2 notes from the risk management workshop

7/28/2019 2 Notes From the Risk Management Workshop

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Risk Management Workshop, Blackwater, 21 September 2010 1

The Challenge..


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Applicable Reference Material


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Workshop pictures Page 1

Jim Knowles and the Panel (Andrew Morrell, Gavin Taylor, Tim Whyte,

John Sleigh, Jane Moss, Richard Mills, Adam Garde).


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Andrew Morrell

Jane Moss


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Adam Garde

Grant Cook


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Key Points (John Sleigh) .

When to use a JSA

1. Most tasks will start out either as a part of a plan or as a response to anunexpected event.

2. If the job is planned, then a procedure should be part of the plan. Considerthe task of adding another trailing cable in line either to a shovel (surface) or

Continuous Miner (underground).

3. The procedure should include a number of controls checking that the cable issuitable, isolating power, testing before restoring power.

4. In the case where a plan is in place, the JSA is to make sure that the controlsare in place or followed and to see if any additional controls are required

because of local conditions. E.g. Weather (surface) or accumulated water

(underground)5. If the job is not planned, for example machine breakdown, strata failure then

the JSA should look for what parts are covered by procedures and what parts

are not. The controls in the relevant prepared procedures should be in place or

equally robust alternatives adopted. The parts for which there are no

procedures require additional job steps in the JSA.

6. Unplanned jobs certainly require change management what additionalhazards or process steps were introduced by the unexpected event?

7. Planned jobs may also require change management how does this job differfrom the standard envisaged when the procedure was developed?

Environmental conditions? Personnel? Tools?

8. Assessing the risk is about identifying the controls that are required. Managingthe risk is about putting the controls in place and monitoring their

effectiveness.

The hierarchy of controls

There is an order of preference for controls those higher in the list are most

effective. The terms vary between lists, but this is the list in the Queensland Mining

and Quarrying Safety and Health regulation, 2001.

(a) elimination of the hazard;

(b) substitution with a lesser hazard;

(c) separation of persons from the hazard;

(d) engineering controls;Examples of engineering controls

1 using fans and ducting to remove dust

2 using guards on conveyors

(e) administrative controls;Examples of administrative controls

1 a restriction on the time a worker is exposed to a hazard

2 a procedure or standard work instruction

(f) personal protective equipment.


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This is how the NSW Coal Mine Health and Safety Regulation, 2006 lists them:

(a) firstly, substituting the hazard giving rise to the risk with a hazard that gives rise to

a lesser risk,

(b) secondly, isolating the hazard from the person put at risk,

(c) thirdly, minimising the risk by engineering means,

(d) fourthly, minimising the risk by administrative means (for example, by adopting

safe working practices or providing appropriate training, instruction or information),

(e) fifthly, using personal protective equipment.

In todays mining practices, there is another level below PPE and that isMaking people aware of the hazard.

This is where barrier tape, signs and pre shift briefings belong. The objective is to control the risk as high up the list as is reasonably

achievable.

The control will usually only affect the likelihood, or frequency of an incident.It will rarely affect the consequences.

It doesnt matter whether you support the roof with timber, roof bolts ortendons, if a piece falls out hits a mineworker, the consequences are the same.

It doesnt matter whether a railway level crossing is protected by signs, boomgates or an overbridge. If the car finds its way onto the tracks as the train

approaches, the consequences are the same.

Using a matrix to assess risk requires people who have a strong knowledge ofpast incidents, their causes and controls which were not in place or which were

not adequate.

It is unlikely that a work team will have that expertise. So it is not an accuratetool for use in a JSA.

It is even less likely that a mineworker will have that knowledge, so it is lessuseful in a SLAM or Take 5.

The value of the matrix is in deciding a priority in which controls are appliedat the planning stage.

If a mineworker assesses that a job is unsafe, the first step is to make it safe ifpossible, and if not to withdraw and report it.


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Key Points (Jim Knowles).

The main points that I considered were,

The interest show by the number of participants tells me that there is a greatneed for more of these types of forums

There appears to be a need for better consistency in the risk managementprocess between organisations/ regulators/ unions/ consultants

Improved education for Risk Managers More clarity on the residual risk ranking, re; acceptable level of risk

particularly in Qld

Possibility of the major players getting together to try for a consistentapproach to RA i.e.: Rio, Anglo, BMA and Xstrata


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Key Points (Tim Whyte).

