W Do Fall Protection Systems Need to Be Load

A technical publication of ASSE’s
Engineering Practice Specialty
Volume 13 • Number 3
Do Fall Protection
Systems Need
to Be Load
By Kevin Wilcox
hile the answer to the
question, “Has this
fall protection system
been load tested?” is a
simple yes or no, the
answer to the underlying question,
“Should this fall protection system
be load tested, and if so, how?” is
not nearly as simple. Load testing
of fall protection systems should
be conducted as part of a complete
design program. Load testing is not
Load testing can
be a powerful
tool for fall
protection system
designers, but the
method is often
a substitute for sound engineering
Many people believe that load
testing of fall protection systems is
required by law, ANSI standards or
by both. The only requirement for
load testing related to fall protection
is found in the ANSI/ASSE Z359
and A10 families of standards. The
standards contain provisions for load
testing of manufactured fall protection equipment, such as harnesses,
continued on page 8
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Safe Design
For a complete
Table of Contents,
see page 3
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Engineering Information
Trena Adair, Harbor
Environmental & Safety
Chandler Bane
Christopher Banyai, GeorgiaPacific
Lauren Bradshaw
Bryan Carrington
Melissa Colby, Spectra Energy
David Curry
Robert Dougherty, UTC
Alyssa Duncan
William Dunlap, W.L. Gore &
Associates, Inc.
Ricardo Espinosa, Kimball
Kenton Heuertz, Aboitiz Power
Mitchell Hora
David Houle
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Carl Kraft, Lyondell
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Eon Licorish
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Michael Munoz, Southern Wine
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Robert Simon, Cooper Bussmann
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Forensic Engineering
Jeremy Tjundes
David Troutman, Wrigley
Manufacturing Co.
Nicholas Urbanowitz, Bunge
North America Oilseed
Processing Division
Omote Victor, Aspon Oil
Company Ltd.
Ana Wauthion-Melgar
James Weber, BNSF Railway
Jacob Weis
Joshua West, Occidental Oil &
Billie Willard, Ingredion
Robert Yanez
Deli Yu •
Body of Knowledge
Journal of SH&E Research
International Resource Guide
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Manager, Communications
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Bethany Harvey
ByDesign is a publication of ASSE’s Engineer­
ing Practice Specialty, 1800 East Oakton St.,
Des Plaines, IL 60018, and is distributed free
of charge to members of the Engineering
Practice Specialty. The opinions expressed in
articles herein are those of the author(s) and
are not necessarily those of ASSE. Technical
accuracy is the responsibility of the author(s).
Send address changes to the address above;
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c o n t e n t s
Volume 13 • Number 3
1 Do Fall Protection Systems
Be Load Tested?
PAGE Proven Solutions
From Prevention
Through Design
By Kevin Wilcox
Load testing benefits include determining structural capacity for
existing systems, as well as cost savings in design and construction of new fall protection systems.
By Dave Walline
4Electrician Electrocuted
PAGE Troubleshooting Envelope
Manufacturing Machine
An overview of an incident in which an electrician was electrocuted while troubleshooting a medium open-end envelope machine.
Causal data from fatal and serious injury
events suggest the decisions arising from
the prevention through design process
play a central role in avoidance of catastrophic events.
PAGE Do Not Be
Fooled by Falls
By Thomas Kramer
Properly identifying and evaluating fall
hazards can help one more intelligently
prioritize projects—with risk and other
factors considered.
22How Do Human
Factors Influence
Inherently Safe Design?
Fall Hazard
Risk Assessment
& Ranking
By Don Enslow
A critical component of incident management is a sound incident
investigation system that includes employee involvement and recognizes incident investigation techniques that focus on root-cause By Bethany Harvey
processes and on all contributing factors, including human factors. Safety professionals must seek to identify all risks rather than focus on a few
categories of risk.
26 T
Managing Fatalities
& Serious Injuries
By Scott Stricoff
While many organizations have some awareness of exposures,
near misses and minor injuries that have high potential, few possess the consistent reporting, measurement and tracking visibility
needed to address these precursors in sustainable ways.
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Electrical Hazards
Electrician Electrocuted
Troubleshooting Envelope
Manufacturing Machine
Massachusetts FACE Investigation: 12-MA-007-01
n April 4, 2012, a 53-year-old male electrician
(victim) was electrocuted while troubleshooting a medium open-end envelope machine. The
machine’s blower was not working, and the
victim was working to repair it. The victim was reaching into the machine to access wiring for the blower
contained in an electrical junction box when he was
The employer is a manufacturer
The victim had and printer of envelopes and stationery and has been in business
been working extra for 24 years. The company has
82 employees, about
hours to direct approximately
60 of whom work in the manufacthe project and turing department while 20 work
sales and office positions. Three
disconnecting and in
employees made up the maintereconnecting any nance department in which the victim worked. Employees worked 5
electrical compo- days per week,
nents affected by Monday
Friday. There
the facility’s move. were two work
shifts each day.
Saturday was
a designated maintenance day for
the machines, a downtime when
machine setters could come in to
adjust the machines.
Written Safety
Programs & Training
The victim was the company’s
main safety and health representative/trainer. At the time of the incident, the company did not have a
comprehensive safety and health program. New hires were provided with
an orientation that included training
on multiple safety and health topics,
including machine guarding, lockout/
tagout, hazard communication and powered industrial
During the site visit, it was reported that since the
incident, the company had started to develop a safety
and health program and was holding weekly planning
meetings of management and key production staff to
develop a safety committee.
The victim had been employed by the company as an
electrician for approximately 7 years at the time of the
incident. He held a valid master electrician license. The
victim’s normal work schedule was first shift, Monday
through Friday. For 2 months before the incident, he
had been working extended hours in support of the company’s relocation. It was reported that the victim had
worked about 12 hours the day before the incident and
was on site at 5:00 a.m. or 6:00 a.m. on the day of the
Photo 1: A medium open-end envelope machine viewed from the front end.
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At the time of the incident, the
company had been moving its
entire facility to the newly renovated factory building where the
incident occurred. Reportedly, the
victim was playing a large role in
this move, overseeing the breaking down, moving and setting up/
reassembling of approximately
15 manufacturing machines. The
move had started 1 month prior to
the incident with the machinery
being moved in stages so that production could continue with limited downtime. A few machines had
Photo 2: The envelope machine’s blower motor.
been split into two or three pieces
and moved by a rigging contractor
into the new facility. The victim
Incident Location
hours to direct the project and
The company was in the process of moving into a
any electrical compobuilding built around 1900 and historically operated
company contracted an
as a fabric mill. The building had been recently renoadditional
this process.
vated to accommodate the envelope company. The
was one of
entire building was more than 300,000 sq ft, and the
pieces for
company was to occupy about half of that space. The
machinery was set up on the ground floor, which was a
frame at
large open space.
approximately the midpoint of the machine’s length,
and disconnecting all wiring/conduit and other compoEquipment
nents, which crossed this midpoint (Photo 3, p.6). The
The machine involved in the incident was a medium
open-end envelope machine (Photo 1) that the company machine had been moved, reassembled, tested and running the evening before the incident.
had owned for about 14 years. It was estimated that the
machine was manufactured more
than 30 years ago and perhaps as
early as the 1960s. The machine was
Figure 1
configured to punch and install an
Envelope Machine’s Blower Motor
address window on presized sheets
of paper, fold and glue the envelope
Power Supply Shown From Above With
into shape and put on a strip of selfsealing glue with removable strip to
Approximate Pathway of Conduit
seal the envelope.
The machine was equipped with
a blower motor (Photo 2) that provided airflow to different sections
of the machine through a series of
hoses. The blower’s main function
was to create negative air pressure
on the underside of the transfer belts
to keep the paper flat and in position
as it passed from one process to the
next. The blower motor was powered
by 480 V through a three-phase format, (three powered lines and a neutral line), which ran through conduit
and many junction boxes from the
main fuse panel (Figure 1).
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The day of the incident, the machine setter/
operator had been scheduled to resume work
as the machine was ready to use. While making adjustments, the machine operator noticed
he could not hear the blower motor running and
reported the issue. The victim discovered during his initial troubleshooting that the blower
may have been running at a reduced power, and
perhaps one of the electrical lines had shorted or
disconnected after being set up at the new facility. The victim then continued to further troubleshoot the motor wiring, replacing some fuses in
the main panel and apparently locating a short in
the blower’s wiring.
At the time of the incident, the victim was
accessing a junction box located near the break
in the machine at floor level (Photo 4). It was
unclear if the victim was voltage testing to
ensure that the junction box was de-energized
or if he was continuing to troubleshoot. While
accessing this junction box, he came in contact
with an energized component and was electrocuted. It is suspected the current traveled from
one hand, through his torso and out his other
hand or perhaps another part of his body touching the machine. The machine operator noticed
the victim looked like he was straining while
reaching into the machine and walked over to
offer assistance. He realized the victim was being
electrocuted and pulled on the victim’s sleeve to
move him away from the machine. The machine
operator then yelled for help and another
coworker called emergency medical services.
