This philosophy is based on the work of an engineer named H. W. Heinrich in the 1930’s who was trying to determine the causes of accidents and how to prevent them. The model grabbed the attention of many managers and business owners seeking to reduce downtime, lost production and injury to their workers and increase their returns. The model gives management the impression that the only things they can do to improve their health and safety performance are to:

* Hire smarter people,
* Give them plenty of training,
* Supply detailed standard operating procedures, and
* Use the safety department as a kind of police force to ensure employees adhere those policies and procedures

This thinking persists to this day in spite Heinrich’s second book, in which he dismisses the misconceptions people had on his previous work. Unfortunately, this book was not that popular and the original misinterpretations persist.

The supply of training and procedures assumes that they are comprehensive, correct and applicable for every possible situation in the workplace. During audits of work place procedures it becomes clear that the procedures are more a statement of intent, rather than a strict list of steps to follow. Examination of what actually occurs on the workplace floor often reveals the procedures do not, and cannot, take into account all the possible variations and permutations possible. There are just too many of them to adequately take into account for any procedure to be comprehensive and constantly applicable.

Employees at all levels instinctively know this, and follow their own logic and reasoning based on the information presented to them at the time. In our accident investigation work it is often revealed that the information presented to employees is plainly incorrect and leads to incorrect decisions (although that will not be identified at the time) and/or enforcing the procedures without regard for the particular circumstances can actually makes things worse, not better.

Another model of accident causation is the Energy Damage Model. It contends that damage (and the resulting loss) is caused by the exchange of energies, and the only way to change the state of something in this universe is to apply energy. In industry, we use various energies to do our work. We use it to lift heavy things, grind materials, mix liquids, break chemical bonds, dig holes and move things about. The use of energy is an absolute in order to achieve technological leverage, become more efficient and improve profits - after all, profit is the creation of something worth more to others than it cost you to produce.

However, when this energy is misdirected and uncontrolled it can have consequences we did not intend. The Australian Standard for Risk Management (AS4360) defines an incident as “an unwanted consequence”, so by this definition we can conclude that accidents, injuries and damage are caused by uncontrolled energies. This leads our minds in a different direction when considering the causes of accidents.

The technology we use and the methods in which we use it are not perfect. Things can, and do, go wrong. The design of the equipment is not perfect, they are not built or maintained perfectly, or run with perfection by perfect people with perfect systems. The inherent errors (or latent conditions) in the design, construction, operation and maintenance may lay dormant for many years before playing their part in an incident.

Injuries to employees is only one outcome of an energy interacting in a way that we did not intend. I dislike the term accident as society in general believe accidents are unforeseeable and unavoidable - “a freak accident”. Other outcomes may be damage to plant or equipment, loss in production and/or efficiency, or environmental damage, but the mechanisms remain the same. To pretend otherwise is to miss real opportunity to prevent injury, increase reliability, increase production and reduce environmental impacts. The entire system can be improved of a more holistic, systematic approach is taken.

The research of James Reason shows that people make mistakes on a regular basis and it is the consequences of those mistakes that vary. The uncomfortable reality is that we all make mistakes, but most of the time we are unaware of those mistakes because they have little or no consequence, or we are able to recover from them without incident, or they occur in a context that helps to prevent serious consequences.

This is not to say that training is a waste of time. James Reason’s work does acknowledge a slight decrease in the frequency of errors between inexperienced workers and highly experienced workers (the rate shift from around 1 mistake per 10 attempts to 1 in 100), but these failure rates are horrendous in comparison to engineering controls, many of which are in the order to 1 in a million or less.

This is a different accident causation philosophy that recognise people *will* make mistakes, regardless of how much training they undergo, and concentrates prevention activities on designing the equipment, environment, and systems to be tolerant of the human errors that will inevitably occur. Concentrating on the environment and circumstances of an accident is not something that is easily achieved when the model you use forces you to “blame to worker” with little regard to the multitude of factors that contributed to the incident outside the worker’s control.

