Human Factors (HF) covers a variety of issues that relate primarily to the individual and workforce, their behavior and attributes. Human error is still poorly understood by many stakeholders and so the risk assessments of operations or process often fall short in their capture of potential failures. There is little consideration of human factors in the engineering design of equipment, operating systems and the overall process, procedures and specific work tasks. Operational human factor issues are often treated on an ad-hoc basis in response to individual situations rather than as part of an overarching and comprehensive safety management strategy. The role that human factors play in the rate of incidents, equipment failure and hydrocarbon releases is poorly understood and underdeveloped.

1. Presented by:Presented by:
Bernard L. Fontaine, Jr., CIH, CSP, AIHA FellowBernard L. Fontaine, Jr., CIH, CSP, AIHA Fellow
The Windsor Consulting Group, Inc.The Windsor Consulting Group, Inc.

3. Error s
Violatio ns
Development of an Organizational Accident (developed from J. Reason)
PersonPerson
Human Factors in Incidents

5. 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.”

6. ““80-85% of accidents over a reporting80-85% of accidents over a reporting
period of 1999 to 2001 involved humanperiod of 1999 to 2001 involved human
error (USCG)error (USCG)
50% of these initiated by human error,50% of these initiated by human error,
another 30% of these associated withanother 30% of these associated with
human errorhuman error”

7. Hazard, Risk and SafetyHazard, Risk and Safety
ManagementManagement

8. Setting policy
Organizing
Identification &
assessment
Procedures
Communication
Employee
participation
Acceptance
monitoring
Active
monitoring
Reactive
monitoring
Review
Continual
improvement
Planning
phase
Performance
phase
Assessment
phase
Improvement
phase
Hazard, Risk and SafetyHazard, Risk and Safety
ManagementManagement

9. Safety Management SystemSafety Management System
(SMS)(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

10. 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 re-
evaluated 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)
Human Factors and SafetyHuman Factors and Safety

11. 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.

12. Drivers for Human FactorsDrivers for Human Factors
in Safety Management andin Safety Management and
RiskRiskCommitment 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 short-term 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

13. Drivers for Human FactorsDrivers for Human Factors
in Safety Management andin Safety Management and
RiskRiskCommitment Cognizance Competence
Procedure
s
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 error-provoking 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

14. 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

15. Engineering
Safety management
Human factors
Time
Accident
rate
Human Factors in Safety
Management and Risk Governance

16. Engineering
Safety management
Human factors
Better design More
procedures!
Time
Accident
rate
Human Factors in Safety
Management and Risk Governance

17. Engineering
Safety management
Human factors
Need to design
better engineering
More
procedures!
Behavioural
modification
will fix it…
Time
Accident
rate
Human Factors in Safety
Management and Risk Governance

18. Engineering
Safety management
Human factors
Better design More
procedures!
Behavioural
modification
will fix it…
Time
Accident
rate
Continuous improvement
Human Factors in Safety
Management and Risk Governance

19. Engineering
Safety management
Human factors
Better design More
procedures
Behavioural
modification
will fix it…
Time
Accident
rate
The “Engineers Graph” or why I don’t need to do anything...
Continuous improvement
Workforce
involvement
Human Factors in Safety
Management and Risk Governance

20. 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?

21. Organizational ChallengesOrganizational Challenges
10
Human Factor
Intervention
20
and 30
Human Factor
Interventions

22. Lagging IndicatorsLagging Indicators Leading IndicatorsLeading 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

23.  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
 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
 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
 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
Organizational ChallengesOrganizational Challenges

24. 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 a critical factor
Change management does not always consider human factors in
final equation since it is considered inherent to the organization