The local fire department was at the site to
inspect the fire alarm panel as part of
the move into the renovated facility.
A coworker informed fire department
personnel of the incident, and they
started to care for the victim. Local
police, additional fire department
personnel and state police arrived at
the incident location. The victim was
transported by ambulance to a local
hospital where he was pronounced
Face Program
he NIOSH Fatality Assessment and Control
Evaluation (FACE) program is a research program
designed to identify and study fatal occupational
injuries. The FACE program’s goal is to prevent occu­
pational fatalities across the U.S. by identifying and
investigating high-risk work situations and then
formulating and disseminating prevention strate­
gies to those who can intervene in the workplace.
Investigations conducted through the FACE program
allow the identification of factors that contribute to
these fatal injuries. This information is used to devel­
op comprehensive recommendations for preventing
similar deaths.
Participating states voluntarily notify NIOSH of
traumatic occupational fatalities resulting from spe­
cific causes of death, including confined spaces, elec­
trocutions, machine-related, falls from elevation and
logging. FACE is targeting investigations of deaths
associated with machinery, falls, energy production,
deaths of youths under 18 years of age not covered
by child labor hazardous orders and deaths of for­
eign-born workers.
Nine state health or labor departments have
cooperative agreements with NIOSH for conducting
surveillance and on-site investigations and for recom­
mending prevention activities at the state level using
the FACE model.
For more information, contact Nancy Romano at
ndr4@cdc.gov or (304) 285-5889.
Cause of Death
The medical examiner listed the
cause of death as electrocution.
Recommendation 1: Employers
should ensure that electrical circuits
and equipment are de-energized and
that lockout/tagout standard operating procedures are implemented and
enforced prior to beginning work.
Photo 3: The bridge plates at the envelope machine’s split point.
ByDesign www.asse.org 2014
Recommendation 2: Employers
should provide and ensure that
employees use appropriate PPE and
tools for troubleshooting live circuits.
Recommendation 3: Employers
should develop, implement and
enforce an injury and illness prevention program that addresses hazard
recognition and avoidance of unsafe
Recommendation 4: Employers
should ensure that work is scheduled
to allow for sufficient rest periods
between work shifts.
Recommendation 5: Machine
manufacturers should implement
the prevention through design
concept to ensure the safety and
health of machine users, including
machine operators and maintenance
workers. •
Photos 4-5: The envelope machine’s junction box (view from left and right of bridge plate) where
the worker contacted live wire.
Z359 Fall Protection Code
Now Available on Flash Drive
ersion 3.0 of the ANSI/ASSE
Z359 Fall Protection Code is
now available on a flash drive,
allowing SH&E professionals worldwide to have instant and portable
access to what is considered the
definitive resource for fall protection.
Initially released in 2007, the code
is a series of coordinated standards
and reference documents that establish the requirements for an effective
and comprehensive fall protection
management system. Version 3.0
includes the following standards:
ANSI/ASSE Z359.0-2012,
Definitions & Nomenclature Used
for Fall Protection & Fall Arrest
ANSI/ASSE Z359.1-2007,
Safety Requirements for Personal
Fall Arrest Systems, Subsystems &
ANSI/ASSE Z359.2-2007,
Minimum Requirements for a
Comprehensive Managed Fall
Protection Program
ANSI/ASSE Z359.3-2007, Safety
Requirements for Positioning &
Travel Restraint Systems
ANSI/ASSE Z359.4-2013, Safety
Requirements for Assisted-Rescue &
Self-Rescue Systems, Subsystems &
ANSI/ASSE Z359.62009, Specifications & Design
Requirements for Active Fall
Protection Systems
ANSI/ASSE Z359.7-2011,
Qualification & Verification Testing
of Fall Protection Products
ANSI/ASSE Z359.12-2009,
Connecting Components for Personal
Fall Arrest Systems
ANSI/ASSE Z359.13-2013,
Personal Energy Absorbers &
Energy-Absorbing Lanyards
ANSI/ASSE Z359.14-2012,
Safety Requirements for SelfRetracting Devices for Personal Fall
Arrest & Rescue Systems
ANSI/ASSE Z359.1-1992
(R1999)—Historical Document,
Safety Requirements for Personal
Fall Arrest Systems, Subsystems &
Fall Protection
Systems for
& Demolition
ASSE Z490.12009, Criteria
for Accepted
Practices in
Safety, Health &
Click here for more information
on the code or click here to purchase it. •
ByDesign www.asse.org 2014
cover story
Do Fall Protection Systems
Need to Be Load Tested?
continued from page 1
lanyards and other PPE, but they do not discuss load
testing of anchorages or anchorage connectors.
Load testing can be a powerful tool for fall protection
system designers, but the method is often misunderstood.
Load testing is not given extensive or specific treatment
in the codes and standards, so interpretation and sound
engineering judgment are necessary to determine appropriate applications of this testing method.
Load testing benefits include determining structural
capacity for existing systems, as well as cost savings in
design and construction of new fall protection systems.
Load testing can also help prevent incidents and injuries
on systems that are in use but have insufficient documentation to demonstrate their structural capacity.
testing program can confirm the adequacy of the structural capacity and can yield the necessary documentation
for their recertification. Likewise, load testing will expose
any system deficiencies, mitigating the unknown hazard
that may cause a failure. After all, a false sense of security might increase the risk of a fall.
Confirm Existing Systems
In some cases, load testing may be the only feasible
way to determine structural capacity. Because fall protection systems are often installed on structures long after
their initial construction, a variety of structural (and nonstructural) materials can serve as the substrate through
which the fall protection loads must ultimately travel and
be resisted. For the designer, this means that the structure
to which the fall protection system is attached may not be
readily assessed by analytical means.
As with any construction project, installation of fall
protection may vary widely in quality between projects
Regulations & Standards
and contractors. Load testing is often a valuable alternaExisting fall protection regulations and standards offer tive to structural analysis in locations where information
only limited provisions regarding load testing. In fact,
needed to perform a conventional analysis is not availOSHA does not address the subject at all. The ANSI/
able or when the structure cannot be assessed by convenASSE standards contain provisions for load testing of
tional analytical methods. In some cases, fall protection
manufactured fall protection equipment, such as harness- systems are installed without proper oversight or docues, lanyards and other PPE, but they mentation. In the author’s experience, load testing has
do not discuss load testing of anchor- been conducted to verify that the installation was perLoad testing is ages or anchorage connectors. Many formed in accordance with proper construction methods
manufacturers of subsystems, such
a visual inspection of adhesive anchors installed
often a valuable as horizontal lifelines, require that (e.g.,
into concrete cannot be relied on to evaluate the strength
installers test the equipment to
of those anchors).
alternative to the
verify that it was properly installed,
structural analysis but this requirement rarely (if ever)
System Redesign or Reconfiguration
extends to testing the anchorage to
Load testing may also be a useful tool in the reconin locations where the building structure.
figuration or redesign of existing fall protection systems
information needed Although the building code does for new applications and new loadings. Reuse of part
not prescribe fall protection loads,
or all of an existing system as part of a new fall protecto perform a con- the International Building Code
tion design may be a cost-effective alternative to new
regulaconstruction. Because of the evolving nature of fall
ventional analysis tions for in-situ load testing of
protection regulations and standards, loadings and usage
is not available or building structures, written in the needs may change over a system’s lifespan. Load testof building code loading
ing is a means of establishing structural adequacy for
when the structure context
conditions. Concerning window
components of an existing system that cannot be readily
cannot be assessed cleaning, the ANSI/IWCA I-14.1 analyzed for new loading conditions. Note that load teststandard addresses load testing of
ing should not be considered a replacement for proper
by conventional window cleaning anchorages, but its analysis. However, load testing is often useful in verifyof the topic is somewhat
ing assumptions that must be made to proceed with engianalytical methods. treatment
incomplete and ambiguous. More
neering analysis.
specifically, the standard does not
Commissioning & Certification
require load testing of anchors. It merely gives guidMany proprietary systems, such as horizontal lifeance in the event that a professional engineer deems
lines, need to be certified or commissioned by the
load testing necessary.
In short, load testing of fall protection system anchor- installer or the designer prior to use. Manufacturers often
require load testing as part of the certification process for
ages is not required.
their systems. This may also be true for systems requirWhy Load Test Fall Protection Systems?
ing recertification.
Although it is not required, a designer may choose to
load test fall protection systems for many reasons. A load
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Load Testing Program
Load testing of fall protection needs to be more
than simply pulling on anchorages and giving them
approval. A complete program includes an investigation
phase with an approved group of carefully selected and
designed load tests that address the specific components
in question for the systems being tested. Testing requires
deliberate planning of test logistics and complete documentation of the entire process. This documentation provides a vital record of work for future use.
Pretesting Investigation
Designers should investigate the fall protection
systems and their supporting structures before testing.
Performing this due diligence will limit the inherent
risks associated with load testing of an existing structure. Without sufficient knowledge of the structure, it
is not possible to reliably predict how it may behave
when subjected to a concentrated test load. Furthermore,
pretesting investigation aids in the selection of system
components that will actually require a load test. In addition, the investigation informs the designer’s decision
about the type of test that will most effectively test those
For example, load testing is only useful if it provides
information about how an anchorage will perform when
loaded in the same direction as a force that a fall will
generate. One would not conclude that an anchor in a
roof could withstand a 200-lb pullout load just because a
200-lb person could stand on it.
