Risk Tolerance Strategies for Understanding and Addressing

Risk Tolerance Strategies for Understanding and Addressing
January 2011 Presented by: D.J. (Dave) Fennell Senior Safety Advisor, Imperial Oil Resources Senior Technical Professional –Safety, ExxonMobil Production Company On behalf of: ExxonMobil Human Factors Center of Excellence Facilitators Note: This presentation package on Risk Tolerance was developed to communicate the results of an ExxonMobil Working Group and the ExxonMobil Human Factors Centre of Excellence who have researched the concepts of Risk Perception and Risk Tolerance. Their research involved the use of internal experts as well as tapping into the research done by the airline industries, NASA, the University of Calgary and Dr. Gerald Wylde (to name just a few of the key sources). The Working Group consisted of representatives from the various ExxonMobil Companies and from various parts of the world. This package has been developed to introduce the concepts to the management and supervisors in ExxonMobil and to the Managers and Supervisors in our contract companies. This ‘General’ package is supplemented by 10 auxiliary packages that can be used by supervisors and safety professionals to lead workshops (approximately 30 minutes each) on each of the 10 Influencing Factors of Risk Tolerance indentified in this general presentation. It is important the management understand and support the concepts of Risk Tolerance before rolling it out to their line workers. These Facilitators Notes should be reviewed before presenting this package and they can be used as a Guide for your presentation or can even be used as a script for the presenter. Questions on content can be referred to the Human Factors Centre of Excellence or to the members of the Risk Tolerance Working Group. Dave Fennell, Senior Safety Advisor, Imperial Oil Resources, Canada. Member of the Risk Tolerance Working Group

Actions to Address Risk Tolerance at Your Worksite
10 Factors Influencing Risk Tolerance Strategies for Reducing Risk Tolerance The purpose of this presentation is to introduce you to the 10 Factors Influencing Risk Tolerance and how these factors impact the safety of our worksites. Risk Tolerance deals with our Acceptance of risk ... the amount of risk we as groups or individuals are prepared to accept. We will identify and explain the 10 Factors and will then discuss the strategies that can be used to reduce risk tolerance. The strategies include preliminary actions that you can take at your work sites to address specific Risk Tolerance issues. This general presentation is supplemented by 10 Presentation and Workshop Packages on each of the 10 Factors. These individual packages will be rolled out in our group throughout the next year. (determine what your schedule for roll out will be. We suggest a year so that each topic can be reviewed and implemented before moving on to the next. There is no specific order for the roll out of the supplemental packages) Actions to Address Risk Tolerance at Your Worksite

Risk Perception and Tolerance Model
Maturity of Supporting Tools at ExxonMobil Tools in place and being used, effectiveness may lack in some areas Hazard Identification “See it” Mature safety culture will be functional on this topic, some areas will require more effort to understand the consequences of hazards. Risk Perception “Understand it” There are three key components involved in Risk Tolerance, specifically: Hazard Identification “Did we see it?” Risk Perception “Did we understand that it was a risk?” Risk Tolerance “Did we accept or reject the risk that we perceived?” In general (this may vary by various work groups), the systems in place for Hazard Identification are mature in our company. We have systems in place reporting (Hazard ID’s), we have training in place to help workers recognize hazards, we have tools in place that help identify potential hazards in our tasks (permits, JSA’s, inspections). Our workers usually have the ability to understand how the hazard could result in an incident ... Risk Perception. They may need additional assistance in this area through review of incidents and safety alerts that show how the hazard has resulted in an incident. This helps them understand it. Systems are in place for this (safety meetings, incident reviews, hazard ID reviews, near miss reports) The greatest issue that remains is the Risk Tolerance. Generally, we (either individuals, work groups and even company departments) may have an acceptance of risk that is too high. It is this area that is the focus of this presentation. Approaches for addressing tolerance are general weak across the company, this is the focus of this presentation. Risk Tolerance “Accept or Reject it”

The ExxonMobil working group addressed each of the three areas (Hazard Recognition, Risk Perception and Risk Tolerance) but this presentation will focus mainly on the Perception and Tolerance (acceptance) aspects.

