HSE information sheet

Organisational change and major accident hazards

Chemical Information Sheet No CHIS7 Introduction analysed and controlled as thoroughly as plant changes, resulting in reduced defences against major This information sheet provides guidance for employers accidents, sometimes with fatal consequences (as in responsible for major hazards on how to manage the the Hickson & Welch incident). This is because, unlike impact of organisational change on their control of the management of plant change, impacts of organisational hazards. It covers offshore and onshore oil, gas, and change are less well understood, and there is a lack of chemical installations and it will also apply to railway robust, generally accepted approaches to ensuring operators and nuclear installations. Following the safety. This guidance aims to help employers manage guidance means that you will be complying with your change that impacts on health and safety. general legal responsibilities, although there can be additional requirements specific to your industry (see What changes? Legal requirements). Many forms of organisational change can affect It is for employers and senior managers dealing with management of major hazards. Changes could include: organisational change, and anyone involved in planning changes to roles and responsibilities, organisational or implementing such change. It will also be helpful to structure, staffing levels, staff disposition or any other employees and, trade union or staff representatives change that may directly or indirectly affect the control of the hazard. The following are some common and safety representatives. management terms for such changes: It describes common pitfalls to look for, suggests a ● business process re-engineering; three-part framework for managing organisational ● delayering; change, and explains your legal duties as the employer. ● introduction of ‘self-managed’ teams; ● multi-skilling; Organisational change is a normal and inevitable part ● outsourcing/contracterisation; of business life in all sectors. But organisations ● mergers, de-mergers and acquisitions; associated with major accident hazards have a greater ● downsizing; potential for disastrous consequences and higher costs ● changes to key personnel; in terms of lives and money. These consequences ● centralisation or dispersion of functions; mean that organisations managing major hazards must ● changes to communication systems or reporting aim for much higher reliability than is normally relationships. necessary in commercial decision making. The main focus of this guidance is on change at operational and site level. It is also relevant to changes Overstressed manager at corporate level which can have a significant impact on safety at operational level. Examples of this include In 1992, at Hickson & Welch, in Castleford fires killed changes in reporting relationships, objectives, five employees during the cleaning of a vessel resources, management system, available expertise for containing potentially unstable sludge. Because of a design, engineering support, procurement and so on. recent company reorganisation, the cleaning task had Although the guidance is specifically about major been organised by inexperienced team leaders accident prevention, the processes outlined should reporting to an overworked area manager.1 have benefits for other aspects of health, safety and environmental management, and even commercial risk. The HSE incident report said: ‘Companies should assess ... the workload and other implications of How to use this guidance restructuring ... to ensure that key personnel have adequate resources, including time and cover, to This guidance sets out a three-step framework: discharge their responsibilities.’ Step 1 - Getting organised for change Step 2 - Assessing risks Step 3 - Implementing and monitoring the change Organisational change is often an opportunity to improve health and safety, for example though Each step is explained and various important topics are reappraisal of safeguards or clarification of personal covered which you should address at each stage of the accountabilities. However, HSE’s experience is that in process. Use these steps to plan and manage your many instances organisational changes are not organisational changes.

Figure 1 Managing organisational change Getting organised checklist

Don’t make too many simultaneous changes, resulting in inadequate attention to some or all. Step 1 Getting organised

Have a strong policy Don’t delay or defer safety issues compared to other aspects considered more pressing, because: Make senior-level managers accountable

Have a clear change-management ● it is seen as a side issue; ● it is delegated to people with inadequate procedure influence; Communicate and include everyone ● it is not considered early enough in the change process; Review and challenge ● inadequate time or resource is allocated to the assessment; ● teams making decisions are too inward looking; ● there is lack of objectivity; ● objectives are passive, maintaining rather than Step 2 Risk assessment improving standards; Identify the people involved ● appropriate management controls are missing. Identify all changes Commitmentandresources Assess the risks

Consider human factors, competence and Although the motivation for the change may be commercial, and not obviously connected with safety, workload major accident prevention must be regarded as core Test scenarios business, not a side issue. Senior management need to demonstrate a clear commitment to safety by their actions, from the outset.

There should be a distinct safety focus within overall Step 3 Implementing and monitoring change processes, with positive objectives. Make a senior, highly influential manager the sponsor or Provide enough resources to make the champion for this. They should ensure the safety change safely aspects of the change receive an appropriate level of resource and attention. Monitor risks during change Keep your plan under review, track actions The effort and resource put in must be proportionate to: the complexity of the change; the scale of the hazards Monitor performance after change concerned; and the degree to which the change may Review your change policy impact on the management of major hazards. This can be by categorising of changes, with greater importance and a higher level of management approval for more safety-significant categories.

