Introduction Every day we face things that potentially could cause harm or damage to ourselves, our organisations and the environment. To understand what these things could be, first of all, we have to understand the term “hazard”.
The term “hazard” A hazard can be defined in more than one way. Many times, it is defined in combination with the term “risk” or “danger”. In the Cambridge Dictionary a hazard is defined as “something dangerous and likely to cause damage” (Definition of hazard). Another way of defining a hazard can be found on the Canadian Centre for Occupational Health and Safety (CCOHS), whose definition is commonly used when talking about workplace health and safety. The definition they use is: “A hazard is any source of potential damage, harm or adverse health effects on something or someone.” (CCOHS: Hazard and Risk). So basically, a hazard is the potential of harm that may cause loss of life, health impacts, property or equipment losses, social and economic disruption, or environmental impacts.
Sources Used Cambridge Dictionary. (n.d.). “Definition of hazard“. Retrieved from dictionary.cambridge: https://dictionary.cambridge.org/dictionary/english/hazard
CCOHS. (n.d.). “Hazard and risk“. Retrieved from Canadian Centre for Occupational Health and Safety: https://www.ccohs.ca/oshanswers/hsprograms/hazard/hazard_risk.html
When cooperating across sections there may arise a line of potential problems, mainly in regards to the communicative aspect. These problems arise as a result of the clashing of different expertise, authorities and cultural differences. In relation to this a professor within the field of management by the name of Jody H. Gittel has come up with her theory of relational coordination. This theory is mainly focused on the public sector, it is however still applicable for international private organizations. By using this theory as a tool, this theory can help analyse the interpersonal processes, which could potentially be barriers for optimal efficiency. This theory has furthermore been the foundation for multiple Danish consultants, whom have come with their own additions to this theory. Consultants such as Carsten Hornstrup claim that the definition of a good relationship is subjective, and a certain relationship can therefore be seen in two completely opposite ways. A relevant factor in this is the individuals authoritative position within the hierarchy of the organization, whereas leaders will often have a more positive outlook on the relation.
Jody H. Gittel has put up a negative and positive spiral with the purpose of illustrating what indicates a positive and negative relationship. The reason it is illustrated as a spiral is that, a relation is heavily built upon the communication and likewise. There is therefore no real ‘starting point’ and one should try to improve one of the following aspects, in order to breakthrough the next until it comes into full circle.
The theory of relational coordination is based on two different dimensions: Relations and communication. The quality of these aspects are defined as such:
Mutual goals: Same interpretation of the mission objective within an organization, where a task is solved based on a set of common, clarified goals. This is also synonymous with the organization’s vision, so it is crucial that everyone is on the same page regarding the overall goal.
Mutual knowledge: To which degree are the different groups familiar with each others professional field and competences? This is not only about perfoming one another’s list of duties, but also knowing and understanding them.
Mutual respect: Whether the different groups feel acknowledged for their contribution to solving the common task. This is where the higher placed personnel may show a lack of respect other groups, which ultimately affects the common engagement in a negative way
Frequent and timely: This indicator revolves around whether communication is timed correctly, often and interpreted in a meaningful way. The overall coordination suffers if the communication is too frequent, too rare or timed incorrectly.
Precise and problemsolving: Is the communication constructive, practical and relevant? The task needs to be presented in a comprehensive way for the receiver, and needs to address the actual issue at hand.
In the following three weeks, the theoretical debate between two dominant schools on the origins of accidents and reliability, Normal Accident Theory (NAT) and High Reliability Theory (HRT), is elaborated and evaluated. For this week, we will start with NAT.
Charles Perrow’s initial formulation of what has come to be known as Normal Accident Theory (NAT) was developed in the aftermath of the accident at the Three Mile Island nuclear power plant in 1979. Perrow introduced the idea that in some technological systems, accidents are inevitable or “normal”. He defined two related dimensions; interactive complexity and loose/tight coupling – which Perrow claimed together determine a system’s susceptibility to accidents. Interactive complexity refers to the presence of unfamiliar or unplanned and unexpected sequences of events in a system that are either not visible or not immediately comprehensible. A tightly coupled system is one that is highly interdependent: Each part of the system is tightly linked to many other parts and therefore a change in one part can rapidly affect the status of other parts. Tightly coupled systems respond quickly to perturbations, but this response may be disastrous. Loosely coupled or decoupled systems have fewer or less tight links between parts and therefore can absorb failures or unplanned behavior without destabilization.
According to the theory, systems, company, and organizations which is interactive complexity and tight coupling will experience accidents that cannot be foreseen or prevented. These systems are called System Accidents.
Why is this important?
But how do we get from nuclear meltdown to offshore projects or construction projects? Once you start to dissect them, some of the proceedings we manage exhibit both these features in abundance.
