Note : Les descriptions sont présentées dans la langue officielle dans laquelle elles ont été soumises.
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TITLE
FATALITY LEARNING SYSTEM AND METHOD
FIELD OF INVENTION
[0001] The present invention relates to a fatality learning system and
method.
[0002] More particularly, the present invention relates to a fatality
learning system and
method for use in computer implemented global risk management systems.
BACKGROUND ART
[0003] Workplace safety is of the utmost importance in many industries,
especially
industries such as mining, oil and gas, manufacturing, power generation,
aviation, aerospace
and nuclear, due to the numerous opportunities for harm to be caused to
personnel. Risk
management techniques have been adapted to reduce instances of injury to
workers, damage
to equipment and loss of production time.
[0004] It is known in the art to manage risk in high risk environments by
the use of
checklists, which must be completed prior to an individual engaging in a high
risk activity, to
ensure all required steps have been taken to reduce the risk of injury or
death.
[0005] Risk is typically managed by supervisors and operators in each
facility,
completing checklists in accordance with company procedures.
[0006] In the event of a fatality, or the recognition of a potential fatal
incident, it is
known that an incident record may be created, providing details of the
incident.
[0007] Common problems with managing risk on a global scale include the
ability to
learn from fatalities and significant incidents, to capture, share and embed
the lessons learned
and to reduce risk by implementing improvements. Incident records may be
inconsistent,
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with information provided therein being difficult to standardise and share
with other locations
in a way that ensures transfer of knowledge.
[0008] Further inconsistencies exist due to the often global nature of
businesses, with
facilities across numerous continents and involving different languages, and
these
inconsistencies can pose severe difficulties in both reporting incidents and
effecting
sustainable change.
[0009] The difficulty of capturing the incident information and
implementing change
often results is similar fatalities and potentially fatal incidents occurring,
which may have
been preventable.
[0010] It is an object of the invention to suggest a fatality learning
system and method,
which will assist in at least partially overcoming these problems.
SUMMARY OF THE INVENTION
[0011] A fatality learning system and method, the system comprising; a
centrally located
critical risk database comprising questions classified in a taxonomic
structure; a lessons
learned database comprising information taken from fatality learnings and
incident reports;
and checklists comprising questions selected from the critical risk database,
wherein a
plurality of checklists are directed to an activity, the different checklists
being configured to
be suit different roles required to perform the activity, wherein the critical
risk database is
arranged to be updated based on information added to the lessons learned
database, and
wherein the checklists are updated with the updated critical risk database
content, the method
comprising the following steps:
a. Following a fatality or a potentially fatal incident during a critical risk
activity,
an incident report is created comprising a detailed description of the
incident,
the incident report is added to the lessons learned database.
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b. The incident report is used to identify the classifications and questions
in the
critical risk database relevant to the incident.
c. Amendments to the critical risk database in the form of amendments to
questions or new questions are proposed based on content of the incident
report.
d. The classifications identified and proposed amendments to the questions are
reviewed and further amendments made where required.
e. The amendments are uploaded to the critical risk database, making updated
information available to the checklists instantaneously and revised checklists
subsequently being available to users in the field instantaneously.
[0012] Preferably, the roles to which the different checklists are adapted
comprise
manager, supervisor and operator, so that checklists are available reflecting
the questions
relevant to manager, supervisor and operator aspects of performing an
activity.
BRIEF DESCRIPTION OF DRAWINGS
[0013] The present invention will now be described, by way of example, with
reference
to the accompanying drawings, in which:
Figure 1 identifies the key elements and illustrates the process from
occurrence of an
incident, creation of an incident report, submission of the incident report to
the lessons
learned database, amendment of the critical risk database and amendment of
checklist
questions.
Figure 2 illustrates the different roles of end user, and how the different
critical control
checklists are provided based on different user levels.
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Figure 3 illustrates the structure of the questions according to the different
roles of end
user, according to a preferred embodiment of the present invention.
Figure 4 illustrates the structure of the questions according to the different
roles of end
user, according to another preferred embodiment of the present invention.
DETAILED DESCRIPTION OF THE PREFFERRED EMBODIMENT
[0014] As shown in the Figures, there is provided a fatality learning
system and method,
the system comprising; a centrally located critical risk database 20
comprising questions 22
classified in a taxonomic structure; a lessons learned database 30 comprising
information
taken from fatality learnings and incident reports 40; and checklists 50
comprising questions
52 selected from the critical risk database 20, wherein a plurality of
checklists 50 are directed
to an activity 60, the different checklists 50 being configured to suit
different roles required to
perform the activity 60, wherein the critical risk database 20 is arranged to
be updated based
on information added to the lessons learned database 30, and wherein the
checklists 50 are
updated with the updated critical risk database content, the method comprising
the following
steps:
a. Following a fatality or a potentially fatal incident during a critical risk
activity,
an incident report is created comprising a detailed description of the
incident,
the incident report is added to the lessons learned database.
b. The incident report is used to identify the classifications and questions
in the
critical risk database relevant to the incident.
c. Amendments to the critical risk database in the form of amendments to
questions or new questions are proposed based on the content of the incident
report.