Clearsystems STEP 1: GETTING ORGANISED Organisational change should be planned in a thorough, systematic, and realistic way. You should Policy follow a documented and structured procedure for each element of organisational change management. This is The organisation should have a clear policy for similar to the processes for managing plant change. management of organisational change. This should set The following should be clear: out principles, commitments and accountabilities in relation to impact on health, safety and the ● Identify the processes or activities that are to be environment. Ideally the policy should commit to carried out (to ensure that risks arising from the proportionate consideration of all organisational change are identified, assessed and reduced to as changes, large and small; as even those not at first low as is reasonably practicable). connected to safety need to be given consideration to ● Set out the protocols to be followed. confirm whether or not they may have indirect impacts ● Who is accountable and who is responsible for on safety. these activities?

● Who else is involved, and how? contingency plans can be helpful, HSE requires ● What potential risk factors are to be considered? contingency planning by nuclear licensees. (See examples under Step 2.) ● Who reviews the change process, when and how? It can often be very difficult to be objective during organisational change. This might be because of The design of the procedure should take into account: enthusiasm for a particular plan, pressures from a parent company, budgetary pressure, or simply the ● this guidance; stress of high workload and uncertainty. Reviews of ● previous experience of change; plans and assessments by independent internal or ● the experiences of other organisations, where external experts should be used to reduce such feasible. problems. As change can be almost constant for larger organisations, it is helpful to maintain a register of individuals and their tasks, roles and responsibilities STEP 2: RISK ASSESSMENT related to the major hazard. This eases assessment of the frequent changes (large and small) that bigger organisations experience, rather than starting the process ‘from scratch’ with each change. This is a legal The key aim of risk assessment is to ensure that requirement for nuclear licensees. following the change, the organisation will have the resources (human, time, information etc), competence All stages of the process should be adequately and motivation to ensure safety without making recorded, including all relevant factors, questions, unrealistic expectations of people. assessments, responses, decisions and reasons for decisions. This has a number of benefits: Two aspects of the change need risk assessment, they are related but different and should not be confused: ● transparency; ● easier to audit and assess under quality ● risks and opportunities resulting from the change assurance; (where you want to get to); ● accountability of decisions and their authorisation ● risks arising from the process of change (how you can be traced. get there). A clear implementation plan, such as a project plan, The first aspect is dealt with in this section, the second must be produced and approved at a senior level of is dealt with in Step 3. management. This should be reviewed on a regular basis. Avoid trying to do too much too quickly. The risk assessment needs to consider potential impacts upon safe operation in the full range of Participationandcommunication foreseeable conditions and scenarios, as well as: The process of organisational change should involve all ● all activities required to maintain plant in a safe those concerned from an early stage. This is not only condition; for industrial relations reasons, staff at all levels will ● all activities required for a fully functioning health, have unique knowledge of what their own work involves safety and environmental management system, and how it is really done; this may include contractor including all aspects required for major accident and agency staff. This knowledge is often crucial and prevention or ‘process safety’ (such as safe must be given proper consideration. This is sometimes design and plant inspections); and difficult given the emotions and agendas involved. ● effective emergency response. Those making decisions should be careful to analyse all information and views carefully, and be made aware Assessmentprocedures of their own potential lack of objectivity through an independent challenge process (see below). There are two complementary approaches to ensure Involvement in this context means active participation that the main risks are identified: in decisions, not just passive consultation. The HSE ● mapping of tasks and individuals from the old publication Involving employees in health and safety gives examples of active involvement. Wide to the new organisation; ● scenario assessments when the reorganisation participation can also help to ensure a higher level of acceptance of the changes. impacts staff who may have a role in handling or responding to crises such as upsets and Reviewandchallenge emergencies.

Senior management need to be given adequate In both cases it is important that organisations use all information to review progress regularly. The of the knowledge and expertise available to them and organisation should be prepared to change plans if risk involve the workforce in the risk assessment process. assessment shows a potential risk. Preparation of

Assessment checklist changes that may interact with each other, eg roles or responsibilities passing from one area to another. A � Do use the experience of others, don’t make specific person or body (such as a ‘management of mistakes because you haven’t consulted. change project board’) can be allocated responsibility to ensure that these cross-organisation issues are � Do listen adequately to employees, don’t miss or tracked and co-ordinated. dismiss serious issues hidden among all the natural concerns and complaints. Scenarioassessments

