Hearts

AND
Minds

Identify your problems in Supervision

Name Preferred Best fit Skill

style

P03141
 Hearts
AND
Minds

Action Plan

ACTION DO WELL COULD BE IMPROVED

A Reaction to
technical
problems

B Job planning

C Personal
planning

D Team
Leadership

E Work related
behaviour

F Communication

G Motivation
& trust

P03141
 Shell Exploration & Production

Improving Supervision
SIEP B.V.
Copyright 2004

1
 Who is a Supervisor ?
A supervisor is someone who is in charge of one or more people in a
working environment e.g. charge-hand, foreman, manager.

To be a Super-Visor you need to be good (Super) at performing the

job, in a safe way, and have the foresight (Vision) to manage
unexpected events.

A supervisor is the last link between the planning of a job and the real
action of doing the job.

In this last link the supervisor is responsible to ensure that controls

are in place.
SIEP B.V.
Copyright 2003
 Why are Supervisors important ?

The vital role of supervisors within

our operations

You are key in safety leadership and performance

You are responsible for multi-million pound operations
You are often working in less than ideal environments
You are responsible for some smart people who look to you
for your expertise and leadership
You are able to interact with different people from
different organisations
SIEP B.V.
Copyright 2003
 Why focus on Supervision?

Supervision needs to improve across the Energy

Industry
Incident reports and audits often show inadequate or
lack of Site Safety Supervision and a lack of
Situation Awareness
The focus needs to be on safety leadership of people and
not just on the technical aspects of the job - we
need to supervise people more effectively
Accident statistics show supervisors run a higher risk of
becoming hurt - supervisors sometimes jump in
without thinking
SIEP B.V.
Copyright 2003
 HSE Management

Barriers
Hazard/ or Controls
Risk WORK

Undesirable
outcome
SIEP B.V.

Supervisors
Copyright 2003
Copyright 2003 SIEP B.V.
 HSE Performance over time

Technology
and standards
• Behaviour
• Visible leadership / personal accountability
HSE • Shared purpose & belief
• Aligned performance commitment & external
Management view
• HSE delivers business value
• Engineering improvements Systems
• Hardware improvements
• Safety emphasis
Incident rate

• E&H Compliance

• Integrated HSE-MS
• Reporting Improved
• Assurance
• Competence culture
• Risk Management

Time
SIEP B.V.
Copyright 2003
Copyright 2003 SIEP B.V.
 Leadership The right style at the right time

Supportive, facilitative Guidance and direction

Frameworks & Explanation &
examples encouragement
PARTICIPATING SELLING

SUPPORTIVE

DELEGATING TELLING Strongly directive

What, where,
when and how
Giving freedom, trusting
Support &
DIRECTIVE
monitoring The team’s level of:-
• motivation and confidence
• competence
SIEP B.V.
Copyright 2003
 Improving Supervision – How?
SIEP B.V.
Copyright 2003
Copyright 2003 SIEP B.V.
 “The right style at the right time”

Key Message: A successful leadership style in one situation will not guarantee success in
another
SIEP B.V.
Copyright 2003
 Shell Exploration & Production

Understanding Your HSE Culture

SIEP B.V.
Copyright 2004

1
 Session Objectives

• Learn more about our HSE Culture

• Understand your own level of HSE cultural maturity
• Identify your personal role in building a stronger HSE
culture
• Commit to personal action
SIEP B.V.
Copyright 2003
Copyright 2003 SIEP B.V.
 HSE Performance over time

Technology
and standards
• Behaviour
• Visible leadership / personal accountability
HSE • Shared purpose & belief
• Aligned performance commitment & external
Management view
• HSE delivers business value
• Engineering improvements Systems
• Hardware improvements
• Safety emphasis
Incident rate

• E&H Compliance

• Integrated HSE-MS
• Reporting Improved
• Assurance
• Competence culture
• Risk Management

Time
SIEP B.V.
Copyright 2003
 Culture Ladder

GENERATIVE
HSE is how we do business round here

PROACTIVE
we work on the problems that we still find
Increasingly
informed
CALCULATIVE
we have systems in place to manage all hazards

REACTIVE
Safety is important, we do a lot every time we have an
accident
Increasing Trust/Accountability

PATHOLOGICAL
who cares as long as we’re not caught
SIEP B.V.
Copyright 2003
 Culture Ladder – Short exercise
chronic unease
GENERATIVE safety seen as a profit centre
new ideas are welcomed

resources are available to fix things before an accident

PROACTIVE management is open but still obsessed with statistics
procedures are “owned” by the workforce

we cracked it!
CALCULATIVE lots and lots of audits
HSE advisers chasing statistics

we are serious, but why don’t they do what they’re told?

REACTIVE endless discussions to re-classify accidents
You have to consider the condition under which we are
working
the lawyers/regulator said it was OK
PATHOLOGICAL
of course we have accidents, it’s a dangerous business
SIEP B.V.

sack the idiot who had the accident

Copyright 2003
 Selection of dimensions
SIEP B.V.
Copyright 2003
 Working Session 1
• On your score sheets, you can make a mark next to
the dimensions that match your function.
• Read through the applicable dimensions 1 by 1
• Score the level that feels like your part of the
business
• If you can’t decide between descriptions score both
• Calculate your scores
• Keep your score sheet
SIEP B.V.
Copyright 2003
Copyright 2003 SIEP B.V.
Copyright 2003 SIEP B.V.

Scoring
 Culture Ladder

GENERATIVE
HSE is how we do business round here

PROACTIVE
we work on the problems that we still find
Increasingly
informed
CALCULATIVE
we have systems in place to manage all hazards

REACTIVE
Safety is important, we do a lot every time we have an
accident
Increasing Trust/Accountability

PATHOLOGICAL
who cares as long as we’re not caught
SIEP B.V.
Copyright 2003
 Working Session 2

Individually
 Consider the “Examples of how the culture feels personally” at your
aspired level
 Do you fit in? Use these examples of what it looks/feels like as to
generate your own ones to climb the ladder. Write them on stickers
starting with “I will ….”
Jointly in groups
 Share your I-statements with the people at your table
 Write the best ones on a flip chart (everybody to submit at least one)
Plenary challenge session
 One member from each table presents the 2 best “I statements” and
where they lie on the culture ladder. Everybody else to challenge
SIEP B.V.
Copyright 2003
Copyright 2003 SIEP B.V.
 Group Work
“I statements”
How can I change my behaviour to shift the
culture to the next level upwards?

 I will do regular walkabouts to catch people working unsafely –

(Reactive)
 I will make sure everyone uses the PTW properly and all the right
signatures are in place - (Calculative).
 I will make sure everyone at each toolbox talk talks about their
risks and how they will manage them – (Proactive)
SIEP B.V.
Copyright 2003
Working Safely
 Working Safely

• Safe working practices are an essential defence against

dangers
• Some hazards are impossible to control any other way
• Analyses of incidents show unsafe working practices to
be a major cause of accidents - It’s a problem
• This workshop helps people to establish safe working
practices, not just punishing unsafe work
Some Recent Incidents

• Add local incidents here - where unsafe

working (at all levels) was the primary
cause
Some Recent Incidents

• Add local incidents here

 Working Safely:
From Seeing to Doing
Look, Speak and Listen

Sense Know Plan Act

Can you do it?

Can you Do you know Do you know
Can you keep
see it? how bad it is? what to do?
doing it?

Maintain - keep on doing it

 Processes

• Learning to recognise your hazards

• Discovering who is in danger
• Setting priorities
• Planning to work around your hazards
• Communication
• Taking personal responsibility for your actions and those
of others
• Keeping it alive
 Using the Model to
Understand Our Incidents
• Sense =
• Know =
• Plan =
• Act
• Maintain =
• Look, Speak, Listen (no intervention) =
 Risk Assessment Matrix
Risk Assessment Matrix
CONSEQUENCE INCREASING LIKELIHOOD
A B C D E

Environment
Severity

Reputation
Never Heard of Incident Happens Happens
People

Assets
heard of in …. has several several
in ….. industry occurred times per times per
industry in our year in year in a
Company our location
Company
0 No health No damage No effect No impact
effect/injury
1 Slight health Slight Slight effect Slight impact
effect/injury damage
2 Minor health Minor Minor effect Limited Manage for continuous
effect/injury damage impact improvement
3 Major health Localised Localised Consider- Incorporate risk
effect/injury damage effect able impact
reduction
4 PTD or 1 to 3 Major Major effect National measures &
fatalities damage impact
demonstrate Intolerable
5 Multiple Extensive Massive International ALARP
fatalities damage effect impact

The level of control should depend on the level or risk !

