Seasons greetings to everyone who has read and supported this blog over the past 4 years. It started as a hobby and has grown into … a hobby. That said, it has brought me in touch with a range of very nice, intelligent and interesting people so, for that reason alone, it has been worthwhile

To add a little festive cheer to your lives, I have linked to this wonderful example of dynamic incident management. To appreciate it in all its splendour, you have to have the sound turned up so you can hear the commentary

Meantime, I wish you all a happy, healthy and prosperous 2012. Please don’t worry that the world will end. It won’t. The Mayan calendar only had 360 days so, given that they clearly could not even accurately predict the end of a solar year, the chances of them being any more successful predicting the end of days I would say is remote

Shaun

Click here to view the embedded video.

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Seasons Greetings from Capable Blog

I first posted this blog link in 2009. The video clips that it links to catalogue the disaster that occurred on the North Sea Piper Alpha rig on 6th July 1988. 167 men died. It is a fascinating and sobering document that shows, if nothing else, how a combination of apparently individually innocuous failings contributed to a cataclysmic and devastating failure in the management of safety on that rig, with terrible human consequences. It remains Capable Blogs most consistently visited post.

The story has taken on added poignancy for me lately. During a couple of assignments with Chevron earlier in the year I was fortunate to meet a number of experienced North Sea workers who gave me some first hand insights into the course of events on that night. I met people who lost friends, and also people who were working on that night, but on neighbouring rigs. One of the most unnerving facts that came to light during our discussions was that those terrible events that occurred on that night on Piper Alpha could easily have happened on any of the other rigs on that Occidental network. The message for us all being that the lack of a disaster does not necessarily mean a sound safety system, it could just mean a run of good luck …

Click here to view the embedded video.

Part 1

Click here to view the embedded video.

Part 2

Click here to view the embedded video.

Part 3

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A Case Study in Accident Investigation – Piper Alpha

ISO 9001 Clause 5.4.1

Clause 5.4.1 of ISO 9001 requires that organisations “establish” quality objectives, and that these objectives “shall be measurable and consistent with the Quality Policy”. Fair enough, you could say, but saying it simply doesn’t make it happen. That’s why there is an additional requirement within clause 5.4.2 (QMS Planning) that states that planning “shall be carried out” in order to meet the requirements of the quality objectives. In other words, we set a target to achieve something, then we put a plan in place for managing the job. What could be simpler? Well, lots apparently. I have lost count of the number of times I’ve been presented with the vaguest of QMS objectives to “strive“ for this and “endeavor to achieve“ that. Virtually meaningless objectives that would make a politician blush, generally unsupported by any kind of rational plan or monitoring. It’s a common problem, and more often than not,  it is ignored or tolerated during a third party audit

OHSAS 18001 Clause 4.3.3

The strange thing is, there is a similar coupling of requirements in OHSAS 18001 with regard to OHS objectives and planning (clause 4.3.3), but the failure to identify meaningful objectives and to support the objectives with a plan is much less of a weakness in that discipline. It is actually relatively uncommon to encounter vague and meaningless OHS objectives, or to find there is no method for working towards them. Why is that? Is it that the penny has dropped better and farther with OHS people? Are they cleverer than “Quality” people? Does the training that OHS people tend to go through (IOSH, NEBOSH or whatever) emphasise this planning discipline more effectively? Or is it down to the fact that the requirement is consolidated within a single cohesive clause, so it is harder to overlook or wriggle out of?

Sharing best practice

From time to time I do get involved in various consultative processes relating to the review of standards, particularly ISO 9001, and I must say I would be lying if I said I enjoyed it. That’s probably more to do with the type of person I am, and the requirement to get a large number of people agreed around (first) general principles, and then around actual words, frankly takes ages. It wears me down quicker than it seems to wear down others. But that is my problem. I also get frustrated by what I would call a general “not invented here” syndrome. In my view, anyone with the slightest degree of objectivity would have to admit that ISO 14001:2004 and OHSAS 18001:2007 do at least a couple of things better than ISO 9001. It has long been my opinion that ISO 9001 could achieve a couple of “quick wins” simply by acknowledging the fact and replicating the structural and content issues that quite obviously work much better. The main things, in my view, are the following;