How can people injure themselves? How can they recognise a mistake has been made? Is it clear what the corrective actions are? How are the controls arranged? Are the labels easy to understand (ideally they should not be required at all)? What signals do we give the operator that the machine acknowledges the commands and is acting appropriately? Are the monitoring instruments measuring the correct things? Is it clear what the potential consequences of the error may be?

To many readers, this may look like behaviour based safety, but it is not. It is taking into consideration the limited cognitive abilities of the human race when designing a system in which they are going to work. No amount of training will improve the cognitive abilities of people, so we must concentrate of making machines, equipment, systems, and interfaces as natural and as easy to follow as possible.

With thoughtful engineering and design we can create an environment in which the operators perform fewer errors, are able to detect any error that occur and respond appropriately. The application of such basic concepts as affordances, natural mapping, and feedback can vastly improve the overall reliability of the system.

“Since culture is defined as ‘the collective belief of the group’, then we must change the beliefs of the individuals that comprise that group in order to change the culture”.

Changing the core personal values and beliefs of adults is extremely difficult, takes a long time and can cost an enormous amount of money. A sustained, conscious, deliberate effort must be maintained in order to embed the new behaviour expected and prevent a relapse to the old ways. Furthermore, such efforts are undermined by the forced requirement to concentrate on small groups of people in turn, making it very difficult to effect a tsunami sized sea-change.
The problem is the logic of the model is incomplete which undermines the entire process. What is missing from the is *why* those beliefs came into being and *how* they are persisted within the organisational systems. Schien (1992:12) says culture is:

“… a pattern of shared basic assumptions that the group learned as it solved problems … that has worked well enough to be considered valid … and taught to new members as the correct way to perceive, think and feel”

The implication here is that by breaking the validations used to perpetuate the rules we will shift beliefs about the system itself. This provides a shortcut to cultural change - change the what is expected of the workforce and you will change the culture. Schein(1992:231) says it in this way:

“Leaders create culture by what they systematically pay attention to.”

I agree; If you change the Key Performance Indicators, you will change the performance and you will eventually change the beliefs (although, this is not that important). I recently gave a presentation to a safety group in Smithton covering this subject, which I have attached for your reference. Let me know what you think….
Safety Culture.ppt 14Mb Power Point file

“Caution: Floor may be slippery when wet”

There are two main flaws with this particular sign:

1) The language is interesting/wrong. The floor “may be” slippery, but were not sure and if it is, then it’s only when it’s wet. Unfortunately the sign is located outside the showers where the floor will almost always be wet. The sign may as well read:

“Be careful - the floor is slippery!”

2) It does nothing to actually fix the problem! In fact the owners may have opened themselves up to common law claims from patrons who injure themselves. And no, it is not sufficient to just put up a sign.

Think of this situation: Say there was a bridge over a deep ravine with a walkway on one either side; however no guard rails were installed exposing pedestrians to a fatal fall. The owners recognised the risk and put up a sign that read:

“Caution: sharp drop on sides!”

Most people would say this is not sufficient given the magnitude of the potential consequences – in fact common law in Australia is largely based on the statement: “What would a reasonable man have done in this situation?” It is not reasonable to put up a sign and leave people exposed to the risk when a solution is readily available.

The same principle applies at the gym although the consequences may not be as great. The most likely consequences of slipping on a wet, tiled floor may be bruising, broken coccyx (tail bone), broken clavicle (collar bone), broken arms, sprains, twists, torn ligaments, concussion or head other injuries. The cost of an individual injury may not be that great, but if combined with the number of injuries the costs to the business may be high indeed.

The good news is that the solution is simple – buy some non slip matts, or apply a high friction pool paint, or replace the tiles with a non-slip surface. These solutions do not need to cost much to install, actually fix the problem (not just make people aware of it) and lower the probability of injury.

The writing is on the wall

What signs do you have in your workplace? What hazards and risks have you identified and acknowledged by putting up a sign? Have you done all you can do actually address the issue? Putting up a sign does not transfer your liability. You can always leave the sign there, but make sure you have taken all reasonable step to minimize the risk first.

