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#1 Posted : 15 March 2001 15:24:00(UTC)
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Posted By Ciaran McAleenan Dear All, I would contend that risk management has failed and that it is time to rethink the strategy! I have extracted the following two postings from a thread on the Study Forum. I choose to post these under a new heading since the title of the thread this debate was developing under bore no resemblance to the direction it is heading. I trust this will broaden the audience. Any comments on the ideas presented below? Here is my posting from the ‘Confined Spaces - Your questions answered’ thread, followed by Stuart Nagle’s response. “I have no reason to believe that Ian Waldram accepts that zero fatalities are an impossibility, but his question; “If it is truly a ‘high risk environment’ how could you ever have zero fatalities?” goes to the heart of my company’s thinking on the concept of risk and risk management. We do believe that both technologically and intellectually there is the capacity to achieve zero fatalities, but what prevents this is the ideological basis underpinning risk management. Logically ‘risk management’ is a ‘self contradicting’ statement that promotes the concept of acceptable levels of risk, i.e injury and fatality. ‘Risk’ is a subjective measure of the possibility of danger being realised, used where there is an absence of certainty. In this absence of certainty you have ‘chance’ and it is chance that determines which of two outcomes are likely in the workplace; incident or no incident. Management is the authoritative control of operations. Where there is control of an operation ‘chance’ is removed and the only possible outcome is that which has been established at the outset. If the outcome can not be determined with certainty then chance exists and any action taken is a gamble that the outcome will be the desired one. In practice risk management posits an acceptable level of risk and proceeds to manipulate the circumstances to increase the odds in favour of a non-injurious outcome. Ultimately, by accepting and acting on any level of risk we are gambling with the safety of workers. Ian suggested in his original posting and elaborated upon it in his most recent posting that what we mean is that we put in place sufficient control measures to reduce the risk in hazardous environments. On the contrary we are not interested in reducing the risk, rather we make the case for managing any operation in hazardous environments such that there is no risk. If safety, not the risk, is managed and we can control the safety of the operation then it does not matter how hazardous the environment is since the operation itself is non-hazardous and the outcome will always be non-injurious. Finally, Stuart your point, made in your last posting is well made. People do and probably will continue to die in confined spaces for the foreseeable future and for the reasons you outline. It is not because fatalities and major injuries can not be prevented, rather it is because risk management acknowledges this as an acceptable outcome.” Stuart’s Response follows; “Sorry Ciaran, but I cannot accept your agument that "rather it is because risk management acknowledges this as an acceptable outcome". No death in confined spaces is either a risk management decision or an acceptable risk management option. Death occurs through a number of factors, and the results nearly always point to a lack of risk management, not an acceptance that this will be the outcome of an acceptable risk management stategy. This would obviously contradict all H&S law and standards. Death is avoidable, perhaps with the exception of rare, unforeseeable and uncontrollable circumstances. The true risks lay in the facts that incompetent or untrained and inexperienced persons are often in control of, or undertaking such work. Management often fails to either recognise this or provide suitable and sufficient levels of experienced and competence to ensure that works carried out are done in a healthy and safe manner. In the last 3 years, since the Confined Spaces Regulations 1997 were introduced, I have looked at many 'safe systems of work' for works in confined spaces. I can honestly say that I have found few that I could not find fault with, sometimes serious enough to have resulted in serious harm or death to persons at work, particularly where your stated 'chance' elements arise. However, we contuniue to seek to irradicate such problems and ensure fewer people suffer the fate of many gone before them.” Regards Ciaran mailto:ciaran@confinedspaces.com P.S. If you want to see how this debate started visit the study forum and click on ‘Confined Spaces - Your questions answered’.
