2006 - Steel manufacture
The client had experienced an incident that should have been predicted and prevented as a result of risk assessment carried out for COMAH. Andy was asked to investigate how the risk assessment process had failed. From talking to key personnel and reviewing related documents, Andy was able to develop a root cause 'why tree.' From this he recognised that the incident had been predicted but the mindset of people at the site meant they focused on only part of the problem and hence did not develop a full solution. This was further affected because assessments had been carried out at a generic level, and specific areas with higher risks had not been identified . Also, changes had occurred in the way areas of the site were being used and because the management of change processes had not worked as intended, there had been no prompt to revisit the original risk assessments. Andy was able to make recommendations about how to improve the underlying processes and specific applications of risk assessment and management of change. The objective being to not just prevent the same incident occurring, but to have a wide ranging impact on how risks are managed.