THE INTEGRATION OF STANDARDS‐BASED AND BEHAVIOURAL‐BASED SAFETY PROGRAMS IN
A HAZARDOUS INDUSTRIAL ENVIRONMENT
Matthew Orr
INTRODUCTION
PT International Nickel Indonesia (PT Inco) is a world‐class nickel mining and processing operation
located in Sulawesi, Indonesia. The large workforce and the diversity of significant hazards associated
with an integrated mining and processing operation present a considerable safety management
challenge in the context of the Company’s goal of zero harm.
This paper presents an overview of the strategy being implemented to minimise the risk of serious
injuries and fatalities at PT Inco. This strategy is based on the premise that both workplace condition and
worker behaviour are critically important in the prevention of serious accidents, and each must be
addressed by specific and complementary programmes.
ABOUT PT INCO
The PT Inco operation consists of an open‐cast nickel laterite mine, a pyrometallurgical processing plant,
thermal and hydroelectric power generating facilities, a port, a company township and other support
facilities. The remoteness of the site requires the Company to provide a range of services and facilities
typical of a small town, including for example, schools, a hospital, an airport and a fire service. Total
workforce is approximately 5,000 persons, the large majority of whom are local to the district. The
majority owner of PT Inco is Vale Inco. Commercial production commenced in 1978 and is expected to
continue beyond 2025.
BACKGROUND TO THE CURRENT PROGRAMMES
In 2004, the safety programmes at PT Inco received critical review at the request of the Executive. At
that time, there had been 25 work‐related fatal incidents at PT Inco since 19901. PT Inco has a goal of
zero harm to its workers and a policy of ongoing improvement. With this in mind, the Executive agreed
to the development of new programmes directly addressing the risk of serious incidents. These
programmes commenced in early 2005, and are still being implemented and progressively improved
today.
1
Fatal accidents are not uncommon in the Indonesian Mining industry. For example, 27 fatalities were formally
reported in 2006. A single incident in 2009 reportedly resulted in at least 28 fatalities.
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SAFE CONDITIONS OR SAFE BEHAVIOUR?
Over recent decades there has been increasing support for behavior‐based safety management
programs. Behavior‐based safety is based on the idea that workers need to take accountability for
working safely, that they have a natural interest in being safe, and that this can be harnessed through a
structured conversation or some other communication that leads to modification of behavior. Unsafe
behavior should be discouraged through persuasion rather than penalty, as penalties only have effect if
a worker believes he will be “caught”, and may imply blame. This may have a range of undesirable
unintended consequences such as non‐reporting or concealment of incidents.
An alternative and sometimes competing approach to the management of safety is a standards‐based
approach whereby hazards in the workplace are mitigated through a range of controls. These are often
presented as a hierarchy of controls from most to least desirable, namely elimination, engineering
controls, administration controls and personal protective equipment. The implied assumption is if the
workplace is sufficiently safe, worker behavior becomes less important, or a greater range of behavior is
tolerable (and this is necessary as people will always make mistakes). In a standards‐based approach,
accountability for workplace safety largely rests with management.
A brief review of information available on the internet makes it clear that there are proponents for both
approaches, and limitations associated with each.
One of the limitations of a behavior‐ based approach is that it does not directly address the behavior of
persons removed from the workplace, who may directly affect conditions within the workplace. Also, it
can be viewed as shifting accountability for safety from management to the worker, and for this reason
receives criticism from trade unions. The proponents of behavior‐based safety systems are often from
countries with highly developed safety legislation. In these environments, workplace safety is arguably
already being addressed, because it is a legal requirement and failure to do so will lead to fines or
prosecution. In countries with less developed safety legislation or less effective enforcement by
Government, there is a greater need for systems within the company that achieve the same outcomes.
In reality, both approaches are important. In an industrial environment the causes of serious injuries or
fatalities are typically complex and usually the incident occurs as a final step in a chain of events. If our
goal is zero harm, then all links in the causal chain need to be systematically addressed, including both
condition and behavior. It may be far easier to simply remove a hazard rather than train a large
workforce to work safely in proximity with it. Likewise, it is never possible to eliminate every hazard
from a workplace, and workers must want to work safely and understand how to do this.
