Transcript Slide 1

Behavioral Safety and Situation Awareness: Union
Approach to Understanding and Addressing
Management Safety Programs
Nancy Lessin, USW/Tony Mazzocchi Center for
Health, Safety and Environmental Education
BLET Health and Safety Conference
University of Iowa Labor Center - October 15, 2013
What’s happening in your workplace
that’s causing or contributing to your
members being injured, made ill and/or
stressed on the job?
• Downsizing/Fewer workers
• More work: Intensified work/increased work
load/job combinations
• Longer, crazier hours/fatigue
• Working alone
• Lack of maintenance
• Lack of adequate training
• (and much more…)
Doing more (work) with less (people):
LEAN comes to the Railroad
Are U.S. Workplaces Getting
Healthier/Safer?
• BLS Data shows significant and steady
decline in job injury/illness rates -- from 8.9
cases per 100 full-time employees in 1992
to 3.5 cases per 100 full-time employees
in 2011
• This is a 60.7% decline in recordable
injury rates between 1992 and 2011;
“It is extremely unlikely that
injury rates would plummet
like this.”
Susan Baker, Professor, Johns Hopkins
Bloomberg School of Public Health
Non-fatal Rail Worker Injuries
2010:
4,424
2011:
4,222
2012:
3,938
2013 (to date):2,353
Government Accountability Office
Report, 2009:
• More than 2/3’s of occupational health
practitioners observed worker fear of disciplinary
action or job loss for reporting their job injuries
• Over ½ of occupational health practitioners said
they were pressured by employers to downplay
an injury to avoid it being a recordable injury.
• 1/3 of occupational health practitioners said they
were pressured by employers to provide
insufficient treatment to injured workers
http://www.gao.gov/new.items/d1010.pdf
ACCIDENT REPORT
The Accident: Worker was stung by a bee
Question on Employer’s Accident Report Form:
“What did the affected employee do or not do
that contributed to the accident? Why do you
feel their actions contributed to the
accident?”
The Answer:
“The employee should have been aware that a
bee had landed on his shirt and taken the
appropriate steps to remove the bee without
being stung.”
Management Has a Plan for
Reorganizing Work:
It’s Happening Everywhere,
It’s Hurting Our Members and
It’s Weakening Our Unions
Key Work Process Trends
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Standardization/De-Skilling
Intensification/Lean/Speed-up
Multi-Skilling/Job Combination/Flexibility
Automation/New Technologies
Monitoring
Contracting Out/Outsourcing
From 10 workers
with downtime/
micro-breaks
To 7 workers with
little downtime/
micro-breaks
Multi-skilling
Multi-tasking
Flexibility
Job Combination
Operator Maintenance
“And other duties as assigned”
Monitoring
On your ankle
In your truck
Under your skin
In your face
In your pocket
Work that has been
 Standardized
 Analyzed
 Automated
 Simplified
Is work that is easier to
Contract Out or Outsource
All of these trends have
negative impacts on union
members
Speed-up, Stress, Fatigue
Job Insecurity/Job Loss
Increased tension between workers/violence
Loss of Skill
Low Morale
Repetitive Strain Injuries
Job Injury, Illness and Death
Injury and Illness
BY
Design
All of these trends also have
negative impacts on union
strength
Elimination of Skilled Work
Loss of Security/Bargaining Leverage
Isolation of Members/Loss of Solidarity
Division/Loss of solidarity
Loss of Jobs, Members and Dues
Drain on Union Resources
Loss of Faith in the Union
Fear, along with various
restructuring programs are used
to get the workforce to:
•
Accept the idea of “Change”, and
•
Contribute our ideas and knowledge
to Management’s Plans for change
They use techniques we call the
Tricks and Traps
to get us to go along

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Brainstorming
Language
Improvement
 Empowerment


The Myth of Common Goals
“If you are not at
the table,
you will be on the
menu.”
Behavior-Based Safety/Blame-the-Worker
Programs, Policies and Practices
• Safety Incentive Programs
• Injury Discipline Policies
– (e.g. Accident Repeater Programs)
• Post-injury Drug Testing for all injuries
• Signs tracking lost-time or recordable
injuries
• Management bonuses for low/no injuries
• Behavioral Safety Observation Programs
“The fact is, it is not easy for an
individual to have a serious injury
in today’s workplace.”
