Recognizing Predictive Indicators for Fatalities and Serious Injuries

1
Recognizing Predictive IndicatorsforFatalities
and Serious Injuries

• Fred A. Manuele, CSP, PE
• President
• Hazards, Limited

2
What I Will Comment On

• A phenomenon
• Statistics on fatalities and serious injuries
• Debunking a myth

3
What I Will Comment On

• Fatalityserious injury characteristics
• Significance of organizational culture
• The business climate, and culture
• A mechanism for an internal study

4
What I Will Comment On

• Improving incident investigation
• Making gap analyses
• A near hit data gathering system
• The need for a different mind set

5
The Phenomenon

• Reliance on traditional approaches to fatality
• prevention has not always proven effective.
• This fact has been demonstrated by many
• companies, including some thought of as top
• performers in safety and health, as they
• continue to experience fatalities while at the
• same time achieving benchmark performance
• in reducing less-serious injuries and illnesses.

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The Phenomenon

• ORC Worldwide 140 Fortune 500 companies
• Data gathering system on fatalities and life
  threatening incidents
• We, collectively, do not know enough about causal
  factors

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Statistical Indicators Fatalities

• National Safety Council Accident Facts
• (Now Injury Facts)
• Bureau of Labor Statistics National
• Census of Fatal Occupational Injuries

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Statistical Indicators Fatalities

• No. of
• Number of Fatality Workers
• Year Fatalities Rate in 1000s
• 1941 18,000 37 48,100
• 1951 16,000 28 57,450
• 1961 13,500 21 64,500
• 1971 13,700 17 78,500
• 1981 12,500 13 99,800
• 1991 9,800 8 116,400
• 2001 5,900 4.3 136,000

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Statistical Indicators Fatalities

• From 1941 through 2001
• Employment increased over 280
• Number of fatalities down over 67
• Fatality rate reduced over 88

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Statistical Indicators BLS ReportsAll
Fatalities All Occupations

• Number of Fatality
• Year Fatalities Rate
• 2001 5,900 4.3
• 2002 5,524 4.0
• 2003 5,559 4.0
• 2004 5,703 4.1
• 2005 5,702 4.0
• 2006 5,703 3.9

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Statistical Indicators BLS ReportsAll
Fatalities All Occupations

• Relate 2002 to 2006
• Number of fatalities increased 3.2
• Fatality rate stayed the same
• Why did the number of fatalities increase?
• Why did the fatality rate not continue the
  downward trend in previous years?

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Statistical Indicators BLS ReportsFatality
Rates Selected Occupations

• Industries 2005 2006
• Mining 25.6 27.8
• Transportation/wrhsing 17.6 16.3
• Construction 11.0 10.8
• Utilities 3.6 6.2
• Wholesale trade 4.4 4.8
• Manufacturing 2.4 2.7

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Statistical Indicators BLS

• Lost-Worktime Injuries and Illnesses
• Characteristics and Resulting Time
• Away From Work
• Table 10 Percent distribution of nonfatal
• occupational injuries and illnesses involving
• days away from work Private Industry

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Statistical Indicators BLS

• Percent of days-away-from-work cases involving
• these numbers of days
• 1 2 3-5 6-10 11-20 21-30 31 or more
• 1995 16.9 13.4 20.9 13.4 11.3 6.2 17.9
• 2005 14.3 11.6 19.0 12.7 11.5 6.5 24.2
• -15.4 -13.4 -09.1 -6.0 1.8 4.8
  35.2
• Change
• from 1995

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Statistical Indicators

• You can not conclude from the BLS
• data that the number of incidents
• resulting in severity has increased
• You can conclude that incidents
• resulting in severity are a larger
• segment of all lost time injuries

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Statistical Indicators

• National Council on Compensation
• Insurance
• The Remarkable Story of Declining FrequencyDown
  30 in the Past Decade
• Also down in Canada, France, Germany,
• UK, Japan

17
Statistical Indicators

• National Council on Compensation Insurance (2005
  paper)
• Decline in the frequency of smaller
• lost-time claims is larger than in the
• frequency of larger lost-time claims

18
Statistical Indicators

• 1999 to 2003, in 2003 hard dollars
• Value of Claim Frequency Declines
• 1. Less than 2,000 34
• 2. 2,000 to 10,000 21
• 3. 10,000 to 50,000 11
• 4. More than 50,000 7

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Debunking a Myth

• A barrier
• Reducing injury frequency will
• equivalently reduce incidents
• resulting in severe injury

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Debunking a Myth

• Many safety practitioners believe and
• profess that efforts concentrated on
• the types of accidents that occur
• frequently will also address the
• potential for severe injuries.