These are realistic, structured appraisals that the X Don’t rely on arrangements that make unrealistic, proposed new arrangements will perform adequately in over-optimistic assumptions about human a range of foreseeable upsets, incidents and performance and reliability. emergencies. HSE Contract Research Report Assessing the safety of staffing arrangements for X Don’t staff for normal operation only, be able to process operations in the chemical and allied respond adequately to foreseeable crises and industries2 contains an example which assesses emergencies. staffing arrangement at chemical sites. X Don’t fail to consider realistically the whole An alternative is to carry out exercises and human workload for people following the change, reliability assessments of how the scenarios would be including extra delegated tasks. handled by people (see Human reliability and competence). � Do ensure that all key tasks and responsibilities are identified and successfully transferred to the Scenario assessments will often be appropriate in new organisation. addition to mapping, especially for large or complex changes. X Don’t fail to consider the infrastructure for delivering safe operation. Factors to consider

Mapping During the assessment consider the following factors:

Mapping is the painstaking process of understanding ● Past experience eg previous accidents and and tracking the detail of the change. It involves: incidents, maintenance records, or hours worked ● identifying all people in the existing and to see whether there had been any stress points proposed organisations who will be affected by the in the existing organisation. change. It is important that this data is accurate ● Risks from using contractors eg in high hazard and complete eg maintain a register of all staff in industries, your policy for using contractors or the organisation with relevant roles. outsourcing needs to be clear and major accident ● identify the tasks each person carries out, prevention is paramount. including non-production tasks such as: If you contract out safety-critical work: communication or paperwork; relevant roles and - retain adequate resources to closely supervise responsibilities they have, including those that are and monitor the expertise of people employed, not their mainstream daily duties such as roles in and the quality and safety of their work; emergency response; and the competences - remain an ‘intelligent customer ’, in other words required (special knowledge or skill that each task retain adequate technical competence to judge or responsibility requires); and the working time whether, and ensure that, work done is of the required for the tasks. required quality and safety; and ● Compare the information carefully checking: - have contingency plans to maintain low risks - whether any tasks or responsibilities have (and not increase risks) should the contractor been overlooked; lose the capacity or willingness to deliver to - what training will be required, especially in requirements. relation to health, safety and the environment; ● Assessing workload, especially individual - what the total accumulated workload is likely to workloads in the new organisation. Take into be for individuals; account all required tasks, peaks and troughs. - whether there are tasks that may need to be Overloading can lead to: done simultaneously; - Omission or poor execution of safety-related - what other risks there might be from the tasks such as plant checks or shift hand-overs. changes. - Fatigue from working excess hours, leading to reduced reliability, errors, or short cuts. This process becomes more complex in larger - ‘Bunching’ of tasks preventing quick response organisations where there may be simultaneous or adequate execution.

Contractor checklist One danger that is easy to overlook is the loss to the business of informal knowledge and processes. At most ! Avoid erosion of competence in your sites there will be important knowledge, skills, organisation leading to dependency on relationships and activities that are not recorded and which can be lost unless specific effort is made to contractors and reduced control of risks. capture them through discussion with the people involved, eg during their participation in the mapping � Ensure your contractors, or their sub-contractors, process. have the competence or financial resource to undertake work to required levels of safety or Remember that competence issues do not only apply quality. to operators. The business needs to have a clear idea of the core level of technical competence it requires � Monitor your contractors’ work, if your resources among engineers and scientists to ensure that it for monitoring work are low contractors may continues to be in control of its hazards and avoid compliance with agreed procedures or technology. rules. Competence checklist � Capture and retain essential information and knowledge held, often informally, by the staff who � Identify any gaps in skills and knowledge, will be lost to the organisation through the use of particularly for roles in relation to the major contractors. hazard.

● Action tracking, all information should be collated � Identify how these gaps will be addressed, for and made available to senior management on example by reallocation of roles or training. progress with all actions identified by risk assessments and reviewed as required before the � Select suitable methods for training and change is completed. This should ensure that all assessment. necessary arrangements for safety are in place before key changes, and that nothing is � Plan the availability of competent trainers and overlooked. assessors. ● Human reliability and competence, human factors are generally less well understood than � Plan cover for those involved in training. engineering risks, the risk assessment should consider potential human failures (see Reducing � Verify that the training meets requirements. error and influencing behaviour4). In high hazard environments, you need to consider or seek � Ensure that adequate time and resources are advice from human factors specialists. allowed for necessary training prior to implementation of the new organisation. Risk alert � Set clear criteria with regard to competence Your risk assessments should always consider the levels to judge when it is safe to ‘go live’. full range of potential human failure that may follow a change. These include: Performanceindicators ● excessive workload; ● lack of competence; The risk assessments should result in action plans, ● poor communications; milestones and identify key performance indicators that ● deficiencies in team-working; can be used to monitor the impact of the change ● conflicting priorities; process on the management of major hazards. This is ● low morale. particularly important where consequences could be subtle or long term, such as reducing maintenance staff. The actual measures chosen should be specific to One of the most critical tasks to face is assurance of the change and the potential risks identified by the the competence of people with changed or additional assessments, and wherever possible should be ‘lead’ roles. Many