Insights from the 4th EU-STAMP Workshop on Audits and Inspections in Process Safety
USE OF STAMP AND RELATED METHODS
IN
AUDITS AND INSPECTIONS
4
th
European STAMP Workshop, Zürich, Switzerland
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4th EU - STAMP Workshop October Zürich
1
Professional Background and Timeline
•
1979 : Chemical Engineer
•
1979 - 1982
•
: 3 yr Research
Chemical Catalytic Kinetics + Modelling
•
1982 - 2003 : 22 years industrial experience
•
: several Managerial functions:
Production Manager , Project Manager , Logistics Manager
Operations Manager , R & D Manager , Manager (Q , P , Eng )
•
: several sectors:
Non ferrous Metallurgy, Print & Packaging, Automotives
•
2003 - Present
:
13 yrs Process and Labour Safety Inspector
:
-
Inspecting and auditing activities
- Guest lectures on University
•
2015
- 2016
- Research (e.g. ESReDA
*
vice Chairman)
- Technical Workgroup EU- CCPS
- Participant MAHB Project Benchmark
4th EU - STAMP Workshop October Zürich
2
*European Safety Reliability and Data Association
Disclaimer
•
Although many insights came from my experience as
Labour and Process Safety Inspector
•
This presentation in total is NOT an official viewpoint of
my organisation.
4th EU - STAMP Workshop October Zürich
3
Journey
to STAMP (1)
•
Many ways converged:
•
Multiple Managerial functions: executive functions and Leadership
e
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Inspector’s experience
with Accidents and Incidents
•
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4th EU - STAMP Workshop October Zürich
4
Journey
to STAMP (2)
•
Many ways converged: (continued)
•
Inspector’s experience
with Accidents and Incidents
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4th EU - STAMP Workshop October Zürich
5
Journey
to STAMP (3)
•
Many ways converged: (continued)
•
Further Personal Inspector experience + several other audits on other
PSM elements:
•
ALSO
Risk Analysis
Design of Installations and Workplaces
Management of Changes
Development of Procedures / Instructions
Auditing
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4th EU - STAMP Workshop October Zürich
6
FACTORS
7
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4th EU - STAMP Workshop October Zürich
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Seveso Regulation : essential 7 elements in the MAPP:
•
organisation and personnel
•
identification and evaluation of major hazards
•
operational control
•
management of change
•
planning for emergencies
•
monitoring performance
•
audit and review
8
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A quote about systems
4th EU - STAMP Workshop October Zürich
10
10
Major Hazards
+ Accidents in Major Hazards Industries
More complicated or Higher complexity
+
More severe consequences
Need a
higher level of protection
Need a
specific more severe regulation and enforcement
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4th EU - STAMP Workshop October Zürich
Journey
to STAMP (4)
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4th EU - STAMP Workshop October Zürich
12
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FINANCIAL
CONTEXT
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4th EU - STAMP Workshop October Zürich
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Operator
Operator
mistake
mistake
Flaws in
Flaws in
Procedure
Procedure
W
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h
h
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No one checks
No one checks
the procedures
the procedures
Cost cutting ??
Cost cutting ??
W
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?
?
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14
W
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Strategy ??
Strategy ??
H
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A
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Job is removed
W
h
y
?
So the Journey became a project !
•
2013 Conference Göteborg (SE)
•
Learning from Incidents (presentation of research on Audits on AccIncInv)
•
Benchmark Study
•
2012 – 2016 Personal Research in Safety literature
= > New(er) AccInc Investigations
= > Combination System Thinking and Safety
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•
2016 Project
Study STAMP and Auditing
Reinforcing Loop for
STAMP,CAST,STPA on
Audits
4th EU - STAMP Workshop October Zürich
15
15
Project WIP
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4th EU - STAMP Workshop October Zürich
16
16
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AUDITING
[
STAMP use for AUDITING
]
H
O
W
?
?
4th EU - STAMP Workshop October Zürich
17
17
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”
models
with
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- controlling constraints
- different levels of responsibilities
4th EU - STAMP Workshop October Zürich
18
18
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4th EU - STAMP Workshop October Zürich
19
19
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4th EU - STAMP Workshop October Zürich
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4th EU - STAMP Workshop October Zürich
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4th EU - STAMP Workshop October Zürich
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4th EU - STAMP Workshop October Zürich
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4th EU - STAMP Workshop October Zürich
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4th EU - STAMP Workshop October Zürich
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4th EU - STAMP Workshop October Zürich
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Explore the journey and insights shared by Frank Verschueren, a Labour and Process Safety Inspector, at the 4th European STAMP Workshop in Zurich. Discover the use of STAMP and related methods in audits, inspections, and accident investigations. Gain valuable perspectives on managerial functions, organizational factors, and the importance of deep investigations in improving safety practices.
