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Risk Assessment
Risk Assessment
Residual Risk
Reduction Systematically deciding what is safe
By George D. Don Tolbert
dictable ways in the systems employed. When setting physical characteristicswhat can be designed or
out to understand, measure and reduce it, the per- built as part of the system. Capability factors com-
spective that risk resides in all activities is essential. prise what the person who interacts with the system
is able to do. These elements include physical abili-
A Systems Perspective ties, skill sets, and the knowledge of fit and purpose
Websters Dictionary defines system as a grouping of the system. Motivation characteristics include be-
combined to form a whole and function interde- havioral cues and consequences that govern per-
pendently and harmoniously. This definition formancewhat signals people to act and the
serves well to describe the gamut of systems, from consequences of those actions.
most simple to most complex. A Boeing 777 is a sys- The three types of system characteristics are
temone of the most complex ever assembled. linked to the extent that they cannot be separated.
Pencil and paper is a very simple system. Either Whether examination of the system begins with
example meets this definition. environment, capability or motivation, one must
The terms system and process are sometimes used remember that each affectsand is affected bythe
interchangeably, yet they are not synonymous. other characteristics. Engineering changes most
Referring once again to Websters, process is often demand additional education and training.
defined as a series of actions, operations or changes People cannot be motivated to perform if they can-
that produce an outcome. It could be said that sys- not meet the physical demands of the job, or do not
tems and processes are interdependent; neither know what to do, how to do it or why. The most
exists without the other. skilled and motivated people cannot execute opti-
Systems in which people work can be described mally without adequate tools.
in terms of three sets of characteristics (Figure 1). Another perspective on systems is that they exist
Environmental elements are those that comprise the to convert input to output (Figure 2). Work is per-
formed using environment,
Figure 1
Figure 1
capability and motivation
inputs to produce a set of out-
puts. The inputs encompass
Systems at Work everything that goes into the
system, the process encom-
passes what is done to or with
them, and the outputs include
whatever is produced. Systems
are not black boxes. Inputs
can be identified, the processes
central to them can be de-
scribed and the outputs can be
listed.
Perfection is as elusive in sys-
tems as it is in everything else.
While continuous improvement
initiatives can reduce variance
to extremely low levels, sustain-
ing systems with no variance in
output is not possible in practi-
cal terms. System output is actu-
ally a range that includes what
is intended (productive) and
what is unintended (nonpro-
ductive). Most readers will
accept that in the typical system
productive output significantly
exceeds the nonproductive. If it
does not, the system is re-
designed or adjusted.
Nonproductive yet accept-
able output, such as minor
waste, so far exceeds what is
unacceptable that occurrence of
the latter is comparatively rare.
Unacceptable system outputs
2005 Liberty Mutual Insurance Co. such as injurious events can be
so rare that they are not recog-
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Measuring Risk
A requirement for the meas-
urement of anything is at least a
basic understanding of its
nature. This is certainly true of
measurement of risk. Three ele-
ments of risk, while widely
accepted, bear repeating:
Risk in a system can never
be a zero quantity. Nothing is
free of the ability to do harm.
However, reduction of specific
risk to increasingly lower levels
is possible to the extent that
acceptability is reached, then redefined. Examples of In dice, skill is not a factor. Influencing risk in this
this exist in every discipline and field of study system is possible only by affecting the number of
touched by the SH&E profession. rolls and the bet on each one. The problem for the
Risk is situational. The variables that influence gambler at the craps table is that s/he does not have
risk acceptability and the myriad ways they can a large number of rolls to make use of this and can-
interact are as numerous as the situations in which not change the variables which affect the outcome of
they exist. the next roll. This is what the aspiring gambler real-
Probability governs the occurrence of the effects ly needs to know.
of risk. Events that produce harmthose for which Risk can be managed and reduced for practically
risk can be described and measuredare distributed every other industrial system. The first step is to
normally in the array of outcomes from activities. define its characteristics for specific events or out-
These elements are revealed in simple games of comes. Once defined, risk can be quantified to the
chance such as one of the most ancientdice. In extent that a judgment of its acceptability can be
Figure 3, the 11 possible outcomes of rolling two dice made. System variables can then be adjusted so that
are listed across the top. One white die and one black the characteristics used to define risk of an unde-
die are used to illustrate the 36 possible combina- sired outcome are affected.
tions. The combinations are sorted by the outcome As the definition provided by Lowrance sug-
produced. The odds of each outcome are listed gests, risk is the product of probability and severity.
