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Accident Reporting - An Opportunity for Improvement

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Industry News

Written by Kevin Doffing 25 September 2015

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I received this article from a customer and cannot find a link to an original source posting. If you find it please send that to me so I can backlink and credit the author of this insightful article.

 Accident reporting 

The accident triangle, asserting a fixed ratio between the worst accidents in a workplace and the smallest ones has come under sustained attack. Bridget Leathley asks whether it still has any value.

  • Challenging the idea of a fixed statistical relationship between major and minor incidents


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    The big, signposted change to the 2013 issue of the HSE’s management system guidance HSG65 was from POPIMAR (policy, organising, planning and implementing, measuring performance, audit and review) to PDCA (plan, do, check, act). A less trumpeted alteration was the loss of the text box Inset 1.

    Did anybody notice? The 300 words of Inset 1 summarised the results of accident ratio studies, also known as accident triangles. It cited work by the HSE’s Accident Prevention Advisory Unit which confirmed “the general validity of earlier work by [safety academics] Bird (1969) and Tye and Pearson (1974/75)” on accident ratios, and produced the triangle shown in Figure 1.

    Bird’s work was based in turn on earlier work by Herbert William Heinrich in the 1920s, published and republished from 1932 to 1959 in his book Industrial Accident Prevention: A Scientific Approach.


Triangular lessons


In the 2nd edition of HSG65 the HSE highlighted three principles based on the accident triangle. There are consistently greater numbers of less serious events than more serious ones. Many near misses could have become events with more serious consequences.  All the events (not just those causing injuries) represent failures in control, so are potential learning opportunities.




Figure 1: HSE's triangle




It is the third conclusion that points towards the value of the triangle as a useful model, and which keeps it on the curriculum of most safety management courses.


When asked why the accident triangle material had been dropped from the new HSG65, the HSE would say only that it had been left out as part of a “shift from primary research sources to focus on available guidance on how to deliver the various aspects of effective health and safety management”.


Others have been more forthcoming with their criticisms of Heinrich. In his 2001 book Reviewing Heinrich, US author and consultant Fred Manuele notes that one premise of the triangle model is that reducing accident frequency will equivalently reduce severe injuries, but that “misdirection has resulted from applying … his premises”.


In their book Risk Led Safety, Evidence Driven Management Duncan Spencer and Chris Jerman of the John Lewis retail group are unequivocal: “The Heinrich ratios and associated work by others are misleading and scientifically disproved theories. Let’s stop using them!”

Numbers and illusions

The most basic criticism of Heinrich’s ratios attacks his data. If his sources were insurance claims, asks Manuele, where did he get such accurate figures on near misses? No one since has been able to verify his data.

Heinrich’s statements were definitive: “Analysis proves that ... from data now available … it is estimated that in a unit group of 330 accidents, 300 result in no injuries, 29 in minor injuries and one in a major or lost time case.”

In HSG65’s Inset 1, the HSE used its own accident prevention department’s ratio to illustrate the triangle: 189 non-injury accidents for every seven minor injuries for one major injury (see Figure 1 above). Bird and others suggested different ones. Some have used these variations to dismiss the usefulness of the ratios. But Dr Linda Bellamy’s research (see below) suggests there are different ratios for different types of hazard and you will get different results depending on which organisation, industry or even in which country you have conducted your study. 

It is likely the ratios will change over time. But the important points in Inset 1 were not that the numbers formed a golden rule, but that “there are consistently greater numbers of less serious events compared to more serious ones” and that “all the events … are potential learning opportunities”.

There is probably insufficient data to make drawing up a triangle for your own organisation a worthwhile exercise, but looking at those that have access to larger data sets shows that the patterns are there, and it is worthwhile understanding your own incidents.

In support of their dismissal of ratios, Spencer and Jerman cite the Baker report on the BP Texas City Oil Refinery explosion in 2005. The report finds there is little relationship between every­day near misses and the circumstances that result in a major process disaster. 

“BP mistakenly interpreted improving personal injury rates as an indication of acceptable process safety performance at its US refineries,” says the report. “BP’s reliance on this data, combined with an inadequate process safety understanding, created a false sense of confidence that BP was properly addressing process safety risks.”

This was not a case that the accident ratio theory was wrong; rather, BP’s managers used something they did understand — slips and trips, for example — as a substitute for something they did not understand. 

The US Chemical Safety Board (CSB), which pressed BP to commission the Baker report, did not see this as reason to abandon the triangle and investigation of minor incidents at the base. In 2010, CSB chairman John Bresland said: “Only the highest commitment to running down the even smallest of problems and upsets will assure the prevention of so called low probability, high consequence events like the tragedy that took so many lives in Texas City.”

Pick and choose

That the conditions leading to a given major process disaster do not relate to slips and trips or your workplace transport accidents does not mean there is nothing to learn from minor accidents and near misses. 

People failing to clear up or report slip hazards could indicate you have a safety culture where people also fail to report machine leaks, out of range readings and process anomalies. Identifying that one factor in a near miss between a vehicle and an employee was that the pedestrian missed the part of the induction training that explained walking routes should lead to checks on how critical learning points in the induction training are reinforced and tested.