 Risk identification and classification
exercise
1. Identify what could go seriously wrong. Think of
bad, but credible scenarios.
– Write one scenario per sticker
– Share stickers and make groups on flip over

2. Consider the HSE consequences and assign a

severity to the consequences using the RAM
severity definitions.

3. Estimate the likelihood that such consequences

have materialised within the industry, the
company or a smaller unit. Place sticker on the
RAM
 Time Out
reflect and share
• Do you have a list of the most critical scenarios for the
areas for which you are responsible?

• Have you placed them on the Risk Assessment Matrix?

• Are you convinced that you and/or your colleagues are

doing enough and quickly enough to get out of the red
“intolerable” area?

• Can you provide a demonstration that risks in the yellow

area are managed to ALARP risk?
Facilitator’s notes Improving Supervision

Why these facilitator’s notes? 2

Background 2

Objectives 2

Material and Equipment: 3

Phones and email – distractions from outside 3

Room layout: 3
Level in the organisation 4
Number 4
What to do when managers join! 4

Time frame – how long should it take? 5

How do you know how you are doing during a workshop? 5

Roles: 6
A hearts and minds champion- a believer 6
Facilitator – a believer 6
Management representative 7
Administrative support 7

Overview of workshop Centrefold 8

Start 3.1 in the Centrefold 8

Give the presentation "Improving supervision" 3.2 in the Centrefold 8

Break 9

Does what you do match your crew’s needs? 3.3 in the Centrefold 9

Style 3.4 in the Centrefold 10

Break: Where to go next 12

Skill 3.5 in the Centrefold 12

Break 13

Action Planning 3.6 in the Centrefold 13

Why these facilitator’s notes?

These facilitator’s notes will give some additional information to go with the
Improving Supervision brochure. In the brochure, the different subjects have been
discussed thoroughly but in a compressed form, to avoid the brochure becoming a
book. In these notes we give some extra information on how to facilitate the
workshops that are in the brochure (general and specific information) and some extra
background information and ideas that might be useful.
These notes are not meant as something you have to read from cover to cover, you
can just take out of it what you need or want. The suggestions in the facilitators notes
are just that; suggestions. It is not a recipe. The way described here is just one
possibility, not the only one. You might find not all the information you are looking
for here or you have some comments, ideas or experiences that you think others might
be interested in or find useful. This is useful feedback for the Hearts & Minds team,
which we can use to improve these notes so please contact us.
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General information for the Improving Supervision exercises

Background
Poor supervision has been shown through incident reports and audits to be one of the
most common causes of accidents in Shell and supervisors run a higher risk of getting
hurt than others. The development focus has traditionally been on technical aspects of
the supervisor’s job rather than the non-technical skills associated with good
supervision. The exercises in the brochure are meant for all levels of management;
anyone who supervises other people. ‘Improving supervision’ will impact those being
supervised and the supervisor and should positively impact safety performance. This
effect cannot be reached though if the brochure and the tools in it are used as a one –
off event. To change leadership styles, skills and attitudes the tools must be used
repeatedly.
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Objectives
This brochure gives an overall tool for improving non-technical supervision skills. It
does this by providing a number of specific micro-tools and a way to use these (the
workshops) for supervisors and their teams.
The specific aim of these tools is to improve the non-technical skills needed to be a
good supervisor through:
1. Understanding more about supervision skills and leadership styles
2. Self-assessment of personal styles, how they impact team behaviour and how
you may need to adapt or modify your own style
3. Assessing supervision skill levels and focusing on areas for improvement
4. The development of personal action plans
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Material and Equipment: What if…..
The Improving Supervision
brochure and its inserts that are - You cannot get the PDF files printed on
handed out to participants at the A0 sheets; just copy the information onto a
flipchart by hand
start of the workshop.
Presentation PowerPoint slides - People have to get their coffee somewhere
for supervisor’s role in safety else;
management (section 3.2) leave some time for this in your timetable
including your own local
examples. - Somebody has to be reachable (e.g. wife
might be going into labour); let them put
Overhead projector or laptop and their phone on silent mode. Only tell them
projector. this if they object to turning their phone off
Flipcharts; pre-printed A0 from
PDFs and empty ones.
Wall space or easels for
flipcharts and posters
Refreshments (coffee, tea etc.)
Red and green pens and notepaper
Enough chairs and tables (See room layout)

Use of the (pre-printed) flipcharts

In the brochure there are examples of how the flipcharts can be used. Please note that
what is in these flipcharts in handwriting are only examples of what could be in there.
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Phones and email – distractions from outside

Mobile phones are preferably off or, at least, in silent/vibrating mode; they will
disturb the exercises. Try to keep people away from their offices (this applies
especially to managers), as they are usually tempted to do some of their usual work in
between. A possibility is to start the workshop/ training day (half) an hour later than
people usually begin.
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Room layout
Tables - preferably small tables in cabaret
style with 3 or 4 at each table.
Table for facilitator’s stuff, including laptop
and projector; place this table where
everyone can see the facilitator from their Cabaret style
chair.

Large enough space for people to move

around and work in different groupings
(especially the facilitator will need the
space as they will move from group to
group).
U form
Another option for presentations is to place
everyone in a U form. This does not work too well for the exercises participants need
to do in syndicates. There is no need for syndicates to move to different rooms, they
can all sit in groups in the same room. In the end the cabaret style is almost always
preferred over other styles.

Let people sit wherever they like when they arrive (the groups will be made later and
those people who work together or regularly interact will probably sit with each other
anyway.)
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Style:
The notes are based upon the brochure being used as a one-day workshop but the
different elements can also be used independently. Either way the material is designed
to be informal, highly interactive and to allow for discussion, practice and giving and
receiving feedback. It is geared towards self-assessment and action planning; the
focus being on the participants to learn about themselves and what they need to do
differently.
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Participants:
Level in the organisation
This series of exercises is intended for people who have a The group that is
supervisory role (supervisors, team leaders or managers), or going to do the
are being developed as ‘supervisors of the future’, either in workshops can consist
operational or non-operational roles. of only supervisors or
supervisors with some
of their crew.
Number
There is a maximum of 18 participants for the workshop. The
most value will be gained from the exercises if the group is split up into smaller
subgroups i.e. 3 or 4 people who work together or regularly interact.

What to do when managers join!

The workshops might be meant for supervisors If you can find out who is coming to
and workforce, but can be very useful for the workshops and what their
managers as well. This way they might get to hear functions are beforehand, you can
things that they otherwise never would have plan what to do with the managers
that might show up. Are they going
known, or not have understood. When managers to form a subgroup, or are they
join the workshops you run the risk though that going to function as facilitators? If
they will take over. the latter; are there as many
What you can do depends on the number of managers as subgroups? Have they
managers that are in the group. When there are read the brochure in advance so that
they can help and facilitate, or have
quite a lot (4 – 6) they can form a separate they done this before?
subgroup. When there are less then 4, those
managers can function as facilitators of the subgroups.
When you have a group of people who speak a different language, are (functionally)
illiterate or who do not want to speak up you need to deal with these problems. Get
smaller groups and more facilitators (one per subgroup). These facilitators can help
them with the material of course but can also encourage them to speak their mind.
When someone shows up late, for whatever reason, let him/her join the group, even
when you have already gone ahead without this person. While the rest of the group
does an exercise/ assignment you can go up to them, thank them for coming even
though they were late and give them a five-minute catch-up talk before they join their
group in the exercise.

When you are facilitating these exercises on behalf of someone else make sure you
have agreed on the deliverables of this training and what will be done with these, in
advance. This way everyone knows what can be expected, and problems because of
different expectations can be avoided. The deliverables can vary from detailed plans
on how to deal with a problem indicated beforehand to mere awareness of the subject
at hand.
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Time frame
How long should it take?
The aim is to spend about 6 to 7 hour(s) on the exercises all together and no more. If
the participants have not worked with the micro tools before, you will probably need
the time. When people become more experienced and practiced it will take much less
time. The individual exercises can be done in private as well at a later time.

Do I do this only once?

