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Safety Leadership

February 1, 2012

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Serious event prevention: Setting the stage for real change

Editor’s Note: Creating a dialogue, keeping the focus, asking the right questions – achieving and sustaining an injury-free workplace demands strong leadership. Throughout 2012 in Safety+Health, experts from Ojai, CA-based consulting firm BST will share their point of view on what leaders need to know to guide their organizations to achieve world-class safety performance.

By Thomas R. Krause, Ph.D.

Following the 1988 Piper Alpha disaster that killed 167 workers, the controlling company’s CEO infamously responded, “We have done all we can to prevent catastrophic failures like this one.” More than two decades later, belief in the inevitability of serious injury and fatality (SIF) events is still commonplace. We often hear leaders say “accidents sometimes happen,” or “we don’t know where these events are coming from.” These leaders aren’t callous. Many are deeply troubled by the persistence of SIF events, particularly as the rate of less severe injuries continues to fall. What’s really happening is that leaders have been hamstrung by a paradigm that misrepresents the nature of SIF events.

In last month’s column, we outlined the findings of a new study that shows why traditional safety efforts so often fail to reduce SIFs: They just weren’t designed to. SIF events usually have different causes and correlates than less serious injuries, and the potential for serious injury is low for the majority (about 80 percent) of non-SIF injuries. Put in practical terms, if you used traditional means to reduce overall injuries by 20 percent, you would net a corresponding reduction in SIFs of only about 4 percent.

The new findings in SIFs are important for many reasons, not least of which is that they provide something concrete that leaders can do. There are four key actions that leaders can take to act on this new paradigm. The first two outlined here establish a platform for action:

1. Educate key stakeholders about serious injuries and fatalities. Philosopher Thomas Kuhn once observed that people won’t let go of an old paradigm – even in the face of overwhelming counterevidence – until there is a new paradigm to replace it. In organizational safety terms, this means that to launch true change, leaders must present a complete picture of what SIF events are and how they are created. People need to be able to see SIFs in their true context. Specifically, we need to show why SIFs are not random events but the culmination of precursor situations and actions that are both distinct from the causes of less serious events and also detectable. Educating key stakeholders in this new paradigm provides a framework and common vocabulary essential to designing effective interventions.

2. Measure and understand serious injury potential. Many of the catastrophic events of the past several years (e.g., BP Texas City, Qinghe Special Steel Corp., Upper Big Branch Mine, Deepwater Horizon) illustrate the critical role of metrics in SIF prevention. In virtually every case, the incident was preceded by years in which the rate of recordable injuries was low, very low, or improving. In retrospect, the indicators of impending disaster were available – they just weren’t detected with the measures traditionally tracked in safety performance. These missed opportunities reflect confusion and misunderstanding of the relationship between minor and severe injuries, and between personal safety and process safety; and it points to the negative effect of the unexamined safety triangle. As a starting point, organizations need to analyze their own data to identify and track those precursors most frequently associated with SIF events. 

SIFs don’t have to be inevitable facts of organizational life. They can be understood, detected and prevented. Next month, we will look at two critical steps for developing an effective intervention strategy. 

Thomas R. Krause, Ph.D., is chairman of the board and co-founder of BST. Author of several books in the field of workplace safety and leadership, Krause consults with senior executives on leadership, culture and behavior change in the service of safety improvement.

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