A much-needed SHIFT IS UNDERWAY in the safety field related to how success is measured and what must occur to PREVENT catastrophic, life-altering, or FATAL incidents in the CONSTRUCTION INDUSTRY.
Since the inception of the safety profession, a fundamental cornerstone of the theory of accidents was based on Herbert William Heinrich’s Safety Triangle (HST) theory: For every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injury.1 (See Exhibit 1 a few pages ahead.)
Moreover, it was believed that since many accidents share common root causes, addressing more commonplace incidents that do not result in injuries actually prevents those that do cause injuries. Heinrich’s research suggested that 88% of all workplace accidents are caused by unsafe acts, which became the basis for the popular Behavior Based Safety.
Interestingly, over the past five years, safety and operational leaders have noticed an alarming trend. In spite of best safety efforts, the number of serious injury and fatality (SIF) events have increased while less serious injuries have decreased. This pattern can be seen across many industries, at company and national levels, and has called into question some of the fundamental scientific assumptions related to safety.
Although time, resources, and effort have been spent to improve safety, the number of devastating incidents resulting in death and life-altering injury continues to rise. In the construction industry, a fatal work injury rate of 9.8 (per 100,000 full-time equivalent workers) was reported for 2014 by the U.S. Bureau of Labor and Statistics.2
This new paradigm states that the top of Heinrich’s triangle will not be impacted by attempting to prevent all accidents at the bottom of the trian-gle. In other words, eliminating the accidents that do not result in injury will not reduce SIFs. In fact, the causes of SIFs are different from the causes of non-SIFs, and the old way of investigating accidents will not prevent SIFs.
SIF precursors are actually high-risk situations where manage-ment controls are often absent, ineffective, or are simply not complied with and, if allowed to continue, will result in a SIF.
How is this shift accomplished? What must a progressive organization do to implement change? These questions are at the forefront of safety professionals’ minds.
Larry Simmons, a leading expert on SIF from PotashCorp, has devoted his life’s work to preventing SIFs in the workplace. Patricia Kagerer, Risk Management Executive at ACIG, sat down with Larry to discuss the cultural shift necessary to influ-ence change that will ultimately save lives.
Kagerer: In your view, what is a SIF?
Simmons: A SIF identifies a life-threatening or life-altering work related injury or illness.
A life-threatening injury or illness refers to one that, if not immediately addressed, is likely to lead to the death of the affected individual and usually requires internal and/or external emergency response intervention to provide life-sustaining support. Examples include:
• A laceration or crushing injury that results in significant blood loss
• An injury involving damage to the brain or spinal cord
• An event that requires application of cardiopulmonary resuscitation or an external defibrillator
• Chest or abdominal trauma affecting vital organs
• A serious burn
A life-altering injury or illness results in permanent or long-term impairment or loss of use of an internal organ, body function, or body part, such as:
• A significant head injury
• A spinal cord injury
• Paralysis
• An amputation
• Broken or fractured bones
• A serious burn
For example, if a head injury resulted in blindness, then it would be life-altering and permanent.
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Kagerer: How has the traditional safety triangle changed to focus on SIF prevention?
Simmons: Research has shown two primary reasons why reducing smaller injuries does not reduce SIF proportionately:
1) The causes and correlations of SIFs are different from those of smaller injuries; and
2) The potential for serious injury is low for the majority (about 80%) of non-SIF injuries.
Heinrich’s Safety Triangle claims two basic relationships:
1) Descriptive – Frequency and severity are inversely related.
2) Predictive – Reductions in smaller injuries will result in proportionate reductions and more serious injuries.
However, research shows that in virtually every case, a catas-trophe was preceded by years of recordable injury rates at very or extremely low and even decreasing levels. The HST is confusing and creates misunderstanding of the relationship between minor injuries and serious injuries.
The new model in Exhibit 2 above shows that not all minor injuries are the same in their potential for SIF; precursors for SIFs are actually just a subset of the entire bottom triangle. Non-causal factors for non-SIFs have different underlying precursors. The HST asserted that minor injuries predict serious injuries, and by controlling the causes behind minor injuries, SIFs will also be controlled.
This assertion has been shown to be misleading because the number of minor injuries continues to decline while the num-ber of SIF injuries have plateaued or increased. Since a reduc-tion in smaller injuries may not reduce SIF, we can no longer assume that a reduction in minor incidents will cause a reduc-tion in SIFs. Rather, we must focus on the minor incidents that have potential to be SIFs and look at the root cause in order to prevent them. Identifying SIF exposures is most important to implementing an effective intervention strategy.
