RESPONDING TO

AND MANAGING
WEAK SIGNALS
xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025
WEAK SIGNALS – THREATS -- OPPORTUNITIES

Weak Signals are like warning signs

that something is wrong or about to
go wrong. They may be thought of
as Threats, but they are also an
opportunity to improve. They are
an early, low-intensity indication of a
potential future trend, threat, or
opportunity. These signals are often
subtle and can be easily overlooked

When Weak Signals are recognized and acted on, a loss may be
prevented. This will only happen when we know what to look for
and are willing to take the initiative to do something about it.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

A threat to a business isn't just a potential
problem—it can be a catalyst for innovation and
growth. Instead of viewing threats purely as
risks, businesses can analyze them as
opportunities to refine processes, strengthen
resilience, and gain a competitive edge.

For example, observing increasing pump vibrations isn't just a weak signal,
it’s a chance to optimize the pump performance. Instead of waiting for
failure, engineers investigate the root cause. They might discover
inefficiencies in alignment, outdated components, or operational factors that
contribute to wear and tear. This situation presents an opportunity to:
• Upgrade to advanced vibration monitoring systems for predictive
maintenance.
• Evaluate new pump models with improved design and durability.
• Refine operational procedures to reduce unnecessary strain on equipment.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

WEAK SIGNALS – THREATS -- OPPORTUNITIES

By addressing weak signals (or “Threats”) proactively, the

company not only prevents unplanned downtime but also
improves energy efficiency, reduces maintenance costs, and
extends equipment lifespan—all while strengthening risk
management practices.

A workplace near miss can prompt a company to overhaul its

safety protocols. If a manufacturing facility experiences a
simple mishap without consequence due to outdated equipment
or inadequate safety training, this as an opportunity to
implement stronger safety measures, invest in modern
equipment, and provide enhanced training for employees. This
not only reduces future risks but also fosters a culture of safety
and may even boost operational efficiency.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 WEAK SIGNALS – THREATS -- OPPORTUNITIES

The overwhelming tendency is to respond to weak signals with a relaxed response.

Yes, something happened, but it didn’t result in anything major.

• “It is tragic the number of times people are harmed in accidents where
earlier warning signs had been overlooked”. - CCPS Recognizing Catastrophic
Incident Warning Signs in the Process Industries, 2012 [61, p. 120].

• “An organization with a high reliability for safe operations sees the
significant meaning of these weak signals and gives a strong response
to those weak signals.” - Managing the Unexpected: Sustained Performance in a
Complex World, Third Edition. March 6, 2015 Weick KE, Sutcliffe KM. San Francisco, CA:
Jossey-Bass; 2015.

Organizations with high reliability are exceptionally consistent in accomplishing their

goals and avoiding potentially catastrophic errors. They have found it essential to
identify weak danger signals and to respond to these signals strongly so that
system functioning could be maintained, and disasters could be avoided.

- Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. March 6,
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 RESPONDING TO WEAK
SIGNALS IS IMPORTANT FOR
SAFE AND RELIABLE
OPERATIONS

BUT HOW DO YOU IDENTIFY

AND THEN MANAGE THEM?
• Train people on how to recognize weak signals (or Threats or Opportunities)
• Create a reporting Culture
• Plan how to respond
• Install a system to track and manage them

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

TRAIN PEOPLE TO RECOGNIZE WEAK SIGNALS

Everyone is aware of and thinking about the potential for

failure. People understand that new threats emerge
regularly from situations that no one imagined could occur,
so all personnel actively think about what could go wrong
and are alert to small signs of potential problems.