PDCA Structure

ISO 14001/OHSAS 18001 clauses are structured around a PDCA model. ISO 9001 clauses are not. They could be, but they aren’t. ISO 9001 supports a PDCA approach, so why does it not adopt the obvious sensible approach of structuring its higgledy piggledy clauses more rationally? You tell me. Our environmental and health & safety cousins have shown that it can easily be done

System Planning

For reasons I have stated above, the system planning requirements are included in a more integrated way

Management Processes

These are described in a more grown up, detailed and practical way. They are also NOT grouped together as they are in section 5 of ISO 9001. In my view this is a good thing. Again it represents a more integrated approach where “management processes” are not disaggregated from the system and applied as “bolt ons”

There are other issues that those standards just do better, but in my view these are the ones that jump out at you when you work across all three standards. The irony is indeed thick. A quality management approach supports the idea that continual improvement is supported by processes of organisational learning and the sharing of best practice. The huge caveat appears( to me at leas)t to preclude a requirement to learn from them over there ….

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Quality Management System Planning

Here is a link to a comprehensive narrative and analysis of the Herald of Free Enterprise disaster, featuring some quite alarming lapses in the safety management system. It also illustrates the significance of promoting the right culture on the implementation of effective systems

Click here to view the embedded video.

Part 1

Click here to view the embedded video.

Part 2

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Herald of Free Enterprise Disaster – Case Study

*A very special thanks to Phil Knowles for drawing attention to this fantastic treasure trove of nostalgia*

Everyone in the UK over a certain age will remember those fabulously tacky and, some would say, iconic short public  information films that the BBC used to broadcast

• Are you an amber gambler?
• Learn to swim (with Rolf Harris)
• Driver fatigue
• Charlie says …
• Burst pipe!
• Ear protection (the one set in the working men’s club)
• Chip pan fire (with Keith Floyd)

They are all on TV Ark, free to download and enjoy

So follow this link and re-live the good old days of industrial deafness, strikes, power cuts and litter

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BBC Public Safety Video Clips

Transition to the revised standard for registered organisations There will be a two year transition period, starting 1st July 2007

Summary of revisions
The importance of “health” has been given greater emphasis BS OHSAS 18001:2007 can now be referred to as a standard, rather than a specification New definitions have been added, old definitions have been revised Improved alignment and compatibility with ISO 9001 and ISO 14001 The term “tolerable risk” has been replaced with the term “acceptable risk” The term “accident” has been included in the term “incident” The definition of the term “hazard” no longer makes reference to the damage to property, workplace or environment

Sub-clauses 4.3.3 and 4.3.4 have been merged (objectives and management program) in line with ISO 14001 A new requirement to consider the hierarchy of controls as part of the OH&S planning process has been introduced Management of change is now more specifically addressed within clauses 4.3.1 & 4.4.6 A new requirement “Evaluation of Compliance (4.5.2)” has been introduced Requirements for consultation and participation have been expanded A new requirement “Incident Investigation (4.5.3.1)” has been introduced

Overall, and at first site, the revision does seem to constitute a significant improvement, both in content and user friendliness. Obviously time will tell, but early signs are positive

Auditor CPD transition requirements
Auditors wishing to update their skills and knowledge, particularly with regard to the IRCA OHS Auditor Certification Scheme should complete a minimum 4 hour structured workshop and complete an appropriate number of audits to the BS OHSAS 18001:2007 standard

Shameless Plug
Capable People has developed a distance learning program that meets the IRCA transition requirements outlined in Briefing Notes IRCA 531 and 532. Details on our web site

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OHSAS 18001:2007 – a heads up on the major changes

Certain things shouldn’t happen, true enough, but if they can happen they will do In risk management terms we must assume that anything that can happen, sooner or later, will. The only question worth asking is whether the risk is worth managing, or whether we are prepared to accept the risk and live with the consequences The recent problems concerning the contamination of baby milk, and confectionery with the harmful chemical melamine, demonstrate the potential consequences of poor management of risk.

But let’s not dress this up as anything it is not. This is not a case where incompetence, weak process control or contaminated materials have allowed out of specification product to be inadvertently produced and shipped. In each of these cases it was a deliberate act by the manufacturer concerned. The melamine was supposed to be there, the products were designed to be poisonous. The consequences for the consumer being of secondary importance to the manipulation of test results to show a higher than actual protein content (something that melamine does), and therefore to command a higher sale price So what lessons can be learned from these recent events?