Kagerer: What is a SIF precursor event?
Simmons: A SIF precursor is an unmitigated high-risk situa-tion in which management controls are either absent, ineffec-tive, or not complied with and will result in a serious or fatal injury if allowed to continue.
For example, hydroblasting is used in many industries to clean equipment. Hydroblasting is the use of high-pressure water, with or without the addition of other liquids or solid particles, to remove unwanted matter from various surfaces. Typically, employees who perform hydroblasting are working with jet streams with velocity greater than a .45 caliber bullet. The water jets can easily puncture and tear skin or penetrate deeper, causing infection, serious internal damage, amputa-tion, or death.
Hydroblasting can present a potential exposure if an employee operating a hydroblaster loses control of the hose. Other employees working in the area could also be directly in the line of a stream of high-pressure water. Precautions include securing the area prior to commencement of the
Exhibit 1: Heinrich’s Safety Triangle
Exhibit 2: The New SIF Prevention Model
Precursers
Recordable Injuries
Lost Time Injuries
FatalitiesSIF
Exposures
Minor Incidents Subset of SIF Accidents
300No-InjuryAccidents
29Minor
Injuries
1MajorInjury
work, training an operator on how to hold the equipment correctly, and providing appropriate Personal Protection Equipment (PPE) including face shields, rain suits, gloves, metatarsal guards, rubber steel-toed boots, and Kevlar suits under certain conditions. The operator must also be trained on how to regulate the pressure of the hydroblaster. Failure of any of these precautions could result in a SIF.
Oftentimes, organizations determine that SIF precursors have existed for quite a long time. We must identify precur-sors to high-risk situations and develop intervention strate-gies to reverse the exposure.
As an example, since hydroblasting and employees work-ing in the proximity of that type of work are a recognized SIF potential, we met with our hydroblasting contract com-panies to implement robotic equipment and eliminated all operators (employees, subcontractors, etc.) from the process. Essentially, we engineered the operator out of the hydroblast exposure.
Kagerer: What are some examples of activities with high precursor events?
Simmons: While the safety profession has developed exten-sive safety procedures (e.g., lock-out/tag-out, hot work per-mits, confined space, work zone, hazard communication), SIFs continue to occur – especially if the culture is one where shortcuts are common or written procedures are not followed. The following list identifies activities in which high precursor events are likely:
• Mobile equipment (operation and interaction with pedestrians)
• Confined space entry
• Jobs that require lock-out/tag-out
• Lifting operations
• Working from heights
• Manual handling
• Unexpected maintenance
• Unexpected changes
• High energy potential jobs
• Emergency shutdown procedures
• Dropped or falling objects
• Contact with energized electrical conductors
Kagerer: What are the steps to developing a SIF interven-tion strategy?
Simmons: A SIF prevention program requires taking correc-tive action to the next level. We know that a corrective action
is implemented to address at-risk behaviors or conditions. However, an intervention strategy is much larger than a cor-rective action plan – it requires holistic thinking and affects all change at the management level.
Intervention strategies are much more difficult to implement because they require an organization to look deeper. It is not a quick fix. It may include human factors, intervention design, management systems, and an overall commitment to a different way of doing things and eliminating those systems that no longer function well within an organization. A new strategy may require redesign of a program that was believed to be working for many years, or it may require more train-ing or more communication and follow up to see progress with the effort. Intervention strategies are not quick fixes, but rather complex ways of approaching a system deficiency.
Kagerer: What changes need to occur to ensure leadership support of a SIF prevention process?
Simmons: Leadership must understand the entire concept of measuring the right things. We can still measure record-able incidents and lost times, but management must commit to doing more and taking it even further. Management must support processes and procedures that determine their greatest exposures on site and then identify the necessary steps that must be taken to address them.
It is extremely important that leaders become well versed in the SIF initiative language, understand it, and are able to engage with employees at all levels of an organization. Therefore, management must be out speaking to operators, superintendents, workers, and laborers to create a common language around SIF that is communicated throughout the entire company.
If the executive management team cannot succinctly com-municate what a SIF initiative is and have a conversation about precursors and strategic intervention strategies, then the program will never be effective, understood, or embraced by supervision or the labor force.
Kagerer: What is the most radical change you have observed as a result of your company’s SIF prevention initiative?