The absence of errors or accidents leads not to complacency

but to a heightened sense of vigilance for the next possible
failure. Minor errors/failures are viewed as opportunities to
learn about systems issues and potential improvements.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

TRAIN PEOPLE TO RECOGNIZE WEAK SIGNALS
What are indicators of a potential issue (weak signals / threats)?
• an event that does not accomplish its intended purpose
• the act or result of not achieving success in some effort or
activity
• the fact of not meeting the objective, goal or specified action
• the fact of not doing something that must be done or are
expected to do
• the fact of something not working, or stopping working as well
as it should
• that something should have been secured or managed but is
left unmanaged
These “early minor failures” are clues that the system is not as
healthy as thought.
J. Reason, A Life In Error: From Little Slips to Big Disasters
(Burlington, VT: Ashgate, 2013)

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 RECOGNIZING WEAK SIGNALS (Threats)

People strive to maintain a high awareness of operational conditions, a

chronic unease or constant vigilance. This sensitivity is often referred to
as "situational awareness." It means that people cultivate an
understanding of what is going on around them and how the current
state might support or threaten safety.
- Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. March 6,
Weick KE, Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015.

They seek underlying rather than surface explanations.

Commitment to resilience involves an assumption that the system is at

risk for failure, and they practice performing rapid assessments of and
responses to challenging situations. Teams cultivate situational
assessments so they may identify potential safety threats quickly and
either respond before safety problems cause harm or mitigate the
seriousness of the safety event.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

COMMUNICATING WEAK SIGNALS / THREATS
➢ A reporting culture – people are competent to identify anomalies - the “early,

low-intensity indications”. Not just in decision-making, but rather with

sensemaking - clues that the system is not as healthy as they thought it was.

➢ A just culture - an atmosphere of trust in which people believe they are safe to

report anomalies, the “early minor events”. Leaders welcome this information,

show trust that they will act on them and there is never repercussions for “bad

news”.

➢ A learning culture - possess the willingness and the competence to draw the

right conclusions from the safety information system and the will to address

problems identified through the reporting culture and implement necessary

reforms.

➢ A flexible culture – the organization is able to reconfigure themselves in the

face of high tempo operations or certain kinds of hazards. How adequately can

people convert the lessons that they have learned into new assumptions,

frameworks, and action.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 MANAGING THREATS & OPPORTUNITIES
(MTO)

• MTO is a threat/opportunity management system - Identify,

prioritize, and take action on threats to the business plan
commitments before they strike or harm the business.
• MTO is a Work Process, not just a Reliability database. A
“tracking system” to help identify, prioritize, and plan resolution
to threats as well as take advantage of opportunities.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 ASSESS THREATS/OPPORTUNITIES

An ad hoc Reliability Action team should consist of the

following:
• The person that has identified a Threat or Opportunity
• Operations Representative helps with determining the
consequence of the threat/scenario occurring.
• Other Technical Expert (Unit Support – inspector, engineer,
etc.)
Fundamental responsibilities:
• Review if the proposed is or is not a Threat/Opportunity
• If it is a Threat - then assign a Risk Score
• Assign Threat Owners – they own the follow-up and
resolution. Responsible for pushing progress, holds others
accountable
• Assign and Track Actions

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

WHAT IS A THREAT? OPPORTUNITY?

A Threat is a An Opportunity is a
reactive issue proactive issue

Can be related to hardware (pumps, motors, instruments, valves)

Can be related to process (increased temperatures, decreased flow)
Can be related to other gaps (e.g. poor communication from Solvents
Unit when their feed tank is low)

A Threat is not a simple maintenance task

• “Need pressure transmitter changed on pump” – is not a
threat

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 ASSESS WITH A “IS / IS NOT” EXERCISE
IS A THREAT
✓Longer term threats to delivering business plan commitments
that typically require more than 30 days to mitigate after
identification.
✓Threats or Opportunities related to: HSSE, Process Safety,
Reliability, Margin, Cost, and Product Quality
✓Threats that result in organizational distraction:
• Nuisance alarms/alarm
• Bad Actor Equipment: Equipment that fails more
frequently than designed/premised resulting in
organizational distraction (cost, craft scheduling, Operator
attention)
✓Threat requiring Capital funding
✓MTO work process is used to help prioritize line items in
the site annual capital plans.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 ASSESS WITH A “IS / IS NOT” EXERCISE

EXAMPLES
Threat: Multiple Seal Failures on P-1234 Affecting Feed
Rates to Solvent Unit
• Statement: Seal Failures on P-1234
• Solution: Need a New Seal Design on P-1234

