A pillar of Risk Based Process Safety (RBPS) is Learn from Experience.\u00a0 The work we do and the processes we use to analyze our work provide significant learning opportunities to enhance process safety competency.\u00a0 This is a derivative of Kolb\u2019s experiential learning cycle [1], but many times we fail to take advantage of the learning opportunities available to us unless there is an incident or a near miss.<\/p>\n
This Tip of the Month (TOTM) will introduce a simple method for debriefing the job tasks we perform to close the loop on this cycle and capture appropriate data to develop competency, work safely and capture near miss\/incident data quickly and efficiently.<\/p>\n
Conducting a simplified job hazard analysis will ensure that all hazards are identified, managed, and mitigated prior to performing work.\u00a0 Performing a simple debrief at the conclusion of the work will ensure that we learn from the experience. By considering every job to be performed a learning opportunity, the experiential learning cycle can be used to identify what was done, how well it was done, and how we might improve in the future.<\/p>\n
This Month\u2019s Tip was recently presented at the Mary K. O\u2019Connor Process Safety Symposium at Texas A&M University [1].<\/p>\n
One of the pillars of the Center for Chemical Process Safety\u2019s (CCPS) Guidelines for Risk Based Process Safety is \u201cLearn from Experience.\u201d\u00a0 What does this mean?<\/p>\n
The elements of this pillar include:<\/p>\n
Each of these elements provides findings, lessons and data that are useful for learning and thus changing and enhancing behaviors and attitudes.\u00a0 The change and enhancement will influence an organization\u2019s culture and ultimately push the organization toward a learning culture.<\/p>\n
These are not the only opportunities available for organizations to learn from experience.\u00a0 Metrics and audits can allow a general overview of process safety performance.\u00a0 Incident investigation insures that when reported, incident information is transmitted to all who will benefit from the learning.<\/p>\n
The job hazard analysis process that many organizations use to identify and mitigate hazards provides a tremendous opportunity to capture data and use the experiential learning cycle if the job is debriefed properly after completion.\u00a0 This paper will provide guidance and explain the benefits that can be derived from debriefing completed jobs.<\/p>\n
At the 2008 symposium, this author presented a paper entitled \u201cThree Simple Things to Improve Process Safety Management.\u201d\u00a0 One of those simple things was to conduct a formalized Job Hazard Analysis (JHA) for the tasks being performed in the life cycle of a process.\u00a0 That paper presented a checklist that could be used to guide personnel in the process of conducting a JHA.\u00a0 (See checklist at end of this paper)<\/p>\n
Many facilities have embraced the concept of conducting JHA.\u00a0 They may be called something else\u00a0 (job safety analysis, job safety checklist, job task analysis) but the process is essentially the same.\u00a0 The job or task is identified and analyzed step by step.\u00a0 The analysis is to identify hazards that may be involved with each step and then develop strategies to mitigate the hazards.\u00a0 This sounds simple in theory, but in reality there are many things that can and do go wrong with this process.<\/p>\n
To provide consistency and to make it easier to track that these analyses have been completed, standardized checklists and forms have been created that list the most common hazards that can be found with a job and logically guide the user toward identification and mitigation of hazards.\u00a0 Experience shows that after these forms and checklists have been used regularly, some personnel have a tendency to try and short cut the process.\u00a0 This leads to what is known as \u201cpencil whipping\u201d the JHA.\u00a0 In other words, personnel will complete the checklist or form without actually performing the analysis required.\u00a0\u00a0 Familiarity with the forms and checklists may drive personnel to identify common hazards, but do little to mitigate the hazards.\u00a0 For example, a common checklist item is \u201cslips, trips and fall hazards\u201d.\u00a0 Personnel will identify that the ground is rutted or that there is ice on the ground, but few will actually smooth the ground or cover the ice with sand to mitigate the hazards identified.<\/p>\n
It is generally agreed among those who supervise personnel performing JHAs that the most important part of the process is not the completion of the forms and checklists but the discussion that happens among a group performing the work.\u00a0 In order to focus the discussion and insure that all issues are addressed, the JHA checklist at the end of this paper can be used.\u00a0 The JHA checklist is not intended to replace the checklists and forms that an organization may already have in place.\u00a0 The JHA checklist can enhance the process by focusing a group\u2019s thoughts on individual checklist items.\u00a0 By answering each question a work group should be able to identify all issues associated with any job they are conducting.<\/p>\n
As work groups become more familiar with the JHA checklist and the process of discussing and documenting the efforts of the group, a simplified method can be adopted.\u00a0 By answering six key questions, a group of workers can focus discussion on the issues that are most important.\u00a0\u00a0 The six questions and the benefits of using them include:<\/p>\n
What are we doing?\u00a0 If we can\u2019t answer this question completely and in simple terms, then we should not be doing the job.\u00a0 A simple explanation will insure that all members of the team are working toward the same goal.<\/p>\n
What is the most dangerous part?\u00a0 If we can identify the most dangerous part of what we are doing we have identified all hazards, ranked them and determined the most dangerous part.<\/p>\n
What will we do to protect ourselves?\u00a0 Answering this question ensures that all mitigation measures have been put into place and that all personnel know what is being done.<\/p>\n
How will we know we are changing what we are doing?\u00a0 To answer this question effectively, we will need to be creative and analytical.\u00a0 Examination of the work site, knowledge of simultaneous operations, and competency in our job will be required.\u00a0 Anticipating potential changes will insure that we are not surprised when things do change.<\/p>\n
What will we do about it?\u00a0 Again, creativity and analytical thinking are critical here.\u00a0 Many times we hear the phrase, \u201cprior planning prevents poor performance\u201d.\u00a0 Effectively answering this question insures that performance will be as designed.<\/p>\n