The key points as I see them could be encapsulated in the following;

The legislation requires individual mines to develop PHMPs and SOPs, whythen are we performing multiple JSEA (or whatever) for a task that hasalready been assessed and work instructions drawn up? If, as conveyed at the

seminar, that S&HMS are a monster, then this is our own making. If the mines

S&HMS is accessible and clear to read, then it should be robust enough to

instruct those performing the task to understand the process and assist in

identifying the hazards. Tools such as Take 5, SLAMs etc. are for the

individual - not to change the S&HMS to suit the daily condition. If not then a

review of the procedure is required.

I have attached an Audit tool for all to use that relies on the person performingthe task to map against the procedure and what they are actually being

requested to perform. This tool, if used, not only gives the mine a free auditbut also gets buy in by the mine workers. (You would have seen something

similar at MNC)

S&HMS have grown out of control, this sometime being due to multipleaccess to add or change the mines current S&HMS. I believe all mines must

have a dedicated S&MS Document controller to ensure that there is only but

one of each required procedure available to all coal mine workers. In addition,

all mines need to halt the practice on performing risk assessments to come up

with another procedure to allow a task to continue, when a procedure already

exists. As stated in my presentation, a procedure, once developed and signedoff as part of the S&HMS is a statute of law. A dedicated Document controller

would alleviate this debacle by ensuring only access to the mines S&HMS for

change is performed by an authorised person.

Restriction, if not prescribed removal of Corporate bullying to push theirbarrow on how they see the world. The SSE has the obligation to develop and

implement the S&HMS not the associated Corporation.


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Key Points (Jane Moss)

Please find below key points as a result of the workshop in Blackwater;

Simplicity is the key to effective risk management - back to basicsA JSA is a part of the complete risk management framework, however it is nota risk assessment. A wide variety of tools exist within a sound risk

management framework, it is important we educate (training and coaching)

our workforce to effectively use the risk management tools most relevant to

them

Residual risk scores provide clarity around priority setting, they do notindicate a level of risk acceptance

Critical control effectiveness should be the key driver of risk tolerability. We

must challenge ourselves to devise ways to continually monitor critical control

effectiveness so that it becomes a common understanding and a part of the

way we operate.

Risk management is the key foundation to Safety and Health management,however it is an area that has been somewhat neglected and misguided over

the past 5 - 10 years. It was encouraging to see so much interest in this topic

and to discover such commonality in thinking. To achieve

the greatest improvement in risk management, within the mining industry, we

need to strive to achieve a more consistent approach, if there is anything that I

may be able to do to further assist in achieving this, please let me know.


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Key Points (Adam Garde)

The few points I feel are truly important to making a positive difference with regard

to improving risk management in the workplace are as follows;

Current legislation places obligations on all mineworkers, and for a person todischarge those obligations then all possible action must be taken to reduce the

level of risk that personnel are exposed to within our operations to an ALARA

level. Ignorance, short cuts, poor planning, training or available resources,

under no circumstances makes it allowable not to do everything that is

possible to protect the health and safety of all concerned. With this point in

mind, no matter the risk identification or management tool utilised by an

operation, the key purpose remains the same, hazard identification and

acceptable control are the outputs required from the process.

Nearly all mines have a documented SHMS that on paper meets therequirements of legislation in regard to having prescribed PHMPs and

SOPs etc. The key to improving the safety of the mine environment and the

workforce is for the workforce to have an active understanding and

involvement with their sites SHMS. The most perfectly written procedures

are useless without an understanding of how to implement and apply them into

every task within the mine. A safe mine and mine culture does not happen by

accident, it takes planning, effort, team participation and continual review.

Whilst it is the operators and tradesmen that normally perform the tasks on aday to day basis, it is critical that the people in supervisory and senior

supervisory roles have a real understanding of exactly what is involved in the

tasks they plan for completion. It is very easy to get bogged down and spend

the whole day glued to the computer, but if you really want to be a part of your

work groups and improve the performance in all areas, you need to spend real

time in the workplace and see the day to day struggles and then action the

issues to make a change. When planning tasks, ALL the required

documentation should support the daily plan. Auditing your procedures

against the actual way the tasks are done underground is the only way to

ensure your systems and documents are adequate.


