


Studies show that human factors are responsible for nearly 60-80% of mishaps and nearmiss incidents. These human errors can be identified and controlled using a continuous
integrated management system.
Understanding the frequency and severity of human errors as well as the root cause helps
business determine which innovations are needed to reduce risk. Oftentimes, business has
not developed a risk register to identify all of the ergonomic issues, especially those related
to psychosocial disorders. Our research has found that shift changes, fatigue, work stress,
poor planning, and other factors lead individuals to make decisions that put them at risk of
injury or illness. These decisions may also result in catastrophic property damage,
interruption in business continuity, damage to business reputation, brand, and image, as
well as loss of production and profitability. Occurrence of the human factor issues can be
reduced or eliminated by changing the safety culture and behavior at all levels within the
organization. This includes, but is not limited to setting policy, developing written
programs and procedures, identifying hazards, communicating the hazards and associated
risk with stakeholders, engaging employee participation, monitoring the work or project,
collaborating on systematic changes to improve human performance and ensuring
continued improvement.
Practical recommendations and conclusions:
• Integrate risk governance with techniques applied in the human factors to improve the safety
management of process hazards
• Review best practices in similar industry around the world and other industries
• Hold industry workshops to present and review the proposed approach and seek stakeholder input on
human factors content
• Balance prescriptive and goal setting approach and predictive solutions to deliver a more human
approach to industry
• Use predictive analytic data to determine how human factors concerns can be applied to hazard
identification and risk control
• Industry needs to raise the bar using predictive analytic data to improve human performance, reduce
risk, limit liability, sustain productivity, and meet regulatory obligations
• Focus on managing process major hazards through the design and incorporation of more complex
equipment and systems
• Challenges of industry continue and require multi-disciplinary and cross functional collaboration
(internal/external) to the organizations even when manpower and resources are stretched
• Industry has made great progress managing process related hazards and preventive strategies to
protect workers, property, and environment.
• Accidents continue to happen and the majority of them can be linked to a human error or inadequate
human performance.
References
The Human Factors Analysis and Classification System—HFACS; Shappell, S.A., and Wiegmann,
(2000) D.A., Report DOT/FAA/AM-00/7, Federal Aviation Administration, 800 Independence
Ave., S.W. Washington, DC 20591
Health and Safety Executive (HSE) Offshore Division, Human Factors and Organizational Factors
Strategy (2009 – 2012)
Human Factors, WorkSafeBC, 2014
OPNAV Instruction 3500.39C, Operational Risk Management, Department of the Navy Office of
the Chief of Naval Operations (2010)
National Institute of Standards and Technology Special Publication 800-30 Natl. Inst. Stand.
Technol. Spec. Publ. 800-30, (2002)
Miccolis, Jerry, and Samir Shah. Enterprise Risk Management, an Analytic Approach.
Tillinghast - Towers Perrin. A Tillinghast - Towers Perrin Monograph. 1-36. 18 Apr. 2008.
Presented by:
Bernard L. Fontaine, Jr., CIH, CSP, AIHA Fellow
The Windsor Consulting Group, Inc.
Courtesy of Patrick O Connor and Ken Arnold
Hazard Management and the Importance of Human Factors
Presentation to the Marine Board
Human Factors in Incidents
Person
Errors
Violations
Development of an Organizational Accident (developed from J. Reason)
Baker report on Texas City: “[BP’s] employees were not
empowered with a positive, trusting, and open
environment with effective lines of communication
between management and the workforce.”
Kansai Electric Power Company incident (which killed 5
people) in Mihama, Japan in August 2004 was attributed to
‘a demise in safety culture’.
Lord Cullen in his report on the causes of Piper Alpha: “it
is essential to create a corporate atmosphere or culture in
which safety is understood to be and accepted as, the
number one priority.”
“80-85% of accidents over a reporting
period of 1999 to 2001 involved human
error (USCG)
50% of these initiated by human error,
another 30% of these associated with
human error”
Hazard, Risk and Safety
Management
Hazard, Risk and Safety
Management
Planning
phase
Performance
phase
Assessment
phase
Improvement
phase
Setting policy
Communication
Active
monitoring
Review
Organizing
Employee
participation
Reactive
monitoring
Continual
improvement
Identification &
assessment
Acceptance
monitoring
Procedures
Safety Management System (SMS)
Using national and international standards, guidelines, and
