Jim Kleinstuber-Safety Observations

7/23/2019 Jim Kleinstuber-Safety Observations

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Safety Observation

Safety Observation Process

Pathway to anInjury Free Career

If we can predict it: we can prevent it!



Safety Observation

What Is a Safety Observation?

• Tool to raise safety awareness in a non-threatening way

• Allows for directed / guided observation teams

• Tool to build trust

• eedbac! loo" mechanism

• # increase safety awareness

• $ decrease an%iety or threat of re"orting errors

• &oal is to fi% things 'uic!ly and effectively



Safety Observation

(haracteristics of effective safety "erformance)

*easurable+

ocuses on "ositive activities+

,irect im"act on outcomes+

O""ortunity for two-way feedbac! and "ositive

reinforcement+

O""ortunity for goal setting based on "erformance data+

ffective Safety *anagement



Safety Observation

Observations identify .ob site haards0 controls0

conditions0 manage e%"osure to ris!s0 reduce

e%"osure0 and thereby reduce in.ury+

A""ly a strategic a""roach)

Antici"ate and "revent active error at the .ob site+

1educe total number of 2at-ris!3 critical behaviors and/or

conditions+

Identify and eliminate the related barriers/latent organiationalwea!nesses+

(hange other factors to encourage safe behaviors+



Safety Observation

Safety Observation4Ob.ectives

• Provide "ositive reinforcement / feedbac! for safebehaviors observed+

• Identify error-li!ely conditions for corrective actions+

• &ather meaningful data for analysis that identifiesinstitutional wea!nesses in wor! managementsystems+

Do Work Safely



Safety Observation

i% the Person or the System?

Is the Person

(lumsy?

Or Is theProblem + + +

The Ste"???


http://slidepdf.com/reader/full/jim-kleinstuber-safety-observations 7/38Safety Observation

II+ 5uman Performance 6

Integrated Safety *anagement



ive 7asic Princi"les

5uman Performance Im"rovement

8+ Peo"le are fallible0 and even the best ma!e mista!es+

9+ rror-li!ely situations are "redictable0 manageable0 and "reventable+

:+ Individual behavior is influenced by organiational "rocesses and values+

;+ Peo"le achieve high levels of "erformance based largely on the

encouragement and reinforcement received from leaders0 "eers0

and subordinates+

<+ vents can be avoided by understanding the reasons mista!esoccur and a""lying the lessons learned from "ast events+



Industry Statistics on

(auses of vents

5uman

rror

=ne%"ected

rror 'ui"ment

ailures

5uman rror

O"erational ="set

System Induced rror

>organiational wea!ness



When Things &o Wrong

5ow It Is @ow

Human error is the cause of

accidents:

You are highly trained

and If you did as trained, you would

not make mistakes

so

You weren’t careful enough

so

You should be PUNIH!"#

5ow It Should 7e

Human error is a sym$tom of

trouble dee$er inside a system%

You are human

and Humans make mistakes

so

&et’s also e'$lore why thesystem allowed, or failed to

accommodate your mistake

&et’s I(P)*+! H! Y!(#



When Things &o Wrong



Where we are coming from)

I !ee" entering this in the system but something needs to be done+ The ma.ority

of the traffic going down and u" Pecos drive is s"eeding+ and a lot of the traffic

is &ov+ vehicles+ S"eed hum"s need to be "ut in "lace+ Someone is going to get

hit+

There should be S"eed hum"s installed on Pecos 1oad because of the e%cesss"eeding going on while "eo"le are wal!ing to there buildings in the morning

and also during lunch+ &ov+ vehicles and "ersonal vehicles driving very fast u"

and down the road+ @, SP, 5=*PSBBBB

As I was wal!ing from the guard gate into P-80 I observed a craft truc!ing

s"eeding from the south to the north in a 8C *P5 "osted area+ I was about to

ste" into the crosswal! when they saw me and sto""ed suddenly+ I motioned tothe driver to slow down+ They .ust laughed+



Dehicle O"erator Observation

8+C Pre Tri" Ins"ection

• Observed multi"le cars in TA-<< "ar!ing lot and discovered that several of their tires were

either under inflated or over inflated+ with weather conditions becoming a factor "ro"er

tier "ressure is im"ortant to chec! before driving+

• rost on windshield caused "otential visibility "roblem+ On discussing the issue it was

decided to be late for a meeting and ta!e the necessary time to com"letely clean the frost

from the window before travelling+

• ,uring ins"ection of my motorcycle "rior to leaving home for wor!0 I found the bra!e light

to be non-o"erational+ The tail light was wor!ing0 but not the bra!e light+ I installed a s"are

bulb and that fi%ed the "roblem+

• Observed EA@E semi driver leaving yard "ulling trailer0 he did not do a "ull test on trailer

to ma!e sure it was secure to tractor0 sto""ed driver hel"ed with "ull test+

Where we are headed)