All the time our industry deals with risk analysis scenarios, foul weather, temporary infrastructure and communications, staff unfamiliar with their role or location, large-scale deployment of team members with low levels of training, contractors, supply-chain and much more. Any single one of these elements has the potential to suffer a failure that might interact unexpectedly with another part of the system. There are so mange variables for a project team to deal with – especially when you add the unpredictability of humanity into the mix – that it’s easy to imagine the interaction of dozens of potential accident scenarios over the course of just a single project day. It is Perrow’s “complexity” in a nutshell.
Perrow concludes, however, that accidents are inevitable in these systems and therefore systems for which accidents would have extremely serious consequences should not be built is overly pessimistic. The argument advanced is essentially that the efforts to improve safety in interactively complex, tightly coupled systems all involve increasing complexity and therefore only render accidents more likely. The flaw in the argument is that the only solution he considers improving safety is redundancy, where decisions are taken at the lowest appropriate level and coordination happens at the highest necessary level. In such systems staff at all relevant levels are trained and – just as importantly – empowered and supported to take the potentially economic and life-saving decisions.
Of course, this is easy to write and far harder to achieve: such is the complexity of the systems in which we operate that the impacts of decisions by individuals throughout the chain can have far-reaching effects, themselves adding to the problems we seek to resolve. Through planning and training, however, key roles and positions can be identified where fast-paced coupling can be matched.
In next week we will elaborate and evaluate High reliability Organizations, so stay tuned!
Shrivastava, S., Sonpar, K. &Pazzaglia F. (2009) ”Normal accident theory versus High reliability theory: a resolution and call for an open systems view of accidents”, find it here
Marais, K., Dulac, N. & Leveson, N.: ”Beyond normal accidents and high reliability organizations: The need for an alternative approach to safety in Complex systems”, MIT find it here
Most, if not all, project managers know what a SWOT Analysis is. If not, they are probably not doing their best job of being a PM. A SWOT analysis is an acronym for analysis of Strengths, Weaknesses, Opportunities and Threats. With a SWOT analysis you analyse your organisation both Internally and Externally. We usually set this up in a handy two by two table, each axis will have a one label for one column or row, and another label for the other column or row. One axis will have the labels “Helpful” and “Harmful” while the other has the labels “External Origin” and “Internal Origin”
How to Conduct a SWOT Analysis
First, assemble your dream team. Then, take a look at the internal factors that affect your business or project. Do you have an exceptionally dedicated team? Do you lack the finances to achieve the success you’re looking for? These internal factors, positive and negative, will become your business’s strengths and weaknesses.
Next, examine the external factors that affect your business. Is there a need for your product in the market? Are there competing businesses that offer a better product? These positive factors are your opportunities while the negative ones are your threats.
Examine every possible factor and don’t be afraid to poll your employees. They may see factors you don’t.
As a risk tool
In order to determine risk factors with a SWOT analysis you kind of use it the same way. First figure out the internals: What strengths do you have? Is it a great safety policy or a great risk manager? What are your weaknesses? Does the company policy disappoint in the safety department? Are some employees not following SOP’s or other safety regulations? What is helpful and what is harmful to your project and the workers?
The external factors are then not directly related to opportunities or threats. But you can still analyse external factors based on whether they are helpful or harmful.
As with the above examples; use your employees! They are the ones doing the bulk of the work so listen to their expertise. They may surprise you with their knowledge.
Bow-tie diagram is a qualitative visual risk analysis tool, that can be used to communicate and analyse risk scenarios. To use the bow-tie, you first start with visually analysing plausible incident scenarios that could exist around a certain hazard. Second the bow-tie represent what an organisation does to control those scenarios by identifying safety barriers. Barriers are then divided into 2 groups; Prevention and Mitigation. Preventive barriers are placed on the left of the top event and Mitigation barriers on the right.
How do we use a Bow-Tie Diagram?
In the bow-tie diagram you have a hazard, which creates the top event. On the left side of the diagram, the threats are placed. Threats are those events that ‘’can’’ happen. How do we prevent them? The answer is barriers. Barriers has the function to prevent, control and mitigate treats or consequences. Now we talked about what could happen, and how to prevent it. But what if it happens, and the barriers does not prevent the threat. If you look at the diagram, you will see consequences on the right side of the diagram. Consequences is those events that happen, if the selected barriers are not durable.
