a asse’s bydesi ngineering s · pdf file · 2014-09-22factors considered....
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PAGE 12PTD PROCESSProven SolutionsD
PAGE 21RISK ASSESSMENTFall PreventionD
PAGE 22HUMAN FACTORSInherently Safe DesignD
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Do Fall Protection Systems Need to Be Load Tested?
While the answer to the question, “Has this fall protection system been load tested?” is a simple yes or no, the
answer to the underlying question, “Should this fall protection system be load tested, and if so, how?” is not nearly as simple. Load testing of fall protection systems should be conducted as part of a complete design program. Load testing is not
Load testing can be a powerful
tool for fall protection system designers, but the method is often misunderstood.
For a complete Table of Contents,
see page 3
a substitute for sound engineering practice.
Many people believe that load testing of fall protection systems is required by law, ANSI standards or by both. The only requirement for load testing related to fall protection is found in the ANSI/ASSE Z359 and A10 families of standards. The standards contain provisions for load testing of manufactured fall protec-tion equipment, such as harnesses,
continued on page 8
By Kevin Wilcox
Volume 13 • Number 3
A techNicAl publicAtioN of ASSe’S eNgiNeeriNg prActice SpeciAlty
PAGE 18FALL HAZARDSIdentifying RisksD
ByDesign©
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ByDesign
Trena Adair, Harbor Environmental & Safety
Chandler Bane Christopher Banyai, Georgia-
PacificLauren Bradshaw Bryan Carrington Melissa Colby, Spectra EnergyDavid Curry Robert Dougherty, UTC
AerospaceAlyssa Duncan William Dunlap, W.L. Gore &
Associates, Inc.Ricardo Espinosa, Kimball
InternationalKenton Heuertz, Aboitiz PowerMitchell Hora David Houle Wimberly Hoyle Rebecca King Carl Kraft, Lyondell
PetrochemicalsMichael Leach Eon Licorish Gabe Lorack Adam Lu William Mainord, Riverside
Public UtilitiesAngie Meyer Fredrick Mlakar, Shaw
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Roger Poore Robert Ray Ryan Ricci, Alliance PipelineStephanie Richmond Tyler Ritland Anthony Rose, SWSCraig Ruberti Herbert Santos Ted Sberna Jennifer Schroeder Ernest Sholtz Robert Simon, Cooper BussmannJohann Szautner, Szautner
Forensic EngineeringJeremy Tjundes David Troutman, Wrigley
Manufacturing Co.Nicholas Urbanowitz, Bunge
North America Oilseed Processing Division
Omote Victor, Aspon Oil Company Ltd.
Ana Wauthion-Melgar James Weber, BNSF RailwayJacob Weis Joshua West, Occidental Oil &
GasBillie Willard, IngredionRobert Yanez Deli Yu •©
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PAGE 1 Do Fall ProtectioN systems NeeD to be loaD testeD?
By Kevin Wilcox
Load testing benefits include determining structural capacity for existing systems, as well as cost savings in design and construc-tion of new fall protection systems.
PAGE 4 electriciaN electrocuteD troubleshootiNg eNveloPe maNuFacturiNg machiNe
An overview of an incident in which an electrician was electrocut-ed while troubleshooting a medium open-end envelope machine.
ProveN solutioNs From PreveNtioN through DesigN
By Dave Walline
Causal data from fatal and serious injury events suggest the decisions arising from the prevention through design process play a central role in avoidance of cata-strophic events.
Do Not be FooleD by Falls
By Thomas Kramer
Properly identifying and evaluating fall hazards can help one more intelligently prioritize projects—with risk and other factors considered.
PAGE 12
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PAGE 22 hoW Do humaN Factors iNFlueNce iNhereNtly saFe DesigN?
By Don Enslow
A critical component of incident management is a sound incident investigation system that includes employee involvement and rec-ognizes incident investigation techniques that focus on root-cause processes and on all contributing factors, including human factors.
PAGE 26 targeteD metrics For maNagiNg Fatalities & serious iNjuries
By Scott Stricoff
While many organizations have some awareness of exposures, near misses and minor injuries that have high potential, few pos-sess the consistent reporting, measurement and tracking visibility needed to address these precursors in sustainable ways.
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Fall hazarD risk assessmeNt & raNkiNg
By Bethany Harvey
Safety professionals must seek to iden-tify all risks rather than focus on a few categories of risk.
PAGE 21D
On April 4, 2012, a 53-year-old male electrician (victim) was electrocuted while troubleshoot-ing a medium open-end envelope machine. The machine’s blower was not working, and the
victim was working to repair it. The victim was reach-ing into the machine to access wiring for the blower contained in an electrical junction box when he was electrocuted.
emPloyer
The employer is a manufacturer and printer of envelopes and sta-tionery and has been in business for 24 years. The company has approximately 82 employees, about 60 of whom work in the manufac-turing department while 20 work in sales and office positions. Three employees made up the mainte-nance department in which the vic-tim worked. Employees worked 5 days per week, Monday through Friday. There were two work shifts each day. Saturday was
a designated maintenance day for the machines, a downtime when machine setters could come in to adjust the machines.
WritteN saFety Programs & traiNiNg
The victim was the company’s main safety and health representa-tive/trainer. At the time of the inci-dent, the company did not have a comprehensive safety and health pro-gram. New hires were provided with an orientation that included training on multiple safety and health topics, including machine guarding, lockout/
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tagout, hazard communication and powered industrial trucks.
During the site visit, it was reported that since the incident, the company had started to develop a safety and health program and was holding weekly planning meetings of management and key production staff to develop a safety committee.
victim
The victim had been employed by the company as an electrician for approximately 7 years at the time of the incident. He held a valid master electrician license. The victim’s normal work schedule was first shift, Monday through Friday. For 2 months before the incident, he had been working extended hours in support of the com-pany’s relocation. It was reported that the victim had worked about 12 hours the day before the incident and was on site at 5:00 a.m. or 6:00 a.m. on the day of the incident.
electrical hazards
Electrician Electrocuted Troubleshooting Envelope Manufacturing MachineMassachusetts FACE Investigation: 12-MA-007-01
The victim had been working extra
hours to direct the project and
disconnecting and reconnecting any electrical compo-nents affected by
the facility’s move.
Photo 1: A medium open-end envelope machine viewed from the front end.
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iNciDeNt locatioN
The company was in the process of moving into a building built around 1900 and historically operated as a fabric mill. The building had been recently reno-vated to accommodate the envelope company. The entire building was more than 300,000 sq ft, and the company was to occupy about half of that space. The machinery was set up on the ground floor, which was a large open space.
equiPmeNt
The machine involved in the incident was a medium open-end envelope machine (Photo 1) that the company had owned for about 14 years. It was estimated that the machine was manufactured more than 30 years ago and perhaps as early as the 1960s. The machine was configured to punch and install an address window on presized sheets of paper, fold and glue the envelope into shape and put on a strip of self-sealing glue with removable strip to seal the envelope.
The machine was equipped with a blower motor (Photo 2) that pro-vided airflow to different sections of the machine through a series of hoses. The blower’s main function was to create negative air pressure on the underside of the transfer belts to keep the paper flat and in position as it passed from one process to the next. The blower motor was powered by 480 V through a three-phase for-mat, (three powered lines and a neu-tral line), which ran through conduit and many junction boxes from the main fuse panel (Figure 1).
iNvestigatioN
At the time of the incident, the company had been moving its entire facility to the newly reno-vated factory building where the incident occurred. Reportedly, the victim was playing a large role in this move, overseeing the break-ing down, moving and setting up/reassembling of approximately 15 manufacturing machines. The move had started 1 month prior to the incident with the machinery being moved in stages so that pro-duction could continue with limit-ed downtime. A few machines had been split into two or three pieces and moved by a rigging contractor into the new facility. The victim
had been working extra hours to direct the project and disconnecting and reconnecting any electrical compo-nents affected by the move. The company contracted an additional electrician to help with this process.
The machine involved in the incident was one of the machines that had been split into two pieces for the move. Splitting this particular machine required removing plates, which bridged the machine frame at approximately the midpoint of the machine’s length, and disconnecting all wiring/conduit and other compo-nents, which crossed this midpoint (Photo 3, p.6). The machine had been moved, reassembled, tested and run-ning the evening before the incident.
Photo 2: The envelope machine’s blower motor.
Figure 1 Envelope Machine’s Blower Motor
Power Supply Shown From Above With Approximate Pathway of Conduit
STANDARDANSI/ASSe Z244.12003 (R2008) W
The day of the incident, the machine setter/operator had been scheduled to resume work as the machine was ready to use. While mak-ing adjustments, the machine operator noticed he could not hear the blower motor running and reported the issue. The victim discovered dur-ing his initial troubleshooting that the blower may have been running at a reduced power, and perhaps one of the electrical lines had shorted or disconnected after being set up at the new facil-ity. The victim then continued to further trouble-shoot the motor wiring, replacing some fuses in the main panel and apparently locating a short in the blower’s wiring.