The ‘Improving supervision’ workshop, is not supposed to be a one off. Supervisors
can check if they are still using the appropriate style or find another aspect to work on
when they have finished working on the one already identified. They can do this by
themselves, or by meeting each other again to do another round of exercises. Meeting
up regularly will give the participants the opportunity to form a support group or
become each others mentors.

What do I do the second time I run the workshop with the same group?
The second time you run the Improving Supervision workshop with the same group,
you do not have to do all of the exercises again. The preferred styles of the
participants will probably not have changed and unless there is a good reason to
assume that the needs of people’s teams have changed (e.g. different team or suddenly
much more motivated) you can move straight to the skills exercise. If people have
already worked on one of there skills before, have them pick another that could use
some development.
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How do you know how you are doing during a workshop?

WELL BADLY
• People come up • People are only What to do when people just
with lots of bitching about complain?
examples and what other
discuss amongst people are doing Don’t immediately stop a complaining
themselves. wrong. session, it can be useful. Be careful,
though, that it doesn’t get out of hand.
• You can’t get a • Everybody is Give them five minutes, you can even
tell them so- “You have five minutes
word in; everyone talking but not then we get down to serious business”.
is very busy and about the things You can also try to steer a complaining
talking about the that they are here session towards the subject, this can be
matter at hand. for. very difficult though.

• People listen to • Nobody is

what you have to talking at all they
say and ask are just sitting
questions before and waiting for
you have you to answer
finished. the questions.

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Roles:
A hearts and minds champion- a believer
• Is the sponsor for the workshops, engages the necessary workforce and
management support and provides any funding required
• Responsible for identifying and inviting participants
• Identifies and enrols the management representative and a facilitator if this is a
different person from the believer or management representative. The Champion
may act as facilitator first time – a believer can cascade facilitation down one level
• Ensures that everyone is aware of their responsibilities

Facilitator – a believer
(Most effective when this is someone from the line e.g. the management rep or the
champion, external consultants can be used for the 1st time but this is not usually
necessary or recommended.)
• Takes responsibility for the process outlined in the brochure
• Is familiar with all the materials and knows when and how to use them
• Provides some knowledge of the Leadership models and supervisor skills
• Can challenge the participants as well as offer support and feedback
Management representative
• Is familiar with the background to the workshop and can welcome the participants
• Is prepared to deliver the introductory presentation on the importance of
supervision in safety management and understands how it fits into the workshop
process
• Understands how the workshop process changes attitudes
• Is welcome to stay for the workshop (they can learn for themselves!)
• Preferably someone the group knows and respects
• Could be very senior. If they are willing to make the commitment this will have a
major effect on its own∗.

Administrative support
• Liaises with the participants in terms of arrangements, timing, place etc.
• Responsible for the venue arrangements

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∗
In one operation an EP company MD personally taught the Accident Investigation Course. People
were still talking about this a year later!
Overview of workshop Centrefold
Start 3.1 in the Centrefold
Time: approximately 20 minutes
Preparation – homework before the workshop
Collect a number of local and recent problems due to lack of or ineffective
supervision (pictures/ videos/ stories) before starting with the exercises. Consider
recent incidents, audits and site observations. People relate best to their own incidents
and they can’t say, “It wouldn’t happen here”; because it did.
Identify where improvement is needed most in supervision (asset, workgroup, team)
and select a maximum of 18 people who are going to try to improve their supervisory
skills. The group that is going to do the exercises can consist of only supervisors or
supervisors with their crew.

Safety briefing
Covering local rules, fire alarms and exits, hazards in the room if any, location of
toilets etc. If you are in a hotel or conference centre, maps of the location are probably
available here (in projector form or on paper).

Welcome
Thank you for coming, background to Hearts and Minds and this workshop;
preferably given by the Management Representative.

Objectives
Put on a Flipchart and run through, check that the group is ok with the objectives.
Facilitator agenda and style - put on flipchart and run through, check ok with group,
especially the timing, emphasise informal, interactive style.

Introductions and communication exercise

The intention is for everyone to get to know each other and to highlight some insights
into listening, as it is a key skill for supervisors and for learning in this sort of
workshop. Ask people to pair up with someone they do not know and spend 5 minutes
learning about them personally; names, family, hobbies, supervisor experience etc.
After the 5 minutes ask them to put down or put away any notes they took and to
introduce the person they spoke to and briefly describe what they learned about the
other person. Only ask 3 or 4 people for the introductions, otherwise it will take to
long. Wait for reactions i.e. ‘I did not realise what we were going to have to do’,
‘what’s your name again?’ – explain that that was a demonstration of poor
communication – that you did not set expectations or communicate clearly enough.
Capture the challenges of good communication on a flipchart. Discuss the importance
of listening (2 ears and only 1 mouth should be used in that ratio!) and make reference
to the Hearts and Minds communication material that is available in the Working
Safely brochure.
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Give the presentation "Improving supervision" 3.2 in the Centrefold

Time: approximately 30 minutes
A management representative gives a presentation (the slide materials can be used for
help) covering: why the focus on supervision (technical versus non technical
supervision), who are supervisors, supervisor’s role in HSE management (standard
setting etc.), the differences between skill and style and specifics on where it can and
does go wrong using recent incidents as examples. Discuss one of these incidents; has
anyone ever been in this situation? What had happened? How could it have been
prevented?
Participants can ask questions during the presentation. But the presenter can pose
some questions to the group as well; e.g. “Who supervises in our
company/workplace?”

You can show that the people in the room have the most important role in preventing
incidents by translating the company’s HSE policy into action, by making a plot.
Draw a line graph with the axis; “Proximity” and “Influence” and plot a diagonal line
from bottom left to top right. The people at the top right (the people in the room) are
the closest to the hazards and can exert the most influence on them. Put names and/ or
functions on the graph based on their distance and influence on the work site starting
with the Managing Director and ending with the supervisors in the room.

Managing
Director
Distance

Line
manager

Supervisors and
teams

Influence

Do you find it surprising that incident reports often show a lack of non- technical
supervision is a problem? Why do you think this happens? (Possible questions are
included in the presentation notes as part of the PowerPoint presentation).
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Break
Time: 15 - 30 minutes
During the break; put up pre-printed flipchart 1 which shows the 7 aspects of
supervision and the 4 styles in which they can be done and have the slide ready which
explains the four styles.
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Does what you do match your crew’s needs? 3.3 in the Centrefold
Time: approximately 30 minutes
Self-assessment using worksheet H
All the participants should get out worksheet H and look at table 1. Everyone should
circle the description that best represents/fits their own preferred style for each aspect
(A – G) of supervision.
When participants have circled a description for each aspect they should consider if
their overall style is consistent. Do the circled behaviours all belong to the same style,
or are they examples of different styles?
If your overall style is made up of different styles for different aspects, something
needs to change; your style, some of your skills (categorised as the aspects of
supervision) or both.

The style a supervisor needs to use should change with the changing needs of the
crew. If a supervisor gets a new crew, or their competence or motivation changes,
their supervisor’s style might have to change as well. It is important that the style
matches the situation/ the needs of the team.

• Have the participants share their conclusions (consistent /inconsistent style,

certain aspects/skills not matching the overall picture) with the group.
• These individual conclusions can help the group in the next step of this workshop,
deciding what to work on first.
• Do they wish to continue with style (exercise 3.4) or work on personal skills
(exercise 3.5)?
• If a decision on what to do next cannot be made, just continue with the style
exercise and work your way from there.
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Style 3.4 in the Centrefold

Time: approximately 15 + 45 minutes
Building on the previous work on leadership style this exercise focuses on the
leadership styles participants prefer and the style their how these fit with their team’s
needs, using coaching and support from other participants to explore where change
may be needed. Emphasising that the right style should be used at the right time.

Introductory style exercise

This exercise is a fun piece on preferences, it demonstrates that we have preferences,
but this doesn’t mean that we cannot learn to adapt and modify our preferences if we
choose to.
- Ask the participants to put a pen in hand they don’t normally write with and then
write down their name and where they were born. How did that feel?
- Now ask them to do the same with the hand they usually write with. How is this
different?
- What would happen if someone could no longer use the hand they prefer? People
will learn to write with the other hand, and this will become easier over time.

Identify appropriate Leadership style for your crew

Using the results from exercise 3.3 (table 1 on worksheet H) define the overall
preferred personal style of each of the participants and note these on flipchart 1 (as
shown in the centrefold).

