Unit 5 article review

46 ProfessionalSafety FEBRUARY 2017 www.asse.org

Program Management Peer-reviewed

P art 1 of this article (PS, January 2017, pp. 36-45) discussed the three key elements of a modern occupational safety program:

engineering and technical standards and controls, management and operation systems, and human factors. Each element plays an important role, yet many organizations continue to stress one at the expense of the others, which creates an unbalanced and ineffective OSH program. The human factor is present in most every incident, yet often the focus is too narrowly trained on blaming at-risk behav- iors or unsafe acts rather than on identifying and addressing the conditions, systems and norms that enable or cause those errors.

Part 2 of this article examines how employers can better incorporate engineering and system elements into worker-oriented initiatives to cre- ate a more comprehensive approach to OSH and thereby better understand incident causes, reduce incident rates, confirm regulatory compliance, and prevent serious injuries and fatalities.

Proving due diligence While some allege that companies may use

behavior-based safety (BBS) as due-diligence or reasonable-care proof in potential litigation (United Steelworkers Local 343, 2000), in the au- thor’s opinion, BBS observation documentation does not appear to be strong in that regard, as it is typically based on basic observations of work- ers’ behaviors by nonprofessionals, and often has nothing to do with recognizing and control-

ling occupational hazards. Traditional regulatory compliance-based safety systems should be ex- pected to provide due diligence.

only applicable to “best in class”? BBS programs are often recommended for best-

in-class companies that already have engineering controls and systems in place and an excellent safety culture. Implementation in less-advanced safety systems may be less ideal.

For example, “Practical Guide for Behavioral Change in the Oil and Gas Industry,” states:

During the past 10 years, large improvements in safety have been achieved through improved hardware and design, and through improved safety management systems and procedures. However, the industry’s safety performance has leveled out with little significant change being achieved during the past few years. A different approach is required to encourage further im- provement. This next step involves taking action to ensure that the behaviors of people at all lev- els within the organization are consistent with an improving safety culture. (Step Change in Safety, 2001)

The potential effect of behavior modifications on safety performance (incident rates) is illustrated in Figure 1 (p. 48). The conclusion suggested by Fig- ure 1 is that significant incident reduction can be achieved through engineering and systems con- trols. When those two are addressed, an organi- zation can then work on behavioral modifications for further improvements. At that advanced stage, the unsafe behavior component may become a significant source of injuries; engineering and sys- tems components are “completely” corrected, and any further improvement is impossible. It appears, however, that neither of these stages likely exists in a pure form, and engineering and systems controls must be continuously maintained and improved.

Optimizing Safety

Engineering, Systems, Human Factors: Part 2

By Vladimir Ivensky

Vladimir Ivensky, CSP, CIH, has more than 25 years’ experience in OSH. He is a corporate vice president of safety, health and environment for a global multidis- ciplinary consulting and construction management firm. Ivensky holds a master’s degree and doctorate (equivalents) in Occupational Safety and Health and Envi- ronmental Protection from the Rostov Civil Engineering Institute in the former Soviet Union. He is a professional member of ASSE’s Philadelphia Chapter and an author of numerous peer-reviewed articles in a wide range of OSH topics.

 

© IS

T O

C k

P h

O T

O .C

O M

/S G

U r

S O

Z l U

www.asse.org FEBRUARY 2017 ProfessionalSafety 47

It also can be suggested that the cultural and behavioral aspect is an integral part of any safety management system at any phase. Its role can vary depending on the type and maturity of a safety management system. Ultimately, as pointed out by United Steelworkers (2000), there is only one comprehensive safety program (Figure 2, p. 48): Behavioral/administrative safety should be applied together with engineering and systems safety.

implementing observation Programs To make a safety observation program work for a

specific company it should be properly designed, fit local culture, be understood, and be agreed upon and supported by senior management, technical professionals and employees. Management must be vigilant to prevent a situation similar to the fol- lowing example:

One of the companies I worked for used a safety observation program. This program essentially required supervisors to record observations and turn them in for review. The program almost destroyed the positive culture that had been fostered by our forward-thinking operations manager. The regional safety folks for this com- pany established quotas for these observation cards. The supervisors would sit around a table fabricating observations to meet their quotas on the Thursday before they were due. When they did record field observations, the employees re- sented it because the program seemed to as- sign blame to the workforce (whether that was the intent or not). In many cases, the supervisors knew employees were engaged in “unsafe” be- haviors because they were short on resources, equipment or some other necessary tool, sys- tem or process necessary to perform their work safely. (Smith, 2007)

To be most effective, observation sheets must include not only behaviors, but also field hazards and management controls (Mangan, 2015). This

approach allows proper balance of necessary ele- ments (i.e., behavioral, engineering, systems) into one integrated inspection and auditing tool. The resulting program is a comprehensive safety pro- gram with a behavioral safety element.

