The Challenge..

Risk Management Workshop, Blackwater, 21 September 2010

Applicable Reference Material

Risk Management Workshop, Blackwater, 21 September 2010

Applicable Reference Material

Risk Management Workshop, Blackwater, 21 September 2010

Applicable Reference Material

Risk Management Workshop, Blackwater, 21 September 2010

Workshop pictures Page 1

Jim Knowles and the Panel (Andrew Morrell, Gavin Taylor, Tim Whyte, John Sleigh, Jane Moss, Richard Mills, Adam Garde).

Risk Management Workshop, Blackwater, 21 September 2010

Workshop pictures Page 2

Andrew Morrell

Jane Moss

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Workshop pictures Page 3

Adam Garde

Grant Cook

Risk Management Workshop, Blackwater, 21 September 2010

Key Points (John Sleigh) . When to use a JSA 1. Most tasks will start out either as a part of a plan or as a response to an unexpected event. 2. If the job is planned, then a procedure should be part of the plan. Consider the task of adding another trailing cable in line either to a shovel (surface) or Continuous Miner (underground). 3. The procedure should include a number of controls checking that the cable is suitable, isolating power, testing before restoring power. 4. In the case where a plan is in place, the JSA is to make sure that the controls are in place or followed and to see if any additional controls are required because of local conditions. E.g. Weather (surface) or accumulated water (underground) 5. If the job is not planned, for example machine breakdown, strata failure then the JSA should look for what parts are covered by procedures and what parts are not. The controls in the relevant prepared procedures should be in place or equally robust alternatives adopted. The parts for which there are no procedures require additional job steps in the JSA. 6. Unplanned jobs certainly require change management what additional hazards or process steps were introduced by the unexpected event? 7. Planned jobs may also require change management how does this job differ from the standard envisaged when the procedure was developed? Environmental conditions? Personnel? Tools? 8. Assessing the risk is about identifying the controls that are required. Managing the risk is about putting the controls in place and monitoring their effectiveness. The hierarchy of controls There is an order of preference for controls those higher in the list are most effective. The terms vary between lists, but this is the list in the Queensland Mining and Quarrying Safety and Health regulation, 2001. (a) elimination of the hazard; (b) substitution with a lesser hazard; (c) separation of persons from the hazard; (d) engineering controls;
Examples of engineering controls 1 using fans and ducting to remove dust 2 using guards on conveyors

(e) administrative controls;

Examples of administrative controls 1 a restriction on the time a worker is exposed to a hazard 2 a procedure or standard work instruction

(f) personal protective equipment.

Risk Management Workshop, Blackwater, 21 September 2010

This is how the NSW Coal Mine Health and Safety Regulation, 2006 lists them: (a) firstly, substituting the hazard giving rise to the risk with a hazard that gives rise to a lesser risk, (b) secondly, isolating the hazard from the person put at risk, (c) thirdly, minimising the risk by engineering means, (d) fourthly, minimising the risk by administrative means (for example, by adopting safe working practices or providing appropriate training, instruction or information), (e) fifthly, using personal protective equipment. In todays mining practices, there is another level below PPE and that is Making people aware of the hazard. This is where barrier tape, signs and pre shift briefings belong. The objective is to control the risk as high up the list as is reasonably achievable. The control will usually only affect the likelihood, or frequency of an incident. It will rarely affect the consequences. It doesnt matter whether you support the roof with timber, roof bolts or tendons, if a piece falls out hits a mineworker, the consequences are the same. It doesnt matter whether a railway level crossing is protected by signs, boom gates or an overbridge. If the car finds its way onto the tracks as the train approaches, the consequences are the same. Using a matrix to assess risk requires people who have a strong knowledge of past incidents, their causes and controls which were not in place or which were not adequate. It is unlikely that a work team will have that expertise. So it is not an accurate tool for use in a JSA. It is even less likely that a mineworker will have that knowledge, so it is less useful in a SLAM or Take 5. The value of the matrix is in deciding a priority in which controls are applied at the planning stage. If a mineworker assesses that a job is unsafe, the first step is to make it safe if possible, and if not to withdraw and report it.

