Serious Injury Prevention
Our profession should examine how well incident investigation is done. It will reveal causal factors deriving from system shortcomings that must be corrected.
- By Fred A. Manuele
- Jun 01, 2005
THIS paper will establish that two age-old beliefs, often applied, are barriers to inquiry into the reality of systemic design and engineering, operational, and cultural causal factors for incidents resulting in serious injury. Those beliefs are:
* reducing incident frequency will equivalently reduce the occurrence of low probability/serious consequence events, and
* unsafe acts of workers are the principal causal factors for occupational incidents.
Further, the case will be made that the data is convincing in support of special recognition being given in safety management systems to the prevention of incidents resulting in serious injury.
Defining the Problem--and the Opportunity
From 1973 to 2001, according to the National Safety Council's Injury Facts, 2003 Edition, the total occupational injury and illness rate for private industry dropped 50 percent--from 11.3 to 5.7. In the same period, the incidence rate for Total Lost Workday Cases decreased only 18 percent -- from 3.4 to 2.8 (p60).
Significant data pertaining to occupational deaths also can be found in Injury Facts, 2003 Edition. From 1992 to 2002, the death rate per 100,000 workers dropped from 4.2 to 3.6, only a 14 percent reduction; the number of deaths has remained fairly constant--4,965 in 1992 and 4,900 in 2002 (p49).
In several organizations with which I have been involved in the past few years, the incidence rate for lost work days with days away from work has leveled off or increased. Also, the number of fatalities in some of those organizations has increased.
As an indication of concern over the occurrence of serious injuries and fatalities, ORC International, an entity with a membership of about 125 of the Fortune 500 companies, has formed a task group to study the causal factors for such incidents.
Comments made by James Spigener, representing Behavioral Science Technology (BST) at the 2004 Behavioral Safety Now Conference, are a further indication of serious injury trending. He said that for several of their clients, the fatality rate had flattened or increased.
At a workshop held in April 2004, Dr. Franklin Mirer, director of the UAW Health and Safety Department, presented statistics pertaining to fatalities that have occurred to UAW members. He said that during a period of 20 years, skilled trades personnel--about 20 percent of the UAW membership--had 41 percent of the fatalities. Hours worked during the period Mirer referenced are in the billions. Thus, his fatality numbers are statistically significant.
Skilled trades people are maintenance personnel, millwrights, tinsmiths, machinists, electricians, and steamfitters. Please note: Skilled trades people are not production workers. Mostly, they do non-routine work, are exposed to sources of high energy, and are engaged sometimes in at-plant construction.
In the 2003 Liberty Mutual Workplace Safety Index, this statement appears:
A small percentage of workers compensation claims continue to be responsible for the bulk of direct costs. In 2000, disabling workplace injuries were 18 percent of workers compensation claims but 93 percent of direct costs.
A paper issued by Employers Insurance of Wausau in the 1970s titled "Pareto's Law and the Vital Few" includes similar data:
A study showed that 86% of total injuries produced only 6% of total costs, while 14% of total injuries produced 94% of total costs. Here we can distinguish between the "Trivial Many" and the "Vital Few."
Employers of Wausau concluded: It becomes readily apparent that the logical approach to effective loss control is to concentrate major efforts on the "Vital Few." That is the theme of this paper.
A study I completed in February 2004 to determine the work categories for employees involved in lost workday cases with days away from work produced an interesting result. Three of the companies that provided data had OSHA incidence rates less than 0.5--exceptionally good for their industries. A composite of the data for those companies, with a total of 230,000 employees, indicated 74 percent of lost workday cases with days away from work occurred to ancillary and support personnel, rather than employees engaged in "the principal business."
(Two safety directors who were asked to contribute data for my study said that the study was unnecessary because they believed that if incident frequency was reduced, severity potential would also be comparably reduced.)
Premises That Need Examination
In a speech at the 2003 Behavioral Safety Now Conference, James Johnson, a vice president at Liberty Mutual, said, "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."