At the time of the incident, the victim was accessing a junction box located near the break in the machine at floor level (Photo 4). It was unclear if the victim was voltage testing to ensure that the junction box was de-energized or if he was continuing to troubleshoot. While accessing this junction box, he came in contact with an energized component and was electro-cuted. It is suspected the current traveled from one hand, through his torso and out his other hand or perhaps another part of his body touch-ing the machine. The machine operator noticed the victim looked like he was straining while reaching into the machine and walked over to offer assistance. He realized the victim was being electrocuted and pulled on the victim’s sleeve to move him away from the machine. The machine operator then yelled for help and another coworker called emergency medical services.
The local fire department was at the site to inspect the fire alarm panel as part of the move into the renovated facility. A coworker informed fire department personnel of the incident, and they started to care for the victim. Local police, additional fire department personnel and state police arrived at the incident location. The victim was transported by ambulance to a local hospital where he was pronounced dead.
cause oF Death
The medical examiner listed the cause of death as electrocution.
recommeNDatioNs
Recommendation 1: Employers should ensure that electrical circuits and equipment are de-energized and that lockout/tagout standard operat-ing procedures are implemented and enforced prior to beginning work.
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Face Program
The NIOSH Fatality Assessment and Control evaluation (FACe) program is a research program
designed to identify and study fatal occupational injuries. The FACe program’s goal is to prevent occupational fatalities across the U.S. by identifying and investigating highrisk work situations and then formulating and disseminating prevention strategies to those who can intervene in the workplace. Investigations conducted through the FACe program allow the identification of factors that contribute to these fatal injuries. This information is used to develop comprehensive recommendations for preventing similar deaths.
Participating states voluntarily notify NIOSH of traumatic occupational fatalities resulting from specific causes of death, including confined spaces, electrocutions, machinerelated, falls from elevation and logging. FACe is targeting investigations of deaths associated with machinery, falls, energy production, deaths of youths under 18 years of age not covered by child labor hazardous orders and deaths of foreignborn workers.
Nine state health or labor departments have cooperative agreements with NIOSH for conducting surveillance and onsite investigations and for recommending prevention activities at the state level using the FACe model.
For more information, contact Nancy Romano at [email protected] or (304) 2855889.
Photo 3: The bridge plates at the envelope machine’s split point.
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Recommendation 2: Employers should provide and ensure that employees use appropriate PPE and tools for troubleshooting live circuits.
Recommendation 3: Employers should develop, implement and enforce an injury and illness preven-tion program that addresses hazard recognition and avoidance of unsafe conditions.
Recommendation 4: Employers should ensure that work is scheduled to allow for sufficient rest periods between work shifts.
Recommendation 5: Machine manufacturers should implement the prevention through design concept to ensure the safety and health of machine users, including machine operators and maintenance workers. •
Photos 4-5: The envelope machine’s junction box (view from left and right of bridge plate) where the worker contacted live wire.
Version 3.0 of the ANSI/ASSE Z359 Fall Protection Code is now available on a flash drive,
allowing SH&E professionals world-wide to have instant and portable access to what is considered the definitive resource for fall protection.
Initially released in 2007, the code is a series of coordinated standards and reference documents that estab-lish the requirements for an effective and comprehensive fall protection management system. Version 3.0 includes the following standards:
ANSI/ASSE Z359.0-2012, Definitions & Nomenclature Used for Fall Protection & Fall Arrest
ANSI/ASSE Z359.1-2007, Safety Requirements for Personal Fall Arrest Systems, Subsystems & Components
ANSI/ASSE Z359.2-2007, Minimum Requirements for a Comprehensive Managed Fall Protection Program
ANSI/ASSE Z359.3-2007, Safety Requirements for Positioning & Travel Restraint Systems
ANSI/ASSE Z359.4-2013, Safety Requirements for Assisted-Rescue & Self-Rescue Systems, Subsystems & Components
ANSI/ASSE Z359.6-2009, Specifications & Design Requirements for Active Fall Protection Systems
ANSI/ASSE Z359.7-2011, Qualification & Verification Testing of Fall Protection Products
ANSI/ASSE Z359.12-2009, Connecting Components for Personal Fall Arrest Systems
ANSI/ASSE Z359.13-2013, Personal Energy Absorbers & Energy-Absorbing Lanyards
ANSI/ASSE Z359.14-2012, Safety Requirements for Self-Retracting Devices for Personal Fall Arrest & Rescue Systems
ANSI/ASSE Z359.1-1992 (R1999)—Historical Document, Safety Requirements for Personal Fall Arrest Systems, Subsystems & Components
ANSI/ASSE A10.32-2012, Fall Protection Systems for Construction & Demolition Operations
ANSI/ASSE Z490.1-2009, Criteria for Accepted Practices in Safety, Health & Environmental Training
Click here for more information on the code or click here to pur-chase it. •
Z359 Fall Protection Code Now Available on Flash Drive
lanyards and other PPE, but they do not discuss load testing of anchorages or anchorage connectors.
Load testing can be a powerful tool for fall protection system designers, but the method is often misunderstood. Load testing is not given extensive or specific treatment in the codes and standards, so interpretation and sound engineering judgment are necessary to determine appro-priate applications of this testing method.
Load testing benefits include determining structural capacity for existing systems, as well as cost savings in design and construction of new fall protection systems. Load testing can also help prevent incidents and injuries on systems that are in use but have insufficient docu-mentation to demonstrate their structural capacity.
regulatioNs & staNDarDs
Existing fall protection regulations and standards offer only limited provisions regarding load testing. In fact, OSHA does not address the subject at all. The ANSI/ASSE standards contain provisions for load testing of manufactured fall protection equipment, such as harness-
es, lanyards and other PPE, but they do not discuss load testing of anchor-ages or anchorage connectors. Many manufacturers of subsystems, such as horizontal lifelines, require that the installers test the equipment to verify that it was properly installed, but this requirement rarely (if ever) extends to testing the anchorage to the building structure.
Although the building code does not prescribe fall protection loads, the International Building Code contains a full section of regula-tions for in-situ load testing of building structures, written in the context of building code loading conditions. Concerning window cleaning, the ANSI/IWCA I-14.1 standard addresses load testing of window cleaning anchorages, but its treatment of the topic is somewhat incomplete and ambiguous. More specifically, the standard does not
require load testing of anchors. It merely gives guid-ance in the event that a professional engineer deems load testing necessary.
In short, load testing of fall protection system anchor-ages is not required.
Why loaD test Fall ProtectioN systems?Although it is not required, a designer may choose to
load test fall protection systems for many reasons. A load 8
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testing program can confirm the adequacy of the struc-tural capacity and can yield the necessary documentation for their recertification. Likewise, load testing will expose any system deficiencies, mitigating the unknown hazard that may cause a failure. After all, a false sense of secu-rity might increase the risk of a fall.
coNFirm existiNg systems
In some cases, load testing may be the only feasible way to determine structural capacity. Because fall protec-tion systems are often installed on structures long after their initial construction, a variety of structural (and non-structural) materials can serve as the substrate through which the fall protection loads must ultimately travel and be resisted. For the designer, this means that the structure to which the fall protection system is attached may not be readily assessed by analytical means.
As with any construction project, installation of fall protection may vary widely in quality between projects and contractors. Load testing is often a valuable alterna-tive to structural analysis in locations where information needed to perform a conventional analysis is not avail-able or when the structure cannot be assessed by conven-tional analytical methods. In some cases, fall protection systems are installed without proper oversight or docu-mentation. In the author’s experience, load testing has been conducted to verify that the installation was per-formed in accordance with proper construction methods (e.g., a visual inspection of adhesive anchors installed into concrete cannot be relied on to evaluate the strength of those anchors).
system reDesigN or recoNFiguratioN
Load testing may also be a useful tool in the recon-figuration or redesign of existing fall protection systems for new applications and new loadings. Reuse of part or all of an existing system as part of a new fall protec-tion design may be a cost-effective alternative to new construction. Because of the evolving nature of fall protection regulations and standards, loadings and usage needs may change over a system’s lifespan. Load test-ing is a means of establishing structural adequacy for components of an existing system that cannot be readily analyzed for new loading conditions. Note that load test-ing should not be considered a replacement for proper analysis. However, load testing is often useful in verify-ing assumptions that must be made to proceed with engi-neering analysis.
commissioNiNg & certiFicatioN
Many proprietary systems, such as horizontal life-lines, need to be certified or commissioned by the installer or the designer prior to use. Manufacturers often require load testing as part of the certification process for their systems. This may also be true for systems requir-ing recertification.
cover story
Load testing is often a valuable
alternative to structural analysis in locations where
information needed to perform a con-ventional analysis is not available or
when the structure cannot be assessed
by conventional analytical methods.
Do Fall Protection Systems Need to Be Load tested?continued from page 1
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loaD testiNg Program
Load testing of fall protection needs to be more than simply pulling on anchorages and giving them approval. A complete program includes an investigation phase with an approved group of carefully selected and designed load tests that address the specific components in question for the systems being tested. Testing requires deliberate planning of test logistics and complete docu-mentation of the entire process. This documentation pro-vides a vital record of work for future use.