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#2 Posted : 15 March 2001 19:31:00(UTC)
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Posted By Steve Crookes I view "risk management" a little less cynically. I try to take a holistic approach to the subject and view the overall aspects of risk management as per 8800, 18001 & HS(G)65- a cycle of continuous improvement, much as any other subject, skill etc is improved continuosly. No-one, or at least very few, have the resources to go from X amount of risk to zero risk in an instant. Risk management is about identification of hazards and prioritisation. This means that it takes time to eliminate all the possible hazards that face an organisation. And organisations change, ergo, new hazards arise that present risks that need to be addressed, or "managed" according to current legislation, so the cycle of continuous improvement goes on. There is also the application of the reasonably practicable risk/sacrifice equation. Skill and experience is required to get it right. Risk management failed? I don't think so. In fact, it has probably only just begun.
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#3 Posted : 16 March 2001 08:43:00(UTC)
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Posted By Malcolm I would like to agree completly with the posting by Steve. The holistic approach to Risk Management is the only viable route that can be taken. As the working environment is continuously evolving unless we are all going to turn into "Mystic Meg" there are always going to be injuries and deaths in the workplace. I should be the primary role of Risk Management to aim for complete control of risk. While realising that to achieve this is virtually impossible.
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#4 Posted : 16 March 2001 10:06:00(UTC)
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Posted By Ian Harper I have always held the opionion that zero accidents are a realistic goal but that in achieving that, managing risk has to prioritse the risks in order to eliminate them. Risk management is about about determining what risks require managing to what level. Determining the level of acceptable risk is just as important as managing the risk itself. Looking at larger orgainisations, some accept a level of fatality! The rail industry accepts 1 trackside fatality per 100000 employees as the target. If this is acheived then everyone will be happy and give themselevs a pat on the back. But now we are moving into zero accidents as a statement for promoting cultural change. As a safety manager, I always define the goal a zero accidents. I will never accept an accident as acceptable and as such risk managment must comform to that thinking in my orgainsation. In reality, when investigating accidents and incidents I do understand where forseeable and unforseen boundaries lie and try to make them forseeable and solvable in the future. My simple answer is that you will get closer to the standard of saftey you really want if you define it. If you accept that accidents will happen in accordance to the national averages and you are happy you are just under them, good for you. Risk management is about constant improvement, what we accept today we must not accept tomorrow. Risk management is the tool for the job and I think its real value lies in idnetifying the very things its being challenged on, what is acceptable and how long can it continue.
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#5 Posted : 23 March 2001 11:42:00(UTC)
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Posted By Stuart Nagle Dear, All. No one has stated that risk management cannot, and perhaps will not, achive it's ultimate goal of 'nil accidents' Obviously time is a considerable factor in the achievement (aim) of the management process, however, I was responding the Ciarans remarks on the specific response that in the area of confined spaces working, death or serious injury was an acceptable management risk. I do not accept this !! Interestingly, the terms reasonably forseeable risk and unforseen risk have their part in this debate - managed or unmanaged, competent or not-competent (as opposed to incompetent !!) Obviously some risks are more liklely to be reasonably forseeable to some, than to others, and experience also has it's role to play in the risk management activity. No one is stating that it is possible to leap from risk to no risk, a practically impossible task, as there will always (to some extent) be residual risk to manage arising from the associated hazards. I firmly belive that management systems camn and do provide the answers, through the management of systems that control and supervise (say, contractors on-site). Costs are incurred in such systems, however most studies seem to agree that such costs are a lesser outlay than fines and other costs imposed for not managing the risks. Further to this, it is my experience that such costs reduce over time, given the increase in awareness of systems, competency and experience acquired by employees and others (e.g. contractors) that systems are operated, are in place for a reason, and compliance is the better wisdom .... There will always be those who wish to jump into holes in the ground, as there will those who wish to swing from scaffolding, apelike, to achieve the quick-fix, however this is a matter of education as well, how many 55 year old scaffolders (for example) remain to be seem traversing the heights without fall arresters ?? In most places, I find that the 'actual' control measures represent the largest and most important safety factor. Doing is one thing - seeing to be done another - overseeing is done the necessity... Stuart Nagle
