Severe Incident Prevention - Iowa-Illinois Safety Council · • d. Chest or abdominal trauma affecting vital organs; • e. Severe burns • 2. Life-altering injury or illness: one

D.J. Moran, Ph.D., BCBA-D

Severe Incident Prevention

4/14/17

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What is a serious incident?

Definition of Serious Injury •  Any injury or illness that resulted in:

•  1. Life-threatening injury or illness: one that if not immediately addressed is likely to lead to the death of the affected individual, and will usually require the intervention and/or external emergency response personnel to provide life-sustaining support. Examples include, but are not limited to:

•  a. Laceration or crushing injuries that results in significant blood loss; •  b. An injury involving damage to the brain or spinal cord; •  c. An event which requires the application of cardiopulmonary

resuscitation or an external defibrillator; •  d. Chest or abdominal trauma affecting vital organs; •  e. Severe burns

•  2. Life-altering injury or illness: one that results in permanent or long-term impairment or loss of use of an internal organ, body function, or body part. Examples include, but are not limited to: a. Significant head injuries b. Spinal cord injuries c. Paralysis d. Amputations e. Broken or fractured bones

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Definition of Serious Incident

•  Includes the definition of Serious Injury, and also •  An event that leads to significant environmental impact:

–  Contamination •  Biohazard release

–  Food –  Air

•  Volatile organic compounds (VOC) –  Pollution

•  Poison gas in the air •  Poison in the water supply •  Oil spills

–  Radiation release

….and much more!


•  Includes the definition of Serious Injury, •  Includes significant environmental impact, and also: •  Loss of additional critical organizational resources

–  Structural damage –  Loss of stock, supplies, equipment, natural resources –  Damaged reputation –  Financial resources

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What are the consequences of serious incidents?

•  Every day, 6,300 people die worldwide due to occupational accidents or work-related diseases –  More than 2.3 million deaths per year.

– Over 317 million accidents occur on the job annually •  Many of these resulting in extended absences from work

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What are the consequences of serious incidents?

•  The economic burden of poor occupational safety and health practices is estimated at 4 per cent of global Gross Domestic Product each year.

•  The safety and health conditions at work are very different

between countries, economic sectors and social groups. –  Deaths and injuries take a particularly heavy toll in developing

countries, especially –  Agriculture –  Fishing – Mining

Notes:

What are examples of serious incidents?







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ThePrevailingPerspec1ve

“…understand that much of the work necessary to sustain incident-free operations is of low visibility – often performed in the trenches of the organization.” p. 1 “Since the mid-1980s, industry and many service organizations have made great strides in improving key performance areas… Is the progress in preventing serious safety-related incidents consistent…? Evidence indicates that progress has been less than stellar.” p. 4

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Injuries have been reduced over the decades while

major incidents have not had a similar decline

Occupational Fatalities and Non-Fatalities

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Industry Data

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SIF Rate Example

A Common & Significant Struggle

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There are Barriers to Improvement

•  Sustainingseriousincident-freeopera1onsforthelong-termhasprovenelusiveformanycompanies.

•  Mostaccidentscouldhavebeenpreventedthroughfundamentalsafetyprac1ces.

•  Whyhaven’tcompaniesbeenmoresuccessful?Maintainingconstancyofpurposeisdifficult

•  Organiza1onalpriori1esareoHenchangingandinfluencemanagersandleaderstofocuson:–  highvisibilityoutcomes–  short-terminterests–  profit

•  Wecansaythefocusisonshort-termreinforcersratherthanlong-termreinforcers

Doesn’t Heinrich’s Safety Triangle Say These Types of Injuries and Incidents

Should have a Similar Decrease?

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Fatali1esandSeriousInjuries(FSIs)

RecordableIncidents

At-RiskBehavior

PhysicalHazards

SafetyOutcomes

ProcessIssues

OtherSystemFailures

LostTimeIncidents

FirstAid/NearMisses

l -asingleincident

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Organiza1onalBarriers

•  Afocusontoday’sproblems•  Limitedemployeeinvolvement•  Inadequatemeasurementandfeedback•  Inadequaterecogni1on•  Limitedlineorganiza1onownership•  Limitedpersonalexperience•  Misguidedop1mism

