Bay Area Safety Symposium - Darryl C...The Logic of Failure 6 “Difference between near misses and...

Bay Area Safety Symposium

How Profound Knowledge can contribute to

Safety Excellence

Darryl C. Hill, Ph.D., CSP

Outline

• Learning Objectives

• Resources

• Profound Knowledge

• Systems Thinking

• Principles of Variation

• Case Study

• Exercise

• Results

• Summary

• References

2

Learning Objectives

• Examine Systems Thinking and Profound Knowledge

• Contrast Profound Knowledge / Systems Thinking to Traditional Approaches

• Describe how an OSH Professional can use Systems Thinking to improve Safety Performance

3

Published by ASSP in 2018

• Ethics and integrity

• Certifications and accreditation

• Professional development

• Technical contents

• Culture

4

Road to Transformation

5

Safety Professional CharacteristicsSafety Professional of Yesterday

Perceived: A “burden”

Organizational Alignment: No one cares or no thought goes into who supervises safety

Interests: Posters, days without a lost-time accident board

Characteristics:

• Specialists (fire, industrial hygiene, safety)

• Minimal planning

• Reactive

• Conducts inspections via predetermined form / checklist

Safety Professional of Today

Perceived: Compliance-oriented

Organizational Alignment: Reports to a director (manager) or shared services function – human resources

Interests: Incentives, behavior-based safety, disciplinary procedures

Characteristics:

• Generalist

• Short-term planning

• Relies on recordable/lost-workday incident rates

• Chairs safety committee

• Use audits that parallel the regulatory process

Safety Professional of the Future

Perceived: Value-added business leader

Organizational Alignment: Accountable to senior-executive who completely supports OSH process

Interests: Six Sigma, financial principles, systems thinking, values-driven safety

Characteristics:

• MBA, Ph.D.

• Knowledgeable in all aspects of organization

• Relies on variation (common / special causes)

• Facilitates safety process

• Utilizes employee feedback for continuous improvement

Hill, D.C. (2002). Time to transform? Assessing the future of the SH&E

profession. Professional Safety, pp. 18-26.

The Logic of Failure

6

“Difference between near misses and failures are enabling

conditions”

“There will always be warning signs”

“It’s not the numbers it’s the interpretation of the numbers –

How risky does this feel?”

Profound Knowledge

7

• Appreciation of a System

• Understanding Variation

• Theory of Knowledge

• Psychology

Systems Thinking

• Our ability to understand systems is hampered by our inability to accept that the system itself, not some person or process in it, is to blame for what goes wrong.

Russell Ackoff

Principles of Variation

10

Variations are normal in every system.

Causes of variation lie within the system (common causes), or outside the system (special causes).

When a system is running consistently within its upper and lower control limits, is left untouched, variations that occur are due to common causes.

Principles of Variation

11

Common causes arise out of characteristics of the system, which are determined and corrected by management. Workers usually have no control over common causes.

The 85-15 Rule of System Variation: In a normal system, 85% or more of the variations are due to common causes, 15% or less are due to special causes.

Common Causes

12

Poor LayoutPoor

Maintenance

High Worker Turnover

Inadequate Training

Not wearing appropriate

PPE

Unrealistic Schedule

Control Chart

13

Special Causes

Malfunction of a

particular Machine

Batch of off-grade

Materials

Blown FuseNew

untrained worker

Control Chart with a Special Cause

15

Use of Traction Aide (Shoe-Grips)

16

• All depot employees are required to wear the shoe-grips when ground

conditions merit.

• The shoe-grips should be worn during the complete pre-trip, both inside and

outside the truck.

• The shoe-grips are but one component of our comprehensive effort to prevent

ice and snow related slips, trips and falls.

• Use of shoe-grips must be accompanied by aggressive snow and ice removal,

salting and sanding, and management coaching of employees to use best

practices when walking in snow or ice conditions.

• The Depot Manager or designee must determine days when

the wearing of shoe-grips is mandatory. A colored flag, posted

sign, or other form of notification (e.g. flashing beacon) shall

be clearly placed at the front entrance of the yard to alert

arriving employees of the need to wear.

Slip, Trip & Fall Incident: Not wearing Shoe Grips

• Driver injured when not wearing shoe grips at satellite location.

• Driver was issued a pair of shoe grips.