25. Hazard ID, Risk Assessment & Prioritization
Triggers Tools
-New Projects
-Renew al of Facilities
-New Standards
-Incident Response
-Periodic Review s
-Audits
-Regulatory
-Employee Concerns
-Excursions
-M AR
-HAZID
-HAZOP
-LOPA
-FM EA
-QRA
-ESSA
-EERS
-Blast Study
Major
Hazard
& Risk
Register
Common Risk Matrix
Risk Mitigation Planning & Controls
Options Decisions Plan
-Engineering Studies, FEL
-Non Engineering Options, e.g.
Administrative Controls
-Evaluation by Risk Ow ner
Execute Plan
•Priority
•Resources
•Progress Tracking and Review s
Emergency Response Plan
•Update
Communicate Hazards & Plan
Text Description
Profile &
Score Cards
-Text
-Text
-Text
-Text
Evaluation
-Text
-Text
-Text
-Text
Corrective
Action
-Text
-Text
-Text
-Text
KPI
Measurement
-Action Tracking
-Leading Indicators
-Lagging Indicators
Measurement, Evaluation & Corrective Action
Management
Review s
-Text
-Text
-Text
-Text
Improvement
Thru Strategic
Direction
-Text
-Text
-Text
-Text
Risk
Management
System
-Text
-Text
-Text
-Text
Management Review & Improvement
Continuous Hazard Assessment and Risk Reduction
-Partner Approval -Roles &
-Residual Risk Responsibilities
-Business Decision Process -M ilestones/
-Commercial Decisions Dates
-Action Tracking
Levels of authority based on
level of risk -Progress
Integrated Engineering
and Business Plan
Review s

26. Evaluate the Human
Element

27. Most Common Issues…
Organizational change
Staffing levels/workload
Training and competence
Operating procedures
Managing human failure
Correct hard/soft skills
Fatigue and shift change
Organizational culture
Human factors in design
Communications/interfaces
Integration of human factors into risk
Assessment and investigations
Behavioural safety = Human factors/

28. Balance of Hard and Soft Skills
Hard Skills
Calculate to solve problem
Operate machinery
Speak a foreign language
Following directions
Demonstrate competence
Previous work experience
Soft Skills
Good manners and trustworthy
Time management
Accept suggestions or criticism
Ability to ask for help or support
Integrity and leadership
Teamwork and adaptability

29. 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

30. 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 atSafety Behaviour/Risk at
WorkWork

31. 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.
Safety Behaviour/Risk atSafety Behaviour/Risk at
WorkWork
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

32. Linear risk problems can be managed using a ‘routine-
based’ 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

33. 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.
Acceptance
Reduction
Prohibition or
Substitution
No formal intervention
necessary
Benefit is worth the risk,
but risk reduction
measures are necessary
Risk so much greater
than benefit that it
cannot be taken on

34. 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

35. Assessment Sphere:
Generation of Knowledge
Management Sphere:
Decision on & Implementation of Actions
Risk Characterisation
• Risk Profile
• Judgement of the
Seriousness of Risk
• Conclusions & Risk
Reduction Options
Risk Evaluation
• Judging the Tolera-
bility & Acceptabiliy
• Need for Risk
Reduction Measures
Tolerability & Acceptability Judgement
Pre-Assessment:
• Problem Framing
• Early Warning
• Screening
• Determination of Scientific Conventions
Pre-Assessment
Risk Appraisal:
Risk Assessment
• Hazard Identification & Estimation
• Exposure & Vulnerability Assessment
• Risk Estimation
Concern Assessment
• Risk Perceptions
• Social Concerns
• Socio-Economic Impacts
Risk AppraisalRisk Management
Implementation
• Option Realisation
• Monitoring & Control
• Feedback from Risk Mgmt. Practice
Decision Making
• Option Identification & Generation
• Option Assessment
• Option Evaluation & Selection
Risk Management
Communication
1 Knowledge Challenge:
 Complexity
 Uncertainty
 Ambiguity
2 Risk judged:
 acceptable
 tolerable
 intolerable
3 Risk Management Strategy:
 routine-based
 risk-informed/robust focus
 precaution-based
 resilience-focus
 discourse-based