practices, safety management systems provide widespread
benefits in productivity, financial, human performance, quality and
other business objectives.
Management leadership and commitment – manpower and resources
Employee participation and engagement – surveys, training, meetings
Planning – written rules, SOPs, and JSAs
Implementation – surveys, inspections, audits, and safety committee
Operation – written safety program, leading and lagging indicators
Evaluation – annual self assessment and mishap investigations
Corrective action – relative to outcome of lagging/leading indicators
Management review – annual program evaluation for improvement
Human Factors and Safety
Human Factors
and Safety
Topics
Procedures
Inspections, Audits,
Workplace Surveys
Training
Organizational
Culture
Relevant human
factors to worker
health, safety, and
risk governance
Written, technically correct,
maintained and accessible,
and easy to understand.
Hazard identification and
quantitative or qualitative
risk assessment of
workers in critical roles
Competence in job
function, knowledge of
hazard and control
measures
Leadership support of
compliant workers and
workers seeking
improvement
Associated health
and safety
outcomes from
performance
Applied, tested, and reevaluated for valid human
performance. Evaluate
personnel decision-making
needs. Right tools for job
and used correctly.
Evaluate fitness for duty
Measurement of worker
exposure, monitor of work
performance, and
evaluation of competence.
Consider human factors
and ergonomic issues.
Evaluate proficiency of
completing work tasks.
Training applicable to
specific hazards and risk,
and capability for each
worker. Matched skills
and aptitude. Know how to
use right tools or
equipment and report
deficiency gap in safety.
Evaluate safety
climate and culture
Construct of safety
policy, program, and
operating procedures
Provide right tools and
equipment for job.
Report deficiencies.
Critical Elements
Procedures reviewed and
relevant to current
operations/process.
Critical tasks identified
and analyzed. Work
aligns with hiring process
Evaluation of mishaps,
near-miss events, levels
of exposure, and safety
controls. Workers
capable of completing
job tasks/assignments
Formal and practical
training provided for
identified hazards
and/or training to use
and operate equipment
and machinery.
Training objectives
commensurate with
safety hazards/risk.
Workers selected
based on capability
and experience.
Performance
Indicator(s)
Percent (%) of operating
procedures based on
recent self-assessment of
human performance
(Leading indicator)
Percent (%) of facility
inspections, audits,
surveys both planned vs
performed annually
(Leading indicator)
Number of workers or %
of staff provided safety
training and determined
to be competent
(Leading indicator
Health and safety
climate measurement
and evaluation of
psychosocial issues
(Leading indicator)
Commitment: In the face of ever-increasing commercial and
economic pressures, does the organization have the will to make
SMS tools work effectively?
Cognizance: Does the organization understand the financial and
social impact of safety relative to the involvement of human and
organizational factors?
Competence: Neither of the other two drivers is sufficient without
the necessary practical skills. Does the organization’s SMS possess
the right tools, and are they properly understood and utilized
appropriately by leadership and the workforce?
Predictive analysis and solutions can be applied to properly manage
human factors issue related to safety management and risk.
Drivers for Human Factors
in Safety Management and Risk
Commitment
Cognizance
Competence
Principles
Safety management is an
integral part of the business
process. Past events are
carefully reviewed; novel
scenarios are imagined. Top
management is actively
engaged in safety-related
issues.
No final victories in the safety
war. Human fallibility and natural
hazards will never be eliminated, only
moderated. Organization understands:
person, engineering and system models
of safety management It expects its
workforce to make errors and trains
them to detect and recover. ‘Upstream’
systemic factors are easier to manage
than fleeting psychological states like
inattention or forgetfulness.
Organization recognizes that the
effective management of safety. It
involves the regular sampling of a
variety of organizational parameters
(scheduling, planning, resource
allocation, procedures, defenses,
training, communication,
production conflicts, and the like),
identify which of these ‘vital signs’
is most in need of attention, and
carrying out remedial actions
Policy
Company policy to remind all
levels of leadership that
safety is everyone’s
responsibility. Resolve shortterm production and
protection issues safely.
Policies should be in place to
encourage safety
messengers.
Organization should publically
recognize critical dependence of
effective SMS upon the trust of the
workforce. A safe culture is the product