Root Cause Analysis Flow Chart
Incident, Near Miss or Questionable Item Occurs – Why? Personal Factors Job Factors 8. External Factors 1. Lack of skill or knowledge 5. Lack of or inadequate procedures 6. Inadequate communication of expectations regarding procedures or standards 2. Doing the job according to procedure or standards takes more time and effort 7. Inadequate tools or equipment (availability, condition & use; workplace design) 3. Short-cutting the procedure or standards has been tolerated The root cause analysis flowchart is the process that links the proactive and behaviour based tools of LPS. This is a common process that is applied to incident, near misses and behaviour observations and is used in many parts of the company. This provides a simple method for determine root causes, three of which relate directly to Risk Tolerance. Specifically: RCAF # 2 ‘Doing the Job According to Procedure or Standard takes more time and effort’ RCAF # 3 ‘Short-cutting the procedures or standards has been tolerated’ RCAF # 4 ‘In past, not following the procedure or standards did not result in an incident’ Collectively, the these three factors will give an indication of the level of risk tolerance in an organization. The following pages show some examples from our company on the magnitude of risk tolerance. Develop follow up actions 4. In past, not following procedure or standards did not result in an incident Implement follow up actions Verify and validate follow up actions LPS 4

42% Conventional Operations (Sept 3 2009) RCAF Category Category Count
7. Inadequate Tools or Equipment 301 4. In the Past, No incident occurred 282 1. Lack of Skill or Knowledge 253 6. Inadequate Communication 191 3. Short-Cutting the standard has been Tolerated 148 2. Correct Way Takes More Time/Effort 137 5. Lack of or Inadequate Procedures 30 8. External Factors 24 Grand Total 1366 42% This is an example from a conventional oil and gas operation from % of incidents and at risk behaviours had a component of risk tolerance as a cause.

40% Cold Lake Operations (Sept 3 2009) RCAF Category Category Count
7. Inadequate Tools or Equipment 349 1. Lack of Skill or Knowledge 330 4. In the past, no incident occurred 288 6. Inadequate Communication 244 2. Correct Way Takes More Time/Effort 177 3. Short-Cutting the standard has been Tolerated 152 5. Lack of or Inadequate Procedures 44 8. External Factors 13 Grand Total 1597 40% This example is from a heavy oil operation % of at risk behaviour and incidents had a risk tolerance component. For organizations that use the RCAF’s from the Loss Prevention System, it would be effective to use your own numbers to help the group relate. If this isn’t possible, you can use a generalization of the range that we found during the development of this package % to 46%.

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 ↑ Here is the list of the 10 Factors That Influence Risk Tolerance. The arrows next to each factor indicate whether this factor increases risk tolerance (a negative influence) or helps reduce it (a positive influence). This presentation will go into the details of each to show you exactly how they impact the acceptance or rejection of risk. The supplemental workshop packages will take the discussion to a more in depth level again.

= Hazard Recognition and Risk Tolerance
Hazard Recognition Risk Tolerance = The most significant result of the research on this topic is represented by this slide. In the past few years there has been a lot of talk and discussion about Hazard Recognition and Risk Tolerance. The words have been used almost as a single word or phrase that suggests that hazard recognition and risk tolerance is the same thing. This is not correct and the first thing we must do to fully understand the concepts or risk tolerance is to separate the two concepts. The second thing that must happen is that we need to understand that good hazard recognition does NOT unto itself create lower risk tolerance. Our approach of putting more and more effort into hazard identification in order to resolve risk tolerance is not an effective strategy. We do need to good hazard recognition up front but it is not the cure in itself for risk tolerance. The following example from one of the development team members (Dave Fennell) provides a dramatic demonstration of how good hazard recognition does not necessarily reduce risk tolerance.

Dave describes his recreational activity
Dave describes his recreational activity ... snowshoeing in the Canadian Rocky Mountains as a leisure activity he enjoys. To ensure he was safe in this activity, he decide to get training in avalanche awareness and safety so that he would be able to recognize the hazards ... Hazard identification training.

