Ansi Z10 Powerpoint

Recognizing Predictive Indicators
for
Fatalities and Serious Injuries
Fred A. Manuele, CSP, PE

President
Hazards, Limited
1
What I Will Comment On
A phenomenon
Statistics on fatalities and serious

injuries
Debunking a myth
2
Fatalityserious injury characteristics
Significance of organizational culture
The business climate, and culture
A mechanism for an internal study
3
Improving incident investigation
Making gap analyses
A near hit data gathering system
The need for a different mind set

4
The Phenomenon
Reliance on traditional approaches to fatality
prevention has not always proven effective.
This fact has been demonstrated by many
companies, including some thought of as top
performers in safety and health, as they
continue to experience fatalities while at the
same time achieving benchmark performance
in reducing less-serious injuries and illnesses.
5
The Phenomenon
ORC Worldwide: 140 Fortune 500

companies
Data gathering system on fatalities

and life threatening incidents
We, collectively, do not know

enough about causal factors
6
Statistical Indicators Fatalities
National Safety Council Accident
Facts
(Now Injury Facts)
Bureau of Labor Statistics National

Census of Fatal Occupational Injuries
7
No. of
Number of Fatality Workers
Year Fatalities Rate in 1000s
1941 18,000 37 48,100
1951 16,000 28 57,450
1961 13,500 21 64,500
1971 13,700 17 78,500
1981 12,500 13 99,800
1991 9,800 8 116,400
2001 5,900 4.3 136,000
8
From 1941 through 2001
Employment increased over 280%
Number of fatalities down over 67%
Fatality rate reduced over 88%
9
Statistical Indicators BLS
Reports
All Fatalities All Occupations
Number of Fatality
Year Fatalities Rate
2001 5,900 4.3
2002 5,524 4.0
2003 5,559 4.0
2004 5,703 4.1
2005 5,702 4.0
2006 5,703 3.9
10
Reports
All Fatalities All Occupations
Relate 2002 to 2006
Number of fatalities increased 3.2%
Fatality rate stayed the same
Why did the number of fatalities
increase?
Why did the fatality rate not
continue the downward trend in
previous years?
11
Reports
Fatality Rates Selected
Occupations
Industries 20052006
Mining 25.6 27.8
Transportation/wrhsing 17.6 16.3
Construction 11.0 10.8
Utilities 3.6 6.2
Wholesale trade 4.4 4.8
Manufacturing 2.4 2.7
12
Statistical Indicators: BLS
Lost-Worktime Injuries and Illnesses:
Characteristics and Resulting Time
Away From Work
Table 10 Percent distribution of nonfatal

occupational injuries and illnesses
involving
days away from work Private Industry
13
Statistical Indicators: BLS
Percent of days-away-from-work cases involving
these numbers of days
1 2 3-5 6-10 11-20 21-30 31 or more

1995 16.9 13.4 20.9 13.4 11.3 6.2 17.9
2005 14.3 11.6 19.0 12.7 11.5 6.5 24.2
% -15.4 -13.4 -09.1 -6.0 +1.8 +4.8 +35.2

Change
from 1995
14
Statistical Indicators
You can not conclude from the BLS
data that the number of incidents
resulting in severity has increased
You can conclude that incidents

resulting in severity are a larger
segment of all lost time injuries
15
National Council on Compensation
Insurance
The Remarkable Story of Declining

FrequencyDown 30% in the Past Decade
Also down in Canada, France, Germany,

UK, Japan
16
National Council on Compensation
Insurance (2005 paper)
Decline in the frequency of smaller

lost-time claims is larger than in the
frequency of larger lost-time claims
17
1999 to 2003, in 2003 hard dollars
Value of Claim Frequency Declines
1. Less than $2,000 34%

2. $2,000 to $10,000 21%
3. $10,000 to $50,00011%
4. More than $50,000 7%
18
Debunking a Myth
A barrier
Reducing injury frequency will

equivalently reduce incidents
resulting in severe injury
19
Debunking a Myth
Many safety practitioners believe
and
profess that efforts concentrated
on
the types of accidents that occur
frequently will also address the
potential for severe injuries.
20
Debunking a Myth
Jim Johnson: Im sure that many of us
have said at one time or another that
frequency reduction will result in
severity
reduction. This popularly held belief is
not necessarily true. If we do nothing
different than we are doing today, these
types of trends will continue.
21
DNV Consulting
Much has been said about the
classical loss control pyramid, which
indicates the ratio between no loss
incidents, minor incidents, and major
incidents, and it has often been
argued that if you look after the
small potential incidents, the major
loss incidents will improve also.
22
DNV Consulting
The major reality however is somewhat
different. If you manage the small
accidents effectively, the small accident
rate improves, but the major accident
rate stays the same, or even slightly
increases
23
Debunking a Myth
Recall Jim Johnson saying that:
If we do nothing different than

