Mercer ORC Task Forces: What’s Hot and What’s Not
Stephen Newell
Principal
Mercer ORC Networks
© 2010 Mercer LLC. All rights reserved.
0
Fatality and Serious Injury Prevention
OSHA’s I2P2
© 2010 Mercer LLC. All rights reserved.
1
I. Evolving Concepts In Fatality and
Serious Injury Prevention
“Even if you are on the right track, you’ll
get run over if you just sit there.”
Will Rogers
© 2010 Mercer LLC. All rights reserved.
2
We Will Cover:
A.
Fundamental “pillars” of the safety and health profession that may be
“myths”/barriers when it comes to fatality and serious injury prevention
B.
A new approach for using data, based on work of Dan Petersen, Fred
Manuele, Rand, Tom Krause and BST, and the Mercer ORC Alternative
Metrics Task Force
C.
A new approach for addressing risk that creates a different risk
recognition, assessment and mitigation paradigm for exposures with high
gravity potential
D.
A few perspectives on human error and the link to better informed incident
investigations
E.
A best practice example

There is always risk in sharing developmental work that is not yet
complete, but ….
© 2010 Mercer LLC. All rights reserved.
3
Problem Statement…
In many industries OSHA injury and illness rates have dropped
dramatically in recent years; fatalities and serious injuries have not
experienced a similar decline
 S&H pros perplexed about continuation of serious cases
 Some companies experiencing an up tick in “serious near misses”
 It is clear that traditional approaches to safety and health are not
working
 Contractors represent a particular challenge
“You only see what you know..”
Albert Einstein
© 2010 Mercer LLC. All rights reserved.
Copyright © 2010, ORC Worldwide
4
Why This Matters
 Premise: No matter how low its OSHA recordable rate, no organization
can consider itself “best in class” or “world class” if it continues to
experience fatalities and serious injuries
 If employee health and well-being is a core value, then companies with
potentially serious hazards need to be proactive in addressing them.
– Managing/eliminating these hazards is also an opportunity to
streamline processes, reduce operating cost and eliminate
waste.
 Addressing fatalities and serious incidents requires re-evaluating some
longstanding concepts that underpin the S&H profession
– Some approaches may need to be changed; others
supplemented with additional protections that address high
risk, high hazard exposures
– Well known definition of insanity…
© 2010 Mercer LLC. All rights reserved.
5
A. “Pillars” of the SH Profession That May be
“Myths” When It Comes to Serious Injury Prevention
1.
The mistaken interpretation of the Heinrich Pyramid that managing
personal safety for less serious hazards will also address high gravity
hazards at the top of the safety triangle
2.
Our collective misuse of OSHA data as the primary metric for driving
and assessing safety performance;
3.
Our over emphasis on probability and "likelihood" in conducting risk
assessments that relate to high gravity hazards
4.
Our failure to effectively argue against the mistaken belief that higher
level controls are cost prohibitive; and
5. The incorrect and really unsupported assumption that most injuries
result from unsafe acts (fueled and reinforced by flawed incident
investigations).
© 2010 Mercer LLC. All rights reserved.
Copyright © 2008, ORC Worldwide
66
Cumulative Impact of S&H “Myths”:
• Inertia driven by mistaken belief that current
approaches work, based on misuse/misunderstanding
of the OSHA data.
 Alternative approaches not fully considered due to
belief that higher level controls are cost prohibitive
 Some feel that if injuries are really due to unsafe acts
then all that is needed is training and administrative
controls i.e., fix the employee, not the process
© 2010 Mercer LLC. All rights reserved.
7
Drilling Down on Precursors to Fatalities and Serious
Injuries: NEW Study Results re. The Heinrich Pyramid
BST- led study to better understand precursors to serious incidents
Objectives: To assess accuracy and predictability of Heinrich Pyramid and
to identify precursors to serious incidents
Participants
• BST
•
•
•
•
•
•
•
•
Mercer LLC
A.P. Moeller – Maersk Group
Archer Daniels Midland Company
BHP Billiton
Cargill Inc.
