Role of data and horizon scanning in Management of Change ... · © Crown Copyright, HSE 2019...

Health and Safety Executive

© Crown Copyright, HSE 2019

Role of data and horizon scanning in Management of Change (MoC)

02 July 2019

Matt Clay CEng CMIOSHPrincipal Engineer, Science & Research Centre,

Health & Safety Executive, UK


Content

• Overview of the Discovering Safety Programme

• Why horizon scanning is relevant to Management of Change (MoC)

• The problems and opportunities within ‘big data’ as applied to MoC

• Benchmarking against guidance and other sectors

• Questions, feedback & further engagement


Discovering Safety Programme


Why Data and Safety?

1908-1913 1st

HSL coal dust

experiments

UK Employee Fatalities

Population has increased ~60% over time series


Major Accidents

1900 1920 1940 1960 1980 2000 2020

1915

Quintinshill

rail crash,

Scotland

(200+)

1921

Oppau

Explosion,

Germany

(~600)

1942

Benxihu

Colliery,

China

(1549)

1966

Aberfan,

Wales

(144)

1974

Flixborough,

UK (28)

1984

Bhopal, India

(~3878 -

16000+)

1986

Chernobyl,

Ukraine (31+)

1987

Herald of

Free

Enterprise,

Zeebrugge

(193)

1987

King's

Cross

Fire, UK

(31)

1989

Hillsborough

(96)

1993

Kader Toy

Factory

Fire,

Thailand

(188)

2003

Columbia

Disaster

(7)

2004

Stockline

Plastics,

UK (9)

2005

Buncefield,

UK (0 but

£1Bn)

2012

Costa

Concordia,

Tuscany

(32)

2013

Santiago de

Compostela

derailment

(79)


Programme Goals

Improving ‘plateaued’ performance

Accelerating improvements

All while the economy, society and technology constantly change

Harm


Anticipating Change…

‘There is not the slightest indication that

nuclear energy will ever be obtainable. It

would mean that the atom would have to

be shattered at will’

Albert Einstein

‘This 'telephone' has too many

shortcomings to be seriously considered

as a means of communication. The device

is inherently of no value to us.’

Western Union internal memo, 1876

‘I think there is a world market for

maybe five computers.’

IBM Chairman, 1943

‘While theoretically and technically

television may be feasible,

commercially and financially it is an

impossibility’

Lee DeForest, Inventor

‘Stocks have reached what looks like

a permanently high plateau’

Irving Fisher, Professor of

Economics, Yale, 1929

‘Louis Pasteur's theory of germs is

ridiculous fiction.’

Pierre Pachet, Professor of

Physiology at Toulouse, 1872


Data growth

Data collection forecast to increase ~40% annually into the next decade – roughly doubling every two years!


Workforce demographics

Cited in: Energy production and utilities: Sector Skills Assessment 2012

41%

above

age 45

45%

above

age 45


Technology Changes

Historically Future

- -electricity distributed to users

Hazardous feedstocks centrally located, Energy cell concept – including power to gas

and gas to power

Well established hydrocarbon fuels (e.g.

natural gas)

New fuels: hydrogen, biofuels etc deployed in

transport and energy sector

Electromechanical control systems with low

functionality but well understood failure modes

Internet-of-things, highly distributed control

systems, cloud based networks,

cybersecurity vulnerabilities

Well established materials produced in well

established machining techniques –

‘subtractive’ manufacturing

Additive manufacturing , new polymers,

nanomaterials, composites replacing metallics

Standards based on conservative approach

and iterating lessons from failure

First principles and detailed analysis

increasingly important


The Problem

• Safety performance has plateaued in many established economies and major accidents continue to occur.

• Management of change has been a problem throughout history but now the pace of change is set to rapidly accelerate – there are workforce, economic and technology changes

• Data collection is rapidly increasing – this could be useful to develop better safety insights but often data is chaotic, unstructured and not necessarily created with safety ‘users’ in mind.

• How can hazardous industries, regulators and academics collaborate to address these challenges?


HSE COIN Database

• Company Records – 2855

• Sites – 10551

• Cases – 282846

• Service Orders – 65093

• Database Size (Data only) = 432GB

• Document Attachments Size = 1350 GB (1.35TB)

• Data is held for 7 years from the last activity on a case – this is a challenge for us

• The above is the total database size – hazardous industry relevant entries will be a subset of this


COIN Case Header


Underlying Causes


Attachments


Emerging findings

• Some good data in the coded fields – useful findings for industry in terms of taxonomy

• Small data size (N=~670) due to

– Short data retention policy (~7 years)

– Coded data only collected from RIDDOR Dangerous Occurences not other data (e.g. LoC events causing injury)

• Much more value in the unstructured data – text mining required.

• Huge value in the associated attachments – but significant challenges around lack of consistent structure and depth

• Some attachments are ‘flattened’ PDF with no OCR text associated (e.g. scanned investigation reports) etc.


Underlying causesH

azar

d A

nal

ysis

/ R

isk

Ass

essm

ent

Pla

nt

& P

roce

ss D

esig

n

Mai

nte

nan

ce P

roce

du

res

Op

erat

ing

Pro

ced

ure

s

Age

ing

Pla

nt

Man

age

me

nt

of

Ch

ange

Han

do

ver

/ C

om

mu

nic

atio

n

Pla

nn

ed M

ain

ten

ance

Pro

ced

ure

No

t A

pp

licab

le

Un

kno

wn

Pla

nn

ed P

lan

t In

spec

tio

n

Pla

nt

Co

mm

issi

on

ing

Per

mit

to

Wo

rk

Sele

ctio

n &

Man

agem

ent

of

Co

ntr

acto

rs

Sup

ervi

sio

n

Lead

ersh

ip

Secu

rin

g A

sses

sin

g C

om

pet

ence

N=670, methodology & limitations in full paper at https://www.researchgate.net/profile/Matt_Clay4


Occupational & Process Safety

“…the presence of an effective personal safety management system does not ensure the presence of an effective process safetymanagement system.” [Baker Panel, 2007]

OccupationalSafety

ProcessSafety

Does this area exist? How big is it? What are the limitations of the overlap?


Gold in them hills?


Risk management maturity model (RM3)


RM3 change management (RCS3)


Summary

• Historically society has been poor at anticipating and responding to change.

• Poorly managed change is associated with a significant major accident history within hazardous industries.

• Significant change is yet to come – particularly linked to decarbonisation and demographic changes.

• Data collection is increasing rapidly – this is a challenge but could also help us develop evidence-based responses to change management challenges.

• It is worthwhile looking outside of your own sector for tools and benchmarks to help you ensure robust MoC approaches.

• We are keen to engage and consult with hazardous industries – register for updates at [email protected]

• We are particularly keen to hear from people with datasets and are developing techniques and tools to address the challenges of personal data protection and commercial confidentiality.

Role of data and horizon scanning in Management of Change ... · © Crown Copyright, HSE 2019...

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Transcript of Role of data and horizon scanning in Management of Change ... · © Crown Copyright, HSE 2019...