of a reporting culture that, in turn, can
only arise from a just culture. Use
crisis emergency and recovery planning
to test business.
Policies relating to near-miss and
incident reporting should make
clear the company’s stance.
Disciplinary policies should be
predicated on distinction between
acceptable/unacceptable behavior.
Key determinant is not so much the
act — error or violation—as the
nature of the embedded behavior.
Excerpts taken from unpublished paper entitled “Human Factors Aspects of Safety
Management Systems” written by James Reason
Drivers for Human Factors
in Safety Management and Risk
Commitment
Cognizance
Competence
Procedures
Organization should establish
written operating procedures
for each work task based on
hazard identification using a
job safety analysis and risk
assessment. Controls should
be identified to include
engineering, administrative,
and finally the use of personal
protective equipment suited
for the individual work tasks.
Procedures, i.e., maintenance, should
not only explain how the job be done,
but also identify the likely error-prone
steps in the task. Training in the
recognition/recovery of errors should
support appropriate procedures. Inform
by data on recurrent error traps derived
from safety information reporting
systems. Procedures should be well
written in cooperation with those
actually experienced doing the job.
Procedures should be appropriate,
accessible, intelligible and
workable. Write procedures with the
understanding that people hardly
ever read and do at the same time.
Such a balance is very important in
relation to intrinsically errorprovoking activities like repairs and
maintenance activities.
Practice
Routine audits, inspections,
and surveys along with
interviews of the workforce
are needed to understand
what gets done and how it
gets done. Errors and
omissions can be detected
and corrections made before
a crisis develops.
The ‘safety health’ of the organization
should be continuously monitored
using both reactive outcome data and
proactive process measures. The
former help to identify recurrent error
traps, while the latter focus attention
upon current systemic weaknesses. Use
rapid, useful and intelligible feedback
channels to communicate the lessons
learned and the actions needed.
Visible top-level involvement in
safety practices. Management
should not only walk the talk,
but also talk the walk. Each level of
management should understand the
hazards and risks associated with
the work and the need to have
established policy, programs, and
operating procedures to the work.
Excerpts taken from unpublished paper entitled “Human Factors Aspects of Safety
Management Systems” written by James Reason
Operators setting up the process made an error and tank
outlet inadvertently closed causing the phenol to overflow
No one was injured, but the direct cost in loss of materials,
lost production and recovery of the phenol was £39,800.
Indirect cost not calculated.
Investigations found the system for controlling pumps and
valves was badly designed and prone to human error.
Phenol is a systemic poison from exposure by inhalation and
direct skin contact and absorption
Source: HSE website www.hse.gov.uk/comah/index.htmT
Human Factors in Safety
Management and Risk Governance
Engineering
Safety management
Accident
rate
Human factors
Time
Human Factors in Safety
Management and Risk Governance
Engineering
Safety management
Accident
rate
Human factors
Time
Better design
More
procedures!
Human Factors in Safety
Management and Risk Governance
Engineering
Safety management
Accident
rate
Human factors
Time
Need to design
More
better engineering procedures!
Behavioural
modification
will fix it…
Human Factors in Safety
Management and Risk Governance
Continuous improvement
Engineering
Safety management
Accident
rate
Human factors
Time
Better design
More
procedures!
Behavioural
modification
will fix it…
Human Factors in Safety
The “Engineers Graph” or why I don’t need to do anything...
Management and Risk Governance
Continuous improvement
Engineering
Safety management
Accident
rate
Workforce
involvement
Human factors
Time
Better design
More
procedures
Behavioural
modification
will fix it…
Is there a way to establish a true and measure effective safety
culture within the industry that ensures how people recognize
risks and act upon them decisively?
Does the current leadership and organizational structure
adequately manage the health or safety risks in the industry?
Does leadership understand the hard and soft aspects of the
human element and direct/indirect cost associated with errors?
Are global occupational health and safety policy, programs, and
procedures too rigid/complicated or inadequate to manage risks?
Is risk communication used to affect safety culture and change
management as a driver for the continuous improvement of the
safety management system?
Organizational Challenges
10 Human Factor
Intervention
20 and 30 Human Factor
Interventions
Leading Indicators
Lagging Indicators