PretestiNg iNvestigatioN
Designers should investigate the fall protection systems and their supporting structures before testing. Performing this due diligence will limit the inherent risks associated with load testing of an existing struc-ture. Without sufficient knowledge of the structure, it is not possible to reliably predict how it may behave when subjected to a concentrated test load. Furthermore, pretesting investigation aids in the selection of system components that will actually require a load test. In addi-tion, the investigation informs the designer’s decision about the type of test that will most effectively test those components.
For example, load testing is only useful if it provides information about how an anchorage will perform when loaded in the same direction as a force that a fall will generate. One would not conclude that an anchor in a roof could withstand a 200-lb pullout load just because a 200-lb person could stand on it.
oFFice iNvestigatioN
Several tasks should be performed in the office before the load testing begins. Designers should review any available documentation regarding installation of the existing fall protection systems to assess whether certain system components will require testing and
to understand the overall quality of the installation. Designers should review structural drawings and per-form calculations to identify building structures eligible for testing and to set safe limits for testing loads. At times, load testing may be ruled out by analysis for some structures that cannot handle the concentrated loads necessary to test certain system components. This in-house work lays the groundwork for effective test design and meaningful results.
PoteNtial PitFalls & DisaDvaNtages
While load testing can be a valuable tool in the evalu-ation and design of fall protection systems, it has some drawbacks that should be considered before proposing a load testing program.
Research & DevelopmentAny load testing program, even if similar to past proj-
ects, will need to be somewhat customized to the current project’s specific needs. This may include significant amounts of research, investigation and test development. The costs associated with the program development effort should be estimated at the outset so that the owner can decide whether the value added by the testing is worth the cost of bringing it to fruition.
Risk of Accidental Damage/LiabilityDespite a designer’s best efforts, risks will remain
during a load testing operation. While contracts and agreements with the client, testing agency and other concerned parties can limit the test designer’s liability, a lawsuit is always a possibility if collateral damage occurs. In most cases, the benefits will outweigh the risks, but those risks should always be kept in mind when pursuing load testing as means to a fall protection solution.
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Unfavorable ResultsAlthough load testing is designed to identify deficien-
cies in fall protection systems, too many unfavorable results eliminate the economic benefits of load testing. While discovering inadequate systems can help avoid incidents, failed systems must be rejected, removed, redesigned and replaced. Load testing then becomes an expensive extra step in the redesign and renovation of fall protection systems. If it is predicted that a group of systems will experience a high rate of failure during load testing, or if high failure rates are experienced in a suf-ficient sample of tests early in a program, the designer and client should consider abandoning load testing in favor of pursuing new design and installation. However, this situation is not likely to be revealed until substantial amounts of time and money have been invested in the development of a load testing program and the genera-tion of a sufficient body of data.
Practical coNsiDeratioNs
The types of load tests employed in a fall protection testing program will vary between projects. The tests used will correspond to the specific system components identified for testing and will also vary based on the makeup of the building structure as well as the types of fall protection systems installed.
Selection of a test type in a given application depends on what the test needs to prove and what component of the fall protection system needs to be tested. The design-er should consider the following questions when select-ing the tests used in the load testing program:
•What am I trying to test?•How can it be isolated from the other system compo-
nents?•Can a single test prove the capacity of multiple com-
ponents?•Is a physical test required or will an inspection suffice?Although the planning and theory behind a load test-
ing program are critical to achieving successful results, those results will only be valuable if the tests are well executed and well documented. Design professionals possess the greatest amount of responsibility for ensuring that the testing is a success and should, therefore, main-tain an appropriate level of control over practical aspects of the testing, particularly if a third party is physically performing the tests. Laying the groundwork for proper field methodologies and documentation of test results will ensure that testing is delivered with the highest value possible. •Kevin Wilcox is principal at LJB Inc.
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Classroom@ASSEUpcoming Live Webinars
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temporary Workers SafetyMarch 12, 2014
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On-Demand Offerings
ANSI/AIHA/ASSE Z10-2012: Standard for Occupational Health & Safety Management Systems
Changing Behaviors: Balancing the Elements for Effective Safety Management Systems
International Society for Fall Protection Symposium
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Making Metrics Matter
Global Safety Experience
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SAFETY 2014 PROFESSIONAL DEVELOPMENT CONFERENCE & EXPOSITION
June 8-11, 2014 | Orange County Convention Center West Building | Orlando, FL www.safety2014.org | 847.699.2929
Natalie Skeepers, South Africa
“Why would I travel so far to attend the conference? There are so many reasons . . . education, networking, social gatherings, international perspective, specialty discussions, exhibits, etc.”
Join your fellow safety professionals at the much-
anticipated Safety 2014 Conference. Experience
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You’ll come back refocused, revitalized, reconnected, READY.
preoperational stage. SH&E profes-sionals must shift and even depart from traditional safety roles and daily job duties, such as compliance program writing, training, inspec-tions and claims management, and must transition into risk avoidance and risk mitigation activities related to organizational planning, design, specifications, safety procurement specifications, design safety reviews, proven solution development and risk assessment.
Based on the author’s informal research and discussion with many global SH&E professionals over the past 5 years, the SH&E community roughly spends its time as follows:
1) preoperational, 10% (avoidance and elimination focus);
2) operational, 70% (compliance and retrofit focus);
3) postincident, 20% (claims management, litigation, regulatory issues);
4) postoperational, <1% (decom-missioning, demolition).
Today’s best organizations seek out innovative and creative SH&E professionals, but the SH&E job description of tomorrow will likely look much different. Progressive employers will look for SH&E pro-fessionals who possess these key core competencies (working in the preop-erational risk management stage):
1) PTD;2) risk assessment;3) management of change;4) fatal and serious injury pre-
vention;
Causal data from fatal and serious injury events sug-gest the decisions arising from the prevention through design (PTD) process play
a central role in avoidance of cata-strophic (life-ending or life-altering) events. Numerous studies and research reveal 20% to 50% of all mishaps reported indicate a design gap finding. From the author’s first-hand experience and study, fatal and serious events are at the high end of this percentage range.
The central question is, What is holding back organizations from addressing design-related events head-on? The author believes a criti-cal organizational and cultural blind spot exists. Through benchmarking with other SH&E professionals, he has found that most injury/illness data management systems used by organizations do not ask for, capture or highlight design-related causal factors. This data gap has caused latent, design-related conditions to go uncontrolled and undetected in most organizations. As a direct result, both existing and new designs continue to be operated or procured with inherent uncontrolled hazards and risks that can potentially cause serious mishaps.
To avoid such design-related inci-dents, the author strongly suggests that SH&E professionals personally dive deep into their own organiza-tions’ injury/loss experience if they have not done so already. By criti-
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cally examining previous incidents, startling answers can be uncovered.
The author has gained new insight from his own experiences by drilling deeper into causal data from past mishaps. Other SH&E profes-sionals can also discover compel-ling information that can be used to generate a stronger focus on PTD in their organizations.
One key outcome of the author’s work has been the development of a design safety checklist centered on fatal and serious mishap prevention controls related to past events. This design-focused checklist has been a game changer for designing out fatal and serious mishap-related risks.
PtD skill-builDiNg
To enhance their skill level and efforts around PTD, SH&E pro-fessionals should first obtain and read ANSI/ASSE Z590.3-2011, Prevention through Design: Guidelines for Addressing Occupational Hazards and Risks in Design and Redesign Processes.
Section 1.3 of the standard, which is focused on application, states the PTD standard applies to four main stages of occupational risk management:
1) preoperational;2) operational;3) postincident;4) postoperational.The author believes for PTD to
come to the forefront of business deci-sion making, the SH&E community must begin to spend more time in the
ptd process By Dave Walline, csp
Proven Solutions From Prevention Through Design
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5) operational risk management system;
6) contractor risk management;7) safety specifications for pro-
curement;8) human error and human per-
formance.These core competencies are
highlighted in ANSI/AIHA/ASSE Z10-2012, Occupational Health and Safety Management Systems, another document SH&E professionals should obtain, read, fully understand and adopt.
SH&E professionals who possess these core competencies will bring the required leadership and creativ-ity to their organizations and facili-ties by identifying, establishing and driving proven solutions into new designs and processes. The author believes future SH&E professionals should establish a career target (both time and skill set) to work 70% in the preoperational stage of risk man-agement. In this stage, the business world sees the SH&E professional as a leader, valued business partner and risk mitigation advisor. Personal recognition and reward come with this new role.
According to the author’s obser-vations, SH&E professionals spend most of their time in a firefighting and/or compliance mode while mak-ing these common mistakes:
1) Assume their business lead-ers know what they should be doing next in SH&E (such as PTD).
2) Believe nothing can be done in PTD without a corporate edict or standard.
3) Think that PTD is to be left only to engineers and designers.
4) Fear that they will not per-fectly implement PTD when start-ing out.
5) Wait for others to engage them in the PTD process.
saFe DesigN myths & baD DesigN hurt orgaNizatioNs
Five common myths must be dispelled and overcome to move an organization forward:
1) The design meets minimum compliance; therefore, it is safe.