This belief, that addressing the causal factors for incidents that occur frequently will also encompass severity potential, derives from the work of H. W. Heinrich as set forth in Industrial Accident Prevention: A Scientific Approach, Fourth Edition. In a discussion of his 300-29-1 ratios, this appears:
From a review of the data available concerning the frequency of potential-injury accidents, it is estimated that in a unit group of 330 accidents of the same kind and involving the same person, 300 result in no injuries, 29 in minor injuries, and 1 in a major lost-time injury (p26: Emphasis is as in the original).
Upon examination, the premise is unsustainable. Nevertheless, from that premise, Heinrich arrives at this conclusion:
The foregoing statements and figures justify the conclusion that in the largest group--the minor injuries--lie the more valuable clues to accident causes (p33).
Heinrich's premise--that the more valuable clues to accident causes lie in minor injuries--has been translated into the commonly held belief that safety efforts focused on the prevention of incidents that occur frequently will also encompass severity potential. Statistics and analysis have proven this assumption to be unsupportable. But, the premise is widely taught and is a significant part of the thinking of many safety practitioners. It represents a distracting mindset that impedes our addressing the reality of the causal factors for low probability/serious consequence events.
Another part of that interfering mindset also derives from a Heinrich premise. He makes these observations:
Among the direct and proximate accident causes for industrial accidents, 88 percent are unsafe acts of persons, 10 percent are unsafe mechanical or physical conditions, and 2 percent of accidents are unpreventable (p20).
Many safety professionals have adopted Heinrich's premise, and the safety management systems for which they provide counsel focus extensively on what the worker does. Adopting that mindset results in giving inadequate attention to those causal factors that are systemic, cultural, operational, and design and engineering based. (For a critical review of the Heinrich premises, see "Heinrich Revisited: Truisms or Myths" in On The Practice Of Safety, Third Edition.)
Reorienting the Focus
R. B. Whittingham, in his book The Blame Machine: Why Human Error Causes Accidents, describes how disasters and serious accidents result from recurring, but potentially avoidable, human errors. He shows that such errors are preventable because they result from defective systems within a company.
Whittingham identifies the common causes of human error and the typical system deficiencies that lead to those errors. They are principally organizational, cultural, and management system deficiencies. Whittingham says that in some organizations, a "blame culture" exists whereby the focus in incident investigation is on individual human error, and the corrective action is limited to that level. He writes: "Organizations, and sometimes whole industries, become unwilling to look too closely at the system faults which caused the error" (xii).
That is a challenging statement. It suggests a disinclination to identify the realities of error-provocative organizational, cultural, and management system shortcomings. Whittingham says putting responsibility for the occurrence of an incident on what an individual did or did not do results in overly simplistic causal factor determination. If the investigation stops there, a more thorough investigation that looks into the reality of the root causal factors, meaning the operating system faults, is avoided.
Promoting Thorough Incident Investigation
Whittingham's comments are comparable to statements about inadequacies in incident investigations made in the August 2003 Report of the Columbia Accident Investigation Board. These are two excerpts from that report.
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. 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 (p6).
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. 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. Putting these corrections in place leads to another mistake--the belief that the problem is solved (p97).
James Reason and Alan Hobbs, in Managing Maintenance Error: A Practical Guide, offer similar comments about the need to look into systemic causal factors when human errors occur:
Errors are consequences not just causes. They are shaped by local circumstances: by the task, the tools and equipment and the workplace in general. If we are to understand the significance of these factors, we have to stand back from what went on in the error maker's head and consider the nature of the system as a whole . . . this book has a constant theme . . . that situations and systems are easier to change than the human condition (p10).
Because of my recent studies, I make more of the importance of incident investigation as an element within a safety management system than previously. Many safety professionals who have studied trailing indicators and leading indicators consider incident investigation a trailing indicator, as I did. I now suggest that incident investigation be considered a principal source for identifying leading indicators for the prevention of low-probability incidents that could result in serious consequences.
Why? Because incident investigations done well will reveal the reality of the causal factors deriving from design and engineering, organizational, cultural and management systems shortcomings. If they are not identified and corrected, they will remain dormant and, in time, be the causal factors for incidents, again.
