Ok you had an incident at work but did you DEBRIEF the incident and explain FULLY those changes! Kolb’s theory applies

Too often it is heard that the reason something is done a certain way is because it’s always been done that way.  That does not mean the way things are done is correct or efficient.  These three simple things may seem onerous at first, but they do not have to be permanent changes.  They only need to be implemented long enough to insure personnel are competent and efficient at process safety. Conducting a simplified job hazard analysis will ensure that all hazards are identified, managed, and mitigated prior to performing work.  Performing a simple debrief at the conclusion of the work will ensure that we learn from the experience. By considering every job to be performed a learning opportunity, the experiential learning cycle can be used to identify what was done, how well it was done, and how we might improve in the future. Processes are designed to run in a “normal” mode.  No process is really stagnant and throughout the life cycle of a process, changes will be made.  When defining “normal”, some tolerance should be built in to allow a range of operating conditions for operators to work within.  When changes to operating parameters, or the equipment in the process are required, these must be evaluated and approved. Any effective process safety management system will contain an element to deal with Management of Change (MOC).  Experience conducting training, audits and process hazard analysis studies indicate that identifying what changes require evaluation using the MOC process can be confusing at times.  Some organizations only evaluate technical changes to the process and equipment and ignore or forget about managing changes to the PSM system or personnel changes within the organization.

What does this mean?

The elements of this pillar include:

• auditing,
• management review and continuous improvement,
• measurement and metrics and
• incident investigation.

Each of these elements provides findings, lessons and data that are useful for learning and thus changing and enhancing behaviors and attitudes.  The change and enhancement will influence an organization’s culture and ultimately push the organization toward a learning culture.

These are not the only opportunities available for organizations to learn from experience.  Metrics and audits can allow a general overview of process safety performance.  Incident investigation insures that when reported, incident information is transmitted to all who will benefit from the learning.

The job hazard analysis process that many organizations use to identify and mitigate hazards provides a tremendous opportunity to capture data and use the experiential learning cycle if the job is debriefed properly after completion.  This paper will provide guidance and explain the benefits that can be derived from debriefing completed jobs.

To provide consistency and to make it easier to track that these analyses have been completed, standardized checklists and forms have been created that list the most common hazards that can be found with a job and logically guide the user toward identification and mitigation of hazards.  Experience shows that after these forms and checklists have been used regularly, some personnel have a tendency to try and short cut the process.  This leads to what is known as “pencil whipping” the JHA.  In other words, personnel will complete the checklist or form without actually performing the analysis required.   Familiarity with the forms and checklists may drive personnel to identify common hazards, but do little to mitigate the hazards.  For example, a common checklist item is “slips, trips and fall hazards”.  Personnel will identify that the ground is rutted or that there is ice on the ground, but few will actually smooth the ground or cover the ice with sand to mitigate the hazards identified.

It is generally agreed among those who supervise personnel performing JHAs that the most important part of the process is not the completion of the forms and checklists but the discussion that happens among a group performing the work.  In order to focus the discussion and insure that all issues are addressed, the JHA checklist at the end of this paper can be used.  The JHA checklist is not intended to replace the checklists and forms that an organization may already have in place.  The JHA checklist can enhance the process by focusing a group’s thoughts on individual checklist items.  By answering each question a work group should be able to identify all issues associated with any job they are conducting.

As work groups become more familiar with the JHA checklist and the process of discussing and documenting the efforts of the group, a simplified method can be adopted.  By answering six key questions, a group of workers can focus discussion on the issues that are most important.   The six questions and the benefits of using them include:

• What are we doing?  If we can’t answer this question completely and in simple terms, then we should not be doing the job.  A simple explanation will insure that all members of the team are working toward the same goal.
• What is the most dangerous part?  If we can identify the most dangerous part of what we are doing we have identified all hazards, ranked them and determined the most dangerous part.
• What will we do to protect ourselves?  Answering this question ensures that all mitigation measures have been put into place and that all personnel know what is being done.
• How will we know we are changing what we are doing?  To answer this question effectively, we will need to be creative and analytical.  Examination of the work site, knowledge of simultaneous operations, and competency in our job will be required.  Anticipating potential changes will insure that we are not surprised when things do change.
• What will we do about it?  Again, creativity and analytical thinking are critical here.  Many times we hear the phrase, “prior planning prevents poor performance”.  Effectively answering this question insures that performance will be as designed.

How will we know we are finished?  Review of completed job hazard analysis documents has shown that it may be difficult to determine at what point the job is complete.  If the permit for the job being performed provides a scope of work like, “replace mechanical seal in hot oil pump”, once the seal is replaced, there are numerous tasks that still need to be performed before the job is complete.  Numerous times the JHA does not go beyond analyzing the tasks associated with the scope of work and do not consider additional tasks; like testing, clean up and turnover to operations.

