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 consequences resulting 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 Page 1
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 an opportunity 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 Decision 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 Violations Failed to adhere to brief Failed to use equipment Violated training rules Used an unauthorized approach Used an overaggressive maneuver Failed to properly prepare Not current / qualified for task Intentionally exceeded limits of the equipment Unauthorized actions Perceptual Misjudged Spatial disorientation Visual illusion 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. Page 2
Substandard Conditions Adverse 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 Substandard Practices Human Resource Management Failed to back-up Failed to communicate / coordinate Failed to conduct adequate brief Failed to use all available resources Failure of leadership Misinterpretation of information Personal Readiness Excessive physical training Self-medicating Not rested (tired) Physical/Mental limitations Insufficient reaction time Visual limitation Incompatible intelligence/aptitude Physical inability 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 up for work). Supervised Inadequately Failed to provide guidance Failed to provide oversight Failed to provide training Failed to track qualifications Failed to track performance Failed to Correct Problem Failed to correct document in error Failed to identify an at-risk worker Failed to initiate corrective action Failed to report unsafe conditions Planned Inappropriate Operations Failed to provide correct information Failed to provide adequate time (for briefing) Improper staffing Task not in accordance with rules/regulations Failed to provide adequate opportunity for rest Violations of Supervisor Authorized unnecessary hazard Failed to enforce rules and regulations 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 to succeed. 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. Page 3
Resource Management Human Selection Staffing Training Monetary / Budget Excessive cost cutting Lack of funding Equipment / Facility Poor design Purchase of unsuitable equipment Operations Operational tempo Time pressure Production quotas Incentives Measurement / Appraisal Schedules Deficient planning Organizational Climate Structure Chain-of-command Delegation of authority Communication Accountability for actions Culture Norms and Rules Values and beliefs Organizational justice Organizational Process 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 allocation and 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. Page 4
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 a short amount of time. She s been through ergonomics training, and had her workstation evaluated by an ergonomist 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 indicates she 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? Page 5