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#6 Posted : 25 March 2001 19:13:00(UTC)
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Posted By Adrian Watson Dear all, Whilst, I would tend to agree with those who argue that it is not possible to eliminate or control all risks and thereby prevent all losses, injuries and ill health and doubt whether it will be ever possible to eliminate or control all risks, I strongly believe that we should try to achieve this objective! However, I disagree with Ciaran’s contention that risk management has failed and we should discard this paradigm and contend that in attempting to identify and manage risks, we are now better placed to prevent losses, injuries and ill health than when we followed prescriptive standards that were reactive by their very nature. Additionally, whilst I agree with Ciaran’s prepositions that "...‘risk management’ ... promotes the concept of acceptable levels of risk" and that “risk management posits an acceptable level of risk and proceeds to manipulate the circumstances to increase the odds in favour of a non-injurious outcome” and that risk is subjective I do not accept that it is totally subjective, or that we are gambling with the safety of workers, or with Ciaran’s implicit conclusion that because we accept the concepts of risk management, we necessarily embrace the risk of injury or fatalities lightly. Finally I cannot agree with Ciaran’s statement that “If safety, not the risk, is managed and we can control the safety of the operation then it does not matter how hazardous the environment is since the operation itself is non-hazardous and the outcome will always be non-injurious” I believe that this point of view is not only erroneous but also dangerous, because if you assess the risks from the hazards implicit in the operation without taking into account those risk factors introduced by the physical, psycho-social or organisational environment you will fail to examine all the risks and are unlikely to manage or carry out the work safely, even if no loss occurs. For example in working in confined spaces in limestone regions carbon dioxide may migrate into confined spaces under low pressure, if this is not taken into account in the safe working procedures and practices, then asphyxiation could result, even though the atmosphere is not deficient in oxygen. In this case the fact the risk was not accessed does not mean that it was acceptable, nor does it mean that because someone was not asphyxiated does it necessarily mean that he was safe! Regards Adrian Watson.
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#7 Posted : 26 March 2001 18:06:00(UTC)
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Posted By Stuart Nagle Adrian. I was very impressed with your 'statement'. I would point out however, that when working in confined spaces where the hazard is carbon dioxide, this gas being heavier than the normal air,. the normal air, in which oxygen is contained, is 'displaced' and replaced by the heavier carbon dioxide gas. Thus asphyixation can occur by there being lack of, or, no oxygen in the atmosphere. Oxygen deficient atmospheres in such circumstances can be caused by the gradual ingress of carbon dioxide, where oxygen still exists in the atmosphere, but may be too little to support normal bodily function/activities (walking,climbing or working). this will, in most circumstances, lead to collapse and possible asphyixation if rescue is not forthcoming reasonably quickly. Personally speaking, this type of incapacitation may be the worst of all, as you know exactly what is happening (or you should do), but may be completely unable to assist yourself. Grizzly... Stuart Nagle
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#8 Posted : 29 March 2001 15:03:00(UTC)
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Posted By Ciaran McAleenan There is no risk in an operation. Either you will achieve your objective or you won’t. Risk exists only in ignorance, that is that you don’t know whether you will succeed or fail. A managed operation, however, is one in which all of the hazards have been considered and the controls have been put in place so that the operation itself is free from risk. If risk continues to exist it can only be because there are insufficient controls and that may be for a variety of reasons. Challenging an accepted paradigm is not cynical as Steve Crooks suggests since the concept of continuous improvement has to extend to looking at how well our management systems perform and to moving on when they fail to meet our expectations. Risk management is not a divine paradigm above evaluation and criticism. On the contrary by exposing its limitations we can go beyond it to a paradigm that will achieve the “nil accident” objective. Risk management by definition is self-contradictory and as it is practised accepts that an injurious outcome to some work activities is unavoidable such that it merely seeks to reduce the likelihood. The H&S legislation “so far as is reasonably practicable”, HSG65, BS8800, and OHSAS18000 all accept this position. Proper management of the entire operation requires that you define your operational outcome, provide