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Update on Mercer ORC Task Forces -- What’s Hot and What’s Not

October 8, 2012

Stephen Newell

Principal

MERCER

Obligatory Plug: Mercer HSE Network Practice Summary

• Nine different networks with approximately 130 large global

corporations in 20 industry sectors

• The Mercer HSE Networks:

– Promote effective occupational safety, health and environmental

programs and practices in business

– Serve as a forum for key HSE developmental work

– Facilitate industry understanding of and input into national

occupational safety, health, and environmental policy

The Mercer ORC HSE Network model is built upon the premise that

member value can be maximized through diversity; by cross-industry

benchmarking to share best practices and lessons learned

MERCER

Sample of Mercer HSE Network Member Companies

3M

Abbott Laboratories

Air Products and Chemicals, Inc.

Alcoa

Allergan

Altria

Amgen Inc.

AT&T

AstraZeneca Pharmaceuticals LP

Baxter Healthcare Corporation

Becton Dickinson and Company

Biogen Idec

The Boeing Company

BP America Inc.

Bristol-Myers Squibb Company

Cargill, Inc.

Caterpillar, Inc.

Chevron Corporation

The Coca-Cola Company

Colgate-Palmolive Company

Corning Incorporated

Chrysler LLC

The Dow Chemical Company

Duke Energy

E. I. DuPont de Nemours & Co., Inc.

Eastman Chemical Company

Eli Lilly and Company

ExxonMobil Corporation

Ford Motor Company

General Electric Company

General Motors Corporation

Goodrich Corporation

The HEICO Companies

Hess Corporation

Hewlett-Packard Company

Honeywell International

Ingersoll-Rand Company

International Paper Company

ITT Corporation

John Deere

Johnson & Johnson

Kimberly-Clark Corporation

Kraft Foods Global, Inc.

Lawrence Berkeley National

Laboratory

Lockheed Martin Corporation

Marathon Oil Company

Mars, Incorporated

MeadWestvaco Corporation

MedImmune

Merck & Company, Inc.

Miller Coors LLC

Monsanto Company

Navistar Inc.

Northrop Grumman Corporation

Novartis Corporation

Pfizer, Inc.

Philip Morris, USA

Pitney Bowes Inc.

PPG Industries, Inc.

Pratt & Whiney/Rocketdyne

The Procter & Gamble Company

Raytheon Company

Sanofi-aventis

Schering-Plough Corporation

The ServiceMaster Company

Shell Chemical Company

The Sherwin-Williams Company

Siemens Power Generation, Inc.

Sprint Nextel Corporation

Sunoco, Inc.

U. S. Steel Corporation

United Parcel Service

United Technologies Corporation

Verizon Communications

W. L. Gore & Associates

W. W. Grainger, Inc.

Walt Disney Company

MERCER

I. What We Will Cover re. Metrics

A. Background: Hard to chart a future if you don’t understand the past

B. Challenge/Problem Statement: What are we trying to fix and why does it

matter?

C. Proposed Path Forward – Mercer ORC Alternative Metrics Pilots

– Why needed

– Rationale for approach

– Proposed metrics

– Possible barriers and ways to overcome them

D. Shaping the future

– How do we get leadership to focus on the issue?

– How do we successfully advocate change?

– How do we make change sustainable?

MERCER

II. What We Will Cover re. Fatality and Serious Injury Prevention

A. A new approach for using data, based on work of Dan Petersen, Fred

Manuele, Rand, Tom Krause and BST, and the Mercer ORC Alternative

Metrics Task Force

B. A new approach for addressing risk that creates a different risk

recognition, assessment and mitigation paradigm for exposures with

high gravity potential

C. Evolving perspectives on human error, that lead to a new approach to

getting better informed incident investigations

D. Perspectives on foundational aspects of prevention such as leadership

commitment, employee engagement, management systems, and

metrics and what needs to be different in situations with FSI potential.

NOTE: Much of this work is still in the developmental stage.

MERCER

I. Alternative Metrics Task Force

“The Secret To Creativity Is Knowing How

To Hide Your Sources”

Albert Einstein

MERCER


B. Challenge/Problem Statement: What are wee trying to fix and why does it

matter?


– Why needed









MERCER

A. Background – Evolution of Current S&H Performance Metrics

1. Pre- OSHA Era– ANSI Z-16.1 and Z-16.2

2. Implementing the OSHA Act

3. OSHA metrics twenty years later…what changed in the late ‘80s and

early ’90s

4. Current metrics realities

MERCER

1. Pre-1970 (OSHA) Era: ANSI Z-16.1 and Z-16.2

• System not mandatory

• Data not consistently reported

• Complicated time charges for different case types

• No data for occupational illness

• Serious deficiencies for operating national system and generating data that

is consistent nationwide

MERCER

2. 1970 -- Implementing the OSHA Act: New metrics required by federal law

• Sections 8(c)(2) and 24(a) of the OSHA act specify the type of data that

employers are required to maintain and report. 8(c)(2) language:

– Work related deaths, injuries, and illnesses,

– Other than minor injuries requiring only first aid treatment

– Which do not involve medical treatment, loss of consciousness, restriction of

work or motion, or transfer to another job

– 24(a) specified another criteria: “loss of time from work”

• Purpose was to describe the “nature and extent” of the injury and illness

problem in the United States

• Criteria were mandatory

• Responsibility for statistical system delegated to the US Bureau of Labor

Statistics. BLS known for statistically sound (voluntary) programs

• Data were collected to produce aggregate statistics only…little pressure

from business because no real impact

MERCER

Quick Review…BLS Survey of Occupational Injuries and Illnesses (still underway)

• Mandatory survey

• Counts OSHA-recordable fatal and nonfatal workplace injuries and illnesses

• Includes all private industry plus State and local government

– Includes employers normally keeping OSHA records

– A small sample of employers normall exempt from OSHA recordkeeping

“Summary” Estimates • Number and incidence rate of cases by state and detailed industry

– Total recordable cases

– Cases with days away from work

– Cases with only job transfer or restriction

– DART cases

– Other recordable cases

• Estimates released in October after reference year

10

MERCER

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4

6

8

10

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US Occupational Injury and Illness Rates, 1973 - 2010

Total cases Cases with days away, restricted work or transfer

Cases with days away from work Cases with job transfer or restricted work

Other cases

MERCER

“Case and Demographic” Estimates

• Case characteristics

– Nature (sprain, fracture)

– Part of body

– Event (fall, overexertion from lifting)

– Source (type of machine, chemical, floor)

– Number of days away from work

– Timing of incident (day of week, time of day, hours on shift)

12

MERCER

Distribution of Injuries and Illnesses by Nature, 2010

Sprain, strains

39.8%

Bruises

8.4% Soreness, pain, except back

7.8%

Cuts, lacerations, punctures

7.7%

Fractures

7.2%

Total multiple trauma, 4.8%

Back pain, hurt back only, 3.4%

Heat burns, 1.4%

Carpal tunnel syndrome, 0.8%

Amputations, 0.5%

Tendonitis, 0.4%

Chemical burns, 0.4%

All other nature, 17.3%

MERCER

Number of fatal work injuries, 1992–2010*

The 2010 preliminary total of 4,547 fatal work injuries stayed at about the same level as the final count of 4,551 fatal work injuries reported for 2009.