Provide an overview of the leadership styles (summary of the 4 styles using slide 12
provided). Explain the rationale behind ‘the right style at the right time’ (situational
leadership) when to use and not to use particular styles.
 Discuss the concept of using different styles for different crews/crew members. Why
do different people need different leadership styles?
Other contexts e.g. children, relationships etc can be used in the discussion as well to
clarify situational leadership. Talk about what happens when styles are taken to
extremes. Keep reminding the participants that there is no one RIGHT style; all are
valid depending on the team and the situation. It is about being able to adapt.

Have the participants identify their crew’s level of motivation and competence. They
can do this by themselves or with colleagues who know the crew in question.
Identification is done the following way:
• Decide if your crew is high or low in motivation
• Decide if your crew is high or low in competence for the work they have to do.
After this the most appropriate leadership style for the combination of these two
factors can be selected. Table 2 on worksheet H can be used as a guide to decide on
the appropriate style.

Is their crew highly motivated to do the job well, or not motivated at all? Is their crew
competent or not (e.g. because they are new on the job and still learning)?

When the participants have determined the motivation and competence of their crew
they can select the leadership style that best fits their needs. Put the required styles for
each participant’s crew on flipchart 1 as well. What style do the participants want to
work on personally? If people already master the style required by their crew, they
might want to go for a style that they aren’t too comfortable with yet, but might need
in the future. If participants are ‘perfect’ and don’t think they need to work on
anything, make them facilitate for the others.

When a supervisor has a mixed group, for example newcomers to the job and very
experienced people as well in one team, more than one style might be required.
Working on more than one style can be necessary in that case. Choose one style to
work on right now and do the other one later (Don’t wait too long with this).

There are two main options for how people can work on their chosen leadership style
depending on the mix of people in the workshop
If there are people who have as their current style a style that others want to improve
upon, they can pair up and provide coaching. The pairs could practise by role-playing
the new style if they feel comfortable with this.
If a number of people want to work on developing the same style then they can be
paired up to practise and provide support.

Break the group up into smaller groups to work on the chosen styles; discuss the
styles they want to develop.
The questions people should try and answer in the discussion will vary depending on
the group and style discussed, but could include the following: What would it sound
like to use this style? Why do you feel uncomfortable using this style? What do others
who frequently use this style do differently from me? What do you need to do
differently? What kinds of behaviours do you display that are not in concordance with
the desired style, which behaviour do you need to change?
After the group discussion all participants should note in their booklets under My
Leadership Style and on flipchart 1, which behaviours they need to change.

People, who have the same current style as
chosen style, should participate in this exercise
as well.
They can help others who want to improve on
the style they have as a current style, or join
others in improving a style that is not their
current /chosen style.
Which style they choose, depends on their
team; what style will the crew/team need when
their motivation and competence improves or
deteriorates? Which one is more likely?
People can also examine their leadership styles on their
own (this is not recommended though, as others can give
different insights) or with their crew if they feel
comfortable doing this.
This is for advanced level supervisors who can cope
with having their crew teach them how to supervise.
NB. Some cultures might feel uncomfortable if a
supervisor admits ‘weakness’ and a need to improve. In
those cases examining the leadership styles among
supervisors is advised.

Go to top of the document

Break: Where to go next

Time: 15 - 30 minutes
At this point you (the facilitator) can make the choice to either go straight to Action
Planning (exercise 3.6) or to start with Skills (exercise 3.5). The decision will
probably depend mostly on how much time you have left for the session.
Go to top of the document

Skill 3.5 in the Centrefold

Time: approximately 15 + 35 minutes
Individuals explore their own strengths and weaknesses with coaching and support
from other participants, highlighting key areas for improvement.

An introduction to the aspects

Go through the 7 aspects of supervision. Depending on time you can discuss what
they look and feel like (do not spend more than 5 minutes on each aspect). To
encourage the discussion you can ask questions like - What does this aspect involve?
What are the day to day activities?

Ask for examples for each of the aspects, what do the participants do well and what
could they improve on as
supervisors? Write the examples on If participants have several aspects that are
flipchart 2. candidates for improvement they can quickly
read through the relevant worksheets to
Use the worksheets (A – G) decide which of the aspects needs the most
Each participant should select an improvement and hence is the one they want
aspect that they would like to to work on. This may require some
improve on most. explanation of the culture ladder from the
The skill aspects from table 1 Understanding Your Culture tool.
(exercise 3.3) with differences
between preferred and desired styles are the best candidates for improvement. Write
the selected aspect down on flipchart 1.
Skills Gap analyses
Break into groups of people (3 – 5 + a facilitator) who share common aspects they
wish to improve on e.g. a group working on aspect A, and 2 groups working on
aspect C.
• Select the worksheet from A –G that covers the Another possibility is to first
aspect the people in the groups wants to improve circle where you want to be in
upon. green, and then your current
• For each of the sub elements: skill in red.
o First: circle in red the statements that described your current skill.
o Second: circle in green the statements that best describe what you would
like to become.
The differences between the red and green circles form the gaps you need to
bridge.
• Organise the subgroups into pairs who have identified the same or similar
improvement areas. Discuss the outcomes of the previous action in these pairs,
swap the worksheets and challenge each other on where your skill is for each sub-
element. Do you really do that or is that If there is an uneven number,
something you think you ought to or are thinking the remaining person should
about doing? If we asked your crew/team just join one of the pairs. Swap
members what would they say about that? the worksheets as well and do
what you would have done if it
The green circles should be closer to generative had been a pair.
then the red, as the idea is to aim for a more
advanced HSE culture. If it is the other way around you might want to reconsider
Working on the area that has been identified for improvement, individuals
should focus on specific gaps and what they can do to improve, ideally
highlighting specific changes that can be made. Improvement actions that are
your current skill (or explain again what they should be doing).
Go to top of the document

Break
Time: 15 - 30 minutes

Action Planning 3.6 in the Centrefold

Time: approximately 15 + 30 minutes
Individuals, with the help of other participants, develop their own personal action
plans, which define what they are going to do differently, by when and how they will
know if they are being successful.

Work improvement sheet

The participants should each take their own general Work improvement Sheet, work
on their own first for few minutes (to think about the questions on the sheet) then
share and discuss their ideas with their partner – supporting and challenging each
other. Where are you now? Where do you want to be? What can YOU do to improve?
Personal Action Plan
All participants should go to their Personal Action Plan booklet and complete the
sheet. After completion the participants should share with the rest of the group:
- What aspects of supervision they need to improve on.
- What they are going to do.
- When they are going to do it.
- Who will review.
- When the follow up will be.

Are the plans people have SMART actions, i.e. Specific, Measurable, Achievable,
Realistic and Time based. Participants should challenge each others actions on these
features.

Emphasis that this workshop is not a “fit and forget” tool and that to get the benefit
out of the time that has been put in, it is up to the participants to follow through on
what they have committed to in their personal action plans. Tell the participants to
carry the Personal Action Plan booklet in your pocket or put it on the wall, this will
make your plan prominent every day and will allow you to review your improvement
progress.

Can the action plan be a part of people’s personal contracts?

Go to top of the document

Go to top of the document

To close the participants
can discuss ways of
achieving the changes
they have identified. A
few suggestions:
• Tell your team what
you have been doing and
show them your
personal action
plan.
 Hearts
AND
Minds

Why break the rules

P03141
 Hearts
AND
Minds

Procedures and Practices scores

rule breaking

Items 1-5 Items 6-10 Items 11-20 Items 21-30 Items 31-40 Items 41-45
Type of

Unintentional Unintentional Routine Situational Optimizing Exceptional

Understanding Awareness
Scores
Average

Critical ? Critical ? Critical ? Critical ? Critical ? Critical ?

score <15 score <15 score <30 score <30 score <30 score <15

Types of problem

Specific Examples of Rules or Procedures that

Lead to Critical Scores

P03141
 Hearts
AND
Minds

Do we need this procedure ?

Procedure

Hazards managed by procedure

YES (Arguments) NO (Arguments)

Possible solutions

Solutions chosen

Ensuring compliance

P03141
 Hearts
AND
Minds

Action Plan

ACTION

What are we
going to do ?

Who will do it ?

When will it
be done ?

Who will
review it ?

When will the

review take
place ?