Threat: Potential Failure of MVR Small Bore Piping could

Delay Vapor Loading
• Statement: MVR Vibration of small bore piping
• Solution: Need Vibration Monitoring on MVR Small
Bore Piping

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

ASSESS WITH A “IS / IS NOT” EXERCISE

IS NOT A THREAT
❖Threats to delivering business plan commitments that
typically require less than 30 days to mitigate after
identification.
▪ These threats should be captured and tracked in the
daily production team meeting.
❖Threats entered and tracked within another work process.
Examples include:
• Work Orders (i.e. pump repair, calibrate transmitter, etc)
• Preventative Maintenance items tracked via the
Equipment Integrity work process
• PHA items entered and tracked in Process Safety
Management system

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

ASSESS WITH A “IS / IS NOT” EXERCISE
EXAMPLE IS / IS NOT EXERCISE

There have been multiple minor leaks from the ‘M’ System line. Rate of seepage is
increasing.
✓ Yes, a threat should be entered.

There is a seal failure on P-1234. The seal has never failed before.
❖ No, a threat should not be entered. This is a maintenance task. However, if seal
failures persist, a threat should be entered.

RDP-1234 is obsolete. We can no longer find replacement parts.

✓ Yes, an opportunity should be entered.

Tank 54 Level gauge (tape system) gets “hung up”. Tank readings not always accurate.
No, a threat should not be entered. This is a maintenance task. However, if there are
repeated failures of this type of gauging system, an opportunity should be entered.

Whenever Pressure on Reactor 7 has exceeded upper limit, Operator opens valve XV21 to
lessen pressure and continues operation.
✓ Yes, a threat should be entered.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

DETERMINING RESPONSE TO WEAK SIGNALS / THREATS

The identifying and reporting of a

Weak Signal / Threat /
Opportunity will result is a large
number to address and manage.

An organization has limited

resources and must apply those
with best effect and most impact.

Need a process to sort out these

Weak Signals / Threats /
Opportunities so that resources
can be properly applied.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

ASSIGN A RISK SCORE
A Risk Score uses the Risk Assessment Matrix to help prioritize a threat
based on four categories:
• People
• Environment
• Asset
• Reputation
Each category has a Consequence ( C) and Likelihood (L)

Risk Score = People (C*L) + ENV (C*L) + Asset (C*L) + Reputation (C*L)

NOTE: THIS IS NOT QUANTIFYING RISK NOR IS IT TO

CALCULATE RISK OR PROBABILITIES.
SOLEY A COMPARISON FACTOR – ORDER OF MAGNITUDE
COMPARISON BETWEEN DIFFERENT THREATS/OPPORTUNITIES.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 Risk Score = People (C*L) + ENV (C*L) + Asset (C*L)
+ Reputation (C*L)

Consequence Factor ( C)
HARM TO ASSET ENVIRONMENTAL BUSINESS
FACTOR
PEOPLE DAMAGE IMPACT IMPACT

0 No injury or health effect No damage No effect No impact

Slight effect
Slight damage - Costs less
10 Slight injury or health effect. Slight environmental damage – Slight impact
than 10,000 US$.
contained within the premises.

Minor impact – Local and

Minor effect some regional media
Minor damage - Costs between
100 Minor injury or health effect Minor environmental damage, but coverage. Local
10,000 and 100,000 US$.
no lasting effect. governmental and regulatory
scrutiny.

Moderate damage - Costs Moderate effect Moderate impact -

1000 Major injury or health effect between 100,000 and 1 million Limited environmental damage that Significant impact in region
US$. will persist or require cleaning up. or country

Major effect
Severe environmental damage that Major impact - Likely to
Permanent total disability or up to Major damage - Costs between
10,000 will require extensive measures to escalate and affect Shell
three fatalities 1 and 10 million US$.
restore beneficial uses of the reputation
environment.

Massive effect
Persistent severe environmental
Massive damage - Costs in Massive impact - Severe
100,000 More than three fatalities damage that will lead to loss of
excess of 10 million US$. impact on Shell reputation
commercial, recreational use or loss
of natural resources over a wide area.