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Debunking a Myth

• Jim Johnson Im sure that many of us
• have said at one time or another that
• frequency reduction will result in severity
• reduction. This popularly held belief is
• not necessarily true. If we do nothing
• different than we are doing today, these
• types of trends will continue.

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DNV Consulting

• Much has been said about the classical loss
  control pyramid, which indicates the ratio
  between no loss incidents, minor incidents, and
  major incidents, and it has often been argued
  that if you look after the small potential
  incidents, the major loss incidents will improve
  also.

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DNV Consulting

• The major reality however is somewhat
• different. If you manage the small
• accidents effectively, the small accident
• rate improves, but the major accident
• rate stays the same, or even slightly
• increases

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Debunking a Myth

• Recall Jim Johnson saying that
• If we do nothing different than we
• are doing today, severe injury
• trends will continue

25
Debunking a Myth

• Jims view supported by a world famous
  philosopher who said
• If you keep doing what you
• did, you will keep getting what
• you got

26
Debunking a Myth

• The world class philosopher
• If you keep doing what you did,
• you will keep getting what you got
• Dr. Lawrence Berra

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Debunking a Myth

• As the data clearly shows, frequency
• reduction does not necessarily produce
• equivalent severity reduction
• Severity reduction requires specially
• crafted initiatives, focused on hazards
• and risks that present severe injury potential

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A Different Approach Needed

• The data requires that we adopt a
• different mind set, one that results
• in a particularly directed focus on
• preventing low probability, severe
• consequence events.

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Characteristics of Severe Injuries Studies Over
1,200 Incidents

• A large proportion of severe injuries occur
• In unusual and non-routine work
• Where upsets occur normal to abnormal
• In non-production activities
• Where sources of high energy are present
• In at-plant construction operations

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Characteristics of Severe Injuries

• Many accidents resulting in
• severity are unique and singular
• events, having multiple, complex,
• cascading technical, organizational
• or cultural causal factors

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Characteristics of Severe Injuries

• Largely, causal factors for low
• probability/severe consequence events
• are not represented in the analytical
• data on incidents that occur frequently,
• but such incidents may be predictors of
• severity potential if a high energy
• source is present

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In the Studies Made

• The quality of incident investigations,
• on average, was abysmal.

33
Predictive Specifics From Studies

• Thirty-five percent of severe injuries
• were triggered by a deviation from
• normal operations upsets
• Over a 10 year period, 51 of fatalities
• occurred to contractor employees

34
Predictive Specifics From Studies

• In three companies with a combined
• total of 230,000 employees, each
• company having very low OSHA rates,
• 74 of severe injuries occurred to
• support personnel

35
Predictive Specifics From Studies

• Percent of severe injuries that occurred to
  non-production personnel in two other companies
• Company A 63
• Company B 67

36
Predictive Specifics From Studies

• For companies with OSHA rates higher
• than industry averages, and in
• companies where there is heavy
• material handling or the work is highly
• repetitive, the percent of severe injuries
• occurring to production personnel was
• higher

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Predictive Specifics From Studies

• About 50 of major accidents involved
• powered mobile equipment fork lift
• trucks, cranes, etcetera
• Reviews of electrical fatalities indicate
• that, the design of the systems
• produced error-inducing situations

38
Predictive Specifics From Studies

• Having effective management of
• change procedures would have greatly
• reduced major accident potential
• Complacency and overconfidence was
• often a factor

39
Dan Petersen On Severe Injuries

• The mass data indicates that the types of
• accidents resulting in temporary total
• disabilities are different from the types of
• accidents resulting in permanent partial
• disabilities or in permanent total
• disabilities or fatalities

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Dan Petersen On Severe Injuries

• The causal factors are different
• There are different sets of
• circumstances surrounding severity
• If we want to control serious injuries,
• we should try to predict where they will
• happen

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A Study of Fatalities

• UAW Data
• Skilled trades people, 20 percent
• of population
• Have 41 percent of fatalities

42
Corporate Culture and Safety

• The physical cause of the loss of
• Columbia and its crew was a breach
• in the Thermal Protection System
• on the leading edge of the left wing.
• In our view, the NASA organizational
• culture had as much to do with this
• accident as the foam.

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Corporate Culture and Safety

• Columbia
• Organizational culture refers to the basic
  values, norms, beliefs, and practices that
  characterize the functioning of an institution.

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Corporate Culture and Safety

• Columbia
• At the most basic level, organizational
• culture defines the assumptions that
• employees make as they carry out
• their work. It can be a positive or a
• negative force.

