CAKE Q3 – Major accident
worst case scenario game for each department
Contains:
Gameboard (poster)
Post-it
Preparation:
Section leader has the role as ’gamemaster’.
The scenario-poster to be hanged on the wall. The crew gathers around(standing).
Section leader explains the scenario and the rules.
Time ca. 15 min (discussion and summary)
Game objectives:
Based on the silent deviations identified in CAKE Q2, we have developed a worst case scenario game which uses silent deviations and our role in the work process to raise focus on major accidents. The main purpose is to use the game to increase understanding of personal risk and consequences by indentifying which role you play in breaking barriers.
The game presents a top event, a threat that can lead to this top event and examples of 3 barriers that prevent the threat to develop to a top event. The course of events are taken from the bow tie part of the HSE case, and simplified.
Each department have a relevant top event, on the right hand side of the poster.
The threat that can lead to the top event is on the lefthand side on the poster.
To prevent a situation where the threat escalates and results in a top event/major accident, there are different barriers in place. In this scenario/game, we have chosen 3 barriers for each potential top event.
The objective with this exercise is to identify the role we each play that might affect/reduce/break the 3 barriers. What kind of influence do our decisions have in this course of events? Together, the crew discusseshow their own actions can weaken the barriers that prevent the threat to escalate to a top event/major accident.
Example: technical/marine – how do my actions influence the barrier “visual checks/inspections”?
Example reply:
-I don’t have the time, but doesn’t let anyone know
-I observe someone not finishing the inspection in a correct way, and does not say stop
-I don’t have the necessary training in performing the inspection, but doesn’t let anyone know
-Loose focus due to trouble at home
-I’m getting other tasks that has to be prioritized
-My colleague needs assistance, and I have to suspend what I’m doing
The discussion starts on barrier 1. Each person writes down suggestions to own actions which might influence the barrier on post-it notes and attach it to the poster. Section leader decides when you move on to the next barrier when the first barrier is declared broken. When all 3 barriers are gone through and the result is a top event/major accident, the section leader ends the session with a summary.