P03141
 Culture Ladder
chronic unease
GENERATIVE safety seen as a profit centre
new ideas are welcomed

resources are available to fix things before an accident

PROACTIVE management is open but still obsessed with statistics
procedures are “owned” by the workforce

we cracked it!
CALCULATIVE lots and lots of audits
HSE advisers chasing statistics

we are serious, but why don’t they do what they’re told?

REACTIVE endless discussions to re-classify accidents
You have to consider the condition under which we are
working
the lawyers/regulator said it was OK
PATHOLOGICAL
of course we have accidents, it’s a dangerous business
SIEP B.V.

sack the idiot who had the accident

Copyright 2003
 Risk Assessment Matrix
Risk Assessment Matrix
CONSEQUENCE INCREASING LIKELIHOOD
A B C D E

Environment
Severity

Reputation
Never Heard of Incident Happens Happens
People

Assets
heard of in …. has several several
in ….. industry occurred times per times per
industry in our year in year in a
Company our location
Company
0 No health No damage No effect No impact
effect/injury
1 Slight health Slight Slight effect Slight impact
effect/injury damage
2 Minor health Minor Minor effect Limited Manage for continuous
effect/injury damage impact improvement
3 Major health Localised Localised Consider- Incorporate risk
effect/injury damage effect able impact
reduction
4 PTD or 1 to 3 Major Major effect National measures &
fatalities damage impact
demonstrate Intolerable
5 Multiple Extensive Massive International ALARP
fatalities damage effect impact

The level of control should depend on the level or risk !

 Manage Risks
Approach Type of controls

Identify, Keep a record in

Risk Assessment Matrix watch your issues register
Put in place essential
CONSEQUENCE INCREASING LIKELIHOOD

Address all work programme per

A B C D E
Environment
Severity

Reputation

Never Heard of Incident Happens Happens

People

Assets

heard of in …. has several several

in ….. industry occurred times per times per

HSE-MS
industry in our year in year in a

issue, e.g. E/S

Company our location
Company
0 No health No damage No effect No impact

requirements assessments, local

effect/injury
1 Slight health Slight Slight effect Slight impact
effect/injury damage
2 Minor health Minor Minor effect Limited Manage for continuous
effect/injury damage impact improvement
3 Major health
effect/injury
Localised
damage
Localised
effect
Consider-
able impact
Incorporate risk
reduction communication, review
ALARP
programme
4 PTD or 1 to 3 Major Major effect National measures &
fatalities damage impact
demonstrate Intolerable
5 Multiple
fatalities
Extensive
damage
Massive
effect
International
impact
ALARP
intolerable

Assess each threat which

could cause the risk to
Actively happen. Put in place
programme to address
manage each threat, e.g., plans,
the risks resources, targets, review
programme.
 Risk identification and classification
exercise
1. Identify what could go seriously wrong. Think of
bad, but credible scenarios.
– Write one scenario per sticker
– Share stickers and make groups on flip over

2. Consider the HSE consequences and assign a

severity to the consequences using the RAM
severity definitions.

3. Estimate the likelihood that such consequences

have materialised within the industry, the company
or a smaller unit. Place sticker on the RAM
 Time Out
reflect and share
• Do you have a list of the most critical scenarios for the
areas for which you are responsible?

• Have you placed them on the Risk Assessment Matrix?

• Are you convinced that you and/or your colleagues are

doing enough and quickly enough to get out of the red
“intolerable” area?

• Can you provide a demonstration that risks in the yellow

area are managed to ALARP risk?
 Hearts
AND
Minds
TM

Winning Hearts and Minds:

The Road Map
World-class HSE performance
World-class HSE performance
involves more than mechanically
applying a management system – it
requires the involvement of all in the
organisation, from top to bottom.
Winning Hearts and Minds is
intended to help the organisation to
improve by:
1. Leading the way – the “Route to
the Top” of the HSE Culture
ladder.
2. Providing process and tools to
facilitate behavioural change –
the necessary components of a
solution
The Route to the Top
The overall “Route to the Top”
(world-class HSE performance) means
progressing up the HSE Culture
ladder, developing an HSE maturity
HSE is how we do business
ed
to become truly pro-active and gene-
rative. There are many advantages to
be had from such improvement and
these will have impact well beyond
our HSE performance. The workload
actually decreases as an organisation
becomes pro-active. Increasing trust
and informedness allow us to get on
with our work without requiring
extra supervision and control; audits
become more efficient and directed,
taking less time; managers can be left
to manage, workers get on to do the
work. Being better informed and
aligned around the business goals and
trusted to deliver, we can be held
accountable for our performance in a
just and fair way.
The Process
For HSE, the process to achieve
world-class performance is moving
GENERATIVE
round here
PERSONAL
PROACTIVE
INTERVENTIONS
PERSONAL
ESPONSIBILITY
Bringing the HSE-MS to Life and Beyond
from having an HSE-MS “in place”
through to actually "bringing it to
life". This require us to focus on
Three Key Elements:
1. Personal Responsibility
We understand and accept what
should be done and know what is
expected of us.
2. Individual Consequences.
We understand and accept that
there is a fair system for reward
and discipline.
3. Proactive Interventions.

PROACTIVE We work safely because we are

rm

We work on problems that we

fo

still find motivated to do the right things

In
y

naturally, not just because we are

gl

y
sin

lit

told to. We want to make

bi
ea

CALCULATIVE
ta
cr

We have systems in place to interventions and actively

un
In

manage all hazards

co

participate in improvement
Ac
d

activities.
an

REACTIVE
st

Safety is important, we do a lot

Tr u

every time we have an accident

Weaknesses in any of these Three Key
g
sin
ea

Elements inhibit behavioural and

cr

PATHOLOGICAL
In

Who cares as long as The HSE cultural change. We must balance our
we're not caught
Culture Ladder resources and efforts such that each
element receives the necessary focus.
Hearts
AND
Minds
TM
What will be the right action at the
right time to achieve this balance will
vary across the business as a function
of differing levels of HSE cultural
maturity and local issues and
priorities.
However, Hearts and Minds
methodology across EP is common
and will focus on these Three Key
Elements and the supporting
processes. The tools and techniques
should be chosen from the Hearts and
Minds Toolkit.
1. Personal Responsibility
We understand and accept
what should be done and
know what is expected of us.
This is about being “crystal clear” in
our HSE expectations. Know exactly
what you expect of others and what
others expect of you. Agreeing how
you are going to deliver on those
commitments, and whether you have
the skills and competence to do it.
To support this and remove ambigu-
ous messages, these expectations and
intentions must be part of a clear line
of accountability that is regularly
discussed so that people only accept
for what they can deliver. The foun-
dation for this is part of the existing
management system. To support our
behaviours towards Personal
Responsibility, specific tools and
techniques are integrated into the
Global Hearts and Minds toolbox.
Specific sub-elements are :
• CMS identifies risks and controls
• Roles and Responsibilities from the
CMS are made crystal clear for all
• Create clarity and passion through
1-to-1 discussions of Roles and
Responsibilities
• Individual “Top Seven HSE
priorities” identified aligned with
job tasks
• People accept roles and are held
accountable through meaningful
personal performance contracts
that drive new pro-active
behaviours.
2. Individual Consequences
We understand and accept
that there is a fair system for
reward and discipline.
The journey to bring HSE-MS to life
is about changing habits, adopting
new pro-active behaviours and
instilling a new level of compliance.
Showing appreciation and providing
encouragement should continue.
There also needs to be a clear formal
link between actions and conse-
quences to reinforce and reward the
required behaviours and actions, and
to discourage incorrect ones.
Appraisal systems also need to reflect
the aspired goals, rewarding those
who deliver but with the appropriate
mechanisms in place when coaching
is needed. Unsafe acts at all levels
must be dealt with immediately in a
just, fair and transparent way.
Several of our operations already have
tools to make individuals clear what
the personal consequences will be for
their HSE behaviours and actions
and should be applied uniformly.
They provide a framework for
holding all people accountable for
their actions. Typical characteristics
are:
Positive Consequences
• Coaching
• Recognition, praise, trust
• Just and Fair Reward
• Career enhancing
• Feel better, be healthy, be safe
Negative Consequences
• Coaching
• Criticism, Distrust
• Just and Fair Discipline
• Dismissal
• Injury and illness
3. Pro-active Interventions
We work safely because we
are intrinsically motivated to
do the right things naturally,
not just because we are told
to, and make interventions
and actively participate in
improvement activities
This element is the very essence of
bringing HSE MS to life, but also the
hardest to achieve. This requires
personal interventions to influence
the behaviour of others and accept
interventions by others. Intervention
tools are accepted as part of a broader
change process towards improvement.
There is a practical Hearts and Minds
toolkit that provides a process and a
set of tools to support most general
HSE improvement programs as well
as helping to solve specific problems
commonly observed in our
operations. The tools are designed to
allow those who wish to improve to
find their own best way forward,
based on research and operational
experience inside and outside Shell
EP. They are designed on a “by you,
for you” basis, without the need for
consultants. Leaders at all levels can
use these tools, and can act as
facilitators for those they manage.
They comprise:
• Understanding your culture
• Managing Rule Breaking
• Risk Assessment Matrix
• Making Change Last
• Improving Supervision
• Seeing yourself as others see you