we
are doing today, severe injury
trends will continue
24
Debunking a Myth
Jims view supported by a world
famous philosopher who said
If you keep doing what you

did, you will keep getting what
you got
25
Debunking a Myth
The world class philosopher
If you keep doing what you did,

you will keep getting what you
got
Dr. Lawrence Berra

26
Debunking a Myth
As the data clearly shows, frequency
reduction does not necessarily produce
equivalent severity reduction
Severity reduction requires specially

crafted initiatives, focused on hazards
and risks that present severe injury
potential
27
A Different Approach Needed
The data requires that we adopt a
different mind set, one that results
in a particularly directed focus on
preventing low probability, severe
consequence events.
28
Characteristics of Severe Injuries
Studies: Over 1,200 Incidents
A large proportion of severe injuries occur:
In unusual and non-routine work
Where upsets occur: normal to abnormal
In non-production activities
Where sources of high energy are
present
In at-plant construction operations
29
Many accidents resulting in
severity are unique and singular
events, having multiple, complex,
cascading technical, organizational
or cultural causal factors
30
Largely, causal factors for low
probability/severe consequence events
are not represented in the analytical
data on incidents that occur frequently,
but such incidents may be predictors of
severity potential if a high energy
source is present
31
In the Studies Made
The quality of incident

investigations,
on average, was abysmal.
32
Predictive Specifics From Studies
Thirty-five percent of severe injuries
were triggered by a deviation from
normal operations upsets
Over a 10 year period, 51% of

fatalities
occurred to contractor employees
33
In three companies with a combined
total of 230,000 employees, each
company having very low OSHA
rates,
74% of severe injuries occurred
to
support personnel
34
Percent of severe injuries that
occurred to non-production
personnel in two other companies
Company A 63%
Company B 67%
35
For companies with OSHA rates higher
than industry averages, and in
companies where there is heavy
material handling or the work is highly
repetitive, the percent of severe injuries
occurring to production personnel was
higher
36
About 50% of major accidents involved
powered mobile equipment: fork lift
trucks, cranes, etcetera
Reviews of electrical fatalities indicate

that, the design of the systems
produced error-inducing situations
37
Having effective management of
change procedures would have
greatly
reduced major accident potential
Complacency and overconfidence was

often a factor
38
Dan Petersen: On Severe Injuries
The mass data indicates that the types of

accidents resulting in temporary total
disabilities are different from the types of
accidents resulting in permanent partial
disabilities or in permanent total
disabilities or fatalities
39
Dan Petersen: On Severe Injuries
The causal factors are different
There are different sets of

circumstances surrounding severity
If we want to control serious injuries,

we should try to predict where they will
happen
40
A Study of Fatalities
UAW Data
Skilled trades people, 20 percent

of population
Have 41 percent of fatalities
41
Corporate Culture and Safety
The physical cause of the loss of
Columbia and its crew was a breach
in the Thermal Protection System
on the leading edge of the left wing.
In our view, the NASA organizational

culture had as much to do with this
accident as the foam.
42
Columbia
Organizational culture refers to

the basic values, norms, beliefs,
and practices that characterize
the functioning of an institution.
43
Columbia
At the most basic level, organizational
culture defines the assumptions that

employees make as they carry out
their work. It can be a positive or a
negative force.
44
In every organization
Values, norms, beliefs, and

practices are translated into a
system of expected behavior
that impacts positively or
negatively on decisions taken
45
with respect to management
systems,
design and engineering, operating
methods, and prescribed task
performanceand how much risk
taking is acceptable
46
On Major Accidents
James Reason Managing the
Risks of Organizational Accidents
Stresses the long term impact of

inadequate safety decision
making
on an organizations culture
47
On Major Accidents
Reason: The impact of (top level)
decisions spreads throughout the
organization, shaping a distinctive
corporate culture and creating
error-producing factors within
individual workplaces.
48
On Major Accidents
Donald A. Norman The
Psychology
of Everyday Things
Most major accidents follow a

series
of breakdowns and errors.
49
On Major Accidents
Norman: In many cases, the
people noted the problem but
explained it away, finding a logical
explanation for the otherwise
deviant observation.
50
On Major Accidents
Normalization of deviation is a
more often used phrase
Where it occurs, it is a predictor of

severe consequences
51
Economics and Culture
A realistic look at the current
business
climate and its possible effect on
organizational culture and decision
making
52
Report of the OECD Workshop on
Lessons Learned from Chemical
Accidents and Incidents
The concept of drift as defined by

