Relying on a third party for safety assurance is like entrusting your
gym instructor with your overall physical well-being. While we might think they
are competent, sincere and loyal to our needs, their motivations are driven
from an entirely different perspective: customer retention, customer satisfaction,
etc. Hired support must maintain a metaphorical “optimum salt level” when it
comes to honest feedback: too much and you spoil the dish (lose the contract),
and too little and you can lose the taste (deemed incompetent). It is not their
fault—their innate
business drive impels them to tone down the real truth. The objective of this
article is to support organizations in implementing and developing their
assurance management system to positively impact their community and people, thus
preventing major accident hazards (MAHs), fatalities and serious injuries.
The International Organization for Standardization ISO-19011: 2018(en) standard
partially covers the subject by providing comprehensive guidance on auditing a
management system.1 This article seeks to supplement existing
information and develop an over-arching system to develop the entire audit and assurance
program. The information that is already available in ISO
standards (conducting the audit, close-outs, etc.) is purposely omitted to
prevent repetition.
If an organization is facing the symptoms listed below, the internal
layers of assurance must be strengthened:
Safety professionals should liaise with other disciplines to strengthen their
tool set for a changing corporate landscape.
Foundations. OSHA safety audits review safety programs and strategies, while an
inspection evaluates current practices. Audits measure and collect information
about the reliability and effectiveness of a safety program, determine if a
company's stated goals are being met, and examine employee safety training and
response efforts.
The safety management system used by the UK Civil
Aviation Authority (CAA) defines assurance as identifying hazards before
they result in occurrences, seeking out system weaknesses and challenging the
effectiveness of risk controls using safety information that may indicate
emerging safety risks.2 It also involves continuously monitoring the
operating environment to detect changes that may introduce emerging risks or
degrade any existing safety risk controls.
The Institute of Chartered Accountants
in England and Wales (ICAEW) defines assurance
as an objective examination of evidence for the purpose of providing an
independent assessment on governance, risk management and control processes for
the organization.3
Therefore, an audit program verifies the effectiveness of risk
mitigations, whereas an assurance program ensures that risk mitigation will do
its intended job. While the former focuses on independent barriers separately, the
latter ensures that all barriers are configured, aligned and robust enough to
prevent the development and escalation of an initiating event to a disastrous
outcome.
The discipline of enterprise risk management (ERM) defines risk appetite
in a similar manner, as safety identifies as low as reasonably possible (ALARP).
An important difference is that risk appetite is driven primarily by the
financial wellbeing and governance of the organization, whereas ALARP is
defined primarily by legislation and interpreted by a competent authority. An
interesting tool that has been developed by the ERM discipline is assurance
mapping, which is a structured way of identifying and mapping the main sources
and types of assurance in an organization across the four lines of defense
listed below,3 and coordinating them to best effect:
Developing a safety assurance
program. A safety assurance program—based on published
guidance related to assurance mapping—can be divided into three tiers, which can be named as per
organizational geographical spread:
These tiers can help define the
important barriers identified in a control of major accident hazard (COMAH)
report, and ensure they remain robust on an evergreen basis. It is important to
plan audits to provide adequate time for the closure of relevant lower tier
audit actions. For example, a Tier 2 assessment should be conducted at least 6
mos–12 mos after a Tier
1 assessment, and so on.
Numerous
facets comprise the configuration of a successful program:
A sample assurance program is
illustrated in FIG. 1
for reference.
Coverage of assets. Renowned
management consultant Peter Drucker remarked, “Only three things happen
naturally in organizations: friction, confusion and under-performance.
Everything else requires leadership.”
While it is expected that an
organization should have similar systems across all assets, it is surprising to
see this expectation fail repeatedly. All assets must be properly covered
within the assurance plan. To maintain consistency, resources conducting Tier 1
internal audits should ideally go through a consistent training and evaluation
by the corporate SME, while Tier 2 audits should ideally be conducted by a
single team across all assets. Tier 3 teams can merge two or more barriers to
manage the workload effectively (TABLE 1).
