ELIMINATING
SERIOUS INJURIES
AND FATALITIES
Safety Driven Performance Conference
October 10, 2013
Houston, TX
Susan M. Murphy, M.Ed.
Principal Consultant
Behavioral Science Technology, Inc.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Why Is This So Important?
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Industry Data
OGP HSE Performance Trend Lines
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
All Injury Frequency Rate (3 Month Rolling
Average) and Fatality Rate 2000.12-2008.08
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Traditional Safety Triangle IS
Descriptive
Data from 2008-2009
*Average Rate*
Serious Injuries
and Fatalities
Restricted and
Lost Workday Cases
0.30
Medical
Treatment
0.98
1028 Total Cases Studied
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
.0014
Serious Injuries & Fatalities (SIF)
Exposure Potential
Theme
SIF or SIF-Potential
Incident
N=55
NON SIF-Potential
Incident
N=35
1
Performing a routine operations/production or a maintenance/repair task,
connected with a deviation from an established Life Safety Rule/Safety
Absolute.
42%
0%
2
Performing a routine operations/production or a maintenance/repair task, (not
governed by an established Life Safety Rule/Safety Absolute), connected to an
exposure that changed from a “normal state”, was not
anticipated/recognized/controlled and likely could have been prevented by a
proper Pre-Task Risk Assessment (PTRA).
29%
17%
3
Self-made human errors that are not connected to a Safety Absolute Involved
in either a routine operations/production or a maintenance/repair task OR
performing a special/unique/unplanned/emergency situation.
11%
74%
4
Involved in routine operations/production or a maintenance/repair tasks, and a
connection to an equipment / facility / process / engineering design flaw has been
established.
5%
3%
5
Involved in routine operations/production or a maintenance/repair tasks, and a
connection to predictive & preventive maintenance & inspection, and
reliability systems has been established.
5%
6%
6
Involved in a special/unique/unplanned/emergency situation, connected to
an exposure that was unknown or unfamiliar, and was not
anticipated/recognized/controlled, and likely could have been prevented by
a proper Pre-Task Risk Assessment (PTRA).
4%
0%
7
Involved in an act or incident or workplace violence, war, or militia attack
or similar.
4%
0%
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Key Findings & Points
1. 42% SIF were from Life Safety Rules
• 98% of those not because employee ignored rule –
more complicated
2. 29% SIF could have been prevented with quality
pre-task assessment
3. 71% of all SIFs fell into these 2 categories
4. First 5 categories involved routine tasks
5. Sample size statistically valid for valid conclusions
• Our clients are finding the same thing (40-50% Life
Safety Rules)
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Cases that Drive the Numbers
1
2
3
4
5
6
7
Theme
SIF or SIF-Potential
Incident
N=55
NON SIF-Potential
Incident
N=35
Performing a routine operations/production or a maintenance/repair task,
connected with a deviation from an established Life Safety Rule/Safety
Absolute.
42%
0%
Performing a routine operations/production or a maintenance/repair task,
(not governed by an established Life Safety Rule/Safety Absolute),
connected to an exposure that changed from a “normal state”, was
not anticipated/recognized/controlled and likely could have been
prevented by a proper Pre-Task Risk Assessment (PTRA).
29%
17%
Self-made human errors that are not connected to a Safety Absolute
Involved in either a routine operations/production or a maintenance/repair
task OR performing a special/unique/unplanned/emergency situation.
11%
74%
Involved in routine operations/production or a maintenance/repair tasks,
and a connection to an equipment / facility / process / engineering design
flaw has been established.
5%
3%
Involved in routine operations/production or a maintenance/repair tasks,
and a connection to predictive & preventive maintenance & inspection,
and reliability systems has been established.
5%
6%
Involved in a special/unique/unplanned/emergency situation,
connected to an exposure that was unknown or unfamiliar, and was
not anticipated/recognized/controlled, and likely could have been
prevented by a proper Pre-Task Risk Assessment (PTRA).
4%
0%
Involved in an act or incident or workplace violence, war, or militia
attack or similar.
4%
0%
SIF: Serious Injuries & Fatalities
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
CHAID Analysis
(Chi-squared Automatic Interaction Detector)
•This
model can accurately predict an incident as being SIF or non-SIF with 78% accuracy.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Definition of Serious Injury
1. Life-threatening injury or illness: one that if
not immediately addressed is likely to lead
to the death of the affected individual, and
will usually require the intervention and/or
external emergency response personnel
to provide life-sustaining support.
