If it seems like I am spending an awful lot of blog time and space on James Loud’s Professional Safety magazine piece regarding major workplace incidents. Well maybe I am, so what of it?
Not to seem defensive, but I do think this is an important article and it deserves a full discussion and encouragement for all of us to honestly look at our safety protocols and try to come to grips with a reality that is seriously injuring and killing people, rather than what we think is reality, which is playing to Heinrich’s theory that as long as the number of incidents drops, the severe incidents will drop as well.
We have plenty of evidence to suggest that Heinrich’s ideas are wrong.
We Have a Sickness
As much as we believe our safety protocols and procedures are sound, and we like to believe that we have data that support it by virtue of having fewer incidents and lower time-loss costs than in prior years, but the fact is what is going on is like a cancer.
We seem healthy and we’re going on about our business, but eventually if we don’t get a full physical exam and don’t catch what is under the surface in time, we’ll find ourselves in pain and fearful for our life and it may be too late to do anything.
As Loud discusses in a latter section of his article titled, “Major Risk: Moving from Symptoms to Systems Thinking,” we have all kinds of signs that there is constant trouble and risk of a major incident occurring. We seem to do a lot to treat the symptoms of a problem, but we don’t seem to get to the root cause and extract it out of our bodies.
A Change in Regimen
We have all been there at some point in our life. We’re trying to be more healthy, and we make some progress, but then that times comes where we plateau. We’re not going backward, but we’re not making progress anymore.
That is usually when we get advice about “shaking things up” to “shock” our body out of its “rut” and compel some progress forward.
This is the main point of Loud’s article. We all need to be shaken awake. What we’ve done has made the workplace generally safer, but we have plateaued and we’re making no real headway forward. We have to take a hard look at what we’re doing now and find ways to shake up our regimen so that our body (the workplace) can get off the treadmill and actually move forward in lowering incident rates and saving lives.
As was mentioned in a previous post of this series (you can see the others in the series here | here | here | here), companies often will investigate an incident until they get to the point where human error played a role, playing into the theory of Heinrich’s Pyramid, where nearly 90 percent of all incidents are supposedly caused by unsafe acts by workers.
But if you realize that the percentage of incidents that are “major” is growing compared to overall incidents, you already know that Heinrich’s Pyramid is wrong. Yet, we stick to it by continuing to press forward with lowering incident rates, stubbornly doing the same thing that hasn’t worked in reducing fatality risks of workers – and in fact, essentially increasing those risks instead.
Why does this happen? Loud writes that is because we are focused too much on that part of Heinrich’s theory – that we’re so sure that most incidents ar caused by worker actions, that we don’t step back to take an honest look at the work conditions. Once we find human error caused an incident, we don’t investigate further to make sure what is wrong isn’t just a cough, but that’s full-blown emphysema.
We have to be willing to face up to the cancer that may exist, or we will never uproot it and our quest for zero incidents will be futile. We have to move past the people-centered aspects to safety and take an honest look at our systems.
A New Approach?
Loud does remind us that there is a reference guide that we can use to do a renovation of our systems, so we don’t have to necessarily create a new system out of whole cloth. His reminder should be familiar: ANSI/ASSE Z10, also known as Occupational Health and Safety Management Systems.
Loud also reminds us that Z10 is not a specific step-by-step system, but rather a guide to develop a safety system framework that would be effective in your own specific industry and worksite(s). No matter what you come up with, Loud says it should meet the PDCA cycle:
- Plan – Set goals and objectives across your company, specifically in each division (even human resources and purchasing) and develop some rubric to measure progress and success in each.
- Do – Execute the Plan. As the great Yoda says, “Do or do not – there is no try.” This is PDCA, not PTCA.
- Check – As each activity is executed in the Plan, check it over and cull feedback and data about the activity to note areas of deficiency and/or the overall effectiveness or efficiency of the activity.
- Act – Act on the feedback from step 3 by making adjustments or improvements to the system.
- Rinse and repeat.
This system has to be dynamic and constantly evolving. It’s like mostthings – the first time you try it, you will probably have a lot of things to adjust and improve, but the more you go though the steps and repeat them, you will soon be able to smooth out the rough spots and before long you will run the system effectively no matter who is working at your company. Suddenly, your safety program becomes system-focused and not worker-focused.
For the final act of this series: Some action steps that we can take as safety professionals to effectively make the transition from worker-based to systems-based safety culture in our workplaces.