Office Investigation
Several tasks should be performed in the office
before the load testing begins. Designers should review
any available documentation regarding installation of
the existing fall protection systems to assess whether
certain system components will require testing and
to understand the overall quality of the installation.
Designers should review structural drawings and perform calculations to identify building structures eligible
for testing and to set safe limits for testing loads. At
times, load testing may be ruled out by analysis for
some structures that cannot handle the concentrated
loads necessary to test certain system components. This
in-house work lays the groundwork for effective test
design and meaningful results.
Potential Pitfalls & Disadvantages
While load testing can be a valuable tool in the evaluation and design of fall protection systems, it has some
drawbacks that should be considered before proposing a
load testing program.
Research & Development
Any load testing program, even if similar to past projects, will need to be somewhat customized to the current
project’s specific needs. This may include significant
amounts of research, investigation and test development.
The costs associated with the program development
effort should be estimated at the outset so that the owner
can decide whether the value added by the testing is
worth the cost of bringing it to fruition.
Risk of Accidental Damage/Liability
Despite a designer’s best efforts, risks will remain
during a load testing operation. While contracts and
agreements with the client, testing agency and other
concerned parties can limit the test designer’s liability,
a lawsuit is always a possibility if collateral damage
occurs. In most cases, the benefits will outweigh the
risks, but those risks should always be kept in mind
when pursuing load testing as means to a fall protection
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Unfavorable Results
Although load testing is designed to identify deficiencies in fall protection systems, too many unfavorable
results eliminate the economic benefits of load testing.
While discovering inadequate systems can help avoid
incidents, failed systems must be rejected, removed,
redesigned and replaced. Load testing then becomes an
expensive extra step in the redesign and renovation of
fall protection systems. If it is predicted that a group of
systems will experience a high rate of failure during load
testing, or if high failure rates are experienced in a sufficient sample of tests early in a program, the designer
and client should consider abandoning load testing in
favor of pursuing new design and installation. However,
this situation is not likely to be revealed until substantial
amounts of time and money have been invested in the
development of a load testing program and the generation of a sufficient body of data.
Practical Considerations
The types of load tests employed in a fall protection
testing program will vary between projects. The tests
used will correspond to the specific system components
identified for testing and will also vary based on the
makeup of the building structure as well as the types of
fall protection systems installed.
Selection of a test type in a given application depends
on what the test needs to prove and what component of
the fall protection system needs to be tested. The designer should consider the following questions when selecting the tests used in the load testing program:
•What am I trying to test?
•How can it be isolated from the other system components?
•Can a single test prove the capacity of multiple components?
•Is a physical test required or will an inspection suffice?
Although the planning and theory behind a load testing program are critical to achieving successful results,
those results will only be valuable if the tests are well
executed and well documented. Design professionals
possess the greatest amount of responsibility for ensuring
that the testing is a success and should, therefore, maintain an appropriate level of control over practical aspects
of the testing, particularly if a third party is physically
performing the tests. Laying the groundwork for proper
field methodologies and documentation of test results
will ensure that testing is delivered with the highest
value possible. •
Kevin Wilcox is principal at LJB Inc.
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Join your fellow safety
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Conference. Experience
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By Dave Walline, CSP
PTD Process
Proven Solutions From
Prevention Through Design
ausal data from fatal and
serious injury events suggest the decisions arising
from the prevention through
design (PTD) process play
a central role in avoidance of catastrophic (life-ending or life-altering)
events. Numerous studies and
research reveal 20% to 50% of all
mishaps reported indicate a design
gap finding. From the author’s firsthand experience and study, fatal and
serious events are at the high end of
this percentage range.
The central question is, What is
holding back organizations from
addressing design-related events
head-on? The author believes a critical organizational and cultural blind
spot exists. Through benchmarking
with other SH&E professionals, he
has found that most injury/illness
data management systems used by
organizations do not ask for, capture
or highlight design-related causal
factors. This data gap has caused
latent, design-related conditions
to go uncontrolled and undetected
in most organizations. As a direct
result, both existing and new designs
continue to be operated or procured
with inherent uncontrolled hazards
and risks that can potentially cause
serious mishaps.
To avoid such design-related incidents, the author strongly suggests
that SH&E professionals personally
dive deep into their own organizations’ injury/loss experience if they
have not done so already. By criti-
cally examining previous incidents,
startling answers can be uncovered.
The author has gained new
insight from his own experiences by
drilling deeper into causal data from
past mishaps. Other SH&E professionals can also discover compelling information that can be used to
generate a stronger focus on PTD in
their organizations.
One key outcome of the author’s
work has been the development of a
design safety checklist centered on
fatal and serious mishap prevention
controls related to past events. This
design-focused checklist has been a
game changer for designing out fatal
and serious mishap-related risks.
preoperational stage. SH&E professionals must shift and even depart
from traditional safety roles and
daily job duties, such as compliance
program writing, training, inspections and claims management, and
must transition into risk avoidance
and risk mitigation activities related
to organizational planning, design,
specifications, safety procurement
specifications, design safety reviews,
proven solution development and
risk assessment.
Based on the author’s informal
research and discussion with many
global SH&E professionals over the
past 5 years, the SH&E community
roughly spends its time as follows:
1) preoperational, 10% (avoidance
PTD Skill-Building
and elimination focus);
To enhance their skill level and
2) operational, 70% (compliance
efforts around PTD, SH&E proand retrofit focus);
fessionals should first obtain and
3) postincident, 20% (claims
read ANSI/ASSE Z590.3-2011,
management, litigation, regulatory
Prevention Through Design:
Guidelines for Addressing
4) postoperational, <1% (decomOccupational Hazards and
missioning, demolition).
Risks in Design and Redesign
Today’s best organizations seek
out innovative and creative SH&E
Section 1.3 of the standard,
professionals, but the SH&E job
which is focused on application,
description of tomorrow will likely
states the PTD standard applies to
look much different. Progressive
four main stages of occupational
employers will look for SH&E prorisk management:
fessionals who possess these key core
1) preoperational;
competencies (working in the preop2) operational;
erational risk management stage):
3) postincident;
1) PTD;
4) postoperational.
2) risk assessment;
The author believes for PTD to
3) management of change;
come to the forefront of business deci4) fatal and serious injury presion making, the SH&E community
must begin to spend more time in the
ByDesign www.asse.org 2014
5) operational risk management
6) contractor risk management;
7) safety specifications for procurement;
8) human error and human performance.
These core competencies are
highlighted in ANSI/AIHA/ASSE
Z10-2012, Occupational Health
and Safety Management
Systems, another document SH&E
professionals should obtain, read,
fully understand and adopt.
SH&E professionals who possess
these core competencies will bring
the required leadership and creativity to their organizations and facilities by identifying, establishing and
driving proven solutions into new
designs and processes. The author
believes future SH&E professionals
should establish a career target (both
time and skill set) to work 70% in
the preoperational stage of risk management. In this stage, the business
world sees the SH&E professional
as a leader, valued business partner
and risk mitigation advisor. Personal
recognition and reward come with
this new role.
According to the author’s observations, SH&E professionals spend
most of their time in a firefighting
and/or compliance mode while making these common mistakes:
1) Assume their business leaders know what they should be doing
next in SH&E (such as PTD).
2) Believe nothing can be done
in PTD without a corporate edict or
3) Think that PTD is to be left
only to engineers and designers.
4) Fear that they will not perfectly implement PTD when starting out.
5) Wait for others to engage them
in the PTD process.
Safe Design Myths & Bad
Design Hurt Organizations
Five common myths must be
dispelled and overcome to move an
organization forward:
1) The design meets minimum
compliance; therefore, it is safe.
2) PTD is cost-prohibitive. Highlevel controls are too costly.
3) PTD will slow down the project. We do not have time for design
reviews and risk assessment.
4) The current/old design is safe
enough. We have always done it this
way. Our injury experience does not
prove otherwise.
5) Low-level controls on the hazard-control hierarchy greatly reduce
severity of harm.
Bad designs can negatively influence an entire organization in the following ways:
1) serious mishaps;
2) low employee morale;
3) elevated risk levels;
4) human performance barriers;
5) product quality issues;
6) losses impacting profitability;
7) poor operating efficiency;
8) equipment and process reliability issues;
9) litigation;
10) poor public image;
11) higher labor costs;
12) compliance gaps;
13) waste and scrap;
14) business interruption;
15) customer expectations not
being fulfilled.