He described the training he received from the premier experts in this field of safety (the University of Calgary) as excellent training on hazard recognition and he made note of how similar it was to our Hazard Recognition training in ExxonMobil. The university provided a reference book and handbook with all the rules and knowledge, similar to our own handbooks. They provided lots of examples and stories to help the participants related to previous incidents on mountains. They even provided a risk matrix card to help with risk assessment and decisions, not unlike our own risk matrix cards.

Dave describes how the training included practical field training in the mountains with measurements and assessments of the hazards. Once all the assessments and study were done, the group hiked a safe route up the mountain and at the top of the slope that they had been studied and assessed using all the science and hazard identification tools, the instructor asked the question: “How many of you believe this slope is ready to avalanche?” out of the 14 group members raised their hands agreeing that this slope was ready at any moment to avalanche ... Perfect hazard recognition! The instructor then asked: “How many of you would be prepared to ski this slope anyway?” 12 of the 14 group members indicated that they would ski the slope anyway even knowing the hazard was extreme! Perfect hazard recognition yet the decision to accept the risk was significantly different. This demonstrates that hazard recognition training alone will not address the issues with Risk Tolerance.

January 2009 This slide shows samples of our safety programs that we use for hazard recognition training ... reference material, handbooks, stories of incidents, safety alerts, tools for hazard identification and a risk matrix to help with decisions on risk ... all meant to address hazards, but like the U of C training, not getting at the individual and group decisions on how much risk is acceptable.

IOR Employees are generally quite good at Hazard Recognition
2008 Safety Perception Survey “Do employees understand the hazards of the operations they perform?” % “Do you initiate action to correct hazards?” - 99% “Did you receive adequate safety training?” - 92% Parts of the company that have used the Safety Perception Survey, have confirmed that hazard identification is a strength, yet risk tolerance remains high. This example is from the Imperial Oil Safety Perception Survey (based on the research and survey from Dr. Dan Petersen). Note the positive scores on hazard identification, yet acceptance has not been reduced by this good hazard identification alone.

JSA often identifies the hazard
Other examples from within our company where the hazards were identified yet the decision was made to accept the risk include these three examples from injury incidents that occurred. In all three examples, the workers identified on their JSA the hazard of the job perfectly. The workers identified that the hazard of the task was that the hammer could deflect off the structure and hit the hand of the person holding the hammer wrench. The workers identified that the home made post pounder could come off the post and hit the users finger. The workers identified that the wrench extension could slip and strike one of the workers. In all three cases, the hazard unfolded exactly as they had predicted on their JSA. The issue was not with Hazard Identification but rather was about the decisions that were made on how much risk they were prepared to take involving that hazard. This is what risk tolerance is all about. JSA often identifies the hazard Hazard is discounted or no follow through on the mitigation

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 ↑ The next series of slides will take a look at each of the 10 Factors that Influence Risk Tolerance. The first on is Over Estimating Capability and Experience.

