Saturday was Day 1 for me at the PDC. I like to stay on top of earning continuing education and certification maintenance points and attending the preconference seminars gives me a leg up in that endeavor.
I arrived in the West concourse of the Orange County Convention Center. Obtaining my registration packet took only moments, once I presented the appropriate picture ID. For my first course I chose “Investigation and Root Cause Analysis of Fatalities and Severe Loss,” presented by Don Martin, CSP, CIH, who is a vice president at BST (Behavioral Science Technology). I have a particular interest in serious injury and fatality (SIF) prevention and BST has a fine reputation in leading efforts to reduce the occurrence of SIFs.
Don started off our enthusiastic group with the thought that the word “investigation” generally invokes a negative connotation among those who are the object of one. It does seem reasonable that those involved in an incident, from hourly employees to supervisors and managers, have some trepidation participating when they fear that their jobs may be on the line. So, as Don says, that should cause us to examine why we do investigations. Are we out to place blame or do we want to improve our ROI – reduction of injuries?
In a course dedicated to SIF prevention, you expect the term to be defined and Don did not disappoint. SIF, he explained, is any life-threatening, life-altering or fatal event or the potential for these to occur. If you overlook the potential for a SIF, then you are overlooking significant opportunities for prevention.
Not unexpectedly, Don presented the results of a study conducted by BST among seven large, multi-national firms. The study looked at the nature of injuries among about 1 million workers, from the less serious to the more serious and fatal types of injuries. While it is heresy to some, the study’s data showed that the age-old and often referenced safety triangle is not predictive of injury prevention. While many of us grew up believing in the predictive power of the triangle (prevent the larger mass of less serious injuries and the more serious and fatal events will also proportionately decrease), BST’s data show that only about 21% of all injuries have SIF potential. The new paradigm espoused in the class is that we need to shift our focus to SIF exposures and the precursors that lead to such events.
What is a precursor? Don defines it this way: “Precursors are 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.” When you break that down into its component parts, you see the power in it. For instance, high-risk situations could refer to situations where high energy sources are present (e.g., electricity, hydraulic or pneumatic forces, weight) or during times of in-plant construction (crane use is a great example) or when heavy mobile equipment is operated around pedestrians—every OSH professional has to make the determination about what is high risk to them.
The next important element of the definition is management controls. You have to know what management controls means to you and your organization. It could be such things as your lock-tag-try policy; confined space entry policy; fall protection program; or your contractor safety management system. Once you are clear on what you mean by management controls you can assess the next element.
And that final element is whether those controls are absent, ineffective or not complied with. This requires honest appraisal, and possibly courage, so that you can confront and improve your system deficiencies.
Don led us through the rest of the class using personal examples, illustrations and discussion. As we neared the end of the class, we heard about several problematic paradigms that currently define the way many SIF investigations are conducted. The gist of several of those paradigms was the sense that we believe we have to investigate all incidents to the same degree and invest the same amount of time, energy and resources to do so. One of the new paradigms that Don proposed was that the depth of our investigations should actually be determined by SIF exposure or potential. The message was that some events are clearly more deserving of a deeper analysis and we can have a greater effect on preventing SIFs by putting our focus where the exposure and potential are the greatest.
Don concluded the class with more enlightening data from BST’s study of fatalities. Unexpectedly, he related that in 81% of the fatalities studied, the employee was doing a job that was described as routine. It is not uncommon for us to believe that fatalities occur mostly during high-risk, non-routine work. Don suggested that when high-risk work becomes routine, sometimes complacency sets in.
And finally Don related two other important statistics: 1) In 42% of the fatalities investigated, the breakdown of life saving safety rules (e.g., confined space entry, lock-tag-try, fall protection) played a significant role; and 2) in 29% of the fatalities pretask risk assessments were either not done, were ineffective or failed to set triggers for when to stop the work. Those two factors were present in 71% of the fatalities studied by BST—that should generate the thought that just focusing on those two areas would provide a significant ROI.
My first day at Safety 2014 was a good day with an excellent learning experience. I hope that each of you will have a similar positive experience throughout the balance of Safety 2014.