All the different bow-tie specific elements are described in detail below, followed by a diagram as an example:
Hazard – The ‘hazard’ is an operation, activity or material with the potential to cause harm. Hazards are part of normal business and are often unavoidable. Some may even be necessary to run an operation (e.g., flammable gas). Some examples of hazards are toxic materials (e.g. paints and solvents) high pressure gases (e.g. oxygen, propane, acetylene) radioactive materials (e.g. NORM)
The “top event” – The top event is the moment when control over the hazard or its containment is lost, releasing its harmful potential. It represents the turning point in the risk analysis, separating prevention from mitigation. This is visually represented in the bow tie diagram by the central ‘knot’ — hence the bow tie analogy. Even though it is undesirable for the top event to occur, there may still be time for barriers to act to stop or limit the consequences. The term top event derives from another type of risk analysis called fault tree analysis, which has similarities with the left side of the bow tie model.
Consequences (bow-tie) – Consequences are unwanted outcomes that could result from the top event and lead to damage or harm. Consequences can be described in terms of safety, environment, asset / property damage, and reputational losses, although the scope of the analysis will determine this. A single top event usually has multiple consequences although typically only the most significant consequences (in terms of quantifiable loss) are included in the analysis.
Threats – Threats are potential reasons for loss of control of the hazard leading to the top event. For each top event there are normally multiple threats placed on the left side of the diagram. Threats have some of the same characteristics as both hazards and barrier failures (fx. having the potential to cause harm) but they are defined separately in the context of bow tie analysis.
Barriers – Barriers are physical or non-physical measures to prevent or mitigate unwanted events. They are the ‘meat on the bones’ of the Bow Tie diagram. Barriers are so-called because each has the capability on its own to interrupt a sequence of events. A barrier is placed on the bow tie diagram where it delivers its function or effect; either prevention (threat side) or mitigation (consequence side). Prevention barriers prevent the top event from occurring. Mitigation barriers are employed after the top event has occurred to help prevent or reduce losses and to regain control once it has been lost.
Degradation factors – The degradation factor is a condition that can reduce the effectiveness of the barrier to which it is attached. A degradation factor does not directly cause a top event or consequence, but since it degrades a barrier on a main pathway, the likelihood of reaching undesired consequences will be higher. A degradation factor can apply to barriers on either side of the bow tie diagram. Degradation factors are sometimes referred to as escalation factors, i.e., Lack of/poor training which makes people unable to activate barriers correctly.
Degradation controls – Degradation controls do not directly prevent or mitigate the sequence of events, as that is the role of the main pathway barriers. Degradation controls provide greater confidence that the barrier will do its job effectively. Degradation controls are frequently human and organisational factors concerned with the management of risk and barrier assurance (fx. competence, scheduled maintenance).
Below is an example of a simple bow-tie diagram. In the sources there is a link to the specific software used to make this bow-tie.
CGE Risk, the wikipedia for risk management, has a great article explaining, in great detail, the bow-tie method. Check it out here.
A capacity analysis is, as the name implies, an analysis of one’s capacities. Specifically, one’s capacity to handle risk and “disasters”. A capacity analysis Is usually made of 2 elements: Before an accident and after an accident, or preventive and reactive. It is a holistic view of your company’s risk prevention and disaster reaction plans/policies.
Preventive: is what measures one has to possibly prevent a disaster, it could be; Company policies, safety regulations, PPE for workers, etc.
Reactive: is what measure one has to react to an accident, it could be; Fire extinguishers, contingency plans, local deals with other companies (example will be given later), etc.
A capacity analysis should be based on the previously made Scenario risk analysis and Risk Matrices your company have made. That makes it possible to more precisely decide where capacity is lacking and where theres need for be better risk managing.
How to use it
There is no “right” way to make a capacity analysis. It is something you have to figure out in your organisation. Do you have the capacity to handle the risks you face during everyday operation? How do you get that? Sometimes just asking the right questions can have a huge impact!
Some of those questions might be:
What does the law say? – Are you required by law to specific risk managing procedures?
What does the company policy say? – Does the company have any policies on the area of risk management? If not, go back and look at the law where the company is placed. Now, should they have policies on risk management?
Does your company offer education to workers on how to handle an accident? – First aid, fire training, SOP’s etc.
Do you perform drills with your employees?
Are you equipped with tools to help you react faster to an accident? – Fire alarms, smoke alarms, sprinklers etc.
Tips and tricks:
If possible, make a deal with other companies to help out in case you face disaster/catastrophe.
Say you’re your crane falls over, then a predetermined deal might save you valuable time and a lot of money. An example of this( almost): The Danish highway Police, have a deal with different companies who does vehicle removal. So, in very little time they can have an accident on the road cleaned up. Where it used to sometime take hours, now they can be on their way in 20-30 minutes (depending on the accident of course).
Put everything in a chart/diagram and write down details.
Debrief your employees after an accident and make sure your employees have access to psychological help.
The Danish Emergency Management Agency (DEMA) has a rather long and detailed document describing capacity assessment. It is unfortunately only in danish… See it here.