Steps to Prevent Serious Workplace Injuries and Fatalities · Steps to Prevent Serious Workplace Injuries and Fatalities ... Was the event related to working under a suspended load?

Steps to Prevent Serious Workplace

Injuries and Fatalities

Karl L. BossungDEKRA Insight

©2016 DEKRA Insight. All rights reserved.

U.S.A. Safety in 21 Years:

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Fatality Rate TR

IR

TRIR (per 200,000 hours) Fatality Rate (per 100,000 workers)


Traditional Safety Triangle – ReductionIn Bottom of TriangleResults in a ProportionalReduction at the TopOf the Triangle


A subset of reported cases will have SIF Exposure.

A reduction of injuries across the base of the triangle or working outside the SIF triangle will not correspond to a proportionate reduction of SIFs.

21% Potentially

SIF

Traditional Safety Triangle is not Predictive


A New Paradigm

A new way of thinking about the Safety Pyramid:Focus on prevention of SIFs.

Fatal &Serious

Recordable Medical &FA Injuries

LT/RD Injuries SIF Exposures

PrecursorsHigh-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.

21%

Near-Misses, Property Damage,Spills & Releases, Fires,

Reliability Incidents, etc.


Headline 1

Don’t Expect SIF Prevention by Working Outside of the SIF Triangle



Headline 2

Recordable Injuries Log is Misleading When it Comes to SIF Exposure



Headline 3

The SIF Blind Spot is Significant



Headline 4

There Are Four Things You Must Do



Four Things You Must Do

1. Educate Senior Leaders on SIF:• They need to understand this problem before they

can act on it.• The solutions to the SIF problem require their attention.• Enlist their sponsorship.

2. Provide Visibility to SIF Exposure:• Define “SI”F: Life-Threatening vs. Life-Altering.• Determine SIF Exposure Potential: Judgment-based versus

Decision-tree. • Calculate SIF Exposure Rate: SIF Recordable and SIF Total.


No

SIF Exposure Decision Tree – SAMPLEDid the event involve LOTO?

Did the event involve a vehicle collision?

Did the event involve Confined Space Entry?

Did the event involve pinched between or in line of fire with a release of significant mass or energy?

Did the event involve working at elevations

Did the event involve barricades/machine guards?

Was the event related to working under a suspended load?

Did the event involve NFPA 70E Arc Flash?

Was it an actual SIF event?Could a fatality or life altering/threatening injury/illness

reasonably have resulted?

SIF Exposure

No SIF Exposure

No

Yes

No

No

No

No

No

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No


SIF Exposure Determination

NEAR-MISS• A forklift slowly fell over

as it was parked on the footbridge of a scaffold. The load was too heavy and improperly secured. Two workers on the scaffold had to jump to ground from 10 feet up as the forklift leaned into the scaffold.

RECORDABLE INJURY• Worker strained his wrist

while pulling a 20 pound condenser out of a cardboard box.



FIRST AID• A welder was removing

welding parts from a supply bag. A tightly coiled hose suddenly uncoiled striking the welder on his bare forearm, scratching it.

LOST TIME INJURY• A Caterpillar tractor

operator was standing on the engine housing about 8 feet off the ground. He was greasing the zirks when he slipped and fell to the ground fracturing his ankle.



PROPERTY DAMAGE• A forklift operator was

backing up his forklift at approximately 5 MPH. He struck a pedestrian walkway guardrail and damaged it. There were no pedestrians in the walkway.

REPORT• An electrical technician

was cutting a cable to the lighting system. Sparks jumped out of the cable. Electrician was wearing protective rubber gloves. He thought the system was de-energized because he left it that way before lunch break.


Four Things You Must Do (continued)

3. Know Your SIF Precursors:• Three places where they hide:

• High Risk/High Exposure Tasks (81% Routine)• Management Systems Missing, Deficient,

or Not Complied With• Allowed to Continue

4. Integrate Interventions into Existing Safety Management Systems (SMS):• Life Saving Safety Rules, Pre-Task Risk Assessments,

Pausing Work, Incident Handling Systems (reporting, reaction, investigation, etc.)


Important SIF Precursor Mitigation Considerations

LIFE-SAVING SAFETY RULES• 42%• Breakdowns occur• Design integrity• Behavioral reliability• Quality & effectiveness

PRE-TASK RISK ASSESSMENT• 29%• Collaborative• Triggers for pause work• Field verifications• Post-job debrief

81% of fatal events involve routine operations and maintenance tasks


Headline 5

Accident Reporting & Investigations Are Not As

Good As You Think They Are

Longitudinal analysis will prove it,and will point out leadership

and culture implications.



Accident Investigation Processes Must Become Transformational

• Longitudinal analysis• Multiple contributing factors, root causes, and SIF Precursors • Effectiveness of corrective and preventive actions (use HOC triangle

to evaluate)• Tracking of recommendations and verification of problem-solved• Effective communication and implementation of lessons learned• The perspective of the affected workers• Proportionate response• Case narrative descriptions must help us understand what really

happened and the context surrounding the exposure.

Encourages and supports reporting!


Proportionate Response

SIF Exposure

Patterns Non-SIF Exposure

Report – High Level / Across Organization

Deeper Investigation

Share Action Plan –High Level / Across

Organization

Report – Locally

Short Form –Investigation

Report – Affected Groups

Root Cause Investigation

Develop Action Plan to Address – Trend

Share Action Plan –Those That Need to Know


EliminationComplete redesign of the system to remove the exposure

Exposure eliminated.