Risk Management Workshop, Blackwater, 21 September 2010

Key Points (Jim Knowles). The main points that I considered were, The interest show by the number of participants tells me that there is a great need for more of these types of forums There appears to be a need for better consistency in the risk management process between organisations/ regulators/ unions/ consultants Improved education for Risk Managers More clarity on the residual risk ranking, re; acceptable level of risk particularly in Qld Possibility of the major players getting together to try for a consistent approach to RA i.e.: Rio, Anglo, BMA and Xstrata

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Key Points (Tim Whyte). The key points as I see them could be encapsulated in the following; The legislation requires individual mines to develop PHMPs and SOPs, why then are we performing multiple JSEA (or whatever) for a task that has already been assessed and work instructions drawn up? If, as conveyed at the seminar, that S&HMS are a monster, then this is our own making. If the mines S&HMS is accessible and clear to read, then it should be robust enough to instruct those performing the task to understand the process and assist in identifying the hazards. Tools such as Take 5, SLAMs etc. are for the individual - not to change the S&HMS to suit the daily condition. If not then a review of the procedure is required. I have attached an Audit tool for all to use that relies on the person performing the task to map against the procedure and what they are actually being requested to perform. This tool, if used, not only gives the mine a free audit but also gets buy in by the mine workers. (You would have seen something similar at MNC) S&HMS have grown out of control, this sometime being due to multiple access to add or change the mines current S&HMS. I believe all mines must have a dedicated S&MS Document controller to ensure that there is only but one of each required procedure available to all coal mine workers. In addition, all mines need to halt the practice on performing risk assessments to come up with another procedure to allow a task to continue, when a procedure already exists. As stated in my presentation, a procedure, once developed and signed off as part of the S&HMS is a statute of law. A dedicated Document controller would alleviate this debacle by ensuring only access to the mines S&HMS for change is performed by an authorised person. Restriction, if not prescribed removal of Corporate bullying to push their barrow on how they see the world. The SSE has the obligation to develop and implement the S&HMS not the associated Corporation.

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Key Points (Jane Moss)

Please find below key points as a result of the workshop in Blackwater; Simplicity is the key to effective risk management - back to basics A JSA is a part of the complete risk management framework, however it is not a risk assessment. A wide variety of tools exist within a sound risk management framework, it is important we educate (training and coaching) our workforce to effectively use the risk management tools most relevant to them Residual risk scores provide clarity around priority setting, they do not indicate a level of risk acceptance Critical control effectiveness should be the key driver of risk tolerability. We must challenge ourselves to devise ways to continually monitor critical control effectiveness so that it becomes a common understanding and a part of the way we operate. Risk management is the key foundation to Safety and Health management, however it is an area that has been somewhat neglected and misguided over the past 5 - 10 years. It was encouraging to see so much interest in this topic and to discover such commonality in thinking. To achieve the greatest improvement in risk management, within the mining industry, we need to strive to achieve a more consistent approach, if there is anything that I may be able to do to further assist in achieving this, please let me know.

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Key Points (Adam Garde) The few points I feel are truly important to making a positive difference with regard to improving risk management in the workplace are as follows; Current legislation places obligations on all mineworkers, and for a person to discharge those obligations then all possible action must be taken to reduce the level of risk that personnel are exposed to within our operations to an ALARA level. Ignorance, short cuts, poor planning, training or available resources, under no circumstances makes it allowable not to do everything that is possible to protect the health and safety of all concerned. With this point in mind, no matter the risk identification or management tool utilised by an operation, the key purpose remains the same, hazard identification and acceptable control are the outputs required from the process. Nearly all mines have a documented SHMS that on paper meets the requirements of legislation in regard to having prescribed PHMPs and SOPs etc. The key to improving the safety of the mine environment and the workforce is for the workforce to have an active understanding and involvement with their sites SHMS. The most perfectly written procedures are useless without an understanding of how to implement and apply them into every task within the mine. A safe mine and mine culture does not happen by accident, it takes planning, effort, team participation and continual review. Whilst it is the operators and tradesmen that normally perform the tasks on a day to day basis, it is critical that the people in supervisory and senior supervisory roles have a real understanding of exactly what is involved in the tasks they plan for completion. It is very easy to get bogged down and spend the whole day glued to the computer, but if you really want to be a part of your work groups and improve the performance in all areas, you need to spend real time in the workplace and see the day to day struggles and then action the issues to make a change. When planning tasks, ALL the required documentation should support the daily plan. Auditing your procedures against the actual way the tasks are done underground is the only way to ensure your systems and documents are adequate.

