Connecting Process Safety Performance OutcomesConnecting Process Safety Performance Outcomesto Process Safety Cultural Root Causesto Process Safety Cultural Root Causes

Process Safety Culture – The Key to Sustainable PerformanceProcess Safety Culture – The Key to Sustainable Performance

Steve Arendt, Vice PresidentOrganizational Performance AssuranceABS Consulting, Houston, Texas USAsarendt@absconsulting.com

AmCham 12th Annual HSSE ConferenceIntegrating HSSE and Business: A Formula for Development15-18 Sept 2008 Port of Spain, Trinidad and Tobago

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Presentation OutlinePresentation Outline

What is EHS/process safety culture? Telltale signs of a EHS/process safety culture Essential features of good culture How to evaluate culture Connect EHS performance to culture Culture case study example results Industry needs in EHS/process safety culture Conclusions

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Safety Culture FailuresSafety Culture Failures Challenger & ColumbiaChallenger & Columbia Piper AlphaPiper Alpha LongfordLongford ChernobylChernobyl FlixboroughFlixborough Texas City

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What Is EHS/Process Safety Culture?What Is EHS/Process Safety Culture?Our Company and Individual DNAOur Company and Individual DNA

Culture is the tendency in all of us – and our organization - to want to do the right thing in the right way at the right time, ALL the time – even when if no one is looking

Culture is the result of all the actions - and inactions - in institutional/workforce memory

Culture is hard to measure and more difficult to change; it will be the “root cause of the decade”

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Telltale Signs of EHS/Safety Culture DiseaseTelltale Signs of EHS/Safety Culture Disease

Ineffective EHS/PSM system performance Inadequate reaction to fixing identified

problems - lack of follow-up/huge backlogs Superficial audits - “check the box”

mentality Inadequate metrics-misplaced confidence

in injury rates Poor management review at all levels

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Telltale Signs of EHS/Safety Culture DiseaseTelltale Signs of EHS/Safety Culture Disease

Weak conduct of operations/lack of operating excellence

Poor incident reporting, learning and risk review

No MOOC (people, policies, or organization) Chronic cost-cutting and production pressure/

emphasis over process safety Plenty of “talk”, but hard to find examples of

leading by doing through the organization

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Accident PyramidAccident Pyramid

Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

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Truncated Accident PyramidTruncated Accident Pyramid

Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

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Improve Throughout the PyramidImprove Throughout the Pyramid

Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

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Process Safety Culture – Essential FeaturesProcess Safety Culture – Essential Features

1. Establish safety as a core value

2. Provide strong leadership

3. Establish and enforce high standards of performance

4. Formalize the safety culture emphasis/approach

5. Maintain a sense of vulnerability

6. Empower individuals to successfully fulfill their safety responsibilities

7. Defer to expertise

8. Ensure open and effective communications

9. Establish a questioning/learning environment

10. Foster mutual trust

11. Provide timely response to safety issues and concerns

12. Provide continuous monitoring of performance

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We Need Something More than “Just We Need Something More than “Just Opinions” upon which to Make Process Opinions” upon which to Make Process

Safety Improvement Investment DecisionsSafety Improvement Investment Decisions

Employee surveys are important, but they have weaknesses Sometimes they are viewed as being informational, but not

providing definitive arguments for action Particularly, expensive action… The PAR approach “connects opinions with process safety

outcomes” that “prove out” the opinions Recommendations from a PAR give confidence that you are

fixing things throughout the accident pyramid

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Connecting the Dots – EHS/Process Safety Connecting the Dots – EHS/Process Safety Performance Assurance Review (PAR)Performance Assurance Review (PAR)©© Strategy Strategy

Mapping of EHS Technical Performance and Culture Evidence to Process Safety Culture Factors

Process Safety/EHS CultureEvaluation Sources

Surveys and interviews

Work observations

PSM/EHSleading indicators

Process Safety/EHS Performance Information Sources

Incidents and investigation results Process Safety/ESH Culture

Essential FeaturesCausal Factors

Tenets of Operation

Audits and assessments

Action item completion history

© ABSG Consulting, Inc.