Number of fatal work injuries

MERCER

MERCER

MERCER

MERCER

3. 1990 -- OSHA Metrics Twenty Years Later; What Changed?!!

• Barlow case required that OSHA have a neutral means for targeting inspections

• Thorne Auchter responded by using BLS industry data (average lost workday

case rates) to target inspections.

• Employers begin to question which cases are recordable; BLS prepares

recordkeeping guidelines to assist employers in making recordkeeping

decisions

• Guidelines morph over time from being advisory to being official Agency

interpretations of the rules…upheld in Court

• Union Carbide case begins egregious wilfull recordkeeping citation

policy…every non recorded case treated as a separate wilful citation;100

egregious willful recordkeeping citations in late ’80s – OSHA never lost a case

MERCER

Reality Check: The Good, The Bad, and The Ugly • The Good: BLS data continue: still have value for general surveillance

– Understanding the magnitude of the problem

– Tracking trends

– Identifying emerging issues

• Survey reliability is well managed and precise

• The Bad: Quality and verification problems with the source data intensify

the more the data is disaggregated

– Estimates of potential under reporting range from 10 to nearly 70%

– Relying on any single metric to gage site or business unit performance is problematic.

Data quality can vary by industry, company, business unit and site.

• The Ugly: OSHA rates, used by themselves to measure site performance,

have serious limitations. In many instances they seem:

– Overly inclusive

– Not very accurate

– The more pressure you put on them, the less accurate they get

MERCER

Drilling Down -- The BLS/OSHA Data Are Subject to Significant “Bias”

• Employers will provide data if they:

1. Can understand what is being requested

2. Think it is fair

3. Obtain some value in return.

• In many cases the OSHA recordkeeping system fails on all three

counts

• Accuracy of the OSHA records is impacted by BOTH employee

reporting practices and employer recording practices

– At least 20 different variables can affect recording and reporting of

occupational injuries and illnesses

– Reporting of most injuries and illnesses is often discretionary --

made on the basis of perceived consequences to the

injured/ill employee

MERCER

4. 21st Century -- Our Current Metrics Realities

a. The OSHA Data – OSHA rates still serve as the primary/sole metric for worker safety and

health

– However growing recognition that the OSHA definitions that may work for

general surveillance do not work well for accountability and performance

measurement purposes

Accountability = OSHA system includes cases that can’t be managed

Performance Measurement/Improvement: The OSHA data do not

provide sufficient insights into the S&H and business process to drive

needed improvements

– Data quality: Serious issues domestically; even more quality drawbacks

when used globally.

MERCER

4. 21st Century -- Our Current Metrics Reality

b. Leading Indicators

• The value of leading indicators for S&H was introduced more than a

decade ago

• Growing recognition that they are needed, but adoption has been

slow

• individual companies have experimented with individual leading

metrics

• However, no real consensus on which leading indicators should be

used; whether or not any should be benchmarked

• No science yet to establish link to outcomes

.

MERCER

Our Dilemma

• It is extremely hard to move companies off the current paradigm

• Company leaders still seem to believe that comparing OSHA injury

and illness data is a valid exercise

• Leaders are suspicious when we (individually) suggest an alternative

approach

• S0….as a profession we keep feeding the beast….

– even though we know the data are suspect

– even though misuse of the data often distorts priorities and diverts

attention away from more important safety and health matters

MERCER



C. Proposed Path Forward

– Why needed








B. Challenge/Problem Statement: What’s the issue and why does it matter?

MERCER Copyright © 2007, ORC Worldwide 25

Other than Frustration – Why Care About Metrics ??!!

1. The OSHA data have serious limitations as a global performance metric and we all know it

2. Performance excellence – you can’t manage (or improve) what you don’t measure (effectively)

3. Empowerment and the quest for our share of shrinking resources

– We occupy the moral high ground

– But…to be empowered in today’s business world you need to drive and demonstrate:

Performance

Value

Industrial hygienists and safety professionals have problems doing both

Ongoing economic pressures increasing scrutiny on all parts of the business

MERCER

Specific Metrics Limitations

1. Little Ability to Drive Continuous Improvement: Using OSHA-

based measures is the equivalent to driving blind…

a. Personal Safety: Use of a single trailing metric does not provide

insights needed to drive continuous improvement

b. Fatalities and Serious Injuries: Focus on OSHA-based measures tends

to create a blind spot for exposures that contribute to more serious

incidents

2. Wasted Time and Misdirected Resources: Use of OSHA data

contributes to behaviors that undermine performance excellence

a. Churn over whether or not a case is technically recordable

b. Diversion of resources and priorities away from more significant,

higher gravity hazards

MERCER

Limitations of Current Measures, cont.

3. Benchmarking: Wide variations exist in global data that severely limit

their value for benchmarking and comparative purposes.

a. Accuracy of the trailing metric in use is suspect – especially when used

globally

i. OSHA-based criteria for determining work relationship and the

seriousness/significance of the case contribute to inconsistent

recording

ii. Ability to audit the data is limited

b. Although industry uses leading indicators in other parts of the

business, and the safety and health profession recognizes their value,

no S&H leading indicators have wide acceptance, either for

prevention or for comparative purposes.

MERCER



B. Challenge/Problem Statement: What’s the issue and why does it matter?





C. Proposed Path Forward

-- Rationale for approach

-- Proposed metrics

-- Possible barriers and ways to overcome them

MERCER

C. Proposed Path Forward: Ideas for Implementing More Effective Safety and Health Performance Metrics

1. Basic Concepts

2. Mercer ORC Metrics Initiative

Even if you are on the right track, you’ll get run

over if you just sit there.”

Will Rogers

MERCER

1. The Opportunity: Enhance Use of Leading Indicators

• Leading metrics are necessary to drive the activities that are critical to

performance

• Leading metrics provide insights on the “quality” and effectiveness of the

safety and health process...

• Leading metrics enable business leadership to identify and drive strategic

actions that will yield performance excellence

Development Approach

• Identify key areas to be measured

• Create S&H measurement questions

• Develop measures to answer the questions

• Rank candidates

MERCER

Balanced Framework ….Metrics Simplified

• What Did We Do?