2. Life-altering injury or illness: one that
results in permanent or long-term
impairment or loss of use of an internal
organ, body function, or body part.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
OSHA 300 Log is Misleading
Fractured Foot
Case A (SIF Potential = No) – Employee suffered a
fractured foot when they climbed out of a truck cab,
missed the bottom rung of the ladder, and fell 30
inches to the ground. Their foot rolled off a small rock,
resulting in a fracture.
Case B (SIF Potential = Yes) – Employee suffered a
fractured foot when backed over by a forklift truck
(PIT). The PIT operator backed up without looking, and
the backup alarm was not functioning. This easily could
have been a serious (life-threatening or life-altering)
injury, or fatality if the employee’s full body had been
struck and run over.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Potential?
Laceration Requiring Sutures
Case A (SIF = No) – A worker cut his finger on the sharp
edge of a pipe flange in the machine shop. He was grinding
the burrs off the flange end, wearing all necessary PPE. He
stopped grinding and removed his glove to feel the edge with
his finger to see if the burrs had been successfully removed.
The edge was sharper than expected, resulting in a cut to
the left index finger that needed two sutures.
Case B (SIF = Yes) – A 4-foot by 8-foot by 1-inch steel plate
was being moved for installation by two workers using an
overhead hoist. The plate shifted unexpectedly and worker
#2 tried to steady it with his hand. The plate shifted again,
this time pinching worker #2’s hand against the steel frame.
He sustained a laceration of his right ring finger, which
required sutures to close.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Potential?
Strained Back
Case A (Non-SIF) – Worker was walking across the
floor, slipped on grease, caught himself on a railing,
and wrenched his back (strained back muscle).
Case B (SIF = Yes) – Worker fell from the top of a rail
car when his car was struck by another rail car that
was being moved into position. The worker fell on top
of the tank car, grabbing the guard rail around the
dome lid, preventing a fall to the ground. The only
injury resulting was some bruising and a strained back
muscle. Even though this event was classified as “firstaid”, it clearly has high potential for SIF.
What about the gray areas?
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
The traditional
safety triangle is
not predictive.
Not all injuries have
Serious Injury and
Fatality (SIF)
potential.
A reduction of
injuries at the bottom
of the triangle does
not correspond to an
proportionate
reduction of SIF’s.
21%
Potentially
SIF
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
The Current Paradigm
‒ Are We Stuck on This?
•
•
•
•
•
Serious Injuries and Fatalities (SIFs) and Non-SIFs
have the same causes and correlates.
You can impact the top of the triangle by working
on the bottom of the triangle (the triangle is
predictive).
TRIR and audit information are reliable indicators
of SIF Exposure Potential.
When SIFs occur, they are one-offs.
Accident investigations are systematized and highly
sophisticated, and good enough.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
A New Paradigm
A new way of thinking
about the Safety Pyramid:
focus on prevention of SIFs
Fatalities
Lost Time Injuries
Recordable Injuries
Precursors
High-risk situations in which management
controls are either absent, ineffective, or
not complied with, and which will result in a
serious or fatal injury if allowed to continue.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Exposures
A New Paradigm
•
The causes and correlates of SIFs are
different from Non-SIFs.
•
You will not impact the top of the triangle
by working on the bottom of the triangle.
•
The SIF blind spot is significant.
•
Our accident investigation processes
are not getting the job done.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Cases that Drive the
Numbers…
…are still important and require attention:
•
•
•
•
•
Observation & Interaction (BAPP®).
Approaching Others (AO).
Incident/Injury Reporting & Handling.
Pre-Task Risk Assessments.
Exposure Recognition:
•
•
Risk perception and risk tolerance.
Blood, break, and bruise.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Exposure Potential
•
Leader education:
•
•
SIF Exposure visibility:
•
•
•
Don’t overlook anything.
SIF exposure metric.
Know your precursors:
•
Mine your data.
•
Discover thru observation & interview.
Interventions integrated into existing SSHE systems:
•
Injury/Incident reporting.
•
Pause work climate – Stop Work Obligation (SWO).
•
Life Saving Rules – quality, integrity and reliability.
•
Pre-task risk assessments (RA/JSA).
•
Accident handling system.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Intervention I
Educate senior leaders, area managers,
and enlist their sponsorship:
•
They need to understand this problem
before they can be expected to act on it.
•
The solutions to the SIF problem are
different and require their attention.
•
See SIF exposure and react appropriately.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Intervention II
SIF Exposure Visibility:
•
Gaining traction in our clients.
•
Prerequisites:
•
•
SIF definition.
•
SIF Exposure Potential determination.
•
SIF Exposure Rate(s) calculation.
BST SIF potential decision-tree.
