Transcript Safety Through Design Concepts In Z10 Will Revolutionize

Recognizing Predictive Indicators
for
Fatalities and Serious Injuries
Fred A. Manuele, CSP, PE
President
Hazards, Limited
1
What I Will Comment On



A phenomenon
Statistics on fatalities and serious
injuries
Debunking a myth
2
What I Will Comment On

Fatality–serious injury characteristics

Significance of organizational culture

The business climate, and culture

A mechanism for an internal study
3
What I Will Comment On

Improving incident investigation

Making gap analyses

A “near hit” data gathering system

The need for a different mind set
4
The Phenomenon

Reliance on traditional approaches to fatality
prevention has not always proven effective.
This fact has been demonstrated by many
companies, including some thought of as top
performers in safety and health, as they
continue to experience fatalities while at the
same time achieving benchmark performance
in reducing less-serious injuries and illnesses.
5
The Phenomenon



ORC Worldwide: 140 Fortune 500
companies
Data gathering system on fatalities and
life threatening incidents
We, collectively, do not know enough
about causal factors
6
Statistical Indicators – Fatalities


National Safety Council – Accident Facts
(Now Injury Facts)
Bureau of Labor Statistics – National
Census of Fatal Occupational Injuries
7
Statistical Indicators – Fatalities
No. of
Year
1941
1951
1961
1971
1981
1991
2001
Number of
Fatalities
18,000
16,000
13,500
13,700
12,500
9,800
5,900
Fatality
Rate
37
28
21
17
13
8
4.3
Workers
in 1000s
48,100
57,450
64,500
78,500
99,800
116,400
136,000
8
Statistical Indicators – Fatalities

From 1941 through 2001

Employment increased over 280%

Number of fatalities – down over 67%

Fatality rate – reduced over 88%
9
Statistical Indicators – BLS Reports
All Fatalities – All Occupations
Year
2001
2002
2003
2004
2005
2006
Number of
Fatalities
5,900
5,524
5,559
5,703
5,702
5,703
Fatality
Rate
4.3
4.0
4.0
4.1
4.0
3.9
10
Statistical Indicators – BLS Reports
All Fatalities – All Occupations

Relate 2002 to 2006




Number of fatalities increased 3.2%
Fatality rate stayed the same
Why did the number of fatalities
increase?
Why did the fatality rate not continue
the downward trend in previous years?
11
Statistical Indicators – BLS Reports
Fatality Rates – Selected Occupations
Industries
2005
2006
Mining
25.6
27.8
Transportation/wrhsing 17.6
16.3
Construction
11.0
10.8
Utilities
3.6
6.2
Wholesale trade
4.4
4.8
Manufacturing
2.4
2.7
12
Statistical Indicators: BLS

Lost-Worktime Injuries and Illnesses:
Characteristics and Resulting Time
Away From Work

Table 10 – Percent distribution of nonfatal
occupational injuries and illnesses involving
days away from work – Private Industry
13
Statistical Indicators: BLS
Percent of days-away-from-work cases involving
these numbers of days
1
1995 16.9
2
13.4
3-5
20.9
6-10 11-20 21-30 31 or more
13.4 11.3
6.2
17.9
2005 14.3
11.6
19.0
12.7
% -15.4 -13.4 -09.1
Change
from 1995
11.5
6.5
24.2
-6.0 +1.8
+4.8
+35.2
14
Statistical Indicators


You can not conclude from the BLS
data that the number of incidents
resulting in severity has increased
You can conclude that incidents
resulting in severity are a larger
segment of all lost time injuries
15
Statistical Indicators



National Council on Compensation
Insurance
The Remarkable Story of Declining
Frequency—Down 30% in the Past Decade
Also down in Canada, France, Germany,
UK, Japan
16
Statistical Indicators

National Council on Compensation Insurance
(2005 paper)

Decline in the frequency of smaller
lost-time claims is larger than in the
frequency of larger lost-time claims
17
Statistical Indicators
1999 to 2003, in 2003 hard dollars
Value of Claim
1.
2.
3.
4.
Less than $2,000
$2,000 to $10,000
$10,000 to $50,000
More than $50,000
Frequency Declines
34%
21%
11%
7%
18
Debunking a Myth

A barrier

Reducing injury frequency will
equivalently reduce incidents
resulting in severe injury
19
Debunking a Myth