Dehicle O"erator Observation 9+C Sto""ing

• ,river initially sto""ed with about 8/9 car length distance between our vehicle and the vehicle in front of us0 but increased

this to a full car length after discussion+

• ,river did a rolling sto" at the sto" sign+ Pointed out the F(aliforniaF sto" in a nice way and driver agreed that full sto"

would have been safer+

• ,river in government vehicle did not fully sto" at sto" sign when leaving "ar!ing lot+ I noted who the driver was >someone I

!new and s"o!e/teased them about it later+ They agreed that they should have fully sto""ed+

• ,river often yields at sto" signs rather than sto"s+ A discussion was held concerning the behavior and the drive admitted to

fault and stated that through awareness0 the drive will be com"ly to sto" signs and ma!ing a com"lete sto"+ In addition0 a

discussion was held concerning crashes that could be "revented if the drivers sto""ed com"letely as re'uired by law+

Dehicle O"erator Observation :+C Par!ing

• Several cars were noted in the "ar!ing lot as having "ar!ed outside of designated s"aces+I s"o!e with one driver0 who didnGt really care that they might get a tic!et+ They did not

want to have to wal! from TA-<C "ar!ing lot stating that it was more dangerous to wal! and

"ossibly sli" on the ice than "ar! in an unmar!ed s"ot+

• The driver did forget the turn the wheels while "ar!ing on a hill+ This behavior was

identified and will be corrected for future vehicle o"erations+



Dehicle O"erator Observation

;+C 7ac!ing

• Air"orts could be designed so that air"lanes would never have to bac! u"+

• ,river and Observer do not understand this 'uestion+ Is this as!ing if the "assenger

bac!ed u" the vehicle before the driver did?

• ,river failed to chec! rear of vehicle for any "ossible haards before bac!ing u"+ S"otter

was needed and used after being notified+

• The driver was not aware that it is a good driving "ractice to sound the horn "rior to0 and if

"ossible0 during the bac!ing u" "rocess+ 5e concurred that this signals "edestrians

behind the vehicle to clear the area and committed to begin using this "ractice+

• The driver did not sound the horn while bac!ing u"+ This was a safety concern that both

the observer and the observee learned by "erforming the ATO*I(S observation+

• ,river and Observer do not understand this 'uestion+ Is this as!ing if the driver bac!s u"

the vehicle by turning the wheels HC degrees and moving the vehicle side ways?



Safety Observation

Safety Observer 1oles and 1es"onsibilities

Observer rules for observing "erformance)

-udge the beha.ior of the worker being obser.ed with the

same criteria you would use for yourself%

/e 0udge oursel.es with e'ternal factors%

/e 0udge others with internal factors%



Safety Observation

undamental Tenets of Safety Observations

1ocuses on beha.iors and conditions

No name, no blame $rocess

Process is for $eo$le, it in.ol.es e.erybody

2i.es $ositi.e reinforcement for safe beha.iors%

Pro3acti.e4 uses leading indicators

tatistically dri.en%

Unlike )56"7) $ro.ides $rocess numbers workers control%



Safety Observation

; ssential lements

ATO*I(S Safety Process

Identify the critical beha.iors and conditions

5ollect data

Pro.ide feedback

Use data to reduce6remo.e latent organi8ationalweaknesses%



Safety Observation

ocus Shifts

rom) crisis reaction To) $rocess im$ro.ement

Safety Stand downs

1e-read "rocedures

Safety *eetings

1etraining

Sto"

Thin!

Act

1eview



Safety Observation

ocus Shifts

rom) tracking accidents To) $re.enting accidents

Total 1ecordable >T1(

,ays Away 1estricted Time >,A1T

irst Aid cases

i% the "roblem

before it in.ures the

wor!er+

Identification of error

li!ely situations+

Strengthen defenses+



Safety Observation

ocus Shifts

rom) downstream factors To) u$stream factors

Eagging indicators

@on diagnostic

(risis 1eactions

Stand downs

T1(/,A1T

Eessons learned

Eeading indicators

Process im"rovement

Accident "revention

@ear miss re"orting

,evelo" defense in de"th

rror tolerance

ust wor! environment



Safety Observation

Observations manage e%"osure to ris!s0

reduce e%"osure0 and reduce in.ury+

A""ly a strategic a""roach)

7ntici$ate and $re.ent acti.e error at the 0ob site%

)educe total number of 9at3risk critical beha.iors%

Identify and eliminate the related barriers6latent organi8ational

weaknesses%

5hange other factors to encourage safe beha.iors%



Safety Observation

Traditional methods to im"rove safety "erformance)

5ow do we change behavior?