NOTE: THIS IS NOT QUANTIFYING RISK NOR IS IT TO CALCULATE RISK OR PROBABILITIES.

SOLEY A COMPARISON FACTOR – ORDER OF MAGNITUDE COMPARISON BETWEEN DIFFERENT
SEVERITIES OF A CONSEQUENCE

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 Risk Score = People (C*L) + ENV (C*L) + Asset (C*L)
+ Reputation (C*L)

Likelihood Factor ( L)
FACTOR LIKELIHOOD

1 x 10 (-0)
1.0
Has happened more than once per year on site, likely to happen

<= 1 x 10 (-1)
0.75
Has happened more than once on site in last 10 years.

> 1 x 10 (-1) and <= 1 x 10 (-2)

0.5
Has happened on site before, or more than once a year in the company

> 1 x 10 (-2) and <= 1 x 10 (-3)

0.25
Has happened in the company before, or more than once per year in industry

> 1 x 10 (-3) and <= 1 x 10 (-4)

0.1
Similar Event Heard of in the industry

> 1 x 10 (-4) up to 1 x 10 (-5)

0.01
Similar Event Never heard of in the industry

NOTE: THIS IS NOT QUANTIFYING RISK NOR IS IT TO CALCULATE RISK OR PROBABILITIES.

SOLEY A COMPARISON FACTOR – ORDER OF MAGNITUDE COMPARISON BETWEEN DIFFERENT
LIKELIHOODS ASSOCIATED WITH A CONSEQUENCE

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 Risk Score = People (C*L) + ENV (C*L)
+ Asset (C*L) + Reputation (C*L)
EXAMPLE:
Weak Signal or Threat
• Pump vibrations are increasing. While still within control limits, the rate of increase will exceed upper limit and
impact the pump seal..
Consequence
• Eventually, if not addressed, the seal can fail, spraying oil in the area. The potential Consequence can be that
the aerosolized oil contacts a nearby ignition source and a conflagration ensues. The pump, piping and a
nearby vessel would be severely damaged costing up to $250,000 and three weeks of downtime (no
production). This could result in over $ 1million Consequential Business Loss. There are usually two
Operators in the area around 50% of a shift time so if seal fails and fire ensures at least one Operator would
be severely burned, permanent total disability. This type of incident has been shown to result in limited
environmental damage that will persist or require cleaning up. Local and some regional media coverage and
local governmental and regulatory scrutiny could result.
Likelihood
• The Likelihood of the Consequence (not the scenario) should a pump seal fail is 1 x 10 -3.
Applying the Factors associated with the described Consequences and the Likelihood to the Risk Score equation:
• Risk Score – People (10,000*0.25) + Environmental (1,000*0.25) + Asset (10,000*0.1) + Business (100*0.1)

• Risk Score – People (2500) + Environmental (250) + Asset (1000) + Business (10) = 3,760

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 USING THE RISK SCORE
GUIDELINES
• Consequence Factor and Likelihood Factor is based on the assumption that the weak
signal leads to an event or the threat scenario occurs.
• The Likelihood Factor should be based on the likelihood of the particular
Consequence under consideration (People, Environment, Reputation, or Asset). It is
Not the Likelihood of the threat scenario being realized or an incident occurring.
• For example, assume threat scenario is a crude pump seal failure near a river.
For the environmental consequence use the likelihood of the crude getting to
the river once the seal leaked, not the likelihood that the seal is going to leak.
• The likelihood is based on similar past events - It doesn’t have to be the exact same
scenario. Given the same crude pump example:
• In the past how many times has a seal pump failure resulting in process
release to a waterway?
• It is not how many times has this particular crude pump seal failed resulting in
crude release to the waterway.
• Evaluate the likelihood of each consequence individually (People, Environment,
Reputation, and Asset). The Likelihoods ARE NOT the same for the different
consequences. The majority of times it will be different likelihoods.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 USING THE RISK SCORE
GUIDELINES (cont’d)