Total lost work days
Restricted work days
Number of fatalities
Injuries/illness rate
Asset/property damage
Vehicle mishaps
Near-miss incidents
Chemical releases
WC trends and amount
Experience modification










Safety/health meetings
Supervisor training
Employee training
Number of inspections
No. of audits/surveys
No. of self-inspections
Reward/recognition
Employee turnover rate
Observations/accidents
Risk/hazard assessment
Organizational Challenges
Unsafe Acts
Errors
Decision
Errors












Improper work procedure
Misdiagnosed situation
Wrong response action
Exceeded ability/authority
Inappropriate maneuver
Poor decision making
Adverse mental state
Haste or task saturation
Situational awareness
Failed to use resources
Hiring the wrong person
Fail to track performance
Skill Based
Errors













Breakdown in visual scan

Failed to prioritize focus

Inadvertent use of controls 
Omitted step in procedure 
Omitted checklist item

Poor technique or ethic

Over reaction to controls

Inexperience or capability

Adverse physiological state 
Physical or mental limitations
Inadequate safety training 
Lack of intelligence/aptitude 
Lack skills or qualifications 

Violations
Perceptual
Errors
Misapplied skill set
Spatial disorientation
Visual illusion
Misunderstood task
Misunderstood rules
Poor work environment
Miscommunication
Tight time constraints
Personal readiness
Work/home distraction
Mental complacency
Inadequate reaction time
Inadequate rest breaks
Time pressures
Exceptional
Routine

















Failed job requirements
Failed to follow direction
Lack of worker training
Breakdown communication
No supervisor oversight
Hazard not identified
Controls in-place not used
Substandard work practices
Pre-existing illness or injury
Failure of leadership to act
Failure to correct problem
Failed to enforce the rules
Failed to report unsafe acts
Lack of funding
Excessive cost cutting
No formal accountability
Poor equipment design