Exxon Mobil Corporation
Potash Corporation
Shell
• Research lead: Tom Krause, Chairman and Founder of BST
© 2010 Mercer LLC. All rights reserved.
8
Is the Heinrich Pyramid Accurate Descriptively?
Data from six organizations
between 2008-2009
Finding: The
traditional
safety triangle
is descriptive
*Average Rate*
Serious Injuries
and Fatalities
0014
Restricted and
Lost Workday Cases
0.30
Medical
Treatment
0.98
* Approximations of rates based on
2008-2009 data, company
populations, and using a basis of 100
employees
BST findings
© 2010 Mercer LLC. All rights reserved.
9
Is the Safety Triangle Accurate Predicatively?
Finding: The traditional safety triangle is
not predictive of FSIs
Not all injuries have
FSI potential.
A reduction of injuries
at the bottom of the
triangle does not
correspond to an
proportionate
reduction of FSI
21%
Potentially
FSI
BST findings
© 2010 Mercer LLC. All rights reserved.
10
Question: Do FSIs Have Different Causes and
Characteristics Than Less Serious Injuries?
Cardinal Rules: Many related to “cardinal rules” or “safety absolutes” (71%)
Select Activities: 90% of fatalities and serious injuries in study related to:
operation of mobile equipment or watercraft, working under suspended loads, or
working at heights.
Safety Controls: All cases related to: lock-out/tag-out, machine guarding and
barricades, confined space entry, use of hot work permits, equipment and pipe
opening of hazardous chemicals resulted in either a fatality or serious injury.
Key Finding: Fatalities and serious injuries have different causes and
contributing factors than less serious injuries.
BST findings
© 2010 Mercer LLC. All rights reserved.
11
Examples of Work Situations that May Have High
Proportions of Precursor Events
– Process instability
– Significant process upsets
– Unexpected maintenance
– Unexpected changes
– High energy potential jobs
– Emergency shutdown procedures
Specific Work Activities that May Have High
Proportions of Precursor Events
– Operation of mobile equipment (and interaction with pedestrians)
– Confined space entry
– Jobs that require lock-out tag-out
– Lifting operations
– Working at height
– Manual handling
© 2010 Mercer LLC. All rights reserved.
BST findings
12
B. Context for A “New” Approach for Using
Data To Support Serious Injury Prevention
 Dan Petersen on serious injuries in 1989…
– The causal factors are different. There are frequently different sets
of circumstances surrounding severity:
•
•
•
•
•
In unusual and non-routine work
Where upsets occur
In non-production activities
Where sources of high energy are present
During at-plant construction operations
 Fred Manuele: ““As the data clearly shows, frequency reduction does
not necessarily produce equivalent severity reduction.”
…The data requires that we adopt a different mindset, and a
particularly different focus on preventing events that have serious
injury potential.”
© 2010 Mercer LLC. All rights reserved.
13
2007 Rand Study
 There appears to be no relationship between OSHA injury rates and
fatalities
– The absence of minor injuries is NOT predictive of the absence of
future fatalities
– The presence of minor injuries is NOT predictive of the presence of
fatalities in the future.
Recent BST Findings (Tom Krause led task force findings)
 Injuries of differing severity have differing underlying causes.
Consequently, reducing serious injuries requires a different strategy than
reducing minor injuries.
 Most fatalities and serious injuries come from a discrete set of
exposures. These exposures can be identified and addressed
 Current measurement systems create a “blind spot” for serious injury
prevention
© 2010 Mercer LLC. All rights reserved.
14
Pulling It All Together
 Dan’s Petersen and Fred Manuele made the initial case that FSI’s result
from a discrete set of exposures. The key question is: “where do you
look?”
 The Rand study reinforced these findings and showed where NOT to
look proving that OSHA injury and illness rates are NOT predictive of
FSIs. Low OSHA rates do NOT indicate that a site is free of exposures
with high gravity potential; high OSHA rates are NOT predictive of FSIs.