2) PTD is cost-prohibitive. High-level controls are too costly.
3) PTD will slow down the proj-ect. We do not have time for design reviews and risk assessment.
4) The current/old design is safe enough. We have always done it this way. Our injury experience does not prove otherwise.
5) Low-level controls on the haz-ard-control hierarchy greatly reduce severity of harm.
Bad designs can negatively influ-ence an entire organization in the fol-lowing ways:
1) serious mishaps;2) low employee morale;3) elevated risk levels;4) human performance barriers;5) product quality issues;6) losses impacting profitability;7) poor operating efficiency;8) equipment and process reliabil-
ity issues;9) litigation;10) poor public image;11) higher labor costs;12) compliance gaps;13) waste and scrap;14) business interruption;15) customer expectations not
being fulfilled.
ProveN solutioNs: PtD culture revolutioN
Risk avoidance and hazard elimination are proven solutions for designing out causal factors. These solutions directly remove high-potential risk factors often faced by exposed groups, such as operations and maintenance personnel, con-struction workers and the public.
PTD decision makers and stake-holders are responsible for risk control, and these entities include business owners, customers, capital project delivery teams, construction managers, design/build firms, engi-neers, designers, machine builders/fabricators, operations and mainte-nance personnel and SH&E profes-sionals. Proven solutions provide a visible means to remove traditional cultural barriers in the form of false beliefs from design-for-safety efforts.
Proven solutions are myth-busters that address causal factors surround-ing catastrophic events and have these key attributes:
1) risk avoidance;2) hazard elimination;3) severity reduction;4) high level of control (control
effectiveness);5) remove barriers to safe work;6) reduce burden costs (e.g., cost-
ly retrofitting, claims, compliance programs);
7) address both normal and abnor-mal conditions;
8) widely accepted by users;9) positive impact on operating
efficiency and maintenance;10) easily incorporated into engi-
neered designs and procurement specifications.
Such solutions should be incor-porated into a project at the earliest stage of the design process as perfor-mance objectives and design criteria and can be used to provide a tangible view of what achieving acceptable risk looks like.
Proven solu-tions originate from the hierar-chy of controls. As presented in Z590.3, this approach is the preferred method of achieving acceptable risk in design through risk avoidance. Avoidance has the greatest net positive impact on safe design because it prevents hazards from entering the workplace though design. When avoidance strategies are used, no hazards need to be elim-inated or controlled.
A good risk avoidance statement begins with a “no” statement. Each no statement bears a proven solu-tion. Taking this approach may seem strange to many SH&E professionals because avoiding risk can rarely be accomplished. Most SH&E profes-sionals tend to work in the reactive or costly retrofit world and never
Proven solutions offer the rare opportunity to design out or to avoid entire hazard/exposure categories.
live in the risk avoidance mindset or workspace.
During the conceptual design stage, risk avoidance and hazard elimination allow SH&E profes-sionals to work and participate with design and project teams. Proven solutions offer the rare opportunity to design out or to avoid entire hazard/exposure categories.
Proven solutions create and shape the bond between the SH&E com-munity and engineering and design communities by allowing engineers and designers to do what they do best—incorporate risk control mea-sures into their designs and redesigns with confidence.
From 2009 to 2011, the author worked on a large capital project in China, a multimillion-dollar manu-facturing facility. He worked with the design/build firm to incorporate proven solutions into the plant design by placing each of the performance objectives into a no statement. The result of this effort came with a no-exposure outcome. Examples of no statements included:
1) No portable ladders.2) No powered forklift trucks
used in the manufacturing space.3) No elevated work.4) No energized electrical work.
5) No manual handling/lifting of manufactured products exceeding 45 lb by production employees.
6) No elevated or remote energy isolation points used for lockout/tagout/try tasks.
7) No open chemical processing and mixing systems.
8) No unsecured trailers while loading.
9) No open electrical panels to perform diagnostics or thermography.
10) No fall hazards during build-ing construction.
11) No congested or restricted workspace regarding people, equip-ment, maintenance and emergencies.
12) No direct interface between employees and powered machinery and equipment (during either normal or abnormal conditions).
Upon completion of this project, many of the 350 employees at this new facility found their new work environment to be world-class and worker-friendly.
Sustainable, proven solutions are now used on all projects based on the no statements the author estab-lished for the China project. For example:
1) Typical portable ladder tasks are designed out by
a) relocating work at ground level;
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b) work made accessible by fixed stairways/platforms;
c) establishing a proper access-way for work-lifts.
2) An automated guided vehicle system eliminates forklift operations.
3) Electrical energy isolation, arc-preventive switchgear/motor control centers and diagnostic ports are used.
4) Piping system isolation valves are used at ground level, as are gauges and filters.
5) A trailer restraint system and dock door barrier guards are used.
6) Automated product convey-ance and lifting systems are used.
7) Fully-enclosed chemical pro-cess and mixing systems are used.
8) Fall prevention, includ-ing perimeter guarding, skylight guarding and aerial lifts, is used
100% of the time during construc-tion.
9) Employees wear less PPE, not more.
10) Devices are enabled under the exclusive control of maintenance workers for approved troubleshoot-ing tasks.
11) All hazardous energy isolation points are at floor level within 3 m of need.
12) Employees are removed from directly interfacing with powered machinery and equipment using barrier guarding and automated jam-clearing systems.
PtD iNFlueNce oN exPosure & humaN PerFormaNce
The only opportunity SH&E professionals and designers have to impact severity of harm is during the avoidance and elimination stage. In some cases, substitution can also affect the severity of harm. Other levels of control can only impact likelihood, not severity.
The author highly recom-mends that SH&E professionals obtain and read ANSI B11.0-2010, Safety of Machinery: General Requirements and Risk Assessment. Table 3 in this stan-dard, the hazard control hierarchy, ©
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outlines the influence each level of control has on risk factors, such as severity and likelihood. The table indicates that the greatest influence on eliminating or reducing severity of harm is at the elimination or sub-stitution level.
Based on the author’s experi-ence, many SH&E professionals, engineers and others hold a false belief that low-level controls have a great impact on severity when they do not. Guarding and engineering controls are excellent risk control measures, but their primary purpose is to reduce likelihood, not severity. That is why control effectiveness and control maintainability are so impor-tant for sustainable protection. To prevent fatal and serious loss events, the focus on design must begin with avoidance and elimination because these highest-control levels relate directly to severity reduction.
Proven solutions also support safe behaviors and eliminate many common human error factors. SH&E leaders begin to understand the affect of PTD in their organizations when they overhear project man-agers, business leaders and others make these statements:
1) “Design the work so it is easy to do it safely and difficult to do it wrong.”
2) “Severe injuries will have a greater impact on the organization than will stopping production to improve safety.”
3) “Someone who wants to do well never underestimates a bad outcome.”
4) “Administrative and PPE con-trols will never replace appropriate safeguarding.”
5) “We could be world-class if this process were not so poorly designed to begin with.”
Proven solutions can significantly enhance human performance through avoidance and elimination of the fol-lowing human error influencers:
1) high ambient noise;2) poor ergonomics (e.g., layout,
job setup, workspace);3) PPE loading and barrier to job
completion;
4) working in high ambient tem-peratures or poor lighting;
5) responding to routine process upsets and abnormal conditions;
6) performing complex work;7) physically demanding work
that leads to fatigue;8) use of hand tools that draw a
worker close to the hazard.
ProveN solutioNs reDuce burDeN costs
A key PTD selling point often overlooked by the SH&E commu-nity and during design reviews is the long-term burden costs the organiza-tion will incur when hazards are not eliminated in the design or redesign phase. The SH&E community can identify and communicate burden costs when low-level controls are selected over one-time, high-level controls designed to avoid or elimi-nate hazards and risks.
Most SH&E professionals spend the majority of their time in the operational and postincident phase due to:
1) burdensome oversight of reg-ulatory-driven programs and claims management;
2) almost daily efforts to find scarce resources for retrofitting
uncontrolled hazards associated with design gaps.
Of special significance is the fact that burden costs, which can be extreme, must be maintained during the facility’s life expectancy.
One example of how burden cost can add up over time is using por-table ladders in a typical manufactur-ing setting. Based on the author’s experience, the burden cost for a new 500,000-sq-ft facility that has a planned lifespan of 50 years with intent to use portable ladders can run as much as $9.3 million.
As an alternative, proven solu-tions to design out the 17 defined routine ladder tasks (for 175 ladder users) in the concept stage would require a one-time capital investment of $500,000. This is a noteworthy net positive capital investment and can prevent the facility from ever having a serious portable ladder-related mishap.
Any capital project always has two monetary spends. The first spend (pay now) is the cost of the new design, and the second spend (pay later) is the long-term burden costs. Long-term burden costs often far exceed the cost of an original design solution that would have eliminated the entire hazard category.
The most commonly seen burden costs linked to a facility’s life expec-tancy are injury claim costs, com-pliance maintenance costs, retrofit costs, business interruption, operat-ing inefficiencies, resource manage-ment and manpower costs.