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Culture Case Study Example ResultsCulture Case Study Example Results Over the past two years, process safety performance and

culture reviews have been conducted for 10+ companies in the oil, chemical, pharmaceutical, consumer products industries Tens of 1,000’s of employees 50+ facilities – onshore and offshore Domestic U.S. and international Old companies and new companies

All of these studies included an evaluation of safety culture – most also involved mapping to process safety performance outcomes

Some observations and lessons from looking at the combined results – company names not included

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Typical

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Overall Culture Survey ResultsOverall Culture Survey Results

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Reporting

Committment to PS

Supervisor Oversight

PS Procedures

Employee Involvement

PS Training

Denmark Overall

Employees

Managers

% Positive Responses

Average of all questions

Obvious result, but look into it

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PAR ApproachPAR Approach

Takes culture survey results and maps them to process safety culture essential features

Takes technical performance outcomes and maps them to the same features Weights PSM outcomes according to risk significance Not all findings are “created equal”

Identifies process safety culture issues that need to be worked on Negative survey responses indicating a problem with one or

more culture features Supported by technical performance evidence from the field that

“backs up” the survey “opinions” so you can be certain that these problems actually exist and are not “just feelings”

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PAR Process Safety Performance vs. Culture MapPAR Process Safety Performance vs. Culture Map

Analysis of all process safety performance data (e.g., audit actions) is sorted into the 12 essential features

Culture survey results and other sourcesare sorted into the 12 essential features

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Cultural Causal Factor Survey Score

PARRank

1. Process safety is NOT a core value 57 1

9. Lack of a questioning/learning environment 56 1

11. Non-responsiveness to safety concerns 59 23. Not meeting performance standards – “normalization of deviance” 61 2

5. Lack of sense of vulnerability 52 3

10. Lack of mutual trust 47 3

6. Empower individuals to fulfill their safety responsibilities 74 4

8. Ensure open and effective communications 70 47. Defer to expertise 58 54. Formalize the Safety culture emphasis/approach 69 5

2. Provide strong leadership 57 6

12. Provide continuous monitoring of performance 67 6

Cultural Causal Factors Needing Attention Cultural Causal Factors Needing Attention

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9. Lack of a Questioning/Learning Environment9. Lack of a Questioning/Learning EnvironmentTechnical Evidence No. of Finding Issues Containment integrity issue allowed to exist 5 Safety hazard situation is allowed to exist 2 Unsafe work practice 2 Action item not completed, late, or chronic 5 Inadequate maintenance, inspection, testing 7 Inadequate monitoring or auditing 4 Inadequate training 3 Inadequate hazard, risk or RCA review/analysis 10

Culture Evidence (% positive responses) In my work area, we actively participate in incident and accident investigations - 62.4% In the past 12 months, I have received adequate training on process safety - 31.2% Newly hired workers at my site receive adequate training in process safety - 30.1% Contractors at my site receive adequate training in process safety - 25.5% Overall, I am satisfied with the process safety training we receive - 36.4%

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Lack of a Questioning/Learning Lack of a Questioning/Learning Environment – Possible SolutionsEnvironment – Possible Solutions Widely circulate the CCPS Process Safety Beacon Distribute summaries of incident reports that include what happened,

lessons learned, and how the lessons learned might apply locally Employ a “high potential incident” practice of communicating notable

incidents across the company and industry Modify the incident investigation system to more fully address “what

could have happened” instead of only the actual incident consequences

Conduct table top drills with operating teams to discuss response to operating problems and incident scenarios

Review key hazard scenarios with highest potential consequences from PHA’s with operating and technical teams

For outside incidents with lessons learned that have serious potential local consequences, require documented follow-up to ensure similar conditions do not exist or are well managed locally

Conduct hazard awareness training for operating/technical teams

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Cultural Causal Factor – Decreasing Frequency

