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Transcript of Update on Mercer ORC Task Forces -- What’s Hot and What’s Notesafetyline.com/eei/conference...
Update on Mercer ORC Task Forces -- What’s Hot and What’s Not
October 8, 2012
Stephen Newell
Principal
MERCER
Obligatory Plug: Mercer HSE Network Practice Summary
• Nine different networks with approximately 130 large global
corporations in 20 industry sectors
• The Mercer HSE Networks:
– Promote effective occupational safety, health and environmental
programs and practices in business
– Serve as a forum for key HSE developmental work
– Facilitate industry understanding of and input into national
occupational safety, health, and environmental policy
The Mercer ORC HSE Network model is built upon the premise that
member value can be maximized through diversity; by cross-industry
benchmarking to share best practices and lessons learned
MERCER
Sample of Mercer HSE Network Member Companies
3M
Abbott Laboratories
Air Products and Chemicals, Inc.
Alcoa
Allergan
Altria
Amgen Inc.
AT&T
AstraZeneca Pharmaceuticals LP
Baxter Healthcare Corporation
Becton Dickinson and Company
Biogen Idec
The Boeing Company
BP America Inc.
Bristol-Myers Squibb Company
Cargill, Inc.
Caterpillar, Inc.
Chevron Corporation
The Coca-Cola Company
Colgate-Palmolive Company
Corning Incorporated
Chrysler LLC
The Dow Chemical Company
Duke Energy
E. I. DuPont de Nemours & Co., Inc.
Eastman Chemical Company
Eli Lilly and Company
ExxonMobil Corporation
Ford Motor Company
General Electric Company
General Motors Corporation
Goodrich Corporation
The HEICO Companies
Hess Corporation
Hewlett-Packard Company
Honeywell International
Ingersoll-Rand Company
International Paper Company
ITT Corporation
John Deere
Johnson & Johnson
Kimberly-Clark Corporation
Kraft Foods Global, Inc.
Lawrence Berkeley National
Laboratory
Lockheed Martin Corporation
Marathon Oil Company
Mars, Incorporated
MeadWestvaco Corporation
MedImmune
Merck & Company, Inc.
Miller Coors LLC
Monsanto Company
Navistar Inc.
Northrop Grumman Corporation
Novartis Corporation
Pfizer, Inc.
Philip Morris, USA
Pitney Bowes Inc.
PPG Industries, Inc.
Pratt & Whiney/Rocketdyne
The Procter & Gamble Company
Raytheon Company
Sanofi-aventis
Schering-Plough Corporation
The ServiceMaster Company
Shell Chemical Company
The Sherwin-Williams Company
Siemens Power Generation, Inc.
Sprint Nextel Corporation
Sunoco, Inc.
U. S. Steel Corporation
United Parcel Service
United Technologies Corporation
Verizon Communications
W. L. Gore & Associates
W. W. Grainger, Inc.
Walt Disney Company
MERCER
I. What We Will Cover re. Metrics
A. Background: Hard to chart a future if you don’t understand the past
B. Challenge/Problem Statement: What are we trying to fix and why does it
matter?
C. Proposed Path Forward – Mercer ORC Alternative Metrics Pilots
– Why needed
– Rationale for approach
– Proposed metrics
– Possible barriers and ways to overcome them
D. Shaping the future
– How do we get leadership to focus on the issue?
– How do we successfully advocate change?
– How do we make change sustainable?
MERCER
II. What We Will Cover re. Fatality and Serious Injury Prevention
A. A new approach for using data, based on work of Dan Petersen, Fred
Manuele, Rand, Tom Krause and BST, and the Mercer ORC Alternative
Metrics Task Force
B. A new approach for addressing risk that creates a different risk
recognition, assessment and mitigation paradigm for exposures with
high gravity potential
C. Evolving perspectives on human error, that lead to a new approach to
getting better informed incident investigations
D. Perspectives on foundational aspects of prevention such as leadership
commitment, employee engagement, management systems, and
metrics and what needs to be different in situations with FSI potential.
NOTE: Much of this work is still in the developmental stage.
MERCER
I. Alternative Metrics Task Force
“The Secret To Creativity Is Knowing How
To Hide Your Sources”
Albert Einstein
MERCER
I. What We Will Cover re. Metrics
B. Challenge/Problem Statement: What are wee trying to fix and why does it
matter?
C. Proposed Path Forward – Mercer ORC Alternative Metrics Pilots
– Why needed
– Rationale for approach
– Proposed metrics
– Possible barriers and ways to overcome them
D. Shaping the future
– How do we get leadership to focus on the issue?
– How do we successfully advocate change?
– How do we make change sustainable?
A. Background: Hard to chart a future if you don’t understand the past
MERCER
A. Background – Evolution of Current S&H Performance Metrics
1. Pre- OSHA Era– ANSI Z-16.1 and Z-16.2
2. Implementing the OSHA Act
3. OSHA metrics twenty years later…what changed in the late ‘80s and
early ’90s
4. Current metrics realities
MERCER
1. Pre-1970 (OSHA) Era: ANSI Z-16.1 and Z-16.2
• System not mandatory
• Data not consistently reported
• Complicated time charges for different case types
• No data for occupational illness
• Serious deficiencies for operating national system and generating data that
is consistent nationwide
MERCER
2. 1970 -- Implementing the OSHA Act: New metrics required by federal law
• Sections 8(c)(2) and 24(a) of the OSHA act specify the type of data that
employers are required to maintain and report. 8(c)(2) language:
– Work related deaths, injuries, and illnesses,
– Other than minor injuries requiring only first aid treatment
– Which do not involve medical treatment, loss of consciousness, restriction of
work or motion, or transfer to another job
– 24(a) specified another criteria: “loss of time from work”
• Purpose was to describe the “nature and extent” of the injury and illness
problem in the United States
• Criteria were mandatory
• Responsibility for statistical system delegated to the US Bureau of Labor
Statistics. BLS known for statistically sound (voluntary) programs
• Data were collected to produce aggregate statistics only…little pressure
from business because no real impact
MERCER
Quick Review…BLS Survey of Occupational Injuries and Illnesses (still underway)
• Mandatory survey
• Counts OSHA-recordable fatal and nonfatal workplace injuries and illnesses
• Includes all private industry plus State and local government
– Includes employers normally keeping OSHA records
– A small sample of employers normall exempt from OSHA recordkeeping
“Summary” Estimates • Number and incidence rate of cases by state and detailed industry
– Total recordable cases
– Cases with days away from work
– Cases with only job transfer or restriction
– DART cases
– Other recordable cases
• Estimates released in October after reference year
10
MERCER
0
2
4
6
8
10
12
Ra
te p
er
10
0 f
ull-t
ime
eq
uiv
ale
nt
wo
rke
rs
US Occupational Injury and Illness Rates, 1973 - 2010
Total cases Cases with days away, restricted work or transfer
Cases with days away from work Cases with job transfer or restricted work
Other cases
MERCER
“Case and Demographic” Estimates
• Case characteristics
– Nature (sprain, fracture)
– Part of body
– Event (fall, overexertion from lifting)
– Source (type of machine, chemical, floor)
– Number of days away from work
– Timing of incident (day of week, time of day, hours on shift)
12
MERCER
Distribution of Injuries and Illnesses by Nature, 2010
Sprain, strains
39.8%
Bruises
8.4% Soreness, pain, except back
7.8%
Cuts, lacerations, punctures
7.7%
Fractures
7.2%
Total multiple trauma, 4.8%
Back pain, hurt back only, 3.4%
Heat burns, 1.4%
Carpal tunnel syndrome, 0.8%
Amputations, 0.5%
Tendonitis, 0.4%
Chemical burns, 0.4%
All other nature, 17.3%
MERCER
Number of fatal work injuries, 1992–2010*
The 2010 preliminary total of 4,547 fatal work injuries stayed at about the same level as the final count of 4,551 fatal work injuries reported for 2009.