It is often useful to use a slogan to encapsulate the basis or intent of a safety programme. Rather than
repeat the commonly expressed observation that “Ninety‐six percent of injuries are caused by unsafe
acts” this author prefers:
SAFE WORKPLACE + SAFE BEHAVIOUR = ZERO HARM
This clearly prescribes accountabilities for management (safe workplace) and the worker (safe
behaviour). Note that in this context “workplace” includes worker competency, in addition to physical
aspects.
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THE BASIS OF THE PT INCO STRATEGY
The strategy being implemented at PT Inco to address the risk of serious incidents is based on the
premise that both workplace condition and worker behaviour can be equally important in the
prevention of serious incidents. The key programmes currently being implemented to address the risk
of serious injuries and fatalities at PT Inco are as follows:
Major Hazard Standard (MHS) program
This is a Standards‐based programme that directly addresses workplace safety, primarily through
minimisation or elimination of hazards, and systems to ensure worker competency. It clearly defines
accountability at the management level.
“Safety Conversations”
This program requires management to visit the workplace on a regular basis and engage workers in a
structured conversation regarding safe behaviour. It clearly defines accountabilities for both
management and workers.
“Golden Rules”
This is a set of “rules” that are designed to protect workers from the most common causes of fatal
accidents at mining and processing operations. It clearly defines accountability at the worker level.
All these programmes are seen as complementary and interdependent. Any reduction in the incidence
of serious injuries and fatalities is seen as the result of the combined approach, with no single
programme having precedence. These programmes are discussed in the following sections.
THE MHS PROGRAM
Overview
The MHS program is based on the understanding that a safe working environment can be defined by
outcomes under a standard set of categories:
9 Hazard Identification, Risk Assessment and Control.
9 Selection, Training, Competency and Authorization.
9 Communication and Awareness.
9 Specifications.
9 Work Method and Condition Control.
9 Maintenance.
9 Emergency Controls.
9 Monitoring, Inspections and Audits.
9 Reporting, Assessment, and Corrective Actions.
These controls can be understood as layers of control between the hazard and the incident (Figure 1).
3
Figure 1
Concept of layers of control in the MHS approach
These outcomes are documented in Major Hazard Standards (MHS). The MHS is a document that lists
the required outcomes together with the position accountable for implementing this outcome. The
clear allocation of accountability is a key feature of the system. There are 18 MHS in place at PT Inco,
which address 18 major hazards identified for the site on the basis of a comprehensive risk assessment:
MHS01 Vehicle & Mobile Equipment Condition
MHS02
Vehicle & Mobile Equipment
Operation
MHS03 Road Condition
MHS04 Isolation & Lockout
MHS05 Electrical
MHS06 Working at Heights
MHS07 Confined Spaces
MHS08 Lifting & Supporting Loads
MHS09 Explosive Management
MHS10 Slope Stability
MHS11 Working Near or In Water
MHS12 Boilers & Pressure Vessels
MHS13 Aviation
MHS14 Molten Materials
MHS15 Rotating & Moving Equipment
MHS16 Clearing Operations
MHS17 Dangerous Goods
MHS18 Tires & Rims
Supporting each MHS is an audit protocol that allows measurement of compliance with all outcomes in
the MHS in an accurate and repeatable manner. Because auditing the entire set of outcomes is a
lengthy process requiring skilled auditors, MHS inspection forms have also been developed, that address
only the physical requirements of the Standards. By ignoring the system requirements, a simpler form is
generated. The MHS, associated audit protocol and inspection form comprise an internally consistent
family of documents that are used by different members of the management team (Figure 2).
4
The supporting audit protocol
and inspection form
The Major Hazard Standard
The
auditable
outcome
The role
accountable
for this
outcome
Figure 2 Overview of the MHS documentation in use at PT Inco
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Measuring Compliance
The format and content of the MHS approach has been specifically designed to facilitate efficient
auditing and inspections, and auditing and reporting of compliance to the standards is an essential part
of the programme.