Rasmussen was generally agreed
upon as being far too common in the
current business environment
53
Rasmussen defined drift as the
systematic organizational performance
deteriorating under competitive
pressure, resulting in operation outside
the design envelope where
preconditions for safe operation are
being systematically violated.
54
Japan Times Professor Norika Hama
In their bid to make profit under
deflationary pressures, [Japanese]
companies have been restructuring their
operations and trying to cut costs, and
are compelled to continue using facilities
and equipment that normally would have
been replaced and renewed years ago,
thereby raising the risk of accidents.
55
Also because of job cuts, the firms do
not have sufficient numbers of workers
who can repair and keep the old
equipment in proper condition.
Major companies have been hit by

major accidents.
56
Jens Rasmussen: Risk
Management in a Dynamic
Society
Companies today live in a very
aggressive and competitive
environment which will focus the
incentives of decision makers on short
term financial and survival criteria
rather than long term criteria
concerning welfare, safety, and the
environment.
57
Jens Rasmussen: Risk
Management in a Dynamic
Society
Studies of several accidents revealed
that they were the effects of a
systematic migration of organizational
behavior toward accident under the
influence of pressure toward cost-
effectiveness in an aggressive,
competitive environment.
58
U.S. Chemical Safety Board
BP Disaster, 2005
The Texas City disaster was caused by
organizational and safety deficiencies
at
all levels of the BP Corporation.
Warning signs of a possible disaster
were present for several years, but
company officials did not intervene
effectively to prevent it.
59
BP Disaster, 2005
Cost cutting and failure to invest left
the Texas City refinery vulnerable to a
catastrophe. BP targeted budgeted cuts
of 25 percent in 1999 and another 25
percent in 2005, even though much of
the refinerys infrastructure and process
equipment were in disrepair.
60
BP Disaster, 2005
Chairwoman Carolyn Merritt said The
combination of cost-cutting,
production
pressures, and failure to invest caused
a progressive deterioration of safety at
the refinery.
61
Assume senior management wants
to know about economics-related
predictors for fatalities and serious
injuries
Safety professionals want to take

the initiative to promote an internal
self-analysis
62
In the current business climate, do incentives
for decision-makers result in focusing on
short
term financial goals, the result being drift
and systematic organizational performance
deteriorating under competitive pressure?
63
Are the incentive systems for executives
and location managers constructed so
that it is to their advantage both for
short term financial considerations and
for job retention to avoid needed capital
expenditure requests, or to avoid
spending the money after project approval
is received?
64
Has the gap widened between issued
policy and procedure and what actually
takes place at locations?
Are risky procedures normalization of

deviation being tolerated that would
have been unacceptable in the past?
65
Does the organization continue using facilities
and equipment that normally would have been
replaced years ago, thereby increasing the risk
of fatality and serious injury?
Because of staff cuts, does the firm have

sufficient numbers of qualified maintenance
workers who can repair and keep equipment in
proper condition?
66
Is staffing at all levels, both as to number
and qualification, sufficient to maintain a
superior level of safety performance?
Does senior management discourage

pushback,
perhaps to the extent of intimidation,
from those seeking to express concerns
about safety?
67
Has outsourcing resulted in more fatalities
and serious injuries occurring to contractor
employees?
Has complacency and overconfidence

developed due to presumed superior
performance, as measured by OSHA
statistics?
68
Every subject I have mentioned
relates to comments made by safety
professionals.
If the culture has deteriorated because

of economic pressures, that must be
addressed in seeking to reduce severe
injury potential.
69
Actions to be Considered
An analysis of severe injuries
Improving incident investigations
Making a gap analysis in relation to the

provisions in ANSI Z10
Initiating an information gathering system

on near hits
70
Analysis of Severe Injuries
To seek predictive indicators
Look for shortcomings in safety

management systems
71
Avoiding Self-Delusion
Chemical Safety Board
A very low personal injury rate at

Texas City gave BP a misleading
indicator of process safety
performance.
72
Chair of the Oil and Gas Producers
Safety Committee
We conclude that the TRIR/LTIFR

have little predictive value towards the
potential escalation to single and
multiple fatalities. They also tell us
little about major accident risk.
73
Neither safety professionals nor
executive managements should
delude themselves into believing
that achieving low OSHA rates
assures that serious injuries and
fatalities will not occur
74
Improving Incident Investigation
In studies of incident investigation
reports, causal factor determination
was abysmal.
Seldom does it occur that incident

