Procedures, said Rob Fisher, president of Fisher IT Inc., are a big part of the equation for addressing serious injuries and fatalities, the focus of the 2012 Fatality Prevention Forum near Pittsburgh. And, he stressed, it’s the system management creates that is responsible for making sure those procedures are clear, consistent and correct.It’s too common, Fisher said, to hear statements like this one: “We have good processes. Now if we could just get people to follow them.” Such a response limits response to incidents and it prevents a true assessment of the systems involved.
Fisher also noted that 90% of events are caused by something other than just the individual and that 95% of people respond similarly to the same stimuli. “People do what they do at the time that they do it for reasons that make sense to them at the time,” he said, adding that what they do may not necessarily be right but the system drives them to believe what they are doing makes sense. “It’s reasonable, therefore, for a person to miss hazards because something makes sense at the time.”
When developing procedures, Fisher advised that it’s important to drive down to the task level. “People get killed doing tasks, not jobs.” That’s why JHA and similar analyses must be task-specific. Beyond that, ensuring consistency of outcomes requires consistency of method—allowing variability in methods leads to variability in outcomes.