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d. The classifications identified and proposed amendments to the questions are
reviewed and further amendments made where required.
e. The amendments are uploaded to the critical risk database, making updated
information available to the checklists instantaneously, the revised
checklists
being available to users in the field instantaneously.
[0015] A critical control checklist 50 is presented to a user before
completing a critical
risk activity 60.
[0016] For clarity and ease of description, the questions are identified as
22, 32 and 52, to
distinguish them at different stages within the process, but otherwise are
essentially the same.
As stored in the central critical risk database 20 the questions are
identified as 22, as
presented to a user in a critical control checklist 50 the questions are
identified as 52, and as
stored in the lessons learned database 30 as amended questions they are
identified as 32.
[0017] Similarly, the lessons learned database 30 and the critical risk
database 20 are
defined as two separate databases for ease of description. This is done to
denote the state of
the content of each database, being proposed amended questions 32 in the
lessons learned
database 30, and approved and classified questions 22 in the critical risk
database 20.
[0018] The taxonomy of the critical risk database 20 is such that the
questions 22 are
classified at a first level by the nature or cause of a potentially fatal
injury (the risk), for
example "Fall from Height" or "Lifting Operations".
[0019] The questions 22 may be classified at a second level into sub-
categories relevant
to the first level, for example within the first level category of "Fall from
height" may be a
number of sub-categories defining factors relevant to the critical controls
that can prevent a
Fall from Height, such as "Scaffolding" or "Fall Protection System".
[0020] In the preferred embodiment of the present invention, an end user
may select and
complete the critical control checklist 50 relevant to the activity 60 about
to be performed
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from the critical risk database 20, wherein the critical control checklist 50
will comprise
questions 52 particular to the activity 60.
[0021] In an alternative embodiment of the present invention, sets of
questions 52 in a
critical control checklist 50 may be tailored to an activity 60, useful
particularly when
working in non-standard conditions, where more than one category may be
relevant to the
task about to be performed, or where some questions may be redundant to a
particular task.
[0022] The critical control checklists 50 correspond to activities 60.
These activities 60
require the appropriate critical control checklist 50, which may be identical
across a number
of different locations worldwide, and in a number of different languages, to
be completed
before proceeding with the activity 60. For example, the activity of repairing
a conveyor belt
may require the same critical control checklists 50 wherever it may be carried
out.
[0023] As shown in Figure 2, the preferred embodiment of the present
invention
comprises three levels of critical control checklist 50, described henceforth
as 53, 55 and 57,
adapted for different levels of end user. The first level critical control
checklist 53 may be
adapted for completion by management 54, and comprises questions 52 relevant
to activities
60 within the scope of work of site managers and superintendents 54, an
example of a
question 52 on a first level checklist 53 may be "Are appropriate permits in
place for the
operation?", or "Has the correct atmospheric monitoring equipment been
supplied for this
task?".
[0024] As shown in Figure 3, the second level critical control checklist 55
is adapted for
completion by the supervisor 56, and comprises questions 52 relevant to the
scope of work of
the supervisor 56, an example of a question 52 on a second level checklist 55
may be "Has the
confined space entry permit been correctly executed in the field?", or "Has
the required
equipment been calibrated and certified within the recommended timescale?"
[0025] In an alternative embodiment of the present invention, shown in
Figure 4, the
second level critical control checklist 55, to be completed by the supervisor
56, comprises
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identical questions 52 to those provided on the third level critical control
checklist 57,
completed by the operator 58.
[0026] In this particular embodiment, the second level critical control
checklist is not
required to be completed before carrying out the activity 60, but the
checklist serves as a
supervisor 56 review, to check that an operator 58 has been completing the
third level critical
control checklist 57 correctly, and provides the supervisor 56 freedom to
decide which
checklists to review, given the supervisor's 56 knowledge of the activities 60
to be performed
and the particular operators 58 assigned to the activities 60.
[0027] The third level critical control checklist 57 is adapted for
completion by the
operator 58, and comprises questions 52 relevant to the scope of work of the
operator 58, an
example of a question 52 on a third level checklist 57 may be "Have you read
and signed the
confined space entry permit?", or "Are you aware of the gases that may be
present in the
confined space and the potential health effects of exposure to these gases?"
[0028] In an alternative embodiment of the present invention, a single
level of critical
control checklist 50 may be provided to the end user.