Factors Influencing Risk Tolerance
1) Overestimating Capability/Experience “I can lift 75 kg in the gym ... I can lift this nitrogen bottle” “I have driven in worse conditions than this and did just fine” Factor # 1 relates to a belief that ones physical ability, strength, agility, reaction time and reflexes can be utilized to prevent an incident. This is over estimating capability. This factor also relates to situations where an experienced worker will rely on their years of experience and their knowledge of the task as justification for doing the work a certain way ... a way that may in fact have higher risk. Over estimating physical capability is the belief that incidents and injuries won’t occur because the worker has the physical capacity to exert extreme forces and their body is in good enough shape and conditioning to withstand them. This can be a characteristic of a younger worker who is in good physical condition and has had situations where they have indeed exert extreme forces without injury ... possibly in a gym, in a sports activity or in another job. It may involve lifting loads beyond the recommend guide (see later in the presentation), pulling on tools or exerting forces on equipment. It may involve situations where reflexes, speed, reaction time and agility are viewed as the ways to prevent an incident. Here’s an excerpt from a near miss. Obviously in jest but a good example of this factor ... “NW Field. EMS. IRT Hall Entrance. Ice build up in front of the door caused slippery conditions. As I walked in my foot slipped calling upon my superior agility and cat like reflexes to spring into action probably saving my life. A lesser man could have been killed”. Over estimating experience can evolve over time, in many cases, years. Past experience with a task or in a situation is relied upon as the method for preventing incidents. The believe is that the task won’t go wrong or result in an incident due to the experience of the individual to prevent it from going wrong or knowing exactly what to do if it does go wrong. For example, a worker may feel comfortable (safe) over pressuring a piece of equipment (tank, hose, etc) because they know the equipment has been pressure tested above the working pressure and previous occasions where working pressure was exceeded did not result in an incident. Similarly, years of driving experience can build confidence in ones driving skills, but then when a worker is exposed to something that is slightly difference, the skill may not be there in that situation. For example, years of experience driving on pavement does not provide the experience needed for driving on gravel. Also, the past experience may not be exactly related to the current conditions. Strategies for Reducing Tolerance Reflect on your role as a mentor – the person who is watching may not have the same skill, experience or capability. Acknowledge that despite your ability, the exposure is still there. Acknowledge that the capability or skill may be sufficient and then reinforce the way that it should be done.

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 ↑

2) Familiarity with the Task - Complacency “He had done this task 500 times without hurting himself” “We had stack about 200 of them when ...” “I do it about 10 times every day” Complacency occurs when a worker completes a task successfully many times and has the skill to complete it successfully without thinking. The worker may become unaware of the potential hazards of the task due to the multiple successful completions without the hazard being an issue. The worker has developed enough skill to complete the task without being fully focused on the task. The potential for work execution without having to refocus or refresh can create a blindness to the hazards and risks, thereby increasing risk tolerance due to familiarity. Complacency is not laziness or lack of interest in job or not caring about results. Complacency occurs when the skill level is achieved where the task can be completed without the worker being fully focused on the task. The task can be completed based on habit and experience. (repetitive and completed correctly numerous times) EXAMPLES: The operator who runs 20 to 30 pigs a day. He opens and close similar valve assemblies in a shift. The opening and closing sequence is identical, no focus required due to repetitive process and no incidents have occurred. The heavy equipment operator who climbs up and down his equipment several times a day. It’s the same task each time and is not the main part of the job (i.e. operating the equipment). Having never fallen off the ladder, he may get lulled into a sense of security where the three point contact on the ladder no longer seems to be important. Strategies for Reducing Tolerance ‘Situational Awareness’ – Treat every time like the first time .... ‘Stop and Think’ ‘What could go wrong this time?’ ‘How would I teach a new person to do this?’ ‘Do I still do it by the book? Have I just been luck?’

Factors Influencing Risk Tolerance 3) Seriousness of the Outcome
‘Pinch Point’ ... what about ‘Crush’ or ‘Amputation’ point Cable suddenly tightened and IP’s hand became trapped between cable and wench drum. 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. 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’? “Sweet gas” ?? “Hot Water” ?? Strategies for Reducing Tolerance Stop and Think “How bad could it be? No, really ...How bad could it be?”

Signaler Pinned by Truck
The Event: While backing a truck/trailer onto a barge, the driver lost sight of the deckhand who was providing direction. The driver continued to move the trailer back after losing sight of the signaler - pinning the signaler's legs between the back of the trailer and a toolbox on the deck. The deckhand suffered soft tissue injuries to their legs (luckily, no broken bones) The Learning: The driver of the truck did not stop when losing sight of their signaler. The signaler put themselves in the line of fire after losing eye contact with the driver. Several fatalities occur in Alberta each year where drivers have backed over their signalers. The standards in the Safety Management System (Section 6 Subject 11 Page 6-91) state: Drivers must: • stop if they lose sight of a signaler Actions: Ensure all drivers: - understand the standards for signalling, - understand their responsibility to maintain eye contact with their signaler - understand the consequences of not strictly adhering to this standard. Signaler Pinned by Truck Deckhand pinned here This slide provides an example of an incident that resulted in bruising and pain yet the true seriousness could have been a leg amputation in the crush point behind the backing vehicle.