Number of fatal work injuries
MERCER
MERCER
MERCER
MERCER
3. 1990 -- OSHA Metrics Twenty Years Later; What Changed?!!
• Barlow case required that OSHA have a neutral means for targeting inspections
• Thorne Auchter responded by using BLS industry data (average lost workday
case rates) to target inspections.
• Employers begin to question which cases are recordable; BLS prepares
recordkeeping guidelines to assist employers in making recordkeeping
decisions
• Guidelines morph over time from being advisory to being official Agency
interpretations of the rules…upheld in Court
• Union Carbide case begins egregious wilfull recordkeeping citation
policy…every non recorded case treated as a separate wilful citation;100
egregious willful recordkeeping citations in late ’80s – OSHA never lost a case
MERCER
Reality Check: The Good, The Bad, and The Ugly • The Good: BLS data continue: still have value for general surveillance
– Understanding the magnitude of the problem
– Tracking trends
– Identifying emerging issues
• Survey reliability is well managed and precise
• The Bad: Quality and verification problems with the source data intensify
the more the data is disaggregated
– Estimates of potential under reporting range from 10 to nearly 70%
– Relying on any single metric to gage site or business unit performance is problematic.
Data quality can vary by industry, company, business unit and site.
• The Ugly: OSHA rates, used by themselves to measure site performance,
have serious limitations. In many instances they seem:
– Overly inclusive
– Not very accurate
– The more pressure you put on them, the less accurate they get
MERCER
Drilling Down -- The BLS/OSHA Data Are Subject to Significant “Bias”
• Employers will provide data if they:
1. Can understand what is being requested
2. Think it is fair
3. Obtain some value in return.
• In many cases the OSHA recordkeeping system fails on all three
counts
• Accuracy of the OSHA records is impacted by BOTH employee
reporting practices and employer recording practices
– At least 20 different variables can affect recording and reporting of
occupational injuries and illnesses
– Reporting of most injuries and illnesses is often discretionary --
made on the basis of perceived consequences to the
injured/ill employee
MERCER
4. 21st Century -- Our Current Metrics Realities
a. The OSHA Data – OSHA rates still serve as the primary/sole metric for worker safety and
health
– However growing recognition that the OSHA definitions that may work for
general surveillance do not work well for accountability and performance
measurement purposes
Accountability = OSHA system includes cases that can’t be managed
Performance Measurement/Improvement: The OSHA data do not
provide sufficient insights into the S&H and business process to drive
needed improvements
– Data quality: Serious issues domestically; even more quality drawbacks
when used globally.
MERCER
4. 21st Century -- Our Current Metrics Reality
b. Leading Indicators
• The value of leading indicators for S&H was introduced more than a
decade ago
• Growing recognition that they are needed, but adoption has been
slow
• individual companies have experimented with individual leading
metrics
• However, no real consensus on which leading indicators should be
used; whether or not any should be benchmarked
• No science yet to establish link to outcomes
.
MERCER
Our Dilemma
• It is extremely hard to move companies off the current paradigm
• Company leaders still seem to believe that comparing OSHA injury
and illness data is a valid exercise
• Leaders are suspicious when we (individually) suggest an alternative
approach
• S0….as a profession we keep feeding the beast….
– even though we know the data are suspect
– even though misuse of the data often distorts priorities and diverts
attention away from more important safety and health matters
MERCER
I. What We Will Cover re. Metrics
A. Background: Hard to chart a future if you don’t understand the past
C. Proposed Path Forward
– Why needed
– Rationale for approach
– Proposed metrics
– Possible barriers and ways to overcome them
D. Shaping the future
– How do we get leadership to focus on the issue?
– How do we successfully advocate change?
– How do we make change sustainable?
B. Challenge/Problem Statement: What’s the issue and why does it matter?
MERCER Copyright © 2007, ORC Worldwide 25
Other than Frustration – Why Care About Metrics ??!!
1. The OSHA data have serious limitations as a global performance metric and we all know it
2. Performance excellence – you can’t manage (or improve) what you don’t measure (effectively)
3. Empowerment and the quest for our share of shrinking resources
– We occupy the moral high ground
– But…to be empowered in today’s business world you need to drive and demonstrate:
Performance
Value
Industrial hygienists and safety professionals have problems doing both
Ongoing economic pressures increasing scrutiny on all parts of the business
MERCER
Specific Metrics Limitations
1. Little Ability to Drive Continuous Improvement: Using OSHA-
based measures is the equivalent to driving blind…
a. Personal Safety: Use of a single trailing metric does not provide
insights needed to drive continuous improvement
b. Fatalities and Serious Injuries: Focus on OSHA-based measures tends
to create a blind spot for exposures that contribute to more serious
incidents
2. Wasted Time and Misdirected Resources: Use of OSHA data
contributes to behaviors that undermine performance excellence
a. Churn over whether or not a case is technically recordable
b. Diversion of resources and priorities away from more significant,
higher gravity hazards
MERCER
Limitations of Current Measures, cont.
3. Benchmarking: Wide variations exist in global data that severely limit
their value for benchmarking and comparative purposes.
a. Accuracy of the trailing metric in use is suspect – especially when used
globally
i. OSHA-based criteria for determining work relationship and the
seriousness/significance of the case contribute to inconsistent
recording
ii. Ability to audit the data is limited
b. Although industry uses leading indicators in other parts of the
business, and the safety and health profession recognizes their value,
no S&H leading indicators have wide acceptance, either for
prevention or for comparative purposes.
MERCER
I. What We Will Cover re. Metrics
A. Background: Hard to chart a future if you don’t understand the past
B. Challenge/Problem Statement: What’s the issue and why does it matter?
D. Shaping the future
– How do we get leadership to focus on the issue?
– How do we successfully advocate change?
– How do we make change sustainable?
C. Proposed Path Forward
-- Rationale for approach
-- Proposed metrics
-- Possible barriers and ways to overcome them
MERCER
C. Proposed Path Forward: Ideas for Implementing More Effective Safety and Health Performance Metrics
1. Basic Concepts
2. Mercer ORC Metrics Initiative
Even if you are on the right track, you’ll get run
over if you just sit there.”