SIF white paper describes “how to” and decision-tree
@ www.bstsolutions.com
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Classification Scheme – Sample 2
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Intervention III
Know Your SIF Precursors:
•
•
3 places where they hide.
Accident Investigation processes must become
transformational:
•
Contributing factors.
•
Root causes.
•
Precursors.
•
Longitudinal analysis.
•
Effectiveness of corrective and preventive actions.
•
Tracking of recommendations.
•
Effective communications of lessons learned.
•
Case narratives do not provide adequate descriptions to help us
understand what really happened and the context surrounding
the exposure.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Identifying SIF Precursors
High-Risk Exposure
Work Activities & Situations
Routine operations or production tasks
Routine maintenance or repair tasks
[81%]
Safety Management
Controls and Measures
Lockout/Tagout
Not aware?
Confined Space Entry
Aware but not acted on?
Working at Elevations/Fall Arrest
Condoned?
Machine Guarding- Barricades
Complacency?
Operations of Mobile Equipment
Culturally acceptable?
Suspended Loads
Normalization of deviation?
Horseplay, working under the influence of
drugs/alcohol
Not observed?
Equipment and pipe opening
Hot work permits
High-Risk Event Combinations
Allowed to
Continue
Excavations, trenches
Work pressure?
No follow-up?
Tolerance for risk?
NFPA 70E- Arc Flash Protection
Tolerance of inadequate
systems?
Process instability
Absent /Non-existent
Every step
Significant process upsets
Ineffective/Deficient
Every level
Unexpected maintenance
Not complied with/ Not followed
Unexpected changes
[If these defenses are not solid, you have a
precursor]
High energy potential jobs
Emergency shutdowns
[Work on the right problem. Generalizations are not
helpful]
Start-ups
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Intervention IV
Integrate Interventions into Existing Safety
Management Systems.
•
BBS SIF precursor discovery – interview
and observation process:
•
An exciting development (87% discoverable
precursors).
•
BBS enhancement workshop.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
SIF Intervention IV (cont.)
•
Life Saving Safety Rules.
•
Pre-Task Risk Assessments.
•
Climate for Reporting and Pausing Work.
•
Incident Handling Systems (reporting,
reaction, investigation, action planning).
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Healthy Incident Reporting
•
Does this truism exist here?
•
•
•
•
•
•
•
Managers think everything is being reported.
Workers know everything is not being reported.
Does fear of reprisal exist here?
Are leader reactions predictable and positive?
Near-misses are a gold mine of information.
How much gold are we mining?
Is accident investigation depth driven by
classification, rather than SIF potential?
Do we pay more attention to classification
or prevention?
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Healthy Incident Reporting
•
•
•
Is our reporting healthy? (Key #1)
Do we have high quality accident case
narratives? (Key #2)
Have we ever done a longitudinal analysis
to look for precursors? (Key #3)
As senior executives, we can’t
“not know” about our SIF potential.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
What Leaders Are Doing
•
Less about TRIR/LTIR, more about what
happened, personal impacts, feelings.
•
Keep case management vigor behind closed doors.
•
Climate supports and encourages near-miss
reports.
•
Gather more info with live conversations, site visits.
•
Zero tolerance for deviation from centerline.
•
Question critical exposures and controls.
•
Never walk past.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Conclusion
•
When and where can I apply these learnings?
•
Reviewing results of accident and near-miss investigations.
•
Reviewing leading indicators such as JSA Quality, JSA Rates,
Accident Investigation Quality.
•
Reviewing safety audit results for leadership & culture
implications.
•
At regular corporate staff meetings.
•
When visiting sites and yards – meeting with site leadership
team, touring and meeting with front-line workers and union reps
•
Does our BAPP® effort have a sampling strategy for critical SIF
behaviors?
•
When you hear reports of near-misses with SIF potential…
“We dodged a bullet”.
SIF Exposure Recognition and Mitigation
A Core Operational Responsibility
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Thank You
susan.murphy@bstsolutions.com
© 2012 BST. All rights reserved. This information is
provided for use within your organization. It may not be
used for training, modified or reproduced or used
outside of your organization without written permission
from BST. All trademarks are owned by BST, Reg. U.S.
Pat. & Tm. Off. BST, Behavioral Science Technology,
Inc. and Leading with Safety are registered trademarks
of BST. All information is BST copyrighted material or is
used with express permission of the copyright owner.
©2012 BST. All rights reserved. This information is provided for informational use within your organization. It may not
be used for training, modified or reproduced, or used outside of your organization without written permission from BST.
Susan M. Murphy, M.Ed.
Principal Consultant
BST