Serious event prevention: Setting change in motion
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.
Two employees each suffer a minor cut. On the surface – and in the data – the outcomes are identical. But while one worker’s injury occurred as he was walking across a busy office and sideswiped a desk, the other’s happened when he slipped and nearly fell from the top of a railcar. If both situations were repeated, we could reasonably expect the office worker to see a similar or better outcome. But how likely is it that the rail worker would again escape with a minor injury?
In previous columns we outlined a study of serious injury and fatality (SIF) events. Undertaken by several major organizations, the findings showed that high-severity outcomes tend to have different causes and correlates than other injury types. Worse, exposures to SIFs are often hidden in the safety data where their significance is not readily apparent.
In addition to building awareness of SIF events and measuring their potential, leaders need a way to put these learnings into action. There are two fundamental things leaders can do.
Identify the precursors to SIFs
An SIF precursor is an unmitigated high-risk situation that has a high probability of resulting in serious injury if repeated. What categorizes a precursor event is not its immediate outcome, but its potential to produce a serious outcome. Sideswiping the desk and falling from a height might both result in a minor cut. But it is only the cut received from falling from height that would be considered an SIF precursor because the potential for serious injury is very high if the event were repeated. Specific types of work activities and safety controls are most closely associated with incidents that have SIF potential. For example, injuries involving hazardous chemicals, lockout/tagout, machine guarding and barricades, confined space entry, and use of hot-work permits tend to have SIF potential. These are general findings; each organization needs to identify its own unique SIF precursors.
Examine safety systems to determine their effectiveness at mitigating precursors
A major event requires a special and infrequent configuration of factors – a variety of conditions must occur and the safety controls designed to protect against a mishap must fail. A series of things all must occur, and each of these things individually has a low probability. A pipe must leak, and contain flammable material, and no one reports the leak, and no inspection identifies it, and the leaking material finds an ignition source, and there is a fire. The chance that this is the first and only time any of these events has occurred is low. It is much more likely that leaks have occurred previously, and reporting of them is sporadic, and inspections are not comprehensive, and so on. Why haven’t safety systems effectively addressed these deficiencies? An effective SIF strategy systematically addresses all the factors that contribute to safe outcomes. Both the design of safety systems targeting SIFs (their integrity) and the quality of how they are implemented (conformance) need to be addressed.
Understanding the nature of SIFs is not an academic exercise but a practical one. New findings provide a starting point for change in how safety is managed. And the implications are profound both for the organizations that apply the new principles and for the workers, families and communities who count on them.
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.