One major component of BBS costs, in addition to training observers and conducting observations, is managing the extensive data collection system. Analyzing collected data would result in finding the main causes of occupa- tional injuries in a specific company to correct them. Typically, employees con- duct safety observations and report the results to a centralized database. Profes- sional safety staff may then be asked to analyze and interpret the data, a task that can be time consuming.

Therefore, it is critical that this ef- fort produce valuable information that would be instrumental to identifying and correcting real safety problems. If collected data are not representative, the effort wastes significant resources and could compromise the integrity of the overall safety program.

It is easier to recognize violations or errors in simple, repetitive tasks than in complicated professional tasks that require special skills and knowledge. For example, it is reasonable to ob- serve and recognize simple safety violations such as not wearing a hard hat or other basic PPE, not using a seat belt or talking on a cellphone while driving (e.g., using dashboard video cameras). Such behaviors can either lead to an incident or make the outcome of an incident more severe; therefore, observing, trending and communicat- ing about those events can help alter the behav- ior, and reduce the probability and severity of the associated negative outcomes.

In BrIef •When planning work safe- ty observation programs, observers should be trained to recognize and report hazards (unsafe conditions) and management system deficiencies in addition to unsafe acts. •Part 2 of this article of- fers recommendations for securing management com- mitment to comprehensive safety and warns against instilling a blame culture.

046_051_F4Ive_0217.indd 47 1/23/17 12:04 PM

48 ProfessionalSafety FEBRUARY 2017 www.asse.org

Errors or violations that occur while performing complicated tasks are more difficult to recognize; doing so would require professional knowledge of the task and/or safety qualification. Figure 3 il- lustrates this point. Some observation tools may ignore nonbehavioral elements such as unsafe conditions/hazards, regulatory compliance defi- ciencies or deficient safety systems.

In many cases, employees are not trained to rec- ognize these deficiencies; they are trained only to recognize simple, visible, observable behaviors such as missing basic PPE, lifting with the back rather than the legs, incorrect posture and proximity to pinch points. Despite this, some organizations may presume that they have observed most safety defi- ciencies (unsafe acts) (Figure 3, left side). While the actual proportion of unsafe acts to unsafe conditions may not be known, the individual looking only at behaviors is clearly missing a significant portion of a complete picture (Figure 3, right side). This bias becomes especially troubling when the observer’s only safety education is a BBS course.

An alternative approach is to include engineer- ing and system elements in the safety observation programs (or behavior elements in traditional safety checklists). Comprehensive safety systems using the BBS element along with other necessary mod- ules would improve safety culture and performance.

What is Working in bbS According to HSE (2005), the lack of effective

management of the human element has been a contributing factor in the causes of many major in- cidents including the Piper Alpha oil rig fire, Esso Longford gas explosion, the passenger ferry capsize at Zeebrugge, the Paddington rail crash at Ladbroke Grove, the explosion and fires at Texaco’s Milford Haven plant, the Chernobyl nuclear explosion, the toxic gas release at Union Carbide’s Bhopal pesti- cide plant and the explosion at BP’s Grangemouth refinery (HSE, 2005). For many of these major in- cidents, human error was not the sole cause but one of several causes, including technical and or- ganizational failures, that led to the outcome (HSE,

Figure 1 The effect of Behavior on Safety

Note. Adapted from Changing Minds: A Practical Guide for Behavior Change in the Oil and Gas Industry, by Step Change in Safety, 2001, Aberdeen, U.K.: Author.

a cc

id en

t/ in

ci de

nt r

at es

time

engineering

Systems

behaviors

Figure 2 Comprehensive Safety Program

a cc

id en

t/ in

ci de

nt r

at es

time

engineering Systems behaviors

Figure 3 Observers’ Perceived Scope of Safety Data Collected From BBS & Comprehensive Safety Points of View

Behavioral safety Comprehensive safety

Unsafe behaviorsOther causes

Other causesUnsafe behaviors

Data collected

by BBS observers

Data missed

by BBS observers

Data collected

by BBS observers

Data missed

by BBS observers

www.asse.org FEBRUARY 2017 ProfessionalSafety 49

2005). Therefore, the need to effectively manage the human-related risks is critical and clear.

Implementing any corporate program requires serious senior management commitment and sup- port. Management has interest in the success of the investment when initiating a safety program. This results in increased management attention and commitment to comprehensive safety. Man- agement leadership, support and participation in a safety program is necessary and beneficial.