 The BST study completed and expanded the analysis by identifying
specific precursor situations that could result in FSIs. More importantly
the BST task force showed how this work could be done.
© 2010 Mercer LLC. All rights reserved.
15
Mercer ORC Alternative Metrics Task Force
(55 member companies; 3 work streams)
 Develop and promote a balanced approach to S&H performance
measurement that supports FSI prevention and global benchmarking:
 A suite of core trailing (outcome) measures that capture fatality and
serious injury data consistently
 Using criteria that establish a closer nexus to work
 Severity based on nature/diagnosis of case
 Leading indicators focused on addressing high gravity hazards
 Leading indicators for activities and programs that address significant risk
 Leading indicators to assess key OHS management system elements
 Work Streams
 Team 1. Risk Focused Metrics. Jeff Shockey, ALCOA, Team Leader.
 Team 2. Management System Metrics. Kurt Krueger, GE, Team Leader.
 Team 3. Suite of Global Trailing Metrics. Tom Slavin, Navistar, Team Leader.
© 2010 Mercer LLC. All rights reserved.
16
A New Strategy for Data Use
 Consequently the strategy for reducing fatalities and serious injuries
should begin with a process to identify exposures/situations that are
precursors to fatalities and serious injuries
• Precursor data may vary by industry, employer, business unit, and even
site. Therefore, companies should begin looking for FSI precursors by
examining their own data.
 Relevant data are also available from BLS, OSHA, NIOSH, worker’s
compensation, insurers, unions, etc.
– Supplemental data are important since individual sites may have exposures with
serious injury potential that have not (luckily) resulted in a loss
– When examining data from outside sources look for information that is relevant
to your processes and potential exposures
 Precursor data should be drawn from all available sources: accidents,
injuries, serious near misses and exposures.
© 2010 Mercer LLC. All rights reserved.
17
C. Mercer ORC Fatality and Serious Injury
Prevention Task Force
 Objective: To develop practical strategies, methods, tools and guidance for
the prevention of fatalities and serious injuries.
– Much of the initial work is conceptual
– But the focus is on developing tools and techniques that have immediate
practical application
 42 participants engaged on 4 member-led teams focused on data analysis,
error prevention, error mitigation and risk.
– We are in the process of launching a fifth team focused on foundational
issues we view critical to success -- including leadership, culture,
management systems and the like.
 A new over arching model is emerging that creates a different track for
addressing high gravity hazards. Tools and techniques are being developed
and catalogued to populate that model.
© 2010 Mercer LLC. All rights reserved.
18
Evaluate Process
Typical S&H Prevention/Risk Model
© 2010 Mercer LLC. All rights reserved.
Risk
Recognition
Risk
Assessment
Risk
Management
19
New FSI Prevention Framework
Evaluate Process
(Same risk management steps; but different approach for potential FSI exposures)
Low
Severity
Exposure
Risk
Recognition
Precursor
to FSI
Risk
Recognition
Risk
Assessment
Risk
Assessment
Risk
Management
Risk
Management
Processes are evaluated to identify precursors to FSIs. Once precursors are identified,
different approaches are used for risk recognition, risk assessment, and risk management.
© 2010 Mercer LLC. All rights reserved.
20
New Framework for Addressing Fatalities and
Serious Incidents: What Is Different for FSI
Prevention?
Precursor
to FSI
Risk
Recognition
Risk
Assessment
Risk
Management
Some existing strategies are still appropriate, but need to be executed flawlessly; other
approaches need to be modified and/or replaced entirely.
© 2010 Mercer LLC. All rights reserved.
21
Effective Risk Recognition Relating to FSIs
 Flawless execution of what we
already know
– Pre-job planning and risk assessment
– Job Safety Analysis
– Behavioral observations
– Assessments and Audits
– Risk tolerance
© 2010 Mercer LLC. All rights reserved.