Proven solutions are myth-busters
that address causal factors surrounding catastrophic events and have
these key attributes:
1) risk avoidance;
2) hazard elimination;
3) severity reduction;
4) high level of control (control
5) remove barriers to safe work;
6) reduce burden costs (e.g., costly retrofitting, claims, compliance
7) address both normal and abnormal conditions;
8) widely accepted by users;
9) positive impact on operating
efficiency and maintenance;
10) easily incorporated into engineered designs and procurement
Such solutions should be incorporated into a project at the earliest
stage of the design process as performance objectives and design criteria
and can be used
to provide a
tangible view of Proven solutions
what achieving
offer the rare
acceptable risk
looks like.
opportunity to
Proven soludesign out or to
tions originate
Proven Solutions:
from the hieraravoid entire hazard/
PTD Culture Revolution
chy of controls.
Risk avoidance and hazard
As presented
exposure categories.
elimination are proven solutions for in Z590.3, this
designing out causal factors. These
approach is
solutions directly remove highthe preferred method of achieving
potential risk factors often faced by acceptable risk in design through
exposed groups, such as operations risk avoidance. Avoidance has the
and maintenance personnel, congreatest net positive impact on safe
struction workers and the public.
design because it prevents hazards
PTD decision makers and stakefrom entering the workplace though
holders are responsible for risk
design. When avoidance strategies
control, and these entities include
are used, no hazards need to be elimbusiness owners, customers, capital
inated or controlled.
project delivery teams, construction
A good risk avoidance statement
managers, design/build firms, engibegins with a “no” statement. Each
neers, designers, machine builders/
no statement bears a proven solufabricators, operations and maintetion. Taking this approach may seem
nance personnel and SH&E professtrange to many SH&E professionals
sionals. Proven solutions provide a
because avoiding risk can rarely be
visible means to remove traditional
accomplished. Most SH&E profescultural barriers in the form of false
sionals tend to work in the reactive
beliefs from design-for-safety efforts. or costly retrofit world and never
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ByDesign www.asse.org 2014
b) work made accessible by
fixed stairways/platforms;
c) establishing a proper accessway for work-lifts.
2) An automated guided
vehicle system eliminates forklift
3) Electrical energy isolation,
arc-preventive switchgear/motor
control centers and diagnostic
ports are used.
4) Piping system isolation
valves are used at ground level, as
are gauges and filters.
5) A trailer restraint system and
dock door barrier guards are used.
6) Automated product conveyance and lifting systems are used.
7) Fully-enclosed chemical process and mixing systems are used.
8) Fall prevention, including perimeter guarding, skylight
guarding and aerial lifts, is used
live in the risk avoidance mindset or
5) No manual handling/lifting of
100% of the time during construcworkspace.
manufactured products exceeding 45
During the conceptual design
lb by production employees.
9) Employees wear less PPE, not
stage, risk avoidance and hazard
6) No elevated or remote energy
elimination allow SH&E profesisolation points used for lockout/
10) Devices are enabled under
sionals to work and participate with
tagout/try tasks.
the exclusive control of maintenance
design and project teams. Proven
7) No open chemical processing
workers for approved troubleshootsolutions offer the rare opportunity to and mixing systems.
ing tasks.
design out or to avoid entire hazard/
8) No unsecured trailers while
11) All hazardous energy isolation
exposure categories.
points are at floor level within 3 m
9) No open electrical panels to
Proven solutions create and shape
of need.
perform diagnostics or thermography.
the bond between the SH&E com12) Employees are removed from
10) No fall hazards during buildmunity and engineering and design
directly interfacing with powered
ing construction.
communities by allowing engineers
machinery and equipment using
11) No congested or restricted
and designers to do what they do
barrier guarding and automated jamworkspace regarding people, equipbest—incorporate risk control meaclearing systems.
sures into their designs and redesigns ment, maintenance and emergencies.
12) No direct interface between
with confidence.
PTD Influence on Exposure
employees and powered machinery
From 2009 to 2011, the author
& Human Performance
and equipment (during either normal
worked on a large capital project in
The only opportunity SH&E
or abnormal conditions).
China, a multimillion-dollar manuprofessionals and designers have to
Upon completion of this project,
facturing facility. He worked with
impact severity of harm is during
many of the 350 employees at this
the design/build firm to incorporate
the avoidance and elimination stage.
proven solutions into the plant design new facility found their new work
In some cases, substitution can also
environment to be world-class and
by placing each of the performance
affect the severity of harm. Other
objectives into a no statement. The
levels of control can only impact
Sustainable, proven solutions are likelihood, not severity.
result of this effort came with a nonow used on all projects based on
exposure outcome. Examples of no
The author highly recomthe no statements the author estabstatements included:
mends that SH&E professionals
lished for the China project. For
1) No portable ladders.
obtain and read ANSI B11.0-2010,
2) No powered forklift trucks
Safety of Machinery: General
1) Typical portable ladder tasks
used in the manufacturing space.
Requirements and Risk
are designed out by
3) No elevated work.
Assessment. Table 3 in this stana) relocating work at ground
4) No energized electrical work.
dard, the hazard control hierarchy,
outlines the influence each level of
control has on risk factors, such as
severity and likelihood. The table
indicates that the greatest influence
on eliminating or reducing severity
of harm is at the elimination or substitution level.
Based on the author’s experience, many SH&E professionals,
engineers and others hold a false
belief that low-level controls have a
great impact on severity when they
do not. Guarding and engineering
controls are excellent risk control
measures, but their primary purpose
is to reduce likelihood, not severity.
That is why control effectiveness and
control maintainability are so important for sustainable protection. To
prevent fatal and serious loss events,
the focus on design must begin with
avoidance and elimination because
these highest-control levels relate
directly to severity reduction.
Proven solutions also support
safe behaviors and eliminate many
common human error factors. SH&E
leaders begin to understand the
affect of PTD in their organizations
when they overhear project managers, business leaders and others
make these statements:
1) “Design the work so it is easy
to do it safely and difficult to do it
2) “Severe injuries will have a
greater impact on the organization
than will stopping production to
improve safety.”
3) “Someone who wants to do
well never underestimates a bad
4) “Administrative and PPE controls will never replace appropriate
5) “We could be world-class
if this process were not so poorly
designed to begin with.”
Proven solutions can significantly
enhance human performance through
avoidance and elimination of the following human error influencers:
1) high ambient noise;
2) poor ergonomics (e.g., layout,
job setup, workspace);
3) PPE loading and barrier to job
4) working in high ambient temperatures or poor lighting;
5) responding to routine process
upsets and abnormal conditions;
6) performing complex work;
7) physically demanding work
that leads to fatigue;
8) use of hand tools that draw a
worker close to the hazard.
The only
opportunity SH&E
professionals and
designers have to
impact severity of
harm is during the
avoidance and
elimination stage.
Proven Solutions
Reduce Burden Costs
A key PTD selling point often
overlooked by the SH&E community and during design reviews is the
long-term burden costs the organization will incur when hazards are not
eliminated in the design or redesign
phase. The SH&E community can
identify and communicate burden
costs when low-level controls are
selected over one-time, high-level
controls designed to avoid or eliminate hazards and risks.
Most SH&E professionals spend
the majority of their time in the
operational and postincident phase
due to:
1) burdensome oversight of regulatory-driven programs and claims
2) almost daily efforts to find
scarce resources for retrofitting
uncontrolled hazards associated with
design gaps.
Of special significance is the
fact that burden costs, which can be
extreme, must be maintained during
the facility’s life expectancy.
One example of how burden cost
can add up over time is using portable ladders in a typical manufacturing setting. Based on the author’s
experience, the burden cost for a
new 500,000-sq-ft facility that has
a planned lifespan of 50 years with
intent to use portable ladders can run
as much as $9.3 million.
As an alternative, proven solutions to design out the 17 defined
routine ladder tasks (for 175 ladder
users) in the concept stage would
require a one-time capital investment
of $500,000. This is a noteworthy
net positive capital investment and
can prevent the facility from ever
having a serious portable ladderrelated mishap.
Any capital project always has
two monetary spends. The first spend
(pay now) is the cost of the new
design, and the second spend (pay
later) is the long-term burden costs.
Long-term burden costs often far
exceed the cost of an original design
solution that would have eliminated
the entire hazard category.
The most commonly seen burden
costs linked to a facility’s life expectancy are injury claim costs, compliance maintenance costs, retrofit
costs, business interruption, operating inefficiencies, resource management and manpower costs.
Many organizations continue to
report falls from portable and fixed
ladders, which are reflected in past
and current data reported by OSHA
and the Bureau of Labor Statistics.
Often, falls from ladders can become
life-ending or life-altering. Portable
ladders also continue to appear on
OSHA’s top 10 violations list.
When looking at portable ladder
use, the ladder and its user are both
considered lower-level controls. A
safe ladder and safe ladder user do
not mean low severity, which is why
ladder-related fatalities continue to
be a commonly reported mishap. In
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Business Value &
Benefits Gained from PTD
A second key selling point for
PTD is the benefits derived from
safe project delivery. Safe designs
offer organizations many benefits.
For example, the new plant built in
China incorporated many proven
solutions into its design and saw
these additional benefits:
1) Project came in $10 million
under budget.
2) Reduced energy consumption.
3) Zero waste to landfill and
overall net positive impact on the
4) Plant sold out of its product
line and achieved full production
capacity ahead of plan.
5) High worker morale.
6) Operating efficiency targets
achieved well ahead of plan.