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Corporate Culture and Safety

• In every organization
• Values, norms, beliefs, and practices are
  translated into a system of expected behavior
  that impacts positively or negatively on
  decisions taken

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Corporate Culture and Safety

• with respect to management systems,
• design and engineering, operating
• methods, and prescribed task
• performanceand how much risk
• taking is acceptable

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On Major Accidents

• James Reason Managing the Risks of
  Organizational Accidents
• Stresses the long term impact of
• inadequate safety decision making
• on an organizations culture

48
On Major Accidents

• Reason The impact of (top level)
• decisions spreads throughout the
• organization, shaping a distinctive
• corporate culture and creating
• error-producing factors within
• individual workplaces.

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On Major Accidents

• Donald A. Norman The Psychology
• of Everyday Things
• Most major accidents follow a series
• of breakdowns and errors.

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On Major Accidents

• Norman In many cases, the
• people noted the problem but
• explained it away, finding a logical
• explanation for the otherwise
• deviant observation.

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On Major Accidents

• Normalization of deviation is a
• more often used phrase
• Where it occurs, it is a predictor of
• severe consequences

52
Economics and Culture

• A realistic look at the current business
• climate and its possible effect on
• organizational culture and decision
• making

53
Economics and Culture

• Report of the OECD Workshop on
• Lessons Learned from Chemical
• Accidents and Incidents
• The concept of drift as defined by
• Rasmussen was generally agreed
• upon as being far too common in the
• current business environment

54
Economics and Culture

• Rasmussen defined drift as the
• systematic organizational performance
• deteriorating under competitive
• pressure, resulting in operation outside
• the design envelope where
• preconditions for safe operation are
• being systematically violated.

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Economics and Culture

• Japan Times Professor Norika Hama
• In their bid to make profit under deflationary
  pressures, Japanese companies have been
  restructuring their operations and trying to cut
  costs, and are compelled to continue using
  facilities and equipment that normally would have
  been replaced and renewed years ago, thereby
  raising the risk of accidents.

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Economics and Culture

• Also because of job cuts, the firms do
• not have sufficient numbers of workers
• who can repair and keep the old
• equipment in proper condition.
• Major companies have been hit by
• major accidents.

57
Jens Rasmussen Risk Management in a Dynamic
Society

• Companies today live in a very
• aggressive and competitive
• environment which will focus the
• incentives of decision makers on short
• term financial and survival criteria
• rather than long term criteria
• concerning welfare, safety, and the
• environment.

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Jens Rasmussen Risk Management in a Dynamic
Society

• Studies of several accidents revealed
• that they were the effects of a
• systematic migration of organizational
• behavior toward accident under the
• influence of pressure toward cost-
• effectiveness in an aggressive,
• competitive environment.

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U.S. Chemical Safety BoardBP Disaster, 2005

• The Texas City disaster was caused by
• organizational and safety deficiencies at
• all levels of the BP Corporation.
• Warning signs of a possible disaster
• were present for several years, but
• company officials did not intervene
• effectively to prevent it.

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U.S. Chemical Safety BoardBP Disaster, 2005

• Cost cutting and failure to invest left
• the Texas City refinery vulnerable to a
• catastrophe. BP targeted budgeted cuts
• of 25 percent in 1999 and another 25
• percent in 2005, even though much of
• the refinerys infrastructure and process
• equipment were in disrepair.

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U.S. Chemical Safety BoardBP Disaster, 2005

• Chairwoman Carolyn Merritt said The
• combination of cost-cutting, production
• pressures, and failure to invest caused
• a progressive deterioration of safety at
• the refinery.

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Economics and Culture

• Assume senior management wants
• to know about economics-related
• predictors for fatalities and serious
• injuries
• Safety professionals want to take
• the initiative to promote an internal
• self-analysis

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Economics and Culture

• In the current business climate, do incentives
• for decision-makers result in focusing on short
• term financial goals, the result being drift
• and systematic organizational performance
• deteriorating under competitive pressure?

64
Economics and Culture

• Are the incentive systems for executives
• and location managers constructed so
• that it is to their advantage both for
• short term financial considerations and
• for job retention to avoid needed capital
• expenditure requests, or to avoid
• spending the money after project approval
• is received?

65
Economics and Culture

• Has the gap widened between issued
• policy and procedure and what actually
• takes place at locations?
• Are risky procedures normalization of
• deviation being tolerated that would
• have been unacceptable in the past?

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Economics and Culture

• Does the organization continue using facilities
• and equipment that normally would have been
• replaced years ago, thereby increasing the risk
• of fatality and serious injury?
• Because of staff cuts, does the firm have
• sufficient numbers of qualified maintenance
• workers who can repair and keep equipment in
• proper condition?

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Economics and Culture

• Is staffing at all levels, both as to number
• and qualification, sufficient to maintain a
• superior level of safety performance?
• Does senior management discourage pushback,
• perhaps to the extent of intimidation,
• from those seeking to express concerns
• about safety?