 Different approach required
– New metrics and surveillance data
required for FSI precursors and
abatements
– New approaches needed for Incident
investigations and root cause analyses
 Identify latent conditions in
addition to active failures
– Improve risk understanding
– Develop training on new methodologies
for identifying risk
22
Effective Risk Assessment Relating to FSI’s
 Flawless execution of what we
 Different approach required
already know
– Realign importance of the “likelihood
– Assess the severity of the hazard
© 2010 Mercer LLC. All rights reserved.
of occurrence” in risk assessment
process
– Rethink application of Hierarchy of
Controls
23
Risk Assessment Example
 Traditional risk assessment is based on judgment about the severity of the
hazard and the likelihood of occurrence.
 Probability (an educated guess in some circumstances) is given the same
weight as scientific information about the severity of the hazard in most risk
assessment matrices
 Knowledge about probability is difficult to obtain; judgment is often
subjective
 Probability assessments are usually based on past experience (OSHA
recordables) which have little bearing on serious incidents; also of which
luck is a component
 Failure to accurately judge probability can lead to serious consequences
 “Low probability high consequence events” really = “misjudged probability
high consequence events”
© 2010 Mercer LLC. All rights reserved.
Copyright © 2010, ORC Worldwide
24
Alternative Risk Assessment Approach for FSI
Prevention – Consider:
1.
The severity of the hazard
2.
Actual exposure
a) Number of employees exposed
b) Frequency (and duration) of exposure
3.
Degree of control
a) The degree of control is linked to probability (high degree of control
= low probability)
b) It is easier to evaluate
c) It is more compelling; high-rated hazards with low degree of control
should be identified for higher priority
In short: In high gravity situations “likelihood” should become a second or
third tier consideration.
© 2010 Mercer LLC. All rights reserved.
Copyright © 2010, ORC Worldwide
25
Effective FSI Risk Management
 Flawless execution of what we
 Different approach required
already know
 Management System issues:







Compliance
Accountability
Management of Change
Incident reporting and investigation
Training
Metrics
Emergency preparedness and fire
prevention
– Activities related to:
 Exposure to and operation of mobile
equipment
 Confined space entry
 Lock-out tag-out
 Working at height
 High energy
– Less reliance on worker to never
–
–
–
–
make a mistake
Better application of hierarchy of
controls
Drive continuous improvement
around precursor situations
Focus on system weaknesses and
latent errors
Special complexities of contractor
arrangements must be addressed
– Addressing active errors
© 2010 Mercer LLC. All rights reserved.
26
Design/Mitigation Team Example: Control
Strategies for Common Fatal/Serious Injury
Contact Types
1. Struck by falling objects
2. Operation of, or interaction with,
powered industrial vehicles
6. Acute chemical exposure or
atmospheric hazard (including
confined space operations)
3. Falls from height
7. Exposure to chronic hazards that
lead to fatal outcomes
4. Electrical contact
8. Fires and explosions
5. Head/torso contact with energized
mechanical equipment
9. Road transportation
10.Workplace violence
© 2010 Mercer LLC. All rights reserved.
27
Compendium of Control Options
1. Management of Change Guidance
2. Prevention through Design Options
3. Engineering (post installation or design) Controls
4. Administrative/Procedural Controls
5. Administrative/Behavioral Controls
6. Collection of Recognized Consensus Standards or Guidance Tools
 Strength of Defense Matrix
© 2010 Mercer LLC. All rights reserved.
28
Sample Solutions Document
© 2010 Mercer LLC. All rights reserved.
29
Well Built Houses Require A Strong
Foundation In addition to new technical approaches,
eliminating fatalities and serious injuries also requires:
 Leadership that views the safety and well being of the
workforce as a critical element of business performance,
and is committed and actively engaged in the injury and
illness prevention process.
 A corporate culture that fosters universal recognition of worker safety
and health as a core value of the company.