[0029] In alternative embodiments of the present invention, different
numbers of levels of
critical control checklists 50 may be provided and may be adapted for
completion by different
types of end user.
[0030] The end users may complete the critical control checklists 50 via a
computer
terminal, or similarly connected device such as a tablet or smart mobile
phone.
[0031] Alternatively, the end uses may complete critical control checklists
50 in paper
format.
[0032] The response time and history of the end user's response may be
logged and
assessed to identify responses which may not be accurate.
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[0033] For example where the responses are unusually quick, this may
indicate that the
end user has not read and understood the question before answering, or for
example where the
end user provides one answer, but then changes to an answer suitable for the
work to proceed,
which may indicate that the answer was provided only to allow the work to
proceed, even if it
did not reflect the situation at the time.
[0034] The fatality learning system and method 10 may comprise a facility
to raise
issues, whereby the end user can HALT the activity, describe the issue, and
raise a support
request 70.
[0035] The support request 70 may then be made available to any relevant
person or
people, for example the manager 54, the supervisor 56 and a maintenance
technician.
[0036] The support request 70 may then be assigned and prioritised
accordingly.
[0037] A support request 70 may refer to activities which are not specific
to maintenance,
for example issuing of a lanyard of good repair, or any action to improve
safety of the activity
60.
[0038] The fatality learning system and method 10 may comprise a HELP
function,
whereby an end user may activate the HELP function in an emergency, or if they
find
themselves in a situation where help is required.
[0039] The HELP function may signal to all end users on the site to provide
assistance,
alternatively the HELP function may be adjusted to signal users nearby for
example.
[0040] The fatality learning system and method 10 may comprise function for
end users
to add to checklists 50, to customise the information and questions 22
according to their
particular situation.
[0041] For example an operator 58 and supervisor 56 may determine a
preferred method
of completing a particular activity 60, and may define additional questions 52
related to
critical risk activities 60.
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[0042] Customised checklists 50 may then be entered into the lessons
learned database
30, and subsequently reviewed to provide further learnings and the content
incorporated into
the critical risk database 20.
[0043] In this example, the operator 58 and supervisor 56 may define and
classify the
additional questions 52, which are then submitted to the lessons learned
database 30. The
questions are submitted as proposed new questions 32 to the lessons learned
database, where
they are reviewed and once confirmed, provided to the critical risk database
20 as critical risk
questions 22. Once stored in the critical risk database 20 the questions 22
become available to
the critical control checklists 50 as questions 52 for the end user.
[0044] The end users may complete the critical control checklists 50 via a
smart watch,
or similarly connected device such as a wrist band, pendant or tracker.
[0045] The end users may complete the critical control checklists 50 via a
voice
recognition device, or similarly connected device such as remote headset or
Amazon Echo.
[0046] The end users may complete the critical control checklists 50 via a
visual device,
or similarly connected device such as Google Glass or Microsoft Halo.
[0047] Alternatively, the end user may complete the critical control
checklists 50 using a
paper print out for example.
[0048] The end users may be assisted with the critical control checklists
50 using
artificial intelligence, where the questions 52 are asked in a suitable manner
using a chat bot
for example.
[0049] Voice recognition may be incorporated to assist the end user with
completing the
critical control checklist 50.
[0050] The fatality learning system and method 10 operates globally with
access points
available for operators across every site in multiple languages.
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[0051] In use, end users access the interface prior to commencing a
critical risk activity
60, and a device or document displays the appropriate critical control
checklist 50 for the
activity 60. The questions 52 on the critical control checklist 50 comprise
the best available
information to prevent injury or death, in the form of a set of questions 52
to be answered
before proceeding with the activity 60. Providing all the questions 52 are
reviewed and
sincerely answered in the affirmative, the risk of harm is reduced
significantly.
[0052] In the event of a fatality or the recognition of a potential fatal
incident while
performing an activity 60 an incident report 40 is created.
[0053] The incident report 40 may be generated using any format, and may
not
necessarily be suited for use with the fatality learning system and method 10
described in the
present invention.
[0054] The incident report 40 may be reviewed, in conjunction with the
critical control
checklist 50 presented to the user prior to performing the activity 60 during
which the incident
occurred, to determine the risk and control classification of the incident
report 40 within the
structure of the critical risk database 20.
[0055] The incident report 40 may further be scanned using a combination of
keywords
and closest match questions to determine the appropriate risk and control
classification of the
incident report 40 within the structure of the critical risk database 20.
[0056] The review and classification of the incident report 40 allows the
specific question
or questions 52 which were associated with the incident, and which were
presented to an
operator on the critical control checklist 50 to be identified.