Similarly, there have been numerous incidents in industry (and yes, even within ExxonMobil) where workers have been fatally injured when working around mobile equipment, examples of where a worker may not understand how serious the outcome could be.

4) Voluntary Actions and Being in Control Key factor in off the job risk – 28 times more likely to be hurt off the job The risk of an activity or task is viewed as less risky when we engage in it voluntarily or when we feel we have complete control of the activity As we go through this risk tolerance factor we will use some off the job and recreational examples as this is where we most often have the choice on what we do and how we do it. As we go through these we need to constantly relate back to our work place and consider the work place tasks where we feel we have full control. These will be the ones where we could be in jeopardy of accepting or tolerating too much risk. To reinforce the message on voluntary activities, relay the fact that. There are three components to this risk tolerance factor. First, we will have already done a conscious or even subconscious assessment of the risk of the activity or task and will have come to our own conclusion (whether right or wrong) that the risk is at an acceptable level before making our decision to progress. Once we have established our perception of the risk, we will subconsciously justify our decision with any additional information that is provided. The justification may come from one of the other risk tolerance factors ... most commonly #1 Over estimating capability or experience, #3 Seriousness of the Outcome and #8 Confidence in Protection and Rescue. Second, when there is something we really want to do (for the personal gain, for the adrenalin rush, for the experience) we will discount the risks associated with the activity to justify our participation. Third, when we feel we have 100% control of a task, we under estimate the risk. This is usually combined with risk tolerance factor #1 Over estimating capability and experience. For example, many people will make a decision to drive to a location rather than take a plane because they feel they have full control over the driving where as they are dependent on others when flying. Strategies for Reducing Tolerance Integrate ‘Stop and Think’ into your personal activities

5) Personal Experience with an Outcome If you have seen a serious outcome, you will be less tolerant of the risk Problem: As Incident Rates improve, fewer people will have had personal experience and leads to Scepticism A personal experience with a serious or traumatic outcome will stick with an individual for a long time ... sometimes a life time. It will impact their decisions on similar tasks and usually results in the individual being very intolerant and not accepting of any risk associated with the task. This will obviously reduce their tolerance for the risk and make the task safer. This is a good thing. Our challenge however is that not every worker on our site will have had a personal experience with a serious outcome related to the task and therefore will not have been impacted and may be prepared to take more risks. As we get a safer operation, even the corporate memory of past lessons from significant incidents may fade and make us more vulnerable to tolerating risks. Our challenge is to ensure that all workers know that a bad outcome could still happen ...even though they may not have seen it personally and even though this work site has been safe and not seen it. This is especially challenging where new workers (‘green’ workers, new to site workers, new to our industry workers) may never have seen nor understand how serious the outcomes could be. We need to take extra time with the newer workers to ensure they understand how the precautions we take have come from lessons learned in the past. . Our ‘corporate memory’ of the lessons learned from past events must be kept alive and relayed to the newer workers. This can be done in formal way through occasional safety meeting topics using the formal communication reports from those events. It can also be done in a less formal and ad hoc manner when a particular opportunity arises ... for example, during a behaviour observation on a related task, during instruction on a task, from a prompt in media article, or from a prompt on a recent industry incident. The purpose is to ensure that workers who may not have seen such an incident are aware that it could happen here if not for our procedures, pre-job planning, management systems, etc. This ad hoc process can be used by anyone doing a behaviour observation, a supervisor, an ‘expert observer’, management or even a worker within the work group who may have had a personal experience with a serious outcome. Strategies for Reducing Tolerance ‘Expert observers’, supervisors, ‘keepers of the corporate memory’ have the obligation to ensure workers know : a) Incidents have occurred because of not following that standard (i.e. What could go wrong?) b) Demonstrate that there have been serious consequences (i.e. How bad could it be?)