Many organizations continue to report falls from portable and fixed ladders, which are reflected in past and current data reported by OSHA and the Bureau of Labor Statistics. Often, falls from ladders can become life-ending or life-altering. Portable ladders also continue to appear on OSHA’s top 10 violations list.
When looking at portable ladder use, the ladder and its user are both considered lower-level controls. A safe ladder and safe ladder user do not mean low severity, which is why ladder-related fatalities continue to be a commonly reported mishap. In
The only opportunity SH&E professionals and designers have to impact severity of harm is during the
avoidance and elimination stage.
fact, portable ladder use is a high-risk task. Our focus must shift from ladder compliance programs to lad-der avoidance through design.
The author uncovered a signifi-cant risk factor when performing an in-depth review of previously unseen causal factors related to poor design. The key risk factor discovered was the impact a congested or restricted access workspace has on worker safety. As most organizations and businesses attempt to cut project costs, a common approach is to reduce floor space or the facility’s footprint. This approach generally results in less workspace and/or restricted access to equipment for maintenance activities. It forces the facility’s operations management to purchase portable ladders because no workspace or access was provided for alternative safer designs, such as stairways, personal lifts and hoisting equipment.
busiNess value & beNeFits gaiNeD From PtDA second key selling point for
PTD is the benefits derived from safe project delivery. Safe designs offer organizations many benefits. For example, the new plant built in China incorporated many proven
solutions into its design and saw these additional benefits:
1) Project came in $10 million under budget.
2) Reduced energy consumption.3) Zero waste to landfill and
overall net positive impact on the environment.
4) Plant sold out of its product line and achieved full production capacity ahead of plan.
5) High worker morale.6) Operating efficiency targets
achieved well ahead of plan.7) Fifty innovative proven solu-
tions incorporated into design (many hazard categories avoided or elimi-nated).
8) Plant design and all job tasks achieved an acceptable risk rating.
9) No reported serious mishaps or near-miss events since plant startup in 2011.
10) CEO and business leadership-level recognition given to the design team and project champion.
The China project team is proud of the new facility, the project team-work displayed and the outcome achieved. Proven solutions that avoid risk and eliminate hazards in design must be our legacy, not programs and firefighting. Knowing that 350 employees of a new facility can go
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home to their families at the end of each workday injury- and illness-free is the true reward.
As SH&E professionals, walking into a new facility or operation dur-ing a ribbon-cutting event with the customer and other leaders and pro-fessionals reinforces the long-term impact our efforts have on those who will be working with the new design for years to come. SH&E profession-als can showcase their overall value to organizations by designing to acceptable risk through sustainable high-level controls.
builDiNg a ProveN solutioNs library
PTD is a culmination of proven solutions (safe designs) to avoid risk and to eliminate hazards in new designs/redesigns. When the SH&E community works in partner-ship with engineers and designers over the next decade to incorporate proven solutions into designs, the net positive results will be the prevention of life-ending and life-altering mis-haps globally. Establishing proven solutions is critical work that places SH&E professionals in the preopera-tional stage of risk management.
Many resources are available to help SH&E professionals develop a
proven solutions library. These include:
1) internal organiza-tional data analysis related to design;
2) NIOSH; 3) ASSE’s Body of
Knowledge;4) ANSI/ASSE
Z590.3-2011; 5) ASSE Risk
Assessment Institute; 6) Design for
Construction Safety; 7) Construction
Industry Institute; 8) ASSE’s PtD
Symposium; 9) OSHA;10) lessons learned
from completed design projects; ©
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11) engineering and design com-munity;
12) vendors and suppliers;13) hourly workers;14) benchmarking;15. Safety in Design.
PtD actioN stePs For sh&e ProFessioNals
The SH&E community should take these actions to drive a cultural revolution around PTD. The rewards and benefits will be many, but the most noteworthy outcome will be the prevention of life-ending and life-altering mishaps. SH&E profession-als should follow these steps:
1) Create a design safety checklist from organizational incident data linked to design gaps.
2) Establish a personal goal to spend more time in the preop-erational stage of occupational risk management.
3) Develop a critical skill set around PTD and risk assessment.
4) Apply a high level of control decision making in the design pro-cess with special focus on severity reduction.
5) Develop and use a proven solu-tions library that achieves risk avoid-ance or hazard elimination in design.
6) Identify and share long-term burden costs related to poor design
decision making with leaders and design teams.
7) Work to dispel common PTD myths.
8) Eliminate barriers to safe work through design.
9) Capture and communicate the benefits of safe design.
10) Make your legacy one that leaves a lasting net positive impact on the organization.
coNclusioN
Incorporating proven solutions into design is critical to the preven-tion of life-ending and life-altering mishaps. Proven solutions have global application and bring demon-strated value on many fronts when such an approach is adapted as part of an organization’s PTD culture and process.
The pace of injury/illness preven-tion improvement during one’s life-time is directly linked to the speed of change led and driven by the SH&E profession. Risk assessment and PTD must be at the forefront of these efforts. The SH&E community has the responsibility, creativity and power to support injury-free lives around the world. •
reFereNces
ANSI. (2010). Safety of machin-ery: General requirements and risk
assessment (B11.0). Houston, TX: B11 Standards Inc.
ANSI/ASSE. (2011). Prevention through design: Guidelines for addressing occupational hazards and risks in design and redesign process-es (Z590.3). Des Plaines, IL: ASSE.
ANSI/ASSE/AIHA. (2012). Occupational health and safety man-agement systems (Z10). Des Plaines, IL: ASSE.David Walline, CSP, is a global safety leader for Owens Corning in Toledo, OH. Walline is a 35-year professional member of ASSE. Prevention through design (PTD), fatal and serious injury prevention and risk assessment have been his primary career focus. He has developed and implemented global risk assessment, PTD processes and training programs within organizations and also influenced the design and risk mitigation levels of projects worldwide. In June 2012, Walline received the CSP Award of Excellence from the Board of Certified Safety Professionals. He was a contributor to and served on the review committee for ANSI/ASSE Z590.3-2011, Prevention Through Design: Guidelines for Addressing Occupational Hazards and Risks in Design and Redesign Processes. He is chair of ASSE’s Risk Assessment Committee, which manages ASSE’s Risk Assessment Institute. He also served on the planning committee for and presented at ASSE’s PTD Virtual Symposium in February 2013.
Reprinted with permission from the pro-ceedings of ASSE’s 2013 Fatality & Severe Loss Prevention Symposium.
Safety 2014 Chapter Night Out
Are you attending Safety 2014 in Orlando, FL? Don’t miss the Chapter Night Out on Tuesday, June 10 (7
p.m. to 11 p.m.) at WonderWorks. Sponsored by ASSe’s Central Florida Chapter, the event is a great way to meet other ASSe members and enjoy an entertaining evening as you explore exhibits throughout the upside down building that houses the indoor amusement park for the mind. The registration fee (adult $75; child, ages 4 to 12, $49.50) includes dinner buffet, dessert, unlimited soft drinks and the entire facility reserved exclusively for ASSe.
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Fall hazards present two conflicting realities: sig-nificant fall incidents do not happen often, but when they do occur, they are catastrophic and costly. Just like most people did not think black swans existed, most organizations do not think
they will ever have a fall fatality at their facility. In this way, fall fatalities can be viewed as black swan events. A black swan event is defined as one that meets the fol-lowing criteria:
•Rarity: Low probability of occurring.•Extreme impact: Consequences are significant or
catastrophic.•Retrospective predictability: In looking back, they
can be easily explained or predicted.The rarity of incidents can lull both management and
workers into a false sense of security. But, managing the major risks presented by falls is a smart and ethical busi-ness investment—in addition to a legal requirement.
Although regulatory agencies and standards commit-tees highlight the value of fall hazard surveys or risk assessments as a critical step in a successful fall protec-tion program, many organizations around the world do not address fall hazards or do so haphazardly. Many still devote money, time and resources toward the first fall hazard brought to their attention, while ignoring high-risk items.
To avoid a black swan fall fatality, fall hazard risk must be systematically managed. Properly identifying and evaluating fall hazards can help one more intelligently prioritize projects—with risk and other factors considered. A clear picture of the hazards can help one best decide how to address them based on level of risk, priorities and budget—not on a first-come, first-served basis.
iDeNtiFyiNg risk
A fall protection pro-gram’s ultimate goal is to create a safer environment for workers. However, until all hazards are identified, it is difficult to develop an effec-tive strategy to reduce risk.
Fall hazards can be clas-sified into three main cat-egories:
1) Means of access. This is the manner of moving from one level to another. Examples include noncom-pliant ramps, runways and
18ByDesign www.asse.org 2014
walkways; fixed stairs; fixed or portable ladders; and personnel lifts.
2) Locations. These are specific areas of immediate exposure to a fall hazard. Examples include unprotected sides, leading edges, elevated walkways, excavations, floor and wall openings, elevated conveyors, scaffolding, lights, overhead mechanical and electrical runs, roofs, pipe racks and tanks.
3) Tasks. These are actions that workers perform that expose them to a potential fall hazard, such as removing a guardrail when hoisting material up to a mezzanine. These hazards typically fall within three general catego-ries: construction, production and maintenance.