Progressi.e "isci$line

7dministrati.e Policies

+isions, 2oals, Plans

5ore +alue tatements

afety raining

New afety Initiati.es

5ommittees

1ocus 2rou$s

7dditional "efense &ayers

5ontests ; 7wards

afety meetings

(oti.ational s$eakers



Safety Observation

Traditional safety res"onse)

In.ury) em"loyee finished cleaning toilet inside stall turned tight and hit head on coat hanger1es"onse) retrain em"loyee on being more aware of surroundings and "otential haards+

In.ury) wal!ing to truc!0 sli""ed on ice

1es"onse) em"loyee reminded to chec! wal!ing area before "roceeding to vehicle for sli""ery

conditions

In.ury) em"loyee wal!ing around vehicle-sli""ed on ice and almost fell1es"onse) retrain em"loyee on sli"s0 tri"s0 and falls safety+

In.ury) em"loyee missed di" in sidewal!0 sli""ed and fell

1es"onse) be conscious of where you are wal!ing

In.ury) em"loyee sneeed acute internal "ain in lower left rib cage area

1es"onse) encourage em"loyee to stabilie body alignment before sneeing

In.ury) dis"osing metal "iece0 cut edge caught em"loyees glove cutting through and cutting

finger

1es"onse) need to describe to wor!ers conditions that ma!e u" 2line of fire3 and self control of

natural refle%es+

5ow do we change behavior?



Safety Observation

• If we can "redict it) we can "revent itB



Safety Observation

Observations identify .ob site haards0 controls0

conditions0 manage e%"osure to ris!s0 reduce

e%"osure0 and thereby reduce in.ury+



Safety Observation

Are you from OS5A?





Safety Observation

=nderstanding 7ehavior With

A7( Analysis

Activator

Police (ar lashing 1ed

Eights

1adiation Wor! Practices

Phone rings

(onse'uence

(itation/nothing

(ontamination J/@

Tal! with caller

7ehavior

Slow down/s"eed

u"

Turbo-ris!ing

Answer "hone



Safety Observation

Influencing Eong-term 7ehavior

(onse'uences control behaviorB



Safety Observation

actors that Affect the Power of (onse'uences

he most $owerful conse<uences are:oon

5ertain

Positi.e

Timing)Sooner

Eater

(onsistency) (ertain

=ncertain

Significance) Positive

@egative



Safety Observation

eedbac!

eedbac! is a "owerful way to influence behavior

eedbac! is a conse'uence+

o be effecti.e it must be:

soon,

certain,

and $ositi.e



Safety Observation

Organiational 1es"onsibilities

)educing !rrors =obser.ations>

It is na?.e =foolish> to think that $ositi.e reinforcement is the singlemechanism for safety obser.ations success%

(anaging "efenses =data analysis>

he organi8ational change initiati.e, identification of system, facility,and e<ui$ment issues identified are at least as likely to be $rimaryim$ro.ement mechanisms as $ositi.e reinforcement%



Safety Observation

@efore the obser.ation:

&et $eo$le know you are obser.ing them 7nswer any <uestions about the $rocess (ention that there will be feedback6discussion after

7fter the obser.ation:

*bser.er reinforces safe beha.iors, and, if needed, discusses

obser.ed at3risk actions and o$tions to a.oid future

occurrence,

Interaction Techni'ue



Safety Observation

,iscuss 2at-ris!s and e%"lore barriers to wor!ing 2safely3

e$arate discussion of 9at3risk beha.iors

from $ositi.e feedback%

7sk o$en3ended <uestions

=!': /hat’s the worst accident that can ha$$enA How couldyou be hurt doing this task% /hy are you doing it this wayA>

7sk for suggestions6ideas, draw out the correcti.e action that

may be re<uired from the $erson%

)ecord comments% eek a $ersonal commitment from that

the indi.idual will carry out the action and thank them for

$artici$ating%

&iving eedbac!



Safety Observation

he goal of the beha.ioral obser.ation is to im$ro.e

=influence> the $erformance =beha.ior> of the workers

obser.ed%

It is critical for workers to understand the ty$es of beha.iors

and conditions that either increase e'$osure =at3risk

beha.iors> or reduce the risk of e'$osure =identified safe

beha.iors>%

&iving eedbac!



Safety Observation

A Safety Observation

Is a sam$ling $rocedure

Is the cornerstone of the safety $rocess

Is systematic and standardi8ed

am$les beha.iors and conditions, not indi.iduals



A Safety Observation

Shares e%"ertise)

1rom -anuary BCDC to (ay BCDC the +ehicle *$erator

*bser.ation sheet was utili8ed by the 7(3(( grou$ BE

times and by all other organi8ations FDE times%

1rom -anuary BCDC to (ay BCDC the &ifting *bser.ation

sheet was utili8ed by 7(3(( GB times and by all other

organi8ations BG times%

Documents

Jim Kleinstuber-Safety Observations