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ARPANSA LICENCE HOLDER FORUM From Risk Assessment to Managing the Risk Controls

ARPANSA LICENCE HOLDER FORUM From Risk Assessment to Managing the Risk Controls. Canberra 20 September 2018. What will I cover?. Why do incidents and accidents occur? Some assumptions about incident causation models Few entirely new accidents?

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ARPANSA LICENCE HOLDER FORUM From Risk Assessment to Managing the Risk Controls

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  1. ARPANSALICENCE HOLDER FORUMFrom Risk Assessment to Managing the Risk Controls Canberra 20 September 2018

  2. What will I cover? • Why do incidents and accidents occur? Some assumptions about incident causation models • Few entirely new accidents? • Many (most?) are a failure to implement well known controls for well known hazards • Do we focus enough on implementation of controls? • How can we improve control implementation? • Recent developments

  3. What is your view of accident causation? • Do you have a shared model of incident causation and therefore prevention?

  4. INCIDENT CAUSATION MODELS • How major incidents occur – require failures by: • Individuals (and not just “front line workers”) • Systems and processes • Engineering Models • Best known is James Reason’s “Swiss Cheese Model.”

  5. In most cases we know the risks and we know the controls!

  6. In most cases we know the risks and we know the controls! • False work and form work failures in construction – 6 Dead • Pouring a mixture of concrete at the Reclaim Tunnel when the two-level formwork structure at the west end of the Reclaim Tunnel failed, killing six and injuring four others. • Deepwater Horizon disaster • 121 well control events • 32 different operators • 6 riser unloading events (2008 – 9) • Source: Transocean Well Control Events & Statistics report, 2005 - 2009

  7. Black Swans are rare…! 2017 Falsework Collapse Major failures of “temporary works” mostly disappeared …. following the 1975 Bragg report Deepwater Horizon Disaster 121 well control events 32 different operators 6 riser unloading events (2008 – 9) Source: Transocean Well Control Events & Statistics report, 2005 - 2009

  8. Typical Situation in many organisations • Written risk assessments • But - ease of use varies due: • length • complexity • clarity • Is it clear which are the risk controls that really matter? From Risk Assessment to Managing the Risk Controls? • How are risk controls implemented?

  9. How do we implement controls?

  10. Too Many Controls?

  11. From Controls to Critical Controls • Each Control has a one page data sheet: • Who is the “owner” of each risk? • What are the objectives of the control? • What has to happen to make the control work? • How is the execution of the control checked, • Who checks (verifies) and at what frequency? • Each control is reported on at a defined frequency

  12. Simplified model of monitoring Audit

  13. Published Guidance ICMM, Critical Control Management – Implementation Guide, 2015 ENFORM, A Barrier Focused Approach, 2016

  14. The end peter.wilkinson@noeticgroup.com

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