• The Risk Score is used as a qualitative prioritizing tool only – not to

quantify Risk or calculate probability
• Threat realization Scenarios must be credible – not worst imaginable.
• Potential Consequences are based on an estimate of what might happen;
worst credible.
• Likelihood refers to the likelihood of the different consequences if the weak
signal leads to an event or the threat scenario occurs.
• For quality results, the assessment must be carried out by a team with the
appropriate background.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

USING THE RISK SCORE

# THREAT / OPPORTUNITY RISK SCORE

A minor seepage is emanating from a pump

A 3,760
seal, could weaken seal & lead to a leak
Reduced temperatures of Product X being
B 1,103
sent to tank
Pressure Indicator Z2 is not holding
C 2,756
readings – obsolete ?

Threat/Opportunity A has priority for action & funding

Threat/Opportunity C has second priority for action & funding

NOTE: THIS IS NOT QUANTIFYING RISK NOR IS IT TO CALCULATE RISK OR PROBABILITIES.

SOLEY A COMPARISON FACTOR – ORDER OF MAGNITUDE COMPARISON BETWEEN DIFFERENT
THREATS/OPPORTUNITIES.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

 USING THE RISK SCORE
RISK
THREAT / OPPORTUNITY OPTION 1
SCORE
PRIORITIZE - which
A minor seepage is emanating from a pump seal, could gets attention /
1 7,050
weaken seal & lead to a leak resourced first, then
second and so on
9 Reduced temperatures of Product X being sent to tank 1,103

6 Pressure Indicator Z2 is not holding readings – obsolete ? 2,756

Pump vibrations are increasing. While still within control

3 limits, the rate of increase will exceed upper limit and 4,540
impact the pump seal OPTION 2
RANKING – Threats /
Whenever Pressure on Reactor 7 has exceeded upper
Opportunities with
7 limit, Operator opens valve XV21 to lessen pressure and 2,101
Risk Score above
continues operation
3,000 get resourced
Activation of safety instrumented system when “out of in first round tranche
5 2,906
acceptable range” process variable is detected
A mechanical shutdown system is called upon to function
8 1,995
whether or not the device actually responds
safety critical equipment, devices and instruments outside
4 of their assigned inspection, testing and/or calibration 3,890
frequency
There are a number of deferred repairs to be addressed
2 4,590
in next opportunity

NOTE: THIS IS NOT QUANTIFYING RISK NOR IS IT TO CALCULATE RISK OR PROBABILITIES.

SOLEY A COMPARISON FACTOR – ORDER OF MAGNITUDE COMPARISON BETWEEN DIFFERENT
THREATS/OPPORTUNITIES.
xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025
MANAGE THREATS / OPPORTUNITIES

Develop a database system to capture, track and manage

the Weak Signals / Threats / Opportunities

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

Weak Signals are like warning signs
that something is wrong or about to
go wrong. They may be thought of as
Threats, but they are also an
opportunity to improve. They are an
early, low-intensity indication of a
potential future trend, threat, or
opportunity. These signals are often
subtle and can be easily overlooked

When Weak Signals are recognized and acted on, a loss may
be prevented. This will only happen when we know what to
look for and are willing to take the initiative to do something
about it.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025

I post with humility. The information that I have posted is based on:
❑ Studies and learnings from researchers:
❑ Managing the Unexpected: Sustained Performance in a Complex World, Third Edition. March 6, Weick KE,
Sutcliffe KM. San Francisco, CA: Jossey-Bass; 2015
❑ CCPS Recognizing Catastrophic Incident Warning Signs in the Process Industries, 2012 [61, p. 120].
❑ J. Reason, A Life In Error: From Little Slips to Big Disasters (Burlington, VT: Ashgate, 2013)
❑ Shell Oil – Managing Threats & Opportunities System (MTO)
❑ Having the opportunity to benchmark the top performers in industry/business. How they achieved top quartile
performance. Not their apparent performance but proven results.
❑ 40 years of experience implementing successful safety programs in many different companies and facilities.

I want to help build the safety profession by sharing with colleagues.

And in the process start a movement – a new, radically different way to approach Safety.

xmilewski@[Link] Intellectual Property of Gregory Milewski Feb 2025