Many safety practitioners believe and
profess that efforts concentrated on
the types of accidents that occur
frequently will also address the
potential for severe injuries.
20
Debunking a Myth
Jim Johnson: “I’m sure that many of us
have said at one time or another that
frequency reduction will result in severity
reduction. This popularly held belief is
not necessarily true. If we do nothing
different than we are doing today, these
types of trends will continue.”
21
DNV Consulting

Much has been said about the classical
loss control pyramid, which indicates
the ratio between no loss incidents,
minor incidents, and major incidents,
and it has often been argued that if you
look after the small potential incidents,
the major loss incidents will improve
also.
22
DNV Consulting

The major reality however is somewhat
different. If you manage the small
accidents effectively, the small accident
rate improves, but the major accident
rate stays the same, or even slightly
increases
23
Debunking a Myth

Recall Jim Johnson saying that:

If we do nothing different than we
are doing today, severe injury
trends will continue
24
Debunking a Myth

Jim’s view – supported by a world
famous philosopher who said

If you keep doing what you
did, you will keep getting what
you got
25
Debunking a Myth

The world class philosopher


If you keep doing what you did,
you will keep getting what you got
Dr. Lawrence Berra
26
Debunking a Myth


As the data clearly shows, frequency
reduction does not necessarily produce
equivalent severity reduction
Severity reduction requires specially
crafted initiatives, focused on hazards
and risks that present severe injury potential
27
A Different Approach Needed

The data requires that we adopt a
different mind set, one that results
in a particularly directed focus on
preventing low probability, severe
consequence events.
28
Characteristics of Severe Injuries
Studies: Over 1,200 Incidents

A large proportion of severe injuries occur:
 In unusual and non-routine work
 Where upsets occur: normal to abnormal
 In non-production activities
 Where sources of high energy are present
 In at-plant construction operations
29
Characteristics of Severe Injuries

Many accidents resulting in
severity are unique and singular
events, having multiple, complex,
cascading technical, organizational
or cultural causal factors
30
Characteristics of Severe Injuries

Largely, causal factors for low
probability/severe consequence events
are not represented in the analytical
data on incidents that occur frequently,
but such incidents may be predictors of
severity potential if a high energy
source is present
31
In the Studies Made

The quality of incident investigations,
on average, was abysmal.
32
Predictive Specifics From Studies


Thirty-five percent of severe injuries
were triggered by a deviation from
normal operations – upsets
Over a 10 year period, 51% of fatalities
occurred to contractor employees
33
Predictive Specifics From Studies

In three companies with a combined
total of 230,000 employees, each
company having very low OSHA rates,
74% of severe injuries occurred to
support personnel
34
Predictive Specifics From Studies

Percent of severe injuries that occurred
to non-production personnel in two
other companies


Company A – 63%
Company B – 67%
35
Predictive Specifics From Studies

For companies with OSHA rates higher
than industry averages, and in
companies where there is heavy
material handling or the work is highly
repetitive, the percent of severe injuries
occurring to production personnel was
higher
36
Predictive Specifics From Studies


About 50% of major accidents involved
powered mobile equipment: fork lift
trucks, cranes, etcetera
Reviews of electrical fatalities indicate
that, the design of the systems
produced error-inducing situations
37
Predictive Specifics From Studies


Having effective management of
change procedures would have greatly
reduced major accident potential
Complacency and overconfidence was
often a factor
38
Dan Petersen: On Severe Injuries

The mass data indicates that the types of
accidents resulting in temporary total
disabilities are different from the types of
accidents resulting in permanent partial
disabilities or in permanent total
disabilities or fatalities
39
Dan Petersen: On Severe Injuries



The causal factors are different
There are different sets of
circumstances surrounding severity
If we want to control serious injuries,
we should try to predict where they will
happen
40
A Study of Fatalities

UAW Data


Skilled trades people, 20 percent
of population
Have 41 percent of fatalities
41
Corporate Culture and Safety


The physical cause of the loss of
Columbia and its crew was a breach
in the Thermal Protection System
on the leading edge of the left wing.
In our view, the NASA organizational
culture had as much to do with this
accident as the foam.
42
Corporate Culture and Safety

Columbia

Organizational culture refers to the
basic values, norms, beliefs, and
practices that characterize the
functioning of an institution.
43
Corporate Culture and Safety

Columbia
 At the most basic level, organizational
culture defines the assumptions that
employees make as they carry out
their work. It can be a positive or a
negative force.
44
Corporate Culture and Safety