7) Fifty innovative proven solutions incorporated into design (many
hazard categories avoided or eliminated).
8) Plant design and all job tasks
achieved an acceptable risk rating.
9) No reported serious mishaps or
near-miss events since plant startup
in 2011.
10) CEO and business leadershiplevel recognition given to the design
team and project champion.
The China project team is proud
of the new facility, the project teamwork displayed and the outcome
achieved. Proven solutions that avoid
risk and eliminate hazards in design
must be our legacy, not programs
and firefighting. Knowing that 350
employees of a new facility can go
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home to their families at the end of
each workday injury- and illness-free
is the true reward.
As SH&E professionals, walking
into a new facility or operation during a ribbon-cutting event with the
customer and other leaders and professionals reinforces the long-term
impact our efforts have on those who
will be working with the new design
for years to come. SH&E professionals can showcase their overall value
to organizations by designing to
acceptable risk through sustainable
high-level controls.
Building a Proven
Solutions Library
PTD is a culmination of proven
solutions (safe designs) to avoid
risk and to eliminate hazards in
new designs/redesigns. When the
SH&E community works in partnership with engineers and designers
over the next decade to incorporate
proven solutions into designs, the net
positive results will be the prevention
of life-ending and life-altering mishaps globally. Establishing proven
solutions is critical work that places
SH&E professionals in the preoperational stage of risk management.
Many resources are available to
help SH&E professionals develop a
proven solutions library.
These include:
1) internal organizational data analysis related
to design;
3) ASSE’s Body of
5) ASSE Risk
Assessment Institute;
6) Design for
Construction Safety;
7) Construction
Industry Institute;
9) OSHA;
10) lessons learned
from completed design
fact, portable ladder use is a highrisk task. Our focus must shift from
ladder compliance programs to ladder avoidance through design.
The author uncovered a significant risk factor when performing an
in-depth review of previously unseen
causal factors related to poor design.
The key risk factor discovered was
the impact a congested or restricted
access workspace has on worker
safety. As most organizations and
businesses attempt to cut project
costs, a common approach is to
reduce floor space or the facility’s
footprint. This approach generally
results in less workspace and/or
restricted access to equipment for
maintenance activities. It forces the
facility’s operations management to
purchase portable ladders because no
workspace or access was provided
for alternative safer designs, such as
stairways, personal lifts and hoisting
PTD Action Steps
SH&E Professionals
The SH&E community should
take these actions to drive a cultural
revolution around PTD. The rewards
and benefits will be many, but the
most noteworthy outcome will be the
prevention of life-ending and lifealtering mishaps. SH&E professionals should follow these steps:
1) Create a design safety checklist
from organizational incident data
linked to design gaps.
2) Establish a personal goal
to spend more time in the preoperational stage of occupational risk
3) Develop a critical skill set
around PTD and risk assessment.
4) Apply a high level of control
decision making in the design process with special focus on severity
5) Develop and use a proven solutions library that achieves risk avoidance or hazard elimination in design.
6) Identify and share long-term
burden costs related to poor design
decision making with leaders and
design teams.
7) Work to dispel common PTD
8) Eliminate barriers to safe work
through design.
9) Capture and communicate the
benefits of safe design.
10) Make your legacy one that
leaves a lasting net positive impact
on the organization.
assessment (B11.0). Houston, TX:
B11 Standards Inc.
ANSI/ASSE. (2011). Prevention
through design: Guidelines for
addressing occupational hazards and
risks in design and redesign processes (Z590.3). Des Plaines, IL: ASSE.
Occupational health and safety management systems (Z10). Des Plaines,
Incorporating proven solutions
into design is critical to the prevention of life-ending and life-altering
mishaps. Proven solutions have
global application and bring demonstrated value on many fronts when
such an approach is adapted as part
of an organization’s PTD culture and
The pace of injury/illness prevention improvement during one’s lifetime is directly linked to the speed
of change led and driven by the
SH&E profession. Risk assessment
and PTD must be at the forefront of
these efforts. The SH&E community
has the responsibility, creativity and
power to support injury-free lives
around the world. •
David Walline, CSP, is a global safety
leader for Owens Corning in Toledo, OH.
Walline is a 35-year professional member
of ASSE. Prevention through design (PTD),
fatal and serious injury prevention and risk
assessment have been his primary career
focus. He has developed and implemented
global risk assessment, PTD processes and
training programs within organizations
and also influenced the design and risk
mitigation levels of projects worldwide.
In June 2012, Walline received the CSP
Award of Excellence from the Board of
Certified Safety Professionals. He was a
contributor to and served on the review
committee for ANSI/ASSE Z590.3-2011,
Prevention Through Design: Guidelines
for Addressing Occupational Hazards and
Risks in Design and Redesign Processes.
He is chair of ASSE’s Risk Assessment
Committee, which manages ASSE’s Risk
Assessment Institute. He also served on
the planning committee for and presented
at ASSE’s PTD Virtual Symposium in
February 2013.
ANSI. (2010). Safety of machinery: General requirements and risk
Reprinted with permission from the proceedings of ASSE’s 2013 Fatality & Severe
Loss Prevention Symposium.
Safety 2014 Chapter Night Out
re you attending Safety 2014 in Orlando, FL? Don’t
miss the Chapter Night Out on Tuesday, June 10 (7
p.m. to 11 p.m.) at WonderWorks. Sponsored by ASSE’s
Central Florida Chapter, the event is a great way to meet
other ASSE members and enjoy an entertaining evening as
you explore exhibits throughout the upside down build­
ing that houses the indoor amusement park for the mind.
The registration fee (adult $75; child, ages 4 to 12, $49.50)
includes dinner buffet, dessert, unlimited soft drinks and
the entire facility reserved exclusively for ASSE.
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11) engineering and design community;
12) vendors and suppliers;
13) hourly workers;
14) benchmarking;
15. Safety in Design.
Fall Hazards
By Thomas Kramer, P.E., CSP
Do Not Be Fooled by Falls
Identifying Risk
A fall protection program’s ultimate goal is to
create a safer environment
for workers. However, until
all hazards are identified, it is
difficult to develop an effective strategy to reduce risk.
Fall hazards can be classified into three main categories:
1) Means of access. This
is the manner of moving
from one level to another.
Examples include noncompliant ramps, runways and
walkways; fixed stairs; fixed or portable ladders; and
personnel lifts.
2) Locations. These are specific areas of immediate
exposure to a fall hazard. Examples include unprotected
sides, leading edges, elevated walkways, excavations,
floor and wall openings, elevated conveyors, scaffolding,
lights, overhead mechanical and electrical runs, roofs,
pipe racks and tanks.
3) Tasks. These are actions that workers perform that
expose them to a potential fall hazard, such as removing
a guardrail when hoisting material up to a mezzanine.
These hazards typically fall within three general categories: construction, production and maintenance.
When identifying risk, it is also important to consider
hidden hazards or hazards that are not always easy to
recognize. Examples of hidden hazards include:
•guardrail size, height, spacing and strength requirements;
•roof edges;
•swing gates on ladders;
•access ladders or stairs between levels;
•smoke/heat relief vents;
•paint booths;
•false ceilings;
•newly installed fall protection systems that may
prove inadequate.
Identification Methods
It is infeasible to identify every hazard within a large
facility or complex, but it is important to identify as
many hazards as possible so that the fall hazards can be
thoroughly evaluated. The four main methods of identification are:
1) suggestion programs;
2) use of statistics;
3) facility walkthrough;
4) wall-to-wall facility survey.
Suggestion Programs
Suggestion programs are the most cost-effective
method used to identify fall hazards. They identify areas
of particular interest through worker participation. These
interest areas typically contain job tasks that workers feel
uncomfortable performing because they know they are at
risk of a fall.
This method also allows a large group of workers to
participate in the process. Although not trained in the
identification of fall hazards, many workers know which
frequently accessed areas are hazardous. An organization’s employees are often a wealth of information about
continuous improvement.
ByDesign www.asse.org 2014
all hazards present two conflicting realities: significant fall incidents do not happen often, but
when they do occur, they are catastrophic and
costly. Just like most people did not think black
swans existed, most organizations do not think
they will ever have a fall fatality at their facility. In this
way, fall fatalities can be viewed as black swan events.
A black swan event is defined as one that meets the following criteria:
•Rarity: Low probability of occurring.
•Extreme impact: Consequences are significant or
•Retrospective predictability: In looking back, they
can be easily explained or predicted.
The rarity of incidents can lull both management and
workers into a false sense of security. But, managing the
major risks presented by falls is a smart and ethical business investment—in addition to a legal requirement.
Although regulatory agencies and standards committees highlight the value of fall hazard surveys or risk
assessments as a critical step in a successful fall protection program, many organizations around the world do
not address fall hazards or do so haphazardly. Many still
devote money, time and resources toward the first fall
hazard brought to their attention, while ignoring highrisk items.
To avoid a black swan fall fatality, fall hazard risk
must be systematically managed. Properly identifying and
evaluating fall hazards can help one more intelligently
prioritize projects—with risk and other factors considered.