Substitution Switch out a process step with a less hazardous step;Use low voltage system versus high voltage; replacea toxic material with a non-toxic material

Exposure significantly reduced.

Engineering Controls/IsolationIsolate hazard; install guards and/or interlocks;build barriers; use light curtain;develop new tool

Exposure controlled during normal ops; still possible during maintenance operations or emergencies.

Administrative ControlsPost signs and warnings;Write procedures and rules;Train employees

Exposure controlled IF employees rigorouslycomply and IF culture supports compliance andIF leadership maintains commitment to verification and oversight.

Personal Protective EquipmentProvide protective equipment for workers (e.g., hard hats, gloves, glasses, respirators)

Last layer of defense; unreliable for full protection; does not mitigate risk or exposure, only extent of possible injury; primarily used when hazard is unpredictable or pervasive; use is dependent on too many variables.

Gimmicks; incentives;hollow threats

Worker seen as the cause of exposure and simply requires motivation; no change in exposure.

Safety depends

LEASTOn

employee Behavior

Safetydepends

MOSTOn

employee behavior

Leverage The Hierarchy of Controls

15%

85%

------

What if N=100 cases?


Headline 6

The Role for BBS is Significant, andUnderutilized



SIF Precursor Discovery –Observation/Interview Process

• Study Results: 87% of the time SIF Precursors discoverablevia interview or observation.

• Critical Behaviors Inventory® could be much deeper.• Observer partnering with front-line supervisors, safety

professionals, and lessons learned processes.• SIF education, SIF exposure selection strategy, different

observation and interview skills, SIF data collection and response.

BAPP®/SIF


Headline 7

SIF Events Are Not One-Offs. The Precursors Have Been There All Along.

Our vocabulary and reaction to SIF must change.



A New Paradigm

• The causes and correlates of SIFs are different from Non-SIFs. Work inside the SIF triangle is required.

• Leadership interest and engagement is necessary to impact the top of the triangle.

• A SIF exposure metric is essential.• Accident reporting and investigation processes are

key to understanding & mitigating the SIF exposure situation.


A New Paradigm

A new way of thinking about the Safety Pyramid:Focus on prevention of SIFs.

Fatal &Serious

Recordable Medical &FA Injuries

LT/RD Injuries SIF Exposures

PrecursorsHigh-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.

21%

Near-Misses, Property Damage,Spills & Releases, Fires,

Reliability Incidents, etc.


Final Thoughts

As senior safety leaders, we can’t“not know” about our SIF exposure.

SIF exposure recognition and mitigation:a core operational responsibility.

New Questions for Leaders on Serious Injury and Fatality Prevention


Leaders and SIFs

• I’m not out in the field! What am I supposed to do?• Vision• Challenge the Status Quo


Life-Saving Safety Rules

• Quality, Integrity & Reliability• Do we have them?• Are they the right ones?• What is the basis for them?• How consistent are we in…

• Understanding? • Explaining?• Interpreting?• Applying?



• Quality, Integrity & Reliability• The rule (and all its moving parts) must truly protect

• If we do it the way it’s described in the paper program, would everyonebe protected?

• Every behavioral aspect at every level must be 100% enabled• Is it even possible to do it the way it’s described in the paper program,

and is everyone enabled to do their part?• People must actually conform• Does everyone actually do it?

• Is “normalization of deviation happening here?”• Is it too easy to grant variances?

• Do we make statements around…• Zero-tolerance?• If only my workers would…?



• 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



Pre-Task Risk Assessments

• What do we have in place?• How does it work?• Is it collaborative?• How is it led?• Does it encourage and support open & complete

discussion about exposure?• Is it documented?• How do we measure quality and effectiveness?

• A great leading indicator!



• Does it accurately predict… • What the real exposures are?• The measures that need to be put in place to protect

the workers?

• What is our climate for enabling, encouraging, and supporting “pause work for safety reasons?”

• Does it happen enough?• Should it happen more?

• How would you know?



• Quality, Integrity & Reliability• Prepare the Job Safety Assessment in a collaborative

manner?• Go out to the field and compare?• Go back out mid-job?• Debrief at job completion?

• Did everything match up?• What else did we need to do that was not predicted

and planned?


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


The SIF Exposure Blind Spot

• Do we really know what our SIF Exposure is?• Can we construct a reliable SIF Exposure metric?• How should we react to cases with SIF potential?• Are my people willing to report, approach others,

pause work?• Are my people capable of recognizing exposure and

exposure change?• Is my accident investigation process healthy?• Can we identify SIF precursors?• Do we have processes to mitigate SIF precursors?


Conclusion

• When and where can I apply these questions/interventions?• Reviewing results of accident and near-miss investigations• Reviewing leading indicators such as JSA Quality, JSA Rates,

Accident Investigation Quality• Reviewing safety audit results• At regular corporate staff meetings• When visiting the sites – meeting with site leadership team, touring

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

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

Are we doing what we should? Are we giving this our best effort?


Additional Reading

• DEKRA Insight White Papers• Determining Serious Injury and Fatality Exposure Potential• New Findings on Serious Injuries and Fatalities• The Paramount Importance of Potential• Implementation of Life-Saving Safety Rules• Does Zero Tolerance Really Work?• Safety Program Execution: A Key to Achieving Consistently

Good Performance

Protecting Lives:Developing Effective

Serious Injury and Fatality Prevention

Karl L. BossungDEKRA Insight

Documents

Steps to Prevent Serious Workplace Injuries and Fatalities · Steps to Prevent Serious Workplace Injuries and Fatalities ... Was the event related to working under a suspended load?