In one of the hottest topics in current health and safety trends, George Coetzee outlined the methodology to follow when using bowtie risk analysis, and the practical application of ‘barrier’ thinking to understand the complexity of how material unwanted events (MUEs) materialise and how to determine pathway vulnerability. The methodology also described a systematic approach to develop an effective critical control framework to prevent MUEs from materialising.

1. Speaker : George Coetzee
Vice President Head of Group Safety AngloGold Ashanti
Presentation : Material Unwanted Event Critical Control Management

2. AngloGold Ashanti Profile
Third-largest gold mining company in the world, measured by
production. Has 17 mines gold mines in 9 countries across the
African, Australian and South American Continents. Exploration
programmes in both the established and new gold producing
regions of the world, e.g. Colombia, Brazil, US. etc.

3. Outline
• Footprint and Major Hazard Management Journey overview
• Identification and assessment of MUE’s
• Development of Safety Enterprise Risk Scorecard
• “Blue Print” BowTie Risk models
• CCM registers, criteria & vulnerability
• Building Organisational capability
• Site specific BowTie Risk models & monitoring regimes
• Performance Monitoring and Lessons Learnt

4. • 65% Reduction in AIFR over 5 years …
• Operations stabilized … variability reduced
over 70%
• FIFR … ‘07/’08 step-change… performance
sustained, but plateaued…similar ’10/’12
• Weak to no correlation between AIFR & FIFR
• Correlation ≠ Causation, Different variables
between AIFR & FIFR
Correlations between AIFR & FIFR

5. ID+AssesMUE’s
Develop & embed
Safety ER Scorecard
HRM Introduction & training delivery
CCM registers, criteria & vulnerability
Develop “Blue Print” Models & MHC guidelines
Building Organisational capability; Leadership alignment, accountability & pro active positioning
Develop Site Specific BowTie Risk Models (3YR plan)
CCM performance requirements, monitoring,
accountability & effectiveness enabling tools
Integrate CCM into Work Management process, reducing variability,
targets for compliance
1.
2.
3.
5.
6.
4.
7.
8.
9.
Responses to inadequate critical control performance10
.
Major Hazard Management Journey overview

6. Identification and assessment of MUE’s
• Based on ISO 31.000 approach
• Related Governance requirements, e.g. King, SOX
• Adopted GMIRM “Four Layered” Risk model approach
• Six (6) supporting Group HSE HRM procedures
• Implementation / Deployment strategy
• Identification and assessment of MUE’s
 Historical information…HPI’s & Fatal Incidents
 Risk Control ratings
 Maximum foreseeable loss

7. Development of Safety Risk Scorecard
• Top nineteen (19) MUE’s
• “High-water mark” risk scores
• Aggregate scores per PUE, Operation & Group

8. “Blue Print” BowTie Risk models
• Over 2,000 controls identified… ave 68 (prev) & 28 (mit) controls per
major hazard…
• Majority (88%) lower order controls… highlights vulnerability
• Control Risk Registers developed and accountabilities assigned
0
20
40
60
80
100
Inrush/Inundation
VT(DroppedObjects)
FlammableGas
VT(ConveyanceOOC)
Hazmat
PressSystems
EnergyIsolation
Rail-BoundTransport
ConfinedSpaces
UGVent
UGGroundControl
WorkatHeights
Fire
Electricity
Explosives
Lifting/Rigging
HME
Aviation
EquipSafeguarding
High-wallStability
LightVehicles
Controls Distribution - Admin vs. Eng (%)
Admin Eng

9. CCM registers, criteria & vulnerability
• Control criteria - Hierarchy aimed at higher order controls
• Control quality using set guidance
• Critical Control identification:
 Control within “dominant” pathways
 Control within vulnerable pathways
 Higher order controls
 Repeatedly used controls
 Independence in managing release of threat
 Controls closest to mechanism of release
• f

10. Building Organisational capability
• Group wide HRM training program…18,000 trained to date
• BTA training - 140 HSE / Risk professionals across the group
• Technical support (45 x BTA workshops facilitated)
• Enabling tools..software licences
• Executive support
• Senior leadership buy in and personal involvement
• Incentivised as leading indicator metric (BSP & LTIPS)

11. Site specific BowTie models & monitoring regimes
• Developed using set evaluation criteria
• Over 260 Major Hazards analysed, critical controls defined and
monitoring regiments implemented

12. Performance Monitoring
• Enabling tools & data visualisation
• New line-of-sight… Critical Control verification count, compliance
and deviation rates by Major Hazard and by Operation
• ~ 105,000 critical controls verified monthly, 96% compliance
• Reducing variability & deviation rate

13. Performance Monitoring continued…

14. Lessons Learnt
• Perfection is the Enemy of Progress…
• Proactive strategic positioning
• Senior Leaders get “fist hand” experience of process
• Facilitators profiling - Skills & experience; Credibility; Challenging paradigms
• “Balanced” BowTie Models, detailed enough but not complex
• Minimising number of critical controls
• Critical control selection, accountability, performance & reporting
• Integration into current work management processes
• Responding and addressing non-compliance to critical controls

15. CCM in context

16. Discussion and Questions