A clear picture of the hazards can help one best decide
how to address them based on level of risk, priorities and
budget—not on a first-come, first-served basis.
A downside of the suggestion program method is that
it is the least comprehensive. The method will identify
some, but definitely not all, fall hazards. Often, it takes
the skills of an experienced competent person in fall protection to identify hazards that the suggestion program
method misses.
A thorough review of statistics can help identify
specific fall hazard exposures. The statistics are based
on incidents that have resulted in citations, injuries and
fatalities. Organizations can learn from these statistics
and can apply them to similar situations.
For example, statistics show that roof fall hazards
account for approximately 20% of all fall fatalities.
Therefore, one action item may be to identify roof fall
hazard exposures. While this is beneficial, using the statistics method leaves out other hazards that do not fall
into high-profile categories.
Bureau of Labor Statistics provides much information
relative to surfaces on which fall hazards occur. Also,
NIOSH collects information and creates reports on certain occupational fatalities so the public can better understand how the incident occurred, learn from the mistake
and share with others. NIOSH publishes these FACE
reports on its website.
Facility Walkthrough
The facility walkthrough method is more facility-specific than the suggestion or statistics methods. However,
this method is still not a complete comprehensive fall
hazard survey.
During a facility walkthrough, a competent or qualified person is brought in to serve as an objective set of
eyes. The objective is to identify typical hazards—not
every hazard. This individual also prioritizes typical
hazards from a risk standpoint and estimates abatement
methods and costs. This method allows the organization
to estimate the order of the magnitude cost for a facility.
Remember that because only typical hazards are identified, the number of hazards and the cost for abatement
are only an estimate of the order of the magnitude.
Wall-to-Wall Facility Survey
The wall-to-wall, or in some cases, an inside-thefence facility survey is the most comprehensive method
to identify hazards.
This method requires competent or qualified persons
with significant industry and fall hazard survey experience. Again, the competent or qualified persons’ goal is
to objectively identify as many hazards as possible.
Due to the vast amount of information collected, this
method requires an experienced team and preplanning so
that data can be collected and managed efficiently. Once
data are collected, identified hazards must be ranked and
prioritized before an abatement plan can be implemented
to address the hazards.
With the goal of identifying as many hazards as possible, this method goes beyond a typical survey. The wallto-wall facility survey is therefore the method of choice.
Table 1 Typical Risk Assessment Code Chart
ByDesign www.asse.org 2014
Once fall hazards
and the potential
risks associated
with them are
identified, evaluated
and ranked,
leadership can use
the information to
create a validated
budget, schedule
and abatement
Risk Assessment & Ranking
A wall-to-wall facility survey
or risk assessment focuses on the
highest risk. The more efficiently
risk is reduced, the better. So, rather
than devoting resources to the most
obvious hazards, organizations can
use the risk assessment process to
systematically identify, evaluate and
control fall hazards. By directing
the budget to the highest-risk items,
organizations can then achieve maximum risk reduction for the investment made.
During a comprehensive fall
hazard risk assessment, detailed data
are gathered on fall hazards. The
data are analyzed to determine the
probability and severity each hazard
presents. In terms of probability,
various factors must be considered:
frequency of task, exposure time, number of workers
exposed and likelihood of falls based on external influences. Severity is measured by determining fall distance
and likely obstructions impacted during a fall.
Many times, risk assessments are conducted using a
simple risk matrix (Table 1, p. 19). However, especially
for locations with hundreds or thousands of hazards,
the information gained from such an assessment is not
granular enough to be effective in long-term planning.
Often, dozens of hazards will fall into one category, giving the program manager no indication of which hazards
to abate first.
When conducting a more granular risk assessment,
the resulting data are organized into a prioritized list of
hazards. This list can be organized by location, maintenance task and type of solution proposed—or in any
other way that helps the organization manage abatements. Once fall hazards and the potential risks associated with them are identified, evaluated and ranked,
leadership can use the information to create a validated
budget, schedule and abatement strategy.
Since organizations may not be able to address every
hazard, the prioritized list provides guidance on what,
when and how to abate hazards. This risk assessment
method transforms an overwhelming list of hazards into a
manageable plan with a beginning and end point. Program
managers can use this information to report metrics on the
amount of risk reduced for a given investment.
Falls are a misunderstood safety issue. The reality
is that falls can and do cause fatalities and catastrophic
losses. Conducting a risk assessment specific to falls
can significantly reduce risk to the workforce and organization. •
Thomas Kramer, P.E., CSP, is principal at LJB Inc. in
Miamisburg, OH. A safety consultant and structural engineer with
18 years’ experience, Kramer specializes in the assessment and
design of fall protection systems. He is a member of the ANSI/
ASSE Z359 Accredited Standards Committee for Fall Protection
and chairs two subcommittees that develop standards for the
design of active fall protection systems (Z359.6 and Z359.17).
He also serves as president of the International Society for Fall
Protection. Kramer holds bachelor’s and master’s degrees in
Civil Engineering, as well as an M.B.A. He frequently speaks on
fall protection at international, national and regional conferences.
Reprinted with permission from the proceedings of ASSE’s
2013 Fatality & Severe Loss Prevention Symposium.
Manufacturing Practice Specialty
The Manufacturing Practice Specialty (MPS) began as a branch of the Management
Practice Specialty in 2006 and became a practice specialty in 2008. MPS’s goal is to provide a forum
for industry-specific issues in manufacturing facilities, such as metalworking, timber and lumber
working, food processing, chemical, rubber, plastics and printing/publishing locations.
In addition to publishing its triannual technical publication Safely Made, MPS helps develop
technical sessions for ASSE’s annual Professional Development Conference, regularly sponsors
webinars on timely manufacturing-related topics, holds conference calls and much more.
Click here to join MPS today or click here to follow MPS on LinkedIn.
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Risk Assessment
By Bethany Harvey
Fall Hazard
Risk Assessment
& Ranking
n September 2013, LJB Inc.
presented Understanding Risk
Assessment & Ranking, a webinar
on how best to identify fall hazards
and prioritize preventive actions.
Speaker Thom Kramer, P.E., CSP,
the managing principal at LJB Inc.
and chair of ASSE’s Professional
Development Conference planning
committee, explained that to abate
fall hazards, safety professionals
need to both evaluate their current
methods of risk assessment and identify the top ten risks found in their
According to Kramer, many
fall hazards go undetected because
workers may believe that a lack of
incidents indicates that no risks are
present. He warns that some safety
initiatives, such as use of PPE and
safer equipment, may lead workers
to take more risks because they perceive their workplace as being safer
than it really is.
To effectively assess risks,
safety professionals must seek to
identify all risks rather than focus
on a few categories of risk. For
example, while hazards associated
with edge distance and slippery
conditions are most often taken
into consideration, some personnel may overlook more unusual
hazards, such as a loose bolt
holding a ladder in place on a
Once all hazards have been
identified, lists of those hazards
must be kept for use in prioritizing concerns and in alerting workers to risks they may
encounter. Kramer says that just
like a grocery list, a list of haz-
ards is necessary for remembering
what the hazards are, where they are
located and how quickly they need
to be mitigated. He suggests using a
risk matrix (Figure 1) to help determine which hazards require immediate attention. Such a matrix measures
the severity of the potential incident
against the probability that workers
will be exposed to the hazard and
can be used for assigning a numerical ranking to every hazard. For
example, a hazard to which workers
have probable exposure would result
in a total temporary disability (TTD)
and would receive a ranking of 2,
meaning that it requires immediate
attention but is not as urgent as a
hazard that receives a ranking of 1.
Simple risk matrixes have some
limitations in their accuracy, so it
is important to also calculate the
maximum risk reduction possible in
respect to the hazards identified and
funds available for risk reduction
strategies. Kramer stresses the need
to identify all risks before mitigating
according to a budget because companies run the risk of spending all of
their available funds on the first risk
they find, which may not be the most
critical hazard to address. •
Bethany Harvey is a communications
and design assistant for ASSE and part of
the editorial staff for Professional Safety.
She holds a B.A. in Interdisciplinary
Communications Mass Media from
Elmhurst College.
Figure 1 Simple Risk Matrix
ByDesign www.asse.org 2014
Human factors
By Don Enslow, CSP
How Do Human
Factors Influence
Inherently Safe Design?
he Engineering Practice Specialty is reinforcing
the concepts discussed in ANSI/ASSE Z590.32011, Prevention Through Design (PTD):
Guidelines for Addressing Occupational
Hazards and Risks in Design and Redesign
Processes, through various forums available within
ASSE to increase visibility and focus on PTD.
This article attempts to raise some questions regarding the relationship between what is referred to as
inherently safe design (ISD) and the unpredictability of
human behavior. By definition, inherently safe implies
that the anticipation and quantifiable predictability of
human response to workplace environments is integral
to ISD. Theoretically, that is the basis and intent for ISD
principles. ISD provides concepts to assist engineers and
safety professionals in establishing and implementing
design processes in anticipation of human error.
Various causes and influences related to human factors are inherent to minor and major incidents, and they
surface in almost every incident and near-miss. How
many times have we documented incident causation factors to include operator inattention, misunderstanding
or violation of a procedure, inadequate design specific
to operating conditions and operator response, fatigue,
ergonomics and the operator’s capability to respond?