How will we know we are finished?\u00a0 Review of completed job hazard analysis documents has shown that it may be difficult to determine at what point the job is complete.\u00a0 If the permit for the job being performed provides a scope of work like, \u201creplace mechanical seal in hot oil pump\u201d, once the seal is replaced, there are numerous tasks that still need to be performed before the job is complete.\u00a0 Numerous times the JHA does not go beyond analyzing the tasks associated with the scope of work and do not consider additional tasks; like testing, clean up and turnover to operations.<\/p>\n
As previously mentioned, most supervisors believe that the discussion associated with this type of analysis is more important than the completion of the form used to show that the JHA has been performed.<\/p>\n
What about the form though?<\/p>\n
Developing competent personnel is an ongoing process for most organizations.\u00a0 A great deal of literature exists on the most effective methods of developing competency in adults. Training sessions are delivered using the concept of Kolb\u2019s theory of the experiential learning cycle.\u00a0 According to Kolb [2], this type of learning can be defined as “the process whereby knowledge is created through the transformation of experience.” [i]<\/a> In other words, adults learn best when they are actively experiencing something and not just listening to lectures or instructor centered learning.<\/p>\n Experienced trainers who deliver adult learning sessions use a process of debriefing to allow reflection, reinforce learning and help the learner apply the knowledge to their life.\u00a0 It is generally acknowledged in the training industry that most real learning takes place in the debrief.\u00a0 This is the opportunity for learners to reflect and develop knowledge from the activity, in our case the job performed.<\/p>\n Very simply, debriefing a learning activity should focus on three questions.\u00a0 What?\u00a0 So What?\u00a0 Now What?<\/p>\n What? is the question that guides the learning toward reflection and what just happened.\u00a0 This question provides a starting point to discover what everyone involved experienced.<\/p>\n So What? is the question that leads to drawing conclusions and exploring alternate methods.<\/p>\n Now What? leads to future planning and continuous improvement initiatives that will be used to strengthen the organization\u2019s culture and work processes.<\/p>\n If we return to question six of the job hazard analysis process, \u201cHow will we know we are done?\u201d, the final answer for this question would be, \u201cWhen we have completed the debrief of the job performed.\u201d\u00a0 There are five questions that should be used for debriefing a job.\u00a0 These five questions, how they relate to the standard debriefing questions and the expected lessons to learn from them include:<\/p>\n What did we do?\u00a0 This is the opportunity for reflection and to insure that the job has been completed appropriately.\u00a0 Each member of the team should come to agreement that what is being described is what was actually done.\u00a0\u00a0 This is the What of debriefing.<\/p>\n Did anything change while doing the job?\u00a0\u00a0 Reflection on this question will lead the team to determine if the job was actually performed as it was initially described and analyzed.\u00a0 This is the question that will also lead to identify incidents for investigation.\u00a0 If anything unusual occurred during the task, reporting should be more efficient because the incident will be fresh in everyone\u2019s mind.\u00a0 Capturing these incidents and changes now will help modify future work orders and insure that we learn something from this experience.\u00a0 This is the So What of the debriefing cycle.<\/p>\n Did anybody get hurt?\u00a0 This question should be answered with all personnel examining themselves for strains, pulled muscles, bumps, bruises, cuts, scrapes, twisted joints, twinges in the back and a general self examination for good health.\u00a0 Any small injury or potential illness should be recorded here.\u00a0\u00a0 This will insure that a worker does not leave the job without reporting an injury or illness, and then visit a medical provider later because something cropped up.\u00a0 Having someone discover they have been injured after leaving the worksite is a problem for managers.\u00a0 This allows measures to be taken early to manage the injury or illness for reporting purposes.\u00a0 Here and the next question is where more exploration of the \u201cWhat\u201d is performed.<\/p>\n Did anybody come close to getting hurt?\u00a0 This is the question that will capture near miss incidents quickly.\u00a0 Near miss reporting programs fail for numerous reasons.\u00a0 Lack of understanding, lack of motivation, blaming the reporter, and convenience of reporting are reasons that near misses may not be reported.\u00a0 Reflection and discussion about the completed job will insure that any near miss is reported quickly.\u00a0 This will lead to creation of a more comprehensive database that can be used to predict trends and identify problems areas in processes.<\/p>\n What would we do differently?\u00a0 This is the question that will tie everything together into a plan for the future.\u00a0 Recommendations and action items should be generated from this final question so that future jobs can be analyzed with more speed and efficiency.\u00a0 Potential training and competency development issues may be discovered.\u00a0 Procedures for modification may be identified.\u00a0 Latent conditions that are not readily apparent may be identified and mitigated before they become active failures.<\/p>\n The Now What of the debriefing cycle is:<\/p>\n The process described in this paper can be expanded to any job and any work group.\u00a0 Consider an engineering team who is working on the design of a new process to be considered for construction.\u00a0 Conducting an effective job task analysis in the beginning stages of the project will insure that roles, goals and expectations are addressed and known.\u00a0 Conducting an effective debrief at the conclusion, or even at selected stages of a project, will enhance the project team\u2019s effectiveness and insure that all team members are always striving to meet the goal of the project.\u00a0 The attached checklist for engineering projects, at the end of this paper, may be helpful for focusing a team\u2019s efforts.<\/p>\n Opportunities exist in all phases of operations and in all activities performed to keep processes safe.\u00a0 It is important that all personnel be aware that learning from experience happens every day and these lessons learned need to be captured and stored for future use.<\/p>\n To develop process safety competency attend our PS-4, Process Safety Engineering<\/a>;\u00a0 HS-45, Risk Based Process Safety Management<\/a>; and PS-2, Fundamental of Process Safety<\/a> courses.\u00a0 To develop competency in other skills, attend one of our other courses.<\/p>\n\n