Unauthorized work
Exceeded authority
Over reaction
Lack of capability
Lack of qualification
Except very high risk
Poor planning
Lack of objectives
Unrealistic goals
Under manned/resourced
Things we know:
Process hazards are understood but human risks vary in uncertainty
The value of managing hazards/controlling risk robustly is accepted
Principles of inherent safety are clear but sometimes ignored
Risk assessment techniques are available and proven within industry
However:
Major hazards, other than process and production; human factors
do not always receive the same level of attention in the initial phase
of design and fabrication
Preventing major accidents tends to focus heavily on the hardware,
less on the outcome of the human experience or performance
Designs continue to increase in complexity but the human element
remains unchanged or not considered a critical factor
Change management does not always consider human factors in
final equation since it is considered inherent to the organization
Hazard ID, Risk Assessment & Prioritization
Triggers
Tools
-New Projects
-M AR
-Renew al of Facilities
-HAZID
-New Standards
-HAZOP
-Incident Response
-LOPA
-Periodic Review s
-FM EA
-Audits
-Regulatory
-Employee Concerns
-Excursions
Risk M itigation Planning & Controls
Options
Decisions
Plan
-Engineering Studies, FEL
-Partner Approval
-Roles &
-Non Engineering Options,
-Residual Risk
Responsibilities
-Business Decision Process
-M milestones/
-Commercial Decisions
Dates
e.g.
Major
Hazard
& Risk
Register
-QRA
Emergency Response Plan
-Evaluation by Risk Ow ner
Levels of authority based
on level of risk
Integrated Engineering
and Business Plan
-Blast Study
• Priority
• Resources
• Progress Tracking and Review s
Administrative Controls
-ESSA
-EERS
Execute Plan
-Action Tracking
• Update
-Progress
Communicate Hazards & Plan
Review s
Common Risk Matrix
Text Description
Continuous Hazard Assessment and Risk Reduction
M anagement Review & Improvement
Management
Review s
Improvement
Thru Strategic
Direction
Risk
Management
System
M easurement, Evaluation & Corrective Action
KPI
M easurement
Profile &
Score Cards
Evaluation
Corrective
Action
-Action Tracking
-Text
-Text
-Text
-Text
-Text
-Text
-Leading Indicators
-Text
-Text
-Text
-Text
-Lagging Indicators
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
-Text
Evaluate the Human Element
Most Common Issues…
Organizational change
Fatigue and shift change
Staffing levels/workload
Organizational culture
Training and competence
Human factors in design
Operating procedures
Communications/interfaces
Managing human failure
Integration of human factors into risk
Correct hard/soft skills
Assessment and investigations
/
Behavioural safety = Human factors
Balance of Hard and Soft Skills
Hard Skills
Soft Skills
Calculate to solve problem
Good manners and trustworthy
Operate machinery
Time management
Speak a foreign language
Accept suggestions or criticism
Following directions
Ability to ask for help or support
Demonstrate competence
Integrity and leadership
Previous work experience
Teamwork and adaptability
Failure to correctly specify behaviour
Individual involved not informed of issue or incompetent
Task personnel engaged in at the time not discussed/informed
What they did (or did not do) – human error related to knowing
the operating procedure and understanding the process
Communicating risk and outcome if rules are not followed
Making early decisions and sticking to them
As new information becomes available, a critical decision may
result in violation of safe operating procedures
Failure to identify the multiple individual and/or organizational
behaviours contributing to a mishap or near-miss incident
Timeline critical and sensitive to process or operation
Safety Behaviour/Risk at Work
Company Understanding
The reality is…
Management should…
Personnel will follow established
written rules for occupational health
and safety while at work. Workers will
ask questions about unfamiliar
assigned work tasks or when
operating new equipment.
Procedures are often out of date,
poorly written, vaguely understood or
ambiguous. Lack of training by
supervisor forcing people make up
their own rules to do the work.
Find out why procedures are not
followed, Determine if the process or
operation can be improved or become
more efficient by engaging
stakeholders. Hire competent talent
and training personnel in the hazards,
risks, and controls.
Personnel will be competent in
everything they do. They have been
hired with the skill sets to do the job
based on past performance training,
and qualifications. Younger hires are
more familiar with safety technology
because of their education to do the
job right.
Everyone has gaps in their knowledge
and understanding of the operation or
process, equipment or machinery
used, and requirements to reduce risk
and use engineered control measures.
Some companies have lost highly
experienced personnel due to attrition
or economic downsizing.
For novices: provide supervision and
train on safety procedures
For those whose knowledge is ‘rusty’:
reassess capability and gaps and
provide refresher training
For those who are leaving: plan to
mentor others to take over by learning
from the experience of old hands
before they retire.
Personnel are highly motivated in their
work, organization, and career.
Personnel demonstrate positive work
ethic, good attitude, and desire to
learn or be trained.
Even the person in their ideal job has
some ‘off days’; routine tasks are
simply boring and workers become
complacent. Workers have social,
religious, or family issues.
Design jobs to stimulate interest; use
engineering/administrative controls to
reduce risk. ‘Rotate’ in and out of the
most boring but necessary jobs.
Consider time-off
Safety Behaviour/Risk at Work
Company Understanding
The reality is…
Management should…
Personnel are always where
they should be
People wander off or are asked to do
favors for others that takes them out
of their normal workplace Downsizing
stress limitation on coverage and
availability.
Accept that people won’t always be
where they should be. Provide radios
and pagers. Arrange for back up cover
when someone really does need to go
elsewhere
In an emergency, personnel will make
right decisions to ‘save the day’
Real emergencies are often highly
complex and stressful. People don’t
react as in the emergency plan
Practice emergencies so everyone is
familiar with required routines and
maintains skills for infrequent events.
Provide clear information/instructions.
Have contingency plan and ensure
everyone knows role and responsibility
Work highly reliably: be very unlikely
to make an error
All tasks are prone to human errors –
some more than others. Human errors
are a major cause of accidents and can
occur in all jobs including operations,
repairs, maintenance, adjustments,
modification and management. Job
safety analysis provides insight into
the hazards and controls for each
phase of the operation or process.
Consider human and operational error
when assessing/evaluating risk. Make
safety systems as ‘forgiving’ as
possible (resistant to error; allow time
for correcting the error). For safety
critical tasks, make sure key steps are
independently checked, and that
procedures and other job aids are
clear. Avoid a ‘blame culture’ game.
Other key problems we have found from inspection and assessment are:
 Too much emphasis being placed on reducing personal accidents (slips,
trips, falls etc.) without an equal focus on preventing major accidents
 Failing to realize that that safety culture is about everyone in the company,
including managers and senior leadership, not just the ‘front line’
 Not being clear how the safety management system will prevent or reduce
human errors which may lead to major accidents
Linear risk problems can be managed using a ‘routinebased’ strategy, such as introducing a law or regulation
Complex risks may be best addressed by accessing and
acting on the best available scientific expertise, aiming for a
‘risk-informed’ and ‘robustness-focused’ strategy
Uncertain risks are better managed using ‘precaution-based’
and ‘resilience-focused’ strategies, to ensure the
reversibility of critical decisions and to increase a system’s
capacity to cope with surprises
Ambiguous risk problems require a ‘dialogue-based’
strategy aiming to create tolerance and mutual understanding
of conflicting views and values with a view to eventually
reconciling them
Based on both the evidence from the risk appraisal and evaluation
of broader value-based choices and the trade-offs involved, decide
whether or not to take on the risk.
Prohibition or
Substitution
Reduction
Acceptance
Risk so much greater
than benefit that it
cannot be taken on
Benefit is worth the risk,
but risk reduction
measures are necessary
No formal intervention
necessary
Basic elements of Risk Governance:
Pre-appraisal of industry hazards
Hazard identification of all occupational risks
Assessment via risk register
Mitigation and strategic management planning
Review for change and continuous improvement
Two broad approaches to apply these principles
Prescriptive
Goal Setting
Management Sphere:
Decision on & Implementation of Actions
3
Pre-Assessment
Pre-Assessment:
Risk Management Strategy:





