Controlling risk – My Top 9 techniques
I was re-reading one of my favourite books the other day – Controlling Risk in a Dangerous World: 30 Techniques for Operating Excellence. Written by Cpt. Jim Wetherbee, Morgan James Publishing. 2016 – and was trying to distil from it what I felt are the most important themes that would absolutely help those at the sharp end of work. Of course it is always dangerous whenever we try to summarize – or pick the best bits out of – anything as a reduction always loses context and detail, but in this case, I feel it is worth it. If for no other reason that it may pique your interest to go and buy Jim’s book and read all of it, a number of times.
I have chosen nine out of the thirty techniques for operating excellence as I feel they offer a central role for those of us who are exposed to the hazards in their workplaces. The intention is not to, in any way, belittle any of the other techniques but rather to focus our conversation somewhat.
I have grouped the ‘Top 9’ into the categories of ‘Thinking’, ‘Planning’, and ‘Doing’ – somewhat inspired by the PDCA (Plan, Do, Check, Act) cycle that we have all seen before. There are overlaps as you can see from the diagram below.
Note: The numbers in brackets represent the number of the technique in Jim’s book
I will go through each of the ‘Top 9’ in an order that seems to make sense – to me at least.
1. Develop and Maintain Risk Awareness
Developing risk awareness requires work. Over time and with practice operators can achieve a high-level awareness of risk, a sense of what is going on around them and if anything dangerous is developing. I am reminded of James Reason’s idea of error awarenessand chronic uneaseand also Dylan Evan’s concept of risk intelligencehere.
Wetherbee talks about developing and maintaining risk awareness by using three steps:
- Learning from past activities – search of vulnerabilities.
- Sensing present operations – maintaining situational awareness, and
- Predicting future activities – anticipate the changing shape of risk.
The three steps can be achieved by operators spending enough time understanding their equipment and systems – looking at their vulnerabilities, understanding the risk profile before starting the task and then monitoring for change and/or drift (See Dekker and Snook) during the task itself, always being mindful during the work.
2. Share and Challenge Mental Models
Once you have thought about the work you are planning on doing and what can bite you, you need to make sure you, and the rest of the team, have an aligned understanding of what is going on. This is called a mental model.
It is important that each member of the team knows what their role is and also what the others in the team are doing. Sharing mental modelsgreatly assists with this. Also during the task, keeping others up to date with what’s going on helps to keep the team aligned. This reminds me of the work of David Marquet around take deliberate actionand the concept of telegraphing actionthat Wetherbee talks about. Wetherbee describes it well: “Before moving any switch or making command inputs to a control device during operations, we indicated our intentions by pausing briefly over the switch or control to allow a second crew member to verify whether the intended action was correct.” Marquet goes a step further and suggests that the intent to action is also verbalized, even when on your own. Doing this keeps the shared mental modelalive. Both take deliberate actionand telegraphing actionwork just as well when you are on your own as they do when you are in a team environment.
3. Control Risk
Given this is very close to the title of the book, it is all about this topic really. Getting it right means that we have created some safe work. Of course it always sounds simple: Identify hazards, Assess risks, and Implement hazard controls. Easy peasy. BUT, it is often hard. It follows on nicely from the techniques already discussed inasmuch as having developed risk awareness and established a shared mental model, the individual and team need to get down to the exercise of understanding what can bite them and then what they can do to make sure they are not bitten.
Identifying hazards is a skill that can be learned and I strongly advise you to establish within your business a process to do just that. There is some excellent work being done using virtual reality and simulations that can really help here.
Assessing risk is really about asking yourself a few questions such as:
- Will I, or anyone on my team be injured? If so, how badly?
- What if…?
- What usually goes right here, but may not today?
- What will happen to me and the team if we do not control the risks?
Implement hazard controls is simple. ‘NIKE – Just Do It’ sums it up pretty well. By this time, you have become aware of what risks there are, how relevant to you and the team they are, what could go wrong and now you simply have to make sure that the things that you are about to do in the task are done in such a way that the hazard does not manifest itself. Always remember the hierarchy of controls, eliminating the hazard is always a better option that talking about it and keeping an eye on it.
4. Develop and Execute A Plan (For All Critical Phases of Operations)
You must have an overall understanding of the mission, capabilities, purpose of the activity, equipment and systems to be used beforeyou can explore the critical phases and build a plan. Wetherbee goes on to say: “Success in complicated operations can only be achieved when operators execute a well-developed plan for all critical phases of the operations.” Once again, we see the previous elements building into this one. You know the hazards, have assessed the risk and worked out how to control them, now you need to make sure you know which bits of the task are critical and develop a plan for how they will be achieved. A task-based risk assessment (TBRA) can be useful here. A TBRA should simply set out the steps of a job, what the hazards are and how to control them. It should also highlight the critical phases of the job and have added emphasis on the work needed to execute those phases. It needs also to have identified the trigger steps (See the next technique). As an aside, I do not believe a TBRA process should require the team to quantitatively, or semi-quantitatively, assess the risk (This is often required via a risk matrix). It should instead focus on what work is to be done, what the hazards are, how to control them, what critical phases and trigger steps are and basically assist in building a common mental modelof the work for the whole team.
