©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not be used for training, modified

©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not be used for training, modified or reproduced, or used outside of your organization without written permission from BST.

ELIMINATING

SERIOUS INJURIES

AND FATALITIESSafety Driven Performance ConferenceOctober 10, 2013 Houston, TX

Susan M. Murphy, M.Ed.Principal Consultant

Behavioral Science Technology, Inc.


Why Is This So Important?


Industry DataOGP HSE Performance Trend Lines


All Injury Frequency Rate (3 Month Rolling Average) and Fatality Rate 2000.12-2008.08

All Injury Frequency Rate (Month Rolling Average) and Fatality Rate 2000.12 - 2008.08

4.06

0.92

0.054

0.1

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

4.50

0

0.02

0.04

0.06

0.08

0.1

0.12

AIFR Fatality Rate Linear (Fatality Rate)


Data from 2008-2009

1028 Total Cases Studied

*Average Rate*Serious Injuries and Fatalities .0014

Restricted and Lost Workday Cases 0.30

Medical Treatment 0.98

Traditional Safety Triangle IS Descriptive


Serious Injuries & Fatalities (SIF) Exposure Potential

ThemeSIF or SIF-Potential

IncidentN=55

NON SIF-PotentialIncident

N=35

1Performing a routine operations/production or a maintenance/repair task, connected with a deviation from an established Life Safety Rule/Safety Absolute.

42% 0%

2

Performing a routine operations/production or a maintenance/repair task, (not governed by an established Life Safety Rule/Safety Absolute), connected to an exposure that changed from a “normal state”, was not anticipated/recognized/controlled and likely could have been prevented by a proper Pre-Task Risk Assessment (PTRA).

29% 17%

3Self-made human errors that are not connected to a Safety Absolute Involved in either a routine operations/production or a maintenance/repair task OR performing a special/unique/unplanned/emergency situation.

11% 74%

4Involved in routine operations/production or a maintenance/repair tasks, and a connection to an equipment / facility / process / engineering design flaw has been established.

5% 3%

5Involved in routine operations/production or a maintenance/repair tasks, and a connection to predictive & preventive maintenance & inspection, and reliability systems has been established.

5% 6%

6

Involved in a special/unique/unplanned/emergency situation, connected to an exposure that was unknown or unfamiliar, and was not anticipated/recognized/controlled, and likely could have been prevented by a proper Pre-Task Risk Assessment (PTRA).

4% 0%

7Involved in an act or incident or workplace violence, war, or militia attack or similar.

4% 0%


Key Findings & Points1. 42% SIF were from Life Safety Rules

• 98% of those not because employee ignored rule – more complicated

2. 29% SIF could have been prevented with quality pre-task assessment

3. 71% of all SIFs fell into these 2 categories

4. First 5 categories involved routine tasks

5. Sample size statistically valid for valid conclusions • Our clients are finding the same thing (40-50% Life

Safety Rules)


Cases that Drive the NumbersTheme

SIF or SIF-PotentialIncident

N=55

NON SIF-PotentialIncident

N=35

1Performing a routine operations/production or a maintenance/repair task, connected with a deviation from an established Life Safety Rule/Safety Absolute.

42% 0%

2Performing a routine operations/production or a maintenance/repair task, (not governed by an established Life Safety Rule/Safety Absolute), connected to an exposure that changed from a “normal state”, was not anticipated/recognized/controlled and likely could have been prevented by a proper Pre-Task Risk Assessment (PTRA).

29% 17%

3 Self-made human errors that are not connected to a Safety Absolute Involved in either a routine operations/production or a maintenance/repair task OR performing a special/unique/unplanned/emergency situation.

11% 74%

4Involved in routine operations/production or a maintenance/repair tasks, and a connection to an equipment / facility / process / engineering design flaw has been established.

5% 3%

5Involved in routine operations/production or a maintenance/repair tasks, and a connection to predictive & preventive maintenance & inspection, and reliability systems has been established.

5% 6%

6Involved in a special/unique/unplanned/emergency situation, connected to an exposure that was unknown or unfamiliar, and was not anticipated/recognized/controlled, and likely could have been prevented by a proper Pre-Task Risk Assessment (PTRA).

4% 0%

7 Involved in an act or incident or workplace violence, war, or militia attack or similar.

4% 0%

SIF: Serious Injuries & Fatalities


•This model can accurately predict an incident as being SIF or non-SIF with 78% accuracy.