Well Servicing Fatality - May 2002
A well servicing worker was fatally injured when he was pulled into the rotating draw works by the strap on his fall arrest harness. 1) Loose clothing and personal protective equipment around rotating equipment 2) Equipment guarding Straps caught here This example from an ExxonMobil fatality can be used to demonstrate the importance of keeping the corporate memory alive so that new workers understand that injuries, and even fatalities have occurred in our company. Draw works guard rail Re-enactment of how straps were caught

Factors Influencing Risk Tolerance 6) Cost of Non Compliance
Greater cost of non compliance lowers risk tolerance Aviation industry – Low risk tolerance, strictly regulated, high cost of non-compliance. A person’s decision to accept risk can be influenced by how high the cost of non-compliance will be. If the cost of non-compliance (e.g. taking a risk) is going to be very high, the person may decide to conduct themselves in the manner that will not result in the cost or penalty. As we go through this discussion on using the Cost of Non-Compliance as a method for reducing the acceptance of risk, it is very important to note that this factor is only one of the ten and must be used in conjunction with the others. It is not acceptable to chose this factor as a ‘favorite’ and to resort to punishment as the sole tool for reducing risk tolerance. This factor must be used selectively and must be used with an understanding of how to identify and classify performance issues (see Managing Personnel Performance Issues EMFOS Module # 5). As the cost of non-compliance increases, the willingness to take the chance may decrease. For Example: If the cost of a speeding ticket is $200, a driver may accept that as a reasonable cost and be willing to accept that penalty for achieving the goal of getting there faster, for the ‘rush’ of driving at a high speed or simply to ‘get the job done’. If the cost of a speeding ticket is increased to $10,000 and the penalty also includes the impoundment of the vehicle, the willingness to take that chance will be greatly reduced. This is an actually example from Ontario where signs are posted on the highways that state “Drivers exceeding the speed limit by more than 50 kmph are subject to a fine of $10,000 and confiscation of the vehicle”. Strategies for Reducing Tolerance Identify the cost of non compliance and increase it where necessary Remove barriers and increase reward for compliance

Factors Influencing Risk Tolerance 7) Confidence in the Equipment
“Ladder is twice as stable, therefore ... ” 1995 US Study – Cars with ABS have more accidents, no safety gain with airbags because drivers became more aggressive. Parachuting – Failure to deploy replaced with late deployment Factor #7,overconfidence in the equipment, occurs when we have placed excessive and some times unwarranted trust that the equipment or tool we are using will always perform exactly as designed. The possibility that the equipment could in fact fail is not considered, discounted or minimized When we become familiar with particular tools and equipment and have not experienced any failures when we have used them, we can become overly trusting that the equipment or tool will never fail. This factor can be linked to Influencing Factor #2 (Familiarity with the Task) except in this situation we have become familiar with the equipment or tool. 1) When we hear a statement such as “It has never failed as long as I have been using it” this is reflective that we may becoming complacent with the particular tool. 2) This factor can also be identified where we hear that a particular piece of equipment is ‘fail safe’, meaning that if something does go wrong, we expect the equipment will be a ‘safe’ failure and nobody will be hurt. 3), A brand new piece of equipment or tool can be perceived as been fail proof. It is new, shiny and clean and this can portray a message that the possibility of it failing is remote. 4) Process equipment often comes with built in safety systems that are designed for safe start up, safe shut down and warning systems and programs that will detect problems and then automatically take care of them. As sophisticated as the devices may be, failures have occurred. Factor #7 , Over confidence in Equipment, is reinforced through studies done in the US and in Britain. The 1995 study on drivers using vehicles with anti-lock braking systems (ABS) and air-bags showed that drivers were more confident that they could stop faster with ABS and therefore tended to drive faster. There was no net gain in the reduction of incidents where braking was a factor. The British study on sky diving revealed that in the early 80’s most of the deaths in the sport were attributed to a parachute not deploying ... essentially a flaw with the equipment. 25 years later, with great improvements to the technology of parachutes, the sport was seeing the same number of fatalities. The cause however had changed and it was rare to find a chute that failed to open. The cause now was that sky divers were so confident that the equipment would deploy that they were deploying the chute as late and the chute did not have sufficient time to deploy. Equipment failures had been replaced with late deployment due to the confidence in the equipment. The three examples shown are re-enactments of work place injuries. The fuse dropped out of the hot stick and hit the operator. The bungee cord hook slipped off the anchor. The brace the worker stood upon failed under his weight. Strategies for Reducing Tolerance Training on limitations of the equipment and engineering Stop and Think ... What will happen if it does fail?