…whileincreasingthese

Decreasethese…

Management Commitment and Leadership

Involve Employees

Understand the Risk

Identify Critical Work for Controlling the Risks

Establish Performance Standards

Maintain Measurement and Feedback Systems

Reinforce and Implement Corrective Action

Improve and Update the Process

ProvenProcessImprovem

entModel

PROXIMALPERSON-RELATEDFACTORS

SafetyMo*va*on

SafetyKnowledge

SAFETYOUTCOMES

Injuries

Accidents

SAFETYPERFORMANCE

SafetyCompliance

FollowingProceduresUsingProtec2veEquipmentPrac2cingRiskReduc2on

SafetyPar*cipa*on

Communica2onHelping

StewardshipCivicVirtue

Ini2a2ngSafetyChange

DISTALSITUATIONFACTORS

SafetyClimate

ManagementCommitmentSafetySystems

SupervisorSupportInternalGroupProcesses

JobRiskWorkPressure

Leadership

DISTALPERSONFACTORS

Personality

Conscien2ousnessNeuro2cismExtraversion

LocusofControlPropensityforRiskTaking

JobABtudes

SafetyAMtudesJobAMtudes

“Experiencecontinuallyreconfirmsthatthetrueexpertsaretheindividualsperformingthework.Employeeinvolvementisclearlyacriticalprerequisiteforidentifyingandimplementingtheactionsnecessarytoachieveandsustainasafeworkplace…”p.48“Thetypicalorganizationisblessedwithtalentedindividualswaitingfortheperceptivemanagertoprovideanopportunitycongruentwiththeirpersonalstrengthsandinterests.”p.55“Theactiveinvolvementofemployeesatalllevelsoftheorganizationisrequiredtoachieveandsustainaneffectivesafetymanagementprocess…performancegapsexistbecausetheorganizationdoeslittlemorethanstatetheirdesireforemployeesinvolvementandteamwork…Understandingtherisksisaprerequisiteforidentifyingthecriticalworknecessarytocontroltherisks.”p.60“Understandingrisksrequiresin-depthknowledgeofspecificconditionsandcausalfactorsthatcouldleadtoseriousincidents.”p.68“Maintaininganadequateunderstandingofrisksinherentincomplexoperationsistrulyanever-endingjourney.Theprocessrequiresperception,attentiontodetail,dedicationandakeenthirstforknowledge.”p.74“[Latentconditions]maybepresentformanyyearsbeforetheycombinewithat-riskbehaviors...Whileunsafeactshavingadirectadverseimpactareusuallycommittedbyhands-onpersonnel,latentconditionsareoftenattributabletofailuresintheupperlayersoftheorganization…Regardlessofthetypeoforganization,thefocusshouldbeonidentifyingandimplementingspecificactionsnecessaryforreducingthepotentialforincidentsduetohumanerror.”p.76“Less-than-outstandingresultsarepredictablewhenpreventativeactionsarefocusedprimarilyonregulatorycompliance…Performancestandardsareaprerequisitetomaintainingtheoperatingdisciplinenecessaryforincident-freeoperations.”p.76“Theprimaryobjectiveofreinforcementistohelpperformersfeelappreciatedforworkwelldone.Reinforcementfacilitatestheconstancyofpurposeneededtosustainandcontinuallyimproveperformance.”p.143“Organizationalprioritiesmustcontinuallysupportimprovementandupdatingoftheseriousincidentpreventionprocess.”p.154

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Involve Employees

Understand the Risk







•  Many surveys suggest that “commitment” on the part of leaders and managers is critical for achieving excellent safety performance. – Do they know what it means to make a commitment? –  Is the term commitment overused? – What are the challenges to staying committed?


•  What is “leadership” and how does it relate to safety? •  Safety leadership seems to have its own meaning. •  Without good safety leadership, serious incidents are

more likely. – Why?

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Serious Injury Prevention

Other Objectives

Cost Control Production Customer Satisfaction

Environmental Concerns

tension Aspecificanddedicated

leaderisneededforsafety


Involve Employees

Understand the Risk






Involve Employees

•  Peopleat“point-of-control”posi8onsmustbeconsultedwhenconsideringSIPplans.– Manypeopledearlycareabouttheirjob– Workerspossessdetailedknowledgeabouthowtobestensuresafetyandevenimproveworktaskcomple8on

– Leverageknowledge;treatemployeesasvaluableresourcesratherthansimplyoverheadcosts

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Involve Employees

•  Industrial-Organiza8onalPsychologistshavecoinedthetermjobcontroltodescribe:– “aperceivedabilitytoexertsomeinfluenceoverone’sworkenvironmentinordertomakeitmorerewardingandlessthreatening”(Bond&Bunce,2003;Ganster,1989)