When identifying risk, it is also important to consider hidden hazards or hazards that are not always easy to recognize. Examples of hidden hazards include:
•guardrail size, height, spacing and strength require-ments;
•roof edges;•swing gates on ladders;•access ladders or stairs between levels;•smoke/heat relief vents;•skylights;•paint booths;•false ceilings;•newly installed fall protection systems that may
prove inadequate.
iDeNtiFicatioN methoDs
It is infeasible to identify every hazard within a large facility or complex, but it is important to identify as many hazards as possible so that the fall hazards can be thoroughly evaluated. The four main methods of identi-fication are:
1) suggestion programs;2) use of statistics;3) facility walkthrough;4) wall-to-wall facility survey.
suggestioN Programs
Suggestion programs are the most cost-effective method used to identify fall hazards. They identify areas of particular interest through worker participation. These interest areas typically contain job tasks that workers feel uncomfortable performing because they know they are at risk of a fall.
This method also allows a large group of workers to participate in the process. Although not trained in the identification of fall hazards, many workers know which frequently accessed areas are hazardous. An organiza-tion’s employees are often a wealth of information about continuous improvement.
Fall hazards By Thomas Kramer, p.e., csp
Do Not Be Fooled by Falls
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A downside of the suggestion program method is that it is the least comprehensive. The method will identify some, but definitely not all, fall hazards. Often, it takes the skills of an experienced competent person in fall pro-tection to identify hazards that the suggestion program method misses.
statistics
A thorough review of statistics can help identify specific fall hazard exposures. The statistics are based on incidents that have resulted in citations, injuries and fatalities. Organizations can learn from these statistics and can apply them to similar situations.
For example, statistics show that roof fall hazards account for approximately 20% of all fall fatalities. Therefore, one action item may be to identify roof fall hazard exposures. While this is beneficial, using the sta-tistics method leaves out other hazards that do not fall into high-profile categories.
Bureau of Labor Statistics provides much information relative to surfaces on which fall hazards occur. Also, NIOSH collects information and creates reports on cer-tain occupational fatalities so the public can better under-stand how the incident occurred, learn from the mistake and share with others. NIOSH publishes these FACE reports on its website.
Facility Walkthrough
The facility walkthrough method is more facility-spe-cific than the suggestion or statistics methods. However,
this method is still not a complete comprehensive fall hazard survey.
During a facility walkthrough, a competent or quali-fied person is brought in to serve as an objective set of eyes. The objective is to identify typical hazards—not every hazard. This individual also prioritizes typical hazards from a risk standpoint and estimates abatement methods and costs. This method allows the organization to estimate the order of the magnitude cost for a facility.
Remember that because only typical hazards are iden-tified, the number of hazards and the cost for abatement are only an estimate of the order of the magnitude.
Wall-to-Wall Facility survey
The wall-to-wall, or in some cases, an inside-the-fence facility survey is the most comprehensive method to identify hazards.
This method requires competent or qualified persons with significant industry and fall hazard survey experi-ence. Again, the competent or qualified persons’ goal is to objectively identify as many hazards as possible.
Due to the vast amount of information collected, this method requires an experienced team and preplanning so that data can be collected and managed efficiently. Once data are collected, identified hazards must be ranked and prioritized before an abatement plan can be implemented to address the hazards.
With the goal of identifying as many hazards as possi-ble, this method goes beyond a typical survey. The wall-to-wall facility survey is therefore the method of choice.
Table 1 Typical Risk Assessment Code Chart
risk assessmeNt & raNkiNg
A wall-to-wall facility survey or risk assessment focuses on the highest risk. The more efficiently risk is reduced, the better. So, rather than devoting resources to the most obvious hazards, organizations can use the risk assessment process to systematically identify, evaluate and control fall hazards. By directing the budget to the highest-risk items, organizations can then achieve maxi-mum risk reduction for the invest-ment made.
During a comprehensive fall hazard risk assessment, detailed data are gathered on fall hazards. The data are analyzed to determine the probability and severity each hazard presents. In terms of probability, various factors must be considered:
frequency of task, exposure time, number of workers exposed and likelihood of falls based on external influ-ences. Severity is measured by determining fall distance and likely obstructions impacted during a fall.
Many times, risk assessments are conducted using a simple risk matrix (Table 1, p. 19). However, especially for locations with hundreds or thousands of hazards, the information gained from such an assessment is not granular enough to be effective in long-term planning. Often, dozens of hazards will fall into one category, giv-ing the program manager no indication of which hazards to abate first.
When conducting a more granular risk assessment, the resulting data are organized into a prioritized list of
hazards. This list can be organized by location, main-tenance task and type of solution proposed—or in any other way that helps the organization manage abate-ments. Once fall hazards and the potential risks associ-ated with them are identified, evaluated and ranked, leadership can use the information to create a validated budget, schedule and abatement strategy.
Since organizations may not be able to address every hazard, the prioritized list provides guidance on what, when and how to abate hazards. This risk assessment method transforms an overwhelming list of hazards into a manageable plan with a beginning and end point. Program managers can use this information to report metrics on the amount of risk reduced for a given investment.
coNclusioN
Falls are a misunderstood safety issue. The reality is that falls can and do cause fatalities and catastrophic losses. Conducting a risk assessment specific to falls can significantly reduce risk to the workforce and orga-nization. •Thomas Kramer, P.E., CSP, is principal at LJB Inc. in Miamisburg, OH. A safety consultant and structural engineer with 18 years’ experience, Kramer specializes in the assessment and design of fall protection systems. He is a member of the ANSI/ASSE Z359 Accredited Standards Committee for Fall Protection and chairs two subcommittees that develop standards for the design of active fall protection systems (Z359.6 and Z359.17). He also serves as president of the International Society for Fall Protection. Kramer holds bachelor’s and master’s degrees in Civil Engineering, as well as an M.B.A. He frequently speaks on fall protection at international, national and regional conferences.
Reprinted with permission from the proceedings of ASSE’s 2013 Fatality & Severe Loss Prevention Symposium.
20ByDesign www.asse.org 2014
Once fall hazards and the potential
risks associated with them are
identified, evaluated and ranked,
leadership can use the information to create a validated budget, schedule
and abatement strategy.
Manufacturing Practice SpecialtyThe Manufacturing Practice Specialty (MPS) began as a branch of the Management
Practice Specialty in 2006 and became a practice specialty in 2008. MPS’s goal is to provide a forum for industryspecific issues in manufacturing facilities, such as metalworking, timber and lumber working, food processing, chemical, rubber, plastics and printing/publishing locations.
In addition to publishing its triannual technical publication Safely Made, MPS helps develop technical sessions for ASSe’s annual Professional Development Conference, regularly sponsors webinars on timely manufacturingrelated topics, holds conference calls and much more.
Click here to join MPS today or click here to follow MPS on LinkedIn.
risk assessMent
In September 2013, LJB Inc. presented Understanding Risk Assessment & Ranking, a webinar
on how best to identify fall hazards and prioritize preventive actions. Speaker Thom Kramer, P.E., CSP, the managing principal at LJB Inc. and chair of ASSE’s Professional Development Conference planning committee, explained that to abate fall hazards, safety professionals need to both evaluate their current methods of risk assessment and iden-tify the top ten risks found in their facilities.
According to Kramer, many fall hazards go undetected because workers may believe that a lack of incidents indicates that no risks are present. He warns that some safety initiatives, such as use of PPE and safer equipment, may lead workers to take more risks because they per-ceive their workplace as being safer than it really is.
To effectively assess risks, safety professionals must seek to identify all risks rather than focus on a few categories of risk. For example, while hazards associated with edge distance and slippery conditions are most often taken into consideration, some person-nel may overlook more unusual hazards, such as a loose bolt holding a ladder in place on a structure.
Once all hazards have been identified, lists of those hazards must be kept for use in pri-oritizing concerns and in alert-ing workers to risks they may encounter. Kramer says that just like a grocery list, a list of haz-
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funds available for risk reduction strategies. Kramer stresses the need to identify all risks before mitigating according to a budget because com-panies run the risk of spending all of their available funds on the first risk they find, which may not be the most critical hazard to address. •Bethany Harvey is a communications and design assistant for ASSE and part of the editorial staff for Professional Safety. She holds a B.A. in Interdisciplinary Communications Mass Media from Elmhurst College.
ards is necessary for remembering what the hazards are, where they are located and how quickly they need to be mitigated. He suggests using a risk matrix (Figure 1) to help deter-mine which hazards require immedi-ate attention. Such a matrix measures the severity of the potential incident against the probability that workers will be exposed to the hazard and can be used for assigning a numeri-cal ranking to every hazard. For example, a hazard to which workers have probable exposure would result in a total temporary disability (TTD) and would receive a ranking of 2, meaning that it requires immediate attention but is not as urgent as a hazard that receives a ranking of 1.