investigations peel the onion back to
the core causal factors.
75
ReportColumbia Accident
Many accident investigations do not
go
far enough. They identify the technical
cause of the accident, and then
connect
it to a variant of "operator error." But
this is seldom the entire issue.
76
When the determinations of the causal
chain are limited to the technical flaw
and individual failure, typically the
actions taken to prevent a similar event
in the future are also limited: fix the
technical problem and replace or retrain
the individual responsible.
77
Putting these corrections in place

leads to another mistakethe
belief
that the problem is solved.
78
Improving Accident Investigation
Too often, accident investigations
blame a failure only on the last step in
a complex process, when a more
comprehensive understanding of that
process could reveal that earlier steps
might be equally or even more
culpable.
79
In this Board's opinion, unless the
technical, organizational, and cultural
recommendations made in this report
are implemented, little will have been
accomplished to lessen the chance
that another accident will follow.
80
Substantial reductions in severe
injuries are unlikely if incident
investigation systems are not
improved to address the reality of
their causal factors.
The 5 Why System

81
A Gap Analysis
To compare existing safety
management systems with the
content of ANSI/AIHA Z10-2005,
the Occupational Health and
Safety
Management Systems standard.
82
A Gap Analysis
Stress those provisions that are seldom
included in safety management
systems
Design reviews
Risk assessments
Hierarchy of controls
Management of change
Procurement
83
The Critical Incident Technique
An information gathering system
on near hits
To involve personnel at all levels

in gathering data, predictive data,
on severe injury potential
84
Johnson on Incident Recall in MORT
Safety Assurance Systems.
Such [incident recall] studies,

whether by interview or
questionnaire, have a proven
capacity to generate a greater
quantity of relevant, useful reports
than other monitoring techniques.
85
A system that seeks to identify
causal
factors before their potentials are
realized would serve well in
attempting
to avoid low probability-serious
consequence events.
86
Wrap-up
It must be understood that to reduce
severe injury potential, management
must embed that purpose in its
culture,
thus impacting every element of the
safety management system.
87
Wrap-up
That will require giving severe

injury
prevention a high priority, and
adopting
a different mindset.
88
Wrap-up
The intent would be to achieve an
understanding that personnel at all
levels have a particular
responsibility to:
89
Wrap-up
Give specific emphasis to
anticipating,
predicting, and taking corrective
action
on hazards and risks that may have
fatality or serious injury potential.
90
Wrap-up
Assure that in-depth reviews of the
reality of the root causal factors for
incidents that result in fatalities and
severe injuries are made.
Identify predictive indicators, including

knowledge obtained from studies of
near-hits.
91
Wrap-up
Address organizational, operational,
technical, and cultural causal factors
I am assigning you the responsibility

to get all that done.
92

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Recognizing Predictive Indicators

Fred A. Manuele, CSP, PE

Statistics on fatalities and serious

Significance of organizational culture

The business climate, and culture

A mechanism for an internal study

Making gap analyses

A near hit data gathering system

The need for a different mind set

ORC Worldwide: 140 Fortune 500

Data gathering system on fatalities

We, collectively, do not know

Bureau of Labor Statistics National

Employment increased over 280%

Number of fatalities down over 67%

Fatality rate reduced over 88%

Table 10 Percent distribution of nonfatal

1 2 3-5 6-10 11-20 21-30 31 or more

2005 14.3 11.6 19.0 12.7 11.5 6.5 24.2

% -15.4 -13.4 -09.1 -6.0 +1.8 +4.8 +35.2

You can conclude that incidents

The Remarkable Story of Declining

Also down in Canada, France, Germany,

Decline in the frequency of smaller

Value of Claim Frequency Declines

1. Less than $2,000 34%

Reducing injury frequency will

If we do nothing different than

If you keep doing what you

If you keep doing what you did,

Dr. Lawrence Berra

Severity reduction requires specially

Where upsets occur: normal to abnormal

Where sources of high energy are

The quality of incident

Over a 10 year period, 51% of

Reviews of electrical fatalities indicate

Complacency and overconfidence was

The mass data indicates that the types of

There are different sets of

If we want to control serious injuries,

Skilled trades people, 20 percent

Have 41 percent of fatalities

In our view, the NASA organizational

Organizational culture refers to

culture defines the assumptions that

Values, norms, beliefs, and

Stresses the long term impact of

Most major accidents follow a

Where it occurs, it is a predictor of

The concept of drift as defined by

Major companies have been hit by

Safety professionals want to take

Are risky procedures normalization of

Because of staff cuts, does the firm have

Does senior management discourage

Has complacency and overconfidence

If the culture has deteriorated because

Improving incident investigations

Making a gap analysis in relation to the

Initiating an information gathering system

Look for shortcomings in safety

A very low personal injury rate at

We conclude that the TRIR/LTIFR