Managing improvement against 18 MHS simultaneously would be daunting, and so each operational
Department at PT Inco selects 4 MHS at a time to implement. The audit cycle commences with a
“baseline” audit. The Departmental management team is then required to develop a Safety
Improvement Plan for each standard. A follow‐up audit takes place after 12 to 24 months to measure
progress in implementing the plans. A rolling schedule will result in all Departments being audited
against all MHS after around four years.
The audit process provides a quantitative score against all the requirements of each standard. A simple
scoring system is used to report compliance against each element, namely:
0: No controls in place to manage the risk.
1: Some controls in place but improvement is required to reach best‐practice.
2: Controls largely in place.
The initial target for the Department was the elimination of all “0” scores. The use of “traffic light”
colour‐coding allows simple and effective reporting of these results (Figure 3).
Assigning Accountability
Every outcome in an MHS has a corresponding accountable position. This may be a specific role
(“Manager Utilities”) or a general role (“Area Managers”). This secures several key benefits:
1. All significant outcomes for the management of a major hazard are allocated to a staff position
(there are no “ownerless” outcomes).
2. The accountabilities reporting to a particular management position can be quickly collated over a
range of MHS, effectively defining safety management accountabilities for that role.
3. The performance of the manager in meeting these accountabilities can be scored. At PT Inco, MHS
score is included in the annual performance appraisal of General Managers. This approach has
resulted in dramatic improvements in compliance over time (Figure 4).
Summary of Advantages and Limitations of the MHS Programme
The advantages of the MHS program be summarised as follows:
1.
2.
3.
4.
The approach directly targets hazards in the workplace.
The approach is readily embraced by the management team, particularity those with a system or
engineering background.
The requirements for addressing hazards and the accountabilities for implementing these controls
are clearly and systematically defined. This is particularly relevant where there is no
comprehensive legal framework that defines workplace condition requirements.
It provides a numerical measure of risk in the workplace, which in turn can be used as input into
key performance indicators, balanced score cards, or performance appraisals. This provides a very
effective means of driving sustainable improvement.
The recognised limitation of the MHS programme is that it does not directly address behaviour of the
worker in the workplace. Its scope is largely workplace condition, procedural controls and the
competencies of the workforce. Compliance with rules or regulations is not specifically addressed nor
audited. It is also recognised that there will always be occurrences or conditions not fully addressed by
the standards, that would require active intervention or initiative by the worker to avoid an incident.
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An important consideration is that compliance with MHS style standards may require a significant
investment of funds, particularly when applying it to existing plant and facilities. The estimated cost of
MHS implementation at PT Inco from 2006 to present is $US 7.3 M. This includes $US 1.7 M in
document development and auditing costs.
The MHS approach is described in more detail in Orr & Uren (2007) and Orr & Thorpe (2007).
Compliance per MHS Audited - Process
40
Compliance
5
2
35
30
11
3
19
25
4
20
15
6
24
10
5
0
13
16
2
1
0
20
0
MHS 02 Vehicle
Operation
MHS 06 Working at
Heights
MHS 07 Confined
Spaces
MHS 08 Lifting
MHS
Figure 3. Compliance with MHS for the Process Plant ‐ Baseline audit. The magnitude of the red bars
provides a visual indicator of the absence of controls for each hazard and a readily understood target
for improvement.
Figure 4. Compliance with MHS for all Departments over time. All Departments achieved a very
significant improvement in compliance with the MHS in the two years following the baseline audits.
This indicates a substantially safer workplace.
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SAFETY CONVERSATIONS
Overview
In a given workplace, hazard elimination and engineering controls may be used to remove or reduce
risk. However, there are always hazards remaining that can only be addressed through procedural
controls. Even reliance on procedural controls will not be sufficient due to the complexity of a
workplace and the unusual situations that may occur. There will always the need for workers to actively
assess risk and identify and implement safe ways of working.