BBS is a valued addition to a comprehensive safety program when applied proportionally. It in- tegrates important human and psychological ele- ments with technical safety.

Safety culture development and improvement programs play a remarkably positive role. BBS pro- grams newly integrated into existing safety man- agement systems may revitalize them.

integrating bbS into a comprehensive Safety Program Secure Management Commitment

Provide a review of comprehensive safety pro- grams (engineering controls, management sys- tems, human behaviors), explaining that BBS is one component of a comprehensive safety program. As any safety tool, it should be applied correctly and proportionally, and should fit the task. Explain the hierarchy of safety controls. When appealing for management and employee commitment and buy- in, seek commitment to comprehensive safety.

When discussing safety culture and commitment, emphasize that “creating the right mind-set is not a strategy which can be effective in dealing with hazards about which workers have no knowledge and which can only be identified and controlled by management” (Hopkins, 2000). Technical safety training, qualified, competent management and personnel, effective safety management and haz- ard control are required.

Work toward securing management commit- ment to provide necessary project safety resources and budget, hazard recognition, evaluation and control, ensuring competent, qualified, trained employees and supervision, and subcontractors’ safety qualification.

Avoid stating that human error risks are com- pletely managed through commitment to safety and BBS (HSE, 2005). Explain exactly how human factor safety risks will be mitigated to achieve the selected standard of care.

Explain that frontline supervisors’ behavior and actions toward safety have a direct effect on work- ers’ perception of safe behavior and actions. Su- pervision must demonstrate leadership and safe behavior, and adhere to site policies.

Incident Causation When an organization believes that most oc-

cupational injuries are caused by unsafe behaviors that can be observed, measured and corrected, it logically leads to similarly proportioned attention to employees’ behaviors in the field. This may skew the safety priorities away from recognizing, evalu- ating and controlling occupational hazards, and

identifying and correcting management system deficiencies (including nonobservable decisions) in favor of observing and correcting defined visible behaviors of line workers.

Discuss the elements of root-cause analysis in incident investigations to illustrate the diversity of potential incident causes. If managers state that unsafe acts are the cause of almost all incidents, mention that this incident causation theory is con- tested and debated (as are other incident causation theories) (Hopkins, 2006).

When discussing unsafe acts, differentiate be- tween unintentional errors, habits, and negligent or willful safety violations. Explain the differences in causes and management of these categories. For example, consider mentioning that up to 70% of human errors are management-system induced (Conklin, 2016) and up to 90% of errors in avia- tion maintenance were judged blameless (Reason, 2000). As Reason (2000) says, “It is often the best people who make the worst mistakes—error is not the monopoly of an unfortunate few.” Warn of the dangers of assigning blame for unintentional errors and of instilling a blame culture (Myketiak, 2015).

Consider replacing the term behavioral safety with human factors safety, expanding the scope to differentiate between various types of unsafe acts: intended/unintended, habits, violations, mistakes, lapses and slips (HSE, 2005). The meaning of un- safe behavior may imply that an employee is aware of safe behavior but intentionally chooses to act un- safely. This is not always the case, as unintentional errors make up the majority of so-called unsafe acts.

It appears that the A-B-C model, popular in BBS and safety culture improvement efforts is more ap-

Frontline supervisors’ behavior and actions toward safety have a direct effect on workers’ perception of safe behavior and actions. Supervision must demonstrate leadership and safe behavior, and adhere to site policies.

© IS

T O

C k

P h

O T

O .C

O M

/S G

U r

S O

Z l U

50 ProfessionalSafety FEBRUARY 2017 www.asse.org

plicable to reducing intentional safety violations and simple reparative habitual acts (e.g., failure to buckle up in a car, failure to wear hard hat and safety glasses on a project site) and less effective in controlling human (employee and management) errors in more complicated tasks.

Do not assume that highly safety-motivated em- ployees are exempt from unintentional errors or deliberate violations (HSE, 2005).

Observation Programs Concentrating on high-frequency, simple and

easily observable behaviors could obscure address- ing more sophisticated safety problems that may be the real priority. Manuele (2003) disproved the premise that the predominant causes of minor in- cidents are identical to the predominant causes of serious incidents and catastrophes. The types of ele- mentary unsafe behaviors, visible to unprofessional observers, are not correlated to the causes of cata- strophic incidents (especially in high-hazard indus- tries). Continuous emphasis on search and control of unique or rare critical hazards, stringent control of known critical hazards and compliance with safe- ty management system requirements (e.g., regula- tory audits, maintenance audits, ensuring employee and management qualification, safety inspections and corrective actions) are necessary.