– Company - specific leading indicators

• What Were the Impacts?

– Injuries, illnesses, fatalities, workers’ comp., absenteeism, etc.

• What Value Did We Generate?

– Morality

– Reduction of loss

– Financial measures (e.g., ROI)

– Productivity

– Product quality

– Corporate responsibility/marketability

– Corporate business strategy

• How Was It Perceived?

MERCER Leading Metrics Trailing Metrics

- Observations

- Feedback

loops

- Inspections

- Audits

- Risk

Assessments

- Prevention

and Control

Behavior

(action)

Physical

Conditions

Incident

or

Near Miss

- TRIR

- LWIR

- LWSR

- Perception

Surveys

Factors

Systems

- Training

- Accountability

- Communications

- Planning and

Evaluation

- Rules and

Procedures

- Incident

Investigations

- Perception

Surveys

Incident Causation

Process Outcomes

MERCER

Which Indicators Matter?

Measure key factors that

drive performance

Support safety and health

improvement strategy Correlate with other

indicators

Get to the root cause(s)

Link to enterprise

business plan

MERCER

2. The Mercer ORC Initiative to Improve Global S&H Performance Measurement

Do the right thing. It will gratify some people

and astonish the rest.

Mark Twain

MERCER

Alternative Metrics Task Force Objectives • Develop and promote a balanced approach to S&H performance

measurement that includes:

– Leading indicators for activities and programs that address

significant risk

– Leading indicators to assess key OHS management system

elements

– A suite of trailing (outcome) measures that can form the basis of a

new global standard for benchmarking OHS performance

• Work Streams

• Team 1. Risk Focused Metrics. Jeff Shockey, ALCOA, Team Leader.

• Team 2. Management System Metrics. Kurt Krueger, GE, Team

Leader.

• Team 3. Suite of Global Trailing Metrics. Tom Slavin, Navistar, Team

Leader.

Working towards a January 1, 2013 implementation date.

MERCER

Alternative Metrics Pilot Strategy

Pilot Test One: Identify high level leading indicators that focus on

enterprise level issues, are relatively easy to compile,

Pilot Test Two: Utilize the work of the leading indicator risk and

management system teams for leading indicators that can drive

continuous improvement by focusing on metrics related to site level

programs/activities and mgt system improvements related to managing

risk

Pilot Test Three: Create a set of outcome metrics that have more value

for prevention than current OSHA-based measures

• All three sets of measures will be evaluated for global benchmarking

purposes

MERCER

New Framework: A Vertical Look At Leading Indicators

Enterprise Level Questions:

Are there policies, programs and processes in place across the enterprise that support safety and health excellence?

Do they contain elements needed to drive worker protection? Are they effectively communicated?

Site Level Questions:

Are the policies being carried out and the programs and processes being done? Is there a process to verify effective implementation?

Are they being done well? Are they having the desired impact/result?

Bridges : Evaluations

Audits Selected metrics

MERCER

Pilot Test Number One: Enterprise-Wide Leading Indicators

We can't solve problems by using the same kind of

thinking we used when we created them.

Albert Einstein

MERCER

Suggested Measurement Areas and Metrics Questions For Enterprise-Wide (Global) Benchmarking

1. Leadership commitment and support

Question: Is an effective process in place for demonstrating leadership commitment to worker safety and health?

2. Accountability

Question: Is there a process in place for holding leaders, managers, supervisors, and employees at all levels of the organization accountable for worker safety and health?

3. Risk

Question: Are there effective risk identification, assessment, and control processes in place for identifying and abating hazards?

4. Employee involvement

Question: is there a process in place to insure that employees are effectively involved in worker safety and health?

MERCER

1. Leadership Commitment: Is an effective process in place for demonstrating leadership commitment to worker safety and health? “Yes/No” evaluation criteria:

1. Worker safety and health is articulated as a core value of the

company in written policy statements.

2. A written safety and health management system is in place.

3. Safety and health goals and objectives are established in writing for

each major operating or administrative function

4. The budget process includes resource allocations to meet each

safety and health goal and objective

5. A written policy exists that employees have the right to refuse unsafe

work and the authority to correct unsafe conditions.

6. A written policy exists that employees will be provided the resources

they need to perform their jobs safely

MERCER

2. Accountability: Is there a process in place for holding leaders, managers, supervisors, and employees at all levels of the organization accountable for worker safety and health? 1. Safety and health criteria are included in performance standards for

employees, supervisors and manager throughout the organization.

2. Written performance objectives at all levels include incident

prevention activities, hazard elimination and safety and health

performance improvement (not OSHA rates)

3. Performance against safety and health goals is included in annual

performance reviews for individual employees

4. Safety and health specifications are incorporated into performance

criteria for functions such as operations, purchasing, design,

engineering, etc.

5. Cardinal rules (violation of which result in harsh penalty or

termination) have been established for key high-risk activities

MERCER

3. Risk: Are there effective risk identification, assessment and control processes in place for identifying and abating hazards? 1. A process is in place for routinely identifying hazards and conducting

risk assessments.

2. The process insures that hazard identification and risk assessments are conducted as frequently as required to ensure the safety of employees.

3. A process is in place to insure prompt incident investigation.

4. The incident investigation process includes hazard analysis to root cause.

5. A process is in place to insure the availability of effective and adequately maintained control measures.

6. A process is in place to insure timely implementation of controls.

7. A system is in place to assure abatement follow-up on all incidents and hazards.

8. A process exists for reviewing and implementing system improvements to continually reduce risk

MERCER

4.Employee Involvement: Is there a process in place to insure that employees are effectively involved in worker safety and health?

1. There is a process for involving employees in the development of

safety and health programs and policies.

2. Employees are involved in conducting safety and health training

and education.

3. Employees are involved in safety and health program audits and

reviews.

4. A system is in place to address and follow up on employee

concerns about workplace safety and health.

5. A system is in place to assess employee perceptions about

workplace safety and health.

6. A system is in place to encourage employee reporting of hazards

MERCER

Pilot Test Number Two: Leading Indicators To Drive Continuous Improvement for Critical Aspects of Risk Management (Site-Based) Management System Elements Programs and Activities

The measure of who we are is what we do

with what we have.

Vince Lombari

MERCER

Summary of Key Leading Indicators to Drive Continuous Improvement For Critical Aspects of Risk Management (Mgt. Systems, Programs, etc.)