As previously mentioned, most supervisors believe that the discussion associated with this type of analysis is more important than the completion of the form used to show that the JHA has been performed.

What about the form though?

• What happens at the conclusion of the job?
• Does anyone review the form to determine if all the hazards were found and mitigated?
• Does anyone follow up with the work group to see if anything happened that made them change the work?
• How should this review be performed and what are the benefits that will be gained by this?
• How can we learn from our experience?

Developing competent personnel is an ongoing process for most organizations.  A great deal of literature exists on the most effective methods of developing competency in adults. Training sessions are delivered using the concept of Kolb’s theory of the experiential learning cycle.  Experienced trainers who deliver adult learning sessions use a process of debriefing to allow reflection, reinforce learning and help the learner apply the knowledge to their life.  It is generally acknowledged in the training industry that most real learning takes place in the debrief.  This is the opportunity for learners to reflect and develop knowledge from the activity, in our case the job performed.

Very simply, debriefing a learning activity should focus on three questions.  What?  So What?  Now What?

What? is the question that guides the learning toward reflection and what just happened.  This question provides a starting point to discover what everyone involved experienced.

So What? is the question that leads to drawing conclusions and exploring alternate methods.

Now What? leads to future planning and continuous improvement initiatives that will be used to strengthen the organization’s culture and work processes.

If we return to question six of the job hazard analysis process, “How will we know we are done?”, the final answer for this question would be, “When we have completed the debrief of the job performed.”  There are five questions that should be used for debriefing a job.  These five questions, how they relate to the standard debriefing questions and the expected lessons to learn from them include:

What did we do?  This is the opportunity for reflection and to insure that the job has been completed appropriately.  Each member of the team should come to agreement that what is being described is what was actually done.   This is the What of debriefing.

Did anything change while doing the job?   Reflection on this question will lead the team to determine if the job was actually performed as it was initially described and analyzed.  This is the question that will also lead to identify incidents for investigation.  If anything unusual occurred during the task, reporting should be more efficient because the incident will be fresh in everyone’s mind.  Capturing these incidents and changes now will help modify future work orders and insure that we learn something from this experience.  This is the So What of the debriefing cycle.

Did anybody get hurt?  This question should be answered with all personnel examining themselves for strains, pulled muscles, bumps, bruises, cuts, scrapes, twisted joints, twinges in the back and a general self examination for good health.  Any small injury or potential illness should be recorded here.   This will insure that a worker does not leave the job without reporting an injury or illness, and then visit a medical provider later because something cropped up.  Having someone discover they have been injured after leaving the worksite is a problem for managers.  This allows measures to be taken early to manage the injury or illness for reporting purposes.  Here and the next question is where more exploration of the “What” is performed.

Did anybody come close to getting hurt?  This is the question that will capture near miss incidents quickly.  Near miss reporting programs fail for numerous reasons.  Lack of understanding, lack of motivation, blaming the reporter, and convenience of reporting are reasons that near misses may not be reported.  Reflection and discussion about the completed job will insure that any near miss is reported quickly.  This will lead to creation of a more comprehensive database that can be used to predict trends and identify problems areas in processes.

What would we do differently?  This is the question that will tie everything together into a plan for the future.  Recommendations and action items should be generated from this final question so that future jobs can be analyzed with more speed and efficiency.  Potential training and competency development issues may be discovered.  Procedures for modification may be identified.  Latent conditions that are not readily apparent may be identified and mitigated before they become active failures.

The Now What of the debriefing cycle is:

• Conducting an effective job task analysis and following with an effective debriefing of the job will yield several benefits.
• Competency gaps of personnel associated with the work will be identified.
• Training topics and on the job mentoring for personnel with these identified gaps, can be more quickly delivered.
• Procedural modifications that are necessary to insure that work is performed safely and efficiently will be quickly identified and addressed.
• Potential process safety incidents will be quickly identified and investigated.
• Near miss incidents will be reported quickly and the organization’s near miss/incident database will be enhanced.

Job Hazard Analysis Checklist

1. PROCEDURES
2. EQUIPMENT AND TOOLS
3. POSITIONS OF PEOPLE
4. PERSONAL PROTECTIVE EQUIPMENT

• ·What are the procedures for the task?
• ·What is unclear about the procedures?
• ·What order will we use these procedures?
• ·What permits are needed for hazard controls?

• ·What are the right tools for the job?
• ·What is the correct way to use them?
• ·What is the condition of the tool?