In every organization

“Values, norms, beliefs, and
practices” are translated into a
system of expected behavior that
impacts positively or negatively on
decisions taken
45
Corporate Culture and Safety

with respect to management systems,
design and engineering, operating
methods, and prescribed task
performance—and how much risk
taking is acceptable
46
On Major Accidents

James Reason – Managing the Risks of
Organizational Accidents

Stresses the long term impact of
inadequate safety decision making
on an organizations culture
47
On Major Accidents

Reason: The impact of (top level)
decisions spreads throughout the
organization, shaping a distinctive
corporate culture and creating
error-producing factors within
individual workplaces.
48
On Major Accidents

Donald A. Norman – The Psychology
of Everyday Things

Most major accidents follow a series
of breakdowns and errors.
49
On Major Accidents

Norman: In many cases, the
people noted the problem but
explained it away, finding a logical
explanation for the otherwise
deviant observation.
50
On Major Accidents


“Normalization of deviation” is a
more often used phrase
Where it occurs, it is a predictor of
severe consequences
51
Economics and Culture

A realistic look at the current business
climate and its possible effect on
organizational culture and decision
making
52
Economics and Culture


Report of the OECD Workshop on
Lessons Learned from Chemical
Accidents and Incidents
The concept of ‘drift’ as defined by
Rasmussen was generally agreed
upon as being far too common in the
current business environment
53
Economics and Culture

Rasmussen defined ‘drift’ as “the
systematic organizational performance
deteriorating under competitive
pressure, resulting in operation outside
the design envelope where
preconditions for safe operation are
being systematically violated.”
54
Economics and Culture


Japan Times – Professor Norika Hama
In their bid to make profit under deflationary
pressures, [Japanese] companies have been
restructuring their operations and trying to
cut costs, and are compelled to continue
using facilities and equipment that normally
would have been replaced and renewed years
ago, thereby raising the risk of accidents.
55
Economics and Culture


Also because of job cuts, the firms do
not have sufficient numbers of workers
who can repair and keep the old
equipment in proper condition.
Major companies have been hit by
major accidents.
56
Jens Rasmussen: Risk Management
in a Dynamic Society

Companies today live in a very
aggressive and competitive
environment which will focus the
incentives of decision makers on short
term financial and survival criteria
rather than long term criteria
concerning welfare, safety, and the
environment.
57
Jens Rasmussen: Risk Management
in a Dynamic Society

Studies of several accidents revealed
that they were the effects of a
systematic migration of organizational
behavior toward accident under the
influence of pressure toward costeffectiveness in an aggressive,
competitive environment.
58
U.S. Chemical Safety Board
BP Disaster, 2005

The Texas City disaster was caused by
organizational and safety deficiencies at
all levels of the BP Corporation.
Warning signs of a possible disaster
were present for several years, but
company officials did not intervene
effectively to prevent it.
59
U.S. Chemical Safety Board
BP Disaster, 2005

Cost cutting and failure to invest left
the Texas City refinery vulnerable to a
catastrophe. BP targeted budgeted cuts
of 25 percent in 1999 and another 25
percent in 2005, even though much of
the refinery’s infrastructure and process
equipment were in disrepair.
60
U.S. Chemical Safety Board
BP Disaster, 2005

Chairwoman Carolyn Merritt said “The
combination of cost-cutting, production
pressures, and failure to invest caused
a progressive deterioration of safety at
the refinery.”
61
Economics and Culture


Assume senior management wants
to know about economics-related
predictors for fatalities and serious
injuries
Safety professionals want to take
the initiative to promote an internal
self-analysis
62
Economics and Culture
In the current business climate, do incentives
for decision-makers result in focusing on short
term financial goals, the result being “drift”
and “systematic organizational performance
deteriorating under competitive pressure?”
63
Economics and Culture
Are the incentive systems for executives
and location managers constructed so
that it is to their advantage – both for
short term financial considerations and
for job retention – to avoid needed capital
expenditure requests, or to avoid
spending the money after project approval
is received?
64
Economics and Culture
Has the gap widened between issued
policy and procedure and what actually
takes place at locations?
Are risky procedures – normalization of
deviation – being tolerated that would
have been unacceptable in the past?
65
Economics and Culture
Does the organization continue using facilities
and equipment that normally would have been
replaced years ago, thereby increasing the risk
of fatality and serious injury?
Because of staff cuts, does the firm have
sufficient numbers of qualified maintenance
workers who can repair and keep equipment in
proper condition?
66
Economics and Culture
Is staffing at all levels, both as to number
and qualification, sufficient to maintain a
superior level of safety performance?
Does senior management discourage pushback,
perhaps to the extent of intimidation,
from those seeking to express concerns
about safety?
67
Economics and Culture
Has outsourcing resulted in more fatalities
and serious injuries occurring to contractor
employees?
Has complacency and overconfidence
developed due to presumed superior
performance, as measured by OSHA statistics?
68
Economics and Culture


