Our Stubborn Problem with Serious Incidents and Fatalities (SIFs) – Part II

Serious Incidents and Fatalities (SIFs)

Risk exists in an interactive system, much of which is beyond the workers’ influence. Risk and reliable performance are, therefore, systems issues, not personal issues. Bringing risk to an acceptable level begins with analyzing the work, not just the personal acts of the worker. Adopting a management strategy to continuously improve system and cultural influences addresses both minor and major risk because it deals with root causes rather than symptoms (e.g., unsafe acts). 

How Can Safety Professionals Help?

Safety professionals should ask themselves whether person-focused, rather than system-focused, tactics contribute to or impede the organizational change necessary to address all risk, not merely employee behavior. Systems thinking is needed to unearth latent and systemic risk factors commonly associated with Serious Incidents and Fatalities (SIFs). Unless OSH professionals, and their employers, begin looking at safety as a strategic integrated system, rather than a compendium of worker-focused tactics and low-order administrative controls, serious incident rates will likely not improve.

Fortunately, there are a multitude of opportunities for safety professionals to help their companies move to a more systems-based approach.  The author suggests the following as fundamental:

1) Become familiar with systems in general and safety management systems (e.g., ANSI Z10, ISO 45001) in particular. Since incidents, unsafe acts and unsafe conditions all demonstrate system weaknesses, safety professionals need to become system evaluators. Those who do not have a good working knowledge of how systems and the PDCA cycle operate, or should operate, have some catching up to do. 

2) Recognize that low or even zero personal injury rates do not protect against the likelihood of more serious incidents. The effort needed to drive the most common and minor injuries to zero can deflect significant resources from more serious risk and safety overall. Resist the temptation of quick fixes promising instant or near-instant injury reductions. Quick fixes for SIF reduction, or for sustainable safety improvement, simply do not exist.

3) Move beyond single-event thinking that workers’ unsafe acts are the principal cause of safety problems. Controlling risk involves far more than controlling people. Systems thinking requires looking at safety and risk holistically, not merely at symptoms in isolation. Attempting to control or manipulate the workforce may achieve compliance (when someone is looking), but not the discretionary worker engagement needed for sustainable safety and continuous improvement. When workers lack any sense of autonomy and are treated as a problem to be controlled or fixed, they are more likely to behave in that manner.

4) Seek opportunities to involve and engage the workforce in every aspect of the safety effort. No one understands the work better than those who perform it.  An important by-product of worker engagement is the sense of ownership that facilitates worker buy-in. Worker engagement is a win-win but it requires a willingness to give up some perceived control to empower workers with a sense of ownership for their work.

5) Promote strategic safety management. Any improvement journey should begin with a thorough assessment of the starting point (the “as is”) versus the destination (the “should be”). Competent safety professionals versed in root-cause analysis and assessment skills can make a major contribution here. Many managers do not have a strategy for creating safety in their organizations, and really do not know what to do other than maintain traditional methods. The safety profession has a responsibility to help strategically guide them to a better place.

6) Collect and Use Better Data.  Much of the data we traditionally collect in the safety practice consists of lagging indicators and safety findings heavily focused on easily  observable behaviors and conditions such as PPE use and trip hazards.  Nothing necessarily wrong with that but such data does little to address the tasks, hazards and systemic issues that are more likely to trigger Serious Incidents and Fatalities (SIFs) (e.g., confined space entry, electrical exposures, work at heights, etc.).

Consider capturing data more useful to the identification and control of Serious Incidents and Fatalities (SIFs) such as:

  • Incident data grouped by risk potential rather than by consequence.  Even first aid injuries can expose high risk potential.
  • Leading indicator data (e.g. number of safety inputs from the workforce, corrective action closure rates, etc.)
  • Feedback from work performed successfully including what went right as well as improvement opportunities.
  • Observations of high consequence work.  The importance of this data cannot be over emphasized yet many companies don’t routinely observe work with high SIF potential.

When it comes to controlling Serious Incidents and Fatalities (SIFs) we have a choice.  We can either keep doing what we’ve always done and hope for better results (aka insanity) or take the advice of Terry Norris and develop a more holistic and risk-based paradigm.  It really is up to us. 

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Jim Loud

Mr. Loud’s over 40 years of safety experience includes 15 years with the Tennessee Valley Authority (TVA) where he served as the supervisor of Safety and Loss Control for a large commercial nuclear facility and later as manager of the corporate nuclear safety oversight body for all three of TVA’s nuclear sites. At Los Alamos National Laboratory he headed the independent assessment organization responsible for safety, health, environmental protection, and security oversight of all laboratory operations.

Mr. Loud is a regular presenter at national and international safety conferences. He is the author of numerous papers and articles. Mr. Loud is a Certified Safety Professional (CSP), and a retired Certified Hazardous Materials Manager (CHMM). He holds a BBA from the University of Memphis, an MS in Environmental Science from the University of Oklahoma and an MPH in Occupational Health and Safety from the University of Tennessee.

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