CHAID Analysis(Chi-squared Automatic Interaction Detector)


Definition of Serious Injury

1. Life-threatening injury or illness: one that if not immediately addressed is likely to lead to the death of the affected individual, and will usually require the intervention and/or external emergency response personnel to provide life-sustaining support.

2. Life-altering injury or illness: one that results in permanent or long-term impairment or loss of use of an internal organ, body function, or body part.


OSHA 300 Log is Misleading

Fractured FootCase A (SIF Potential = No) – Employee suffered a fractured foot when they climbed out of a truck cab, missed the bottom rung of the ladder, and fell 30 inches to the ground. Their foot rolled off a small rock, resulting in a fracture.

Case B (SIF Potential = Yes) – Employee suffered a fractured foot when backed over by a forklift truck (PIT). The PIT operator backed up without looking, and the backup alarm was not functioning. This easily could have been a serious (life-threatening or life-altering) injury, or fatality if the employee’s full body had been struck and run over.


SIF Potential?

Laceration Requiring SuturesCase A (SIF = No) – A worker cut his finger on the sharp edge of a pipe flange in the machine shop. He was grinding the burrs off the flange end, wearing all necessary PPE. He stopped grinding and removed his glove to feel the edge with his finger to see if the burrs had been successfully removed. The edge was sharper than expected, resulting in a cut to the left index finger that needed two sutures.

Case B (SIF = Yes) – A 4-foot by 8-foot by 1-inch steel plate was being moved for installation by two workers using an overhead hoist. The plate shifted unexpectedly and worker #2 tried to steady it with his hand. The plate shifted again, this time pinching worker #2’s hand against the steel frame. He sustained a laceration of his right ring finger, which required sutures to close.


SIF Potential?

Strained BackCase A (Non-SIF) – Worker was walking across the floor, slipped on grease, caught himself on a railing, and wrenched his back (strained back muscle).

Case B (SIF = Yes) – Worker fell from the top of a rail car when his car was struck by another rail car that was being moved into position. The worker fell on top of the tank car, grabbing the guard rail around the dome lid, preventing a fall to the ground. The only injury resulting was some bruising and a strained back muscle. Even though this event was classified as “first-aid”, it clearly has high potential for SIF.

What about the gray areas?


The traditional safety triangle is not predictive.

Not all injuries have Serious Injury and Fatality (SIF) potential.

A reduction of injuries at the bottom of the triangle does not correspond to an proportionate reduction of SIF’s.

21% Potentially

SIF


The Current Paradigm ‒ Are We Stuck on This?• Serious Injuries and Fatalities (SIFs) and Non-SIFs

have the same causes and correlates.• You can impact the top of the triangle by working

on the bottom of the triangle (the triangle is predictive).

• TRIR and audit information are reliable indicators of SIF Exposure Potential.

• When SIFs occur, they are one-offs.• Accident investigations are systematized and highly

sophisticated, and good enough.


A New Paradigm

Precursors High-risk situations in which management controls are either absent, ineffective, or

not complied with, and which will result in a serious or fatal injury if allowed to

continue.

Fatalities

Recordable Injuries

Lost Time Injuries SIF Exposures

A new way of thinking about the Safety Pyramid:

focus on prevention of SIFs


A New Paradigm

• The causes and correlates of SIFs are different from Non-SIFs.

• You will not impact the top of the triangle by working on the bottom of the triangle.

• The SIF blind spot is significant.• Our accident investigation processes

are not getting the job done.


Cases that Drive the Numbers…

…are still important and require attention:• Observation & Interaction (BAPP®).• Approaching Others (AO).• Incident/Injury Reporting & Handling.• Pre-Task Risk Assessments.• Exposure Recognition:

• Risk perception and risk tolerance.• Blood, break, and bruise.


SIF Exposure Potential• Leader education:

• Don’t overlook anything.

• SIF Exposure visibility:• SIF exposure metric.

• Know your precursors:• Mine your data.• Discover thru observation & interview.

• Interventions integrated into existing SSHE systems:• Injury/Incident reporting.• Pause work climate – Stop Work Obligation (SWO).• Life Saving Rules – quality, integrity and reliability.• Pre-task risk assessments (RA/JSA).• Accident handling system.


SIF Intervention I

Educate senior leaders, area managers, and enlist their sponsorship:• They need to understand this problem

before they can be expected to act on it.• The solutions to the SIF problem are

different and require their attention.• See SIF exposure and react appropriately.