5. Identify Trigger Steps (execution steps with immediate consequences)
This step is really done alongside the previous one. A trigger step is one that has immediate consequences. There is no time to stop and go back. Whether you get it right or whether you get it wrong, there is no going back. Once you have cracked the egg into the soup, you cannot get it back into its shell.
The trigger steps are identified in the “Develop and execute a plan” step and now extra vigilance is needed prior to auctioning the step. (I’m about to do something that will have consequences. Have I checked everything one last time? Have I forgotten anything?). Telegraphing action really helps here as well.
6. Expect Failures (System and Human)
Expect failure in yourself, what you are using and everyone else. (I assume everyone else on the road is trying to kill me). Chronic unease fits in here nicely. Always have that level of alertness about what could go wrong – everything is going along swimmingly – this cannot last. Try to keep on eye on things and have a back-up plan if things go south. Anticipate a failure and already know what you are going to do.
If there is one guarantee in the world of safety and work, it is that people will fail. If someone goes up onto a scaffold with tools and equipment, they will drop them at some point in time. This is the only reason we put drop zones around scaffold that is being worked on. As you drive a car, you need to be very aware of what others are doing. Always look in the mirrors, down the side roads you pass, at the traffic lights, what pedestrians and cyclists are doing, planning to yourself all the time, what you will do if…
7. Follow Procedures (and Rules) Thoughtfully
I love this idea. Procedures seem to be here to stay. They are, to me at least, both a curse and a savior. Corinne Bieder and Mathilde Bourrier, in Trapping Rules Into Safetysum it up well when they say “it is not always clear what procedures are really meant to achieve. Are they guidance to operate complex system? Ensure safe operation? Or maybe to provide management or regulators with an easy and explicit reference that allows them to easily identify indicators to monitor performance?” They argue that even the definition of what a procedure is vague – “a single word for a variety of objects”.
Having smart procedures, ones that are accurate is a good thing. Wetherbee suggests we need to ask each front-line leader in the organization two questions:
-Do you think all your operating procedures are accurate? (‘Accurate’ includes being effective and representative of the organization’s collective wisdom on the best way to accomplish a task or activity?
– Does each of your operators think all of your procedures are accurate – and will help him or her be successful?
If the answer is ‘No’ to the first question, then fix the procedures and do not expect or demand compliance. The same applies for the second question.
Wetherbee suggests that there are only two ways to get into trouble with procedures: not following them, and following them blindly. So regardless of whether your procedures are accurate as yet, the best advice to be given is to follow them thoughfully. Ask yourself if you follow the procedure will it deliver what the boss wants and will I not get hurt. Is it easy to follow correctly or difficult. Does it all make sense for you, the end-user?
8. Be Mindful During Operations
I am reminded here of a couple of authors (and their books) worthy of exploring in relation to this technique: Carol Dweck with Mindset, Karl Weick and Kathleen Sutcliffe with Managing the Unexpected, They are worth a read. Wetherbee talks about mindfulness in terms slightly differently that these authors. He talks about five aspects that enhance mindfulness that the operator can learn, develop and then maintain. They are: Technical knowledge, the need for operators to know all they can about the systems they operate; Teamwork, knowing their own and their team mates strengths and weaknesses and how the team members can best be used for the success of the activity; T-0 vigilance (T minus zero). This is based on what astronauts use to remain present before and after take-off. He explains that operators must remain present and focus on everything necessary to be successful. Of course they cannot focus on everything so their needing to know what bits are important is a pre-cursor to this work; Cognition (controlling and automatic)is next. Through practice it is possible to move work from the controlling (manual, mentally draining) to the automatic (like the complex activities required to drive a car after years of doing it – not so mentally draining). He recognizes that multitasking is only possible in the automatic mode. Think about chatting to a friend whilst driving a car; Lastly is Fields of vision. During critical or complicated tasks, narrow your vision and then periodically scan the rest of the world to make sure it is still as your mental modelexpects it to be.
9. Preserve Options During Operations
Somewhat related to many of the other Top 9, preserving optionsis like having a plan that is just there for when things go wrong. Always keep at least one option on the table. Keep the options updated as things progress. Wetherbee has some great illustrations on this technique. These include: when he is driving he is always looking for options if the car coming the other way does something unexpected; when cycling, he rides out wide of parked cars, just in case they open a door. He advises us not to get trapped without an escape route, to be always thinking ‘what if…?’ and having an answer ready about what to do if it does.
In summary
As I said at the top, it is always dangerous whenever we try to summarize – or pick the best bits out of – anything as a reduction always loses context and detail. I hope that I have not done Jim Wetherbee a dis-service by focusing on a few of his excellent techniques. I strongly advise you to buy Jim’s book as I really think it is an excellent set of tools to think about and apply as you strive to create safe work.
Controlling Risk in a Dangerous World: 30 Techniques for Operating Excellence. Cpt. Jim Wetherbee, Morgan James Publishing. 2016