1. Number and percent of high risk tasks identified for control

2. Percent deviation from safe work methods and permit conditions

3. Percent of inspections and testing of safety critical equipment that are

on time

4. Percent of safety–critical maintenance actions addressed on time

5. Percent of corrective actions from S&H inspections, audits, accident

and near miss incidents closed on time

6. Percent of Senior Executives with S&H goals and objectives

established for both leading and lagging measures

MERCER

Pilot Test Number Three: Developing and Implementing A New Global Trailing Metric

If you can't explain it simply, you don't understand

it well enough.

Albert Einstein

MERCER

Global Outcome Metric Team Objective: To

develop a suite of OHS Trailing Metrics that: 1. Effectively support continuous improvement, and 2. Are more suitable for global benchmarking purposes

Team Approach: Three Levels of Reporting Level One: Comprised of the most consistent data; cases with a

clearer connection to work than current data that are reasonably

serious and/or significant to the injury/illness prevention process

Level Two: Will include data from existing systems; primarily cases

recorded under the current OSHA-based criteria

Level Three: Will include near misses that could have resulted in

Level One cases

MERCER

Key Issues for Identifying Useful Trailing Metrics

1. Determining whether or not cases are work related

2. Determining whether or not cases are serious and/or significant to the injury and illness prevention process

Other Issues

• Injury vs. illness

• New case vs. old case

• Rate calculations

• Data outputs, collection cycles, etc.

MERCER

Tests for Determining Work Relationship

• The core set of global outcome metrics are limited to those cases that have

a clear connection to work. Work relationship can be determined with the

following Three-Step Analysis:

Step 1. Was the case related to a condition of employment and

therefore within the general scope of employment? Specifically, was

the employee:

• Being paid at the time of the injury and illness exposure, or

• Required by his or her employer to do the job and/or task; or

• Performance of the job mandated that the activity be undertaken?

– If the answer is “no,” then the case is not work related.

– If the answer to any of these three questions is “yes,” then the case is “in

scope” and may be considered work related if the following two tests are

satisfied.

MERCER

Tests For Determining Work Relationship, Cont.

Step 2. Was there sufficient connection between the exposure and

the resulting employee condition? Did the exposure either trigger the

onset of symptoms or contribute to the severity of the case?

• For all cases, ask: “would the case have occurred at the same time and

with the same degree of severity without the work exposure identified in

number 1 above?”

MERCER

Tests for Determining Work Relationship, Cont.

Step 3. Was the activity the employee was engaged in at the time of

the exposure so personal in nature as to negate its relevance for

prevention purposes? Even if the tests in Steps One and Two are met,

do not consider the case work related if the exposure was not subject to the

employer’s control. Examples:

– Employee throws back out from sneeze (normal body movement)

– Employee injures herself while preparing her own food or drink

• Note: Employees can be doing something other than a specific work task

and still be subject to the employer’s control. This includes support

functions connected to work processes and operations, administrative

functions connected to work, and normal living activities that routinely take

place at work IF the employer has the authority to regulate how those living

activities are conducted.

MERCER

Specific Criteria for Level One Cases Level One is intended to be a subset of relatively serious cases that have significance for the I&I prevention process and are likely to be consistently diagnosed.

A. Injuries 1. Fatalities

2. Amputations (involving bone)

3. Spinal cord injuries

4. Herniated discs of the cervical, lumbar,

and/or thoracic spinal regions

5. Concussions and/or cerebral hemorrhages

6. Loss of consciousness

7. Injury to internal organs

8. Fractured bones or teeth

9. Cartilage, tendon, and ligament tears

10. Dislocation of any joint

11. Lacerations and punctures requiring wound

closure, such as sutures, surgical glue, etc.

12 MSDs requiring surgery or resulting in

permanent impairment

13. All 3rd degree burns. 2nd degree burns greater

than 3 inches in diameter (100 cm2)

14. A punctured eardrum or confirmed work related

STS and a 25db shift from audiometric zero in

same ear

15 . Injuries of the eye requiring the services of a

physician (unless treatment is preventive)

MERCER

Specific Criteria for Level One Cases Level One is intended to be a subset of relatively serious cases that have significance for the I&I prevention process and are likely to be consistently diagnosed.

B. Illnesses 1. Occupational dermatitis with blistering and/or

cracking covering an area of skin greater than 3

inches in diameter (100cm2).

2. Occupationally acquired HIV, hepatitis B or C

3. Occupationally acquired cancer

4. Occupationally acquired lung diseases

5. Occupationally acquired infectious diseases

6. Occupationally acquired disease of the liver,

spleen, kidney, heart, brain, nervous system, pancreas, thyroid, or other vital organ

MERCER

What Would it Take to Implement These New Criteria?

• Not much additional effort

• OSHA logs currently have an “employer use column” – the margin

• Recordkeepers or managers could screen existing OSHA cases (Our Level

Two cases) and place a check in the margin for cases that are in scope for

Level One benchmarking.

• This could be done solely from existing documentation

– Work relationship determinations could be made from the log and/or

from supplementary information kept for each log entry (OSHA 301 or

equivalent)

– Selections based on Level One criteria for severity and/or significance

to the injury or illness prevention process could largely be made from

Column F of the log which requires that entries “Describe the injury or

illness, part of body affected, and object /substance that directly injured or made

the person ill”

MERCER

Questions We Are trying to Answer

Cognitive understanding: Are the case definitions worded

clearly so that they can be understood globally, and recorded and

reported consistently among members in different companies, business

units and sites?

Workload: How difficult is it to compile the data? Is it relatively easy to

derive the trailing indicator data from existing (largely OSHA-based)

records? Can the enterprise-wide leading indicators be gleaned from

records kept in corporate offices within reasonable time and resource

constraints? Can the site and program leading indicators be derived

within a reasonable time?

Value: Are the new metrics better than the existing ones? Do they

provide new insights into the efficiency and effectiveness of company

injury and illness prevention processes? Does the “gain” justify the “pain”

of compiling new data?

MERCER

What Are The Benefits of the New Mercer Data? Is the “Pain” Justified By the Gain??? • Leading Indicators

1. Data to drive continuous improvement

2. Addressing issues that are more related to fatality and serious injury

prevention than current measures

3. Will help shift leadership S&H focus from negative to positive issues; from

solely tracking “failures” to recognizing positive workplace contributions

• Trailing Indicators

1. More consistent data for internal tracking and for benchmarking

2. Focused on more conditions that have significance for the injury and illness

prevention process

3. More aligned with prevention programs that are often driven by the nature of

the injury (MSDs. Amputations, etc.)

4. Increased focus likely to increase leadership attention and investment

5. Could help address the problem of “what next” for companies with extremely

low OSHA rates

MERCER

Mercer ORC Implementation Objectives For Enhanced Metrics

• We are surveying pilot participants in October to explore their

experience and tabulate the findings.

