Managing the error trap

Managing the error trap

 

Viva Energy’s Geelong Refinery is committed to maintaining the strongest safety management culture, systems and processes possible. As part of this commitment, in 2019 we set about to tackle one of the more challenging factors relating to safety: human error.

In many situations, human error is a significant contributor to incidents that can compromise safety outcomes. At our Geelong Refinery, Viva Energy has taken steps to minimise such errors with the introduction of the AERO program.

Based on science, AERO (Advanced Error Reduction for Organisations) is a tool that empowers people with a common language and belief, to help them achieve a shared goal and minimise the potential for errors.

Identifying the problem

If you’re asked to complete a task that you’ve done a thousand times before, your knowledge of that task, its inherent risks and potential safety concerns, would be thorough.

But what if that task is done infrequently, or you are new to the job and have never conducted the task before? What if there is also a time pressure associated with completing the job?

These scenarios are all examples of an error trap: which is a condition that provides an opportunity for an error to occur.

Perhaps the procedural guidelines aren’t clear, or the reinforcement of a rule or standard expectation haven’t been communicated adequately. Distractions in the work area, first time doing a task, first day back at work after an extended break or tiredness at the end of a shift are all error traps.

In 2019 our Geelong Refinery recognised that to further improve our safety performance, we needed to reduce or manage the error traps that exist.

The AERO solution

AERO provides tools to help people understand their personality tendencies, so they can more easily recognise and manage error traps associated with performing certain tasks.

One tool is called e-colours. Everyone who undertakes the training has their personality tendency analysed and categorised by a percentage breakdown of four colours.

Green (thinker) - The part of your personality that helps you plan and analyse information.

Blue (Relator) - The part of your personality that helps you empathise with and support others.

Red (The Doer) - The part of your personality that helps you take action and get things done.

Yellow (Socialiser) - The part of your personality that helps you interact and engage with others.

Following the training, a lot of employees at the refinery now visually display their primary e-colour as a sticker on their hat or they wear on a wristband, or they display their e-colours in the email signature. This makes communication easier, as knowledge of the colours means you can tailor your language to suit the personality of the person you’re talking with.

Poor communication can also be a trigger for error traps. By responding to error trap triggers in this way we can predict when errors are most likely to occur and reduce their likelihood of occurring.

Training and more training

A huge amount of time was invested in AERO training, starting with 70 leaders across the site. Equipped with a strong, in-depth knowledge of the AERO concepts, this group became our champions and advocates.

From these advocates we asked for 10 trainers and 21 people volunteered to commit to additional training in AERO and to cascade this training to everyone on site. We then formed a coalition of people who believed in the AERO concepts. This steering committee has also helped us integrate the program into our culture, with the aim of the concepts becoming a natural part of our daily activities.

Over 1,000 people who work at the refinery have now had at least one day of training, focused on understanding the core AERO concepts.

Message reinforcement

Making the messages visible so they remain top of mind has also been important. As well as people wearing their e-colours, signs and posters have been placed around the refinery and in the work areas, to visually reinforce the messages.

Verbal reinforcement happens on a daily basis at our Pre-Start or Toolbox meetings. There are approximately twenty-three work groups holding toolbox meetings at the start of each day. Members of the Viva Energy extended leadership team attend at least one meeting per week, to champion the integration of AERO and ensure it is part of our daily discussions.

Discussions at these toolbox meetings focus on questions about the day’s highest risk task, the error traps to watch for and the tools we can apply to manage those error traps and potential hazards.

Importantly, the toolbox meetings are also an opportunity to recognise and reward times when we have stopped work to ensure safety outcomes are achieved – which is part of our STOP and SEEK OUT help program.

We now award prizes for ‘stop of the week’ and ‘stop of the month’, which is a massive change of mindset; taking this initiative from being something to be avoided to something positive and that is celebrated.

Now people are stopping work whenever they need help, advice, or have any kind of safety concern, and set about finding a solution before recommencing. Safety is never compromised.

A complementary system

Importantly, AERO does not replace the strong safety systems already in place at the refinery. It actually complements them.

Our existing culture of having the courage to intervene to correct behaviour that may compromise safety, and the strength of character to accept that kind of intervention and understand that it’s coming from a good place, is part of our cultural DNA. AERO complements that mindset.

Re-writing the rules

Anyone working in a major hazard facility like the Geelong Refinery must follow explicit rules to protect their safety when performing any tasks.

Rules tell us how to perform tasks as safely as possible. They’re usually printed for easy access and reference, but they aren’t always easy reading.

We identified an opportunity to rewrite our rules and procedures, to make them easier to understand.

As part of AERO we’ve also trained fifteen people (with more training planned) to rewrite our rules as concisely and clearly as possible, eliminating vague language and ambiguity (which is another one to the error trap).

Immediate impact

The feedback we’ve had from our workforce about how we’re engaging differently, and from our senior leaders who are now equipped to have quality discussions around particular work tasks using the AERO language, has all been extremely positive.

Using more specific language is key. Rather than asking “is this task safe?” the question we now ask is “what are the error traps associated with this task and how are we going to manage them?” The conversations to find a solution are more genuine and less confrontational.

The way that we conduct our incident investigations has led to a marked improvement in our safety performance. We now identify improvements to systems that might have previously focused on the individual but look beyond just the individual and consider the systemic drivers of incidents.

But perhaps the greatest impact has been on the level of engagement across the board, which was unexpected. We’re having richer, more positive conversations around where we’re heading and we’re all working towards the same goal – which is Goal Zero.

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