Traditionally, safety-critical industries have tended to see the health and safety risks they face as unique to them, but there is a growing consensus that they have more in common with each other than they might think. But how can this knowledge and expertise be pooled and shared for the wider benefit of safety? Perhaps, ponders Dave Mason, there is a lesson we can take from the nuclear industry.
In the aftermath of Chernobyl, the worldwide nuclear industry was cast into the wilderness, with questions hanging over its safety and value to society. Recognising that any incident anywhere in the world had the potential to impact on the whole nuclear community, the World Association of Nuclear Operators (WANO) was formed, with the intention of raising standards of operation worldwide.
Today, the impact of globalisation has led to boardrooms all over the world reviewing the lessons from any major accident, regardless of sector. Indeed, an analysis of major accidents shows that there are common lessons that relate to leadership, communications, and making lasting improvements. However, I have long considered that rather than wait for the lessons of major accidents to be reported and broadcast, safety-critical industries that rely on process safety should be more pro-active and share experience and best practice.
Process safety ensures that there are sufficient barriers to prevent or mitigate against harm. The aim of a pro-active approach would be to ensure the integrity of these different barriers. Using a ‘Swiss cheese’ model, for example, this approach would aim to make sure the size and number of holes in safety procedures are reduced or eliminated before they can be infiltrated and an accident is allowed to occur. Called peer review, an effective approach to pro-active learning has been developed by WANO.
I first became aware that there were common lessons to be learnt across different industries several years ago, when the UK Offshore Operators’ Association set standards on maintenance. The similarities with the nuclear industry struck me then, and I later shared these ideas through the IOSH Hazardous Industries Group (HIG), which decided to make cross-industry sharing a key part of its work plan.
In 2008, the HSE’s chair, Judith Hackitt, set industry the task of sharing best practice and learning, using peer review. The HIG has taken up this challenge and has so far undertaken two successful reviews. These have involved widely different industries, namely nuclear/chemical plant, defence, ship-building, and gas storage, processing and distribution. The reviews have also focused on two very different aspects of operations: control-room operations and maintenance.
Structure of the review
When WANO undertakes a peer review it can involve up to 20 specialists, including a support team to help run the process, and generally lasts three weeks. Each reviewer is paired with a counterpart at the site under review. A senior industry advisor spends the last week of the review period ensuring a balanced perspective has been achieved. Verbal feedback is given to the host site at the end of the review.
Each site would then receive a confidential report, outlining its strengths and areas for improvement, along with a list of observations made across all aspects of operations. Although this is a huge investment of resources, it does pay dividends in the form of continually improving operational and safety performance for all WANO members.
The approach that the HIG adopted chose to validate cross-industry review, using focused areas of operations and retaining the key attributes of the WANO review process. Each review covered three sites and took between five and seven days to complete. Each site also provided a specialist to undertake the review, which was facilitated by individuals familiar with the WANO processes and cross-industry working practices.
So what is it that makes the WANO-style peer review such a useful tool in encouraging health and safety improvements, and what criteria did we retain when we carried out the HIG pilot reviews?
Firstly, peer review is underpinned by sound safety management principles. Secondly, it engages people in a way that values their skills and knowledge, while forging high-performing teams and networks. Finally, it engages people in such a way that it reinforces their understanding of process safety and secures an emotional commitment to act on learning and improve.
Safety principles
The safety principles are embodied in a set of ‘performance objectives and criteria’ that WANO has developed over time and represent a vision for excellence in all aspects of nuclear-plant operation. They are as follows:
Engaging people
The process engages and values people by matching peers. We made sure that the people carrying out the review had similar background skills and experience. Also, the singular task and format we gave to the process helped galvanise the teams, who developed mutual trust and respect. As an outcome of both reviews, we established high-performing teams and cross-industry networks. This spirit of teamwork and openness was underpinned by retaining confidentiality, which meant that all information provided by a site remained on that site.
A particularly forceful aspect of the process that we adopted was to deal only with facts, i.e. the observations we recorded were only of what was seen, or said (see above example). There was no examination of policy or procedures to determine how a system should work, as that would have been an audit.
The observations took place in the workplace and examined how people behaved, what information they worked with, what they did and didn’t do, and which plant they worked on and its condition. Every factual observation was linked to a performance aim and expectation, while a consequence of the action or omission was also recorded. Facts were verified with the hosts to confirm context and accuracy.
Feedback
The format of the feedback and reporting was important. How often do we see analyses of incidents that simply list the failures and corrective actions? This might be useful but is essentially self-referencing. Feedback is more meaningful if you create a picture of the situation as it was observed, how things should be done, and the improvements that are needed to bridge the gap. This is how we reported back our observations.
We created the vision by quoting the performance aim; we identified the fundamental problem that needed to be addressed as indicated by the facts that we had accumulated; we quoted the key supporting facts; and we identified how many other observations pointed to the same problem.
This information is particularly potent when you hear it from someone who has won your trust and respect. It is this engagement of people, the careful selection of peers, and using peers to give the feedback that leads to the emotional impact and commitment to change.
It is relatively easy to gain an emotional commitment to personal safety by getting people to listen to individuals who can share a personal tale of trauma as a result of an injury. However, it is not so easy with something as abstract as process safety. Peer review offers a means to achieve this connection.
Results and benefits
What we have developed is a very focused and condensed form of peer review that contains the key elements of the WANO approach. The review process involves:
Both review exercises have shown that the process translates well across very different safety-critical industries, and that different industries not only share common issues but can also aspire to the same operational aims of excellence without any commercial conflict.
Each reviewer was a specialist and practising expert in their own field and brought a fresh perspective to what they observed at each site.
The approach also enabled people on sites to be more observant, by giving them a fresh perspective and overcoming the dangers of over-familiarity, which can cause people to disregard unsafe behaviours or issues they might otherwise question. These observational skills were an important aspect of the project that each participant acknowledged. Finally, the process helped each reviewer to forge strong networks outside of their own industry.
Each site acknowledged the value added by the observations and reports that were given to them at the end of the review. As with the WANO review, when someone you trust and respect tells you straight where you are falling short, it is a welcome experience. Some sites have shared learning across their industry, others have resolved to improve local findings, and others have committed to integrate the findings into long-term improvement plans.
To ensure its initial findings were properly acted upon, WANO would carry out a follow-up review some years later. So far, however, this is not part of the HIG’s plans.
Where next?
The next steps are to encourage more industries to engage in peer review. So far, the HIG has shared its experiences with MOD Submarine Enterprise, the UK Oil and Gas Association’s Fair Share, and later this year, Gordon Sellers, who facilitated the first pilot review, is presenting at the Hazards XXI symposium.
We have shared our results with the HSE, which is currently considering how it can support our work. We have engaged in dialogue with WANO, and an invitation has been extended to the IOSH president, Nattasha Freeman, to explore how the type of information discussed can be shared in the interests of safety.
My long-term vision is that we will find a vehicle similar to WANO that will allow safety-critical industries to sign up to a common vision of operational excellence and, because of mutual interests, take a collaborative and pro-active approach to avoiding major accidents and ensuring the very highest standards of safety.
Dave Mason is a safety management consultant with experience at board level in the nuclear industry.
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