 Employees that are actively engaged in planning and driving the
company’s safety and health program
 An effective safety and health management system that translates
values, beliefs, commitments, and objectives into action
 Objective = Healthy employees productively at work
© 2010 Mercer LLC. All rights reserved.
30
Understanding the Incident Causation
Process is Key
Factors
Systems
Physical
Behavior
Conditions
(action)
Outcomes
Incident
or
Near Miss
- Perception
Surveys
- Training
- Inspections
- Observations
- Accountability
- TRIR
- Audits
- Communications
- Risk
Assessments
- Feedback
loops
- LWIR
- Planning and
Evaluation
- Rules and
Procedures
- Prevention
and Control
- Perception
Surveys
- Incident
Investigations
Copyright © 2007, ORC Worldwide
© 2010 Mercer LLC. All rights reserved.
- LWSR
Leading Metrics
31
31
Trailing Metrics
D. A Few Thoughts On Human Error
© 2010 Mercer LLC. All rights reserved.
32
Problem Statement
 There is a basic misunderstanding of
human error – fueled by flawed incident
investigations that frequently focus on
affixing blame and concentrate on the
last factor in a chain of events
leading up to the case
Human Error
Misunderstanding
Poor Incident Investigations
© 2010 Mercer LLC. All rights reserved.
33
Understanding Human Error:
James Reason
 Serious injuries have multiple causal
factors
 Less than adequate tools and equipment may be
present for many years before they combine with local circumstances and
active failures to penetrate the system’s layers of defenses.
Todd Conklin: Los Alamos National Laboratory
 Workers don’t usually cause events.
 Workers trigger latent conditions that exist in systems, processes,
procedures, and expectations that always lie dormant on the job site.
© 2010 Mercer LLC. All rights reserved.
34
Views of Human Error – Sydney Dekker
1. Human error is a symptom of trouble deeper inside a system
2. Complex systems involve trade-offs between multiple irreconcilable
goals. In normal work that goes on in normal organizations safety is
never the only concern or in many instances even the primary concern.
3. People have to create safety through practice at all levels of an
organization
4. To explain failure find how people’s assessments and actions made
sense at the time, given the circumstances that surrounded them.
Consider their:
• Point of view and focus of attention;
• Knowledge of the situation;
• Objectives and the objectives of the larger organization in which
they work
© 2010 Mercer LLC. All rights reserved.
35
E. Best Practice Example
 Data use
 “Capturing” your leadership
 Effective communication strategy
 Special thanks to Dave Kiser and Ken Joerger at International Paper
© 2010 Mercer LLC. All rights reserved.
36
IP LIFE Initiative
© 2010 Mercer LLC. All rights reserved.
37
37
LIFE Incident Definition/Criteria
What is a LIFE Incident?
An injury that results in 14 or more calendar days away from work AND involves:
 Organ Damage
 Concussion or Other Brain Trauma
 Bone Fracture
 Crushing Injury
 Degloving of the Hand, Finger, or other Extremity*
 Serious 2nd or 3rd Degree Burn**
*Degloving is an injury to an extremity – finger, hand, arm, leg, or foot – in which the soft tissue is peeled off
down to the bone.
**A serious burn covering 10% or more of the body, or results in diminished function or significant scarring.
OR
A Fatality or Amputation (regardless of lost workdays)
“Life-Changing” Injuries and Fatalities
© 2010 Mercer LLC. All rights reserved.
3838
2007 - 2010 LIFE Incidents By Type
6% 2%
(All IP – 204 Incidents)
Machine Safeguarding
Falls
17%
Other
Motorized Equipment
30%
27%
Exposure to Harmful
Substances
Driver Safety
18%
Other: Hit by falling objects or
caught between objects or
materials; 1 workplace violence
case
© 2010 Mercer LLC. All rights reserved.
Slips/Trips - 76%
Fall from Height - 24%
39
39
5 LIFE Focus Areas
Machine Safeguarding/ZES
Motorized Equipment
Falls
Exposure to Harmful
Substances or Environments
Driver Safety
© 2010 Mercer LLC. All rights reserved.