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Key Messages (Andrew Morrell) ..

1 - Things go-wrong because of poor decision-making

All 'Mishaps'; be they, injuries, fatal injuries, damage or failures to deliver on critical

business objectives, are the result of one or more defective decision-makingsequences used within the organisation.

2 - Good quality Risk assessments support good quality decision-making

Timely, well-designed and completed Risk assessments are the best practice tool

that helps the organisation to maximise the effectiveness of its decision-making. It

does this by generating thorough understanding of what needs to be done, by when

and the methods to be used that ensure that required outcomes are achieved, despite

the presence of threatening, and often uncertain, energies/hazards.

3 - The quality of risk assessments is entirely dependent on the process used

The value of a risk assessment is dependent on the integrity of the processes used and

how it is implemented so that it accurately:

3.1 Identifies the steps that will be taken to achieve the required outcomes;

3.2 Prioritizes the issues that threaten the required outcomes;

3.3 Uses sound principles of Hazard (energy) Control that ensure the

adequacy of control over the life of the assets being considered (including the

potential for failure-on-demand);

3.4 Harnessing the strengths of group analysis (e.g. synergy) without

suffering from the inherent weaknesses of Group Think, Bias or Capture by

individuals; and3.5 Reveals those things that the organisational decision-makers didnt know

that they didnt know.

4 - To be duly-diligent Hazard Control must be founded on sustainable &

justifiable logic

It is important to understand that most risk management concepts are based on

models of the real world. If these models are pushed too hard, they can fail to yield

helpful answers (or worse still they can give the wrong answer).

Some examples are: the use of the 5 x 5 matrix to estimate controlled risks, a task for

which, this simple and useful tool, was not designed. It is important to

understand that it is a tool designed to logically allocate limited

organisational resources with some capability to drive referral to other

managerial or expertise levels; it is not a useful tool to measure hazard

control effectiveness.

Use of matrix risk ranking can inadvertently encourage personnel torank risks off-the-page as a method of avoiding effort (particularly in

JSAs or WRAC exercises)

Quoting residual risks, using a 5 x 5 matrix, often results indocumented evidence of risks being accepted that are indefensible inlaw. The chosen risk rating is not an acceptable risk because the


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matrix was only intended for use as measure of raw risk and unless

consequences can be significantly reduced the matrix will always

prioritise the risk as unacceptable (too high). Good practice does not

require qualitative residual risks, instead it needs evidence of adequate

hazard control!

Relying on arbitrary judgements on residual (controlled) risk using arisk matrix without a full explanation of how the reduction is to be

achieved through the use of chosen layers of protection over the life of

the asset.

5 - Beware of ill-considered delegation in risk decision-making

The tools of risk assessment (JSA, WRAC, HAZOP, FMECA, FTA, Bowtie etc.)

can usefully be employed, together or individually, at any organisational level in an

organisation. However, it is important to recognise that for each level, the specific

needs for sound risk assessment are different. The competence set of those taking part

in the risk assessment must be sufficiently wide and deep, to provide the rightanswers. It is vital that each managerial level of risk assessment process is tuned to

reflect the authorities and accountabilities of those charged with providing guidance to

decision-makers. In every type of risk assessment, someone in the risk assessment

exercise has to be held accountable for ensuring the integrity of the assessment

process, irrespective of other organisational priorities.

6 Managements job is to find the right balance between thoroughness and

efficiency.

The real challenge for organisational management is to ensure that there is adequate

and effective effort put into risk assessment and hazard control implementation in

order to deliver on the organisationss aspirations for an adequate return for all

stakeholders. This requires the organisation to embed an in-depth understanding of

capable risk assessment processes and the will to adopt it, even in the face of the

relentless imperative to be efficient.


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Key Messages (Richard Mills)

In general mine personnel are not developing a risk assessment scope to thelevel of detail required so the outcome is a risk assessment that does not

adequately address the issue when it is completed

Risk assessment documents at various sites have a similar basic WRAC layouthowever not all encompass the required information input to prompt /

encourage the necessary prework

JSA formats are not suitable for all risk assessment tasks and limited personnelhave the confidence and skills to complete a comprehensive WRAC FMEA or

HAZOP etc or know when they should be used and help of a skilled facilitator

is required

Separating or explanation of hazards in the correct terms (task, what could gowrong, why could that go wrong) to promote the use of targeted control

methods rather than generalisations (encourages the correct use of the

hierarchy of controls)

Personnel are being educated in basic JSA and modified JSA methods andsome times WRAC through S1, S2,S3 and G2A process but in the field my

experience has shown there still exists a considerable lack of knowledge in

risk management by front line supervisors

There is a tendency to rush the process which misses the necessary detail ordoes not adequately address the task, hazard and controls effectively.