Will Rogers
MERCER
1. The Opportunity: Enhance Use of Leading Indicators
• Leading metrics are necessary to drive the activities that are critical to
performance
• Leading metrics provide insights on the “quality” and effectiveness of the
safety and health process...
• Leading metrics enable business leadership to identify and drive strategic
actions that will yield performance excellence
Development Approach
• Identify key areas to be measured
• Create S&H measurement questions
• Develop measures to answer the questions
• Rank candidates
MERCER
Balanced Framework ….Metrics Simplified
• What Did We Do?
– Company - specific leading indicators
• What Were the Impacts?
– Injuries, illnesses, fatalities, workers’ comp., absenteeism, etc.
• What Value Did We Generate?
– Morality
– Reduction of loss
– Financial measures (e.g., ROI)
– Productivity
– Product quality
– Corporate responsibility/marketability
– Corporate business strategy
• How Was It Perceived?
MERCER Leading Metrics Trailing Metrics
- Observations
- Feedback
loops
- Inspections
- Audits
- Risk
Assessments
- Prevention
and Control
Behavior
(action)
Physical
Conditions
Incident
or
Near Miss
- TRIR
- LWIR
- LWSR
- Perception
Surveys
Factors
Systems
- Training
- Accountability
- Communications
- Planning and
Evaluation
- Rules and
Procedures
- Incident
Investigations
- Perception
Surveys
Incident Causation
Process Outcomes
MERCER
Which Indicators Matter?
Measure key factors that
drive performance
Support safety and health
improvement strategy Correlate with other
indicators
Get to the root cause(s)
Link to enterprise
business plan
MERCER
2. The Mercer ORC Initiative to Improve Global S&H Performance Measurement
Do the right thing. It will gratify some people
and astonish the rest.
Mark Twain
MERCER
Alternative Metrics Task Force Objectives • Develop and promote a balanced approach to S&H performance
measurement that includes:
– Leading indicators for activities and programs that address
significant risk
– Leading indicators to assess key OHS management system
elements
– A suite of trailing (outcome) measures that can form the basis of a
new global standard for benchmarking OHS performance
• Work Streams
• Team 1. Risk Focused Metrics. Jeff Shockey, ALCOA, Team Leader.
• Team 2. Management System Metrics. Kurt Krueger, GE, Team
Leader.
• Team 3. Suite of Global Trailing Metrics. Tom Slavin, Navistar, Team
Leader.
Working towards a January 1, 2013 implementation date.
MERCER
Alternative Metrics Pilot Strategy
Pilot Test One: Identify high level leading indicators that focus on
enterprise level issues, are relatively easy to compile,
Pilot Test Two: Utilize the work of the leading indicator risk and
management system teams for leading indicators that can drive
continuous improvement by focusing on metrics related to site level
programs/activities and mgt system improvements related to managing
risk
Pilot Test Three: Create a set of outcome metrics that have more value
for prevention than current OSHA-based measures
• All three sets of measures will be evaluated for global benchmarking
purposes
MERCER
New Framework: A Vertical Look At Leading Indicators
Enterprise Level Questions:
Are there policies, programs and processes in place across the enterprise that support safety and health excellence?
Do they contain elements needed to drive worker protection? Are they effectively communicated?
Site Level Questions:
Are the policies being carried out and the programs and processes being done? Is there a process to verify effective implementation?
Are they being done well? Are they having the desired impact/result?
Bridges : Evaluations
Audits Selected metrics
MERCER
Pilot Test Number One: Enterprise-Wide Leading Indicators
We can't solve problems by using the same kind of
thinking we used when we created them.
Albert Einstein
MERCER
Suggested Measurement Areas and Metrics Questions For Enterprise-Wide (Global) Benchmarking
1. Leadership commitment and support
Question: Is an effective process in place for demonstrating leadership commitment to worker safety and health?
2. Accountability
Question: Is there a process in place for holding leaders, managers, supervisors, and employees at all levels of the organization accountable for worker safety and health?
3. Risk
Question: Are there effective risk identification, assessment, and control processes in place for identifying and abating hazards?
4. Employee involvement
Question: is there a process in place to insure that employees are effectively involved in worker safety and health?
MERCER
1. Leadership Commitment: Is an effective process in place for demonstrating leadership commitment to worker safety and health? “Yes/No” evaluation criteria:
1. Worker safety and health is articulated as a core value of the
company in written policy statements.
2. A written safety and health management system is in place.
3. Safety and health goals and objectives are established in writing for
each major operating or administrative function
4. The budget process includes resource allocations to meet each
safety and health goal and objective
5. A written policy exists that employees have the right to refuse unsafe
work and the authority to correct unsafe conditions.
6. A written policy exists that employees will be provided the resources
they need to perform their jobs safely
MERCER
2. Accountability: Is there a process in place for holding leaders, managers, supervisors, and employees at all levels of the organization accountable for worker safety and health? 1. Safety and health criteria are included in performance standards for
employees, supervisors and manager throughout the organization.
2. Written performance objectives at all levels include incident
prevention activities, hazard elimination and safety and health
performance improvement (not OSHA rates)
3. Performance against safety and health goals is included in annual
performance reviews for individual employees
4. Safety and health specifications are incorporated into performance
criteria for functions such as operations, purchasing, design,
engineering, etc.
5. Cardinal rules (violation of which result in harsh penalty or
termination) have been established for key high-risk activities
MERCER
3. Risk: Are there effective risk identification, assessment and control processes in place for identifying and abating hazards? 1. A process is in place for routinely identifying hazards and conducting
risk assessments.
2. The process insures that hazard identification and risk assessments are conducted as frequently as required to ensure the safety of employees.
3. A process is in place to insure prompt incident investigation.
4. The incident investigation process includes hazard analysis to root cause.
5. A process is in place to insure the availability of effective and adequately maintained control measures.
6. A process is in place to insure timely implementation of controls.
7. A system is in place to assure abatement follow-up on all incidents and hazards.
8. A process exists for reviewing and implementing system improvements to continually reduce risk
MERCER
4.Employee Involvement: Is there a process in place to insure that employees are effectively involved in worker safety and health?
1. There is a process for involving employees in the development of
safety and health programs and policies.
2. Employees are involved in conducting safety and health training
and education.
3. Employees are involved in safety and health program audits and
reviews.
4. A system is in place to address and follow up on employee
concerns about workplace safety and health.
5. A system is in place to assess employee perceptions about
workplace safety and health.
6. A system is in place to encourage employee reporting of hazards
MERCER
Pilot Test Number Two: Leading Indicators To Drive Continuous Improvement for Critical Aspects of Risk Management (Site-Based) Management System Elements Programs and Activities
The measure of who we are is what we do
with what we have.
Vince Lombari
MERCER
Summary of Key Leading Indicators to Drive Continuous Improvement For Critical Aspects of Risk Management (Mgt. Systems, Programs, etc.)