SIF Intervention II

SIF Exposure Visibility:• Gaining traction in our clients.• Prerequisites:

• SIF definition.

• SIF Exposure Potential determination.

• SIF Exposure Rate(s) calculation.

• BST SIF potential decision-tree.

SIF white paper describes “how to” and decision-tree @ www.bstsolutions.com

http://www.bstsolutions.com/


SIF Classification Scheme – Sample 2


SIF Intervention IIIKnow Your SIF Precursors:• 3 places where they hide.• Accident Investigation processes must become

transformational:• Contributing factors.• Root causes.• Precursors. • Longitudinal analysis.• Effectiveness of corrective and preventive actions.• Tracking of recommendations.• Effective communications of lessons learned.• Case narratives do not provide adequate descriptions to help us

understand what really happened and the context surrounding the exposure.


Identifying SIF PrecursorsHigh-Risk Exposure

Work Activities & SituationsSafety Management

Controls and Measures Allowed to Continue

Routine operations or production tasks

Routine maintenance or repair tasks

[81%]

High-Risk Event Combinations

Lockout/Tagout

Confined Space Entry

Working at Elevations/Fall Arrest

Machine Guarding- Barricades

Operations of Mobile Equipment

Suspended Loads

Horseplay, working under the influence of drugs/alcohol

Equipment and pipe opening

Hot work permits

Excavations, trenches

NFPA 70E- Arc Flash Protection

Not aware?

Aware but not acted on?

Condoned?

Complacency?

Culturally acceptable?

Normalization of deviation?

Not observed?

Work pressure?

No follow-up?

Tolerance for risk?

Tolerance of inadequate systems?

Process instability

Significant process upsets

Unexpected maintenance

Unexpected changes

High energy potential jobs

Emergency shutdowns

Start-ups

Absent /Non-existent

Ineffective/Deficient

Not complied with/ Not followed

[If these defenses are not solid, you have a precursor]

[Work on the right problem. Generalizations are not helpful]

Every step

Every level


SIF Intervention IV

Integrate Interventions into Existing Safety Management Systems.• BBS SIF precursor discovery – interview

and observation process:• An exciting development (87% discoverable

precursors).

• BBS enhancement workshop.


SIF Intervention IV (cont.)

• Life Saving Safety Rules.

• Pre-Task Risk Assessments.

• Climate for Reporting and Pausing Work.

• Incident Handling Systems (reporting, reaction, investigation, action planning).


Healthy Incident Reporting

• Does this truism exist here?• Managers think everything is being reported.• Workers know everything is not being reported.

• Does fear of reprisal exist here?• Are leader reactions predictable and positive?• Near-misses are a gold mine of information.

How much gold are we mining?• Is accident investigation depth driven by

classification, rather than SIF potential?• Do we pay more attention to classification

or prevention?


Healthy Incident Reporting

• Is our reporting healthy? (Key #1)• Do we have high quality accident case

narratives? (Key #2)• Have we ever done a longitudinal analysis

to look for precursors? (Key #3)

As senior executives, we can’t

“not know” about our SIF potential.


What Leaders Are Doing

• Less about TRIR/LTIR, more about what happened, personal impacts, feelings.

• Keep case management vigor behind closed doors.

• Climate supports and encourages near-miss reports.

• Gather more info with live conversations, site visits.

• Zero tolerance for deviation from centerline.

• Question critical exposures and controls.

• Never walk past.


Conclusion• When and where can I apply these learnings?

• Reviewing results of accident and near-miss investigations.• Reviewing leading indicators such as JSA Quality, JSA Rates,

Accident Investigation Quality.• Reviewing safety audit results for leadership & culture

implications.• At regular corporate staff meetings.• When visiting sites and yards – meeting with site leadership

team, touring and meeting with front-line workers and union reps• Does our BAPP® effort have a sampling strategy for critical SIF

behaviors?• When you hear reports of near-misses with SIF potential…

“We dodged a bullet”.

SIF Exposure Recognition and Mitigation A Core Operational Responsibility


Thank [email protected]

Susan M. Murphy, M.Ed.Principal Consultant

BST

© 2012 BST. All rights reserved. This information is provided for use within your organization. It may not be used for training, modified or reproduced or used outside of your organization without written permission from BST. All trademarks are owned by BST, Reg. U.S. Pat. & Tm. Off. BST, Behavioral Science Technology, Inc. and Leading with Safety are registered trademarks of BST. All information is BST copyrighted material or is used with express permission of the copyright owner.

Documents

©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not be used for training, modified