As an early part of their endeavors to reduce serious injury potential, I suggest that safety professionals examine how well incident investigation is done. They may believe that they have a good incident investigation system in place. Nevertheless, I suggest a thorough analysis. What might be found? For example: A safety director boasted about having an effective "5 Why" investigation system in place. But, for every investigation report reviewed, the first "Why" was a what.
Is Whittingham Right?
Is it true, as Whittingham said, that in many organizations, and sometimes whole industries, there is an unwillingness to look closely into error-provocative system faults? That statement compelled a review of the analyses I had made of more than 1,000 incident investigation reports. In that review process, this question was asked: Do some organizations avoid design and engineering, organizational, management systems, and cultural root causal factors for incidents that result in serious injuries?
In no instance have I had an experience in which avoiding root causal factors was an active process, one in which instructions were given to avoid the identification of systems causal factors. But it is a certainty that avoidance of systems causal factors passively occurs in many places. To make studies of the quality of incident investigations, I asked safety directors in several large companies to send me copies of incident investigation reports completed by supervisors and investigation teams.
One of the purposes was to determine how deeply the investigations delved into causal factors. On a scale of 10, with 10 being best, some of these companies scored as low as two. In those companies, causal factor determination was abysmal. (See "Incident Investigation: Studies of Quality" in On The Practice Of Safety, Third Edition.)
Management Must Want to Address the Reality of Serious Injury Causation
To move forward to reduce the probability of occurrence of incidents resulting in serious injuries and fatalities, managements must have procedures in place that assure an in-depth review of the reality of their root causal factors, the reality of the safety culture that has evolved, and the reality of the extent to which risk taking permeates operations.
Significance of an Organization's Culture
These excerpts are taken from the 2003 Report of the Columbia Accident Investigation Board:
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 (49). In our view, the NASA organizational culture had as much to do with this accident as the foam.
Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution. At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It is a powerful force that can persist through reorganizations and the change of key personnel. It can be a positive or a negative force (p97).
In every organization, its "values, norms, beliefs, and practices" are translated into a pattern of expected behavior that impacts positively or negatively on decisions taken with respect to safety management systems. Those decisions impact on safety with respect to design and engineering, operating methods, prescribed task performance--and how much risk taking is expected and acceptable. The following examples demonstrate how the culture, the expected pattern of behavior, came up short with respect to hazardous situations and risk taking.
Two workers refuse to do a job, saying that the work is too hazardous. Another worker is assigned to do the work, and he is killed. Speculate on the possible cultural and operational causal factors for that situation.
There is deterioration in a tray of electrical cables, and occasionally the workers get a minor jolt. Work orders to correct the condition are not acted upon. Over time, little notice is given to the jolts, and the hazard's potential is played down. Getting a jolt occasionally becomes an accepted norm. The deterioration continues. Eventually, a worker makes the contact that results in his electrocution. What does this sort of incident say about cultural and operational problems? Does it not establish that excessive risk taking had become acceptable?
Studies I made of investigation reports indicate that, for many incidents resulting in serious consequences, there had been, over time, a continuum of less-than-adequate safety decision-making and an accumulation of accepted risk taking. That inadequate safety decision-making reflected the actuality of the organization's safety culture.
James Reason's book Managing the Risks of Organizational Accidents is a good read with respect to the occurrence of incidents that result in severity. Reason's principal research area has been in human error and the way organizational processes and people contribute to system breakdown. This is taken from Reason:
Latent conditions, such as poor design, gaps in supervision, undetected manufacturing defects or maintenance failures, unworkable procedures, clumsy automation, shortfalls in training, less than adequate tools and equipment, may be present for many years before they combine with local circumstances and active failures to penetrate the system's layers of defenses They arise from strategic and other top-level decisions made by governments, regulators, manufacturers, designers and organizational managers. The impact of these decisions spreads throughout the organization, shaping a distinctive corporate culture and creating error-producing factors within the individual workplaces (p10).
Over time, the effect of decisions that do not adequately treat with hazards and risks permeates operations and they shape "a distinctive corporate culture." The outcomes of that culture become the negative pattern of expected behavior that personnel at all levels believe to be acceptable with respect to the both the technical and operational aspects of safety management.