• The plan is to modify/refine the metrics based on pilot results; release

“final” metric criteria at the November OSH meeting

• Implement new metrics concepts January 1, 2013.

• To be clear…in 2013 we will encourage members consider

using/providing:

1. Level One “core” outcome data

2. Level Two OSHA-based outcome data

3. Enterprise-wide leading indicators

4. Site-based leading indicators related to risk management

a. New concepts being tested

b. Existing Mercer ORC tool

MERCER



B. Challenge/Problem Statement: What are wee trying to fix and why does it

matter?


– Why needed





-- How do we get leadership to focus on the issue?

-- How do we successfully advocate change?

-- How do we make change sustainable?

MERCER

Shaping the Future…

1. Develop a more balanced, robust approach to S&H performance

measurement

2. Engage a “critical mass” of companies

3. Drive consensus towards a few key metrics

4. Test and validate data

5. Establish linkage between leading indicators and outcomes

MERCER

Overall Metrics Summary • Our current metrics paradigm does not work and we all know it.

• In part, the metrics we use (or don’t use) contribute to our current

plateau in injury and illness performance… because:

1. Key data are lacking to drive performance

2. We don’t fully utilize the data that already exists

3. Cases related to critical hazards are buried in other data

• Improving data on occupational injuries and illnesses requires a

different approach than has traditionally been used.

– We need to re-examine several key concepts

– We need to think about clarity and ease of use

• As a profession we know what needs to be done. The hard work will

be in getting consensus and changing the existing paradigm.

MERCER

By Now…Most of You Need A BREAK

… Warning…5 Minute Stretch Break…Then Back to Work…

MERCER

EVOLVING CONCEPTS IN FATALITY AND SERIOUS INJURY PREVENTION Preliminary Report of the Mercer ORC Fatality and Serious Injury Prevention Task Force

Ray Comingore ExxonMobil David Jacobi Kimberly Clark Glenn Murray ExxonMobil Lisa Potts

Sikorsky

Stephen Newell

Dee Woodhull

Principals

Mercer ORC HSE Networks

MERCER

“The greatest reward for doing, is the opportunity to do more.”

Earl Warren

MERCER

Session Objectives

I. Quick Problem Statement

II. Overview of Preliminary Task Force Findings and Deliverables:

a. Data

b. Risk

c. Human and Organizational Performance

d. Design and Mitigation

e. Foundations

III. Pulling it All Together (10 minutes)

a. FSI prevention Deployment Roadmap

b. Practical Tools and Checklists to Get the Job Done

c. Link to Resources and Materials

IV. Questions/Dialogue

MERCER 65 October 11, 2012

I. Problem Statement… In many industries OSHA injury and illness rates have dropped

dramatically in recent years; fatalities and serious injuries have not

experienced a similar decline

S&H pros perplexed about continuation of serious cases

Some companies experiencing an up tick in “serious near misses”

It is clear that traditional approaches to safety and health are not working

Contractors represent a particular challenge

“You only see what you know..”

Albert Einstein

Copyright © 2010, ORC Worldwide

MERCER 66 October 11, 2012 Copyright © 2008, ORC Worldwide 66

“Pillars” of the SH Profession That May be “Myths” When It Comes to Serious Injury Prevention

1. The mistaken interpretation of the Heinrich Pyramid that managing

personal safety for less serious hazards at the bottom of the safety

triangle will also address high gravity hazards at the top

2. Our collective misuse of OSHA data as the primary metric for driving

and assessing safety performance;

3. Our over emphasis on probability guesstimates when determining and

"likelihood" in conducting risk assessments that relate to high gravity

hazards

4. Our failure to effectively argue against the mistaken belief that higher

level controls are cost prohibitive; and

5. The incorrect and really unsupported assumption that most injuries

result from unsafe acts (fueled and reinforced by flawed incident

investigations).


Cumulative Impact of S&H “Myths”:

• Inertia driven by mistaken belief that current approaches work, based

on misuse/misunderstanding of the OSHA data.

• Alternative approaches not fully considered due to belief that higher

level controls are cost prohibitive and serious events are unlikely to

happen anyway

• Some feel that if injuries are really due to unsafe acts then all that is

needed is training and administrative controls…i.e., fix the employee,

not the process

MERCER

II. Task Force Findings and Deliverables A. Data Team Report

• Objective: Develop a model that can be used to identify and differentiate

situations (hazards and related contributing factors) that are precursors to

fatalities and serious injuries (FSIs)

• Findings and Deliverables:

– Fatalities and serious injuries result from situations involving a discreet

set of exposures…coupled with key contributing factors

Serious hazards are often coupled with organizational and human

factors that increase the likelihood of an incident

– Companies cannot adequately control these situations/exposures

without placing special emphasis on them

– These exposures must be identified and addressed. A tool has been

developed to identify precursor situations

– Metrics can be applied to driving continuous improvement through their

management and control


Context for A “New” Approach for Using Data To Support Serious Injury Prevention • Dan Petersen on serious injuries in 1989…

– The causal factors are different. There are frequently different sets of circumstances surrounding severity:

• In unusual and non-routine work

• Where upsets occur

• In non-production activities

• Where sources of high energy are present

• During at-plant construction operations

• Fred Manuele: ““As the data clearly shows, frequency reduction does not necessarily produce equivalent severity reduction.”

…The data requires that we adopt a different mindset, and a particularly different focus on preventing events that have serious injury potential.”


Tom Krause, BST: The traditional

safety triangle is not predictive of

FSIs

Not all injuries have

FSI potential.

A reduction of injuries

at the bottom of the

triangle does not

correspond to an

proportionate

reduction of FSI

21%

Potentially

FSI

Is the Safety Triangle Accurate Predictively?

BST findings


Examples of Work Situations that May Have High Proportions of Precursor Events

– Process instability

– Significant process upsets

– Unexpected maintenance

– Unexpected changes

– High energy potential jobs

– Emergency shutdown procedures

Specific Work Activities that May Have High Proportions of Precursor Events

– Operation of mobile equipment (and interaction with pedestrians)

– Confined space entry

– Jobs that require lock-out tag-out

– Lifting operations

– Working at height

– Manual handling

BST findings

MERCER

BST Findings (Tom Krause led task force findings)

• Injuries of differing severity have differing underlying causes.

Consequently, reducing serious injuries requires a different strategy than

reducing minor injuries.

• Most fatalities and serious injuries come from a discrete set of exposures.

These exposures can be identified and addressed

Current measurement systems create a “blind spot” for serious injury prevention

2007 Rand Study

• There appears to be no relationship between OSHA injury rates and

fatalities

– The absence of minor injuries is NOT predictive of the absence of

future fatalities

– The presence of minor injuries is NOT predictive of the presence of

fatalities in the future.