68
Economics and Culture

• Has outsourcing resulted in more fatalities
• and serious injuries occurring to contractor
• employees?
• Has complacency and overconfidence
• developed due to presumed superior
• performance, as measured by OSHA statistics?

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Economics and Culture

• Every subject I have mentioned
• relates to comments made by safety
• professionals.
• If the culture has deteriorated because
• of economic pressures, that must be addressed
  in seeking to reduce severe
• injury potential.

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Actions to be Considered

• An analysis of severe injuries
• Improving incident investigations
• Making a gap analysis in relation to the
• provisions in ANSI Z10
• Initiating an information gathering system
• on near hits

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Analysis of Severe Injuries

• To seek predictive indicators
• Look for shortcomings in safety
• management systems

72
Avoiding Self-Delusion

• Chemical Safety Board
• A very low personal injury rate at
• Texas City gave BP a misleading
• indicator of process safety
• performance.

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Avoiding Self-Delusion

• Chair of the Oil and Gas Producers Safety
  Committee
• We conclude that the TRIR/LTIFR
• have little predictive value towards the
• potential escalation to single and
• multiple fatalities. They also tell us
• little about major accident risk.

74
Avoiding Self-Delusion

• Neither safety professionals nor
• executive managements should
• delude themselves into believing
• that achieving low OSHA rates
• assures that serious injuries and
• fatalities will not occur

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Improving Incident Investigation

• In studies of incident investigation
• reports, causal factor determination
• was abysmal.
• Seldom does it occur that incident
• investigations peel the onion back to
• the core causal factors.

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Improving Incident Investigation ReportColumbia
Accident

• Many accident investigations do not go
• far enough. They identify the technical
• cause of the accident, and then connect
• it to a variant of "operator error." But
• this is seldom the entire issue.

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Improving Incident Investigation

• When the determinations of the causal
• chain are limited to the technical flaw
• and individual failure, typically the
• actions taken to prevent a similar event
• in the future are also limited fix the
• technical problem and replace or retrain
• the individual responsible.

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Improving Incident Investigation

• Putting these corrections in place
• leads to another mistakethe belief
• that the problem is solved.

79
Improving Accident Investigation

• Too often, accident investigations
• blame a failure only on the last step in
• a complex process, when a more
• comprehensive understanding of that
• process could reveal that earlier steps
• might be equally or even more
• culpable.

80
Improving Incident Investigation

• In this Board's opinion, unless the
• technical, organizational, and cultural
• recommendations made in this report
• are implemented, little will have been
• accomplished to lessen the chance
• that another accident will follow.

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Improving Incident Investigation

• Substantial reductions in severe
• injuries are unlikely if incident
• investigation systems are not
• improved to address the reality of
• their causal factors.
• The 5 Why System

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A Gap Analysis

• To compare existing safety
• management systems with the
• content of ANSI/AIHA Z10-2005,
• the Occupational Health and Safety
• Management Systems standard.

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A Gap Analysis

• Stress those provisions that are seldom
• included in safety management systems
• Design reviews
• Risk assessments
• Hierarchy of controls
• Management of change
• Procurement

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The Critical Incident Technique

• An information gathering system
• on near hits
• To involve personnel at all levels
• in gathering data, predictive data,
• on severe injury potential

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The Critical Incident Technique

• Johnson on Incident Recall in MORT Safety
  Assurance Systems.
• Such incident recall studies, whether by
  interview or questionnaire, have a proven
  capacity to generate a greater quantity of
  relevant, useful reports than other monitoring
  techniques.

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The Critical Incident Technique

• A system that seeks to identify causal
• factors before their potentials are
• realized would serve well in attempting
• to avoid low probability-serious
• consequence events.

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Wrap-up

• It must be understood that to reduce
• severe injury potential, management
• must embed that purpose in its culture,
• thus impacting every element of the
• safety management system.

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Wrap-up

• That will require giving severe injury
• prevention a high priority, and adopting
• a different mindset.

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Wrap-up

• The intent would be to achieve an understanding
  that personnel at all levels have a particular
  responsibility to

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Wrap-up

• Give specific emphasis to anticipating,
• predicting, and taking corrective action
• on hazards and risks that may have
• fatality or serious injury potential.

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Wrap-up

• Assure that in-depth reviews of the
• reality of the root causal factors for
• incidents that result in fatalities and
• severe injuries are made.
• Identify predictive indicators, including
• knowledge obtained from studies of near-hits.

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Wrap-up

• Address organizational, operational,
• technical, and cultural causal factors
• I am assigning you the responsibility
• to get all that done.