hazards factors

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University of California Risk Summit 2011

Integrating Safety into Operations

A Systems-Thinking Approach

Janette

de

la

Rosa

Ducut,

Ed.D.

Summary

A systems-thinking approach to safety allows consideration of more complex relationships between safety-related events. This

approach provides a way to look more deeply at why accidents occurred. A system can consist of the interaction between people

(man), their machines (equipment), and the environment. The environment is where conditions for unsafe acts, unsafe supervision, and

organizational influences on safety can be discovered. Knowing one part of a system enables us to know something about another part

Using systems theory encourages us to adopt a systems perspective (avoid linear, unidirectional, causation) and focus on

interrelationships and processes that produce change (avoid cause-and-effect chains).

The 1986 Space Shuttle Challenger accident and University ergonomic injuries provide specific examples of the consequencesresulting from systemic breakdown. You can integrate safety into operations through the identification and prevention of overall

structures, patterns, and cycles that contribute to injuries and death. This presentation provides an overview of accident investigation

and organizational characteristics; that highlight the powerful role that structure takes in driving (safety) behavior.

For more information

View the course materials used for this presentation online at http://ehs.ucr.edu/safety/systems



Accident Investigation

The Swiss Cheese model by James Reason

The Swiss Cheese Model of Accident Causation suggests that systemic failures, or accidents, occur from a series of events at different

layers of an organization. A system is similar to slices of Swiss cheese. There are holes which represent opportunities for failure, and

each slice is a layer of the system. When holes in the layers line up, a loss (or accident) occurs. Each layer of the system is anopportunity to stop an error; the more layers, the less likely an accident is to occur. The major layers of a system are: Unsafe acts,

Conditions (for unsafe acts), unsafe Supervision, and influences of an Organization. Below are selected examples of each layer

(NOTE: This is not a complete listing).

Errors ViolationsDecision

Improper procedure

Misdiagnosed issue

Wrong response Exceeded ability

Inappropriate act

Poor decision

Skill-based

Failed to prioritize

Inadvertent use of

equipment Omitted step in procedure

Ignored checklist item

Poor technique

Overcontrolled the situation

Perceptual Misjudged

Spatial disorientation

Visual illusion

Failed to adhere to brief

Failed to use equipment

Violated training rules

Used an unauthorizedapproach

Used an overaggressivemaneuver

Failed to properly prepare

Not current / qualified for task

Intentionally exceeded limitsof the equipment

Unauthorized actions

Unsafe Acts of people can be loosely classified into two categories: errors and violations (Reason, 1990). Errors generally represent

the mental or physical activities of individuals that fail to achieve their intended outcome. Decision errors represent intentional

behavior that proceed as intended, yet the plan proves inadequate or inappropriate for the situation. Skill-based errors occur when people operate without significant conscious thought. Perceptual errors occur when one’s perception of the world differs from reality;

typically when sensory input is degraded. Violations, on the other hand, refer to the willful disregard for the rules and regulations that

govern the safety of work. They can be habitual by nature, as well as atypical actions.



Substandard

Conditions

Substandard

PracticesAdverse Mentality

Channelized attention

Complacency

Distraction

Mental fatigue

Get-home-it is

Haste Loss of situational

awareness

Misplaced motivation

Task saturation

Adverse Physiology

Medical illness

Physiological incapacitation

or impairment

Physical fatigue

Physical/Mental limitations

Insufficient reaction time

Visual limitation

Incompatible

intelligence/aptitude

Physical inability

Human Resource Management

Failed to back-up

Failed to communicate /

coordinate

Failed to conduct adequate

brief

Failed to use all availableresources

Failure of leadership

Misinterpretation of

information

Personal Readiness

Excessive physical training

Self-medicating

Not rested (tired)

Conditions for unsafe acts of people can be categorized into two categories: substandard conditions people, and substandard practices

of people. Substandard conditions of people involve adverse mentality or mental states (stressors and personality traits), adverse

physiology (conditions, such as illness, that preclude safe work), and physical / mental limitations (when work requirements exceed

the basic sensory capabilities of people at the) . Substandard practice of people, on the other hand, refer to human resource

management (poor coordination among employees), and personal readiness (when people are not at optimal levels when they show upfor work).