1. Number and percent of high risk tasks identified for control
2. Percent deviation from safe work methods and permit conditions
3. Percent of inspections and testing of safety critical equipment that are
on time
4. Percent of safety–critical maintenance actions addressed on time
5. Percent of corrective actions from S&H inspections, audits, accident
and near miss incidents closed on time
6. Percent of Senior Executives with S&H goals and objectives
established for both leading and lagging measures
MERCER
Pilot Test Number Three: Developing and Implementing A New Global Trailing Metric
If you can't explain it simply, you don't understand
it well enough.
Albert Einstein
MERCER
Global Outcome Metric Team Objective: To
develop a suite of OHS Trailing Metrics that: 1. Effectively support continuous improvement, and 2. Are more suitable for global benchmarking purposes
Team Approach: Three Levels of Reporting Level One: Comprised of the most consistent data; cases with a
clearer connection to work than current data that are reasonably
serious and/or significant to the injury/illness prevention process
Level Two: Will include data from existing systems; primarily cases
recorded under the current OSHA-based criteria
Level Three: Will include near misses that could have resulted in
Level One cases
MERCER
Key Issues for Identifying Useful Trailing Metrics
1. Determining whether or not cases are work related
2. Determining whether or not cases are serious and/or significant to the injury and illness prevention process
Other Issues
• Injury vs. illness
• New case vs. old case
• Rate calculations
• Data outputs, collection cycles, etc.
MERCER
Tests for Determining Work Relationship
• The core set of global outcome metrics are limited to those cases that have
a clear connection to work. Work relationship can be determined with the
following Three-Step Analysis:
Step 1. Was the case related to a condition of employment and
therefore within the general scope of employment? Specifically, was
the employee:
• Being paid at the time of the injury and illness exposure, or
• Required by his or her employer to do the job and/or task; or
• Performance of the job mandated that the activity be undertaken?
– If the answer is “no,” then the case is not work related.
– If the answer to any of these three questions is “yes,” then the case is “in
scope” and may be considered work related if the following two tests are
satisfied.
MERCER
Tests For Determining Work Relationship, Cont.
Step 2. Was there sufficient connection between the exposure and
the resulting employee condition? Did the exposure either trigger the
onset of symptoms or contribute to the severity of the case?
• For all cases, ask: “would the case have occurred at the same time and
with the same degree of severity without the work exposure identified in
number 1 above?”
MERCER
Tests for Determining Work Relationship, Cont.
Step 3. Was the activity the employee was engaged in at the time of
the exposure so personal in nature as to negate its relevance for
prevention purposes? Even if the tests in Steps One and Two are met,
do not consider the case work related if the exposure was not subject to the
employer’s control. Examples:
– Employee throws back out from sneeze (normal body movement)
– Employee injures herself while preparing her own food or drink
• Note: Employees can be doing something other than a specific work task
and still be subject to the employer’s control. This includes support
functions connected to work processes and operations, administrative
functions connected to work, and normal living activities that routinely take
place at work IF the employer has the authority to regulate how those living
activities are conducted.
MERCER
Specific Criteria for Level One Cases Level One is intended to be a subset of relatively serious cases that have significance for the I&I prevention process and are likely to be consistently diagnosed.
A. Injuries 1. Fatalities
2. Amputations (involving bone)
3. Spinal cord injuries
4. Herniated discs of the cervical, lumbar,
and/or thoracic spinal regions
5. Concussions and/or cerebral hemorrhages
6. Loss of consciousness
7. Injury to internal organs
8. Fractured bones or teeth
9. Cartilage, tendon, and ligament tears
10. Dislocation of any joint
11. Lacerations and punctures requiring wound
closure, such as sutures, surgical glue, etc.
12 MSDs requiring surgery or resulting in
permanent impairment
13. All 3rd degree burns. 2nd degree burns greater
than 3 inches in diameter (100 cm2)
14. A punctured eardrum or confirmed work related
STS and a 25db shift from audiometric zero in
same ear
15 . Injuries of the eye requiring the services of a
physician (unless treatment is preventive)
MERCER
Specific Criteria for Level One Cases Level One is intended to be a subset of relatively serious cases that have significance for the I&I prevention process and are likely to be consistently diagnosed.
B. Illnesses 1. Occupational dermatitis with blistering and/or
cracking covering an area of skin greater than 3
inches in diameter (100cm2).
2. Occupationally acquired HIV, hepatitis B or C
3. Occupationally acquired cancer
4. Occupationally acquired lung diseases
5. Occupationally acquired infectious diseases
6. Occupationally acquired disease of the liver,
spleen, kidney, heart, brain, nervous system, pancreas, thyroid, or other vital organ
MERCER
What Would it Take to Implement These New Criteria?
• Not much additional effort
• OSHA logs currently have an “employer use column” – the margin
• Recordkeepers or managers could screen existing OSHA cases (Our Level
Two cases) and place a check in the margin for cases that are in scope for
Level One benchmarking.
• This could be done solely from existing documentation
– Work relationship determinations could be made from the log and/or
from supplementary information kept for each log entry (OSHA 301 or
equivalent)
– Selections based on Level One criteria for severity and/or significance
to the injury or illness prevention process could largely be made from
Column F of the log which requires that entries “Describe the injury or
illness, part of body affected, and object /substance that directly injured or made
the person ill”
MERCER
Questions We Are trying to Answer
Cognitive understanding: Are the case definitions worded
clearly so that they can be understood globally, and recorded and
reported consistently among members in different companies, business
units and sites?
Workload: How difficult is it to compile the data? Is it relatively easy to
derive the trailing indicator data from existing (largely OSHA-based)
records? Can the enterprise-wide leading indicators be gleaned from
records kept in corporate offices within reasonable time and resource
constraints? Can the site and program leading indicators be derived
within a reasonable time?
Value: Are the new metrics better than the existing ones? Do they
provide new insights into the efficiency and effectiveness of company
injury and illness prevention processes? Does the “gain” justify the “pain”
of compiling new data?
MERCER
What Are The Benefits of the New Mercer Data? Is the “Pain” Justified By the Gain??? • Leading Indicators
1. Data to drive continuous improvement
2. Addressing issues that are more related to fatality and serious injury
prevention than current measures
3. Will help shift leadership S&H focus from negative to positive issues; from
solely tracking “failures” to recognizing positive workplace contributions
• Trailing Indicators
1. More consistent data for internal tracking and for benchmarking
2. Focused on more conditions that have significance for the injury and illness
prevention process
3. More aligned with prevention programs that are often driven by the nature of
the injury (MSDs. Amputations, etc.)
4. Increased focus likely to increase leadership attention and investment
5. Could help address the problem of “what next” for companies with extremely
low OSHA rates
MERCER
Mercer ORC Implementation Objectives For Enhanced Metrics
• We are surveying pilot participants in October to explore their
experience and tabulate the findings.
• The plan is to modify/refine the metrics based on pilot results; release
“final” metric criteria at the November OSH meeting
• Implement new metrics concepts January 1, 2013.