Pulling It All Together

• Dan’s Petersen and Fred Manuele made the initial case that FSI’s result

from a discrete set of exposures. The key question is: “where do you

look?”

• The Rand study reinforced these findings and showed where NOT to

look proving that OSHA injury and illness rates are NOT predictive of

FSIs. Low OSHA rates do NOT indicate that a site is free of exposures

with high gravity potential; high OSHA rates are NOT predictive of FSIs.

• The BST study completed and expanded the analysis by identifying

specific precursor situations that could result in FSIs. More importantly

the BST task force showed how this work could be done.


A New Strategy for Data Use

Consequently the strategy for reducing fatalities and serious injuries

should begin with a process to identify exposures/situations that are

precursors to fatalities and serious injuries

• Precursor data may vary by industry, employer, business unit, and even

site. Therefore, companies should begin looking for FSI precursors by

examining their own data and their own processes and creating an

inventory of their own serious hazards. Underlying conditions that could

activate or intensify the hazard should be also be factored into the

hazard inventory.

• Relevant data are also available from BLS, OSHA, NIOSH, worker’s

compensation, insurers, unions, etc.

– Supplemental data are important since individual sites may have exposures with

serious injury potential that have not (luckily) resulted in a loss

– When examining data from outside sources look for information that is relevant

to your processes and potential exposures

• Precursor data should be drawn from all available sources: accidents,

injuries, serious near misses and exposures.

MERCER

Culture, Culture,

Perceptions, Perceptions,

and Beliefsand Beliefs

F&SIF&SI PrecursorsPrecursors

–– CognitiveCognitive

–– PsychoPsycho--

behavioralbehavioral

–– Physical andPhysical and

Mental Mental

limitationslimitations

–– PerceptualPerceptual

–– SelfSelf--imposed imposed

stressstress

–– PersonnelPersonnel

–– ControlsControls

–– VisibilityVisibility

–– UpsetUpset

conditionsconditions

–– Noise/vibrationNoise/vibration

–– Equipment/Equipment/

facility designfacility design

–– WarningsWarnings

Human Human

Factors Factors

ProcessProcess

ConditionsConditions

Fatality Fatality

or or

Serious InjurySerious Injury

Risk toleranceRisk tolerance

Employee Employee

engagementengagement

Value for Value for

safetysafety

Contributing Contributing

FactorsFactors

Management Management

SystemsSystems

–– TrainingTraining

–– AccountabilityAccountability

–– CommunicationsCommunications

–– Planning andPlanning and

EvaluationEvaluation

–– Rules and Rules and

ProceduresProcedures

–– SupervisionSupervision

–– IncidentIncident

InvestigationsInvestigations

F&SIF&SI Causation Causation ProcessProcess

OutcomesOutcomes

Po

ten

tial

F&

SIH

aza

rd

Fatality Fatality

or or

Serious InjurySerious Injury

EVENTEVENT

Mercer HSE Networks Fatality & Serious Injury Task Force

Fatality Precursor Rating Matrix: Task Assessment

MERCER



Contributing Factors (activate or intensify hazard) (1 point each)

A. Hazards

(10 points each)

B. Cultural/

Organizational

(attitudes and

values)

C. Management

Systems

(policies

and practices)

D. Process

Conditions

E. Human

Factors/Behavioral

Electrical energy High risk tolerance Goals and objectives for safety performance have not been established

Significant process upsets

Physical ability not matched to job/task requirement(s)

Mechanical energy (machinery and equipment)

Low employee engagement

Low management accountability

Unexpected maintenance

Physical or mental fatigue likely

Pressurized vessels of all types (cylinders, tanks, pipes, etc.)

Value for safety is not demonstrated by senior management

Poor risk recognition training

Unexpected repair Cognitive oversaturation

Falls from Elevations Production has higher priority/value than safety

Infrequent inspections Unexpected process changes

Time pressure

Falls on same level Supervisors do not receive support for safety decisions

Poor follow-up on identified corrective actions

Emergency shutdown Incompatible work space(s)

Explosion and fire potential (chemical energy)

Safe behavior is not recognized by supervisors/managers

Poor communication of safety-critical information

Prior changes not communicated

Distraction

Crushing hazards (heavy objects—caught under or between)

Alcohol and drug abuse is found in

the workplace

Potential for miscommunication

Production pressure Pre-existing illness/injury/ condition

Engulfment hazards Employees do not receive support for safety decisions

Procedures/work instructions not adequate

Poor visibility or lighting

Circadian rhythm desynchrony

Suspended loads Personnel resources not adequate

Checklists not in use Noise/vibration Poor visual adaptation possible

MERCER

Contributing Factors (activate or intensify hazard) (1 point each)

A. Hazards

(10 points each)

B. Cultural/

Organizational

(attitudes and

values)

C. Management

Systems

(policies

and practices)

D. Process

Conditions

E. Human

Factors/Behavioral

Confined spaces or other suffocation hazards

Inadequate financial resources for safety

Standard terminology not in use

Confusing Controls/switches

Physical task oversaturation

Highly toxic chemicals Cross-monitoring not in use

Use of personal protective equipment creates awkward job performance

Drug use/self- medication

Extreme heat and cold Pre-task planning not in use

Work/task resources inadequate

Dehydration

Radiation Pre-task briefing not in use

Inadequate design Lack of skills/education for task/job

Motor vehicles Work-in-progress re- planning not in use

Inadequate warning mechanisms

Other potential fatality and serious injury exposures should be anticipated

Inadequate leadership/supervision /oversight

Improper task delegation

Authorized unnecessary hazard



MERCER

Precursor Rating Score

A. Hazards

B. Cultural/

Organizational

C. Management

Systems

(policies

and practices)

D. Process

Conditions

E. Human Factors/

Behavioral

Instructions for Use: The Initial Fatality and Serious Injury Precursor Rating Matrix is NOT a risk assessment. Rather it is a tool to

identify possible precursor situations that require further attention and assessment for inclusion in the site’s comprehensive inventory

of Fatality and Serious Injury Precursors. To make an Initial Fatality and Serious Injury Precursor Rating, select the hazards from

Column A that are associated with the potential precursor situation; then look at Columns B-E and select each contributing factor

present. Assign 10 points to each hazard and 1 point to each contributing factor.

Sum up the total points from the hazard(s) selected and from the contributing factors present. The total is the Initial Fatality and

Serious Injury Precursor Rating.

Note: Risk assessments will differ because they factor in likelihood of occurrence based on degree of control. Control issues are

addressed later in the FSI prevention process.


