Environmental Health and Safety Management unit 2

BOS 3651, Total Environmental Health and Safety Management 1

Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:

7. Examine management tools necessary to implement effective safety management systems. 7.1 Discuss the need for a safety management system to focus on serious injuries and fatalities. 7.2 Explain how human behavior and workplace processes combine to create the potential for

serious injuries.

Reading Assignment Chapter 3: Innovations in Serious Injury and Fatality Prevention Chapter 4: Human Error Avoidance and Reduction Chapter 5: Macro Thinking: The Socio-Technical Model

Unit Lesson Serious injuries and human error play pivotal roles in the success of any accident prevention effort. The costs and other consequences created by accidents dictate the need for changes that will ensure a reduction in their occurrence. Discussing serious injuries and human error in this unit will better prepare us to tackle the details of safety management systems and ANSI/AIHA Z10 in subsequent units.

UNIT II STUDY GUIDE

Serious Injury Prevention

and Human Error Reduction

Safety pyramid based on H. W. Heinrich’s study of industrial accidents. “Heinrich’s Law” proposed that for every major injury 29 minor injuries and 300 noninjury incidents occur (Heinrich, 1931).

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In the course textbook, Manuele (2014) challenges the notion that if we eliminate all the minor injuries, the severe injuries will be taken care of as well. The accident pyramid concept first proposed by H.W. Heinrich in the 1930s has been embraced by safety professionals for decades. Manuele (2014) presents some compelling evidence that perhaps we need to focus on the top of the pyramid rather than the bottom. His research has demonstrated that incident frequency may have been reduced over the past several decades, but severity has not decreased proportionately. He also shows that serious injuries most often occur in nonroutine and nonproduction activities. On what do safety professionals focus most of their prevention efforts? Routine and production activities! Of course, increased exposure increases the risk, but if we are not experiencing serious injuries in these routine operations, maybe we have them under control and should focus more of our efforts on the nonroutine. Keep in mind that one fatal injury can quickly undo years of safety program building. Trying to identify the nonroutine operations is reminiscent of former Secretary of Defense Donald Rumsfeld’s “known knowns and unknown knowns” comments from a few years ago. Or was it “known unknowns”? Whatever—the point is that we need to examine our safety culture to see if it supports identification of the unknowns. Is incident reporting supported by policies that do not place blame? Does the incident investigation process really identify root causes, or does it stop at the most obvious causes, such as not following procedures? Does the organization provide incentives for working quickly rather than incentives for working safely?

In addition to the Accident Pyramid, one of the other concepts credited to Heinrich is that unsafe acts are the major causes of occupational incidents (Manuele, 2014). Sometimes the 80/20 Pareto ratio is applied: 80% of incidents are caused by unsafe acts and 20% are caused by unsafe conditions. As with the pyramid, we have come to realize over the past decades that maybe it is not that simple. We now understand that while human error is often involved in an incident, there are almost always multiple causes, many of which relate back to management actions or inactions. Accident investigations need to look beyond the obvious—an employee did not wear his personal protective equipment (PPE)—to systemic issues—was there a clear PPE policy? Was it enforced? Certainly, the employee’s actions are central, but what might have motivated the disregard for adequate protection? Manuele (2014) demonstrates that many errors have roots in processes and procedures outside the employee’s control. He states “You cannot change the human condition, but you can change the conditions under which people work” (p. 93). That is not to say that people cannot learn to avoid situations that may result in injury or illness, but that human behavior is influenced by many factors. This concept is what gave rise to the behavior based safety (BBS) movement in recent years. Originally focused on identifying and correcting unsafe behaviors, BBS has grown to include examination of outside influences that cause people to make specific choices. Safety professionals need to understand at least some of the psychology that affects choices and decisions. For example, if workers are rewarded for completing a task in a specific amount of time, they may be more likely to disregard safe procedures that add time to the process. Decisions made at the top levels of management have a significant effect on unsafe behaviors and the resulting incidents.

Secretary of Defense Donald Rumsfeld (McNeeley, 2006)

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ANSI/AIHA Z10 provides a framework for safety management that shifts the focus from individual behavior, or

specific hazards or any single process, to a system that integrates all social and technical aspects of accident and injury prevention. Using this socio-technical model, we become more aware of the interdependence of all the parts and begin to understand that they cannot be separated from each other.

References Heinrich, H. W. (1931). Industrial accident prevention: A scientific approach. New York, NY: McGraw-Hill. Manuele, F. A. (2014). Advanced safety management: Focusing on Z10 and serious injury prevention (2nd

ed.). Hoboken, NJ: Wiley. McNeeley, C. (2006). Rumsfeld060202-N-0696M-192 [Photograph]. Retrieved from

http://commons.wikimedia.org/wiki/File:Rumsfeld060202-N-0696M-192.jpg Palmer, A. (2008). AlfredPalmerRamagosa [Photograph]. Retrieved from

http://commons.wikimedia.org/wiki/File:AlfredPalmerRamagosa.jpg

Suggested Reading The articles and webpages below are suggested readings or resources that can provide further insight on safety and human error. In order to access the resources below, you must first log into the myCSU Student Portal and access the Business Source Complete database within the CSU Online Library.

Hansen, F. D. (2006). Human error: A concept analysis. Journal Of Air Transportation, 11(3), 61-77.

Manuele, F. A. (2011). Reviewing Heinrich: Dislodging two myths from the practice of safety. Professional Safety, 56(10), 52-61.

In order to access the resource below, you must first log into the myCSU Student Portal and access the Academic Search Complete database within the CSU Online Library.

Reason, J. (2000). Safety paradoxes and safety culture. Injury Control & Safety Promotion, 7(1), 3-14.

“…if workers are rewarded for completing a task in a specific amount of time, they may be more likely to disregard safe procedures that add time to the process.” (Palmer, 2008)

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Learning Activities (Non-Graded) Injury/Illness Analysis If you have access to your organization’s injury/illness records, sort the records from the past 3-5 years according to the severity of the incident (use days away from work or worker’s compensation costs) and then look for trends in the types of operations where the most serious incident occurred. How does your data compare with Manuele’s list of activities where serious injuries occur (page 62 of the course textbook)? If your findings are different, what could be a reason for the difference? Manuele & Myths Fred Manuele’s October 2011 article on Heinrich’s “myths” challenges what some consider part of the foundation of modern safety practice. Do you agree or disagree with Manuele’s position? Support your opinion. (See Suggested Reading for article reference citation and source). Non-graded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information.