1 Recognizing Predictive Indicators for Fatalities and Serious Injuries Fred A. Manuele, CSP, PE President Hazards, Limited

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Recognizing Predictive Indicatorsfor

Fatalities and Serious Injuries

Fred A. Manuele, CSP, PEPresident

Hazards, Limited

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What I Will Comment On

A phenomenon

Statistics on fatalities and serious injuries

Debunking a myth

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Fatality–serious injury characteristics

Significance of organizational culture

The business climate, and culture

A mechanism for an internal study

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Improving incident investigation

Making gap analyses A “near hit” data gathering system

The need for a different mind set

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The Phenomenon

Reliance on traditional approaches to fatalityprevention has not always proven effective.This fact has been demonstrated by manycompanies, including some thought of as topperformers in safety and health, as theycontinue to experience fatalities while at thesame time achieving benchmark performancein reducing less-serious injuries and illnesses.

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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

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Statistical Indicators – Fatalities

National Safety Council – Accident Facts(Now Injury Facts)

Bureau of Labor Statistics – NationalCensus of Fatal Occupational Injuries

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No. of Number of Fatality

WorkersYear Fatalities Rate in

1000s1941 18,000 37 48,1001951 16,000 28 57,4501961 13,500 21 64,5001971 13,700 17 78,5001981 12,500 13 99,8001991 9,800 8 116,4002001 5,900 4.3 136,000

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From 1941 through 2001

Employment increased over 280%

Number of fatalities – down over 67%

Fatality rate – reduced over 88%

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Statistical Indicators – BLS Reports

All Fatalities – All Occupations

Number of FatalityYear Fatalities Rate2001 5,900 4.32002 5,524 4.02003 5,559 4.02004 5,703 4.12005 5,702 4.02006 5,703 3.9

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Statistical Indicators – BLS ReportsAll 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?

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Statistical Indicators – BLS ReportsFatality Rates – Selected Occupations

Industries 2005 2006Mining 25.6 27.8Transportation/wrhsing 17.6 16.3Construction 11.0 10.8Utilities 3.6 6.2Wholesale trade 4.4 4.8Manufacturing 2.4 2.7

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Statistical Indicators: BLS

Lost-Worktime Injuries and Illnesses:Characteristics and Resulting TimeAway From Work

Table 10 – Percent distribution of nonfataloccupational injuries and illnesses involvingdays away from work – Private Industry

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Statistical Indicators: BLS

Percent of days-away-from-work cases involvingthese numbers of days

1 2 3-5 6-10 11-20 21-30 31 or more

1995 16.9 13.4 20.9 13.4 11.3 6.2 17.9

2005 14.3 11.6 19.0 12.7 11.5 6.5 24.2

% -15.4 -13.4 -09.1 -6.0 +1.8 +4.8 +35.2Changefrom 1995

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Statistical Indicators

You can not conclude from the BLSdata that the number of incidentsresulting in severity has increased

You can conclude that incidentsresulting in severity are a largersegment of all lost time injuries

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National Council on CompensationInsurance

The Remarkable Story of Declining Frequency—Down 30% in the Past Decade

Also down in Canada, France, Germany,UK, Japan

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National Council on Compensation Insurance (2005 paper)

Decline in the frequency of smaller lost-time claims is larger than in thefrequency of larger lost-time claims

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1999 to 2003, in 2003 hard dollars

Value of Claim Frequency Declines

1. Less than $2,000 34%2. $2,000 to $10,000 21%3. $10,000 to $50,000 11%4. More than $50,000 7%

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Debunking a Myth

A barrier

Reducing injury frequency willequivalently reduce incidentsresulting in severe injury

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Debunking a Myth

Many safety practitioners believe andprofess that efforts concentrated onthe types of accidents that occurfrequently will also address thepotential for severe injuries.

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Debunking a Myth

Jim Johnson: “I’m sure that many of ushave said at one time or another thatfrequency reduction will result in severityreduction. This popularly held belief isnot necessarily true. If we do nothingdifferent than we are doing today, thesetypes of trends will continue.”

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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.

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DNV Consulting

The major reality however is somewhatdifferent. If you manage the smallaccidents effectively, the small accidentrate improves, but the major accident rate stays the same, or even slightlyincreases

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Debunking a Myth

Recall Jim Johnson saying that:

If we do nothing different than weare doing today, severe injurytrends will continue

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Debunking a Myth

Jim’s view – supported by a world famous philosopher who said

If you keep doing what youdid, you will keep getting whatyou got

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Debunking a Myth

The world class philosopher

If you keep doing what you did,you will keep getting what you got

Dr. Lawrence Berra

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Debunking a Myth

As the data clearly shows, frequencyreduction does not necessarily produceequivalent severity reduction

Severity reduction requires speciallycrafted initiatives, focused on hazardsand risks that present severe injury potential

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A Different Approach Needed

The data requires that we adopt adifferent mind set, one that resultsin a particularly directed focus onpreventing low probability, severeconsequence events.