8) Confidence in Protection and Rescue British study – workers with back belts tend to lift greater weights This factor specifically deals with over confidence in the safety and personal protective equipment we use and the belief that if something does go wrong, our PPE will protect us from harm. This factor also extends to an over confidence that we will be effectively rescued by our peers, emergency services or even ourselves if we get ourselves into a bind or risk situation. In this case the worker knows what the hazard is, understands what could go wrong but is so confident in being rescued that they pursue the task anyway. Several formal studies and work place observations have shown that people are prepared to accept more risk when they believe their protective equipment will save them if something goes wrong. The British study on back belts revealed that when workers viewed their back support belts as protective equipment, they believed they could safely lift greater weights ... a greater acceptance of risk. Similar behaviour has been observed within the company. When the company went to full time use of Fire Retardant Work Wear, workers were seen to take greater risks in potential explosive and flammable situations. Incidents occurred when workers would bypass a flame arrestor on a burner, knowing full well that a flash back could occur but believing that their FRC would protect them from burns when that occurred. Current studies are under way on PPE that has ‘armour’ type properties, specially impact resistant gloves. Workers have stated that there is certain jobs they can now do with the impact gloves that they would not have felt safe doing with no gloves or general purpose gloves (i.e. holding a post or hammer wrench for someone else to strike with a hammer). The quote on the end can be used to reinforce point 4. A previous VP of Production in IOR made the statement that “Every job should be able to be done safely by a 65 year old with a bad back (he was reinforcing the principle to not over exert the body and to find ways of prevent stress on the body) and stark naked!” The point he was making was to consider how you would make the job safe if you were standing there with no PPE on. Would you touch the same things with no glove on your hand? Would you by pass a flame arrestor if you had no PPE on? Would you handle the chemical differently with no gloves or rain suit? Strategies for Reducing Tolerance Understand the limitations of protection & rescue measures See them as ‘last lines of defence’, or ‘not to be relied upon’ ? “Every job should be able to be done safely by a 65 year old with a bad back and ...” Howie Dingle

9) Potential Profit and Gain from Action US Highways Study – deaths on highways tracks directly with the economy Alberta WHS – fatalities and lost time incidents in the oil patch increase and decrease with the price of oil. This risk tolerance factor stems from the desire for profit, gain, and even recognition. This can occur at an individual level where a person may profit from their own action or it can occur at the corporate level where a company or business can profit from taking higher risks. Companies and corporations (management) are prepared to take more risks when there is more to gain. If a company can make more profit by having more equipment in the field, selling more product, and getting more clients, most companies will be willing to do what ever it takes to take advantage of that. This could mean using equipment that has not been maintained, send out workers who have not been trained and stretching their capabilities to safely deliver their products and services. For Example: Studies of the deaths on US Highways have shown that the fatality rates on the highways tracks directly with the health of the economy. When there is more to gain from a robust economy, transportation companies have been seen to use more less experienced drivers, get trucks on the road that may have deficiencies and bypass time consuming maintenance in order to get the load through. Similar observations have been made in the oil and gas industry by Alberta Workplace Health and Safety. As the price of oil rises and there is more money to be made, Alberta WHS reported that the fatality and lost time rates increase. They have attributed this to companies putting equipment into service that may not be ready or inspected, assembling crews of new workers who may not have the training or experience to safely operate the equipment and to the demands on schedule ‘to get it done’. WHS also noted that the incident rates increase at a rate that is higher than the rate of activity increase. Strategies for Reducing Tolerance Remove rewards for risk taking Eliminate barriers to doing it the ‘right way’