across the bottom of the graphic. Severity is relatively easy to describe in plausible
It is easy to see why seven is often referred to as terms for harmful events that could be expected as
lucky. Seven can occur in six ways. Knowing this, outputs of systems. Probability, on the other hand,
one might expect a seven to occur once in every six can be more difficult to grasp and measure. Few, if
rolls of the dice. Indeed, if the dice are rolled a large any, industrial systems are as simple and straight-
number of times, the outcomes are distributed forward as rolling dice.
according to the probability of their occurrence. As Figure 5 suggests, probability can be more eas-
Charting a thousand or so rolls of the dice, as ily considered in risk assessment by recognizing that
depicted in Figure 4, produces the familiar bell curve it is the product of two interacting components. The
of normal distribution. This is all a gambler needs to opportunity for a specific event or outcome to occur
know, right? Not quite. is a function of the likelihood of the occurrence and
Each roll is an independent event; none have any the extent to which the situation exists in which its
effect on any of the others. While a two is a compar- occurrence is possible.
atively rare outcome, it could occur on the first roll, Using the rolling dice example, the probability of
on any rolls after that or quite easily on several suc- a 12 occurring is 1/36. For even one 12 to occur,
cessive rolls. The gambler has no control (with however, the dice must be rolled. The more the dice
unadulterated dice) over the outcomes and cannot are rolled, the more closely practical experience
affect the distribution illustrated in Figure 4. demonstrates the mathematical odds of rolling a 12.
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Figure
Figure 6 6
system limits, inputs and out-
puts are readily identifiable and
the processes used are well
The F-L-S Technique understood. Brainstorming op-
erational work activities not
only provides an inventory of
systems to examine, but is also
an excellent way to build team
cohesiveness. Selection of the
actual system to be studied
should be influenced quantita-
tively through examination of
incident trends by activity and
qualitatively in which the team
agrees on activities with the
most urgent need for risk
assessment.
Step two is the identification
of the injurious events, usually
described as concerns, for
which the opportunity for
occurrence exists. Again, both
qualitative and quantitative
means of identifying concerns
are used. If incidents or near-
hits have arisen in the activity
in the past, including these in
the list of concerns to be ana-
lyzed is a given. Hazards for
2005 Liberty Mutual Insurance Co. which risk exists without inci-
dent occurrence are equally
important. It is identifying
higher quality, the people closest to the risk in the these concerns for which a jury of system experts is
system will be tuned in to its reduction, and the most important. In Severe Injury Potential,
increased associate involvement in the safety Manuele describes critical incident analysis: Skilled
process will have far-reaching effects. observers interview a sampling of personnel, elicit-
The terminology used in Figure 6 may be familiar ing their recall of critical incidents that caused them
to those who involve teams in problem solving. The concern, whether or not injury occurred (Manuele
F-L-S Technique, as it is widely known, is a quali- 29). This perfectly describes the qualitative identifica-
tative method for assessing the criticality of a con- tion of concerns by R3 team members.
cern. It is typically a group-processed activity used Once concerns have been listed, the next step is to
in the same way as criticality matrix (Prouty) analy- identify the existing state of control for each. This
sis, pair-wise ranking and similar activities. It uses a provides context for the risk rating that will follow,
Likert scale to rate and rank frequency, likelihood facilitating consensus within the team on the nature
and severity for a given occurrence. and extent of risk which resides in the system for
Using R3, the user defines the five points on fre- each concern identified.
quency, likelihood and severity scales to reflect situa- Step four is the actual rating of risk for each con-
tion and application. Figure 6 illustrates a typical set cern. The rating process is virtually identical to that
of scales for workplace safety and health application. described earlier for the F-L-S techniqueexcept that
Figure 7 provides a general overview of the R3 the scales defined and adopted by the team are used
process flow. Step one is to identify the system for in lieu of Likert scales. The risk score for each concern
which risk is to be assessed. It is important to note is the multiplicative product of the ratings assigned
that while the process is adaptable in complexity to to it for frequency, likelihood and severity. The sum
the system being studied, practical experience has of risk scores of the concerns provides the initial
shown that the simpler the system, the more efficient (baseline) residual risk index for the system/activity.