Involve Employees

•  Jobcontroliscorrelatedwith:–  Jobperformance–  Jobsa8sfac8on– Mentalhealth– Lowerlevelsofstress– Lowerlevelsofabsenteeism

Involve Employees

•  Organiza8onshavetalentedworkerswai8ngforpercep8vemanagerstoprovideopportuni8estocapitalizeontheirstrengths– Encourageteamwork– Supportsynergy

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Involve Employees•  Iden8fica8onofrisks–  TheSIPdesignteambrainstormsconcerns

•  Iden8fica8onofcri8calwork–  Pointofcontrolemployeesprovideinforma8onaboutproac8veac8onsrequiredtoeffec8velycontrolrisks

–  JobHazardAnalyses•  Understandingprocessfirst-hand–  Interviewabreadthofemployees–  Includepeoplewithdeepknowledge

•  Prideofownership–  Increasebuy-inbypromo8ngthevalueoftheproject


Involve Employees

Understand the Risk






Understand Risks

•  Whatcangowrong?•  Howlikelyiseachundesirableevent?•  Whatarethepoten8alimpacts?

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FailureMode&EffectsAnalysis•  Failure modes and effects analysis (FMEA) is a step-

by-step approach for identifying all possible failures in a design, a manufacturing or assembly process, or a product or service.

•  “Failure modes” means the ways, or modes, in which something might fail. Failures are any errors or defects, especially ones that affect the customer, and can be potential or actual.

•  Helps us identify how our process is most likely to fail •  Points to process failures that are most difficult to

detect

AssessmentTools

Understand the Risk•  Iden8fica8onofrisks–  TheSIPdesignteambrainstormsconcerns

•  Iden8fica8onofcri8calwork–  Pointofcontrolemployeesprovideinforma8onaboutproac8veac8onsrequiredtoeffec8velycontrolrisks

–  JobHazardAnalyses•  Understandingprocessfirst-hand–  Interviewabreadthofemployees–  Includepeoplewithdeepknowledge

•  Prideofownership–  Increasebuy-inbypromo8ngthevalueoftheproject

Ac8veandLatentErrors

Therearetwobasickindsofhumanerrors:ac8veerrorsandlatenterrors.*

•  Ac8veError–Anac8onthathasanimmediateeffect.

•  LatentError–Anac8onthathasadelayedeffect

*Reason,J.(1990).HumanError,Cambridge,UK:CambridgePress.

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•  Ac#veerrors–Ac8onsthathaveimmediateeffect.Peoplearemostfamiliarwithac8veerrors.–  Errors–  Viola8ons–  Unsafeacts

•  Haveadirectandimmediateimpactonsafetywithpoten8allyharmfuleffects

Ac8veandLatentErrors.

•  Latenterrors–Ac8onsthathavedelayedeffect.Latenterrors,ontheotherhand,areerrorswhoseeffectsaredelayedin8meandspaceandmaynotbefeltimmediately.–  Increasethelikelihoodofac8vefailures


Becauseofthe8medelaybetweenerrorandconsequence,latenterrorsandtheircausesaremuchmoredifficulttotracethanareac8veerrors.

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The Original Swiss Cheese Model

•  DevelopedbyJamesReason1990

•  Isrecognizedworldwideasanerrormodel

•  Thismodelhasbeenadaptedandupdatedmany#mes

Latent Conditions

Management Decisions

•  Setthe“scene”fortheAc#veFailuretooccur

•  Seemlikegoodideasatthe#me

•  Maylaydormantforalong#me

•  Whenallthecondi#onsare“wrong”anaccidentoccursifthereisnoSafetyNettostopit.

•  TheSafetyNetmaybepresenthoweverithasaholeinit(notbeingfollowed)

•  Management Decisions set up “Latent Conditions”

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Line Management Decisions

•  LineManagementDecisions“LatentCondi#ons”•  Aredecisionsmadebasedonwhattheythinkthemanagementreallywants

•  Aretherebutarenotrecognizedaspoten#allydangerous

•  Mayalsolaydormantforalong#me•  Whenallthecondi#onsare“wrong”anaccidentoccursifthereisnoSafetyNettostopit


Precondi#ons-TheDirtyDozen

1. Lack of Communication

2. Complacency

3. Lack of Knowledge

4. Distraction

5. Lack of Teamwork

6. Fatigue

7. Lack of Resources

8. Pressure

9. Lack of Assertiveness

10. Stress

11. Lack of Awareness

12. Norms

The Dirty Dozen of Preconditions

The Active Failure The “guilty party” who makes the mistake that results in a human error

It will be an action or lack of action that results in the error

It is the RESULT but NOT the CAUSE

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•  Is usually very experienced •  Has no intention of making the error (He knows better) •  Often has no idea how he could have been so “careless” •  Will often punish himself more than the system can •  Is very unlikely to ever do it again

Active Failures Are Usually Productive Activities That Involve an Unsafe Act

Safety Nets •  Lastchancetopreventtheaccidentfromoccurring

•  IfthereisnoSafetynetinplacethenitisaLatentFailure


•  IftheSafetynetisnotbeinguseditisanAc#veFailure

How many times does the chain of events get all the way to the Safety net and is stopped there?