Fatality Precursor Rating Matrix: Task Assessment Score

MERCER

B. Risk Team Report

• Objectives: Assess effectiveness of current approaches for identifying,

evaluating, and managing situations involving serious hazards. Identify

problems/gaps and develop new tools and approaches.

• Findings and deliverables: – A new risk model that creates a separate track for addressing serious

hazards

– A new approach for conducting risk assessments that incorporates

underlying factors that activate or intensify the hazard and places

more emphasis on the degree of control

– A compendium of successful practices and tools used by member

companies


Typical S&H Prevention/Risk Model

Eval

uat

e P

roce

ss

Risk Recognition

Risk Assessment

Risk Management

MERCER

Dual Path Strategy for Prevention

Risk

Assessment:

F(x): Severity

+ Experience-

Based

Likelihood

Low

Severity

Exposure

Risk

Assessment:

F(x): Severity

+ Control-

based

Likelihood

Likely

Precursor

to Fatality

or Serious

Injury

Risk

Mitigation:

Low to Middle

Order from

Control

Hierarchy

Risk

Mitigation:

High Order

from Control

Hierarchy;

Layers of

Protection

Hazard

Recognition


New Framework for Addressing Fatalities and Serious Incidents: What Is Different for FSI Prevention?

Some existing strategies are still appropriate, but need to be executed flawlessly; other

approaches need to be modified and/or replaced entirely.

Likely

Precursor

to Fatality

or Serious

Injury

Risk

Assessment:

F(x): Severity

+ Control-

based

Likelihood

Risk

Mitigation:

High Order

from Control

Hierarchy;

Layers of

Protection


Effective Risk Recognition Relating to FSIs

• Flawless execution of what we

already know

– Pre-job planning and risk assessment

– Job Safety Analysis

– Behavioral observations

– Assessments and Audits

– Risk tolerance

• Different approach required

– New metrics and surveillance data

required for FSI precursors and

abatements

– New approaches needed for Incident

investigations and root cause analyses

Identify latent conditions in

addition to active failures

– Improve risk understanding

– Develop training on new methodologies

for identifying risk


Effective Risk Assessment Relating to FSI’s

• Flawless execution of what we

already know

– Assess the severity of the hazard


– Improve understanding of potential

severity by assessing underlying factors

that can activate or intensify the hazard

– Realign approach for determining

“likelihood of occurrence” in risk

assessment process; base likelihood on

degree of control instead of past

experience


Alternative Risk Assessment Approach for FSI Prevention – Consider:

1. The severity of the hazard, and the underlying factors that could

activate or intensify the hazard

2. Degree of control

a) The degree of control is linked to probability (high degree of

control = low probability)

b) It is easier to evaluate

c) It is more compelling; high-rated hazards with low degree of

control should be identified for higher priority

In short: In high gravity situations “likelihood” should become a second or

third tier consideration.

3. Actual exposure

a) Number of employees exposed

b) Frequency (and duration) of exposure

b



Effective FSI Risk Management • Flawless execution of what we

already know

• Management System issues: Compliance

Accountability

Management of Change

Incident reporting and investigation

Training

Metrics

Emergency preparedness and fire

prevention

– Activities related to: Exposure to and operation of mobile

equipment

Confined space entry

Lock-out tag-out

Working at height

High energy

– Addressing active errors


– Less reliance on worker to never

make a mistake

– Better application of hierarchy of

controls

– Drive continuous improvement

around precursor situations

– Focus on system weaknesses and

latent errors

– Special complexities of contractor

arrangements must be addressed

MERCER

• Objectives:

– Focus on different aspects of error, including factors that lead to

intentional and unintentional behaviors that contribute to fatal and

serious incidents.

– Identify and test effective techniques for mitigating error

• Findings and Deliverables:

– Identify Appropriate Abatement Strategies and Tools

– Assemble effective strategies to insure operational discipline

C. Human & Organizational Performance


Understanding Human Error: James Reason

• Serious injuries have multiple causal factors

• 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.

Todd Conklin: Los Alamos National Laboratory • Workers don’t usually cause events.

• Workers trigger latent conditions that exist in systems, processes, procedures,

and expectations that always lie dormant on the job site.


Views of Human Error – Sydney Dekker

1. Human error is a symptom of trouble deeper inside a system

2. Complex systems involve trade-offs between multiple irreconcilable

goals. In normal work that goes on in normal organizations safety is

never the only concern or in many instances even the primary concern.

3. People have to create safety through practice at all levels of an

organization

4. To explain failure find how people’s assessments and actions made

sense at the time, given the circumstances that surrounded them.

Consider their:

• Point of view and focus of attention;

• Knowledge of the situation;

• Objectives and the objectives of the larger organization in which

they work

MERCER

Human & Organizational Performance

• Learn from past incidents and near misses;

Incident investigation

Data Analysis

Consider performance modes

Active failures

Latent conditions

Process Characteristics

• Evaluate task and underlying conditions

• Assess current situation for human error potential with high severity

consequences

MERCER

Human & Organizational Performance • Underlying conditions: understanding key concepts

Employee Performance Modes

Skill based: highly practiced, almost automatic

Rule based: apply memorized or written rules (if… situation,,then…do)

Knowledge based: methodical.. trial and error

Active failures

Worker characteristics

Individual capabilities

Individual attitudes/human nature

Latent conditions

Work environment

Organization culture

Equipment flaws

Process Characteristics

Error traps

MERCER

• Error traps—some examples:

Time pressure

Distractions

Vague and Imprecise Guidance

Overconfidence

Inexperience

Complacency

Hazard unawareness

Sleep deprivation

Etc.


MERCER


• Operational Discipline: Defined by DuPont as “the dedication and

commitment by every member of the organization to carry out each task

the right way every time.”

• In a safety and health context, how does the organization keep employees

operating within a zone of safety?

MERCER

Operational Discipline: Key elements

• Accountability

• The head…being trained and knowing what to do

• The heart…wanting to do it

• The tools….

Employees have the checklists needed to support consistent

performance

Pre-job reviews

Behavioral observations

Incident investigation tool (HFACS)

Training: Employees know how to do task right every time

• Approaches

– Make it easy to do things right

– Make it difficult to operate outside of the safety zone

MERCER

D. Design and Mitigation Team Report

• Objective: The team focused on design issues, the Hierarchy of

Controls, layers of defense, etc. Findings from this team were used to

identify effective approaches for controlling exposures to serious hazards.