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Key Messages (Andrew Morrell) .. 1 - Things go-wrong because of poor decision-making All 'Mishaps'; be they, injuries, fatal injuries, damage or failures to deliver on critical business objectives, are the result of one or more defective decision-making sequences used within the organisation. 2 - Good quality Risk assessments support good quality decision-making Timely, well-designed and completed Risk assessments are the best practice tool that helps the organisation to maximise the effectiveness of its decision-making. It does this by generating thorough understanding of what needs to be done, by when and the methods to be used that ensure that required outcomes are achieved, despite the presence of threatening, and often uncertain, energies/hazards. 3 - The quality of risk assessments is entirely dependent on the process used The value of a risk assessment is dependent on the integrity of the processes used and how it is implemented so that it accurately: 3.1 Identifies the steps that will be taken to achieve the required outcomes; 3.2 Prioritizes the issues that threaten the required outcomes; 3.3 Uses sound principles of Hazard (energy) Control that ensure the adequacy of control over the life of the assets being considered (including the potential for failure-on-demand); 3.4 Harnessing the strengths of group analysis (e.g. synergy) without suffering from the inherent weaknesses of Group Think, Bias or Capture by individuals; and 3.5 Reveals those things that the organisational decision-makers didnt know that they didnt know. 4 - To be duly-diligent Hazard Control must be founded on sustainable & justifiable logic It is important to understand that most risk management concepts are based on models of the real world. If these models are pushed too hard, they can fail to yield helpful answers (or worse still they can give the wrong answer). Some examples are: the use of the 5 x 5 matrix to estimate controlled risks, a task for which, this simple and useful tool, was not designed. It is important to understand that it is a tool designed to logically allocate limited organisational resources with some capability to drive referral to other managerial or expertise levels; it is not a useful tool to measure hazard control effectiveness. Use of matrix risk ranking can inadvertently encourage personnel to rank risks off-the-page as a method of avoiding effort (particularly in JSAs or WRAC exercises) Quoting residual risks, using a 5 x 5 matrix, often results in documented evidence of risks being accepted that are indefensible in law. The chosen risk rating is not an acceptable risk because the

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matrix was only intended for use as measure of raw risk and unless consequences can be significantly reduced the matrix will always prioritise the risk as unacceptable (too high). Good practice does not require qualitative residual risks, instead it needs evidence of adequate hazard control! Relying on arbitrary judgements on residual (controlled) risk using a risk matrix without a full explanation of how the reduction is to be achieved through the use of chosen layers of protection over the life of the asset.

5 - Beware of ill-considered delegation in risk decision-making The tools of risk assessment (JSA, WRAC, HAZOP, FMECA, FTA, Bowtie etc.) can usefully be employed, together or individually, at any organisational level in an organisation. However, it is important to recognise that for each level, the specific needs for sound risk assessment are different. The competence set of those taking part in the risk assessment must be sufficiently wide and deep, to provide the right answers. It is vital that each managerial level of risk assessment process is tuned to reflect the authorities and accountabilities of those charged with providing guidance to decision-makers. In every type of risk assessment, someone in the risk assessment exercise has to be held accountable for ensuring the integrity of the assessment process, irrespective of other organisational priorities. 6 Managements job is to find the right balance between thoroughness and efficiency. The real challenge for organisational management is to ensure that there is adequate and effective effort put into risk assessment and hazard control implementation in order to deliver on the organisationss aspirations for an adequate return for all stakeholders. This requires the organisation to embed an in-depth understanding of capable risk assessment processes and the will to adopt it, even in the face of the relentless imperative to be efficient.