Simmons: The most significant change relates to how we track accidents. For example, OSHA’s system for classify-ing and reporting injuries has been one of the most impor-tant drivers of safety improvement over the past 25 years. However, the system does not include a differentiation of smaller injuries and does not distinguish those injuries that have potential for SIF from those without. As a result, organi-zations could be in total compliance with OSHA and industry
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standards, but could lack the critical data required to prevent SIFs from occurring.
Typically, industry success in safety is measured by the absence of failure. For example, days without a lost time accident is a measure of success that is often celebrated with parties, bonuses, and lunches. This can give an inflated sense of security; in reality, you could easily have a first aid event that does not make it onto an OSHA log, but could be classi-fied as a SIF because it could have led to a fatality.
Let’s consider an example: A employee walks under a load suspended from a crane. The load slips and falls 10 feet to the ground next to the employee. The employee is not injured because he was not hit. Since this is not an OSHA recordable incident, it is not investigated.
This kind of important information is not tracked, and there-fore not recognized or identified as a risk by safety manage-ment and executive leadership in the same way a strain injury with one day away from work is often investigated and evaluated.
How we focus our attention on the information that we have available is extremely important. This new focus requires a different way of measuring safety, different incident report-ing, and a different management response. While many com-panies have reduced their incident rate and lost time injury rate, it is not enough to prevent SIFs.
Kagerer: Do job hazard analyses (JHAs) work? If not, what needs to change? Do they need to be revised, tweaked, replaced, or scrapped?
Simmons: With the new SIF prevention model, it’s good prac-tice to review the JHA process for potential improvement. For example, even though we had precursors, the JHA system was not addressing them. My company went through a complete overhaul of the program and now everyone, including man-agement, must complete a JHA.
Now when I visit a jobsite, I complete a JHA and ask the job-site supervisor to review it with me to ensure I did not miss anything. Everyone – including executive management – is engaged, which builds credibility in the JHA process. We also spot-check for JHAs to ensure they are being fully utilized.
Finally, our JHA addresses SIF potential. Any type of work identified as having SIF potential must be reviewed by the next management level in order to build a safe work plan around it.
Kagerer: How are SIF prevention results measured?
Simmons: Understanding what makes things or tasks go right and measuring those “rights” is crucial to preventing SIF events. So, it’s critical to measure both leading indicators and lagging indicators. Since lagging indicators are associated with events that have already taken place, they are easier to mea-sure; leading indicators, however, are a bit trickier to measure.
Kagerer: Please give some examples of leading indicators.
Simmons:
1) Our front line leaders act as “JHA Champions” every day and lead through interaction with the workforce. The discussion and review are measured.
2) Our executive leadership is required to be in the field with our employees for a set percentage of time. This percentage of time is measured.
3) Leadership development and hazard identification training is critical. We established full-time safety lead-ership coaches who coach our front line supervisors on hazard identification and mitigation. Our safety leader-ship coaches used to be line supervisors who are now responsible for full time safety leadership development and training. We measure the delivery and effectiveness of training.
4) The Hierarchy of Control (at right) is a system used to minimize or eliminate exposures to hazards. SIF prevention starts with corrective actions that are ranked on the Hierarchy of Control level of 3 or higher.
All of our incident corrective actions are categorized on this hierarchy. We rely on these controls that produce sustained results – elimination at level 5, sub-stitution at 4, engineering controls at 3 – to reduce an exposure to an acceptable level below SIF potential. We apply this measurement to all of our incidents, whether they are actual incidents or near-miss incidents that had SIF exposure potential.
5) Training and organizational development is provided throughout the year, including a safety summit and structured development events. Training in these events, as well as all of our training exercises, are tracked and measured for effectiveness.
Kagerer: Should an organization expect a reduction in SIF incidents after implementing a SIF process?
Simmons: The more successful that a SIF prevention pro-cess is implemented in the field, the more that SIF potential
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incidents will be communicated to management. Since every potential event is an opportunity for improvement, yes, we expect that by prevention or identification of potential events, actual SIFs will be reduced.
However, it is a slippery slope when seeking an immediate reduction in SIF potential events after a SIF prevention process is implemented. Remember, the goal is to create a culture of honesty and openness among employees and man-agement, where reporting is actually encouraged.
Therefore, SIF prevention is only successful when executive management actually expects to hear bad news. The more opportunities to address potential SIF situations, the more we learn about the organization and underlying issues that create SIF exposure.