David Bradford,
American Society of Safety Engineers,
Behavioral Safety Symposium 2001
Who Sells Behavioral Safety?
• “Behavioral Science
Technology” (BST)
• DuPont “STOP”
• “SafeStart”
• E. Scott Geller’s “Safety
Performance Solutions”
• ProAct Safety/Lean BBS
• Terry McSween’s
“Quality Safety Edge”
• Michael Topf’s “Safor
Program”
• “Safety Pays”
• Aubrey Daniels (formerly “BSafe Program” – now ADI)
• Liberty Mutual Insurance Co’s
“MVP Program”
• FDR Safety (Fred Rine, CEO;
Jim Stanley, President)
• Bill Sims Safety Incentive
Programs
• Structured Safety Process
• MoveSmart
• Latent Safety Analysis
• PTAS
• JMJ Associates
88% of all injuries on the job are
caused by workers’ unsafe acts
• Originated from H.W. Heinrich
• Insurance investigator (Travelers Insurance
Company)
• Studied supervisor accident reports (1931)
• Drew conclusions from supervisorrecommended corrective actions
1930’s Safety Theory -- BST (80%-95%)
and DuPont (96%) call it “leading edge”
It’s a trap!
Fatalities
Lost
Time Cases
Recordables
Medical Visits/First Aid Cases
Unsafe Behaviors/Unsafe Acts
1930’s Safety Theory -- BST & DuPont call this “Cutting-Edge
Technology” - we call it folk lore!
In order to have an
“unsafe” or “at-risk”
behavior, what must be
present?
A HAZARD
All work-related
injuries and illnesses
are the result of
exposure to hazards.
There are no exceptions!
Health and Safety Process Model
Identification
Evaluation
Data Analysis
Prioritize Hazards
• Injury/Illness Logs
Risk Analysis
• Medical Visits
Surveys and Questionnaires
Interviews
Worker Complaints
Government Regulations
Inspections/Audits
Control
Select Controls
Based Upon
Hierarchy
Hierarchy of Controls
Mos t Effective
1 ) Elimination or Subs titution
2 ) Engineering Controls
(Safeguarding Technology)
3 ) Warnings
4 ) Training and Procedures
(Adminis trative Controls )
Leas t Effective
5 ) Pers onal Protective Equipment
Behavior Based Process Model
Identification
Evaluation
Duck!
Data Analysis
Worker Observations
Interviews
Inspections/Audits
Risk Analysis
Duck
Dodge
Jump Out of the Way
Lift Safely
Wear PPE
Avoid “Line of Fire”
Eyes on task
Hierarchy of Health and Safety Controls
Most Effective
Elimination/Substitution
Engineering Controls
Warnings
Training and Procedures
Least Effective
Personal Protective Equipment
Consequences Of A Behavior Based Program
Is To Turn The Hierarchy Upside Down
They Say,
“Most Effective”
Personal Protective Equipment
Training and Procedures
Warnings
Engineering Controls
Not even up
for discussion…
Elimination &/or
Substitution
Why eliminate the hazard when you can
buy personal protective equipment?
Common Behavioral Observation
Program Elements
• Critical behavior lists
• Workers observe workers
• Training for observers
• Frequent observations of workers to
identify at unsafe behaviors
• Heavy emphasis on PPE, “body position”
and “line of fire”
• Commitment of resources
BBS is Based on Two Flawed
and Discredited Theories
• H.W. Heinrich (88% of job injuries caused
by unsafe acts) (See “Reviewing Heinrich: Dislodging
Two Myths from the Practice of Safety” by Fred Manuele, P.E.,
C.S.P., Professional Safety, Oct. 2011)
• B.F. Skinner
(reinforcement theory
derived from experiments with rats, pigeons
and other vermin and then applied to human
beings -- see Alfie Kohn’s book “Punished
by Rewards”)
Changing At-Risk Behavior Process at Union Pacific
Changing At-Risk Behavior (CAB) is a safety process that
is being conducted at Union Pacific’s San Antonio
Service Unit (SASU) with the aim of improving road and
yard safety. CAB is an example of a proactive safety
risk-reduction method called Clear Signal for Action
(CSA) by the Federal Railroad Administration (FRA)
Human Factors Program within the Office of Research
and Development. CSA combines behavior-based
safety, continuous improvement, and safety leadership
development. With sponsorship from FRA, Behavioral
Science Technology, Inc. is instructing and advising on
the implementation of CAB.