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Key Messages (Richard Mills) In general mine personnel are not developing a risk assessment scope to the level of detail required so the outcome is a risk assessment that does not adequately address the issue when it is completed Risk assessment documents at various sites have a similar basic WRAC layout however not all encompass the required information input to prompt / encourage the necessary prework JSA formats are not suitable for all risk assessment tasks and limited personnel have the confidence and skills to complete a comprehensive WRAC FMEA or HAZOP etc or know when they should be used and help of a skilled facilitator is required Separating or explanation of hazards in the correct terms (task, what could go wrong, why could that go wrong) to promote the use of targeted control methods rather than generalisations (encourages the correct use of the hierarchy of controls) Personnel are being educated in basic JSA and modified JSA methods and some times WRAC through S1, S2,S3 and G2A process but in the field my experience has shown there still exists a considerable lack of knowledge in risk management by front line supervisors There is a tendency to rush the process which misses the necessary detail or does not adequately address the task, hazard and controls effectively. Commitment is required to provide the right people not just anybody Suggestion of some site risk management professionals that would be charged with vetting the scope prior to completing the risk assessment may improve the quality (typically some sites have the UMM or MM approve the scope prior to commencing the RA) A common matrix approach across industry Removal of any use of a matrix from the simple JSA approach An industry understanding that Risk Management is not just a WRAC or JSA but a bag of tools that requires knowledge of what tool is best used where when completing a risk management exercise.

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Guidance Point #1 Selecting the most appropriate risk assessment tool Context There is a general lack of understanding as to what risk-assessment tool needs to be applied in what circumstance. There is not enough effort in establishing the context, purpose and scope. These are critical steps and assist in selecting the most appropriate risk assessment tool. Potential Action Plan Recognised Standard 2 (or the equivalent document to be aligned with the harmonised legislation in 2012) to be amended so that it becomes more effective in assisting people to select the most appropriate risk assessment tool To include checks on process performance To include strategies and guidance on how to avoid traps that lead to ineffective risk management processes (refer to National Minerals Industry Safety and Health Risk Assessment Guideline) To include guidance on how mines are to comply with s 62 Safety and Health Management System (1) A safety and health management system for a coal mine is a system that incorporates risk management elements and practices that ensure safety and health of persons who may be affected by coal mining operations the Mine Site Risk Management Standard. The Mine Site Risk Management System (s62) forms a part of the SHMS- it should explain how the mine implements and applies Recognised Standard 2. It should include for example authorisation process and checks for scoping and facilitation via the most appropriate risk assessment tool eg. WRAC vs JSA.

Relevance to existing processes S62 Safety and Health Management System Recognised Standard 2 Control of Risk Management Practices The Coal Mining Safety and Health Advisory Council In fulfilling its mandate is to Periodically review the effectiveness of the Act, regulations and recognised standards, and the effectiveness of the control of risk to any person from coal mining operations. Recognised Standard 9 Guidance Note on Reviewing the Effectiveness of the Safety and Health Management System

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Notes related to Guidance Point #1 Selecting the most appropriate risk assessment tool What Jim Joy said about that..

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Guidance Point #2 Training and Educating people to make effective decisions when applying and implementing risk management practices Context There is a need to re-educate people who apply and implement risk management processes. There is inconsistency in establishing the context, purpose and scope, and in selecting and applying the most appropriate risk assessment tool.
People without the necessary technical competencies and knowledge of the Safety Health Management System are appointed to supervisory positions. G2 and G3 training alone may not have been sufficient in effectively implementing effective risk management practices. Understanding what, why and how may have gone unchecked.

Potential Action Plan Ensure that people on site are appropriately trained in the mine site system on how to implement the Risk Management System. Consider relevance of the site Training Needs Analysis (Regulation 84). This can also be addressed in the review of Recognised Standard 2 (or the equivalent document to be aligned with the harmonised legislation in 2012). Consider if it justifies being a Prescribed task o Set expectations with RTOs. Raise implementation issues associated with risk management practices on mine sites. RTOs to make adjustments to training material and verify same. Relevance to existing processes
This extract immediately below is from the ANNUAL REPORT of the COAL MINING SAFETY AND HEALTH ADVISORY COUNCIL July 2008 - June 2009 Quality of Competency Training Discussion on the quality of competency training, and the performance of Registered Training Organisations (RTOs), concluded that delivery of competencies and testing is often substandard. The Council has begun to investigate options raised, including the possibility of training providers to be recognised by the Board of Examiners or the Council, or whether it is possible for the Department of Employment, Economic Development and Innovation to have a list of preferred or authorised RTOs. It was decided to make RTO training a permanent item on the Councils agenda. 82 Training scheme 84 Refresher training 85 Coal mine worker not to carry out task unless competent Schedule 7 Prescribed tasks for section 76(3)(a) of the Act

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Notes related to Guidance Point #2 Training and Educating people to make effective decisions when applying and implementing risk management processes What Jim Joy said about that..