Competence. Competence is the single most
important aspect of a robust assurance program. Average programs have been
observed to effectively perform thanks to a team of competent resources and
committed leadership. It is essential to set criteria for the selection of SMEs
and technical authorities that can develop, review and add value to the
assurance program as and when needed. Sample competence criteria include:
Auditors are selected based on their competence and not on their
availability. A formal recruitment process is advised—even if it is from within the organization—with
official selection notifications. The team should include auditors-in-training
to curate both a fresh perspective and put a succession plan in action. Select
auditors for their knowledge and train them for the required skills. In
general, audit training should manage the three major constructs of auditing
discipline shown in TABLE
2.
Checklist development for
reproducibility—review cycle and modification protocol. There is a lot of debate about the usefulness
of checklists and how they can potentially inhibit creativity. The authors
believe that checklists are necessary to ensure the reproducibility of results
and help normalize the differences between different auditors with varied
auditing skills. However, checklists are considered as a baseline only, and should
not stop auditors from making observations over and above those mentioned in the
checklist.
The development of checklists should be a joint concerted effort by a
team of experts, encompassing design, project, operations safety and
maintenance/mechanical interfaces. An effective assurance checklist will cover:
Close-out engagement
workshops. An auditor’s role is to point
out the gaps with a risk rating only—it is the responsibility of the action parties to determine the
best way to resolve those problems. Corporate actions are often seen but are
not beneficial for all sites due to different organizational structures, access
to resources and dissimilar procedures. It is recommended that either the
auditors or site audit representatives present the findings and then let the action
parties decide the best actions/breakdown of actions and target dates to
resolve the findings. Experience has shown the best results are achieved in a
follow-up audit where close-out engagement workshops were conducted, rather
than generic corporate-generated actions.
Audit data intelligence. Databases should be designed to
drive intelligence and are often very useful in supporting an effective
assurance system. Databases must be designed to ensure:
Leadership oversight. Leadership
oversight is necessary to enhance visibility, organizational engagement and safety
culture. Business intelligence dashboards, like the ones shown in FIGS. 2 and 3, should be capable of
putting the puzzle pieces together and building a real-time assurance dashboard
for selected hard and soft barriers. Such dashboards can help leaders be
mindful and assertive during decision-making, field visits and employee
engagement opportunities. They can also provide vital information to plan proactive
interventions that will strengthen weak barriers. Organizations can enhance
situational awareness and prioritize resources to enhance the resilience of
controls.
Site leaders can learn from each other
using these dashboards related to best practices, lessons learned and optimum
approaches toward achieving objectives. The authors have frequently observed
audit data that are kept confidential between different sites of the same
organization. Leadership should encourage openness and utilize audit reports as
an opportunity to trigger debates at functional levels, have multi-functional
teams examine audit findings and implement actions globally if an opportunity
is warranted. Technical authorities and SMEs can play a pivotal role only if
they are involved appropriately in the process.
Takeaway.
An assurance
management system can help provide leadership a real-time snapshot of the
robustness of various barriers, enabling them to plan, decide, intervene and
act in the best possible manner. If used well, such a system can empower the
organization to capitalize on integrative intelligence
and eventually transform into a learning organization capable of consistent
innovation, safe operations and long-term competitiveness. HP
LITERATURE CITED
AAMISH J. KHAN is an
Operational Safety Consultant who has been supporting various renowned
companies in the oil and gas, petrochemical and utilities sectors in their safety
culture enhancement journeys for more than two decades. His multifaceted
exposure to operations leadership, occupational safety, process safety
management, integrity assurance, process design and auditing enables him to
identify, analyze and treat risk effectively throughout an asset’s lifecycle. He
is co-authoring the “CCPS Safe Work Practices Guidelines,” with the objective
of enhancing the sharing of lessons learned across global industry and
softening the safety impact on workers lives. Khan is a graduate chemical engineer
and holds an MS degree in enterprise risk management from Boston University.
PETER VERHULST worked for 42 yr for Royal Dutch Shell Companies and has extensive refinery and gas plant experience from both operational and technological standpoints. His expertise ranges from customer relations and service management to governance of JV interests, business performance improvement through the application of balanced score cards, and the implementation of ERM from scratch. In his last assignment, he led the implementation of an ERM system coupled to an internal audit management system and action tracking system, a first in the oil and gas industry in the Middle East. Verhulst is a graduate of Delft Technical University, the Netherlands, and earned an MS degree in chemical engineering.