These causal factors represent only a fraction of contributing causes specific to human factors in incidents.
Case Study
In the U.S., the highest percentage of accidental loss
of life is attributed to the operation of a motor vehicle,
and a major contributor to these incidents is driver
inattention. For motor vehicle incidents, human factor
influences are relatively obvious; however, for some
industrial incidents, they may not be as obvious.
Early in his career, the author investigated an exploIn a perfect world with an unlimited budget and 100% sion and total loss of a hot oil heater on an offshore platpredictability in workplace scenarios/environments,
form. The platform and associated process facilities were
ISD’s goal would be the norm rather than the exceprecently constructed, and the platform was preparing for
tion. History, education and technology have provided
start-up and introduction of crude oil for phase separaa sound foundation for improving designs to accomtion into oil, gas and water. The separated oil and gas
modate potential failures and human exposure to injuries were then to be introduced into pipelines for delivery to
or fatalities. Four challenges that prohibit the execution
onshore facilities and marketing. The water was recycled
and integration of ISD into management systems and
back into the reservoir.
processes are perceived cost, lack of management accepTo facilitate separation, crude oil from the reservoir
tance, limited competency and understanding of the con- needed to be heated. The expected volume of crude oil
cepts, and perceived time/schedule constraints.
was estimated to be 50,000 barrels per day for this platInherent to all four of these challenges is human
form, and the size and capacity of the hot oil heater (the
factors or “the scientific discipline concerned with the
design included two heaters for platform operation at
understanding of interactions between humans and other 100% capacity) was relatively large to ensure the approelements of a system and the profession that applies the- priate design for that volume of fluid.
ory, principles, data and methods to design to optimize
As the steps for platform start-up were initiated, it
human well-being and overall system performance”
was necessary to ignite the pilot flames for the hot oil
(International Ergonomic Association, 2000).
heaters. The pilots were maintained by ignited gas, and
The unpredictability and multitude of influences that
their operating controls ensured the appropriate ignitable
affect human behavior and, ultimately, human factors,
concentration of natural gas and oxygen prior to ignican seem overwhelming. It is important to recognize the tion. The operator responsible for the hot oil heaters was
potential risk and exposure to a workplace that does not unable to initiate ignition of the pilots, and start-up was
integrate human factors into management systems and
delayed. The design of this heater was relatively new,
design/process controls.
and it was determined that it was necessary to consult
with an expert who needed to be summoned immedi22
ByDesign www.asse.org 2014
ately and delivered to the platform via helicopter. This
survival. Delaying start-up meant substantial financial
created a 2-day delay in the logistics of organizing this
and reputational risk. The platform’s geographical locavisit. Anxiety and tension within the operation were
tion was susceptible to dramatic changes in weather and
heightened, and the expectation for immediate results
sea conditions that could delay start-up significantly if
from this expert was the critical path for start-up and
identified personnel were unable to travel to the platform
product delivery.
to evaluate the issue. The expert’s technical competence,
Upon arrival of the heater expert and an evaluation
experience and resume were good relative to his knowlof the pilot ignition controls, it was determined that the
edge of control systems and this particular model of hot
flame safety controls for the pilot system were inhibiting oil heater. This individual also understood his assignthe ignition system’s ability to work. The recommenda- ment to be to provide an immediate fix to the problem.
tion was to defeat the pilot flame safety system and,
The critical need was apparent, and if he could provide
when it was thought to be appropriate (based on operaa quick solution, he would be a hero. Existing managetor observation), manually initiate the igniter. Under the ment systems and deviation processes from established
expert’s observation, the recommended steps were foldesign control systems were not in place to prohibit
lowed, which ignited a gas volume
behavior that exceeded rational limthat exploded and blew the back of
its and increased risk.
the heater vessel several hundred
In reflecting on this incident, the
To better integrate author
feet into the sea. Although the explocan recall many situations he
sion’s magnitude was significant, no
human factors into had been involved with or particione was injured.
pated in as an investigator in which
the inherently safe human factors influenced a system or
At the time of the investigation,
the root cause was determined to
process that was designed to elimidesign process,
be design failure of pilot ignition
nate potentially catastrophic events.
there must be
control system. It was not inherently
The most effective ISD is one that
obvious to the responsible parties,
not allow a system to operate
recognition of how will
nor was it inherent to the incident
under at-risk operating parameters
investigation process at the time, to
human behavior can after discovering that someone has
consider human factors as contributbypassed that control to allow the
influence all aspects system to continue operating.
ing factors to the incident. Looking
back at that incident more than 35
of the operation
years later, it is apparent that human
integrate human factors
throughout the
factors were indeed a major contribinto
process, it is important
uting factor.
how human behavHuman factors influenced the
all aspects of the
management systems, decisions
the facility’s
and behaviors that resulted in the
undesired outcome. Human factors were also involved in
decisions and acceptance during operation design for the
systems including engineering and behavior-based prohot oil heaters. From design to construction to start-up,
human factors played an influencing role in this incident. cesses. Management support is integral to this process’s
effectiveness, and it is important to base measurement
How many times can incidents be attributed to human
and performance on key metrics. The term management
factors? How does ISD play a role in the reduction of
systems is an all-encompassing platitude that can lose
potential risk of human factor failures?
perspective in the day-to-day priorities of a workplace.
The four challenges identified earlier in this article
Management systems can also overwhelm an organizawere apparent in the hot oil heater incident. Perceived
cost was a critical factor in the decision-making process to tion when attempting to integrate assurance processes
from early design all the way through to final production.
defeat the pilot ignition controls. At the time of the inciAccording to the late Trevor Kletz, a chemical process
dent, oil prices were significantly lower than today and
expert, “Some people have forgotten the limitathe world economy was struggling. The start-up of this
management systems. All that a system can
platform was paramount to corporate financial well-being.
the knowledge and experience of people.
To the credit of the responsible platform operator, operaKnowledge
experience without a system will achieve
tions were shut down and start-up was delayed until a
potential. Without knowledge and
second opinion was obtained. However, criteria for indeexperience,
best system will achieve nothing.”
pendent review focused on start-up, not on safe start-up.
that integration of sound manAt the time of this incident, corporate culture and
recognition of human
expectations within management were based on financial
ByDesign www.asse.org 2014
factors, as well as an appreciation for their influence in
sustained safe operations, will provide economic success. The fundamentals are fairly simple; the sustained
implementation and reinforcement of these practices and
principles can be challenging. As always, it begins at the
top. Management must establish the basis for safe operations and focus on continuous improvement. Managers
must also have systems in place to measure performance
and to correct deviations when required. A key to the
successful endorsement of top management relies on
their understanding and appreciation of these concepts.
If the corporate standard is driven by key management
systems and principles, managers will absorb and proactively reinforce the standard.
What do good management systems look like? It
is difficult to provide a one-size-fits-all template with
the variety of processes and business applications that
abound in the work environment; however, some fundamental components must be universally addressed.
There must be a corporate code of operations that
reinforces established safety standards and systems. The
established standards and systems, at a minimum, must
meet regulatory requirements and must integrate lessons
learned specific to internal operations. Within that code
of operations, ISD must be integrated into all design
applications, whether for new facility start-up or facility
renovation, including maintenance turnarounds.
An additional component for success is employee
involvement. Employees must be competent to provide
the service for which they are hired but also must engage
and embrace the established corporate standards. It is
imperative that they participate in design reviews, hazard
analyses, prejob safety assessments and development
of standard operating procedures as well as understand
management of change principles and standards.
If the fundamentals of management and employee
participation exist within an operation, performance must
be continually measured and performance measurement
standards that provide assurance for sustained operation
must be integrated. Critical components of performance
metrics must include measures and critical components
to provide assurance that management systems function
properly and that potential hazards are recognized and
addressed. Employee recognition for promptly addressing risks is fundamental to sustaining this effort.
Metrics also include continued monitoring of nearmiss events and incidents. A critical component of
incident management is a sound incident investigation
system that includes employee involvement and recognizes incident investigation techniques that focus on root
cause processes and on all contributing factors, including
human factors. If the investigation process uses a root
cause identification process, human factors should be
integral to this system. As a result of the investigation
and findings, it is imperative that management reinforces
the corrective actions and addresses any fundamental
system errors that must be changed or calibrated. These
fundamental errors may include proposed changes in the
design process and evaluation of process safety controls
that were thought to be inherently safe. •
Don Enslow, CSP, is the process safety management team lead
at BP Exploration Alaska. He has more than 35 years’ experience
as a safety professional in the oil exploration and production and
nuclear power industries. He is a principal member of the NFPA
Technical Committee on Gaseous Fire Extinguishing Systems
(GFE-AAA), NFPA 12, NFPA 12A and NFPA 2001.