http://www.fra.dot.gov/downloads/Research/rr0919.pdf
Public Law 110-432-Oct. 16, 2008
Federal Rail Safety Improvements Act
“An Act to amend title 49, United States
Code, to prevent railroad fatalities,
injuries and hazardous materials
releases, to authorize the Federal
Railroad Safety Administration, and for
other purposes.”
Public Law 110-432-Oct. 16, 2008
Federal Rail Safety Improvements Act
Sec. 20156. Railroad Safety Risk Reduction Program
(a)(2): Reliance on Pilot Program – The Secretary
may conduct behavior-based safety and other
research, including pilot programs, before
promulgating regulations under this subsection
and thereafter. The Secretary shall use any
information and experience gathered through
such research and pilot programs under this
subsection in developing regulations under this
section.”
“So putting up a guard might
in fact encourage them
(workers) to get closer to the
hole that’s being guarded, or
encourage them to take more
risks because of the extra
perceived safety by that
guard.”
E. Scott Geller, NACOSH Meeting,
Washington D.C. , April 9, 1997
Management uses techniques we
call the Tricks and Traps
to get us to go along with BBS:
• Language
“Safety Culture”
“Human Factors”
Changing Safety Culture:
Interventions
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Behavior Based Safety
Safety Rules Revision
Close Call Reporting Systems
Executive Coaching
Line Operation Safety Audit
Safety Culture Survey Guided Development
Self Analysis
Negotiated Rule Making
Safety Culture, Sponsored by the FRA RDV-30, Volpe National Transportation Systems Center; TRB
Human Factors in Transportation Workshop 105, January, 2003
http://www.fra.dot.gov/Elib/Details/L03570
What “Human Factors” is NOT:
“… ’[H]uman factors’ refers broadly to the
role of human participation in any system
and to the ways in which human beings
contribute toward system performance,
both positively and negatively.
“…FRA supports advances in safety culture
by supporting human factors research
and demonstration programs. One
example of an FRA-sponsored human
factors demonstration program is called
‘Changing At-risk Behavior’”
Congressional testimony (2006) of FRA Administrator Joseph Boardman
What IS “Human Factors”?
“Human Factors is a body of knowledge
about human abilities, human limitations,
and other human characteristics that are
relevant to design. Human factors
engineering is the application of human
factors information to the design of tools,
machines, systems, tasks, jobs, and
environments for safe, comfortable and
effective human use.”
Professor Alphonse Chapanis
Founding Father, Human Factors Engineering
“Everyone, and that includes you and
me, is at some time careless,
complacent, overconfident, and
stubborn. At times each of us becomes
distracted, inattentive, bored, and
fatigued. We occasionally take chances,
we misunderstand, we misinterpret, and
we misread. These are completely
human characteristics.”
Al Chapanis, Professor Emeritus, Human Factors
Engineering Department, Johns Hopkins University
“Because we are human and because
all these traits are fundamental and
built into each of us, the equipment,
machines and systems that we
construct for our use have to be made
to accommodate us the way we are, and
not vice versa.”
Al Chapanis, Professor Emeritus, Human Factors
Engineering Department, Johns Hopkins University
Close clearance
Tracks
repositioned to
eliminate
the hazard.
50
Statement of NTSB Chairman Hersman, speaking at
2/26/2013 NTSB investigative hearing on the 6/24/2012
head-on collision between two Union Pacific trains
near Goodwell, OK:
“Since I joined the Board in 2004, the
NTSB has investigated 22 other train
accidents that took 57 lives, injured more
than 1,000, caused millions of dollars in
damages, and that all could have been
prevented or mitigated by positive train
control.