Assessment Sphere:
Generation of Knowledge
•
•
•
•
routine-based
risk-informed/robust focus
precaution-based
resilience-focus
discourse-based
Problem Framing
Early Warning
Screening
Determination of Scientific Conventions
Management
Risk Risk
Management
Risk Appraisal
Risk Appraisal:
Implementation
• Option Realisation
• Monitoring & Control
• Feedback from Risk Mgmt. Practice
Risk Assessment
• Hazard Identification & Estimation
• Exposure & Vulnerability Assessment
• Risk Estimation
Communication
Concern Assessment
• Risk Perceptions
• Social Concerns
• Socio-Economic Impacts
Decision Making
• Option Identification & Generation
• Option Assessment
• Option Evaluation & Selection
Tolerability & Acceptability Judgement
Risk Evaluation
• Judging the Tolerability & Acceptability
• Need for Risk
Reduction Measures
2
Risk judged:
 acceptable
 tolerable
 intolerable
Risk Characterisation
• Risk Profile
• Judgement of the
Seriousness of Risk
• Conclusions & Risk
Reduction Options
1
Knowledge Challenge:
 Complexity
 Uncertainty
 Ambiguity
Design
Fabrication
Construction
Asset Lifecycle Integrity and Reliability
Operations
Pre-Assessment
Components
Definition
Indicators
1 Problem framing
Different perspectives of how
to conceptualize the issue
 dissent/consent on goals of selection rule
 dissent/consent on relevance of evidence
 choice of frame (risk, opportunity, fate)
2 Early warning
Systematic search for new
hazards
 unusual events or phenomena
 systematic comparison between modeled
and observed phenomena
 novel activities or events
3 Screening
(risk assessment and
concern assessment
policy)
Establishing a procedure for
screening hazards and risks
and determining assessment
and management route
 screening in place?
 criteria for screening: hazard potential,
persistence, ubiquity, etc.
 criteria for selecting risk assessment
procedures for: known risks,
emergencies, etc.
 criteria for identifying and measuring
social concerns
4 Scientific conventions
for risk assessment &
concern assessment
Establishing a procedure for
screening hazards and risks
and determining assessment
and management route
 definition of NOAEL
 validity of methods and techniques for
risk assessments
 methodological rules for assessing
concerns
Risk Assessment
 Hazard identification and estimation
 Exposure assessment
 Risk estimation
Concern Assessment
 Socio-economic impacts
 Economic benefits
 Public concerns (stakeholders and individuals)
Assessment
Definition
Indicators
1. Generation
Identification of potential risk
handling options, in particular risk
reduction, i.e. prevention,
adaptation and mitigation, as well
as risk avoidance, transfer and
retention







standards, voluntary agreements
performance rules
restrictions on exposure or vulnerability
economic incentives
compensation
insurance and liability
labels, information/education
2. Assessment
Investigations of impacts of each
option (economic, technical,
social, political, cultural)