A number of tools or techniques are available to promote safe behavior. The method adopted at PT
Inco can be best described as a “safety conversation”. This is a formal process targeting unsafe behavior
in the workplace. The technique involves managers engaging a worker in a friendly and open
conversation about their work, with three separate but related outcomes if successful:
1. When doing the same task in the future, the worker will work more safely by applying controls
agreed to as part of the conversation.
2. The worker is encouraged to assess the risks in his work and the appropriate controls. Repeated
over many times, this process will improve his or her ability to independently assess risks and work
safely when doing any work.
3. Management is seen to be actively interested in safety and the welfare of the employee, by leaving
the office and reviewing safety in the workplace (sometime referred to as “visible safety
leadership”).
The Technique
Usually a “safety conversation” is conducted by a team of two, at Manager level or above. Optimally,
this team comprises a person from the Department being audited and another from a different
Department. The use of a partner is not mandatory but is encouraged as it allows coaching and review
of technique.
The process commences with a walk‐through of a work area. Typically, after some observation, the
team can identify a person engaged in unsafe behavior. This might include, for example, using an angle
grinder without wearing hearing protection. A “safety conversation” is then initiated in which the
worker is encouraged to identify the hazards related to his or her work and the appropriate controls.
Generally an agreement is sought in which the subject promises to work more safely in the future. The
process should include, if practicable, a follow‐up visit to confirm if this commitment is met (sometimes
this is difficult to achieve with a mobile and large workforce).
A critical component of the technique is the use of open questions to elicit responses and guide the
conversation. Although the “safety conversation” may take many forms, there are several essential
questions that must be answered by the worker:
ƒ What could go wrong?
ƒ What injury could result?
ƒ How could you prevent it?
An additional question that is often useful in guiding the conversation is “What if the unexpected
happened?”
The key to a successful conversation is for the person doing the work to both identify the risks and the
appropriate controls. This requires the use of open, non‐directive questions by the team. A simple
example is “how could you be hurt” rather than “don’t you think you might damage your hearing?” By
avoiding closed questions, the worker becomes actively involved in the conversation – the ideas
become his rather than those of the team, and as a consequence are more meaningful and memorable.
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The author can verify that a well conducted “safety conversation” can successfully lead a worker to
accurately identify the hazards associated with his or her work and the required controls, and to a
willing commitment to work more safely in the future. Within the Indonesia culture, it can be a
significantly positive experience for a worker to have a friendly conversation with senior management in
view of his fellow workers, concluded by a handshake. In many cases this might be his or her first direct
communication with an Executive, General Manager or Manager.
The process is not designed to measure compliance or facilitate sanctions, and therefore
documentation requirements are minimal. So that the process is seen by the workforce as
unthreatening, names of the subjects should not be recorded and the term “audit” should not be used
during the conversation. Writing notes should be avoided, and if possible the person’s supervisor
should not be party to the conversation.
The Team and Quotas
At PT Inco, all site Executives, General Managers and Managers are required to participate in this
programme once they have been trained in the technique, and are assigned a minimum monthly quota,
(either two or four “conversations”). This provides for one of the key benefits of the technique, namely
increasing the visibility of management’s commitment to safety.
Currently, the site has 68 staff trained in this technique, with an aggregate annual target of 3,400
“safety conversations”. With a total non‐staff workforce of around 4,000, there is a reasonable
probability of many of them experiencing a “safety conversation” during a year with senior
management.
Data Collection & Reporting
After the conversation has been conducted, a simple form is used to record the outcome. The main
function of this form is to track progress in meeting quotas, and distribution of conversations by
Department and work area to ensure adequate coverage. The EHS Department releases a monthly
report tracking the performance of the team members in meeting their quotas. An important
understanding is that the programme is not particularly suitable for the collection of data regarding
compliance, as the process of selecting a worker to engage in a conversation is not random – the team
actively searches for unsafe behavior.