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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

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Characteristics of Severe Injuries

Many accidents resulting inseverity are unique and singularevents, having multiple, complex,cascading technical, organizationalor cultural causal factors

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Characteristics of Severe Injuries

Largely, causal factors for lowprobability/severe consequence eventsare not represented in the analyticaldata on incidents that occur frequently,but such incidents may be predictors ofseverity potential if a high energysource is present

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In the Studies Made

The quality of incident investigations,on average, was abysmal.

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Predictive Specifics From Studies

Thirty-five percent of severe injurieswere triggered by a deviation fromnormal operations – upsets

Over a 10 year period, 51% of fatalitiesoccurred to contractor employees

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In three companies with a combinedtotal of 230,000 employees, eachcompany having very low OSHA rates,74% of severe injuries occurred tosupport personnel

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Percent of severe injuries that occurred to non-production personnel in two other companies Company A – 63% Company B – 67%

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For companies with OSHA rates higherthan industry averages, and incompanies where there is heavymaterial handling or the work is highlyrepetitive, the percent of severe injuriesoccurring to production personnel washigher

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About 50% of major accidents involvedpowered mobile equipment: fork lifttrucks, cranes, etcetera

Reviews of electrical fatalities indicatethat, the design of the systemsproduced error-inducing situations

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Having effective management ofchange procedures would have greatlyreduced major accident potential

Complacency and overconfidence wasoften a factor

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Dan Petersen: On Severe Injuries

The mass data indicates that the types ofaccidents resulting in temporary totaldisabilities are different from the types ofaccidents resulting in permanent partialdisabilities or in permanent totaldisabilities or fatalities

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Dan Petersen: On Severe Injuries

The causal factors are different

There are different sets ofcircumstances surrounding severity

If we want to control serious injuries,we should try to predict where they willhappen

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A Study of Fatalities

UAW Data

Skilled trades people, 20 percentof population

Have 41 percent of fatalities

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Corporate Culture and Safety

The physical cause of the loss ofColumbia and its crew was a breachin the Thermal Protection Systemon the leading edge of the left wing.

In our view, the NASA organizationalculture had as much to do with thisaccident as the foam.

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Columbia

Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution.

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Columbia At the most basic level, organizational

culture defines the assumptions thatemployees make as they carry outtheir work. It can be a positive or anegative force.

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In every organization

“Values, norms, beliefs, and practices” are translated into a system of expected behavior that impacts positively or negatively on decisions taken

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with respect to management systems,design and engineering, operatingmethods, and prescribed taskperformance—and how much risktaking is acceptable

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On Major Accidents

James Reason – Managing the Risks of Organizational Accidents

Stresses the long term impact ofinadequate safety decision makingon an organizations culture

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On Major Accidents

Reason: The impact of (top level)decisions spreads throughout theorganization, shaping a distinctivecorporate culture and creatingerror-producing factors withinindividual workplaces.

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On Major Accidents

Donald A. Norman – The Psychologyof Everyday Things

Most major accidents follow a seriesof breakdowns and errors.

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On Major Accidents

Norman: In many cases, thepeople noted the problem butexplained it away, finding a logicalexplanation for the otherwisedeviant observation.

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On Major Accidents

“Normalization of deviation” is amore often used phrase

Where it occurs, it is a predictor ofsevere consequences

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Economics and Culture

A realistic look at the current businessclimate and its possible effect onorganizational culture and decisionmaking

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Report of the OECD Workshop onLessons Learned from ChemicalAccidents and Incidents

The concept of ‘drift’ as defined byRasmussen was generally agreedupon as being far too common in thecurrent business environment

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Rasmussen defined ‘drift’ as “thesystematic organizational performancedeteriorating under competitivepressure, resulting in operation outsidethe design envelope wherepreconditions for safe operation arebeing systematically violated.”

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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.

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Also because of job cuts, the firms donot have sufficient numbers of workerswho can repair and keep the oldequipment in proper condition.

Major companies have been hit bymajor accidents.

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Jens Rasmussen: Risk Management in a Dynamic Society

Companies today live in a veryaggressive and competitiveenvironment which will focus theincentives of decision makers on shortterm financial and survival criteriarather than long term criteriaconcerning welfare, safety, and theenvironment.

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Jens Rasmussen: Risk Management in a Dynamic Society

Studies of several accidents revealedthat they were the effects of asystematic migration of organizationalbehavior toward accident under theinfluence of pressure toward cost-effectiveness in an aggressive,competitive environment.

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U.S. Chemical Safety BoardBP Disaster, 2005

The Texas City disaster was caused byorganizational and safety deficiencies atall levels of the BP Corporation.Warning signs of a possible disasterwere present for several years, butcompany officials did not interveneeffectively to prevent it.

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Cost cutting and failure to invest leftthe Texas City refinery vulnerable to acatastrophe. BP targeted budgeted cutsof 25 percent in 1999 and another 25percent in 2005, even though much ofthe refinery’s infrastructure and processequipment were in disrepair.

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Chairwoman Carolyn Merritt said “Thecombination of cost-cutting, productionpressures, and failure to invest causeda progressive deterioration of safety atthe refinery.”