ByDesign www.asse.org 2014
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By Scott Stricoff
Targeted Metrics for Managing
Fatalities & Serious Injuries
or decades, the safety community has adopted conventional wisdom, which holds
that a reduction in the incidence of minor injuries will
bring about a proportional reduction
in the incidence of serious injuries
and fatalities (SIFs). This thinking
emanates from H.W. Heinrich’s
Safety Triangle, a visual construct of
Heinrich’s Law, which has informed
this paradigm (Figure 1) suggesting
that organizations should address
minor injuries (and near-misses) as
a means of reducing serious injuries
and fatalities.
Despite the longevity and pervasiveness of this paradigm, the reality that has played out in numerous
organizations contradicts many of
The Traditional
the basic relationships the paradigm
espouses. Over the past several
years, many organizations have
experienced a consistent decline in
their occupational injury rates while
concurrently experiencing level or
even increasing numbers of fatalities
and serious injuries.
This pattern has been seen at the
site, organizational and national levels and raises important implications
and questions about how SIF prevention is approached and the validity of
this long-held model.
Fundamentally, the traditional
model claims two basic relationships:
1) Descriptive. An inverse
relationship exists between the frequency of an injury and the severity
of an injury.
2) Predictive.
Reductions in less
serious injuries will
produce proportionate
reductions in more
serious injuries.
In examining these
issues, a comprehensive set of data from
seven large organizations was studied.
The findings of this
study showed that
while the Heinrich
triangle is indeed
accurate descriptively
(there is a higher
incidence of minor
injuries than serious
injuries), it is not
accurate predictively
(reducing minor
injuries at the base of
the triangle does not
produce proportional
reductions throughout
the rest of the tri26
ByDesign www.asse.org 2014
angle). The study further found that a
subset of total injuries and exposures
is disproportionately responsible for
serious injuries and fatalities.
Pitfalls of Inadequate
Performance Measurement
To assess the comprehensive
effectiveness of their safety management capability, many organizations
have relied primarily on lagging
indicators, such as recordable injury
rates. The attractiveness of metrics,
such as these, is understandable.
They are relatively easy to collect,
classify and understand, and in many
cases, governing bodies mandate the
reporting of these metrics. However,
this disproportionate focus and overreliance can mask many serious
safety issues that lie below the surface of awareness generated by these
Over the past several years,
numerous catastrophic workplace
incidents have occurred (e.g., BP
Texas City, Qinghe Special Steel
Corp., Upper Big Branch Mine and
Deepwater Horizon) that clearly
illustrate this problem. In virtually
every case, the catastrophic incident
was preceded by extended periods of low, very low or improving
recordable injury rates. Prior to these
incidents, asking the executives of
these organizations, “How are you
doing in safety?” would have likely
generated a response of “We are
doing great. Our injury rates have
never been lower.” But clearly, serious safety issues persisted outside of
their view.
To manage SIFs more effectively,
it is important for organizations to
measure more than just the incident
frequency and severity. They must
effectively measure their exposure to
the types of incidents that can produce SIFs. This marks a critical shift
in focus from lagging indicators to
leading indicators for a more proactive approach to preventing SIFs.
More specifically, this approach
requires establishing methods of
classifying exposures and incidents
to create a new metric—potential
SIFs. By tracking potential SIFs in
addition to the traditional measures
discussed, an organization can generate a much clearer picture of its
progress. Further, sound evaluation
of the exposures that contribute to
potential SIFs allows for tailored
mitigation programs that focus
squarely on those areas of concern.
Measuring &
Classifying Potential
All exposures are not equal when
it comes to their potential to generate SIF events. Data analyzed in the
aforementioned study that examined
the validity of Heinrich’s Triangle
found that only 21% of the injuries
classified as minor had the potential
to produce an SIF outcome. That is
not to say that the other 79% of injuries are not important but rather that
these incidents require a different
prevention strategy.
To further illustrate this point,
consider the following two incidents,
both of which produce an identical
Incident 1: A worker steps off the
bottom step of an outside stairwell
onto the ground’s gravel surface. In
carrying out this action, he loses traction and sprains his ankle.
Incident 2: A worker steps up
from the top step of an outside stairwell onto a roof’s gravel surface.
As he shifts his weight to the foot in
contact with the gravel surface, he
loses traction and sprains his ankle.
In this case, the most obvious
variable that influences potential is
where the event occurred. Because
the second incident occurred at
significant height, the worker could
have fallen down the stairs or even
off of the roof surface if proper controls were not in place. Because the
first incident essentially occurred on
the ground, an extended fall would
not be a possible outcome.
Although these two incidents produced the same injury outcome, the
second incident has a higher potential to produce an SIF event, whereas
the first incident is not likely to produce anything significantly beyond
the relatively minor injury that
occurred. Yet in many organizations,
these incidents would be identically
classified because of the misplaced
focus on outcome and lack of attention to potential.
To manage SIFs
more effectively,
it is important for
organizations to
measure more than
just the frequency
and severity of
By evaluating and tracking measures such as the quantity, frequency
and percentage of injury and nearmiss events occurring inside the
organization that have the potential
for SIFs, a better sense is gained of
the likelihood that a serious, fatal or
catastrophic event will occur.
Importance of Precursors
Precursor events are defined as
high-risk situations in which management controls are absent, ineffective or not complied with and
which will result in a serious injury
or fatality if allowed to continue.
Precursors can be identified through
proper evaluation of incidents like
the ones discussed by studying data
on exposure and via careful analysis
of injury reports, near-misses, safety
observations and audit findings.
Creating an SIF precursor metric
requires having a method for iden-
tifying those incidents that are SIF
precursors. Three general methods
have been employed:
•Outcome-based. Using the result
as a basis for classification. Although
easy to implement, this does not
identify SIF precursors accurately, as
the previous discussion illustrates.
•Judgment-based. Using professional judgment to assess whether
the event could have resulted in an
SIF. With this approach, it is virtually impossible to achieve consistent
classification as different raters will
assess potential differently based on
their personal judgment about probability and outcome.
•Event-based. Using characteristics of the event to identify those
with SIF potential. This approach
risks missing some SIF precursors
but can capture most with consistent
screening that can be done at the
local level.
When using the event-based
approach, particular activities more
naturally lend themselves to producing higher proportions of precursor
events. Examples of these activities
•operation of mobile equipment
and interaction with pedestrians;
•entering confined spaces;
•performing jobs that require
•operations that entail suspended
•working at height.
Beginning with a generic SIF
classification decision tree, an organization can perform a one-time
customization. A small group applies
the generic decision tree to the
organization’s incident experience
(injuries, near-misses and process
safety events). After identifying most
events that are defined by the generic
tool as SIF precursors and nonprecursors, a group of unclassified events
will remain. The small group then
conducts a one-time judgment-based
assessment of the unclassified events
and from those selected as precursors modifies the generic decision
tree to create a tree customized to
the organization’s exposures. That
ByDesign www.asse.org 2014
While many organizations have
some awareness of exposures, nearmisses and minor injuries that have
high potential, few possess the consistent reporting, measurement and
tracking visibility needed to address
these precursors in sustainable ways.
A reliable, effective system to capture, report and address precursors
minimizes the elevation of trivial
events. While all incidents should
be reported and accompanied by
some level of investigation, the SIF
potential of events must be carefully
considered to inform the depth and
scope of investigations.
The system to address precursors
also dispels beliefs that an SIF is just
a fluke or unpreventable event. With
sound precursor data, leaders who
have said, “We do not know where
to start” or “We do not know where
these events are stemming from,”
will be empowered with information
that answers these commonplace
concerns by showing them a subset
of events on which they need to
In addition, the system lowers serious injury rates. Having a
sharpened focus on events with SIF
potential means that resources, which
previously had been largely wasted
in addressing trivial events, can
instead be allocated to reduce exposures to SIFs.
The information outlined in this
article suggests that significant flaws
exist in the way many organizations
think about and address serious injuries and fatalities. Further, it suggests
that a new metric must be developed
for SIF precursors. What gets measured gets managed, so developing
and implementing an SIF precursor
metric is a key step toward understanding how to better focus various
safety interventions toward reducing
the frequency of the most serious
events. •
Scott Stricoff is president of Behavioral
Science Technology Inc. in Ojai, CA.
Reprinted with permission from the
proceedings of ASSE’s 2011 Prove
It! Measuring Safety Performance
ASSE Elections: Vote Today!
oting in the 2014 ASSE Election is underway,
and this process is important. In the coming
years, the Society will address several critical stra­
tegic issues concerning the path forward for both
ASSE and the safety profession. These issues affect
not only your practice specialty, but your liveli­
hood. By staying informed and voting, you play an
important role in deciding who will lead ASSE. It
is a critical responsibility of membership, and ASSE
encourages you to:
•Get to know the candidates at www.asse
and platform statements posted at www.asse
.org/elections. Please contact Geri Golonka or
Kim McDowell with any questions.
•Cast your vote by March 31.
Ballots have been sent via e-mail to all mem­
bers except those who elected to receive a mailed
ballot. Voting instructions and additional informa­
tion about candidates, along with interviews, bios
ByDesign www.asse.org 2014
customized decision tree can then be
used throughout the organization to
drive event-based classification of all
incidents, providing a SIF precursor
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Learn more about the benefits you receive as an Engineering Practice Specialty
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