Commitment is required to provide the right people not just anybody Suggestion of some site risk management professionals that would be charged

with vetting the scope prior to completing the risk assessment may improve

the quality (typically some sites have the UMM or MM approve the scope

prior to commencing the RA)

A common matrix approach across industry Removal of any use of a matrix from the simple JSA approach An industry understanding that Risk Management is not just a WRAC or JSA

but a bag of tools that requires knowledge of what tool is best used where

when completing a risk management exercise.


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Guidance Point #1

Selecting the most appropriate risk assessment tool

Context

There is a general lack of understanding as to what risk-assessment tool needs to be

applied in what circumstance. There is not enough effort in establishing the context,

purpose and scope. These are critical steps and assist in selecting the most appropriate

risk assessment tool.

Potential Action Plan

Recognised Standard 2 (or the equivalent document to be aligned withthe harmonised legislation in 2012) to be amended so that it becomes

more effective in assisting people to select the most appropriate risk

assessment tool

To include checks on process performance To include strategies and guidance on how to avoid traps that lead to

ineffective risk management processes (refer to National Minerals

Industry Safety and Health Risk Assessment Guideline)

To include guidance on how mines are to comply with s 62 Safety andHealth Management System (1) A safety and health management

system for a coal mine is a system that incorporates risk management

elements and practices that ensure safety and health of persons who

may be affected by coal mining operations the Mine Site Risk

Management Standard.

The Mine Site Risk Management System (s62) forms a part of theSHMS- it should explain how the mine implements and applies

Recognised Standard 2. It should include for example authorisation

process and checks for scoping and facilitation via the most

appropriate risk assessment tool eg. WRAC vs JSA.

Relevance to existing processes

S62 Safety and Health Management System Recognised Standard 2 Control of Risk Management Practices The Coal Mining Safety and Health Advisory Council In fulfilling its

mandate is to Periodically review the effectiveness of the Act,

regulations and recognised standards, and the effectiveness of the

control of risk to any person from coal mining operations.

Recognised Standard 9 Guidance Note on Reviewing the Effectivenessof the Safety and Health Management System


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Notes related to Guidance Point #1

Selecting the most appropriate risk assessment tool

What Jim Joy said about that..


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Guidance Point #2

Training and Educating people to make effective decisions when applying and

implementing risk management practices

Context

There is a need to re-educate people who apply and implement risk management

processes. There is inconsistency in establishing the context, purpose and scope, and

in selecting and applying the most appropriate risk assessment tool.

People without the necessary technical competencies and knowledge of the Safety Health

Management System are appointed to supervisory positions. G2 and G3 training alone

may not have been sufficient in effectively implementing effective risk management

practices. Understanding what, why and how may have gone unchecked.

Potential Action Plan Ensure that people on site are appropriately trained in the mine site

system on how to implement the Risk Management System. Consider

relevance of the site Training Needs Analysis (Regulation 84).

This can also be addressed in the review of Recognised Standard 2 (orthe equivalent document to be aligned with the harmonised legislation

in 2012).

Consider if it justifies being a Prescribed tasko Set expectations with RTOs. Raise implementation issues associated

with risk management practices on mine sites. RTOs to make

adjustments to training material and verify same.


This extract immediately below is from the ANNUAL REPORT of the COALMINING SAFETY AND HEALTH ADVISORY COUNCIL July 2008 - June

2009

Quality of Competency Training

Discussion on the quality of competency training, and the performance of

Registered Training Organisations (RTOs), concluded that delivery ofcompetencies and testing is often substandard.

The Council has begun to investigate options raised, including the possibility of

training providers to be recognised by the Board of Examiners or the Council, or

whether it is possible for the Department of Employment, Economic

Development and Innovation to have a list of preferred or authorised RTOs. It

was decided to make RTO training a permanent item on the Councils agenda.