1. Normalization of deviance

2. Non-responsiveness to safety concerns

3. Lack of a questioning/learning environment

4. No performance monitoring/pursuit of improvement

5. Lack of sense of vulnerability

6. Lack of trust – unsafe reporting environment

Ranking of Cultural Causal Factors Present – Ranking of Cultural Causal Factors Present – Summary of Study Results Summary of Study Results

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Cultural Causal Factor – Decreasing Frequency

7. Not listening to technical experts

8. Process safety is NOT a core value

9. Lack of strong PS leadership

10. Ineffective communications

11. Lack of personal responsibility for process safety

12. No formalization of a “culture process”

Ranking of Cultural Causal Factors Present – Ranking of Cultural Causal Factors Present – Summary of Study Results Summary of Study Results

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Observations on Culture ResultsObservations on Culture Results

The top three cultural problems were way above all the others

Surprising that “culture foundation issues” were so low – core value and strong leadership

Two of the 10 companies had process safety culture problems that were not high in the other 8 cases

Seven out of 10 of the companies had undergone significant organizational change in this decade

No direct information on cultural root causes – research continues as to how these companies got to the point where they are

Even without having robust cultural root cause information, it is possible to heal culture disease

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Sense, Learn, and Fix at Every LevelSense, Learn, and Fix at Every Level

Put sensors, not censors, at every level

Develop learnings at every level

Take corrective action at every level

Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

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Putting Sensors at Every LevelPutting Sensors at Every Level

Some activities must be monitored using leading indicators if they want to improve, not just by having accidents happen

Use a human health care analogy Lagging indicator = an autopsy after a heart attack Leading indicator = blood pressure, cholesterol, EKG Culture indicator = examining DNA

We must use leading indicators in process safety if we hope to drive continuous improvement; we must address culture for sustainable performance

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Examples of Process Safety MetricsExamples of Process Safety Metrics

PS accident rate

PS incident rate

Releases that don’t have consequences Upsets/safety system challenges Significant mgmt system failures

% WOs misclassified as RIK Action item backlog/aging Inspection overdues

Unsafe acts

Culture survey results Work observations Some leading indicators

Accidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

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Improve Throughout the PyramidImprove Throughout the PyramidAccidents

Incidents

Precursors

Management System Failures

Unsafe Behaviors and Attitudes

Culture – Individual and Organizational Tendencies

© ABSG Consulting, Inc.

But If You Fix These, Are You Certain

But If You Fix These, Are You Certain

Things Will Get Better and Stay Better?

Things Will Get Better and Stay Better?

ALLALL have underlying

culture/behavior root

causes

If you don't sense, learn and fix throughout

If you don't sense, learn and fix throughout

the accident pyramid, performance

the accident pyramid, performance

problems will recur

problems will recur

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Industry Needs in EHS/Process Safety CultureIndustry Needs in EHS/Process Safety Culture

No formally recognized, systematic way to evaluate culture

No widely recognized set of metrics Lack of understanding of the "pathology of

process safety culture disease" No prescription or set of remedies for curing

culture ailments No case studies of evolution of cultural root

causes

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Motivations for Improving EHS

Recent major accident Series of incidents Regulatory – new rule or enforcement actions Industry group membership obligation Peer pressure/comparisons of existing practices Perception that risk is not tolerable/increasing Resource pressures Company policy of continuous improvement

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Once You Have Identified Where Your EHS/Process Safety Technical and Cultural Issues Exist…

Use Risk Based Process Safety as the “toolbox” to redesign or improve your EHS/PSM performance

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Risk Based Process Safety CCPS published its original 12 PSM elements in

1989 and followed it with 3 other management system books thru 1994

A lot of experience and lessons have been learned since then; CCPS wanted to update its PSM framework to be useful as an industry thought and action leader for the next 15 years

RBPS came about for two reasons: To be able to generate better results with fewer resources To provide a “target” and an approach for companies of all

needs to implement, correct, and improve PSM systems

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CCPS Risk Based Process Safety –Next Generation in PSM Systems