Not all unsafe acts that lead to an incident can be observed and recognized, even by trained observ- ers. Critical errors can be made in the board room, or by designers or project managers. Recognizing other errors made within a technological process requires special professional knowledge, and effec- tive peer-review and quality-assurance systems.

A typical BBS observation does not probe deep enough to discover and document serious injury or fatality (SIF) exposures, so the observation process must be modified (Mangan, 2015). Observation sheets must include not only behaviors, but also con- ditions and management controls (Mangan, 2015).

Quotas on mandatory periodic observation re- porting may lead to generation of “junk” reports, leading to wasted efforts to produce, analyze and explain those data (Smith, 2007).

Regulatory Compliance Potential BBS program users should be aware

that these programs may not improve regulatory compliance and do not relieve them from legal ob- ligations to manage hazards and provide a work- place free from recognized hazards to employees. To best demonstrate due diligence, users should rely on traditional means of achieving regulatory compliance and safety care to workers.

Reduced Incident Rates The rate at which SIFs are decreasing is lower

than that of minor incidents (Mangan, 2015). Best-in-safety companies demonstrate serious attention to safety before and in parallel with an implemented BBS system, which makes it difficult to determine the effect of the system. In addition, with injury rates (including minor cases) a key per- formance indicator, more attention is applied to postincident case management (Ivensky, 2015). Incident underreporting (Brown & Barab, 2007; U.S. House of Representatives Committee on Edu- cation and Labor, 2008) caused by fears of being blamed for an incident (Myketiak, 2015) or for be- coming a part of a long and difficult investigation is widely documented.

Preventing a Serious Incident Manuele (2003) states that Heinrich’s premise

that the predominant causes of no-injury incidents are identical to the predominant causes of inci- dents resulting in major injuries is invalid. Man- gan (2015) similarly suggests that the discrepancy between minor incident rates and serious incident rates exists in part because practitioners treat all incidents the same, while roughly only 20% of in- cidents have the potential to become an SIF (Man- gan, 2015). Manuele (2003) concludes:

Unfortunately, many safety practitioners continue to act on the premise that if efforts are concen- trated on the types of accidents that occur fre- quently, the potential for severe injury will also be addressed. That results in the severe injury poten- tial being overlooked, since the types of accidents resulting in severe injury or fatality are rarely repre- sented in the data pertaining to the types of acci- dents that occur frequently. A sound case can be made that many accidents resulting in severe injury or fatality are unique and singular events.

The noted references suggest that BBS observa- tion techniques that concentrate on frequent, re- petitive and easily observable events may miss rare, high-potential hazards. Therefore, safety inspection

Not all unsafe acts that lead to an incident can be observed and recognized, even by

trained observers. Critical errors can be made in the board room, or by designers

or project managers.

© IS

T O

C k

P h

O T

O .C

O M

/S G

U r

S O

Z l U

www.asse.org FEBRUARY 2017 ProfessionalSafety 51

and observation techniques must be designed to emphasize a search for critical, high-severity poten- tial hazards, including those with lower probability.

Application in High-Hazard Industries According to Anderson (2006): The majority of major hazard sites [in high-haz- ard industries] still tend to focus on occupational safety rather than on process safety and those sites that do consider human factors issues rarely focus on those aspects that are relevant to the control of major hazards. For example, sites consider the personal safety of those car- rying out maintenance, rather than how human errors in maintenance operations could be an initiator of major accidents. This imbalance runs throughout the safety management system, as displayed in priorities, goals, the allocation of re- sources and safety indicators.

The same point is included in the conclusion of the Baker Panel report (BP U.S. Refineries Independent Safety Review Panel, 2007) of the investigation of the 2005 Texas City, TX, refinery disaster. As Hopkins (2000) states, “Reliance on lost-time injury data in major hazard industries is itself a major hazard.”

Finally, while “the safety professional has to learn more about the psychology of injury pre- vention” (Geller, 2016), behavioral psychologists involved in OSH may benefit from learning more about the technical, engineering and operational aspects of safety to ensure the proper balance and maximum effectiveness of the resulting product: a comprehensive safety program.

conclusion This two-part article reviews ongoing discus-

sions on preventing misbalances among the ma- jor elements of a comprehensive safety program (engineering controls, management systems, hu- mans) potentially impacting those programs’ ef- fectiveness in preventing serious incidents. PS

references

Anderson, M. (2006). Behavioral safety and major accident hazards: Magic bullet or shot in the dark? Mer- seyside, U.K.: Health and Safety Executive.

ANSI/ASSE. (2012). Occupational health and safety management systems (ANSI/ASSE Z10-2012). Des Plaines, IL: ASSE.