82 Training scheme 84 Refresher training 85 Coal mine worker not to carry out task unless competent Schedule 7 Prescribed tasks for section 76(3)(a) of the Act


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Training and Educating people to make effective decisions when applying and

implementing risk management processes



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Guidance Point #3

Inconsistent application and use of Job Safety Analysis (JSA)

Context

JSA forms a healthy part of on-site risk management practices. There are however

inconsistencies in;

Deciding if JSA should be risk scored. Deciding if a JSA should be converted into a documented procedure, in

which case it can be re-used, and reviewed.

Deciding if a procedure developed from JSA is an SOP. If it is, then; Recognised Standard 2 requires it to be risk scored, and Regulation 10

requires it to be developed in consultation with other affected

mineworkers.

Subject to a plan to regularly review if the practice is at an acceptablelevel of risk (s62(1)(f)).

Potential Action Plan;

Recognised Standard 2 (or the equivalent document to be aligned withthe harmonised legislation in 2012) to be amended so that it becomesmore effective in assisting mines to apply JSA. Tri-partite to decide the

above issues, in consultation with Jim Joy.

Potential review and update of National Minerals Industry Safety andHealth Risk Assessment Guideline (v6, 2007).


Recognised Standard 2 Control of Risk Management Practices s10 Standard Operating Procedures s11 Accessing standard operating procedures


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Inconsistent application and use of Job Safety Analysis (JSA)



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Guidance Point #4

Hierarchy of controls, and control effectiveness

Context

In the absence of specific expectations, too much onus is placed on administrative

controls. This maybe influenced negatively by corporate pressure. Sometimes there is

a lack of commitment to engineering/hard controls. Ineffective decision making can

lead to;

Inappropriate controls being identified Critical controls not effectively identified or implemented

Review processes often fail to validate control effectiveness.

Qld Coal Mining Safety and Health legislation does not reference effectiveness of

control hierarchy, other than in Guidance Note 9.


Recognised Standard 2 (or the equivalent document to be aligned with theharmonised legislation in 2012) to be amended to include strategies and

guidance on the identification of appropriate control strategies including

reference to the hierarchy of controls, the identification of critical controls, and

measuring the effectiveness of controls.


S62 Safety and Health Management System Recognised Standard 2 Control of Risk Management Practices Recognised Standard 9 Guidance Note on Reviewing the Effectiveness

of the Safety and Health Management System (Part 9 causal Analysis).


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Notes on Guidance Point #4

Hierarchy of controls, and control effectiveness



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Guidance Point # 5

There may be a need for some mines to improve the effectiveness of their SHMS

in respect to risk management processes. In particular the implementation of

consistent risk management practices, review, and document control.

Context

Section 62 Safety and health management system states(1) A safety and health management system for a coal mine is a system that

incorporates risk management elements and practices that ensure safety and health of

persons who may be affected by coal mining operations.

Notes from the Workshop Flyer

We spend days reviewing SOPs that have not materially changed in yearsbecause the procedures are not fully integrated into the way of working of the

mine. Management are not aware of their responsibilities under or

responsibility for the maintenance of the Safety Health Management System

and therefore there is no ownership.

Senior Management may profess to making safety their number one priorityyet fail to maintain the systems that manage it. Coal mine workers may use

the Safety Health Management System for purposes other than intended. In

the search for clarity and brevity accusations are made of watering down the

system. Most companies now employ electronic risk management systems

and process such as First Priority Enterprise, SAP and Hummingbird but theSafety Health Management System has not necessarily been fully integrated

into these.


Recognised Standard 2 (or the equivalent document to be aligned with theharmonised legislation in 2012) to be amended to include strategies and

guidance on how to measure and improve the effectiveness of risk

management processes, including document control.

To incorporate the need for investigation processes to evaluate theeffectiveness of controls identified in previous risk assessments.


s15 Investigating accidents and incidents Section 62 Safety and health management system Recognised Standard 9 Guidance Note on Reviewing the Effectiveness

of the Safety and Health Management System


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Notes on Guidance Point # 5

There may be a need for some mines to improve the effectiveness of their SHMS

in respect to risk management processes. In particular the implementation of

consistent risk management practices, review processes, and document control.


2 notes from the risk management workshop

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