Moving from Injury to Exposure

Shifting our focus means changing how we engage employees.

• By Donald R. Groover, CIH, CSP
• Aug 27, 2007

IN the first installment of this series, we discussed the foundation of the injury-free culture, creating alignment around what we mean by “zero injury,” and establishing true ownership for this vision. Once we have created alignment and ownership, what’s next? How does this new vision change our approach to, and thinking about, the basic mechanisms that drive safety performance? Traditionally, injuries have been the measure of performance and the trigger for change. If our OSHA rate is down, we say we’re doing well. If we have a rash of injuries, we swing into action. In terms of creating an injury-free culture, however, this focus is highly flawed. It is too imprecise and too reactive to be compatible with a culture where we do everything possible to prevent an injury.

The next step in the injury-free culture, then, is finding a new measure for success and a new way of framing safety activities and decisions. An injury-free culture requires that we shift our focus to exposure. An exposure focus means we are oriented toward finding the potential for injury on the shop floor and examining the systems, procedures, and decision-making that influence the quality and effectiveness of safety systems. This article presents the case for moving from injury to exposure as a measure for safety activities and outcomes with a discussion of the characteristics of this thinking, its effect on decision-making, and the pitfall that can prevent its effectiveness.

The Move from Injury to Exposure
As we have said, the injury-free culture is concerned with doing everything possible to prevent injuries and creating an ethos where safety is the driving value. From this perspective, focusing on injuries and injury rates has inherent weaknesses. If you are always chasing injuries, you are caught in the trap of looking in the rearview mirror, focusing on where you have been rather than where you want to go. This focus also fosters inconsistencies in leadership; it is easy to take action when there is blood on the floor, but it’s harder to take action when the potential has not yet led to an event.

Focusing on exposure allows us to examine and remedy potential for injuries before they occur. It requires leaders to take a long-term view of decisions, and it forces us to think creatively about what safety improvement really means. An exposure focus is characterized by four markers: taking action, shaping the safety mechanism, engaging employees, and leadership direction.

Taking action. The injury-free culture uses exposure, not injury, as a trigger for action. Ask yourself, what determines the level of investigation here? In many cases, the answer is the seriousness of injury, which is often a result of luck. Organizations serious about an injury-free culture are thirsty for information about near misses and first aid events. They use the likely potential of an event to determine the depth of the investigation. Similarly, exposure-focused leaders determine whether a site is making progress in safety not on the injury rate, but on evidence that it is reducing the probability of injury.

Shaping the safety mechanism. An exposure focus also recognizes that not all exposure represents the same level of potential and designs systems for measurement and control accordingly. One of the worst things that can happen to an organization is to achieve a very low injury rate, then to have a serious injury or fatality because the related exposure reduction systems have become lax or have been eliminated entirely. For the limited number of exposures that can likely lead to a life-altering injury or fatality, exposures need to be well managed. They need mechanisms in place to measure for variation and to document the cause of the variation and the actions taken. Leadership, in particular, needs to keep a steady focus on high-potential events while moving the organization to longer and longer periods of injury-free experience. They do this by routinely monitoring indicators related to these exposures at the working interface or measures related to their process safety management systems.

Engaging employees. Shifting our focus also means changing how we engage employees. Exposure occurs at the working interface, the junction where the employee, the facilities and equipment, and procedures come together. If a well-trained and motivated employee meets with the proper, well-maintained equipment, following a set of current and accurate procedures, the probability of injury is very low—not zero, but low. Any misalignment in this configuration increases exposure, resulting in a higher probability of injury.

In order to engage employees either formally through training or audits or informally through conversations with leaders, we need to develop an on-the ground awareness of, and focus on, exposures. For example, organizations often attempt to engage employees by asking, “In doing this job, do you believe you will get injured?” For the most part, employees who get hurt and the supervisors who assign the jobs don’t anticipate injury. A more useful question is, “Did you notice an increase in exposure as you were doing the work?”

Exposure and the leadership team. An exposure-focus must be driven by leadership. The higher in the organization one goes, however, the harder it is for leaders to see how their actions or inactions directly contribute to exposure at the working interface.

Consider some common leadership decisions:
• To cut costs, an organization eliminates all shift supervisors, leaving a day foreman as the point of contact for the shift employees.

• An operations vice president position is filled by a leader from the plant with the worst EHS performance but who is known for “getting the product out.”

• A decision is made to stop lockout/tagout verification audits by the supervisors because they are too busy with other paperwork and need to be in their offices more.

• A senior leader decides not to communicate the five-year plan, which will include consolidation, plant closures, and acquisitions, to the workforce. Instead, employees will hear information as it is released or leaked out.

These four scenarios are common organizational events. They all also state explicitly or implicitly what the organization really values. Such decisions may not increase exposure immediately, but given enough time, they can strongly influence the decisions, actions, and outcomes at the working interface. The trap here is that in spite of their influence, such decisions will rarely be identified through a root cause analysis as the pivotal or defining moment in the path to an injury. That is why leaders who hope to create injury-free cultures must take a long-term view of their decisions’ influence on exposure.

Countering Attribution Bias
Finally, moving our focus from injury to exposure requires an honest evaluation of how we as individuals frame safety activities and outcomes. Cognitive bias—mental shortcuts we use to make judgments about uncertainties—can skew our perceptions of the exposures we are trying to remove. Attribution bias, in particular, plays a role in the unconscious process of determining cause. It describes a tendency to associate success with personal ability and failure with bad luck or chance. This bias can lead us to attribute internal causes of an incident involving someone else (the cause resides in the person—her behavior, lack or training, or intelligence) or external factors when I’m involved (the cause resides outside myself, for instance in the systems, equipment, or policies).

Consider an example where a mechanic is critically injured while working on a pump that is suddenly switched on by an operator. A manager may say, “The employee got injured because he didn’t follow the procedure.” In other words, it was caused by the employee’s poor attitude, poor decision, or faulty belief system (internal attribution). To the contrary, the mechanic may say, “I got hurt because the company didn’t give me the time to do the job safely” (external attribution). In reality, neither account is complete; exposure occurs in the configuration of equipment, systems, procedures, and the work being done. Attribution bias can lead us to see only one piece of a larger picture; in this case, focusing only on the time pressures or only on a deviation from procedure.

The truth is, these elements—with the likely addition of other factors—exist within a context that has a history. Singling out one element to the exclusion of others muddies our view of the context and encourages blame, preventing us from getting to the real issues. When we learn to recognize attribution bias, develop appropriate hazard recognition training, and implement tools such as 5 Whys and ABC Analysis in our investigations, we enable individuals to dig deeper and draw a truer picture of exposures.

Building on the Foundation
In this article, we have highlighted a focus on exposure and the importance of overcoming attribution bias. In future installments, we will explore other factors that build on this foundation; next will be metrics and measures critical to injury-free performance and, finally, the role of true employee engagement for sustainability.

This article originally appeared in the September 2007 issue of Occupational Health & Safety.