Simple risk matrixes have some limitations in their accuracy, so it is important to also calculate the maximum risk reduction possible in respect to the hazards identified and
Fall Hazard Risk Assessment & Ranking
By BeThany harvey
Figure 1 Simple Risk Matrix
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The Engineering Practice Specialty is reinforcing the concepts discussed in ANSI/ASSE Z590.3-2011, Prevention through Design (PtD): Guidelines for Addressing Occupational
Hazards and Risks in Design and Redesign Processes, through various forums available within ASSE to increase visibility and focus on PTD.
This article attempts to raise some questions regard-ing the relationship between what is referred to as inherently safe design (ISD) and the unpredictability of human behavior. By definition, inherently safe implies that the anticipation and quantifiable predictability of human response to workplace environments is integral to ISD. Theoretically, that is the basis and intent for ISD principles. ISD provides concepts to assist engineers and safety professionals in establishing and implementing design processes in anticipation of human error.
challeNges
In a perfect world with an unlimited budget and 100% predictability in workplace scenarios/environments, ISD’s goal would be the norm rather than the excep-tion. History, education and technology have provided a sound foundation for improving designs to accom-modate potential failures and human exposure to injuries or fatalities. Four challenges that prohibit the execution and integration of ISD into management systems and processes are perceived cost, lack of management accep-tance, limited competency and understanding of the con-cepts, and perceived time/schedule constraints.
Inherent to all four of these challenges is human factors or “the scientific discipline concerned with the understanding of interactions between humans and other elements of a system and the profession that applies the-ory, principles, data and methods to design to optimize human well-being and overall system performance” (International Ergonomic Association, 2000).
The unpredictability and multitude of influences that affect human behavior and, ultimately, human factors, can seem overwhelming. It is important to recognize the potential risk and exposure to a workplace that does not integrate human factors into management systems and design/process controls.
22ByDesign www.asse.org 2014
Various causes and influences related to human fac-tors are inherent to minor and major incidents, and they surface in almost every incident and near-miss. How many times have we documented incident causation fac-tors to include operator inattention, misunderstanding or violation of a procedure, inadequate design specific to operating conditions and operator response, fatigue, ergonomics and the operator’s capability to respond? These causal factors represent only a fraction of contrib-uting causes specific to human factors in incidents.
case stuDy
In the U.S., the highest percentage of accidental loss of life is attributed to the operation of a motor vehicle, and a major contributor to these incidents is driver inattention. For motor vehicle incidents, human factor influences are relatively obvious; however, for some industrial incidents, they may not be as obvious.
Early in his career, the author investigated an explo-sion and total loss of a hot oil heater on an offshore plat-form. The platform and associated process facilities were recently constructed, and the platform was preparing for start-up and introduction of crude oil for phase separa-tion into oil, gas and water. The separated oil and gas were then to be introduced into pipelines for delivery to onshore facilities and marketing. The water was recycled back into the reservoir.
To facilitate separation, crude oil from the reservoir needed to be heated. The expected volume of crude oil was estimated to be 50,000 barrels per day for this plat-form, and the size and capacity of the hot oil heater (the design included two heaters for platform operation at 100% capacity) was relatively large to ensure the appro-priate design for that volume of fluid.
As the steps for platform start-up were initiated, it was necessary to ignite the pilot flames for the hot oil heaters. The pilots were maintained by ignited gas, and their operating controls ensured the appropriate ignitable concentration of natural gas and oxygen prior to igni-tion. The operator responsible for the hot oil heaters was unable to initiate ignition of the pilots, and start-up was delayed. The design of this heater was relatively new, and it was determined that it was necessary to consult with an expert who needed to be summoned immedi-
huMan Factors By Don ensloW, csp
How Do Human Factors Influence Inherently Safe Design?
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23ByDesign www.asse.org 2014
ately and delivered to the platform via helicopter. This created a 2-day delay in the logistics of organizing this visit. Anxiety and tension within the operation were heightened, and the expectation for immediate results from this expert was the critical path for start-up and product delivery.
Upon arrival of the heater expert and an evaluation of the pilot ignition controls, it was determined that the flame safety controls for the pilot system were inhibiting the ignition system’s ability to work. The recommenda-tion was to defeat the pilot flame safety system and, when it was thought to be appropriate (based on opera-tor observation), manually initiate the igniter. Under the expert’s observation, the recommended steps were fol-lowed, which ignited a gas volume that exploded and blew the back of the heater vessel several hundred feet into the sea. Although the explo-sion’s magnitude was significant, no one was injured.
At the time of the investigation, the root cause was determined to be design failure of pilot ignition control system. It was not inherently obvious to the responsible parties, nor was it inherent to the incident investigation process at the time, to consider human factors as contribut-ing factors to the incident. Looking back at that incident more than 35 years later, it is apparent that human factors were indeed a major contrib-uting factor.
Human factors influenced the management systems, decisions and behaviors that resulted in the undesired outcome. Human factors were also involved in decisions and acceptance during operation design for the hot oil heaters. From design to construction to start-up, human factors played an influencing role in this incident. How many times can incidents be attributed to human factors? How does ISD play a role in the reduction of potential risk of human factor failures?
The four challenges identified earlier in this article were apparent in the hot oil heater incident. Perceived cost was a critical factor in the decision-making process to defeat the pilot ignition controls. At the time of the inci-dent, oil prices were significantly lower than today and the world economy was struggling. The start-up of this platform was paramount to corporate financial well-being. To the credit of the responsible platform operator, opera-tions were shut down and start-up was delayed until a second opinion was obtained. However, criteria for inde-pendent review focused on start-up, not on safe start-up.
At the time of this incident, corporate culture and expectations within management were based on financial
survival. Delaying start-up meant substantial financial and reputational risk. The platform’s geographical loca-tion was susceptible to dramatic changes in weather and sea conditions that could delay start-up significantly if identified personnel were unable to travel to the platform to evaluate the issue. The expert’s technical competence, experience and resume were good relative to his knowl-edge of control systems and this particular model of hot oil heater. This individual also understood his assign-ment to be to provide an immediate fix to the problem. The critical need was apparent, and if he could provide a quick solution, he would be a hero. Existing manage-ment systems and deviation processes from established design control systems were not in place to prohibit
behavior that exceeded rational lim-its and increased risk.
In reflecting on this incident, the author can recall many situations he had been involved with or partici-pated in as an investigator in which human factors influenced a system or process that was designed to elimi-nate potentially catastrophic events. The most effective ISD is one that will not allow a system to operate under at-risk operating parameters after discovering that someone has bypassed that control to allow the system to continue operating.
suggestioNs
To better integrate human factors into the ISD process, it is important to recognize how human behav-ior can influence all aspects of the operation throughout the facility’s
life cycle. A best practice is to initiate a process within management systems to continually evaluate safety systems including engineering and behavior-based pro-cesses. Management support is integral to this process’s effectiveness, and it is important to base measurement and performance on key metrics. The term management systems is an all-encompassing platitude that can lose perspective in the day-to-day priorities of a workplace. Management systems can also overwhelm an organiza-tion when attempting to integrate assurance processes from early design all the way through to final production.
According to the late Trevor Kletz, a chemical process safety expert, “Some people have forgotten the limita-tions of management systems. All that a system can do is harness the knowledge and experience of people. Knowledge and experience without a system will achieve less than their full potential. Without knowledge and experience, even the best system will achieve nothing.”
Experience has proven that integration of sound man-agement systems that reinforce recognition of human
To better integrate human factors into the inherently safe
design process, there must be
recognition of how human behavior can influence all aspects
of the operation throughout the
facility’s lifecycle.
factors, as well as an appreciation for their influence in sustained safe operations, will provide economic suc-cess. The fundamentals are fairly simple; the sustained implementation and reinforcement of these practices and principles can be challenging. As always, it begins at the top. Management must establish the basis for safe opera-tions and focus on continuous improvement. Managers must also have systems in place to measure performance and to correct deviations when required. A key to the successful endorsement of top management relies on their understanding and appreciation of these concepts. If the corporate standard is driven by key management systems and principles, managers will absorb and proac-tively reinforce the standard.
What do good management systems look like? It is difficult to provide a one-size-fits-all template with the variety of processes and business applications that abound in the work environment; however, some funda-mental components must be universally addressed.
There must be a corporate code of operations that reinforces established safety standards and systems. The established standards and systems, at a minimum, must meet regulatory requirements and must integrate lessons learned specific to internal operations. Within that code of operations, ISD must be integrated into all design applications, whether for new facility start-up or facility renovation, including maintenance turnarounds.
An additional component for success is employee involvement. Employees must be competent to provide the service for which they are hired but also must engage
and embrace the established corporate standards. It is imperative that they participate in design reviews, hazard analyses, prejob safety assessments and development of standard operating procedures as well as understand management of change principles and standards.
If the fundamentals of management and employee participation exist within an operation, performance must be continually measured and performance measurement standards that provide assurance for sustained operation must be integrated. Critical components of performance metrics must include measures and critical components to provide assurance that management systems function properly and that potential hazards are recognized and addressed. Employee recognition for promptly address-ing risks is fundamental to sustaining this effort.