the analysis will be. Large, complex systems will At this point, the team has established a measure
require complex and sometimes onerous examina- of risk through consensus for each concern identified
tion. Most users will find it beneficial to reduce com- as having an occurrence opportunity. The process of
plex systems into subsystems. quantifying residual risk through group consensus
Work activities, as they would be described by also serves to qualify how it originates in the system
those who complete them, provide a particularly use- and/or is allowed to exist. Practical experience with
ful means for defining the systems to be studied. The groups applying the process has revealed that they
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be expected to work in concert to moti- the results of its first R3 analysis to the ly recognized that the R3 team had iden-
vate use of the new procedure. plant leadership group. Submitting and tified an activity with significant oppor-
In this case, the team members had no defending proposals for expenditures on tunity for improvement. In addition to
specific training or experience with sys- improvement projects was as new to the significant risk reduction that could
tem safety or organized risk assessment some as risk assessment and system be achieved through implementation of
before joining the group. At the begin- analysis. After all, no incidents or loss the proposed new controls, efficiency
ning of their first four-hour meeting, costs had been associated with unjam- would also be increased as the number of
they had no knowledge of the R3 ming the high-bay. jams decreased. Expenditure for the pro-
process. The strategy summarized in As it turned out, the leadership group posed risk reduction strategy was enthu-
Table 2 was the result of their second had parallel initiatives to explore princi- siastically approved, and the team was
half-day meeting. ples of lean manufacturing and Six thanked and encouraged to continue its
No amount of commentary can ade- Sigma. The leadership group immediate- work through weekly meetings.
quately describe the level of dis-
cussion within the group about
the effects of the interventions
Table 2
Table 2
on the risk parameters quanti-
fied. Team members intuitively Case Study: Subsequent Assessment
recognized that a significant
opportunity existed to affect fre- Risk
quency, likelihood and severity. Concern New Controls F L S Score
Repairs and preventive mainte- Head injury: Fall Update proximity sensors 2 2 3 12
nance to the racks and ASRS from elevation to increase sensitivity
unit as well as squaring prod-
Various injury: Struck Conduct daily test of 2 3 3 18
uct on pallets could be expected
by, using pry bar the system
to reduce the occurrence of
jams. Thus, the frequency of Head injury: Struck Repair and realign racks 2 1 3 6
the activity is reduced and by, falling pry bar
occurrence opportunity for all Torso injury: Caught Secure pry bars with rope 2 2 3 12
concerns associated with it de- between load and rack
creases. Interventions such as Muscle strain: Square-up loads on skid 2 2 3 12
securing tools with lanyards Using pry bar before placement on ASRS
and use of observers to influ- picking station
ence performance of specific
behaviors reduce the likelihood Extremities fracture: Provide solid cover over 2 1 2 4
of occurrence of specific con- Fall between racks operators platform
cerns when it is necessary to Electric shock: Contact Consult with fall protec- 2 1 5 10
perform the activity. Further- with ASRS circuits tion equipment supplier
more, severity is reduced in the on integrated fall arrest
event of occurrence when PPE system
such as state-of-the-art fall arrest Extremities injury: Jam-clearing procedures 2 2 3 12
devices is used. Fall from ASRS unit written and audited
The team expressed some while traveling
trepidation about presenting
Torso injury: Train and certify 2 2 3 12
Caught in machine technicians
However, one must remember pinch point, automat-
that people must ask the ques- ic motion
tions. The R3 process has been
Pedestrians in aisle Use an observer when a 2 1 4 8
applied in hundreds of settings
struck by falling skids technician is in the rack
across a broad spectrum of
industries. The groups that use Head injury: Provide a clutch brake 2 1 5 10
or adapt it continue to demon- Falling object, hoist on the ASRS platform
strate eagerness to ask the chain failure
questions, diligence in finding Risk Index 116
answers to them and compe-
tence in making sound deci-
sions based on those answers.
In Against the Gods: The Remarkable Story of Risk, Bernstein, P. Against the Gods: The Remarkable Story of Risk.
Bernstein provides insight into the importance of the New York: John Wiley & Sons Inc., 1998.
qualitative judgment on what is safe. The great Damodaran, A. Value and Risk: Beyond Betas. New York: Stern
statistician Maurice Kendall once wrote, Humanity School of Business, 2003.
Karasek, R. and T. Theorell. Healthy Work: Stress, Productivity
did not take control of society out of the realm of and the Reconstruction of Working Life. New York: Basic Books,
Divine Providence . . . to put it at the mercy of the 1990.
laws of chance (Bernstein 329). Lowrance, W. Of Acceptable Risk: Science and Determination of
Safety. Los Altos, CA: William Kaufman Inc., 1976.
Manuele, F. Severe Injury Potential: Addressing an Often-
References Overlooked Safety Management Element. Professional Safety.
Assn. for Manufacturing Technology (AMT). Risk Assess- Feb. 2003: 26-31.
ment and Reduction: A Guideline to Estimate, Evaluate and Re- U.S. Dept. of Defense (DOD). Military Standard System
duce Risks Associated with Machine Tools. ANSI B11.TR3. Safety Program Requirements. MIL-STD-882A. Washington, DC:
McLean, VA: AMT, 2000. DOD, 1977.
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