• Driving Safely
• Working Safely
• Achieving situation awareness -
The Rule of Three
They are available in the form of
controlled packages of brochures,
slide presentations, instructions etc.
What do you do in practice?
Before setting of on this Roadmap to
Winning Hearts and Minds, we need
to ascertain “Why Bother?” Only if
leaders are personally motivated to
make a difference to our HSE
performance, is this approach going
to deliver results. Only then will
people in our organisations truly
change their perceptions of what is
expected from them. Using the
Hearts and Minds process will
identify significant opportunities for
improvement, so everyone involved,
especially senior managers, must see
the advantages and be prepared to
commit to follow though. The first
steps are:
1. What is the HSE culture?
The HSE - Understanding your
Culture brochure will help identify
the local level of HSE cultural
maturity and help you formulate
your way forward. Once you know
where you are, you will challenge
your aspirations and what you
personally and as team will need to
do to achieve them.
2. Who should lead the process
and how?
Leaders committed to improvement
should be champions and facilitators.
They must understand that
behavioural change cannot be pushed
onto people. A lesson from
experience is that there must be
direction and coordination; but the
people who drive and facilitate any
program have to believe in the
processes. Through their
commitment to improve, a pull is
generated whereby others want to
participate, see the benefits, and
themselves become champions. In
more advanced HSE cultures the
workforce will take the initiative, but
whatever the cultural maturity, the
ARE YOU READY
TO CHANGE?
Understand Your Culture
(A)
Realise you have problems
from incidents, audits etc.
Select the right tools to fix
the problem
Find believers
People willing to try
DO IT
journey is not easy. From the initial
motivation, a balance needs to be
maintained between the 3 Key
Elements so that the necessary
support conditions exist to drive an
overall cultural change.
3. Are there specific problems?
A lot of information is out there in
incident investigation reports, audits,
reviews and field inspections and
observations of what is happening.
Typical issues are rule breaking,
incorrect risk assessments, supervisors
who are technically competent but
short on personal management skills,
ineffective contract HSE manage-
ment. If you know what your issues
Hearts
AND
Minds
TM
are then you can use the specific tools
(Route A in diagram). Otherwise you
can use descriptions of the culture
dimensions to identify specific
improvement areas (Route B in
diagram). Use the general tools and
plan how to make the change using
the Making Change Last framework
and Hearts and Minds methodology
to get everyone onboard from the
start.
(B)
Discover you still have a
way to go
Want to improve
Identify what parts of the
culture is lagging
Design change program
Which tools
to use?
4. Specific focus on leadership.
Organisations look to their leadership
for direction, priorities and coaching.
Perceptions of the commitment of
leadership towards HSE rather than
just their intentions have a strong
bearing on the actual behaviours and
performance of that people in the
organisation. The initiation of the
‘Hearts and Minds’ Roadmap lies
with leadership teams. The
commitment of management to HSE
can be tested periodically by the
‘Seeing yourself as others see you’
appraisal technique which also helps
management to improve their
personal effectiveness.
Hearts
AND
Minds
TM

Tools available What they do and When to use them

HSE Understanding What: An engagement tool to identify local strengths and weaknesses identifying a way to improve.
your Culture When: Use 1st to engage people, discover their aspirations and build a case for change (2-3 hours + follow up).

Seeing Yourself as Others What: HSE upwards appraisal tool to understand other’s perceptions and identify how commitment is turned into action.
See You When: Use 2nd to challenge the commitment and behaviours of any "safety leaders", (20 minutes + follow up).

Making Change Last What: A general tool for managing change and supporting any improvement process or organisational change
programmes.
When: To design your own tools (1 –2 hours to start).

Risk Assessment Matrix: What: Helps people understand their risks, makes them personal and stimulate action.
Bringing it to life When: Anytime to better manage the risks. (1 hour).

Achieving Situation What: To help everyone make better risk based decisions and be able to justify them.
Awareness: The Rule of 3 When: If people lose sight of their risks, or if complacency threatens to set in. Can be used anytime, especially when
there is change (<5 minutes).

Managing Rule-Breaking What: To prevent incidents being caused by rule breaking.

When: If procedures are not being followed, or a need to improve procedures (2-3 hours initially then,
1 hour per issue).

Improving Supervision What: To improve the non-technical skills of supervisors.

When: If the quality of supervision, is identified as a (possible) cause of incidents (4-5 hours first time).

Working Safely What: Intervention programme that builds on and supports existing programmes or can be run by itself.
When: If safe working practices are not being followed (8 hours in total, 1 hour slots).

What: A suite of exercises to change the behaviour of drivers and the people who manage them.
Driving For Excellence When: When driving is a significant risk, professionally or personally (8 hours in total, 1 hour slots).

Overview of current Hearts and Minds tools

5. Specific focus on supervision,
contractors and contract
holders.
This group contains key players in
building a strong safety culture
because most of our serious incidents
occur with contractors and involve an
element of ineffective supervision.
Their Hearts and Minds strategy
should not differ markedly from the
overall strategy and ‘Understanding
Your Culture’ is also for this group an
appropriate first step, but another
useful approach is for contractors to
use this tool to appraise their clients
commitment to safety. The contract
holders are viewed as senior managers
by their contractors and will benefit
from the feedback they will receive
on how their commitment to safety is
perceived, by using ‘Seeing Yourself
As Others See You’. The other tools
are just as applicable for contractors
and staff when specific issues are
identified, such as weak supervision.
Underpinning the above proactive
interventions must be the same firm
basis of, crystal clear expectations
from the client, commitments from
the contractor, and commercial
consequences for delivery. Supervisors
have most impact on the day-to-day
behaviour of their teams. They
therefore have to be ‘believers’,
demonstrating the commitment of
top management and supporting and
encouraging their staff when they
want to use the tools.
Creating Buy-in
Winning Hearts and Minds for HSE
is about getting all to work safely not
just because they have been ordered
to, but because that is what they
want to do. The art of good manage-
ment is to get people to want to do
what you may have already decided
they should do. Help them to do so.

The Hearts and Minds logo is a Trademark of Shell and can only be
This brochure has been developed by SIEP B.V. for use by Shell
Hearts Group Companies but can also be made available to third
used with written permission from SIEP, EP-HSE. Documents with the
AND
Minds parties. SIEP B.V. does not accept responsibility for any
Trademark have been checked for their correctness and effectiveness.
TM consequences whatsoever of its use.

Shell International Exploration and Production B.V. ECCN: Not subject to EAR - No US content Unclassified
Postbus 60, 2280 AB Rijswijk, The Netherlands Copyright SIEP B.V. EP 2003-9103
P03978 – November 2003
 Shell Exploration & Production

Unsafe Acts:
Human Error and Violations
SIEP B.V.
Copyright 2004

1
 HSE Management

Barriers
Hazard/ or Controls
Risk WORK

Undesirable
outcome
SIEP B.V.
Copyright 2003
 Human errors and violations
SIEP B.V.
Copyright 2003
 Working Session on Why we break the rules
and Violation Types

Jointly in tables (10 minutes)

 Discuss why you and others break the rules.(aim for 10+ reasons)
 Write them down on a flip chart (everybody to submit at least one)
Jointly in tables (5 minutes)
 Discuss and assign a violation type to each reason for rule breaking on the
flip chart.
SIEP B.V.
Copyright 2003
 Results of questionnaires
Do not
accept 22 % 34 %
violations
Sheep Wolves in
Sheep clothing

14 % 30 %

Sheep in Wolves
wolves
Accept
violations clothing

Never Violate Violate

SIEP B.V.
Copyright 2003
 Why are violations dangerous?