• To be clear…in 2013 we will encourage members consider
using/providing:
1. Level One “core” outcome data
2. Level Two OSHA-based outcome data
3. Enterprise-wide leading indicators
4. Site-based leading indicators related to risk management
a. New concepts being tested
b. Existing Mercer ORC tool
MERCER
I. What We Will Cover re. Metrics
A. Background: Hard to chart a future if you don’t understand the past
B. Challenge/Problem Statement: What are wee trying to fix and why does it
matter?
C. Proposed Path Forward – Mercer ORC Alternative Metrics Pilots
– Why needed
– Rationale for approach
– Proposed metrics
– Possible barriers and ways to overcome them
D. Shaping the future
-- How do we get leadership to focus on the issue?
-- How do we successfully advocate change?
-- How do we make change sustainable?
MERCER
Shaping the Future…
1. Develop a more balanced, robust approach to S&H performance
measurement
2. Engage a “critical mass” of companies
3. Drive consensus towards a few key metrics
4. Test and validate data
5. Establish linkage between leading indicators and outcomes
MERCER
Overall Metrics Summary • Our current metrics paradigm does not work and we all know it.
• In part, the metrics we use (or don’t use) contribute to our current
plateau in injury and illness performance… because:
1. Key data are lacking to drive performance
2. We don’t fully utilize the data that already exists
3. Cases related to critical hazards are buried in other data
• Improving data on occupational injuries and illnesses requires a
different approach than has traditionally been used.
– We need to re-examine several key concepts
– We need to think about clarity and ease of use
• As a profession we know what needs to be done. The hard work will
be in getting consensus and changing the existing paradigm.
MERCER
By Now…Most of You Need A BREAK
… Warning…5 Minute Stretch Break…Then Back to Work…
MERCER
EVOLVING CONCEPTS IN FATALITY AND SERIOUS INJURY PREVENTION Preliminary Report of the Mercer ORC Fatality and Serious Injury Prevention Task Force
Ray Comingore ExxonMobil David Jacobi Kimberly Clark Glenn Murray ExxonMobil Lisa Potts
Sikorsky
Stephen Newell
Dee Woodhull
Principals
Mercer ORC HSE Networks
MERCER
“The greatest reward for doing, is the opportunity to do more.”
Earl Warren
MERCER
Session Objectives
I. Quick Problem Statement
II. Overview of Preliminary Task Force Findings and Deliverables:
a. Data
b. Risk
c. Human and Organizational Performance
d. Design and Mitigation
e. Foundations
III. Pulling it All Together (10 minutes)
a. FSI prevention Deployment Roadmap
b. Practical Tools and Checklists to Get the Job Done
c. Link to Resources and Materials
IV. Questions/Dialogue
MERCER 65 October 11, 2012
I. Problem Statement… In many industries OSHA injury and illness rates have dropped
dramatically in recent years; fatalities and serious injuries have not
experienced a similar decline
S&H pros perplexed about continuation of serious cases
Some companies experiencing an up tick in “serious near misses”
It is clear that traditional approaches to safety and health are not working
Contractors represent a particular challenge
“You only see what you know..”
Albert Einstein
Copyright © 2010, ORC Worldwide
MERCER 66 October 11, 2012 Copyright © 2008, ORC Worldwide 66
“Pillars” of the SH Profession That May be “Myths” When It Comes to Serious Injury Prevention
1. The mistaken interpretation of the Heinrich Pyramid that managing
personal safety for less serious hazards at the bottom of the safety
triangle will also address high gravity hazards at the top
2. Our collective misuse of OSHA data as the primary metric for driving
and assessing safety performance;
3. Our over emphasis on probability guesstimates when determining and
"likelihood" in conducting risk assessments that relate to high gravity
hazards
4. Our failure to effectively argue against the mistaken belief that higher
level controls are cost prohibitive; and
5. The incorrect and really unsupported assumption that most injuries
result from unsafe acts (fueled and reinforced by flawed incident
investigations).
MERCER 67 October 11, 2012
Cumulative Impact of S&H “Myths”:
• Inertia driven by mistaken belief that current approaches work, based
on misuse/misunderstanding of the OSHA data.
• Alternative approaches not fully considered due to belief that higher
level controls are cost prohibitive and serious events are unlikely to
happen anyway
• Some feel that if injuries are really due to unsafe acts then all that is
needed is training and administrative controls…i.e., fix the employee,
not the process
MERCER
II. Task Force Findings and Deliverables A. Data Team Report
• Objective: Develop a model that can be used to identify and differentiate
situations (hazards and related contributing factors) that are precursors to
fatalities and serious injuries (FSIs)
• Findings and Deliverables:
– Fatalities and serious injuries result from situations involving a discreet
set of exposures…coupled with key contributing factors
Serious hazards are often coupled with organizational and human
factors that increase the likelihood of an incident
– Companies cannot adequately control these situations/exposures
without placing special emphasis on them
– These exposures must be identified and addressed. A tool has been
developed to identify precursor situations
– Metrics can be applied to driving continuous improvement through their
management and control
MERCER 69 October 11, 2012
Context for A “New” Approach for Using Data To Support Serious Injury Prevention • Dan Petersen on serious injuries in 1989…
– The causal factors are different. There are frequently different sets of circumstances surrounding severity:
• In unusual and non-routine work
• Where upsets occur
• In non-production activities
• Where sources of high energy are present
• During at-plant construction operations
• Fred Manuele: ““As the data clearly shows, frequency reduction does not necessarily produce equivalent severity reduction.”
…The data requires that we adopt a different mindset, and a particularly different focus on preventing events that have serious injury potential.”
MERCER 70 October 11, 2012
Tom Krause, BST: The traditional
safety triangle is not predictive of
FSIs
Not all injuries have
FSI potential.
A reduction of injuries
at the bottom of the
triangle does not
correspond to an
proportionate
reduction of FSI
21%
Potentially
FSI
Is the Safety Triangle Accurate Predictively?
BST findings
MERCER 71 October 11, 2012
Examples of Work Situations that May Have High Proportions of Precursor Events
– Process instability
– Significant process upsets
– Unexpected maintenance
– Unexpected changes
– High energy potential jobs
– Emergency shutdown procedures
Specific Work Activities that May Have High Proportions of Precursor Events
– Operation of mobile equipment (and interaction with pedestrians)
– Confined space entry
– Jobs that require lock-out tag-out
– Lifting operations
– Working at height
– Manual handling
BST findings
MERCER
BST Findings (Tom Krause led task force findings)
• Injuries of differing severity have differing underlying causes.
Consequently, reducing serious injuries requires a different strategy than
reducing minor injuries.
• Most fatalities and serious injuries come from a discrete set of exposures.
These exposures can be identified and addressed
Current measurement systems create a “blind spot” for serious injury prevention
2007 Rand Study
• There appears to be no relationship between OSHA injury rates and
fatalities
– The absence of minor injuries is NOT predictive of the absence of
future fatalities
– The presence of minor injuries is NOT predictive of the presence of
fatalities in the future.
MERCER 73 October 11, 2012
Pulling It All Together
• Dan’s Petersen and Fred Manuele made the initial case that FSI’s result
from a discrete set of exposures. The key question is: “where do you
look?”