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4th EU - STAMP Workshop October Zrich 1 USE OF STAMP AND RELATED METHODS IN AUDITS AND INSPECTIONS A Journey and a Project Frank Verschueren Labour and Process Safety Inspector 4thEuropean STAMP Workshop, Z rich, Switzerland
2 4th EU - STAMP Workshop October Z rich Professional Background and Timeline 1979 : Chemical Engineer 1979 - 1982 : 3 yr Research Chemical Catalytic Kinetics + Modelling 1982 - 2003 : 22 years industrial experience : several Managerial functions: Production Manager , Project Manager , Logistics Manager Operations Manager , R & D Manager , Manager (Q , P , Eng ) : several sectors: Non ferrous Metallurgy, Print & Packaging, Automotives 2003 - Present: 13 yrs Process and Labour Safety Inspector : - Inspecting and auditing activities - Guest lectures on University 2015 - 2016 - Research (e.g. ESReDA* vice Chairman) - Technical Workgroup EU- CCPS - Participant MAHB Project Benchmark *European Safety Reliability and Data Association
3 4th EU - STAMP Workshop October Z rich Disclaimer Although many insights came from my experience as Labour and Process Safety Inspector This presentation in total is NOT an official viewpoint of my organisation.
4 4th EU - STAMP Workshop October Z rich Journey to STAMP (1) Many ways converged: Multiple Managerial functions: executive functions and Leadership extra interest in Human and Organisational Factors besides TF s Problem Solving : extra interest in Complexity Theories and System Thinking Inspector s experience Personal Investigations on Fatal Accidents ( => conscience of severity !) Review and Assesment of Company Investigation Reports on Serious Accidents ( => conscience of need for local and specific improvement) Auditing in Companies of their Management and Methods of AccInc Investigation ( => conscience of structural and fundamental problems ) ( => conscience of need for global improvement) with Accidents and Incidents Study of Audit results (frequency of shortcomings over the companies)
5 4th EU - STAMP Workshop October Z rich Journey to STAMP (2) Many ways converged: (continued) Inspector s experience with Accidents and Incidents Study of Audit results (2012-2013) (frequency of shortcomings over the companies) Most frequent shortcoming: Investigations : Because too shallow (not deep enough ) Lack of attention for ORGANISATIONAL FACTORS
6 4th EU - STAMP Workshop October Z rich Journey to STAMP (3) Many ways converged: (continued) Further Personal Inspector experience + several other audits on other PSM elements: ALSO Risk Analysis Design of Installations and Workplaces Management of Changes Development of Procedures / Instructions Auditing LACK OF FOCUS on ORGANISATIONAL FACTORS SERIOUS ISSUE !!!
4th EU - STAMP Workshop October Zrich FACTORS WHERE SHOULD BE MORE FOCUS ?? WHAT IS MOST FOCUSED ON ?? ORGANISATIONAL FACTORS HUMAN FACTORS TECHNICAL FACTORS 7
8 Different factors (TF , OF and HF) in REGULATION ===> SAFETY MANAGEMENT SYSTEM Seveso Regulation : essential 7 elements in the MAPP: organisation and personnel identification and evaluation of major hazards operational control HF management of change planning for emergencies + monitoring performance audit and review
9 Why applying a Systemic view on an Organisation? Organisations can be very complicatedSystems or complexSystems with - many (fast) interactions, - interactions which are not seen untill it is too late (accident) Many Organisational Factors are sleeping/dormant in many Organisations When not detected in time SYSTEM FAILURES become ACCIDENTS!!! Horseshoe Bay, TX 10th of April
10 4th EU - STAMP Workshop October Z rich A quote about systems
4th EU - STAMP Workshop October Zrich 11 Major Hazards + Accidents in Major Hazards Industries More complicated or Higher complexity + More severe consequences Need a higher level of protection Need a specific more severe regulation and enforcement a systematic and systemic management of risk =>
12 4th EU - STAMP Workshop October Z rich Journey to STAMP (4) LACK OF FOCUS on ORGANISATIONAL FACTORS (SERIOUS ISSUE !!!) is also A lack of SYSTEMIC VIEW on FUNDAMENTAL ISSUES OSTRICH attitude
4th EU - STAMP Workshop October Zrich BROADENING the CONTEXT PUBLIC ORGANISATIONAL FACTORS TECHNICAL FACTORS VOTER CONSUMER HUMAN FACTORS POLITICS ECONOMY THE OPERATOR LAWS THE INSTALLATION THE ORGANISATION FINANCIAL CONTEXT REGULATOR
14 IMPACT ORGANIZATIONAL FACTORS Strategy ?? Why ? INCREASING RISK Cost cutting ?? Several operators could be making errors in several procedures RISK REDUCTION POTENTIAL Why ? Job is removed ORGANISATIONAL FACTORS INCREASING Why ? No one checks the procedures Why ? Several procedurescan contain (several) flaws Flaws in Procedure Several operators could be making the same error Why ? Operator mistake Individual operator error HUMAN FACTORS