The Swiss view a road accident as a failure of the system in which the car, road, driver, conditions, design, engineering and maintenance all form a part. By shifting their focus from blaming the individual (speed, carelessness, recklessness, inattention, etc) to examining why someone made a mistake, what design errors contributed to the crash and what can be done to reduce the probability and consequences of such an event in the future they have had dramatic effects on the road toll.

The proposed road design has three lanes which separates oncoming traffic and allows alternating overtaking lanes every few kilometres (see the article for a picture). This is the kind of simple engineering solution we have long advocated in an attempt to reduce the carnage on our roads and will prove far more effective and reliable than just telling people to slow down, obey the law and be more careful will ever do!

Well done Mr. Cox!

Update:

Here is my letter to the editor that was posted in the Mercury on the 5th October 2006.

Opponents will point out that the large measures are emergent properties of what happens “at the coal face”. Good operating procedures and permits to work result in lower LTIFRs and reduced injuries, but I have yet to see a single report that successfully correlates anything with the fluctuations in LTIFRs.

The truth is there is a superstring that explains all these things. All these measures are emergent properties of a deeper truth – energy causes damage. In order for injury, disease, plant damage, lost productivity or environmental damage to occur an exchange of energy must occur.

Using deceptively simple methodologies we can identify the potentially damaging energies, examine the controls present over those energies, their likelihood of failure and the potential consequences.These do not need to be big, expensive and difficult to use tools, yet they result in astounding results. Have a look at the presentation and give us some feedback.

Superstrings of Safety (6,757KB PDF)

SEMF are able to provide scientifically sound and field tested solutions to safety problems. The models and methods based in good science allow us to objectively tackle the issues of safety in your workplace and improve performance. We are able to offer a complete, end to end safety solution to help you manage your business more effectively to produce real, measurable results.

The services we provide include:

• Hazard identifications
• Risk assessments
• Risk evaluations
• Risk management
• Accident investigations
• Claims management
• Safety management procedures
• Safety management reviews and audits
• Standards compliance
• Professional training services

Fully Integrated Approach

SEMF has a comprehensive, structured and fully integrated approach to safety. The use of scientifically sound models allows us to effectively capture all hazards in your workplace, measure the probability and consequences of potential problems and suggest responsible solutions. The application of simple yet powerful concepts allows managers to effectively reduce risk and loss, which lowers costs while increasing reliability, production, performance and health.

The use of a good safety system not only reduces injuries and illness to workers, but also increases plant reliability and production while preventing damage to the environment. A common conceptual basis for these seemingly disparate aspects allows us to bring these elements together into a full integrated solution. At SEMF we make no distinction between occupational health and safety, plant and machinery damage, maintenance and damage to the environment. The same mechanisms that cause damage and interruption to any of these are identical, so require the same management systems.

Comprehensive Management

In order to capture all hazards and risks in any endeavour, management must start with a comprehensive list of hazards to search for and apply it in a systematic and systemic way. Only by identifying all the hazards, measuring the risks and evaluating the solutions can you truly prioritize your risk management actions. At SEMF we have the systems that enable companies to target their efforts where they will have the most impact. By continually improving and applying these strategies companies can see tremendous results.

SEMF are able to assist companies with:

• Comprehensive Hazard Identifications
• Sound Risk Assessments
• Logical Risk Evaluations
• Meaningful Risk Controls
• Useful Accident Investigations
• Safety Measurements and Reporting
• Safety Management Systems Auditing
• Project Management
• Loss Adjusting and Insurance Claims
• Workers Compensation and Liability Claims
• Expert Witnesses
• Compliance with statutory regulations and codes
• Mentoring and Training

Scientific Models & Robust Methods

Any system within a business has an impact on the bottom line and safety is no exception, especially if you try to include the human and environmental costs. The use of the correct models simplifies the process by allowing all aspects to be considered and leads to tangible, measurable results.

