Lifting Fatality.docx
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Lifting Fatality.docx
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LiftingFatality
LIFTINGFATALITY–Presenter’sNotes
Introduction
Thislaterallearningworkpackhasbeenwrittenasaresultofafatalincidentwhichoccurredonanoffshoredrillingrig.Theworkpackhasbeendesignedtoallowasitemanager(orothersuitableperson)todeliveraninteractiveworkshopwithpersonnelonsite.Theoriginalvisionwasa+-2hrinteractiveworkshopwithagroupof20orso,whichcouldbesplitinto3or4syndicatesaspartoftheworkshop.
Atthetimeofwriting,over200workshopshavebeenrunat+-30industrialsites,engagingapproximately3000personnel.Workshopshavetakenbetween11/2and3hoursdependingonthediscussionthatwasgenerated.
Generally,non-essentialoperationswereshutdownandtheworkshopsweredeliveredtostaffinpaidtimeon-shift.Thisdemonstratesthecommitmentofthecompanytosafetyculturedevelopment,andavoidedlossofrecreationalorresttime,eitherwhilstoffshoreorduringshorebreaks.
Theworkpackisbasedsolelyonaninvestigationthatwasjointlycarriedoutbytheoperatoranddrillingcontractorinvolved.Itdoesnotusematerialfrominvestigationsperformedbyanyotherbody.
Theintentofeachworkshopistocommunicatethelearningpointsfromthistragicincidenttoothersites,anddevelopthelocalsafetyculturebydiscussingthelearningpoints.Thesoleaimofdoingthisistopreventsuchanincidenthappeningagain.
Theworkpackpromptsdiscussionabouttherealrootcauses-ourpersonalbeliefs,valuesandbehavioursaboutwork-whatistherightthingtodoatahumanlevel.Inthissenseitgoesbeyondthemorefamiliarareasofprocess,safetymanagementsystemandstructure.
Itisimportanttoacknowledgethateveryindustrialsiteisunique.Eachsitemanagermustmakeajudgementabouthowtousethematerialinthisworkpack.Thisisakeypartofsuccessfullyengagingpeopleandgettingapositiveresultfromtheworkshop.Wehavefoundthematerialworkswellasastandalonepackage,butdonotbeafraidtoleaveout,expandormodifythematerialtosuityourlocalsituation.
Finally,developmentofsafetycultureisalongtermprocess,requiringcontinuousdevelopmentandnotashortterminitiative.Pleaseusethispacktocomplementyourexistingsitesafetydevelopmentplans.
WorkpackContents
1.WorkshopDeliverySchedule
2.LateralLearningWorkshop
•Introduction+Icebreakers
•ManagementEndorsement
•IncidentDetails
•Discussion,IdentificationofCausesandResultsfrom
•Investigation
•KeyMessages
•KeyQuestion-CouldSuchanIncidentHappenHere?
•LinktoSyndicates:
CulturePyramid/SafetyTriangle
•SyndicatesandFeedback-CultureOnsiteinRelationtoRootCauses
•SiteActionItems
•CloseoutandPersonalTakeaways
PresentationContents
1.Icebreakers
2.Introduction
3.IncidentDetails
4.Discussion,IdentificationofCausesandResultsfromInvestigation
5.KeyMessages
6.KeyQuestion-CouldSuchanIncidentHappenHere?
7.LinktoSyndicates-CulturePyramid/SafetyTriangle
8.SyndicatesandFeedback-CultureOnsiteinRelationtoRoot
9.Causes
10.ActionItems
11.CloseoutandPersonalTakeaways
Presenter’sNotes
Aim
Theaimofanicebreakeristorelaxtheaudience,involvetheaudienceandcreatetherightatmosphereforanopenmindedapproachtotherestofthepresentation.
Theconclusionoftheseicebreakersisthatthingsarenotalwaysasweseethem.Inparticular,ifwearedoingsomethingveryfamiliar,weoftenseewhatweexpecttosee,notwhatisactuallythere.
Generaladvice-afterdisplayingapicture,waitanythinguptoaminuteforaudienceresponse,don’tforcethepace.Berelaxinganddivergent.Useacoupleoftheicebreakersincludedinthepack,butdon’tover-doit!
Icebreaker1-Duckshead/rabbit
Displaythepictureandasktheaudiencewhatitis.
Avarietyofanswersshouldresult.Considertakingavote.
Makethepointthatitcanbeeitherandwedon’talwaysseethefullpicture.
Icebreaker2–Faces
Displaythepictureandasktheaudiencewhattheysee.
Onefacehas2mouths,onehas2setsofeyes.
Makethepointthatpeopleseethingsdifferentlyandsometimesdon’tnoticeallthedetails.
Icebreaker3-TheCAT
Displaythepictureandasktheaudiencewhattheysee“TheCat”or“TheCHT”.
PeopleexpecttoseeTHEandnotTAE,andalsoCATandnotCHT
Makethepointthatperceptionisinfluencedbyexpectation.
Icebreaker4-Vase/Conversation
Displaythepictureandasktheaudiencewhatitis.
Avarietyofanswersshouldresult.Considertakingavote.
Makethepointthatitcanbeeitherandpeopleseethingsdifferently.
Presenter’sNotes-IntroductionandEndorsement
Usethenewspaperheadlinesasabasistodothefollowingthings:
Grabaudienceattentionandraisetheemotionalstakes
HowShortsharpdescriptionoffatality.