Kagerer: Please describe your seven critical leadership elements to implement a successful SIF prevention process.
Simmons:
1) Create a sense of vulnerability – A company’s leader-ship must embrace hearing bad news. The first time someone is reprimanded for reporting a SIF potential incident, the program will fail.
2) Install a SIF prevention infrastructure – Establish how SIF will be identified and what decision-making process will be used to determine if an event is a SIF. Establish a way to determine SIF precursors. Identify existing systems that can assist with SIF prevention. Implement a way to communicate SIF best practices throughout the organization so teams can learn from each other and share ideas and processes. Determine the mechanism for reviewing SIFs and determine responsibilities around the process.
3) Know and act on SIF precursor data – Review SIF precursor data and intervention strategies onsite so that managers know they will be asked about how these items create buy-in and account-ability.
4) Drive task-based risk assessments – There is a SIF culprit inherent in routine. Routine tasks do not necessarily mean low exposure, they just occur frequently. As a result, we sometimes do not feel vulnerable because the task is familiar and becomes second nature.
One way to address the risk of routine is to create a team to examine the routine work from start to finish and complete a risk assessment. The team will determine if the work is actually being per-formed in accordance with the written procedure.
Is the written procedure accurate? Do employees have to deviate from the procedure because it is not current?
Task-based risk assessments prevent what is known as a “drift into failure,” where a succession of small, everyday decisions eventually produce breakdowns on a massive scale in the complex systems of work.
5) Consider human performance – Embrace people as an important part of the operation. While they do not come to work to fail or make errors, many factors can affect them outside the workplace. For example, when an employee comes to work in the morning after staying up all night with a sick child, fatigue can be a factor that could contribute to a SIF.
6) Dedicate resources and maintain control – When we met with our contract companies to advance the con-cept of robotics for hydroblasting operations, the divi-sion leader clearly stated, “I want to eliminate human exposure to hydroblasting.” He did not say, “I think we should” or “Can we?” SIF prevention requires manage-ment to devote the time, money, and resources neces-sary to facilitate the change or it will fail.
7) Track and communicate SIF metrics – Focus on lead-ing indicators. For example, we have a daily report that tracks our leading indicators. Our front line supervisors are expected to interact daily with employees on JHAs. We track the communication as well as the time our gen-eral managers spend in the field. We track hazard identi-fication training as part of our leadership development to ensure that leaders are capable of defining hazards.
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5: ELIMINATIONDesign it out
4: SUBSTITUTIONUse something else
3: ENGINEERING CONTROLSIsolation and guarding
2: ADMINISTRATIVE CONTROLSTraining and work scheduling
1: PERSONAL PROTECTIVE EQUIPMENTLast resort
BusinessValue
BESTBEST
ControlE�ectiveness
Exhibit 3: Hierarchy of Control
Kagerer: Your work is really the future of the safety profes-sion. How has it changed your outlook?
Simmons: Frankly, this is the most exciting time in my life. As a safety professional, I cannot think of anything more rewarding that I could be doing. SIF prevention is the wave of the future, and I believe it will ultimately reduce high haz-ard exposures and lead to safer jobsites. n
Endnotes
1. Based on information from Herbert William Heinrich’s book, Industrial Accident Prevention: A Scientific Approach.
2. www.bls.gov/iif/oshwc/cfoi/cfch0013.pdf.
PATRICIA KAGERER, ARM, CPCU, CRIS, CSP, is a Risk Management Executive for American Contractors Insurance Group (ACIG) in Richardson, TX. She provides consulting services to large contractors across the U.S.
Before joining ACIG, Tricia was the Vice President of Risk and Safety Management for CF Jordan Construction, where she created a fully integrated, nationally recog-nized approach to risk, safety, and quality management that focused on improving overall corporate performance.
Tricia holds a Master’s Degree in Conflict Resolution from Southern Methodist University in Dallas, TX, and a BA and BS degree from Regis University in Denver, CO.
LARRY SIMMONS, CSP, CMSP, is the Senior Director of Serious Injury & Fatality Prevention for PotashCorp with corporate offices in Saskatoon, Saskatchewan, and Northbrook, IL. He previously served as PotashCorp’s Senior Director of Safety & Health.
Larry led the serious injury and fatality prevention process within PotashCorp, which has contributed to a 60% reduction in the lost time injury rate in the past five years. Larry has been a safety professional for 30 years. He holds a BS in Business Management.