20 subcommittee members representing the process industry

16 peer reviewers 2+ year effort that:

surveyed PSM/ESH systems from around the world to identify good features

benchmarked with over 60 companies in three workshops to compile leading practices, improvement idea, and metrics

760-page guideline written by a team from ABS Consulting

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Risk Based Process Safety

Management systems should be the simplest that they can be while still being fit-for-purpose

Consider the following issues when determining management system “rigor” Perception of complexity, hazard, and risk Demand for the system results and the resources

required to deliver them Current company/facility culture

To design, correct, and improve process safety management activities

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RBPS Accident Prevention Pillars

1. Commit to Process Safety

2. Understand Hazards and Risk

3. Manage Risk

4. Learn from Experience

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A Management System Is… A formal, established set of activities explained in

sufficient detail and designed to accomplish a specific goal by the intended users in a consistent fashion over a long time

Management systems consider the following issues: Purpose and scope Personnel roles and responsibilities Tasks and procedures Necessary inputs and anticipated results Personnel qualifications and training Activity triggers, desired schedule, and deadlines Resources and tools needed Measurement, management review, and continuous improvement Auditing

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Risk Based Process Safety ElementsRisk Based Process Safety Elements

Commit to Process SafetyCommit to Process Safety1. Process Safety Culture2. Compliance to Standards3. Process Safety Competency4. Workforce Involvement5. Stakeholder Outreach

Understand Hazards and RiskUnderstand Hazards and Risk6. Process Knowledge

Management7. Hazard Identification and Risk

Analysis

Manage RiskManage Risk8. Operating Procedures9. Safe Work Practices

Manage Risk (cont.)Manage Risk (cont.)10. Asset Integrity and Reliability11. Contractor Management12. Training and Performance13. Management of Change14. Operational Readiness15. Conduct of Operations16. Emergency Management

Learn from ExperienceLearn from Experience17. Incident Investigation18. Measurement and Metrics19. Auditing20. Management Review and

Continuous Improvement

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RBPS Elements – Relationship to PSMRBPS Elements – Relationship to PSMRBPS Element New

ElementExpanded

ScopeImprovedPractices

Process Safety Culture

Compliance to Standards

Process Safety Competency

Workforce Involvement

Stakeholder Outreach

Process Knowledge Management

Hazard Identification and Risk Analysis

Operating Procedures

Safe Work Practices

Asset Integrity and Reliability

Contractor Management

Training and Performance

Management of Change

Operational Readiness

Conduct of Operations

Emergency Management

Incident Investigation

Measurement and Metrics

Auditing

Management Review and Continuous Improvement

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RBPS System Structure Element

Key Principles Essential Features

Possible Work ActivitiesImplementation Examples

Performance Improvement Practice

Efficiency Improvement Practice

List of metrics Management review items

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RBPS Element Structure Example Process Safety Competency

Key Principle (1 of 4) – Enhance competency Essential Features (1 of 10) – Solicit

knowledge from external sourcesPossible Work Activities (1 of 22) –

Participate in industry group/networksImplementation Examples (1 of 3) –

Encourage certain employees to take committee leadership roles

Improvement Ideas – 19Possible Metrics – 18Management Review

Items - 12

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ESH Management System

Layered Control of ESH Management SystemsLayered Control of ESH Management Systems

Metrics – daily, weekly, monthly

Management Review – monthly, quarterly

Audits – annually and greater

© ABSG Consulting, Inc.

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ConclusionsConclusions

Sustainable process safety performance must: Use a blend of risk management approaches Focus on establishing the right culture Let your “walk” lead your “talk” Use a layered approach to management system

control Sense, learn, and correct throughout the pyramid

Companies need motivation for self-examination and change – the ability to integrate, analyze, and act upon “weak signals”

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ConclusionsConclusions

Have health check-ups to identify early culture disease symptoms

Establish process safety leading indicators Get “vaccinations” by regular, effective

management reviews of process safety performance – spotlight good and bad

Develop and administer process safety culture “vitamins”

??Time for QuestionsTime for Questions