Callingaspade,aspade!
Don’tavoidthedifficultwords.
Upfrontadmissionofany“political”issuesoftheday.
Earnpersonalcredibility
HowExposesomethingoftheemotionalimpactonself.
Howyoufeel.
Admityournotabovecriticism.
Tellpeoplewhatyouwantfromthemforyourself.
Usingtheraisedemotionalenergytoengageusallinthecontent
HowRelateittotheindividual,ourfamilies,brokendreams.
Getustoimaginetheconsequencesonourselves.
Beclearaboutwhatitmeanswewillalldo
HowBeexplicit.Getinvolvedinthisworkshop
Can’tbecomplacent.Speakup.
Don’tjuststandby.
SupplementaryInformation-IncidentCauses
Theincidentinvestigationthatformsthebasisofthisworkpackwasundertakenonajointbasisbythedrillingcontractorandtheoilcompanyinvolved.Thisworkpackisbasedonthisinvestigationaloneanddoesnotuseinformationfromanyinvestigationsperformedbyotherbodies.
DirectCauses
1.Themanthatdiedwasstandinginthepotentialfallingpathoftheload
2.Theliftingslingswereincorrectlyattachedpriortothelift
UnderlyingCauses
Thereareavarietyoflevelsofunderlyingand/orcontributorycausesidentifiedintheinvestigation,including:
1.Riskawareness
2.Riskassessment
3.Proceduralclarity
4.Proceduralcompliance
5.Permissiblevariation
6.Managementofchange(manpowerreduction/jobuncertainty)
7.Shiftchangearrangements
8.STOPethics
9.Crewcustomandpractice.
Theseunderlyingcausesfitthe3genericareasofSTOPethics,riskassessmentandprocedure.
Thekeymessageisthatanyoneofthefollowingactionscouldhavepreventedthisfatality:
1.Followingthecorrectslingingprocedure
2.Beingfullyawareoftherisksofsingleslingingandhowthecasingcouldswingandfall
3.Havingtheunsafepracticestoppedandcorrectedbyacolleague
RootCauses
Theunderlyingcausesareallunderpinnedbyourbeliefs,valuesandbehavioursof‘whatisright’.Thesearethefactorswhichshouldmakeusfollowaprocedure,stopanunsafeact,orperformaqualityriskassessment.Thesamebeliefs,valuesandbehavioursimpacthowasiteismanaged-forexamplehowthemanagementmaintainqualityandawarenessofprocedures,orreacttoarequesttostopthejob.
Presenter’sNotes-ExampleBrainstormandGrouping
SBypassingsafetysystems
S/RA/PDistractionsfromotherwork
S/PLocationofoperator
RA/PAwarenessofrisk
RASafehaven/workingspace
S/PApproachingsuspendedload
SSupervisorintervention
PUseofpipehooks
S/PUnbalancedload
RA/PManning
SFatigue
PAutomatedsystems
RARiskassessment
SSTOP-Safetyinitiative
PProcedures
RARepetitiveworking
SPressuretomeetdeadlines
RA/PShiftpatterns
?
?
Morale
RA/PCompetence
PAlwaysfollowprocedures
RAPhysicalstature/condition
RA/PNotfirsttime
RA/PEquipmenttospec
P=Procedures
RA=Riskassessment
S=STOPEthics
Presenter’sNotes-ReviewofUnderlyingCauses
Aim
ToreinforcethedirectcausesoftheincidentfoundbytheofficialinvestigationandtheproblemswithSTOPethicsandcommunicatetherelatedkeymessages.
Theassumptionismadethatthesystemsavailableforcontrollingthecausesaresufficient(ingeneralthiswasborneoutbytheinvestigation).Thegapisinbehaviours,valuesandbeliefs-thingswhichstoppeoplefromoperatingthesafetysystemsorstoppinganunsafejob.
Thustheissuehereisnotaboutcompliance,itisaboutbasicbeliefs-andwhattodoasaresultofthosebeliefs.
Oneviewgraphisprovidedforeachcausearea.Statementshavebeenwritteninthecontextofbeliefs.Weareaskingpeopletodothingsbecauseofwhattheybelieve,ratherthanasaresultoftheirbossistellingthem.
Steeringtheaudienceontobeliefsatthisstagestartsgeneratingthefocusforsubsequentsyndicatework.
Don’tcoercivelytellorimposethismessageontheaudience-keepthepresenterandaudiencetogetherbyasking“doyouagree”or“anythingelse”.
Presenter’sNotes-Couldithappenhere?
Crux
Itisakeydeliverablethatwegetaudiencebuyintothefactthattherootcausesarehumanissues,andthatweareallsusceptibletothesamefailuremechanismsbecauseweareallhuman.
Thisisthemostimportantpartofthewholeworkshop.Thusunderstandingshouldbeobtainedandthenreconfirmed.
AudienceResponse
Theaudienceresponsetothe“couldithappenhere”questionneedstobecarefullymonitored.Ifthereisnoresponse,consideraskingtheaudiencetodiscussitwiththepersonnexttothem,thenreturninafewminutestocapturethoughts.Orchallengetheaudienceusingthe“reactionstatements”onthesecondslide(e.g.areyouthinking“No-GoAWAY”?
)
Thestructuringofthequestions-”Areweopentothesameissues”-andthen,“C
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