Summary of Advantages and Limitations of the “Safety Conversation” Programme
Compared with programmes such as MHS, the “safety conversation” programme requires little in terms
of system development, and training. It can be implemented immediately once personnel are trained,
and if we consider that senior management should spend time in the workplace in any case, the cost of
ongoing implementation is small. A single conversation might require 30 minutes. If the target is four
per month, this represents about 1‐2% of that person’s working time.
One of the challenges associated with the programme is that it is difficult to directly measure the quality
of the conversations conducted by an individual. Although the technique may appear simple it requires
good interpersonal skills to deliver well. It can be difficult for some senior management to avoid being
directive after a professional career built on this style of communication. Some are tempted to short‐
circuit the “conversation” by directly communicating to the worker what controls are required (and
hence being able to demonstrate their greater knowledge of the issue). At PT Inco we have tried to
assess quality by use of a third‐party assessor/coach but more work remains to be done.
It is also difficult to directly measure the ongoing benefit of the programme because the process does
not directly measure condition or behavior as does a formal audit. However, it is not difficult to
convince most people exposed to the technique that it can bring significant benefits.
A separate challenge is how to integrate the “safety conversation” programme with the site’s
disciplinary sanction system. At times, there is behavior in the workforce that is so dangerous it can
9
never be tolerated. In these cases a different approach is required, and that need is met by the “Golden
Rules”.
GOLDEN RULES
Overview
In a large mining and processing operation such as PT Inco there are certain hazardous activities that are
common across many or all Departments and encountered by large numbers of workers in day‐to‐day
work. While workers are exposed to these hazards, there are types of behavior that are so dangerous
that they can never be tolerated due to the risk of serious injury or death. With this in mind the PT Inco
“Golden Rules” were developed. The purpose of the Golden Rules is two‐fold:
1. To explain in a simple manner the precautions that will, to a large degree, protect workers from
the most common causes of fatal accidents in a mining and processing operation.
2. To document the agreed sanctions to be applied to individuals choosing not to apply these
precautions.
It is no coincidence that the Golden Rules cover most of the hazards addressed by the MHS. The Golden
Rules address aspects of the Standards that are common to most workers at PT Inco and that are within
the ability of the worker to control. There are 17 rules in total, covering the following activities:
•
Vehicle Operation.
•
Working on equipment (isolation and lockout).
•
Working with electricity.
•
Working at heights.
•
Working in confined spaces.
•
Lifting and supporting loads.
•
Working near mine faces.
•
Working near blasting.
•
Working over water and mud.
•
Clearing vegetation.
The rules are presented in a pocket sized booklet, each page dealing with a different activity (Figure 5).
ELECTRICAL SAFETY
“You must ensure that electrical equipment is in safe condition
prior to use”
9
Only personnel approved by PT Inco are allowed to perform tagging,
repairs and installation of electrical equipment.
10
No one shall use a portable electrical tool, instrument or extension cord
if it shows visible signs of being unsafe.
11
No one shall enter any high voltage electrical area (compound or
enclosure) without a high voltage clearance permit.
Figure 5 Extract from the PT Inco Golden Rules (Electrical Safety)
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Communicating the Golden Rules
For the Golden Rules to be effective in protecting the workforce it is essential that most, if not all
workers at PT Inco are familiar with them. Accordingly, prior to the launch of the Golden Rules in
January 2009, PT Inco implemented what is probably the most extensive awareness programme to be
seen at the site. This included:
•
Awareness workshops (7,682 participants).
•
Banners and signs at entry points to the site.
•
A widely‐distributed Golden Rules comic book (Figure 6).
•
Posters.
•
Communication to all new employees via the site’s general induction programme.
Breaches of the Golden Rules
At PT Inco the sanction for breaching a Golden Rule is severe, either a final written warning (with
reduction of bonus) or termination of employment. One of the challenges in applying the Golden Rules
are the many “what if” scenarios that can be raised as exceptions to the rule. The Golden Rules are not
written as a legal document and many exceptions or special circumstances can be thought of that
require some interpretation. To manage this, breaches of the Golden Rules are dealt with using the
company’s existing disciplinary committee process.