Every subject I have mentioned
relates to comments made by safety
professionals.
If the culture has deteriorated because
of economic pressures, that must be
addressed in seeking to reduce severe
injury potential.
69
Actions to be Considered

An analysis of severe injuries

Improving incident investigations


Making a gap analysis in relation to the
provisions in ANSI Z10
Initiating an information gathering system
on “near hits”
70
Analysis of Severe Injuries


To seek predictive indicators
Look for shortcomings in safety
management systems
71
Avoiding Self-Delusion

Chemical Safety Board
A very low personal injury rate at
Texas City gave BP a misleading
indicator of process safety
performance.
72
Avoiding Self-Delusion


Chair of the Oil and Gas Producers Safety
Committee
We conclude that the TRIR/LTIFR
have little predictive value towards the
potential escalation to single and
multiple fatalities. They also tell us
little about major accident risk.
73
Avoiding Self-Delusion

Neither safety professionals nor
executive managements should
delude themselves into believing
that achieving low OSHA rates
assures that serious injuries and
fatalities will not occur
74
Improving Incident Investigation


In studies of incident investigation
reports, causal factor determination
was abysmal.
Seldom does it occur that incident
investigations “peel the onion” back to
the core causal factors.
75
Improving Incident Investigation
Report—Columbia Accident

Many accident investigations do not go
far enough. They identify the technical
cause of the accident, and then connect
it to a variant of "operator error." But
this is seldom the entire issue.
76
Improving Incident Investigation

When the determinations of the causal
chain are limited to the technical flaw
and individual failure, typically the
actions taken to prevent a similar event
in the future are also limited: fix the
technical problem and replace or retrain
the individual responsible.
77
Improving Incident Investigation

Putting these corrections in place
leads to another mistake—the belief
that the problem is solved.
78
Improving Accident Investigation

Too often, accident investigations
blame a failure only on the last step in
a complex process, when a more
comprehensive understanding of that
process could reveal that earlier steps
might be equally or even more
culpable.
79
Improving Incident Investigation

In this Board's opinion, unless the
technical, organizational, and cultural
recommendations made in this report
are implemented, little will have been
accomplished to lessen the chance
that another accident will follow.
80
Improving Incident Investigation


Substantial reductions in severe
injuries are unlikely if incident
investigation systems are not
improved to address the reality of
their causal factors.
The 5 Why System
81
A Gap Analysis

To compare existing safety
management systems with the
content of ANSI/AIHA Z10-2005,
the Occupational Health and Safety
Management Systems standard.
82
A Gap Analysis

Stress those provisions that are seldom
included in safety management systems





Design reviews
Risk assessments
Hierarchy of controls
Management of change
Procurement
83
The Critical Incident Technique


An information gathering system
on “near hits”
To involve personnel at all levels
in gathering data, predictive data,
on severe injury potential
84
The Critical Incident Technique


Johnson on Incident Recall in MORT
Safety Assurance Systems.
Such [incident recall] studies, whether
by interview or questionnaire, have a
proven capacity to generate a greater
quantity of relevant, useful reports than
other monitoring techniques.
85
The Critical Incident Technique

A system that seeks to identify causal
factors before their potentials are
realized would serve well in attempting
to avoid low probability-serious
consequence events.
86
Wrap-up

It must be understood that to reduce
severe injury potential, management
must embed that purpose in its culture,
thus impacting every element of the
safety management system.
87
Wrap-up

That will require giving severe injury
prevention a high priority, and adopting
a different mindset.
88
Wrap-up

The intent would be to achieve an
understanding that personnel at all
levels have a particular responsibility to:
89
Wrap-up
Give specific emphasis to anticipating,
predicting, and taking corrective action
on hazards and risks that may have
fatality or serious injury potential.

90
Wrap-up


Assure that in-depth reviews of the
reality of the root causal factors for
incidents that result in fatalities and
severe injuries are made.
Identify predictive indicators, including
knowledge obtained from studies of near-hits.
91
Wrap-up


Address organizational, operational,
technical, and cultural causal factors
I am assigning you the responsibility
to get all that done.
92