• The Rand study reinforced these findings and showed where NOT to
look proving that OSHA injury and illness rates are NOT predictive of
FSIs. Low OSHA rates do NOT indicate that a site is free of exposures
with high gravity potential; high OSHA rates are NOT predictive of FSIs.
• The BST study completed and expanded the analysis by identifying
specific precursor situations that could result in FSIs. More importantly
the BST task force showed how this work could be done.
MERCER 74 October 11, 2012
A New Strategy for Data Use
Consequently the strategy for reducing fatalities and serious injuries
should begin with a process to identify exposures/situations that are
precursors to fatalities and serious injuries
• Precursor data may vary by industry, employer, business unit, and even
site. Therefore, companies should begin looking for FSI precursors by
examining their own data and their own processes and creating an
inventory of their own serious hazards. Underlying conditions that could
activate or intensify the hazard should be also be factored into the
hazard inventory.
• Relevant data are also available from BLS, OSHA, NIOSH, worker’s
compensation, insurers, unions, etc.
– Supplemental data are important since individual sites may have exposures with
serious injury potential that have not (luckily) resulted in a loss
– When examining data from outside sources look for information that is relevant
to your processes and potential exposures
• Precursor data should be drawn from all available sources: accidents,
injuries, serious near misses and exposures.
MERCER
Culture, Culture,
Perceptions, Perceptions,
and Beliefsand Beliefs
F&SIF&SI PrecursorsPrecursors
–– CognitiveCognitive
–– PsychoPsycho--
behavioralbehavioral
–– Physical andPhysical and
Mental Mental
limitationslimitations
–– PerceptualPerceptual
–– SelfSelf--imposed imposed
stressstress
–– PersonnelPersonnel
–– ControlsControls
–– VisibilityVisibility
–– UpsetUpset
conditionsconditions
–– Noise/vibrationNoise/vibration
–– Equipment/Equipment/
facility designfacility design
–– WarningsWarnings
Human Human
Factors Factors
ProcessProcess
ConditionsConditions
Fatality Fatality
or or
Serious InjurySerious Injury
Risk toleranceRisk tolerance
Employee Employee
engagementengagement
Value for Value for
safetysafety
Contributing Contributing
FactorsFactors
Management Management
SystemsSystems
–– TrainingTraining
–– AccountabilityAccountability
–– CommunicationsCommunications
–– Planning andPlanning and
EvaluationEvaluation
–– Rules and Rules and
ProceduresProcedures
–– SupervisionSupervision
–– IncidentIncident
InvestigationsInvestigations
F&SIF&SI Causation Causation ProcessProcess
OutcomesOutcomes
Po
ten
tial
F&
SIH
aza
rd
Fatality Fatality
or or
Serious InjurySerious Injury
EVENTEVENT
Mercer HSE Networks Fatality & Serious Injury Task Force
Fatality Precursor Rating Matrix: Task Assessment
MERCER
Mercer HSE Networks Fatality & Serious Injury Task Force
Fatality Precursor Rating Matrix: Task Assessment
Contributing Factors (activate or intensify hazard) (1 point each)
A. Hazards
(10 points each)
B. Cultural/
Organizational
(attitudes and
values)
C. Management
Systems
(policies
and practices)
D. Process
Conditions
E. Human
Factors/Behavioral
Electrical energy High risk tolerance Goals and objectives for safety performance have not been established
Significant process upsets
Physical ability not matched to job/task requirement(s)
Mechanical energy (machinery and equipment)
Low employee engagement
Low management accountability
Unexpected maintenance
Physical or mental fatigue likely
Pressurized vessels of all types (cylinders, tanks, pipes, etc.)
Value for safety is not demonstrated by senior management
Poor risk recognition training
Unexpected repair Cognitive over- saturation
Falls from Elevations Production has higher priority/value than safety
Infrequent inspections Unexpected process changes
Time pressure
Falls on same level Supervisors do not receive support for safety decisions
Poor follow-up on identified corrective actions
Emergency shutdown Incompatible work space(s)
Explosion and fire potential (chemical energy)
Safe behavior is not recognized by supervisors/managers
Poor communication of safety-critical information
Prior changes not communicated
Distraction
Crushing hazards (heavy objects—caught under or between)
Alcohol and drug abuse is found in
the workplace
Potential for miscommunication
Production pressure Pre-existing illness/injury/ condition
Engulfment hazards Employees do not receive support for safety decisions
Procedures/work instructions not adequate
Poor visibility or lighting
Circadian rhythm desynchrony
Suspended loads Personnel resources not adequate
Checklists not in use Noise/vibration Poor visual adaptation possible
MERCER
Contributing Factors (activate or intensify hazard) (1 point each)
A. Hazards
(10 points each)
B. Cultural/
Organizational
(attitudes and
values)
C. Management
Systems
(policies
and practices)
D. Process
Conditions
E. Human
Factors/Behavioral
Confined spaces or other suffocation hazards
Inadequate financial resources for safety
Standard terminology not in use
Confusing Controls/switches
Physical task oversaturation
Highly toxic chemicals Cross-monitoring not in use
Use of personal protective equipment creates awkward job performance
Drug use/self- medication
Extreme heat and cold Pre-task planning not in use
Work/task resources inadequate
Dehydration
Radiation Pre-task briefing not in use
Inadequate design Lack of skills/education for task/job
Motor vehicles Work-in-progress re- planning not in use
Inadequate warning mechanisms
Other potential fatality and serious injury exposures should be anticipated
Inadequate leadership/supervision /oversight
Improper task delegation
Authorized unnecessary hazard
Mercer HSE Networks Fatality & Serious Injury Task Force
Fatality Precursor Rating Matrix: Task Assessment
MERCER
Precursor Rating Score
A. Hazards
B. Cultural/
Organizational
C. Management
Systems
(policies
and practices)
D. Process
Conditions
E. Human Factors/
Behavioral
Instructions for Use: The Initial Fatality and Serious Injury Precursor Rating Matrix is NOT a risk assessment. Rather it is a tool to
identify possible precursor situations that require further attention and assessment for inclusion in the site’s comprehensive inventory
of Fatality and Serious Injury Precursors. To make an Initial Fatality and Serious Injury Precursor Rating, select the hazards from
Column A that are associated with the potential precursor situation; then look at Columns B-E and select each contributing factor
present. Assign 10 points to each hazard and 1 point to each contributing factor.
Sum up the total points from the hazard(s) selected and from the contributing factors present. The total is the Initial Fatality and
Serious Injury Precursor Rating.
Note: Risk assessments will differ because they factor in likelihood of occurrence based on degree of control. Control issues are
addressed later in the FSI prevention process.
Mercer HSE Networks Fatality & Serious Injury Task Force
Fatality Precursor Rating Matrix: Task Assessment Score
MERCER
B. Risk Team Report
• Objectives: Assess effectiveness of current approaches for identifying,
evaluating, and managing situations involving serious hazards. Identify
problems/gaps and develop new tools and approaches.