BP U.S. Refineries Independent Safety Review Panel. (2007, Jan.). The report of the BP U.S. Refineries Independent Safety Review Panel (Baker Panel Report). Retrieved from www.csb.gov/assets/1/19/Baker_panel _report1.pdf

British Standards Institute (BSI). (2007). Occupational health and safety management system requirements (BS OHSAS 18001:2007). London, U.K.: Author.

Brown, G.D. & Barab, J. (2007). “Cooking the books”—Behavior-based safety at the San Francisco Bay Bridge. New Solutions: A Journal of Environmental and Occupational Health Policy, 17(4), 311-324.

Byrd, H. (2007). A comparison of three well-known behavior-based safety programs: DuPont STOP Program, Safety Performance Solutions and Behavioral Science Tech-

nology (Thesis). Rochester Institute of Technology. Conklin, T. (2016). Human performance improve-

ment. Los Alamos National Laboratory. Dhillon, B. (2013). Saftey and human error in engineer-

ing systems. Boca Raton, FL: CRC Press. Difford, P. (2012, Jan.). The cause of the next in-

dustrial accident: Will it be man . . . or will it be myth? Retrieved from www.neucom.eu.com/documents/ replytoassemanuele.pdf

Geller, E.S. (2000, Apr. 11). The 10 myths of be- havior-based safety. Retrieved from www.ishn.com/ articles/83587-the-ten-myths-of-behavior-based-safety

Geller, E.S. (2016). How to get more people involved in behavior-based safety: Selling an effective process. Retrieved from www.behavior.org/resources/332.pdf

Health and Safety Executive (HSE). (2005, Oct.). Inspectors toolkit: Human factors in the management of major accident hazards. Retrieved from www.hse.gov .uk/humanfactors/topics/toolkit.pdf

Hopkins, A. (2000). Lessons from Longford. Sydney, Australia: CCH Australia.

Hopkins, A. (2006). What are we to make of safe behavior programs? Safety Science, 44(7), 583-597.

Ivensky, V. (2015, Aug.). Reporting and recordkeep- ing requirements: Their influence on safety manage- ment in the U.S. and the U.K. Professional Safety, 60(8), 34-37.

Krause, T.R. (1997). The behavior-based safety process: Managing involvement for an injury-free safety culture. New York, NY: Van Nostrand Reinhold.

Mangan, M.D. (2015, Feb. 21). Safety in practice: Ap- plying behavior-based safety to serious and fatal injury prevention. Safety + Health, 50.

Manuele, F. (2003). On the practice of safety (3rd ed.). Hoboken, NJ: Wiley-Interscience.

Monforton, C. & Martinez, J. (2015, Aug. 20). Monforton and Martinez: There’s nothing ‘safe’ about DuPont. Retrieved from www.chron.com/opinion/out look/article/Monforton-and-Martinez-There-s-nothing -safe-6456101.php

Myketiak, C. (2015). Blame discourses. London, Eng- land: Queen Mary University of London.

Reason, J. (2000, Mar. 18). Human error: Models and management. BMJ, 320(7237), 768-770.

Smith, S. (2007, Oct. 1). Behavior-based safety: Myth or magic? EHS Today. Retrieved from http://ehstoday .com/safety/ehs_imp_75429

Smith, T.A. (1999, Sept.). What’s wrong with behav- ior-based safety? Retrieved from www.mocalinc.com/ id59.htm

Step Change in Safety. (2001). Changing minds: A practical guide for behavior change in the oil and gas indus- try. Aberdeen, U.K.: Author.

Strahlendorf, P. (2003). Accident theories. In Board of Canadian Registered Safety Professionals (BCRSP) Study Guide. Mississauga, Ontario: BCRSP.

U.S. Army Corps of Engineers. (2014). Safety and health requirements manual (EM 385-1-1). Washington, DC: Department of the Army, Author.

U.S. House of Representatives Committee on Educa- tion and Labor. (2008, June). Hidden tragedy: Underre- porting of workplace injuries and illnesses. Washington, DC: Author.

United Steelworkers Local 343. (2000). Local 343 says no to behavioral safety at Alcan. Retrieved from http:// www.oocities.org/local343/new.html

United Steelworkers. (2000). The steelworker perspec- tive on behavioral safety: Comprehensive health and safety vs. behavior-based safety. Retrieved from http:// assets.usw.org/resources/hse/Resources/uswbbs.pdf

Part 1 of this article can be found at http://bit

.ly/2jcziTc.

046_051_F4Ive_0217.indd 51 1/23/17 12:04 PM

Copyright of Professional Safety is the property of American Society of Safety Engineers and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.