• The location did not have a sufficient pair of shoe grips for new drivers.

• The flag was shown at primary lot but not at the satellite location.

• The incident occurred at 6:10am during the winter.

• The snow removal company had not removed snow at satellite location.

17

Profound Knowledge: Case Study

Name Meaning Example

System What are the parts of the process and how do they relate to one another?

“Frankly, the staff doesn’t know the drivers mood when coming to work, nor have the drivers been disciplined previously for not wearing shoe grips.”

18

Profound Knowledge: Case Study

Name Meaning Example

System What are the parts of the process and how do they relate to one another?

“Frankly, the staff doesn’t know the drivers mood when coming to work, nor have the drivers been disciplined previously for not wearing shoe grips.”

Variation How do the outcomes change from time to time?Which of these changes is an inherent part of the process (common cause) and which is not typical part of the process (special cause)?

“The driver typically arrives to work behind schedule.” (Common cause)

“The strobe light was not functioning properly the morning of the incident.” (Special cause)

19

Profound Knowledge: Case Study

Name Meaning Example

System What are the parts of the process and how do they relate to one another?

“Frankly, the staff doesn’t know the drivers mood when coming to work, nor have the drivers been disciplined previously for not wearing shoe grips.”

Variation How do the outcomes change from time to time?Which of these changes is an inherent part of the process (common cause) and which is not typical part of the process (special cause)?

“The driver typically arrives to work behind schedule.” (Common cause)

“The strobe light was not functioning properly the morning of the incident.” (Special cause)

Theory of Knowledge What do employees in the organization view as meaningful information? (This affects their learning and decision-making?)

“Drivers aren’t aware of the number of serious or major injuries as a result of STFs.”

“Drivers do not understand the relationship between injuries for those that wear grippers and those who don’t wear grippers.”

20

Profound Knowledge: Case Study

Name Meaning Example

System What are the parts of the process and how do they relate to one another?

“Frankly, the staff doesn’t know the drivers mood when coming to work, nor have the drivers been disciplined previously for not wearing shoe grips.”

Variation How do the outcomes change from time to time?Which of these changes is an inherent part of the process (common cause) and which is not typical part of the process (special cause)?

“The driver typically arrives to work behind schedule.” (Common cause)

“The strobe light was not functioning properly the morning of the incident.” (Special cause)

Theory of Knowledge What do employees in the organization view as meaningful information? (This affects their learning and decision-making?)

“Drivers aren’t aware of the number of serious or major injuries as a result of STFs.”

“Drivers do not understand the relationship between injuries for those that wear grippers and those who don’t wear grippers.”

Psychology What is the understanding of the people in the organization on how interpersonal and social structures affect performance of the system or process.

“Most drivers have a sedentary lifestyle and not agile, thus they are prone to injuries.”

21

Profound Knowledge

22

EXERCISE

Safety Excellence Roadmap & Results

Safety Excellence Journey

2001 - 2012

23

• Statistical Process Control (SPC) Tools

• SPC Training

• Incident Investigation

• 8% YoY improvement in TRIR

Systems Thinking

• 75% of sites obtained external OHSAS 18001 certification

• OSHA VPP

• EMR - .58

Safety Management

Systems

• Safety Culture Score, 3.76 – 4.04 (4 years)

• Management Safety Alignment Sessions

Safety Culture

Risk Reduction

SMS

Performance Measurement

Leadership & Engagement

EHS Today Award

CultureLeadership

Summary

• Profound Knowledge and Systems Thinking provides an alternative approach for problem-solving.

• Systems thinking allows an opportunity to consider the human element without behavior-based safety as the primary focus.

• Statistical process control tools will assist the OSH professional to better understand organization processes and improve efficiencies.

References

Deming, W.E. (2000). Out of the crisis. Cambridge, MA: The MIT Press.

Dorner, D. (1996). The logic of failure: Recognizing and avoiding error in complex situations.

New York: Metropolitan Books.

Hill, D.C. (Nov. 2002). Time to transform? Assessing the future of the SH&E profession.

Professional Safety, pp. 18-26.

Olawoyin, R. & Hill, D.C. (2018). Safety leadership and professional development. Park Ridge,

IL: ASSP.

Smith, T.A. (2008). System accidents: Why Americans are injured at work and what can be

done to stop it. Lake Orion, MI: Self-published.

25