• Findings and deliverables: – A new risk model that creates a separate track for addressing serious
hazards
– A new approach for conducting risk assessments that incorporates
underlying factors that activate or intensify the hazard and places
more emphasis on the degree of control
– A compendium of successful practices and tools used by member
companies
MERCER 80 October 11, 2012
Typical S&H Prevention/Risk Model
Eval
uat
e P
roce
ss
Risk Recognition
Risk Assessment
Risk Management
MERCER
Dual Path Strategy for Prevention
Risk
Assessment:
F(x): Severity
+ Experience-
Based
Likelihood
Low
Severity
Exposure
Risk
Assessment:
F(x): Severity
+ Control-
based
Likelihood
Likely
Precursor
to Fatality
or Serious
Injury
Risk
Mitigation:
Low to Middle
Order from
Control
Hierarchy
Risk
Mitigation:
High Order
from Control
Hierarchy;
Layers of
Protection
Hazard
Recognition
MERCER 82 October 11, 2012
New Framework for Addressing Fatalities and Serious Incidents: What Is Different for FSI Prevention?
Some existing strategies are still appropriate, but need to be executed flawlessly; other
approaches need to be modified and/or replaced entirely.
Likely
Precursor
to Fatality
or Serious
Injury
Risk
Assessment:
F(x): Severity
+ Control-
based
Likelihood
Risk
Mitigation:
High Order
from Control
Hierarchy;
Layers of
Protection
MERCER 83 October 11, 2012
Effective Risk Recognition Relating to FSIs
• Flawless execution of what we
already know
– Pre-job planning and risk assessment
– Job Safety Analysis
– Behavioral observations
– Assessments and Audits
– Risk tolerance
• Different approach required
– New metrics and surveillance data
required for FSI precursors and
abatements
– New approaches needed for Incident
investigations and root cause analyses
Identify latent conditions in
addition to active failures
– Improve risk understanding
– Develop training on new methodologies
for identifying risk
MERCER 84 October 11, 2012
Effective Risk Assessment Relating to FSI’s
• Flawless execution of what we
already know
– Assess the severity of the hazard
• Different approach required
– Improve understanding of potential
severity by assessing underlying factors
that can activate or intensify the hazard
– Realign approach for determining
“likelihood of occurrence” in risk
assessment process; base likelihood on
degree of control instead of past
experience
MERCER 85 October 11, 2012
Alternative Risk Assessment Approach for FSI Prevention – Consider:
1. The severity of the hazard, and the underlying factors that could
activate or intensify the hazard
2. Degree of control
a) The degree of control is linked to probability (high degree of
control = low probability)
b) It is easier to evaluate
c) It is more compelling; high-rated hazards with low degree of
control should be identified for higher priority
In short: In high gravity situations “likelihood” should become a second or
third tier consideration.
3. Actual exposure
a) Number of employees exposed
b) Frequency (and duration) of exposure
b
Copyright © 2010, ORC Worldwide
MERCER 86 October 11, 2012
Effective FSI Risk Management • Flawless execution of what we
already know
• Management System issues: Compliance
Accountability
Management of Change
Incident reporting and investigation
Training
Metrics
Emergency preparedness and fire
prevention
– Activities related to: Exposure to and operation of mobile
equipment
Confined space entry
Lock-out tag-out
Working at height
High energy
– Addressing active errors
• Different approach required
– Less reliance on worker to never
make a mistake
– Better application of hierarchy of
controls
– Drive continuous improvement
around precursor situations
– Focus on system weaknesses and
latent errors
– Special complexities of contractor
arrangements must be addressed
MERCER
• Objectives:
– Focus on different aspects of error, including factors that lead to
intentional and unintentional behaviors that contribute to fatal and
serious incidents.
– Identify and test effective techniques for mitigating error
• Findings and Deliverables:
– Identify Appropriate Abatement Strategies and Tools
– Assemble effective strategies to insure operational discipline
C. Human & Organizational Performance
MERCER 88 October 11, 2012
Understanding Human Error: James Reason
• Serious injuries have multiple causal factors
• Less than adequate tools and equipment may be present
for many years before they combine with local circumstances and active failures
to penetrate the system’s layers of defenses.
Todd Conklin: Los Alamos National Laboratory • Workers don’t usually cause events.
• Workers trigger latent conditions that exist in systems, processes, procedures,
and expectations that always lie dormant on the job site.
MERCER 89 October 11, 2012
Views of Human Error – Sydney Dekker
1. Human error is a symptom of trouble deeper inside a system
2. Complex systems involve trade-offs between multiple irreconcilable
goals. In normal work that goes on in normal organizations safety is
never the only concern or in many instances even the primary concern.
3. People have to create safety through practice at all levels of an
organization
4. To explain failure find how people’s assessments and actions made
sense at the time, given the circumstances that surrounded them.
Consider their:
• Point of view and focus of attention;
• Knowledge of the situation;
• Objectives and the objectives of the larger organization in which
they work
MERCER
Human & Organizational Performance
• Learn from past incidents and near misses;
Incident investigation
Data Analysis
Consider performance modes
Active failures
Latent conditions
Process Characteristics
• Evaluate task and underlying conditions
• Assess current situation for human error potential with high severity
consequences
MERCER
Human & Organizational Performance • Underlying conditions: understanding key concepts
Employee Performance Modes
Skill based: highly practiced, almost automatic
Rule based: apply memorized or written rules (if… situation,,then…do)
Knowledge based: methodical.. trial and error
Active failures
Worker characteristics
Individual capabilities
Individual attitudes/human nature
Latent conditions
Work environment
Organization culture
Equipment flaws
Process Characteristics
Error traps
MERCER
• Error traps—some examples:
Time pressure
Distractions
Vague and Imprecise Guidance
Overconfidence
Inexperience
Complacency
Hazard unawareness
Sleep deprivation
Etc.
Human & Organizational Performance
MERCER
Human & Organizational Performance
• Operational Discipline: Defined by DuPont as “the dedication and
commitment by every member of the organization to carry out each task
the right way every time.”
• In a safety and health context, how does the organization keep employees
operating within a zone of safety?
MERCER
Operational Discipline: Key elements
• Accountability
• The head…being trained and knowing what to do
• The heart…wanting to do it
• The tools….
Employees have the checklists needed to support consistent
performance
Pre-job reviews
Behavioral observations
Incident investigation tool (HFACS)
Training: Employees know how to do task right every time
• Approaches
– Make it easy to do things right
– Make it difficult to operate outside of the safety zone
MERCER
D. Design and Mitigation Team Report
• Objective: The team focused on design issues, the Hierarchy of
Controls, layers of defense, etc. Findings from this team were used to
identify effective approaches for controlling exposures to serious hazards.