Since launching of the Golden Rules in January 2009 there have been nine recorded breaches. At the
time of writing, eight had been subject to disciplinary sanction, with two immediate terminations and
five final written warnings. Six breaches involved vehicle operation, two involved working with
inadequate isolation and lockout, and one involved both working at heights and rigging without proper
training. In the latter incident the individual suffered a lost time injury as a direct consequence of the
behavior.
Advantages and Limitations of the Golden Rules
The majority of the workers at PT Inco are local residents from a small town or rural background. Most
of them have never experienced work in a mining or industrial context outside of PT Inco. Many have
limited experience of the more sophisticated safety management processes such as risk assessments,
and the variety of their work means that many activities are not addressed in detail by standard
operating procedures or similar documentation. Several thousand workers do not work for PT Inco but
rather local contractor companies with very simple safety management systems if any. For these
workers, the Golden Rules provides an effective first line of protection against the most common
significant hazards at PT Inco.
As with any sanction system, compliance is questionable if the worker believes he or she will not be
caught. However, the continuing emphasis in presentations on the Golden Rules is that the prime
purpose is communication of safe work practices in a simple manner to a wide audience, rather than
the application of sanctions. With this emphasis, the Golden Rules were readily accepted by the site
trade union.
An obvious limitation of the Golden Rules is that they by necessity do not address all hazards in the
workplace. They specifically do not remove the requirement for more sophisticated controls developed
on the basis of Job Safety Analyses and documented in Standard Operating Procedures and similar.
11
Figure 6 Extract from the PT Inco Golden Rules comic book
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RESULTS
Safety statistics must be used carefully due to the large variability in parameters such as Disabling Injury
Frequency Rate (DIFR), particularly when frequency is relatively low. Many months of data may be
necessary to prove statistical significance. With this in mind it is too early to make a definitive
statement regarding the effectiveness of the programmes outlined in this paper. However, both the
current trend in DIFR (Figure 7) and the absence of a fatality since 2005 (Figure 8) are very encouraging
outcomes. Recently the site achieved 10.9 million hours without a disabling injury, a record for the site
and for a Vale Inco operation.
0.35
0.30
Actual
3-Yr Avg
DIFR
0.25
0.20
0.15
0.10
0.05
2002
2003
2004
2005
2006
2007
2008
As per
June
2009
Figure 7 Disabling Injury Frequency Rate (DIFR) for PT Inco (per 200,000 man‐hours).
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8
6
4
2
Contractor
2008
2009
2000
2001
2002
2003
PT Inco
2004
2005
2006
2007
1996
1997
1998
1999
1992
1993
1994
1995
0
1990
1991
Fatalities
10
Figure 8 Fatalities due to accidents at PT Inco.
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CONCLUSION
The programmes in place at PT Inco to address the risk of risk of serious injuries and fatalities focus on
improvement in:
•
Workplace condition (reduction or elimination of hazards).
•
Worker competency.
•
Worker behavior.
It is hoped that this strategy is effective in addressing the most common causes of serious incidents at
PT Inco. It is recognized that additional techniques are available for the minimization of safety risk and
it is likely that additional programmes will be introduced as the existing programmes become fully
implemented.
The ongoing support for these programmes by the Executive and management team at PT Inco
represents a clear expression of leadership in safety management and care for the welfare of the
workforce.
The author looks forward with interest to reviewing the safety performance of the site as these and
additional programmes reach maturity over the coming years.
REFERENCES
Orr, M. & Uren G. A Risk Based Strategy for the Elimination of Serious Injuries and fatalities in the
Workplace. Proceedings of the NOSHCON Annual International Conference on Occupational Risk
Management. South Africa. 2007.
Orr, M. & Thorpe H. Major Hazard Standard Implementation – A Case Study. Proceedings of the
NOSHCON Annual International Conference on Occupational Risk Management. South Africa. 2007.
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