Risk Tolerance Factor # 3 Seriousness of the Outcome Strategies for Understanding and Addressing Risk Tolerance Factor # 3 Seriousness of the Outcome The risk tolerance is all about answering the question “How bad could it be?”.

Seriousness of Outcome 10 Factors That Influence Risk Tolerance Overestimating Capability/Experience Familiarity with the Task Seriousness of Outcome Voluntary Actions and Being in Control Personal Experience with an Outcome Cost of Non-Compliance Confidence in the Equipment Confidence in Protection and Rescue Potential Profit & Gain from Actions Role Models Accepting Risk “How bad could it be?” When we believe that the outcome of our actions will not be serious, we are prepared to accept more risk. If we believe the outcome to be serious, risk tolerance goes down. This risk tolerance factor deals with the question ... “How bad could it be?” It is based on the premise that something could go wrong but we under estimate or discount how bad or serious the outcome could be. We may believe a ‘scratch’ or bruise could be the worst thing to happen where in fact it could actually be an amputation or broken bone.

‘Pinch’ or ‘Amputation’?? Seriousness of the Outcome The seriousness of the outcome from an action may be underestimated or understated due to: Having seen a negative outcome but the consequences were minimal: - i.e. seen H2S leaks but nothing worst than a bad smell was experienced - over pressured a vessel but nothing worse than a PSV releasing occurred Using language and descriptors that trivialize the true nature of the risk: - referring to a consequence as a ‘pinch’ when it is actually a ‘crush’ - referring to gas as ‘sweet’ when it is actually ‘explosive’. ‘Low speed incident’ or ‘fatality’?? ‘Pinch’ or ‘Amputation’?? When the question “How bad could it be?” is asked, the true consequences may not be realized due to a couple of factors. It may be because there have been similar incidents in the past but the resulting damages have always been minor. We may have seen several ‘Low Speed Vehicle Incidents’ where the results were minor scratches to vehicles. A history of these ‘minor scratches’ may lead us to believe that’s as bad as it could be in a low speed vehicle incident. Could the outcome be worse given a different piece of equipment? A history of minor H2S leaks may lead to complacency on how serious the outcome actually could be. A serious of over pressure events where the protective devices have worked properly could lead to a belief that a vessel failure would not be possible. The second aspect of this factor is the language we use that may trivialize how serious a consequence could actually be. Does a ‘pinch point’ sound serious? What about ‘sweet gas’? ‘Hot water’?

Seriousness of the Outcome Common language that discounts the seriousness of the outcome includes: ‘Pinch Point’ Is a ‘pinch’ the worst that could happen or is it a ‘crush’ that will brake bones or result in an ‘amputation’ Could this ‘pinch point’ result in a fatality? ‘Sweet Gas’ Is it really ‘sweet’ or should we refer to it as ‘explosive’ or ‘flammable’ ‘Hot Water’ - Is it just ‘hot’ like a Jacuzzi or hot tub or is it ‘scalding’ hot like condensed steam? Here are three common examples of where our language does not represent the true seriousness of the risk. The phrase ‘pinch points’ is commonly used throughout our industry to describe situations where a persons hand or body could become caught. The word ‘pinch’ does not represent how serious this could be. Workers have had hands and fingers amputated in ‘pinch points’. Bones have been crushed beyond repair in ‘pinch points’. And yes, workers have been fatally injured when caught in ‘pinch points’. These situations need to be referred to as ‘crush’ points and ‘amputation’ points. Similarly, we discount the seriousness of the explosive and flammable nature of gas when we refer to it as ‘sweet’. That word has a connatation of being harmless. Most people view ‘hot water’ at the temperature at which it may come out of a domestic tap, usually not more than 49 C. A ‘hot’ shower or a ‘hot’ tub can be viewed as relaxing. Yet in our work place we are dealing with industrial hot water at temperatures from 66 C to 99 C or condensed steam in the 99 C range. This is not ‘hot’ like we are used to at home. This is ‘hot’ that will result in third degree burns with as little as 3 seconds contact with the skin. This is ‘hot’ that has resulted in the hospitalization of workers in our company and the fatality of a company employee in April 2009. (see IOR presentation called ‘Flash and Splash’).

Seriousness of the Outcome Strategies for addressing risk created by under estimating the seriousness of the outcome: Use incident communications and safety alerts to demonstrate the seriousness of the outcome: Use language that more appropriately describes how serious the outcome could be: - ‘crush’ instead of ‘pinch point’ - ‘industrial or scalding hot’ instead of just ‘hot’ - ‘explosive’ instead of ‘sweet gas’ - ‘death trap’ instead of ‘unguarded rotating equipment’ The strategies for addressing risk tolerance due to not understanding the seriousness of the outcome focus on using our company and industry experience to demonstrate how serious the consequences could be and to change our language so that we do not ‘sugar coat’ the consequences. How serious could a ‘kick’ or loss of control on a well be? We can use the BP Deep Water Horizon incident from 2010 as an example. How serious could the outcome be with the cyclist? Can serious consequences happen when we do not use our signallers and spotters for moving equipment? Several fatalities have occurred in the past year in our industry doing this type of work. Point 2 reinforces that the language we use is important.

Exercise and Discussion on “Seriousness of the Outcome” Ask the question for each of the pictured scenarios “How bad could it be?” Relay actual events similar to these shown where the outcomes have been extremely serious. 1 Cable suddenly tightened and IP’s hand became trapped between cable and wench drum. 2 The intent of this slide is to generate a group discussion on very specific issues in this work place where this Risk Tolerance Factor may be an issue. Action items to address these should be documented with responsibilities and timing defined. Add in scenarios that this particular work group may be able to identify with. Background on these four slides. Slides 1 and 2 are from actual IOR incidents. Slides 3 and 4 are general scenarios that the workers may be able to relate past incidents to. In May 2002 a worker was putting on his fall arrest as he past by the rotating winch. The tail end of the harness went over the guard, caught on the line and pull the worker into the draw works. He was killed instantly. A worker was adjusting a portable light standard with the small hand winch. He grabbed the cable to adjust it and as he did it went tight and amputated two fingers. A general scenario of lifting loads. Possible outcomes ... Dropped on foot, crushed. Load swings and crushes worker against a solid object. The picker touches an over head power line. A general scenario on driving in harsh conditions. 3 4 What are we going to do about these?

Stop and Think ... How bad could it be ... really, how bad? The top photo is an incident re-enactment where an Imperial Oil contractor was fatally injured in Sept 1999 when a perforating gun discharged on surface. A short cut on disarming and the mix up of two wires, too simple little factors, yet the consequences were catastrophic.