effectiveness and efficiency
minimization of side effects
sustainability
fairness
legal and political implementability
ethical acceptability
public acceptance
3 Evaluation and
Selection
Evaluation of options (multi-criteria
analysis)
 assignment of trade-offs
 incorporation of stakeholders & the public
4. Implementation
Realization of the most preferred
option
 accountability
 consistency
 effectiveness
5 Monitor and
Feedback
 Observation of effects of implementation (link to early warning)
 Ex-post evaluation
 intended impacts
 non-intended impacts
 policy impacts
YES
RISK MANAGEMENT
DECISION PROCESS
DISCOUNTINUE
DISCOUNTINUE
OPERATION
OPERATION
Avoid / Eliminate
Identify Exposure to
Possible Loss
YES
YES
Transfer Risk
NO
Estimate Maximum
Possible Loss / Probability
of Loss
CSURMA
Self- SelfInsurance Pool
YES
Contractual
Transfer
NO
Is Maximum
Possible Loss
(MPL) Severe?
Commercial
Insurance
YES
Transfer
Refused
Risk
Remains
Too High
DO NOT PROCEED
Analyze Factors Affecting Size
of Possible Loss
Reduce Possible
Loss Size by
Positive Action
Insurance
Campus
Deductible
Eliminate
Source(s) of Loss
Assume
Calculated
Severe Risk
Does Any Severe
Possible Loss
Remain?
YES
YES
Assume Risk
Assume Low
Risk Exposure
PROCEED
Risk Communication
Management
Internal
•
Involving all affected regulatory or government bodies if risk
management measures have impacts on their mandate
External
•
•
•
Press conferences on selection of management measures (low
uncertainty and ambiguity)
Information of stakeholders about regulatory impact review and, if
needed, organisation of hearings (high uncertainty and low ambiguity)
Engaging in formal deliberations with stakeholders and representatives
of the public (high ambiguity)
Stakeholder Involvement at
Different Stages
Pre-assessment
Shaping the process (consensus on frames)
Design Discourse
Appraisal
Gathering information and knowledge
Epistemic Discourse
Assessment and Evaluation
Deliberating around values/perspectives and assigning trade-offs
Reflective Discourse
Management
Weighing pros and cons of management measures
Pragmatic Discourse (for low ambiguity)
Participative Discourse (for high ambiguity)
Civil society
Management/
Staff
Scientists/
Researchers
Management/
Staff
Affected
stakeholders
Scientists/
Researchers
Management/
Staff
Affected
stakeholders
Scientists/
Researchers
Management/
Staff
Instrumental
Epistemic
Reflective
Participative
Find the most
cost-effective
way to make
the risk
acceptable or
tolerable
Use experts to
find valid,
reliable and
relevant
knowledge
about the risk
Involve all
affected
stakeholders
to collectively
decide best
way forward
Include all
actors to
expose,
accept,
discuss, and
resolve
differences
Simple
Complexity
Uncertainty
Ambiguity
Actors
Type of
participation
Dominant risk
characteristic
As the level of knowledge changes, so also
will the type of participation need to change
Integrate risk assessment with techniques applied in the human
factors to improve the safety management of process hazards
Some steps to achieve this:
Review best practices from around the world with the industry
and other industries
Update best practices, provides more focus on the human
element, and addresses non-process related hazards more
robustly at the design and fabrication stage
Hold an industry workshops to present and review the proposed
approach and seek stakeholder input on human factors content
Balance prescriptive and goal setting approach and predictive
solutions to deliver a more human approach to industry
Using predictive analytic data to determine how human factors
concerns can be applied to hazard identification and risk control
Industry has made great progress managing process related hazards and
preventive strategies to protect workers, property, and environment
Focus on managing process major hazards through the design and
incorporation of more complex equipment and systems
Non-process related major hazards are well understood but receive less
focus than the process hazards during design and fabrication
Challenges of industry continue and require multi-disciplinary and cross
functional collaboration internal/external to the organizations even when
manpower and resources are stretched
Accidents continue to happen and the majority can be linked to a human
error or inadequate human performance
Industry needs to raise the bar using predictive analytic data to improve
human performance, reduce risk, limit liability, sustain productivity, and
meet regulatory obligations