As a result of the studies I made of incident investigation reports, I offer these observations.
* A large proportion of incidents resulting in serious injury occur in unusual and non-routine work, in non-production activities, and where sources of high energy are present. Also, they occur in what can be called at-plant construction operations.
* Many accidents resulting in severe injury are unique and singular incidents, having multiple, complex, cascading causal factors.
* Causal factors for low probability/high consequence events are seldom represented in the analytical data on accidents that occur frequently.
Dan Petersen, in his book Safety Management, Second Edition, supports the view that severe injury potential needs special attention. These excerpts from Petersen's writings are almost identical with my findings.
If we study any mass data, we can readily see that the types of accidents that result in temporary total disabilities are different from the types of accidents resulting in permanent partial disabilities or in permanent total disabilities or fatalities.
The causes are different. There are different sets of circumstances surrounding severity. Thus if we want to control serious injuries, we should try to predict where they will happen (p11).
For emphasis, Petersen's comments are repeated: the causes and circumstances surrounding severity are different, and we should try to predict where serious injuries and fatalities may occur.
To Move Forward: A Needs Assessment
To begin with, it is suggested that a needs assessment take place, from the top of an organization down through the ranks, to determine how much re-education is needed toward achieving a mindset that gives a proper place in safety management to serious injury potential.
Why recommend a needs assessment? What might be found with respect to the safety culture in place to which attention should be given?
Traditional safety management systems do not include activities to anticipate and identify the causal factors for low probability/severe consequence accidents. Nor do they include particularly crafted efforts for their prevention. Reason has made a similar observation in Managing the Risks of Organizational Accidents. He states that occupational safety approaches directed largely on the actions of persons have limited value with respect to the insidious accumulation of latent practices and conditions that are typically present when organizational accidents occur (p224, p230).
Further, a needs study would determine how extensively the belief is held in an organization that if efforts are concentrated on the types of accidents that occur frequently the potential for serious injury will also be addressed. And, the needs assessment would determine how broadly the premise is accepted and acted upon by senior management, supervisors, workers, and safety professionals that unsafe acts of employees are the principal causes of most accidents.
Wherever a mindset exists that concentrating on incidents that occur frequently encompasses severity potential and that the unsafe acts of employees are the principal causes of accidents, a culture change will be necessary to reduce the potential for the occurrence of low probability/severe consequence incidents.
A needs assessment would determine how much educational effort must be put forth through re-indoctrination programs to achieve the creative destruction and reconstruction necessary to achieve a different mindset--one that recognizes the particulars of serious injury potential and the opportunities that such recognition presents.
The newly adopted mindset--that avoiding serious injury potential requires special attention--must be imbedded in every element in a safety management system so there is continuous thinking about avoiding the occurrence of low probability/serious consequence incidents. For continuing education, this additional question should be added to every element in the safety management system and in the safety audit outline: Has adequate attention been given to the occurrence potential for low probability/serious consequence events?
Additional Ameliorating Actions
I suggest that safety professionals consider extending safety management systems to include two elements that have been adopted infrequently. The critical incident technique is an inexpensive method to obtain information from workers on hazardous operations that have serious injury potential before incidents occur. (See Accident Prevention Manual: Administration and Programs, 12th Edition, National Safety Council.)
For unusual and non-routine work, for work where sources of high energy are present, and for at-location construction operations (e.g., replacing an 800-pound motor on a platform 18 feet above the floor), instituting a Pre-Job Planning and Safety Analysis System can reduce the risks. (For an outline of such a system, see the chapter titled "Addressing Severe Injury Potential" in On The Practice Of Safety, Third Edition.)
The record is clear. While the total incidence rate has come down significantly, the incidence rates for lost work day cases and fatalities have not been reduced comparably. For imaginative safety professionals, that defines opportunity. Effectiveness of the safety management systems for which they provide counsel will be moved to a higher level if specifically crafted methods are put in place to identify serious injury potentials and to reduce the risks relative to those potentials.
This article appears in the June 2005 issue of Occupational Health & Safety.
This article originally appeared in the June 2005 issue of Occupational Health & Safety.