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Assume senior management wantsto know about economics-relatedpredictors for fatalities and seriousinjuries

Safety professionals want to takethe initiative to promote an internalself-analysis

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In the current business climate, do incentivesfor decision-makers result in focusing on

shortterm financial goals, the result being “drift” and “systematic organizational performancedeteriorating under competitive pressure?”

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Are the incentive systems for executives and location managers constructed sothat it is to their advantage – both forshort term financial considerations andfor job retention – to avoid needed capitalexpenditure requests, or to avoidspending the money after project approvalis received?

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Has the gap widened between issuedpolicy and procedure and what actuallytakes place at locations?

Are risky procedures – normalization ofdeviation – being tolerated that would have been unacceptable in the past?

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Does the organization continue using facilitiesand equipment that normally would have beenreplaced years ago, thereby increasing the riskof fatality and serious injury?

Because of staff cuts, does the firm havesufficient numbers of qualified maintenanceworkers who can repair and keep equipment inproper condition?

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Is staffing at all levels, both as to numberand qualification, sufficient to maintain asuperior level of safety performance?

Does senior management discourage pushback,

perhaps to the extent of intimidation,from those seeking to express concernsabout safety?

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Has outsourcing resulted in more fatalitiesand serious injuries occurring to contractoremployees?

Has complacency and overconfidencedeveloped due to presumed superiorperformance, as measured by OSHA

statistics?

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Every subject I have mentioned relates to comments made by safetyprofessionals.

If the culture has deteriorated becauseof economic pressures, that must be addressed in seeking to reduce severeinjury potential.

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Actions to be Considered

An analysis of severe injuries

Improving incident investigations

Making a gap analysis in relation to theprovisions in ANSI Z10

Initiating an information gathering systemon “near hits”

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Analysis of Severe Injuries

To seek predictive indicators

Look for shortcomings in safetymanagement systems

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Avoiding Self-Delusion

Chemical Safety Board

A very low personal injury rate atTexas City gave BP a misleadingindicator of process safetyperformance.

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Chair of the Oil and Gas Producers Safety Committee

We conclude that the TRIR/LTIFRhave little predictive value towards thepotential escalation to single andmultiple fatalities. They also tell uslittle about major accident risk.

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Neither safety professionals norexecutive managements shoulddelude themselves into believingthat achieving low OSHA ratesassures that serious injuries andfatalities will not occur

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Improving Incident Investigation

In studies of incident investigationreports, causal factor determinationwas abysmal.

Seldom does it occur that incident

investigations “peel the onion” back tothe core causal factors.

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Improving Incident Investigation Report—Columbia Accident

Many accident investigations do not gofar enough. They identify the technicalcause of the accident, and then connectit to a variant of "operator error." Butthis is seldom the entire issue.

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When the determinations of the causalchain are limited to the technical flawand individual failure, typically theactions taken to prevent a similar eventin the future are also limited: fix thetechnical problem and replace or retrainthe individual responsible.

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Putting these corrections in place leads to another mistake—the

beliefthat the problem is solved.

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Improving Accident Investigation

Too often, accident investigationsblame a failure only on the last step ina complex process, when a morecomprehensive understanding of thatprocess could reveal that earlier stepsmight be equally or even moreculpable.

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In this Board's opinion, unless thetechnical, organizational, and culturalrecommendations made in this reportare implemented, little will have beenaccomplished to lessen the chancethat another accident will follow.

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Substantial reductions in severeinjuries are unlikely if incidentinvestigation systems are not improved to address the reality of their causal factors.

The 5 Why System

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A Gap Analysis

To compare existing safetymanagement systems with thecontent of ANSI/AIHA Z10-2005,the Occupational Health and SafetyManagement Systems standard.

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A Gap Analysis

Stress those provisions that are seldomincluded in safety management systems Design reviews Risk assessments Hierarchy of controls Management of change Procurement

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The Critical Incident Technique

An information gathering systemon “near hits”

To involve personnel at all levelsin gathering data, predictive data,on severe injury potential

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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.

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A system that seeks to identify causalfactors before their potentials arerealized would serve well in attemptingto avoid low probability-seriousconsequence events.

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Wrap-up

It must be understood that to reducesevere injury potential, managementmust embed that purpose in its culture,thus impacting every element of thesafety management system.

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Wrap-up

That will require giving severe injuryprevention a high priority, and adoptinga different mindset.

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Wrap-up

The intent would be to achieve an understanding that personnel at all levels have a particular responsibility to:

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Wrap-up

Give specific emphasis to anticipating,

predicting, and taking corrective action

on hazards and risks that may havefatality or serious injury potential.

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Wrap-up

Assure that in-depth reviews of thereality of the root causal factors forincidents that result in fatalities andsevere injuries are made.

Identify predictive indicators, includingknowledge obtained from studies of near-hits.

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Wrap-up

Address organizational, operational,technical, and cultural causal factors

I am assigning you the responsibilityto get all that done.

Documents

1 Recognizing Predictive Indicators for Fatalities and Serious Injuries Fred A. Manuele, CSP, PE President Hazards, Limited