Five Ways Significant Injury
Potential Is Overlooked
An employee’s leg is shattered while performing a non-routine
job. It is the first serious injury on site in 28 months — and the
first in this department in more than four years. This site is known
within the company as one of the best in safety and has many
awards to prove it. So what happened?
The infrequency of life-altering
injuries can make them seem random. But when they are looked at
closely, one can see contributing factors to these events that have existed
for a long time. What resulted in a
life-altering injury today may have
produced a minor injury or a nearmiss last year. For too many organizations, the full picture of risk doesn’t
become apparent until the potential
becomes reality. This isn’t surprising;
the cues to significant injury potential can be subtle. Too often, the
signals get lost in the noise of outcomes, metrics and old paradigms.
This article outlines five ways leaders
overlook significant injury potential
with a view to uncovering opportunities to address them.
Detecting Hidden
Dangers
Potential refers to the range of injury
severity possible in a given exposure situation. There are many possible outcomes to any given exposure
(anywhere from “nothing happens”
to fatality), but it is the potential for
— and probability of — a life-altering
injury, fatality or catastrophe that
worries leaders the most. A 2011
study of serious injuries and fatalities
showed that the majority of injuries
— about 80% — represented lowseverity potential. So if these situations were repeated, the likelihood
of a life-altering injury is very low.
That means that about 20% of injuries have high potential to produce
life-altering or fatal injuries.
Learning to distinguish between
high- and low-potential situations
is the key to allocating resources
and supervision effectively. The
trouble is that potential is just that:
something not yet realized. The task
is made harder when considering
that many organizations have an
outcome-driven mindset concerning
AIST.org safety. The company looks at what
has happened, not what could happen. To detect potential, it is helpful
to understand the five chief mistakes
that can cause leaders to ignore or
overlook significant potential.
Mistake 1: Judging an Incident’s
Potential by the Severity of the
Injury — Traditional safety practice has led to thinking in terms of
outcomes. This is helpful in many
respects — one must record what
really happened and know what steps
to take next. But an outcome-only
focus can also limit the ability to
prevent future accidents. Consider
three possible results from the same
situation: a hammer that falls from
a height of 20 feet. It’s possible that:
• The hammer lands 5 feet from
nearby workers.
• The hammer strikes a worker with
a glancing blow, causing a small
bruise on the shoulder.
• The hammer strikes a worker just
below his hard hat and fractures
the vertebrae.
In many workplaces, these outcomes would be recorded as a nearmiss, a first aid and a medical case
with lost time, respectively. And in
most organizations, that outcome
would determine the level of follow-up. Here’s the problem: while
the outcomes are different in each
instance, the outcome potential is
exactly the same. No matter what the
actual outcome, this situation and
others like it will always need full
investigation.
Hazards are ever-present in
the steel plant environment,
and a heightened awareness
and emphasis on safety is
a necessary priority for our
industry. This monthly column,
coordinated by members
of the AIST Safety & Health
Technology Committee, focuses
on procedures and practices
to promote a safe working
environment for everyone.
Author
Donald R. Groover
senior vice president, BST
Certified Safety
Professional and Certified
Industrial Hygienist
donald.groover@
bstsolutions.com
Contact
Comments are welcome.
If you have questions about
this topic or other safety
issues, please contact
safetyfirst@aist.org. Please
include your full name,
company name, mailing
address and email in all
correspondence.
Mistake 2: Assuming That
Lagging
Indicators
Show
the Total Potential That Exists
Organization-Wide — When one
misses capturing potential at the
individual incident level, one naturally gravitates toward aggregating
August 2012 ✦ 35
and reporting the data he/she does have (usually outcome
statistics). The problem here is that one mistakes what he or
she can see as representing everything he or she can’t see.
