Are your Controls really Controls?
Warning – this article may result in a complete review of your fatality prevention process! If you don’t want to read this article, you can watch my video below.
Most bowties for fatal risks have many causes, consequences and controls. We feel good about ourselves because we believe that the more controls we have in any given pathway, the better chance we have in preventing or mitigating the pathway.
Pictured below is an example of a bowtie for a multiple fatality risk from one of our client sites.
At first glance it appears to be a robust Bowtie Analysis, however when we go below the surface a different story emerges.
Control Selection Framework
The process we can use to challenge our controls is through the utilisation of a Control Selection Flowchart.
The flowchart enables an assessment of our controls to determine;
- Is it a true control? or,
- Is it a Support Activity, or
- It is a Verification Activity, or
- Is it not part of the Management System at all
Application of Framework to “Supervision”
Below are some of the controls from the above Bowtie Analysis.
We are going to apply the control selection framework to the control of “Supervision”.
In the first column we must answer the questions below
The Analysis finds;
- Is it a human act, object or system? – Yes
- Does it prevent or mitigate an unwanted event? (i.e. if it was in place it would prevent the timeline from progressing) – No
We find that Supervision is not a Control, which moves us to the Support Activity question set in the second column pictured below.
Our Analysis finds;
- Is it an activity that maximises health / minimises erosion of the control? – Yes (Note – With the control statement of “Supervision” it could also be argued No).
- Is the activity, specifiable, observable and auditable? No
We find that Supervision is not a Support Activity, which moves us to the Verification activity question set in the third column pictured below.
Our Analysis finds;
- Is it an infield check that control is implemented? Yes (With the control statement of “Supervision” it could also be argued No).
- Is it an activity that determines if control is healthy/functioning as required? (With the control statement of “Supervision” it could also be argued No).
- Is it an activity that determines effectiveness of controls? Yes (With the control statement of “Supervision” it could also be argued No).
The Control Selection Framework application has determined that Supervision is not a control and is a Verification Activity (at best).
For orgnisations that use Supervision in their Risk Assessments as the magic panacea, this may come as a surprise, for others this will be a matter of fact.
If we were to apply the Control Selection Framework to the other controls such as Statutory Inspections, Hazard Reporting, and Induction, it’s likely the process will determine these are also not true controls.
Uncovering Issues with Controls
When we applied the Control Selection Framework to the Bowtie Analysis we identified a significant number of controls which were not true controls.
As the review demonstrated a reduction in management of the risk, we were requested to facilitate an end-to-end review and update of the Bowtie.
Bowtie following application of Control Selection Framework
What you need to do
1. Apply the Control Selection Framework to Fatal Risk
If you have fatal risks within your business we recommend applying the Control Section Framework to the Risk Assessments for these risks as the place to start.
This will provide you with an understanding of your True Controls.
To help with this process note the following;
- Any controls that contain the activity or the wording of the following are likely not controls; education, training, monitoring, reviewing, checking, inspecting, verifying, etc.
- This may result in a reversal of Critical Controls
2. Get Help
If you are not sure where to start, or need help, contact us [email protected] and we will perform a free Control Selection Framework review on a Risk Assessment of your choice.
What do you think?
In this article I’ve shared my thoughts on what has worked for us. I would love to hear from you.
Cheers, Christian
Oracle Tree