36. Design Fabrication Operations
Asset Lifecycle Integrity and Reliability
Construction

37. 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

38. Risk Assessment
 Hazard identification and estimation
 Exposure assessment
 Risk estimation
Concern Assessment
 Socio-economic impacts
 Economic benefits
 Public concerns (stakeholders and individuals)

39. 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 imple-
mentation (link to early
warning)
 Ex-post evaluation
 intended impacts
 non-intended impacts
 policy impacts

40. RISK MANAGEMENT
DECISION PROCESS
Is Maximum
Possible Loss
(MPL) Severe?
Analyze Factors Affecting Size
of Possible Loss
Eliminate
Source(s) of Loss
Reduce Possible
Loss Size by
Positive Action
Transfer Risk
Does Any Severe
Possible Loss
Remain?
Assume Risk
Transfer
Refused
Risk
Remains
Too High
DO NOT PROCEED
DISCOUNTINUE
OPERATION
PROCEED
CSURMA Self-
Insurance Pool
Contractual
Transfer
Commercial
Insurance
Avoid / Eliminate
Campus
Deductible
Assume
Calculated
Severe Risk
Assume Low
Risk Exposure
Identify Exposure to
Possible Loss
Estimate Maximum
Possible Loss / Probability
of Loss
CSURMA Self-
Insurance Pool
Contractual
Transfer
Commercial
Insurance
CSURMA Self-
Insurance Pool
Contractual
Transfer
Transfer
Refused
Risk
Remains
Too High
Commercial
Insurance
CSURMA Self-
Insurance Pool
Contractual
Transfer
DO NOT PROCEED
Transfer
Refused
Risk
Remains
Too High
Commercial
Insurance
Self-
Insurance Pool
Contractual
Transfer
Identify Exposure to
Possible Loss
Estimate Maximum
Possible Loss / Probability
of Loss
Analyze Factors Affecting Size
of Possible Loss
Identify Exposure to
Possible Loss
Estimate Maximum
Possible Loss / Probability
of Loss
Reduce Possible
Loss Size by
Positive Action
Avoid / Eliminate DISCOUNTINUE
OPERATION
Reduce Possible
Loss Size by
Positive Action
Avoid / Eliminate
Eliminate
Source(s) of Loss
Assume Risk
Assume
Calculated
Severe Risk
Eliminate
Source(s) of Loss
Assume Risk
Campus
Deductible
Assume
Calculated
Severe Risk
Eliminate
Source(s) of Loss
Assume Risk Assume Low
Risk Exposure
Campus
Deductible
Assume
Calculated
Severe Risk
Eliminate
Source(s) of Loss
Assume Risk
PROCEED
Assume Low
Risk Exposure
Insurance
Deductible
Assume
Calculated
Severe Risk
Eliminate
Source(s) of Loss
Assume Risk
YES
YES
YES
YES
YES
YES
YES
NO
NO
YES
NO
YES
YES
NO
YESYES
YES
NO
NO
YESYES
YES
NO
YES
NO
YESYES
YES
YES
YES
NO
YESYES
YES
YES
YES
YES
NO
YESYES
YES
YES
YES
YES
YES
NO
YESYES
YES

41. 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)
Risk Communication

42. 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)
Stakeholder Involvement at
Different Stages

43. Complexity
Epistemic
Use experts to
find valid,
reliable and
relevant
knowledge
about the risk
Uncertainty
Reflective
Involve all
affected
stakeholders
to collectively
decide best
way forward
Ambiguity
Participative
Include all
actors to
expose,
accept,
discuss, and
resolve
differences
Simple
Instrumental
Find the most
cost-effective
way to make
the risk
acceptable or
tolerable
Management/ Staff
Dominant risk
characteristic
Type of
participation
Actors
Management/ Staff Management/ Staff Management/ Staff
Scientists/
Researchers
Affected
stakeholders
Civil society
Scientists/
Researchers
Scientists/
Researchers
Affected
stakeholders
As the level of knowledge changes, so also
will the type of participation need to change

44. 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

45. 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