A safe working environment reduces loss and injury while increasing reliability and production. SEMF can help you develop the systems to protect workers, plant, machinery, process as well as the environment. In order to achieve these results we draw upon a number of industry tools:

• Energy Damage Model (EDM)
• Generalised Time Sequence Model (GTSM)
• Fault Tree Analysis (FTA)
• Systematic Tool for Assessing Risk (STAR)
• Total Cost of Risk (TCOR)
• Risk Matrix (exceeds Australian Standards)
• Hazard and Operability Studies (HazOP)
• Hazard Analysis and Critical Control Point (HACCP)
• Failure Mode Effect Analysis (FMEA)
• Process Hazard Analysis (PHA)

The selection of these depends on the scope of the project and the level of risks involved. Great safety performance does not mean greater expense; the trick is to select the right tool for the right job. At SEMF we are aware of the need to control loss and this extends to the expenses incurred through examining the loss processes themselves. However, through a continual process of identifying risks and ranking solutions we can prioritize and direct resources to measures that have the most effect. It’s about maximizing your return on investment.

Results Driven

Accidents are, by their very nature, random events and are subject to volatile movements during analysis. This is somewhat overcome if the sample size is large enough, but many ventures do not have this luxury. Even so, the measured employed in many safety systems do not have statistically proven relationships to their outcomes; they are actually ineffective. When easily modifiable measures are used the figures can be manipulated in order to achieve performance targets, without actually resulting increased safety. Compounding the problem is the perceived belief of effectiveness when things are going well – typically there are calls for another “safety drive” when the numbers spike beyond the comfort level.

At SEMF we look very careful at exactly what is being measured by a safety system and if those measurements equate to lower costs and fewer injuries. Those that do not are replaced with measures that are truly useful. SEMF can help you identify what you are truly measuring and suggest replacements.

SEMF are only interested in systems that produce real results.

Industry Experience

SEMF staff has over 50 years of experience in risk management and safety in the power generation, power distribution, coal mining, gold mining and communications in Australia, Thailand, Dubai and Saudi Arabia.

(1) An employer must, in respect of each employee employed by the employer, ensure so far as is reasonably practicable that the employee is, while at work, safe from injury and risks to health and, in particular, must -

(a) provide and maintain so far as is reasonably practicable:
(i) a safe working environment; and
(ii) safe systems of work; and
(iii) plant and substances in a safe condition; and

(b) provide facilities of a prescribed kind for the welfare of employees at any workplace that is under the control or management of the employer; and

(c) provide any information, instruction, training and supervision reasonably necessary to ensure that each employee is safe from injury and risks to health.

The Act itself makes no mention of how these things are to be achieved, or even defines the terms hazard, safe or risk. It is assumed the organisation would use something that conforms to “AS4360:2004 Risk Management”. Unfortunately, this standard only outlines the process and does not detail any procedures. In short, the best way to achieve the aims of the Act is to conduct a scientific and systematic hazard identification and risk assessment, which we are able to supply.

The definition of a hazard which has served us well is ”the presence of a potentially damaging energy source”, which mentions nothing about the probabilities of damage or their consequences. The definition removes any arguments over whether something is a hazard or not and is based on the Energy Damage Model of Professor Derek Viner, which is an excellent scientific approach to safety.

The second stage is to look at the controls in place over a hazard, how those controls may fail and what the likely consequences of those failures may be. This does not need to be a long, difficult or expensive exercise. Typically we use a risk matrix to estimate the risks and determine if further and more detailed analysis is necessary, such as fault trees or HazOps.

The definition of the word “safe” is ”an acceptable level of risk”, which raises the question “aceptable to whom?”. While the organisation initially determines the level of risk they are prepared to accept it is ultimately the worker facing the risk that has the final say. Consequently, it is essential that all stake-holders are involved in the process of risk management from the very beginning. This fosters a collaborative approach that values all opinions and encourages ownership of the process and the results.

At the end of this process the client usually receives:

• A list of hazards (which forms their hazard register),
• The probabilities and consequences of control failures (which is their risk register) and
• Some suggestions for improvements (usually with pay-back and ROI figures).