Metrics also include continued monitoring of near-miss events and incidents. A critical component of incident management is a sound incident investigation system that includes employee involvement and recog-nizes incident investigation techniques that focus on root cause processes and on all contributing factors, including human factors. If the investigation process uses a root cause identification process, human factors should be integral to this system. As a result of the investigation and findings, it is imperative that management reinforces the corrective actions and addresses any fundamental system errors that must be changed or calibrated. These fundamental errors may include proposed changes in the design process and evaluation of process safety controls that were thought to be inherently safe. • Don Enslow, CSP, is the process safety management team lead at BP Exploration Alaska. He has more than 35 years’ experience as a safety professional in the oil exploration and production and nuclear power industries. He is a principal member of the NFPA Technical Committee on Gaseous Fire Extinguishing Systems (GFE-AAA), NFPA 12, NFPA 12A and NFPA 2001.
24ByDesign www.asse.org 2014
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angle). The study further found that a subset of total injuries and exposures is disproportionately responsible for serious injuries and fatalities.
PitFalls oF iNaDequate PerFormaNce measuremeNt
To assess the comprehensive effectiveness of their safety manage-ment capability, many organizations have relied primarily on lagging indicators, such as recordable injury rates. The attractiveness of metrics, such as these, is understandable. They are relatively easy to collect, classify and understand, and in many cases, governing bodies mandate the reporting of these metrics. However, this disproportionate focus and over-reliance can mask many serious safety issues that lie below the sur-face of awareness generated by these indicators.
Over the past several years, numerous catastrophic workplace incidents have occurred (e.g., BP Texas City, Qinghe Special Steel Corp., Upper Big Branch Mine and Deepwater Horizon) that clearly illustrate this problem. In virtually every case, the catastrophic incident was preceded by extended peri-ods of low, very low or improving recordable injury rates. Prior to these incidents, asking the executives of these organizations, “How are you doing in safety?” would have likely generated a response of “We are doing great. Our injury rates have never been lower.” But clearly, seri-ous safety issues persisted outside of their view.
To manage SIFs more effectively, it is important for organizations to measure more than just the incident frequency and severity. They must effectively measure their exposure to
For decades, the safety com-munity has adopted conven-tional wisdom, which holds that a reduction in the inci-dence of minor injuries will
bring about a proportional reduction in the incidence of serious injuries and fatalities (SIFs). This thinking emanates from H.W. Heinrich’s Safety Triangle, a visual construct of Heinrich’s Law, which has informed this paradigm (Figure 1) suggesting that organizations should address minor injuries (and near-misses) as a means of reducing serious injuries and fatalities.
Despite the longevity and perva-siveness of this paradigm, the real-ity that has played out in numerous organizations contradicts many of
26ByDesign www.asse.org 2014
the basic relationships the paradigm espouses. Over the past several years, many organizations have experienced a consistent decline in their occupational injury rates while concurrently experiencing level or even increasing numbers of fatalities and serious injuries.
This pattern has been seen at the site, organizational and national lev-els and raises important implications and questions about how SIF preven-tion is approached and the validity of this long-held model.
Fundamentally, the traditional model claims two basic relationships:
1) Descriptive. An inverse relationship exists between the fre-quency of an injury and the severity of an injury.
2) Predictive. Reductions in less serious injuries will produce proportionate reductions in more serious injuries.
In examining these issues, a comprehen-sive set of data from seven large organiza-tions was studied. The findings of this study showed that while the Heinrich triangle is indeed accurate descriptively (there is a higher incidence of minor injuries than serious injuries), it is not accurate predictively (reducing minor injuries at the base of the triangle does not produce proportional reductions throughout the rest of the tri-
saFety ManageMent By scoTT sTricoff
Targeted Metrics for Managing Fatalities & Serious Injuries
Figure 1 The Traditional Paradigm
27ByDesign www.asse.org 2014
the types of incidents that can pro-duce SIFs. This marks a critical shift in focus from lagging indicators to leading indicators for a more proac-tive approach to preventing SIFs.
More specifically, this approach requires establishing methods of classifying exposures and incidents to create a new metric—potential SIFs. By tracking potential SIFs in addition to the traditional measures discussed, an organization can gen-erate a much clearer picture of its progress. Further, sound evaluation of the exposures that contribute to potential SIFs allows for tailored mitigation programs that focus squarely on those areas of concern.
measuriNg & classiFyiNg PoteNtial
All exposures are not equal when it comes to their potential to gener-ate SIF events. Data analyzed in the aforementioned study that examined the validity of Heinrich’s Triangle found that only 21% of the injuries classified as minor had the potential to produce an SIF outcome. That is not to say that the other 79% of inju-ries are not important but rather that these incidents require a different prevention strategy.
To further illustrate this point, consider the following two incidents, both of which produce an identical injury:
Incident 1: A worker steps off the bottom step of an outside stairwell onto the ground’s gravel surface. In carrying out this action, he loses trac-tion and sprains his ankle.
Incident 2: A worker steps up from the top step of an outside stair-well onto a roof’s gravel surface. As he shifts his weight to the foot in contact with the gravel surface, he loses traction and sprains his ankle.
In this case, the most obvious variable that influences potential is where the event occurred. Because the second incident occurred at significant height, the worker could have fallen down the stairs or even off of the roof surface if proper con-trols were not in place. Because the
first incident essentially occurred on the ground, an extended fall would not be a possible outcome.
Although these two incidents pro-duced the same injury outcome, the second incident has a higher poten-tial to produce an SIF event, whereas the first incident is not likely to pro-duce anything significantly beyond the relatively minor injury that occurred. Yet in many organizations, these incidents would be identically classified because of the misplaced focus on outcome and lack of atten-tion to potential.
By evaluating and tracking mea-sures such as the quantity, frequency and percentage of injury and near-miss events occurring inside the organization that have the potential for SIFs, a better sense is gained of the likelihood that a serious, fatal or catastrophic event will occur.
imPortaNce oF Precursors
Precursor events are defined as high-risk situations in which man-agement controls are absent, inef-fective or not complied with and which will result in a serious injury or fatality if allowed to continue. Precursors can be identified through proper evaluation of incidents like the ones discussed by studying data on exposure and via careful analysis of injury reports, near-misses, safety observations and audit findings.
Creating an SIF precursor metric requires having a method for iden-
tifying those incidents that are SIF precursors. Three general methods have been employed:
•Outcome-based. Using the result as a basis for classification. Although easy to implement, this does not identify SIF precursors accurately, as the previous discussion illustrates.
•Judgment-based. Using profes-sional judgment to assess whether the event could have resulted in an SIF. With this approach, it is virtu-ally impossible to achieve consistent classification as different raters will assess potential differently based on their personal judgment about prob-ability and outcome.
•Event-based. Using character-istics of the event to identify those with SIF potential. This approach risks missing some SIF precursors but can capture most with consistent screening that can be done at the local level.
When using the event-based approach, particular activities more naturally lend themselves to produc-ing higher proportions of precursor events. Examples of these activities include:
•operation of mobile equipment and interaction with pedestrians;
•entering confined spaces;•performing jobs that require
lockout/tagout;•operations that entail suspended
loads;•working at height.Beginning with a generic SIF
classification decision tree, an orga-nization can perform a one-time customization. A small group applies the generic decision tree to the organization’s incident experience (injuries, near-misses and process safety events). After identifying most events that are defined by the generic tool as SIF precursors and nonprec-ursors, a group of unclassified events will remain. The small group then conducts a one-time judgment-based assessment of the unclassified events and from those selected as precur-sors modifies the generic decision tree to create a tree customized to the organization’s exposures. That
To manage SIFs more effectively, it is important for organizations to
measure more than just the frequency
and severity of accidents.
customized decision tree can then be used throughout the organization to drive event-based classification of all incidents, providing a SIF precursor metric.
coNclusioN
While many organizations have some awareness of exposures, near-misses and minor injuries that have high potential, few possess the con-sistent reporting, measurement and tracking visibility needed to address these precursors in sustainable ways. A reliable, effective system to cap-ture, report and address precursors minimizes the elevation of trivial events. While all incidents should be reported and accompanied by some level of investigation, the SIF potential of events must be carefully considered to inform the depth and scope of investigations.
The system to address precursors also dispels beliefs that an SIF is just a fluke or unpreventable event. With sound precursor data, leaders who have said, “We do not know where to start” or “We do not know where these events are stemming from,” will be empowered with information that answers these commonplace concerns by showing them a subset of events on which they need to focus.
In addition, the system low-ers serious injury rates. Having a sharpened focus on events with SIF potential means that resources, which previously had been largely wasted in addressing trivial events, can instead be allocated to reduce expo-sures to SIFs.
The information outlined in this article suggests that significant flaws exist in the way many organizations
28ByDesign www.asse.org 2014
think about and address serious inju-ries and fatalities. Further, it suggests that a new metric must be developed for SIF precursors. What gets mea-sured gets managed, so developing and implementing an SIF precursor metric is a key step toward under-standing how to better focus various safety interventions toward reducing the frequency of the most serious events. •Scott Stricoff is president of Behavioral Science Technology Inc. in Ojai, CA.
Reprinted with permission from the proceedings of ASSE’s 2011 Prove It! Measuring Safety Performance Symposium.
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