The Campbell Institute: Eliminating higher-potential events
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Many companies and industries are experiencing a similar challenge when it comes to improving safety performance and preventing serious incidents. Traditional lagging performance metrics, like Total Recordable and Lost Time Incident Rates, have sharply improved in recent years, often approaching best-ever levels. Yet, these numbers don’t show the complete picture. In fact, the rate of improvement for incidents with actual or potentially serious consequences has either plateaued or is improving at a slower rate. This phenomenon has caused those of us in the “safety business” to call into question long-held views about the Safety Pyramid and to adopt new strategies aimed at the prevention and elimination of potentially life-altering or life-threatening events.
It is becoming widely accepted that the tools and strategies designed to prevent less-severe incidents – like bumps and bruises, or slips, trips and falls – are necessary but probably not sufficient to effectively prevent incidents with the potential for more serious consequences.
It is important to consider the varying degrees of intensity for potential consequences. Think of it this way: When you hurt yourself while walking across the plant floor, you may fall, twist an ankle, or even suffer a fracture or laceration. While such an incident is noteworthy, the injury will generally have “reached its potential.” On the other hand, if you hurt yourself while working at height, or while breaking containment, there is a potential for serious fractures, harmful exposures or even death. The “trip to the top” of the Safety Pyramid is shorter and faster. It makes sense, then, to focus our energies – and our prevention strategies – on analyzing, understanding and developing learnings from these “higher-potential events” in order to prevent and eliminate them.
This begins with a shift in focus to risk and severity. It does not mean that all of those incidents and near misses at the base of the Pyramid don’t matter. But it does mean that we must prioritize based on those events with the greatest potential for more severe consequences. It is an acknowledgment that resources are not unlimited, and that we must first eliminate those events that can have the most significant consequences as we “move down” the Pyramid.
It also calls for us to pay as much attention – if not more – to the potential consequences of incidents versus only the actual consequences. It’s simply a matter of numbers. Thankfully, most of us do not experience enough incidents with actual life-altering or life-threatening consequences to perform meaningful analysis. But if we include in our analysis incidents and near misses with potentially serious consequences, we significantly expand our opportunity for learning.
Analyzing incidents’ potential consequences allows us to begin evaluating barriers – how many barriers and the effectiveness of those barriers in mitigating either the probability or the likely outcome of events. So, it’s not the severity of the actual consequence that determines factors like how extensively we investigate an incident or whether it triggers any number of post-incident actions. Rather, it is the severity of the potential consequences that determines these activities.
It follows, then, that the performance metrics we use to measure our safety performance should align with this philosophy. Most of us today rely on “traditional” metrics, like the aforementioned TRIR or LTIR, to measure our safety performance. Neither of these metrics is particularly meaningful or insightful, as they fail to indicate severity, nor are they risk-based. They provide incident rates based on the treatment the injury received, but they do not generally relate to either how severe the injury was, or more importantly, how severe the injury could have been.
A more effective approach would be to utilize a metric that is based on severity – how bad was it (the actual “hurt”), how bad could it have been (the potential “hurt”) and what barriers were in place to prevent it from reaching its most severe reasonable potential. In this way, an organization can focus its priorities on efforts that will make the greatest contribution to eliminating potentially serious events. And at the same time, it establishes a metric that encourages risk discovery and open reporting – developing a learning culture.
This article represents the independent views of the author and should not be construed as a National Safety Council endorsement.
Glenn Murray has been with ExxonMobil for nearly 32 years. In his current role as Project Executive, Murray is leading a corporate-wide safety initiative. ExxonMobil is a member of the Campbell Institute at the National Safety Council.