Factors Influencing Risk Tolerance 10) Role Models Accepting Risk
When Role Models in a work group accept a certain level of risk, they influence the decisions to accept risk by other members of the group. Factor #10 – The level of risk accepted by our role models and mentors will directly impact the level of risk we as individuals are prepared to accept. The actions and risk acceptance of the role models can impact an entire work group’s acceptance of risk. This risk tolerance factor impacts safety on two levels. First, the way a role model conducts themselves and does a task can be viewed as the way the task should be done with no thought and no conscious decision made about the risk. It is just ‘accepted’ as the ‘norm’ and not questioned. This can happen over time and leads to ‘erosion of standards’ (see EMFOS –Module 5 Managing Personnel Performance Issues for details on Erosion of Standards). The actions of the role model become the group ‘norm’ and ‘the way it is done around here’ with no thought to the risk associated with it. Second, even in those situations where the risk of doing a task may be questionable, once a role model has done the task in that particular manner and no incident has occurred, that now becomes the accepted level of risk. The justification is “If he or she can do it that way and no incident occurred, the rest of us can do it that way and will not have an incident either”. There may have been no incident from ‘luck’, slightly different circumstances or the causal factors just have not yet lined up. (See EMFOS Module 1 for an explanation of the Safety Filters model of incident causation). The picture on the left related back to example of the decision by people in the avalanche training example used earlier. When the role models (the ‘cool’ people) in the group indicated that they were prepared to take the risk, others in the group followed. The purpose of the example and this slide is to get supervisors thinking about who are the role models in their work group and what is their level of risk acceptance. Strategies for Reducing Tolerance Identify and address the risk takers immediately (including yourself – where are you on the ‘risk-taking’ scale?) Recognize ‘Erosion of Standards’ and address immediately

What Could Go Wrong? 1) Review the serious incidents that have happened in the past and learn from these incidents Coach workers on how to recognize new hazards Recognize potential consequences of those hazards Reduce the tolerable level of risk Calibrate others so their judgement is at the same lowest acceptable level of risk The last three slides provide some preliminary tools on how to address risk acceptance. These are just preliminary and the basics. The details are found in the individual workshop packages on each of the 10 Factors that Influence Risk Tolerance.

How Bad Could It Be? Use ‘safety conversations’ (LPO, Stop and Think, Safety Meetings) to increase awareness on potential outcomes. Keep the ‘corporate memory’ alive Risk is impacted by the number of ‘Barriers’ between actions and outcomes

What can I do about this? 2) Follow up on the ‘Personal Risk Behaviours’ identified at Fresh Start: a) Hold safety meeting discussions (or one on one during LPO’s) on what they identified and their progress b) Ask workers to share their identified personal risks and commitments to change at safety meetings. (Start by sharing yours). c) Continue to use the ‘Personal Risk’ Stop and Think cards with the expectation of identifying another personal at risk behaviour

A tool that can be used to introduce a work group to concepts of risk tolerance is this “I Choose To Reduce Risk” card. To address risk tolerance, we need workers (and supervisors) to acknowledge that we all accept risks of one type or another. The purpose of this card is to support an exercise where each individual acknowledges and writes down a risk they knowingly accept and then make a personal commitment to do something about that risk. This simple exercise opens the discussion to talk about other risks that we may take. For each of these risks, the question can be asked ... “Which of the risk tolerance factors influenced by decision on this specific issue?”.

“Together with our contractors we can create the safety culture that lowers Risk Tolerance”
Finish off this presentation by acknowledging there is more information to come on Risk Tolerance and that strategies need to be put in place to roll out the 10 individual workshop packages. For more information on this presentation and for background on the content and examples, feel free to contact Dave Fennell, Senior Safety Advisor at Imperial Oil, the ExxonMobil Human Factors Centre of Excellence, or a member of the Risk Tolerance Working Group.

Risk Tolerance Strategies for Understanding and Addressing

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Risk Tolerance Strategies for Understanding and Addressing

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