• ·What could we be struck by?
• ·What could we strike ourselves against?
• ·What can we get caught in/on/between?
• ·What are potential trip/fall hazards?
• ·What are potential hand/finger pinch points?
• ·What extreme temperatures will we be in/around?
• ·What are the risks of inhaling, absorbing, swallowing hazardous substances?
• ·What are the noise levels?
• ·What electrical current/energized system could we come in contact with?
• ·What would be a cause for overexerting ourselves?

• ·What is the proper PPE?

Hard hat, glasses/goggles, ear plugs, gloves, steel toe boots, respiratory system, fire retardant clothing

1. CHANGING THE COURSE OF WORK

• ·What would cause us to have to stop or rearrange the job?
• ·What would cause us to change our tools or equipment?
• ·What would cause us to have to change our position?
• ·What would cause us to have to change our PPE?

YOU HAVE THE RIGHT AND

THE OBLIGATION TO

STOP UNSAFE ACTS

ENGINEERING JOB ANALYSIS

1. PROCEDURES
2. EQUIPMENT, TOOLS, DOCUMENTS
3. INTERACTION WITH PEOPLE
4. CHANGING THE COURSE OF WORK

• ·What are the procedures for the task?
• ·What is unclear about the procedures?
• ·In what order will we use these procedures?
• ·What is the proper timeline for these procedures?
• ·What permits or permissions are needed for job controls?

• ·What are the right tools for the job? (software, simulators, matrixes, checklists, worksheets…)
• ·What is the correct way to use them?
• ·What forms will be needed for the job?
• ·What documents will we need to produce?
• ·What else do we need to know?

• ·What other departments need to know about this task?
• ·Who are the personnel that need to know?
• ·What other departments will supply information for this task?
• ·Who are the personnel who will supply that information?
• ·What could prevent other personnel or departments from supplying what we need?
• ·What could prevent us from supplying what other departments need?

• ·What would cause us to have to stop or rearrange the job?
• ·What would cause us to change our tools or equipment?
• ·What would cause us to have to change our interaction with people?

Review the checklist below:

• PROCEDURES
• What are the procedures for the task?
• What is unclear about the procedures?
• What order will we use these procedures?
• What permits are needed for hazard controls?

• EQUIPMENT AND TOOLS
• What are the right tools for the job?
• What is the correct way to use them?
• What is the condition of each tool?

• POSITIONS OF PEOPLE
• What could we be struck by?
• What could we strike ourselves against?
• What can we get caught in/on/between?
• What are potential trip/fall hazards?
• What are potential hand/finger pinch points?
• What extreme temperatures will we be in/around?
• What are the risks of inhaling, absorbing, swallowing hazardous substances?
• What are the noise levels?
• What electrical current/energized system could we come in contact with?
• What would be a cause for overexerting ourselves?

• PERSONAL PROTECTIVE EQUIPMENT (PPE)
• What is the proper PPE?

Hard hat, glasses/goggles, ear plugs, gloves, steel toe boots, respiratory system, fire retardant clothing

• CHANGING THE COURSE OF WORK
• What would cause us to have to stop or rearrange the job?
• What would cause us to change our tools or equipment?
• What would cause us to have to change our position?
• What would cause us to have to change our PPE?

• Conducting JHAs is usually considered a personnel safety issue and we know that having a good personnel safety record does not indicate effective process safety.”  This is true, but one of the elements of risk based process safety is safe work practices.  On many occasions, process incidents begin with routine job tasks that are not performed correctly.  Using the JHA checklist according to a formalized procedure yields several benefits.  Personnel performing the jobs have the necessary procedures for performing the task. The procedures are reviewed to insure accuracy. Procedures are identified for development. Training issues are identified for personnel who do not understand the procedures or task. Hazards that are not readily apparent are identified and mitigated before the job. Latent failures are identified and addressed. Deviations from “normal” can be predicted and addressed early in a project or task.  Even if an organization has implemented a global JHA process, local management can use this JHA checklist to enhance the organization’s process.
• Performing a JHA with this checklist may be a bit time consuming at first.  As personnel become more familiar with and practice the process, the time required will be reduced.  The analysis of each job will take as long as necessary to do a thorough review.  Even though production pressures are always part of every job, whatever time is required to do an effective analysis will be worth it.
• The three simple things presented in this paper are meant to be implemented at the process/plant level, not at the global level of an organization.  Implementing them at the process and plant level is much like a pilot project and the process of implementation can be more easily fine tuned.   Effective process safety management system implementation and maintenance can be difficult and time consuming.  These simple things can be modified as personnel become more competent and thus make management of process safety more efficient and effective.

YOU HAVE THE RIGHT AND THE OBLIGATION TO STOP UNSAFE ACTS

The above checklist is being used by a major oil and gas production company and has become a key element of how they do things.  In other words, it is part of their culture.  Contractors working for this company have begun using the checklist to analyze the tasks they perform.