“Mineral Springs, NC; Chatsworth, CA;
Goodwell, OK…
…How many more times are we going
to meet here in this room to talk about
train collisions that could have been
prevented by previously identified
technology? Had PTC [Positive Train
Control] been in place, this crash
would almost certainly have been
avoided.”
Deborah A.P. Hersman, NTSB Chairman, Opening Remarks at NTSB Board
Meeting on 6/18/2013 - Collision Involving Two Freight Trains, Goodwell,
OK on June 27, 2012
Human Factors is NOT
about changing behaviors –
it’s about designing
equipment, jobs and
workplaces for human
beings
Disincentives to Reporting Injuries
and Illnesses
• Awards (prizes and money) for
not have a recordable or lost
time case (or having a low rate)
• Discipline and/or counseling
issued after workers are injured
• Drug testing after every injury
• Peer pressure
No
Injuries
INJURY DISCIPLINE
(“Situational Awareness”)
“Our manager likes to give out written warnings
for employees who get hurt. The usual reason is
‘not aware of your surroundings.’ The latest
one came for an employee who received a
laceration on the finger while moving a piece of
equipment. He had all of the required PPE. Even
after a management investigation revealed that
they did not have the proper device to make this
equipment move, he received a written warning
for ‘not properly evaluating the situation.’ ”
WORK RULE #24
“You must work
carefully.”
Hazardous conditions that we know about
can be difficult to correct.
Hazardous conditions that we don’t
know about are impossible to correct.
Ending/Preventing
Behavior-Based
Safety/“Blame the Worker”
Safety Programs, Policies
and Practices
Educate Union Leaders
and Members:
Behavior-Based Safety is a
Hazard – it must be
Eliminated!
HIDDEN TRAGEDY:
Underreporting of Workplace Injuries and Illness
A MAJORITY STAFF REPORT BY
THE COMMITTEE ON EDUCATION AND LABOR
US HOUSE OF REPRESENTATIVES
THE HONORABLE GEORGE MILLER
CHAIRMAN
JUNE 2008
Hearing Before the House Comm. on Transportation
and Infrastructure, 110th Cong., (2007):
“The Impact of Railroad Injury, Accident, and Discipline
Policies on the Safety of America's Railroads” - Some
of the techniques used by railroad management
include:
• "Risky" employee assessments: Employees are placed
in disciplinary jeopardy by being assigned points for safety
incidents, rule infractions, and injuries regardless of the
cause, often before an investigation is done.
• Targeting employees for increased monitoring and
testing: Injured employees are "targeted" for close
supervisor scrutiny, where minor rule infractions result in
employee termination following injuries.
• Supervisors discouraging employees from filing
accident reports: Front-line supervisors often try to
subtly prevent employees from filing injury reports
and/or lost workday reports in an attempt to
understate or minimize on-the-job injury statistics
• Supervisors attempting to influence employee
medical care: Railroad supervisors are often
accused of trying to accompany injured employees to
their medical appointments to try to influence the type
of treatment they receive. In addition, they try to send
employees to company physicians instead of allowing
them to choose their own treatment providers.
• Light duty work programs v. injury leave: Injured
employees are required to come to work, often doing
nothing but sitting in an empty room and allowing carriers
to minimize the required reporting of lost work days.
• Availability policies: These policies require employees to
work a certain number of days per year. If the employee
cannot work the required number of days, he or she is no
longer a full-time employee.
• Supervisor compensation: Some companies base
management compensation upon performance bonuses,
which can be based in part upon recordable injury
statistics within their supervisory area.
Federal Railroad Safety Act (FRSA)
49 U.S.C. §20109
§20109. Employee Protections.
(a)In general.--A railroad carrier … may not discharge, demote,
suspend, reprimand, or in any other way discriminate against an
employee if such discrimination is due, in whole or in part, to the
employee's lawful, good faith act done, or perceived by the
employer to have been done or about to be done—
(4) to notify, or attempt to notify, the railroad carrier or the
Secretary of Transportation of a work-related personal
injury or work-related illness of an employee;
3/12/2012 OSHA Memorandum:
“Employer Safety Incentive and Disincentive
Policies and Practices”
“Reporting a work-related injury or illness is a core
employee right, and retaliating against a worker for
reporting an injury or illness is illegal discrimination.”