• Findings and Deliverables: – Higher level controls are a preferred option for controlling serious

hazards

– If higher level controls are not feasible, multiple layers of lower level

controls are needed

– A compendium of control strategies for 10 fatal and serious injury

contact types

– A tool to help structure decision making when lower level controls

must be used


Design/Mitigation Team Example: Control Strategies for Common Fatal/Serious Injury Contact Types

1. Struck by falling objects

2. Operation of, or interaction with,

powered industrial vehicles

3. Falls from height

4. Electrical contact

5. Head/torso contact with energized

mechanical equipment

6. Acute chemical exposure or

atmospheric hazard (including

confined space operations)

7. Exposure to chronic hazards that

lead to fatal outcomes

8. Fires and explosions

9. Road transportation

10.Workplace violence


Compendium of Control Options

1. Management of Change Guidance

2. Prevention through Design Options

3. Engineering (post installation or design) Controls

4. Administrative/Procedural Controls

5. Administrative/Behavioral Controls

6. Collection of Recognized Consensus Standards or Guidance Tools

Strength of Defense Matrix


Sample Solutions Document


E. Well Built Houses Require A Strong Foundation In addition to new technical approaches,

eliminating fatalities and serious injuries also requires:

• Leadership that views the safety and well being of the

workforce as a critical element of business performance,

and is committed and actively engaged in the injury and

illness prevention process.

• A corporate culture that fosters universal recognition of worker safety

and health as a core value of the company.

• Employees that are actively engaged in planning and driving the

company’s safety and health program

• An effective safety and health management system that translates

values, beliefs, commitments, and objectives into action

Objective = Healthy employees productively at work

/ark:/13030/hb6x0nb62g/FID4

/ark:/13030/hb6x0nb62g/FID4

MERCER

Foundations Team Report

• Objective: Develop material, guidance, tools to support the key

enablers for effective FSI prevention: Leadership, Culture, and

Management Systems

• Deliverables: – Communication Package

– Metrics

– Diagnostic Tools

– Management Systems Guidance

– FSI Prevention Deployment Roadmap

– Observation & Intervention

MERCER

Foundations Team Deliverables

• Communication Package

– Provide a package for use with Line Managers, company leadership,

other levels as appropriate to support their understanding / build the

business case

+Case for action

+Key concepts

+Deployment strategy

+How to use the toolkit

– Envision prepared PowerPoint w/talking points

• Observation and Intervention

– Integrate FSI prevention concepts into existing Observation and

Intervention tools, i.e., targeting of observation activity based on

precursor/metrics data, more effective leadership intervention and

dialogue, etc.

– Still a work in progress

MERCER


• Diagnostic Tool

– A culture assessment tool is being created that will be evaluated for its

value in predicting fatalities and serious injuries.

– The tool is based on Dan Petersen’s landmark work on S&H culture

surveys and on work from Mercer ORC Networks and the Baker panel.

– Potential to launch research

• Metrics

– A methodology is being developed to identify leading indicators to

improve control of serious hazards and to address the underlying

conditions that could activate or intensify those hazards

– A new trailing metric is being identified that tracks fatalities and serious

injuries and incidents with FSI potential

MERCER


• Deployment Roadmap

– High level intervention strategy

– Detailed implementation steps

• Management Systems Guidance

– Critical Success Factors for ‘generic’ SH&E management systems

– Additional attributes for effective FSI prevention

MERCER

Management Systems Guidance • Critical Success Factors for effective SH&E Management Systems – the

‘base case’ – Appropriate/relevant content and scope

– Truly systematic structure

– Clear ownership and accountability by line management

– Continuous improvement process

– Appropriately resourced / sustained

– Risk-based

• Considerations, aspects, attributes for SH&E Management Systems for enhanced prevention of FSIs – what is ‘different’ for FSI prevention – Risk Discovery

– Focus on incident potential consequences (vs. just actual consequences)

– Questioning culture

– New metrics beyond traditional lagging metrics

– Analyze / ‘mine’ data for FSI precursors, predictive metrics, unexpected/hidden relationships

– Training and awareness of the ‘new paradigm’

– Focus on higher-risk activities / operations

MERCER

Risk

Assessment:

F(x): Severity

+ Experience-

Based

Likelihood

Low

Severity

Exposure

Risk

Assessment:

F(x): Severity

+ Control-

based

Likelihood

Likely

Precursor

to Fatality

or Serious

Injury

Risk

Mitigation:

Low to Middle

Order from

Control

Hierarchy

Risk

Mitigation:

High Order

from Control

Hierarchy;

Layers of

Protection

Hazard

Recognition

III. Pulling it All Together

MERCER

III. Pulling it All Together: Deployment Roadmap

A. Companies need a high level intervention strategy that identifies

necessary steps for integrating new FSI concepts into ongoing operations

B. Detailed implementation steps

1. Identify targets for intervention

2. Prioritize intervention activities

3. Implement intervention

a. Control the hazard

b. Address key underlying factors

4. Assess strategy effectiveness

5. Drive continuous improvement

The key to successfully integration of key concepts into ongoing S&H

systems and processes will be practical, easy to understand

implementation steps and guidance

MERCER

Overall FSI Summary: 10 Specific Suggestions

1. Start with understanding that just managing personal safety and OSHA

recordables can leave your company vulnerable to fatalities and serious

injuries.

2. Why do FSIs continue to occur?

• Failure to recognize precursor events

• Lack of effective pre-job planning and risk analysis

• Use of low level controls against high risk

• Ineffective inspections and audits

• Poor learning from flawed incident investigation techniques

• Failure to effectively implement Management of Change processes

• Failure to recognize and address latent system weaknesses

• Human error

3. Effectively managing high gravity risk requires rethinking some

fundamental S&H concepts that are actually barriers to serious injury

prevention


Overall Summary: 10 Specific Suggestions

4. Examine your data and processes to identify and inventory serious hazards –

precursors to fatalities and serious incidents

5. Once FSI precursors are identified, apply a different risk strategy:

– Identify and understand points of human interaction with hazards at key points in the

process

– Make sure fundamental S&H approaches and controls are executed flawlessly

– Foster heightened sense of awareness and vulnerability in potential high gravity

situations

– Implement new approaches as needed

6. Don’t expect people to be consistently mistake free; especially in high gravity

situations. Provide high-level controls and/or multiple layers of control at critical

steps in your process


Overall Summary: 10 Specific Suggestions

7. Re-examine your incident investigation and root cause analysis

protocols to improve learnings from incidents

– Go beyond active errors

– Identify latent conditions that are error provocative

8. Drive continuous improvement re hazard control and to address

latent conditions that contribute to FSIs.

9. Develop new measures related to FSI prevention.

• Measures that increase focus on precursor situations

• Measures that drive performance excellence on key aspects of

your process

10. Don’t forget the leadership/empowerment/communications piece

Best practice examples are emerging….


Questions??? Comments/Suggestions for Improvement??? Need more information? Please contact Steve Newell at [email protected] or Dee Woodhull at [email protected].


mailto:[email protected]

MERCER