the resources and review to consider the possibility of failure, prior to commencement, during the process and at various other stages. Much of what is defended by the safety professionals in this thread and in the recent letters pages in SHP is defensible but where the risk management paradigm differs is in it’s acceptance of risk and therefore it’s acceptance of some failure. Malcolm and others state that “there are always going to be injuries and deaths in the workplace". Accepting this as an inevitable outcome sets your expectations and limitations. Risk management supports this fatalistic approach to safety and seeks to limit the likelihood of injury rather than to eliminate it totally. Steve Crooks’ statement "reasonably practicable risk/ sacrifice equation" and Ian Harper’s rail industry figure of 1 death in 100000 employees being acceptable sums up my point that risk management accepts failure. I don't see the dead employee, his family or his friends cheering but I totally agree with Ian that you get closer to the standard of safety that you want if you define it and that continuous improvement is a necessary part of the management process. I also agree with Stuart Nagle’s views that management systems do provide the answer and that actual control measures are the most important safety factor. This links to Ian Harper’s point that "you get closer to the standard of safety that you want if you define it". You will achieve it if you manage it. There can only be one standard, no matter how you dress it up. Namely that we produce a product or service in a manner that will not injure our workforce or others. That straightforward position, extended includes; no damage to the environment or to profitability. In other words it is not unreasonable to consider all the potential losses and put the proper controls in place prior to commencement. In disputing my statement; “If safety, not the risk, is managed and we can control the safety of the operation then it does not matter how hazardous the environment is since the operation itself is non-hazardous and the outcome will always be non-injurious “, Adrian Watson lists several issues (physical, psycho-social etc) that he feels I have not considered when setting forth my position. However if the operation is safe then any external or internal hazard has been identified and has either been eliminated or properly controlled. Finally I will post a part of Philip’s statement from an earlier thread “Soundbites Required (union consultation)” that expands further the thinking behind the “Risk Management has failed” argument, “Bear in mind that a risk is basically the element of chance in an activity, whether it is 50:50 or 1:1,000,000. Every week millions of people put their money on lesser odds in the Lottery and most weeks one or more come up trumps. Work environments where the element of chance is retained (for whatever reason) are environments where every week someone's number comes up. And that is why risk costs the UK more the £20bn and the USA more than $127bn every year. No matter what the odds are, no matter how well "managed" the activity, the next time could be that one in a million time because there is no chance rule that says that the activity has to be done a million times before the accident. In fact every time could theoretically be a one in a million time. "Risk Management" simply tries to improve the odds.” Regards, Ciaran mailto:ciaran@confinedspaces.com
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#9 Posted : 30 March 2001 10:39:00(UTC)
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Posted By Stuart Nagle Ciaran. Your opening statement; 'There is no risk in an operation. Either you will achieve your objective or you won’t. Risk exists only in ignorance, that is that you don’t know whether you will succeed or fail. A managed operation, however, is one in which all of the hazards have been considered and the controls have been put in place so that the operation itself is free from risk. If risk continues to exist it can only be because there are insufficient controls and that may be for a variety of reasons'. Is I think contradictory of itself, as seems to be pointed outin the remainder of your argument. If a military unit goes into action, their commander accepts there will be fatalities. This is the nature of war. Far removed however, from the nature of a civilians normal working environment, where one does not expect to get killed, and nor should management systems accept death as an acceptable risk factor !! Hazards may be foreseeable or unforeseen. Risks associated with forseeable hazards are usually foreseeable themselves, and with experience can be managed. There will however always (potenitially) be unforeseen hazards that may result in risks to persons performing a task, remaining unforeseen, but this is where those term come into their own. The term,'Reasonably Forseeable' as defined within the Confined Spaces Regulations 1997, (the term 'Specified Risk' is not particularly applicable here, being that this term is used to identify those hazards that are peculiar to confined spaces of various type and configuration.)expects that hazards concerned with confined spaces entry are usually known, and therefore can be managed. Taken in context to a particular task or type of work, in essence, it simply refers to being able to competently assess a potential hazard that may affect the task or work, and management as being