VIOLATION + ERROR

= DISASTER
SIEP B.V.
Copyright 2003
 Types of violation

Rules are incorrect, unclear, burdensome

Rules are OK but communication of them and training is at

fault

It has become the normal way of doing things

Cannot do the job without breaking the rules.

More convenient/pleasing, satisfy the boss, fun, kick

Novel situations for which there is no guidance

SIEP B.V.
Copyright 2003
 Questionnaire

Read the questions and

assess which response aligns
best with your personal work
environment.

Scratch open only one cell per

question

Results are anonymous

SIEP B.V.
Copyright 2003
 Rule-Breaking Scores from Individual data
Major Problem Problem OK Good

1 2 3 4 5

Expectation

Planning

Opportunity

Pow erfulness

Personal Norms
SIEP B.V.

Wolves and Sheep

Copyright 2003
Copyright 2003 SIEP B.V.
 PR 1508 Lifting tubulars
The slings should be doubled wrapped with a choke
hitch taking care not to cross over the sling on the
underside of the pipe or pipe bundle. The choke hitch
should be pulled tight to secure the bundle and a
bulldog grip fitted. A tie wrap should then be fitted to
prevent the reeving eye slipping over the bulldog.
The included angle between the choke hitches shall
not exceed 120 degrees.
SIEP B.V.
Copyright 2003
 Do you really
mean all of this,
everywhere on
this location?
SIEP B.V.
Copyright 2003
 Field Examples of Rule Breaking (3)
SIEP B.V.
Copyright 2003
 Field Examples of Rule Breaking (4)
SIEP B.V.
Copyright 2003
 Field Examples of Rule Breaking (5)
SIEP B.V.
Copyright 2003
 The Rule of Three: Situation Awareness in Hazardous Situations
P.T.W. Hudson, SPE,Leiden University, G.C. van der Graaf, & Bryden, R.
Shell International Exploration and Production B.V.

Abstract
The criteria for making Go - No Go decisions are often conservative because the decision rule (i.e. to stop flying helicopters, to go
around with a tanker, to shut down a platform or halt concurrent operations) does not take the interaction of multiple factors into
account. All of the situations and events leading to an incident are sub-standard, but taken in isolation none of them usually appear
dangerous enough to warrant halting operations and taking stock. Accidents rarely happen because of a single catastrophic failure,
except when that failure is at the end of a chain of non-catastrophic failures and organisational oversights. Go - No Go decisions are
hard to make, especially when situations have been deteriorating slowly, and a clear decision rule can help. The Rule of Three is
proposed as a way of combining information to make operational decisions in order to maximize opertunities and minimize regrets..

Introduction
Accidents don’t just happen. Rather than having just one cause, it takes a great many factors, often in excess of 50, to lead to an
accident1. Analyses of accidents, both within the Shell Group and outside, show how accidents all too often happen because of
combinations of relatively trivial events and situations2. While any one particular accident can be avoided by stopping any one of
those causes, most accidents happen in the middle of situations which, afterwards, people see as “an accident in the making”. Fixing
one potential cause out of 50 may stop that accident, but with 49 other factors still around we may find ourselves in a state of
permanent near-miss, what we might call Living on the Edge. The Rule of Three is proposed as a way of finding out just how close
we are to the edge and helping us decide what to do, whether to stop operations or manage the risks down to manageable proportions.
The main factors causing accidents are increasingly the result of the human factor, especially as we obtain more control over the
technical causes2,3. As technical safety and integrity is assured, we are left with finding ways of providing the same assurance with
people as we have with equipment. While the absolute number of accidents will fall as technical controls take effect, the remaining
accidents will become increasingly bizarre as human ingenuity is left to test what someone has regarded as foolproof.
One reason why people create problems is because they often fail to understand how small problems, that no one would regard as
particularly dangerous, may interact to become big ones, that suddenly threaten life or limb. Immediate operating conditions can
become such that simple everyday errors, such as turning the wrong control handle or forgetting a part of a check sequence, can
become suddenly dangerous, as when someone who is bending the rules fails to tell his colleagues. Violations interact with errors to
create novel and dangerous situations out of the blue4. The Tripod concept of Error Enforcing Conditions was set up to highlight how
some working conditions make the occurrence of errors much more likely5.
Incidents at the Edge. An analysis of a helicopter accident in the North Sea6 found that there were no specific reasons, in advance,
why the pilots could have reasonably stopped flying. The weather was marginal, but within ‘acceptable limits’; the pilots were close
to the limit of their allowable flying hours, and would have exceeded them on the final leg, but they were still within limits at the time
of the accident; the operational requirements were not impossible, but were changed many times in the course of the mission. The
accident, in which 13 people died, was in hindsight almost inevitable.
In oil tanker operations, one of the most sensitive undertaken by Oil and Gas companies in today’s environmentally-sensitive climate,
a similar picture arises. When a vessel is approaching an unknown harbour in poor weather, having taken on board a pilot whom the
master may not trust entirely, where the draft of the vessel and the available clearance may not leave a large margin, it might be more
sensible to stand off and wait for daylight than press on under the burden of a tight sailing schedule. A grounding and a major
pollution threat would, again, make it seem obvious in hindsight that caution is the only sensible course. Nevertheless such incidents
still occur, unfortunately frequently, even after the a number of major shipping accidents have highlighted how vulnerable
organisations are to such disasters.
Learning from Hindsight. The problem is: How can we acquire the benefits of hindsight, and prevent such accidents, without
unnecessarily curtailing operations by excessive caution? The issue appears not to be one associated with individual limits on
permissible operations, but rather on the way in which the sum total of marginal conditions can be computed in such a way that safe
and sensible decisions are made, whether it be to carry on or to stop. Go - No Go decisions which can lead to shutdown are easily
influenced by production pressures, on the one hand, and the belief of those involved that things will be all right as long as they,
personally, are running the operation (although they may recognise that others might well be less fortunate). The kind of decision that
is required is, also, almost always made under conditions of haste, pressure and expectation, exactly the conditions that are less than
ideal for making such decisions7.
This paper proposes a way of combining information to help in making safe decisions called the Rule of Three. Because much of the
necessary information can be collected and judgements made in advance, outside of the pressure of immediate circumstances,
decisions can be made and, possibly more important, safe conditions can be managed, without losing sight of overall goals of an
2 HUDSON, VAN DER GRAAF & BRYDEN

operation. This should be applicable to a wide range of operations where critical shutdown or go-around decisions need to be made,
and such decisions are often being made under conditions that are not ideal for taking rational decisions.

The Rule of Three

The proposal is that there are, for any operation requiring potential shut-down or No Go decisions, a number of factors that
complicate matters. External factors such as the weather, or internal factors such as the experience of those involved, may not be
enough to trip a stop decision. Many of these marginal conditions may not appear in a direct causal analysis of an accident.
Nevertheless such marginal conditions as bad weather or operators’ inexperience may be enough to make the sudden appearance of
errors much more likely or make recovery from errors less likely. When there are enough of such complicating factors, a sensible
manager calls a halt, or changes the conditions to bring the situation back from ‘The Edge’. The proposal is that three marginal
conditions should be considered as equivalent to a single exceeded limit when deciding to halt operations. This is equivalent to the
three strikes rule in baseball, although the metaphor used here is based on the traffic light, where going through an orange or amber
light may still be acceptable, but it is close to going through a red light.
Threshold Setting. One approach to the problem of setting appropriate Go - No Go thresholds is to be conservative in defining the
point at which an operation has to be halted. A maximum permissable wind speed for a given make of helicopter might have been
defined by the manufacturer as 55 knots, but may be reduced to 52 knots, not because this is a better upper limit, but because such
wind speeds are often accompanied by other weather problems, such as gusts and poor visibility. This approach, that is conservative,
may be understood in terms of compensatory decision-making; Go - No Go thresholds are adjusted downwards to compensate for
other factors that are not otherwise included in the strict set of thresholds defined.
An alternative approach recognises that there is often a range of conditions, from perfectly normal up to unacceptable. In such an
approach values exceeding an absolute safety threshold can be represented by red, the ideal operating environment by green and
marginal situations can be designated as orange. The red threshold can now be set in terms of absolute requirements, such as might be
determined by the laws of aerodynamics in the case of a helicopter’s maximum permissable wind-speed for take-off. The
compensating factors are now handled distinctly (gusting, visibility, icing etc.), each with its own red threshold. At the same time it is
possible to identify less stringent thresholds, beyond which one would proceed with caution. These can be defined as the orange
thresholds. Experienced operators and managers can discuss and set the orange thresholds in the calm of the office and with the
benefit of their experience. Orange thresholds can continue to be reviewed and altered as more experience is gained, whereas red
thresholds are much more likely to remain fixed. In the past the thresholds that are applied in practice form a heterogeneous mix of
what are here distinguished into red and orange thresholds.
The Decision Rule. Too many factors in the ‘orange’ distract and influence decision makers and stress the system’s defensive
barriers. The Rule of Three uses both red-orange and green-orange thresholds, with a summation rule that three orange factors is
equivalent to a single red. At this point operations should be stopped or, possibly better, delayed until a number of the factors in the
orange have been managed back down to the green. For instance, an operation about to be carried out in bad weather, performed with
inadequate planning (“Go out there and fix it”) and with an inexperienced crew, rates as three oranges and should not proceed.
Nothing can be done about the weather, but if the planning is improved, or the experience level of the crew is brought up to the
necessary level, then the number of oranges reduces to two or one, and the operation can proceed. The Rule of Three allows direct
assessment of the total situation, into which people may inadvertently find themselves, framed in terms of the factors which increase
the permeability of the barriers to accidents.

