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Transcript of Hazards Factors
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University of California Risk Summit 2011
Integrating Safety into Operations
A Systems-Thinking Approach
Janette
de
la
Rosa
Ducut,
Ed.D.
Summary
A systems-thinking approach to safety allows consideration of more complex relationships between safety-related events. This
approach provides a way to look more deeply at why accidents occurred. A system can consist of the interaction between people
(man), their machines (equipment), and the environment. The environment is where conditions for unsafe acts, unsafe supervision, and
organizational influences on safety can be discovered. Knowing one part of a system enables us to know something about another part
Using systems theory encourages us to adopt a systems perspective (avoid linear, unidirectional, causation) and focus on
interrelationships and processes that produce change (avoid cause-and-effect chains).
The 1986 Space Shuttle Challenger accident and University ergonomic injuries provide specific examples of the consequencesresulting from systemic breakdown. You can integrate safety into operations through the identification and prevention of overall
structures, patterns, and cycles that contribute to injuries and death. This presentation provides an overview of accident investigation
and organizational characteristics; that highlight the powerful role that structure takes in driving (safety) behavior.
For more information
View the course materials used for this presentation online at http://ehs.ucr.edu/safety/systems
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Accident Investigation
The Swiss Cheese model by James Reason
The Swiss Cheese Model of Accident Causation suggests that systemic failures, or accidents, occur from a series of events at different
layers of an organization. A system is similar to slices of Swiss cheese. There are holes which represent opportunities for failure, and
each slice is a layer of the system. When holes in the layers line up, a loss (or accident) occurs. Each layer of the system is anopportunity to stop an error; the more layers, the less likely an accident is to occur. The major layers of a system are: Unsafe acts,
Conditions (for unsafe acts), unsafe Supervision, and influences of an Organization. Below are selected examples of each layer
(NOTE: This is not a complete listing).
Errors ViolationsDecision
Improper procedure
Misdiagnosed issue
Wrong response Exceeded ability
Inappropriate act
Poor decision
Skill-based
Failed to prioritize
Inadvertent use of
equipment Omitted step in procedure
Ignored checklist item
Poor technique
Overcontrolled the situation
Perceptual Misjudged
Spatial disorientation
Visual illusion
Failed to adhere to brief
Failed to use equipment
Violated training rules
Used an unauthorizedapproach
Used an overaggressivemaneuver
Failed to properly prepare
Not current / qualified for task
Intentionally exceeded limitsof the equipment
Unauthorized actions
Unsafe Acts of people can be loosely classified into two categories: errors and violations (Reason, 1990). Errors generally represent
the mental or physical activities of individuals that fail to achieve their intended outcome. Decision errors represent intentional
behavior that proceed as intended, yet the plan proves inadequate or inappropriate for the situation. Skill-based errors occur when people operate without significant conscious thought. Perceptual errors occur when one’s perception of the world differs from reality;
typically when sensory input is degraded. Violations, on the other hand, refer to the willful disregard for the rules and regulations that
govern the safety of work. They can be habitual by nature, as well as atypical actions.
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Substandard
Conditions
Substandard
PracticesAdverse Mentality
Channelized attention
Complacency
Distraction
Mental fatigue
Get-home-it is
Haste Loss of situational
awareness
Misplaced motivation
Task saturation
Adverse Physiology
Medical illness
Physiological incapacitation
or impairment
Physical fatigue
Physical/Mental limitations
Insufficient reaction time
Visual limitation
Incompatible
intelligence/aptitude
Physical inability
Human Resource Management
Failed to back-up
Failed to communicate /
coordinate
Failed to conduct adequate
brief
Failed to use all availableresources
Failure of leadership
Misinterpretation of
information
Personal Readiness
Excessive physical training
Self-medicating
Not rested (tired)
Conditions for unsafe acts of people can be categorized into two categories: substandard conditions people, and substandard practices
of people. Substandard conditions of people involve adverse mentality or mental states (stressors and personality traits), adverse
physiology (conditions, such as illness, that preclude safe work), and physical / mental limitations (when work requirements exceed
the basic sensory capabilities of people at the) . Substandard practice of people, on the other hand, refer to human resource
management (poor coordination among employees), and personal readiness (when people are not at optimal levels when they show upfor work).