an assessment of the likelyhood of it's occurrence and mitigation of the risk. As long as the hazard is known about, an assessment of its likelyhood to occur must be undertaken in the course of managing the risk. As I am sure you are aware, if we consider confined spaces incidents resulting in deaths, there are only a few where the hazard and resulting fatal outcome could not, in all reasonableness, have been reasonably foreseeable. Therefore, in conclusion, my final argument in this matter is this - Hazard and risk management has on occassion failed, of this there is no doubt. However, the reason for failure, apart from the fact that it most likely arose from an unforessen hazard, is that whether it was actually unforeseeable. There are two questions to ask here; 1) Either the hazard was not identified because the person undertaking the assessment was not sufficently competent or experienced enough. If so this is may be a fault in procedure, policy, or management and/or 2) The hazard was genuinely unforeseeable. There is no middle ground, or room for errors here, particularly in 'high-risk' areas of working. It occurs to me therefore that the element of most importance here, is not the hazard or the risk, they may always be there, but the competency and experience of the persons involved in the assessment and the task itself. Having management suystems in place is fine in theory, and the paperwork will exemplify a managed system even. However, if the practice of the system is floored, it may well fail, and that failure will generally find that the fault was human error, where a particular hazard or related risk was overlooked, incorrectly assessed (often in relation to a 'combination occurence' - the domino theory.), or that those reasponsible where not competent and/or insufficiently trained and experienced. I rest my case... Stuart Nagle
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#10 Posted : 03 April 2001 10:35:00(UTC)
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Posted By Ciaran McAleenan In a recent article in ASSE’s professional journal Dominic Cooper commented; “Taking a more relaxed viewpoint has enormous practical implications. For example, in the UK, aiming for a 99.9% success rate would mean accepting that each day: * 10 trains would crash on the rail network, * 15 babies would be dropped on the floor at birth, * 125 surgical operations would go wrong, * 27 people would be wrongly prescribed dangerous drugs, * 72,000 cheques would be deducted from the wrong bank accounts, * 88 missed heartbeats would be experienced by each citizen, * 96,000 items of mail would be lost by the Royal Mail, and * Hundreds of people would be injured at work. These statistics support the goal of aiming for zero incidents rather than accepting 99.9%” Regards Ciaran mailto:ciaran@confinedspaces.com
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#11 Posted : 04 April 2001 13:40:00(UTC)
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Posted By Arran Linton - Smith Ciaran. I have been following your debate with great deal of interest, particularly your quote: “A managed operation, however, is one in which all of the hazards have been considered and the controls have been put in place so that the operation itself is free from risk”. To me, what you appear to be discussing is risk avoidance, which is in fact an integral element of risk management. If you look at Schedule 1 of the current ACOP for the Management of Health and Safety at Work Regulations, your point is clearly identified there.
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#12 Posted : 04 April 2001 15:56:00(UTC)
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Posted By Rob Todd Sorry Ciaran, Anyone who thinks that you can achieve zero fatalities within the greater concept of health and safety is living in cloud cuckoo land. Within the last 5 years, 450 journalists have lost their lives in the pursuit of news. The only way to achieve a zero level would be to not be a journalist! Risk management is all about bringing the risk of a legitimate activity to it's lowest level. This can still be regarded as high risk so long as the task is necessary and all possible safety aspects have been thought of. You may of course achieve a zero level of fatality if no humans are involved in any work. Rob
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#13 Posted : 04 April 2001 16:33:00(UTC)
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Posted By Tim Rob "In the last 5 years, 450 journalists have lost their lives in the pursuit of news." Was it worth it? Tim
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#14 Posted : 04 April 2001 16:35:00(UTC)
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Posted By Rob Todd Tim, They think it is! Who am I to argue! All we can do is give every possible level of assistance, training, equipment and in some cases actually force them to withdraw (as we did in East Timor and at times in Sierra Leonne etc. etc.) I myself, in the pursuit of achieving the highest level of protection for some of these people, have been shot at, guns been poked up my nose (literally) and flown into war zones in aeroplanes (sort of - looked like one at least) avoiding local missile protection systems. As I said, and although this is an extreme example, it is impossible to achieve a zero fatality level whilst human beings are involved. Cheers
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