Well, if nothing else, that there is no such thing in life as a free lunch. The low cost of Chinese produced goods has been attractive to many western firms over the past half decade or so, but we do need to proceed with our eyes wide open. Certain risks are increased and, let’s face it, if children’s sweets and baby milk are not off-limits for dangerous and fraudulent activity, nothing is. Melamine even poisons primates

The European Commission has “acted swiftly” to suspend the import of all Chinese baby food that contains traces of milk to the EU. Given China’s recent record it beggars belief that anyone would contemplate importing baby milk from that location just now under almost any circumstances Everything comes at a cost, and with low production costs often that means corners are cut.

incredible

www.capablepeople.co.uk

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Understanding your risks – the key to quality control

That is what is commonly known as a “near miss” – although sometimes (maybe more appropriately) termed as a “near hit”. Watch it again. There are some significant points to note from the short clip

1. The lady composes herself quite quickly despite coming within a second of being vapourised – does this mean she’s used to it?
2. No-one else looks too surprised by the passage – does this mean it happens all the time?

Anyway, we might guess that this is a fairly common occurrence and, possibly at this platform, it’s not too rare an occurrence for worse to happen

Near miss reporting is a corner-stone of OH&S management. We learn from all sorts of experiences, accidents included, but the beauty of learning from near misses is that we learn before anyone gets hurt. They are great

The problem is, when you go and talk to any OHS manager about near miss reporting and you’ll always get the same tale. The greatest challenge is persuading people to record them. That’s right, all these wonderful opportunities to learn often go unreported, despite the better efforts of the OHS team – but why?

Because people are people, that’s why

You can program a machine to do anything, even to self-destruct, and it will obey. A person on the other hand might do what you ask, but then maybe he won’t. You see there are a lot of things going on inside the head of a person that we just can’t ignore. Things like:

1. Will I get blamed for this?
2. If I don’t do it, who’ll know?
3. I’ve got more important things to do right now – I’ll maybe do it later
4. I can’t be bothered with all this paperwork, health & safety has gone mad

All these things have to be considered when implementing a system, simply because they exist. Near misses, you see, are quite different to accidents in a couple of key ways. Firstly there is often no victim, and secondly there may be no residual  evidence of the  occurrence. Consequently a lot of lessons that could be learned from near misses just disappear into the ether once the dust has settled and the debris has been hastily shovelled up. So what’s the answer?

Well, we’re not sure. But we did do some work a couple of years ago with a company that had attempted to improve near miss reporting by applying some statistics to it. Most OHS professionals will be familiar with the “Bird Triangle”. That’s the numerical hierarchy that suggests that, statistically, the ratio of near misses to non-serious accidents to serious accidents is about 300:30:1. Meaning that by the time we have a serious accident, we may have had several hundred opportunities to learn. Anyway, this company decided to allocate near miss reporting targets based on “Bird” to each department based on the average number of accidents they reported (they extrapolated the figures upward). So far so good, eh?

Well, it worked on paper … but then people were introduced into the equation. Think about it. Department heads had to report “x” number of near misses on a monthly basis, say on the 28th of each month. The idea being that the “near miss log” is kept updated as and when these near misses happened. Right? Wrong! – the result was that very few near misses were logged in the early part of the month, but the log was back filled on or near the 28th each month following some sort of “creative team brainstorming session” – which no doubt usually took place in the canteen

So what’s the point of the story? Only that people are people and we have to be realistic. The world is not perfect and self-interest will always be a factor. If our systems make the assumption that people are programmable and will simply do what they are told, our systems will ignore an inconvenient, but nonetheless inherent, and very real variable

Finally a word of comfort for all you OHS managers out there who may be struggling to get important points across to a reluctant and unwilling workforce. Well think yourself lucky. Imagine yourself explaining the importance of a near miss reporting system to the young lady in this clip …

Maybe your guys ain’t so bad, after all …

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Near miss reporting (the problem with people) …

Workplace Safety and Health Framework

Have a nice day

Health & Safety in “The Office” (thanks to Steven Howard)

www.capablepeople.co.uk

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Some free OHS video clips

Last week saw a bit of whistle blowing that, if true, would suggest that the aim at London Heathrow is quite the opposite. That is, the airport is so busy that the aim is actually to land planes as close together as is legally possible. So far this has been without significant consequence, but our whistle blower suggests that this is only a matter of time

Catch the full story here and make your own mind up

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Safe system of work or hazarous by design?