Number of Action
Critical Go or Nogo
Dimensions
All Green Proceed normally
One Orange Proceed normally
Two Oranges Proceed with caution
Three Oranges Halt operation
Reduce problems
One Red Halt operation
Table I. The Rule decision criteria framed in terms of Reds and oranges.

Dimensions and Sub-dimensions. The rule is applied using a number of major dimensions, such as Weather, Experience of
Crew/operators, Commercial Setting, quality of plan etc. (See Table II), each of which can be subdivided into a small number of sub-
dimensions. If more than one sub-dimension goes Orange, then we can mark the major dimension as Orange. If any sub-dimension
goes Red then the major dimension is immediately Red. The Rule of Three states that if there is a single Red Dimension, or Three
 THE RULE OF THREE: SITUATION AWARENESS IN HAZARDOUS SITUATIONS 3

Orange Dimensions, then operations should be halted (i.e. three strikes). Three or more Oranges represents an accident in the making,
where hindsight would say, “we should have stopped earlier”.

Major Sub-dimensions
Dimension
Weather Rain
Wind
Lightning
Experience of Individuals in training
crew Percentage with 5+ years
competence
Commercial Profit push
Setting Deadline approach
Sort term Day/night
variation Shift change
Equipment Fit for purpose
Recently maintained
Task Novel
Unpractised
Difficult
Planning Change of Plan
Change of plan timing
Table II. Possible Major and sub-dimensions. The particular thresholds for any operation should be filled in by those with local
experience.

Calibrating Thresholds. Once such a set of dimensions and associated thresholds has been defined for a specific operation, there are
two ways to proceed. One would involve collecting data systematically about incidents, normal conditions, acceptable shut-downs
and unacceptable missed opportunities, followed by a formal optimisation of the settings. This rigorous approach can not always be
applied because there may not be enough decisions made, capable of evaluation afterwards, in a reasonable time period. A more
informal approach would involve renegotiating the thresholds from time to time on the basis of continued experience.
In each case (See Figure 1) we wish to continually minimise the amount we would regret if we either had an accident or, out of
unreasonable fear, stopped operating too early. As the thresholds are directly associated with the line between regret and no-regret, we
can consider using the Rule of Three in a continuous way, aiming to minimise regret, converting hindsight into foresight.

Regret No Regret

Go Accident N ormal
Operations

No-Go Mis s ed S afe

Opportunity Decis ions

Figure 1 The dimensions for calibrating the rule of Three

Relationship with Tripod: Weakened Barriers

In terms of the Tripod Model of accident causation2,7,8 the accident process gathers momentum when situations arise which lead to
the final barriers becoming less effective, and thus easier to pass. Ideally one hopes to have removed all the latent failures in an
operation, in practice some will always remain. The full set of preconditions to an incident include many factors out of an individual’s
4 HUDSON, VAN DER GRAAF & BRYDEN

direct control, such as the weather or the time of day, and others which people quickly grow accustomed to, such as high levels of
work pressure or unusual operating requirements. Finally there are factors, such as time on shift and time of day, or remaining fuel,
that deteriorate inexorably and, at some point, become unacceptable, but prior to that have already become a matter of concern.
Because most systems fail to acknowledge the creeping effect of deteriorating conditions, the Rule of Three provides a way of
bringing their potential into the decision process without, necessarily, immediately leading to a halt of the operation.
In Tripod theory5, when a triggering event happens, it is up to the barriers to avert damage; when and while those barriers are
temporarily weakened, an incident becomes much more likely. People who are insufficiently aware of how close they are to the edge
are those most likely to short-circuit established procedures or actively remove existing defences. The Rule of Three is intended to be
a way of combating such problems by providing a framework which improves situation awareness.
Situation Awareness. The best and most experienced managers recognise the situations they find themselves in. Less experienced or
effective managers often concentrate upon the most obvious problems. Fighter pilots and top-level team sportsmen show similar
abilities to understand the whole situation and profit from it, lesser pilots get shot down, lesser sportsmen lose. The Rule of Three, in
practice, is intended to provide and support situation awareness, to support the risk management process by reminding those involved
of how deep in trouble they are and just how close to the edge they may have come 9. Armed with such knowledge it is easier to
decide whether to halt operations or, minimally, which factors need to be managed down to return to safe operating conditions.
One significant factor in many accident scenarios is the creeping acceptance of a situation that has slowly deteriorated. The fact that
people habituate to initially unacceptable conditions means that they often lose sight of which conditions have become too serious to
ignore. The use in the Rule of Three of a set of predetermined dimensions and associated sub-dimensions helps the decision-maker to
reconsider the sum total of conditions. The specific nature of the rule means that attention has to be directed to the total set of
dimensions, rather than being captured by what appears to be most important at the time.

Applications.
Possible application areas for the Rule, within the Exploration and Production setting, include aircraft operations and platform
shutdowns. Other areas include oil tanker (VLCC) and coal mine operations. The time to apply such a rule can be before starting, on
shift handover, or at critical periods such as prior to coming into harbour in a tanker.
The list is short enough to function like the sort of checklist that is common in the aviation industry, where safety standards are of the
highest. In the aviation industry one of the indications of the existence of a safety culture is the disciplined way in which such
checklists are gone through every time, regardless of how unnecessary it might seem. Such a level of commitment is what can ensure
that problems are not simply accepted and lived with, that everyone is aware of exactly what the situation really is.

Conclusion
The Rule of Three is a decision-making rule intended to upgrade the quality of decision-making. Within Shell companies it is
accepted as providing valuable insights, but it has still to be turned into an effective and working tool. Such a tool has the potential to
be developed further in concrete settings where it is applicable, but has yet to mature into a calibrated tool . One always hopes to
make critical decisions with all the best people available and under ideal conditions, in practice this is not always possible. The Rule
of Three is intended to access the benefits of the best managers’ past experience, set into a simple rule-of-thumb tool that can aid the
less experienced before situations turn nasty.

References
1. Wagenaar, W.A. & Groeneweg, J. 100 Accidents at Sea. International Journal of Man-Machine Studies. (1987)
2. Reason, J.T. OrganisationalAccidents. (1997)
3. Perrow, C. “Normal Accidents: Living with high-risk technologies. Basic Books (1984).
4. Free. R.J. The Role of Procedural Violations in Railway Accidents. Unpublished PhD thesis, University of Manchester. (1994)
5. Hudson et al. The Tripod Manuals Vols I – III. Shell International SIPM EP 93-2800 (1993)
6. Aircraft Accident Investigation Board.
7. Reason, J.T. Human Error. Cambridge University Press, Cambridge. (1990)
8. Wagenaar, W.A., Hudson, P.T.W. & Reason, J.T. Cognitive Failures and Accidents. Applied Cognitive Psychology, 4, 273-294. (1990)
9. Eindsleigh, M.R. “Toward a theory of situation awareness in dynamic systems”. Human Factors, 37, 32-64. (1995)