unreasonable. Take sero-conversion of HIV from needlestick injuries. Until it actually started happening, the WHO had it down as pretty unlikely. We actually had to change the outcome in our risk assessments as their knowledge changed. (Not an expert on HIV by the way, forgive any technical errors in that) In this case, history of event very much changed our view. But not of likelihood as you say. The potential for a needlestick injury was the same. But the outcome was raised. Overall the level of risk went up. As Ray indicates, don't do the task - there's nothing to assess. Jericho
Kate  
#10 Posted : 09 August 2012 11:14:47(UTC)
Rank: Super forum user
Kate

There are two different likelihoods being talked about here. One is the likelihood of an event happening. The other is the likelihood that this event (given that it does happen) could have a major consequence. It's the second likelihood that is relevant here - this isn't a risk assessment of an activity, it's a classification of an event by its potential after it has already happened. It's quite right not to go on the worst consequence that could imaginably happen (as the papercut example shows). But nor is it enough to go on what happened last time, because that may just have been a lucky escape. Lucky escapes are good things to learn from. If you are left thinking after the event "It's lucky no one was killed", then that makes the potential consequence a major one.
jericho  
#11 Posted : 09 August 2012 11:43:42(UTC)
Rank: Forum user
jericho

Kate, I agree and that's the point I (hope) I was making. I see risk assessment and incident investigation as mirror images, with the exception of one point. In a risk assessment, I look at what people are going to be doing, what could happen and why might it, plus of course the possible outcome of that event including the reasonable worst injury prediction. In an investigation, as it is reactive, I look at what were people doing, what did happen, why did it happen but then when it comes to the injury classification which we are talking about here I have two choices. Now I have the actual injury suffered but I also have the predicted injury from my risk assessment. In our system we plot BOTH. ie what we got and what we might have had. It is this that allows us to go back to our risk assessment and compare those outcomes. At times the injury is more than we predicted. Sometimes it is exactly what we said it might be. Of course there are times when it's less or zero. But when we look at the incident itself, we conclude as you did - "we were lucky" What this has allowed us to do is get completely away from the use of terms like accident and near miss in terms of gathering data. We only use the term incident. We gather facts on anything that didn't go as planned in effect. In essence we have shifted the focus away from injury and onto event. That way, we have a hugely successful record of reporting of 'near misses' based on the reasonable potential from the incident. Using exactly your words about being lucky, we have educated people to think like that. The quality of that which is coming in now is really good. It has allowed us to spot trends in non injury events. What we have now each month is largely so eclectic as to be at the point where we are starting to say, 'what more can we realistically do. We are into trying to predict the unreasonably foreseeable. Don't get me wrong, we're not complacent and still have things to do, but in relation to using that concept of reasonable prediction and actual result, we have built a very strong platform. What proof do we have? Well, we report all the incidents each month that did or had the potential to be fatal or life changing and almost all going back around 18 months are incidents that resulted in NO injury whatsoever. But yes, could have. Pretty strong evidence that reporting is alive and well. Do we get them all? Come on we're not daft. But do we get nearly all, actually I think we do. And it's the change of perspective in our employees that has achieved this. I agree that this was not a question about risk assessment, but I don't think that you can separate the two when classifying outcomes. Why would anyone have two different methodologies for determining potential and actual?
SHV  
#12 Posted : 09 August 2012 13:09:32(UTC)
Rank: Super forum user
SHV

I agree with the opinion that we should not go to worse cases for every single incident, however when we get involved in incident investigation and we find adequate evidences that this could lead to fatality , it should be classified as red, no matter it was occurred in project site or not.. One of the view is that, some of control measures were worked, thats why we did not have fatality( lets not say lucky) but when we have lack of details in investigation report and safety climate is not positive.
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