15 4th EU - STAMP Workshop October Z rich So the Journey became a project ! 2013 Conference G teborg (SE) Learning from Incidents (presentation of research on Audits on AccIncInv) Benchmark Study 2012 2016 Personal Research in Safety literature = > New(er) AccInc Investigations = > Combination System Thinking and Safety Reason, Rasmussen, Hollnagel , Nancy Leveson 2015 Benchmark Study (MAHB) participationCAST Nancy Leveson 2016 Project Study STAMP and Auditing Reinforcing Loop for STAMP,CAST,STPA on Audits
16 4th EU - STAMP Workshop October Z rich Project WIP Application STAMP,CAST,STPAon Audits FIRST PHAZE (2016 present) Study STAMP/CAST/STPA if pragmatic for auditing Determine added value for auditing Execution 1
17 4th EU - STAMP Workshop October Z rich AUDITING [STAMP use for AUDITING] HOW ?? AUDIT The BOOK
18 4th EU - STAMP Workshop October Z rich Added value of STAMP/CAST/STPA (1) IMHO : Three large added values for Auditing: (1st) 1/. - Methodical value: safety treated as a CONTROL PROBLEM Large structural FRAMEWORK hierarchical control structure very useful structural models with MORE - information flows (from and to) - controlling constraints fundamental Auditable objects - different levels of responsibilities
19 4th EU - STAMP Workshop October Z rich Added value of STAMP/CAST/STPA (2) IMHO : Three large added values for Auditing (2nd) 2/. Different Levels / Upscaling of models : micro model meso model macro model Enlargement of scope and framework
20 4th EU - STAMP Workshop October Z rich Added value of STAMP/CAST/STPA (3) 3/. Inclusion of Design errors Software MORE Component interaction hazards Cognitively complex human decision-making errors Audit Objects Social Factors Organisational Factors (broader then classic) Management Factors
21 4th EU - STAMP Workshop October Z rich Main value for AUDITS In my opinion: SUBSTANTIAL ENLARGEMENT OF - FRAMEWORK - AUDIT OBJECTS QUESTIONS are more easy to develop or formulate once the Audit Objects are clear
22 4th EU - STAMP Workshop October Z rich Proof and evidences
23 4th EU - STAMP Workshop October Z rich FOCUS on HL OF s = ADDED VALUE (High Level) Organisational Factors v Cfr 7S Model McKinsey (Lower) Organisational Factors + Human Factors + Technical Factors (classic) vv
24 4th EU - STAMP Workshop October Z rich Audit Objects
25 MICRO Models Looking at systems MICRO model Prof Nancy Levinson MI University Audit Objects
26 MESO Models MESO model Audit Objects Looking at systems Prof Nancy Levinson MIT University
27 MACRO model Audit Objects E n l a r g e m e n t MACRO Model S c o p e o f Looking at systems Prof Nancy Levinson MIT University
28 4th EU - STAMP Workshop October Z rich General Purpose of Auditing My inspection experienceconfirms Nancy s MENTAL MODELs and 12.4.1 of her book GAP between REAL world PAPER world and Inspection : first then afterwards verification What do they say they are doing ?? Are they doing what they are saying ??? One of the main purposes of Auditing Identifying and Closing is this GAP on all levels
29 4th EU - STAMP Workshop October Z rich Closing the GAP on ALL levels GAP between PAPER world REAL world and Lower level Supervisors Line Managers Designers Higher levels Higher Management Line Managers/Supervisors Supervisors Technicians Line Managers Operators/Technicians Operators Designers
30 4th EU - STAMP Workshop October Z rich Auditing for detecting the gap Why is auditing so important ? Detecting the gap(s) (by auditing) = Detecting the move(s) or drift(s) of the system towards states of higher risks Generic starting questions for each Audit object How do you garantee that [ AUDIT OBJECT X ] is behaving adequately
31 4th EU - STAMP Workshop October Z rich WIP WORK IN PROGRESS Work done : Framework Micro Meso Macro model Audit objects Audit Questions (generic question done) Work to do (2016 2017) Specific questions : applied per audit object Most difficult: Objective Evaluation criteria (when LTA ??) Solution : Through audit applications
32 4th EU - STAMP Workshop October Z rich Project STAMP,CAST,STPA Inspections on Audits (AccInc Inv can be simular) Improvement of STAMP / CAST / STPA Study STAMP/CAST/STPA if pragmatic for auditing Gather experience 2016 Determine added value for auditing 2017 Application in auditing 2016- 2017 Execution 1 : audit objects and generic questions Develop tools for auditing
33 4th EU - STAMP Workshop October Z rich Thanks for your attention !!!! QUESTIONS ??? BREAKS SOCIAL DINNER LATER : frank.verschueren@werk.belgie.be Linkedin See profile Frank Verschueren Linkedin e-mail fr.verschueren@gmail.com