So when the severity rate trends down, one assumes (falsely)
that it means that the likelihood of a life-altering event is
also going down. This assumption is based on an outdated
paradigm about the relationship between types of injuries;
specifically, that reducing one kind of injury necessarily
reduces other kinds. While it turns out that this model is
accurate descriptively (less severe injuries do occur more
frequently than more severe injuries), it is not accurate predictively (there is not a constant ratio between injury types,
as some people assert).
Mistake 3: Believing That All Injuries and Exposures Have the Same Potential to Be Serious or
Fatal — Two employees break their wrists. In Incident A,
the employee stumbles while she is walking across a paved
surface and fractures her wrist while bracing for impact
with the ground. In Incident B, an employee reaches into
an auger that moves unexpectedly, catching his hand and
fracturing his wrist. Both incidents have identical outcomes
but vastly different potential. If Incident A were to happen
100 more times, it is very unlikely to result in an outcome
much worse than a fractured wrist. If Incident B were to
happen 100 more times, there is a very good chance there
would be loss of limb or life.
It is important to note that there are particular types of
work activities with higher levels of potential for serious
injuries or fatalities. Working at heights, working in and
around mobile equipment, working on equipment that
needs to first be de-energized, and working in a confined
space are examples where there is potential for a more serious outcome if there is variation in the system.
Mistake 4: Devoting Resources Disproportionately
to Low-Potential Events Versus High-Potential
Events — Every incident is important and requires attention. But does that mean they all require the same scope
and depth of action? Consider the example of the broken
wrists. In Incident A, falling while walking at the same level,
a physical inspection of the accident scene and one-on-one
discussion with the injured employee to determine if there
were any underlying physical causes would suffice in almost
all instances. It is even likely that no action items will be
required as a result of the incident. The second incident,
however, requires an exhaustive investigation that identifies
immediate and root causes and results in significant and
meaningful action items. This investigation should occur
even if the machine cycled unexpectedly yet didn’t result
in an injury.
36 ✦ Iron & Steel Technology
In many outcome-based measurement systems, however,
incident investigations are typically triggered by outcomes,
not by potential. This approach often leads to spending
significant time and resources on activities that produce
very little in return. This “focus on everything equally”
mentality can also affect safety processes designed to
identify exposure before an incident occurs (e.g., observation systems, audits and housekeeping inspections). These
systems can easily and predictably devolve into ones that
detect the “easy to find” exposure. The primary focus then
results in identifying behaviors or conditions that have low
potential outcomes and an unintentional de-emphasis on
high potential exposures. Additionally, these systems can
focus on planned, routine events, while events with high
potential are ignored.
Mistake 5: Implementing Systems That Reinforce Focus on Measuring Outcome Instead of
Potential — One of leadership’s toughest challenges with
regard to safety is how to properly measure it. Lagging
indicators, such as medical case and restricted lost time
case rate, have many attractive elements, e.g., availability,
simplicity and mandates for use. It is also known that these
indicators are rife with caveats. For example, medical case
rates can be declining even when serious injuries and fatality rates are not. Medical case rate also gives no real indication of the extent of compliance in the process safety arena.
And sadly, if enough pressure is placed on medical case
rates, people can become creative in how they “manage” an
outcome from recordable to non-recordable.
Additionally, many individual employees are wrongly
rewarded based on outcome measures. Add to this a perception that they do not have time for capturing additional
measures and there will be little motivation for them to
adjust their thinking and systems to include the measurement of leading indicators. Lagging indicators certainly
have their place, but (as is echoed by Mistake 2) using them
as the sole source for monitoring the safety health of an
organization is a recipe for catastrophe.
Changing Your View
Change is never simple. A system based on potential will
necessarily require more time from a process and supervisory perspective. And it will require challenging old
paradigms and legacy systems designed around simply outcomes. That doesn’t mean that such a change is not worthwhile — or possible. It can begin with a discussion of the
safety goal and what a commitment it would be to include
potential in the organization’s view of safety. Ultimately, the
leader’s task is to help others see the potential for serious
injury — and the potential for safety excellence. F
A Publication of the Association for Iron & Steel Technology