Supervised
Inadequately
Planned
Inappropriate
Operations Failed to provide guidance
Failed to provide oversight
Failed to provide training Failed to track
qualifications
Failed to track performance
Failed to provide correct
information
Failed to provide adequatetime (for briefing)
Improper staffing
Task not in accordance with
rules/regulations
Failed to provide adequateopportunity for rest
Failed to Correct
Problem
Violations of
Supervisor Failed to correct document
in error
Failed to identify an at-riskworker
Failed to initiate corrective
action
Failed to report unsafeconditions
Authorized unnecessary
hazard
Failed to enforce rules andregulations
Authorized unqualified staff
to work
Unsafe supervision can be categorized into four areas: supervised inadequately, planned inappropriate operations, failed to correct
problems, and supervisory violations. When people supervised inadequately, there is a general failure to provide the opportunity tosucceed. When those in charge planned inappropriate operations, personnel are generally put at an unacceptable risk (i.e., improper
pairing of team members). When supervisors failed to correct problem(s), there are known unsafe conditions that allow to continue
unabated. Finally, violations of supervisor(s) occur when there is mismanagement of assets, followed by a tragic sequence of events
by people under those supervisors.
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Resource
Management
Organizational
ClimateHuman
Selection
Staffing
Training
Monetary / Budget
Excessive cost cutting
Lack of funding
Equipment / Facility
Poor design
Purchase of unsuitable
equipment
Structure
Chain-of-command
Delegation of authority
Communication
Accountability for actions
Culture
Norms and Rules Values and beliefs
Organizational justice
Organizational ProcessOperations
Operational tempo
Time pressure
Production quotas
Incentives
Measurement / Appraisal
Schedules
Deficient planning
Procedures
Standards Clearly defined objectives
Documentation
Instructions
Policies for hiring/firing/promotion
Oversight
Risk management
Safety programs
Organizational influences are the fallible decisions of upper-management that directly affect supervisory practices, conditions, and
actions of people. Resource management encompasses the realm of organizational-level decision making regarding the allocationand maintenance of assets (i.e., people, money, and equipment/facilities). Organizational climate refers to a broad class of variables
that influence worker performance (i.e., the working atmosphere). Organizational process refers to decisions and rules that govern
everyday activities within an organization (operational procedures and oversight programs to monitor risks).
Integrating
Safety
Research has indicated that “low-accident companies” differed from “high-accident companies” because they
possessed the following organizational characteristics:
Strong senior management commitment, leadership, and involvement in safety
Closer contact and better communications between all organizational levels
Greater hazard control and better housekeeping
A mature, stable workforce
Good personnel selection, job placement, and promotion procedures
Good induction and follow-up safety training
Ongoing safety schemas reinforcing the importance of safety, including “near miss” reporting
Acceptance that the promotion of a safety culture is a long term strategy requiring sustained effort & interest
Adoption of a formal health and safety policy, supported by adequate codes of practice and safety standards
Communication that health and safety is equal to other business objectives
Thorough investigations of all accidents and near misses
Regular auditing of safety systems to provide information feedback and continuous improvement
Source: Cooper, D. (2001). Improving safety culture: A practical guide. Hull, United Kingdom: Applied Behavioural
Sciences.
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Case Study
Imelda Marcos is experiencing pain in her wrist, after heavy use of a standard mouse. The pain began a week
ago when their company website went down, and her supervisor asked to her “work day and night” to bring it
back up quickly. After a week, Susie received an award for returning the website back to its original state, in ashort amount of time. She’s been through ergonomics training, and had her workstation evaluated by anergonomist one year ago. However, there have been recent budget cuts, furloughs, and layoffs which prevent
her from comfortably asking for more resources to deal with the pain. Soon, Imelda files a worker’s
compensation claim, citing tendonitis and median nerve compression caused by her employment. She indicatesshe’s used a standard mouse safely for the past 20 years. You are the person responsible for conducting the
accident investigation.
Questions
1. What are 3 questions you would ask during the accident investigation?
2. What are 3 corrective actions you would take?