• Employer Policies/Practices that Could be Illegal
(depending on the specifics of the policy/practice)
–
–
–
–
Injury Discipline
Discipline for “Untimely” Reporting of Injuries
Discipline for “Violating a Safety Rule”
Certain Safety Incentive Programs
• Violations could be of OSHA 11(c), FRSA or other
whistleblower program; or OSHA’s Recordkeeping Rule
Now You See It --
98 years of the E.H. Harriman Awards
And now you don’t!
Recent Whistleblower Awards for Rail Workers who were
Retaliated Against for Reporting Injuries
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•
•
•
•
•
•
•
$269,707 to conductor, and $154,694 to carman at Illinois Central RR
for retaliation after reporting injuries (6/19/2012)
$38,561 to switchman for Union Pacific RR for retaliation after reporting
injury (6/25/2012)
$300,000 to rail worker at Norfolk Southern Railway for retaliation after
reporting injury (8/8/2012)
$932,000 to switchman and trackman at Norfolk Southern Railway for
retaliation after reporting injuries (8/12/2012)
$288,000 to rail worker at Norfolk Southern Railway for retaliation after
reporting injury (11/29/2012)
$1.1 million to 3 workers at Norfolk Southern Railway for retaliation after
reporting injuries (2/28/2013)
$309,000 to conductor at Union Pacific RR for retaliation after reporting
a co-worker’s injury
$350,000 to rail worker at Union Pacific RR for retaliation after reporting
injury (3/12/2013)
Negotiate Provisions in Collective
Bargaining Agreements
“The employer shall not discriminate or retaliate
in any way against an employee who reports a
work-related injury or illness; reports a safety or
health problem; files a health or safety complaint;
requests access to health or safety records;
violates a safety rule, absent malice or
reckless intent; and/or otherwise exercises any
other health or safety right afforded by local,
state or federal law and/or by this collective
bargaining agreement.”
The ORANGE VEST Strategy
Exercising Leverage/Involving Members
• Distribute Stickers/Buttons/T-shirts
• Observe HAZARDS – Make and use your
own checklist
• Use Safety & Health Complaint form booklets
• Use “Specifically Observe Bosses” Form
Phillips Chemical Company, Pasadena, Texas 1989
•Had just completed 5,000,000 hours
without a lost time injury
•Explosion and fire
•23 dead
•232 injured
It has been 14 days
since Local xxx told
management to fix
[insert name/description
of hazard] and they still
have not addressed this
problem...
It has been 15 days
since Local xxx told
management to fix
[name/description of
hazard] and they still
have not addressed this
problem...
Measuring Success in Workplace
Health and Safety
• How many hazards/hazardous conditions
have been identified?
• How many hazards/hazardous conditions
have been eliminated?
• How many hazards/hazardous conditions
have been reduced (using the Hierarchy of
Controls)
• How long did it take from when the hazard
was identified to when it got addressed?
Union View - Identify Hazards
A hazard is a condition or set of
circumstances that can cause harm
•
•
•
•
•
•
•
•
Crushing
Shearing
Noise, vibration
Chemical, gases,
fumes, mists,
dusts
Entanglement
Pinch point
High pressure
Electrical
• Ergonomics-posture,
force, repetition
• Lifting
• Slips, Trips, Fall
• Fire
• Radiation
• Excessive hours of
work
• Inadequate staffing
• Production pressures
Why Not Accept Systems with
Behavior-Based Safety (BBS)?
• BBS is not about safety
• BBS is about shifting blame and focus -- from
employers (& hazardous conditions) to workers
(& unsafe acts)
• BBS is about power and control (management
will allow “freedom within fences”)
• There is no room for unions’ collective
thinking & approach in BBS
• BBS is a long-term union-busting strategy
Caution – Behavioral
Safety/“Blame the Worker”
Programs Are Hazardous to
Health & Safety and to
Solidarity!
Whose behavior needs
to be changed to
improve health & safety
in your workplace?
Additional Resources:
• www.hazards.org/bs
• “Punished by Rewards”
by Alfie Kohn