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Guidance Point #3 Inconsistent application and use of Job Safety Analysis (JSA) Context JSA forms a healthy part of on-site risk management practices. There are however inconsistencies in; Deciding if JSA should be risk scored. Deciding if a JSA should be converted into a documented procedure, in which case it can be re-used, and reviewed. Deciding if a procedure developed from JSA is an SOP. If it is, then; Recognised Standard 2 requires it to be risk scored, and Regulation 10 requires it to be developed in consultation with other affected mineworkers. Subject to a plan to regularly review if the practice is at an acceptable level of risk (s62(1)(f)).

Potential Action Plan; Recognised Standard 2 (or the equivalent document to be aligned with the harmonised legislation in 2012) to be amended so that it becomes more effective in assisting mines to apply JSA. Tri-partite to decide the above issues, in consultation with Jim Joy. Potential review and update of National Minerals Industry Safety and Health Risk Assessment Guideline (v6, 2007).

Relevance to existing processes

Recognised Standard 2 Control of Risk Management Practices

s10 Standard Operating Procedures s11 Accessing standard operating procedures

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Notes related to Guidance Point #3 Inconsistent application and use of Job Safety Analysis (JSA) What Jim Joy said about that..

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Guidance Point #4 Hierarchy of controls, and control effectiveness Context In the absence of specific expectations, too much onus is placed on administrative controls. This maybe influenced negatively by corporate pressure. Sometimes there is a lack of commitment to engineering/hard controls. Ineffective decision making can lead to; Inappropriate controls being identified Critical controls not effectively identified or implemented Review processes often fail to validate control effectiveness. Qld Coal Mining Safety and Health legislation does not reference effectiveness of control hierarchy, other than in Guidance Note 9.

Potential Action Plan Recognised Standard 2 (or the equivalent document to be aligned with the harmonised legislation in 2012) to be amended to include strategies and guidance on the identification of appropriate control strategies including reference to the hierarchy of controls, the identification of critical controls, and measuring the effectiveness of controls.

Relevance to existing processes S62 Safety and Health Management System Recognised Standard 2 Control of Risk Management Practices Recognised Standard 9 Guidance Note on Reviewing the Effectiveness of the Safety and Health Management System (Part 9 causal Analysis).

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Notes on Guidance Point #4 Hierarchy of controls, and control effectiveness What Jim Joy said about that..

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Guidance Point # 5 There may be a need for some mines to improve the effectiveness of their SHMS in respect to risk management processes. In particular the implementation of consistent risk management practices, review, and document control.

Context Section 62 Safety and health management system states (1) A safety and health management system for a coal mine is a system that incorporates risk management elements and practices that ensure safety and health of persons who may be affected by coal mining operations. Notes from the Workshop Flyer
We spend days reviewing SOPs that have not materially changed in years because the procedures are not fully integrated into the way of working of the mine. Management are not aware of their responsibilities under or responsibility for the maintenance of the Safety Health Management System and therefore there is no ownership. Senior Management may profess to making safety their number one priority yet fail to maintain the systems that manage it. Coal mine workers may use the Safety Health Management System for purposes other than intended. In the search for clarity and brevity accusations are made of watering down the system. Most companies now employ electronic risk management systems and process such as First Priority Enterprise, SAP and Hummingbird but the Safety Health Management System has not necessarily been fully integrated into these.

Potential Action Plan Recognised Standard 2 (or the equivalent document to be aligned with the harmonised legislation in 2012) to be amended to include strategies and guidance on how to measure and improve the effectiveness of risk management processes, including document control. To incorporate the need for investigation processes to evaluate the effectiveness of controls identified in previous risk assessments.

Relevance to existing processes s15 Investigating accidents and incidents Section 62 Safety and health management system Recognised Standard 9 Guidance Note on Reviewing the Effectiveness of the Safety and Health Management System

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Notes on Guidance Point # 5 There may be a need for some mines to improve the effectiveness of their SHMS in respect to risk management processes. In particular the implementation of consistent risk management practices, review processes, and document control. What Jim Joy said about that..

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