[0057] If the questions 52 presented had not been reviewed by the operator,
and as a
result an incident had occurred, it may be that no amendments are required,
although the
incident report 40 may still be added to the critical risk database 20 and
linked to the relevant
questions 22. The addition of the incident report 40 notifies users of the
incident, and provides
a report to them for review.
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[0058] If an incident report 40 is added to the critical risk database 20
and linked to the
relevant questions 22 and 'stamping' a FATALITY symbol or STOP notification
occurs, this
can be sent out as an instant notification to any device prior to the
operator, supervisor or
manager using the critical control checklist.
[0059] Instant notifications, for example push notifications, can be used
to inform the
operator, supervisor or manager of any additions or changes to the critical
risk database 20 or
the lessons learned database 30. Examples of instant notifications include;
new questions
added, questions modified, fatality alerts, black spots, hot spots, changed
conditions, critical
risk alerts and critical control alerts.
[0060] Users who perform activities 60 on a regular basis may proactively
review
incident reports 40 and stored instant notifications from around the world
relevant to these
activities 60, thus gaining an insight into the causes of incidents during the
performance of
these activities 60.
[0061] Amendments are determined by reviewing the questions 52 provided to
the
operator in the critical control checklist 50 and the incident analysis report
40 to determine the
cause or causes of the incident, and prevent the incident occurring again.
[0062] The amendments are added to the lessons learned database 30 in the
form of
amendments to questions 32, or new questions 32.
[0063] The original incident report 40 may also be added to the lessons
learned database
30 as supporting information, and may be linked to the amended questions 32.
[0064] The incident report 40 may further include relevant information
about the operator
58 involved in the activity 60 being performed at the time of the incident.
[0065] Additional information may be added to the incident report 40, in
the form of
supporting information and the outcome of the incident, for example permanent
injury of
death.
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[0066] Once all information particular to an incident has been added to the
lessons
learned database 30, including any amended or new questions 32 and the risk
and control
classification, the information is uploaded to the critical risk database 20.
[0067] At this point the amended or new questions 32 contained in the
lessons learned
database 30 are transferred to the critical risk database 20, updating the
questions 22
contained therein, resulting in an improved set of questions 22 and related
information in the
critical risk database 20.
[0068] This may be done using the risk and control classifications provided
following the
review of the incident report 40.
[0069] Once the amended or new questions 32 are uploaded to the critical
risk database
20, the resultant questions 22 become instantly available to all end users
world-wide, in the
form of questions 52 on critical control checklists 50, which are live-linked
to the critical risk
database 20.
[0070] The availability of the improved questions 52 results in a safer
work environment
by providing the lessons learned immediately to users worldwide.
[0071] The benefit of this method is that users are always applying the
lessons learned
from fatalities and potential fatal incidents in the field, at every level of
the organisation
(Manager, Supervisor and Operator), every day, before an activity 60 is
performed.
[0072] In another embodiment of the present invention, where an incident
has resulted in
a fatality, the amended or new questions 32 may include a FATALITY symbol or
STOP
notification declaring specifically that a fatality has occurred, and it
provides a description of
the activity 60 being performed at the time.
[0073] A STOP notification is highlighted in the associated questions 52
provided to the
user in the critical control checklist 50, and may require the user to read
the fatality
description, including the detailed information of the fatality, before
commencing the activity.
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[0074] The critical risk database 20 may comprise translations of questions
22 into a
number of languages, so that critical control checklists 50 may be provided
with questions 52
in a language native to, or understood by, the end user.
[0075] In another embodiment of the present invention, the critical control
checklists 50
are provided with pictograms for each question that are aligned with the
culture of the end
user.
[0076] In another embodiment of the present invention, the critical control
checklists 50
are provided with photographs or images for each question and aligned with the
culture of the
end user.
[0077] In another embodiment of the present invention, the incident report
40 is created
in a selected format, wherein the format is arranged to be classified
according to the structure
of the critical risk database 20.
[0078] In this embodiment the incident report 40 further comprises sections
to identify
the failures causes, and to provide recommendations to prevent future
failures.
[0079] The use of the incident report 40 in a selected format facilitates
the risk and
control classification and continuous improvement of the database, thus
reducing the
requirement for review and reducing the likelihood of errors by providing the
information in a
preferred format.
[0080] Throughout this specification, the terms management, supervisor and
operator are
used to describe roles, and checklists associated with roles. These terms are
used purely to
identify the different roles and checklists, and are in no way limiting the
scope to users fitting
such descriptions.
[0081] For example a manager 53, and manager level checklist 54 may be
assigned to
someone who is not necessarily considered a manager.
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[0082] Similarly, operators 58 may encompass a variety of roles including
maintenance
technician, contractor and cleaner for example.
[0083] Modifications and variations as would be apparent to a skilled
addressee are
deemed to be within the scope of the present invention.
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