“We can’t solve problems by using the same kind of thinking we used when we created them.”
A renaissance in safety and health thinking is taking place as rates for fatal and serious injuries and illnesses continue unabated. This movement is re-examining some of the concepts that underpin the safety and health profession. How senior leaders set the tone and expectations for their organizations is seen as critical. And the valuable input of front-line operators who best understand the work processes is also critical. Most importantly, there is an increased understanding that risk is heavily influenced by human and organizational factors. These factors determine how employees address hazards and influence an organization’s capacity to address hazards.
Key Issues To Be Resolved
Important issues need to be addressed to develop new approaches to prevent fatalities and serious injuries:
How can we better identify situations that have a greater likelihood to result in a fatality and/or serious injury or illness?
How can we better set priorities for addressing those situations?
How can we develop improved hazard mitigation strategies that help determine the appropriate levels of control, the appropriate number of layers of control, and most importantly, when protection is sufficient?
How can we identify and address company/ site/process human and organizational performance (HOP) characteristics that can contribute to fatalities and serious injuries?
“Low-level controls are used in critical steps and workers are never expected to make a mistake.”
Let’s define at this point fatalities and serious incidents, or FSIs. A serious injury or illness is any life-threatening injury or illness that, if not immediately addressed, is likely to lead to death. It will usually require internal and/or external emergency response personnel to provide life-sustaining support. Serious injuries or illnesses also may be life-altering. Impairment or loss of use of an internal organ, body function, or body part is the result. Examples include, but are not limited to, significant head injuries, paralysis, amputations, and broken or fractured bones.FSIs continue to occur for a number of reasons. One significant cause is a lack of respect for the hazard. This is manifested in several ways. Workplace hazards frequently are not recognized, or the risks they pose are not fully appreciated due to flawed risk assessment techniques. Sometimes employees exposed to a hazard become complacent in living with it, resulting in “normalization of deviation.”
Another reason is employers’ reliance on workers to be the last line of defense in dealing with serious hazards. Low-level controls are used in critical steps and workers are never expected to make a mistake. Perhaps the greatest reason that FSIs continue is the failure to recognize and address related human and organizational performance (HOP) factors. These factors provoke errors and/or undermine defenses.
Myths Must Go
Solutions to these challenges exist. First, we must reassess several pillars of the S&H profession that may be myths when it comes to preventing serious incidents. These long-standing assumptions include:
The mistaken interpretation of the Heinrich Pyramid (otherwise known as the “Safety Pyramid”) holding that managing less serious hazards at the bottom will effectively address higher-consequence hazards at the top;
Collective misuse of OSHA data as the primary metric for driving and assessing safety performance;
Over-emphasis on history-based probability estimates when determining “likelihood” in conducting risk assessments;
The mistaken belief that higher level controls do not provide the best business value; and
The incorrect assumption that most injuries are caused by unsafe acts, which has been fueled and reinforced by flawed incident investigations.