Situational Awareness and the Hearts and Minds Safety Program
Safety is a constant topic of awareness in heavy industry — how to achieve a safe workplace and how do you create an environment that drives toward safety through the organisation? As an organisation are you focusing on process safety or personal safety or both and how do you see them linked?
A block of work I found interesting is the work developed for Shell by Patrick Hudson and his team in the 90’s in the Hearts and Minds program.
This program defines safety culture as follows:
Safety culture is an organisation’s beliefs and attitudes regarding safety, its place and importance in the organisation, and affects how safely people in the organisation behave. It is essentially ‘the way we do things around here’. Safety culture influences the environment in which people work and in which barriers operate.
While hard work and a systematic approach form the necessary basis for implementing a HSE-MS, a good company safety culture that encourages people to work with rather than against the HSE-MS will allow the HSE-MS to flourish.
A good safety culture places the highest value on safety, occupational health and environment. In such a culture:
- people are always alert to expect the unexpected;
- people fully understand what they should do;
- people are open to suggestions;
- people believe their actions make a difference to themselves and to others, and
- managers do not manage, but show genuine leadership.
Out of this program comes the safety culture ladder, which provides an insight into how an organisation treats safety (and many other business aspects.
“Who and what we are, what we find important, and how we go about doing things round here”
A really interesting aspect of this program is the importance of situational awareness in decision making:
Achieving situation awareness is a tool aimed at improving worker’s decision making, in order to help them assess risks locally and at short notice. It is found that, unaided, people tend to overestimate their ability to deal with risk, such as their ability to drive whilst tired. This leads to people making bad decisions that can result in accidents.
This tool uses a simple technique to help people recognise when a normal situation has the potential to become dangerous. The basic premise takes only a few minutes to understand, and is concurrent with the normal traffic light system:
RED = Stop
AMBER = Proceed with caution
GREEN = Go ahead
Importantly, the tool encourages the user to think carefully about the consequences of too many ‘ambers’ and when this means a necessary halt to operations.
Accidents rarely happen because of a single catastrophic failure, except when that failure is at the end of a chain of non-catastrophic failures and organisational oversights. The Rule of Three (red, amber, green) means that risks are no longer considered in isolation, but together to minimise incidents.
The original paper “The Rule of Three: Situation Awareness in Hazardous Situations “ describes how decision makers should assess the situation. There will be certain “Red” factors where the work should not proceed or be stopped immediately. Then there are factors which individually are not enough to stop the job, but when you get too many of them together combine to create a significant safety exposure — hence the rule of 3.
Too many factors in the ‘orange’ distract and influence decision makers and stress the system’s defensive barriers. The Rule of Three uses both red-orange and green-orange thresholds, with a summation rule that three orange factors is equivalent to a single red. At this point operations should be stopped or, possibly better, delayed until a number of the factors in the orange have been managed back down to the green.
For instance, an operation about to be carried out in bad weather, performed with inadequate planning (“Go out there and fix it”) and with an inexperienced crew, rates as three oranges and should not proceed. Nothing can be done about the weather, but if the planning is improved, or the experience level of the crew is brought up to the necessary level, then the number of oranges reduces to two or one, and the operation can proceed.
The Rule of Three allows direct assessment of the total situation, into which people may inadvertently find themselves, framed in terms of the factors which increase the permeability of the barriers to accidents.
The concepts of the Rule of Three also ties in nicely with another concept developed by Rasmussen he called the “drift to danger”
Rasmussen outlines how in a competitive environment business have a space of possibilities that is always being squeezed towards an unsafe region.
Any large system is subjected to multiple pressures: operations must be profitable, they must be safe, and workers’ workload must be feasible. Actors experiment within the space of possibilities formed by these constraints:
- if the system reduces output too much, it will fail economically and be shut down
- if the system workload increases too far, the burden on workers and equipment will be too great
- if the system moves in the direction of increasing risk, accidents will occur
Relating this back to the Rule of Three — every orange flag is moving you closer to an unsafe boundary. Individually each risk is not enough to be an issue and you remain within the safe space of possibility but as they add up the chance of you crossing into unsafe territory increases. The key concept here is you have no idea where that boundary lies until you cross it.
Reference:
Rasmussen, Jens. 1997. “Risk management in a dynamic society: A modelling problem.” Safety Science 27 (2): 183–213
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