4040
LIFE Focus Areas and Initiatives
 Communications and Stakeholder Engagement
– Leadership engagement and support
– LIFE-themed communications and dedicated website
– LIFE Lessons
– Employee and labor union engagement
– Goals and progress reports
– Updated Accountability Standard and “Rules to Live By”
 Information and Data Driven Initiatives
– Ongoing data analysis
– Incident investigation quality and findings
– Near-miss reporting improvement
– Benchmarking
© 2010 Mercer LLC. All rights reserved.
41
41
LIFE Focus Areas and Initiatives
 Training and Education
– Training for high risk and high energy exposures
– Leadership education
– Task and hazard specific training
 Program and Risk Management Initiatives
– Continuous safety improvement projects- global teams to address 5
LIFE hazard categories
– Design and human factors
– New technology deployment
– Contractor performance program
– H&S audit program priority
– Behavior based safety focus for high risk exposures
© 2010 Mercer LLC. All rights reserved.
42
42
2010/2011 LIFE Plan
2010
 LIFE Introduced - Chairman’s Quarterly Broadcast (October)
 Communications Blitz (LIFE videos and talking points) (November)
 Initiated first continuous improvement project – Motorized Equipment (e.g., powered
industrial trucks) (December)
 LIFE Website (December)
2011
 LIFE Leader Guide (February)
 Second Team Initiated – Machine Safeguarding – (March)
 Motorized Equipment Report-out (April)
 First LIFE Quarterly Newsletter (May)
 Updated global Accountability Policy (May)
 Second LIFE Enterprise Video (Summer 2011)
© 2010 Mercer LLC. All rights reserved.
43
43
LIFE Website
http://ipnet.ipaper.com/EHS/LIFE/LIFE-Home.html
© 2010 Mercer LLC. All rights reserved.
44
44
LIFE Lessons
LIFE Lesson
communicates
LIFE incident
investigation
findings and
corrective actions
throughout IP.
© 2010 Mercer LLC. All rights reserved.
45
45
LIFE Communications
© 2010 Mercer LLC. All rights reserved.
46
46
LIFE Message
Safety is not about numbers.
It’s about your health and well-being …
it’s about our teammates and friends…
It’s about family, and our ability to go
home safely every day.
© 2010 Mercer LLC. All rights reserved.
4747
Overall Summary: 10 Specific Suggestions
1. Start with understanding that just managing personal safety and OSHA
recordables can leave your company vulnerable to fatalities and serious injuries.
2. Effectively managing high gravity risk requires rethinking some fundamental
S&H concepts that are actually barriers to serious injury prevention
3. Examine your data and processes to identify high gravity hazards –
precursors to fatalities and serious incidents
4. Once FSI precursors are identified, apply a different risk strategy:
–
–
Identify and understand points of human interaction with hazards at key points in the
process
Make sure fundamental S&H approaches and controls are executed flawlessly
5. Don’t expect people to be consistently mistake free; especially in high gravity
situations
© 2010 Mercer LLC. All rights reserved.
48
Specific Suggestions, Cont.
6.
Provide high-level controls and/or multiple layers of control at critical
steps in your process
7. Re-examine your incident investigation and root cause analysis
protocols to improve learnings from incidents
– Go beyond active errors
– Identify latent conditions that are error provocative
8. Drive continuous improvement to address latent conditions that
contribute to FSIs.
9. Develop new measures related to FSI prevention.
10. Don’t forget the leadership/empowerment/communications piece
 Best practice examples are emerging….
© 2010 Mercer LLC. All rights reserved.
49
Questions???
Comments/Suggestions for Improvement???
Need more information? Please contact Steve Newell at
[email protected] or 202-331-2620.
© 2010 Mercer LLC. All rights reserved.
Copyright © 2010, ORC Worldwide
50
www.mercer.com
© 2010 Mercer LLC. All rights reserved.
51