Supervised

Inadequately

Planned

Inappropriate

Operations Failed to provide guidance

Failed to provide oversight

Failed to provide training Failed to track

qualifications

Failed to track performance

Failed to provide correct

information

Failed to provide adequatetime (for briefing)

Improper staffing

Task not in accordance with

rules/regulations

Failed to provide adequateopportunity for rest

Failed to Correct

Problem

Violations of

Supervisor Failed to correct document

in error

Failed to identify an at-riskworker

Failed to initiate corrective

action

Failed to report unsafeconditions

Authorized unnecessary

hazard

Failed to enforce rules andregulations

Authorized unqualified staff

to work

Unsafe supervision can be categorized into four areas: supervised inadequately, planned inappropriate operations, failed to correct

problems, and supervisory violations. When people supervised inadequately, there is a general failure to provide the opportunity tosucceed. When those in charge planned inappropriate operations, personnel are generally put at an unacceptable risk (i.e., improper

pairing of team members). When supervisors failed to correct problem(s), there are known unsafe conditions that allow to continue

unabated. Finally, violations of supervisor(s) occur when there is mismanagement of assets, followed by a tragic sequence of events

by people under those supervisors.



Resource

Management

Organizational

ClimateHuman

Selection

Staffing

Training

Monetary / Budget

Excessive cost cutting

Lack of funding

Equipment / Facility

Poor design

Purchase of unsuitable

equipment

Structure

Chain-of-command

Delegation of authority

Communication

Accountability for actions

Culture

Norms and Rules Values and beliefs

Organizational justice

Organizational ProcessOperations

Operational tempo

Time pressure

Production quotas

Incentives

Measurement / Appraisal

Schedules

Deficient planning

Procedures

Standards Clearly defined objectives

Documentation

Instructions

Policies for hiring/firing/promotion

Oversight

Risk management

Safety programs

Organizational influences are the fallible decisions of upper-management that directly affect supervisory practices, conditions, and

actions of people. Resource management encompasses the realm of organizational-level decision making regarding the allocationand maintenance of assets (i.e., people, money, and equipment/facilities). Organizational climate refers to a broad class of variables

that influence worker performance (i.e., the working atmosphere). Organizational process refers to decisions and rules that govern

everyday activities within an organization (operational procedures and oversight programs to monitor risks).

Integrating

Safety

Research has indicated that “low-accident companies” differed from “high-accident companies” because they

possessed the following organizational characteristics:

Strong senior management commitment, leadership, and involvement in safety

Closer contact and better communications between all organizational levels

Greater hazard control and better housekeeping

A mature, stable workforce

Good personnel selection, job placement, and promotion procedures

Good induction and follow-up safety training

Ongoing safety schemas reinforcing the importance of safety, including “near miss” reporting

Acceptance that the promotion of a safety culture is a long term strategy requiring sustained effort & interest

Adoption of a formal health and safety policy, supported by adequate codes of practice and safety standards

Communication that health and safety is equal to other business objectives

Thorough investigations of all accidents and near misses

Regular auditing of safety systems to provide information feedback and continuous improvement

Source: Cooper, D. (2001). Improving safety culture: A practical guide. Hull, United Kingdom: Applied Behavioural

Sciences.



Case Study

Imelda Marcos is experiencing pain in her wrist, after heavy use of a standard mouse. The pain began a week

ago when their company website went down, and her supervisor asked to her “work day and night” to bring it

back up quickly. After a week, Susie received an award for returning the website back to its original state, in ashort amount of time. She’s been through ergonomics training, and had her workstation evaluated by anergonomist one year ago. However, there have been recent budget cuts, furloughs, and layoffs which prevent

her from comfortably asking for more resources to deal with the pain. Soon, Imelda files a worker’s

compensation claim, citing tendonitis and median nerve compression caused by her employment. She indicatesshe’s used a standard mouse safely for the past 20 years. You are the person responsible for conducting the

accident investigation.

Questions

1. What are 3 questions you would ask during the accident investigation?

2. What are 3 corrective actions you would take?

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