This case concerns the effects of reducing the number of personnel allocated to each shift at three industrial plants. The reduction was proposed in response to cost savings imposed on the wider business by the need to remain competitive.
The personnel of interest, known as production officers (POs), monitored production equipment, handled routine stoppages and equipment restarts, carried out first-line breakdown maintenance, and notified repair and recovery teams when more extensive intervention was required.
In current operations there were four POs on duty at each site during regular business hours, with three POs allocated to after-hours shifts. The proposed adjustment involved a reduction of one PO per shift: under the right conditions, the shift teams could operate with three POs per plant during business hours and a minimum of two POs outside business hours.
The change in arrangements was very sensitive: there were safety implications associated with reduced numbers of POs, particularly for the after-hours shifts, and the potential loss of jobs was of interest to the employee union. It was important that the review be undertaken with care, by an independent person, to eliminate any perception of bias or that a pre-conceived agenda was being followed.
Prior to our involvement, each site had conducted a risk scenario identification exercise with a group of POs. They identified scenarios that represented risks to the safety of staff as a result of allocating fewer POs to each shift. Standard Operating Procedures for incidents and outages were also reviewed to identify further risks. The outcome of this process was a list of scenarios with hundreds of suggested actions for improvement.
The list of scenarios and actions was valuable in that it identified many issues that existed already at the plants, as well as risks related to moving to fewer shift workers. However, it did not estimate levels of risk. Consequently, it did not provide an objective basis that reflected the organisation’s risk appetite on which to prioritise the risks and the actions that would follow. The organisation decided that a risk assessment would provide a framework and structure around the many risks and actions that had been developed. The organisation had a risk management process, based on its objectives and risk appetite, and this could be used to provide information to decision makers in a format that was readily understood and accepted by them.
The risk assessment
Preparation for the risk workshops
Preparation involved establishing the context: determining the objectives of the exercise, and how they related to the objectives of the organisation; examining the internal and external context; and identifying the stakeholders and their perceived objectives and influence.
Risk registers were seeded with the risks that had been identified in the earlier exercise. Each risk was examined, the descriptions were reworded to make them more consistent, duplicate risks were eliminated and some risks were combined. Descriptions were put into a ‘standard’ form:
While many of the risks referred to the current shift arrangements and not just the proposed change, there were many benefits in examining all the risks:
- The comprehensive risk identification that had been completed already would not be lost
- Risks under the current arrangements would be addressed, regardless of whether or not the proposed change was implemented
- The organisation could demonstrate that no-change options had not been dismissed.
The risk workshops
Participants for the risk workshops were the POs, plant managers, and safety and union representatives. It was important that all stakeholders were able to voice their opinions and provide their expertise for those matters that directly affected them and the way they work.
Each plant had its own risk assessment and risk register, although there were common elements in each.
The first part of each workshop dealt with risks that exist currently, without any changes to the shift arrangements. The second part looked at the same sources of risk, but with the proposed shift changes assumed to be in place, as well as other risks that were particular to a reduced number of POs.
The outcome of each risk assessment provided, for each plant, the current risk levels with regard to safety, as well as a risk profile specifically for the proposed shift model. The challenge was to determine treatment actions that would provide assurance that the plants could be operated with fewer POs but with equivalent levels of safety. If this could not be determined, then the proposed change would not go ahead.
Outcomes from the risk workshops
For each plant, the risk assessments produced 14 risks for both the existing and proposed shift configurations, summarised in Figure 1. These were given consequence and likelihood ratings to produce risk levels, which were used to prioritise the risks. Prioritisation was necessary to determine resource allocations, particularly in this situation where a great number of actions had been proposed.
Two Very High risks were identified for two of the plants, relating to the proposed shift configuration (i.e. fewer POs). Very High risks were considered unacceptable; actions to lower their risk levels to within the organisation’s risk appetite were a priority. The High risks were relatively evenly distributed between the current and the proposed shift configurations; they required actions to reduce the risk levels to as low as was cost effective.
The Very High and High risks were taken forward for the next stage: examination of treatment options.
Bow tie analysis
Risk treatment workshops seek to identify and evaluate options that will lead to better outcomes for the organisation. We used bow tie analysis to assist in the identification of gaps in the current controls, where there are causes or consequences that don’t have a matching control. This helps to identify improvement options, specifically those intended to address the gaps.
Figure 2 shows the structure of a bow tie analysis, placing the causes and their controls on one side and the consequences and their controls on the other, in the manner of a bow tie.
Preparation for the treatment options workshops
Initial bow ties for the Very High and High risks were prepared, shown within the solid line in the upper part of a simple template like the one in Figure 3. They were based on material from the initial risk assessments and risk registers.
The treatment options workshops
Participants in the risk workshops were invited to the treatment options workshops to ensure continuity and transparency of the process. This approach also provided stakeholders with a level of control over the evaluation, as many were resistant to the proposed change.
During the workshop we examined the bow ties in detail, focussing on the tables within the dotted line in the lower part of the template in Figure 2. We
- Reviewed and elaborated on the causes and consequences and the associated controls, revising and adding to the initial information
- Identified options to address control gaps and generate improvements
- Documented the advantages and disadvantages of each option
- Conducted an initial triage of the options to identify those that offered a net benefit, those that were clearly not worth pursuing and those for which more information was needed.
By the end of the workshop the participants had developed:
- A detailed understanding of the control gaps for the Very High and High risks, for the current shift arrangements and for the proposed new arrangements
- A broad set of options for treating each risk, with initial benefits and disadvantages, ready for further analysis internally by the organisation
- Information that could form the basis for business cases and decisions about whether a change to shift resourcing would be feasible, safe and within the risk appetite of the organisation.
Sound preparation is essential before any facilitated workshop. Pre-workshop activities:
- Provide a structure and agenda for the workshop
- Maximise the use of information generated previously
- Allow participants to prepare themselves
- Support the efficient use of time and resources in the workshop
- Provide more confidence that the objectives of the workshop can be achieved.
The early internal workshops illustrate some of the pitfalls that can arise. While they gave the stakeholders a chance to scrutinise both the current situation and the proposed new arrangements, they generated a large number of actions with no prioritisation or even a justification for doing them. There were no risk levels, no structured basis for comparing the two shift arrangements, and no basis for determining whether the new shift pattern would be within the risk appetite of the organisation. They provided little direction about what to do with the information.
Very early in our involvement we ensured that the objectives of the project were clear and well understood, and we structured the process in a way that would assist those who had to make decisions about the shift resourcing. In this case, it was important to:
- Clearly define the risk assessment objectives and how they would relate to the organisation’s objectives
- Relate the outcomes to the organisation’s risk appetite
- Prepare the participants for the process and provide them with relevant information in a form that would maximise the value of their contribution
- Understand how the risk assessment outcome had to be framed so that the decision makers could understand it and work with it.
The stakeholders were involved closely from the beginning of the analysis.
- Their expertise and detailed knowledge was essential in determining where risks could arise, and most particularly risks related to their safety
- Their participation gave them a degree of control over their own destiny, particularly in the face of a difficult decision to be made.
Stakeholders who are involved and engaged in the process are more likely to support decisions, particularly where they have had a hand in providing the relevant information for making those decisions and participating in the analysis. Indeed, in this case it was envisaged that the POs who had attended the workshops would be part of the teams that would further develop the treatment options, decide which actions would be implemented and agree how they would be implemented.