Someresearcherssuggest:

Behavior76%

BehaviorandCondi8on

20%

Condi8ons4%

…butconsiderthis:

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Latent Conditions Latent Conditions

Latent Conditions Active Failures

Active & Latent Failures

Mar8n,D.K.andBlack,A.(2015).Preven8ngseriousinjuries&fatali8es—Studyrevealsprecursors&paradigms.ProfessionalSafety,Sept,35-42.

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Leadership

Observation

Feedback

Measurement

Reinforcement

Inju

ries

& In

cide

nts


Involve Employees

Understand the Risk






General Manufacturing Checklist Example Observer: Date: Observer’s Role: Steering Committee Leader Employee Shift: 1 2 3

Safe Concern N/A Feedback SIF risk? Describe any Concerns What did you see, what injury could result, what is the safe behavior?

1. Keep eyes on path when walking, and task when working

2. Use tools & equipment in good condition as designated

3. Stay clear of the “line-of-fire” and pinch points

4. Three-points of contact

5. Use all appropriate PPE

6. Keep work area free of “slip-and-trip” hazards

7. Lockout/ Tagout

8. Slow down when approaching corners or blind spots

9. Request assistance as required

10. Lift ergonomically

11. Other:

Additional notes:

Definitions

1. Keep eyes on path and task

• Watch hands while engaged in a task. Look at tools & equipment while using them. • Scan for obstructions before moving head or limbs. Scan your environment for obstructions & hazards as you walk. • Point head & face in the direction of travel to watch for protruding objects & a clear path. • Walk at a pace that allows you to react to unexpected obstructions. Stay on designated paths & walkways.

2. Use tools & equipment in good condition

• Use tools & equipment that are in good condition. Use them only as they were designed & designated for specific jobs. For example, do not substitute one tool for another, for example, screwdrivers for a pry bar.

• Only use tools & equipment within their limits. Inspect equipment prior to use. For exampled, meter voltage rating. • Examine cords and straps for nicks and cuts.

3. Stay clear of the line of fire & pinch points

• Pick a position clear of the line of fire & pinch points. Keep body parts from places where they might be crushed or pinched. Move out of wedges, corners, and from under suspended loads.

• Keep hands out from under equipment when lifting & lowering.

4. Three-points of contact

• Inspect ladder prior to use. • When climbing ladders, always have three-points of contact, such as two feet and one hand, etc.

5. Use all appropriate PPE

• Wear PPE as designated per area. • Inspect all PPE before and during use. For example, check for holes in gloves.

6. Keep area free of trip hazards

• Store tools & equipment to prevent injury. For example, remove tools & materials from ground in working area. • Keep aisles, stairwells, & doorways clear of obstacles such as trash, boxes, cords & other equipment. • Ensure the area is safe for others by using caution tape, cones, and verbal warnings, etc.

7. Lockout/ Tagout • Follow Cardinal LOTO procedures and machine specific guidelines from training documents.

8. Slow down approaching blind spots

• Use caution when walking when you approach an intersection, curve, or corner. Ensure that there are no people or solid objects in your path prior to proceeding.

9. Request assistance as required

• Request that another worker help during lifting, spotting, and safety observing. For example, ensure that a two-person lift is executed by two associates. Also ensure that there are associates in place for e-stop standby when required.

10. Lift ergonomically

When lifting manually – even light loads:

• Take a balanced stance, feet placed shoulder width apart. Draw the object close to you holding your elbows close to your body to keep the load & your body weight centered. Tighten your stomach muscles to support your back. Turn your whole body, feet first, rather than twisting at the waist. Keep your back in a neutral or straight position as you lift. Ask for help or use lifting equipment such as a forklift with large, bulky, or heavy equipment.

Documents

Severe Incident Prevention - Iowa-Illinois Safety Council · • d. Chest or abdominal trauma affecting vital organs; • e. Severe burns • 2. Life-altering injury or illness: one