• Findings and Deliverables: – Higher level controls are a preferred option for controlling serious
hazards
– If higher level controls are not feasible, multiple layers of lower level
controls are needed
– A compendium of control strategies for 10 fatal and serious injury
contact types
– A tool to help structure decision making when lower level controls
must be used
MERCER 96 October 11, 2012
Design/Mitigation Team Example: Control Strategies for Common Fatal/Serious Injury Contact Types
1. Struck by falling objects
2. Operation of, or interaction with,
powered industrial vehicles
3. Falls from height
4. Electrical contact
5. Head/torso contact with energized
mechanical equipment
6. Acute chemical exposure or
atmospheric hazard (including
confined space operations)
7. Exposure to chronic hazards that
lead to fatal outcomes
8. Fires and explosions
9. Road transportation
10.Workplace violence
MERCER 97 October 11, 2012
Compendium of Control Options
1. Management of Change Guidance
2. Prevention through Design Options
3. Engineering (post installation or design) Controls
4. Administrative/Procedural Controls
5. Administrative/Behavioral Controls
6. Collection of Recognized Consensus Standards or Guidance Tools
Strength of Defense Matrix
MERCER 98 October 11, 2012
Sample Solutions Document
MERCER 99 October 11, 2012
E. Well Built Houses Require A Strong Foundation In addition to new technical approaches,
eliminating fatalities and serious injuries also requires:
• Leadership that views the safety and well being of the
workforce as a critical element of business performance,
and is committed and actively engaged in the injury and
illness prevention process.
• A corporate culture that fosters universal recognition of worker safety
and health as a core value of the company.
• Employees that are actively engaged in planning and driving the
company’s safety and health program
• An effective safety and health management system that translates
values, beliefs, commitments, and objectives into action
Objective = Healthy employees productively at work
MERCER
Foundations Team Report
• Objective: Develop material, guidance, tools to support the key
enablers for effective FSI prevention: Leadership, Culture, and
Management Systems
• Deliverables: – Communication Package
– Metrics
– Diagnostic Tools
– Management Systems Guidance
– FSI Prevention Deployment Roadmap
– Observation & Intervention
MERCER
Foundations Team Deliverables
• Communication Package
– Provide a package for use with Line Managers, company leadership,
other levels as appropriate to support their understanding / build the
business case
+Case for action
+Key concepts
+Deployment strategy
+How to use the toolkit
– Envision prepared PowerPoint w/talking points
• Observation and Intervention
– Integrate FSI prevention concepts into existing Observation and
Intervention tools, i.e., targeting of observation activity based on
precursor/metrics data, more effective leadership intervention and
dialogue, etc.
– Still a work in progress
MERCER
Foundations Team Deliverables
• Diagnostic Tool
– A culture assessment tool is being created that will be evaluated for its
value in predicting fatalities and serious injuries.
– The tool is based on Dan Petersen’s landmark work on S&H culture
surveys and on work from Mercer ORC Networks and the Baker panel.
– Potential to launch research
• Metrics
– A methodology is being developed to identify leading indicators to
improve control of serious hazards and to address the underlying
conditions that could activate or intensify those hazards
– A new trailing metric is being identified that tracks fatalities and serious
injuries and incidents with FSI potential
MERCER
Foundations Team Deliverables
• Deployment Roadmap
– High level intervention strategy
– Detailed implementation steps
• Management Systems Guidance
– Critical Success Factors for ‘generic’ SH&E management systems
– Additional attributes for effective FSI prevention
MERCER
Management Systems Guidance • Critical Success Factors for effective SH&E Management Systems – the
‘base case’ – Appropriate/relevant content and scope
– Truly systematic structure
– Clear ownership and accountability by line management
– Continuous improvement process
– Appropriately resourced / sustained
– Risk-based
• Considerations, aspects, attributes for SH&E Management Systems for enhanced prevention of FSIs – what is ‘different’ for FSI prevention – Risk Discovery
– Focus on incident potential consequences (vs. just actual consequences)
– Questioning culture
– New metrics beyond traditional lagging metrics
– Analyze / ‘mine’ data for FSI precursors, predictive metrics, unexpected/hidden relationships
– Training and awareness of the ‘new paradigm’
– Focus on higher-risk activities / operations
MERCER
Risk
Assessment:
F(x): Severity
+ Experience-
Based
Likelihood
Low
Severity
Exposure
Risk
Assessment:
F(x): Severity
+ Control-
based
Likelihood
Likely
Precursor
to Fatality
or Serious
Injury
Risk
Mitigation:
Low to Middle
Order from
Control
Hierarchy
Risk
Mitigation:
High Order
from Control
Hierarchy;
Layers of
Protection
Hazard
Recognition
III. Pulling it All Together
MERCER
III. Pulling it All Together: Deployment Roadmap
A. Companies need a high level intervention strategy that identifies
necessary steps for integrating new FSI concepts into ongoing operations
B. Detailed implementation steps
1. Identify targets for intervention
2. Prioritize intervention activities
3. Implement intervention
a. Control the hazard
b. Address key underlying factors
4. Assess strategy effectiveness
5. Drive continuous improvement
The key to successfully integration of key concepts into ongoing S&H
systems and processes will be practical, easy to understand
implementation steps and guidance
MERCER
Overall FSI Summary: 10 Specific Suggestions
1. Start with understanding that just managing personal safety and OSHA
recordables can leave your company vulnerable to fatalities and serious
injuries.
2. Why do FSIs continue to occur?
• Failure to recognize precursor events
• Lack of effective pre-job planning and risk analysis
• Use of low level controls against high risk
• Ineffective inspections and audits
• Poor learning from flawed incident investigation techniques
• Failure to effectively implement Management of Change processes
• Failure to recognize and address latent system weaknesses
• Human error
3. Effectively managing high gravity risk requires rethinking some
fundamental S&H concepts that are actually barriers to serious injury
prevention
MERCER 108 October 11, 2012
Overall Summary: 10 Specific Suggestions
4. Examine your data and processes to identify and inventory serious hazards –
precursors to fatalities and serious incidents
5. Once FSI precursors are identified, apply a different risk strategy:
– Identify and understand points of human interaction with hazards at key points in the
process
– Make sure fundamental S&H approaches and controls are executed flawlessly
– Foster heightened sense of awareness and vulnerability in potential high gravity
situations
– Implement new approaches as needed
6. Don’t expect people to be consistently mistake free; especially in high gravity
situations. Provide high-level controls and/or multiple layers of control at critical
steps in your process
MERCER 109 October 11, 2012
Overall Summary: 10 Specific Suggestions
7. Re-examine your incident investigation and root cause analysis
protocols to improve learnings from incidents
– Go beyond active errors
– Identify latent conditions that are error provocative
8. Drive continuous improvement re hazard control and to address
latent conditions that contribute to FSIs.
9. Develop new measures related to FSI prevention.
• Measures that increase focus on precursor situations
• Measures that drive performance excellence on key aspects of
your process
10. Don’t forget the leadership/empowerment/communications piece
Best practice examples are emerging….
MERCER 110 October 11, 2012
Questions??? Comments/Suggestions for Improvement??? Need more information? Please contact Steve Newell at [email protected] or Dee Woodhull at [email protected].
Copyright © 2010, ORC Worldwide
MERCER