In his criticisms, Manuele highlights how Heinrich changed his emphasis from 1932. He cites Heinrich saying in the first edition of Industrial Accident Prevention “for every mishap resulting in an injury there are many other accidents in industry which cause no injuries whatsoever,” but points out that by the second edition this has changed to “for every mishap resulting in an injury there are many other similar accidents…”

Manuele sees this change as a sign of Heinrich’s flakiness, but this refinement in how to apply the triangle could have been born out of experience in seeing how industry had misapplied the ratios in the intervening years. The word “similar” is important, as the BP Texas City example shows.

A recent study in the Netherlands, reported in the journal Safety Science, illustrates the importance of considering “similar” accidents. Using a database of 23,000 Dutch occupational accidents between 1998 and 2009, Dr Linda Bellamy compared in detail the circumstances of accidents leading to recoverable injury — those where the casualty attends hospital but suffers no permanent harm, accidents leading to permanent disablement, and those leading to fatalities.


Figure 2: accident type specific "triangles"

 HSE Triangle-2

This gives a more accurate picture of the shape of the triangle, albeit it leaves out the bottom layer of inconsistently reported near misses. 

Bellamy found the triangles were different shapes for different hazards (and not perfect triangles). For every death from being struck by a moving vehicle, for example, she found only four permanent injuries and just eight recoverable injuries — few opportunities, therefore, to learn where improvements need to be made (see Figure 2).

By contrast, for every one death from “contact with handheld tool operated by self” there were 280 recoverable injuries. Importantly, within each hazard category, though factors were weighted differently according to the severity of the accident, most factors that were present in the major accidents had been present in the minor ones.

Bellamy concludes: “Investigating the underlying causes of the more minor, more frequent incidents or deviations and fixing the safety barrier problems with a higher severity potential could help prevent the bigger accidents of the same hazard type.”

Voices of experience

The link between frequent minor incidents and infrequent major ones is supported by the many stories in this magazine of HSE prosecutions where there was evidence in advance that something could have been done. 

On 5 February 2010 a bale of insulation fell through a suspended ceiling at a church where two men were insulating the roof space. No one was hurt. The men used a harness they had extended with a nylon rope from a DIY shop. On 12 February one of the pair, a volunteer named Lee Bourn, fell through the ceiling and died. The religious charity involved had received a prohibition notice in 2001 after a non-fatal fall from a roof, further evidence it could have prevented the 2010 death if it had learned from experience.

The report into the 1999 Ladbroke Grove train crash said the crash might have been avoided and 31 lives saved “if management had applied the lessons of past SPADs [signal passed at danger], and if signallers had been adequately instructed and trained in how to react to a SPAD”. 

What is important is not to apply the accident ratios without intelligence. To assume that if you have reduced the number of mispicks, blocked fire exits or uncleared spillages you have dealt with the high severity hazards is missing the point made in Inset 1 in the old HSG65: “All the events ... are therefore potential learning opportunities.” 

But you need to consider carefully, as Bellamy has in her research, the factors surrounding the minor accidents or near misses. Ask whether the lack of a fatality or permanent injury after an incident was because of stable controls, or just chance. 

If the overnight scaffolding collapse was during weather that would have stopped work anyway, then, as long as you are confident that control will be applied, there may be no need for further action; if the scaffolding collapsed overnight but could equally have happened during the day when people were working on and under it, there is a problem that needs fixing.

The accident triangle also serves as a tool to support organisational memory. Chemical safety expert Trevor Kletz spent his working life reminding people that too many industrial accidents are caused by factors that organisations knew about, understood and forgot. If more than a decade passes between fatal accidents, the turnover of people will be such that individuals will have forgotten why the separate (longer) route for pedestrians was put in place, or why we do not store bricks on the scaffolding, or why contractor and client are required to look at the asbestos register together.

The near miss and minor incident analysis reminds us why these controls are there. If someone had been walking across the loading bay when the lorry backed up too far and damaged some pallets, if they had been walking under the scaffolding when the pile of bricks fell, or if the contractor had not noticed the asbestos sticker on the gasket, the result could have been much worse. 

If managers just say, “well, the controls worked this time, no one was hurt”, they allow the dilution of the barriers designed to prevent the serious outcome, increasing the likelihood of such an event.

Thermometer manipulation

It seems we shouldn’t believe there is a magic ratio that can be applied to all hazards; that if we count the near misses, we can work out the probability of a fatality.
Neither should we assume reducing reported near misses has automatically reduced the likelihood of a fatal accident. If you had a thermometer, would you think that you could change the temperature of the room by pushing the mercury up or down with a needle? Of course not, but if you had changed the temperature of the room, you would expect the mercury 
to move. 

So do not expect to change the likelihood of a major accident by tinkering with the number of near misses or minor injuries. But if you use the minor incidents as potential learning opportunities they can reveal changes that could have a positive effect on the serious events.

Many health and safety practitioners still refer to ratios as an educational tool to get buy in from management to the idea of leading indicators, and to explain to staff the importance of reporting. 

Ray Jeffery, group health, safety and environment manager at the Building Research Establishment, uses the triangle in this way, admitting: “I know there is no science behind the numbers, but it does paint a good picture to explain why near miss reporting is an important proactive measure which can prevent something going wrong if acted on.”
















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Confined Space Rule Update

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Fall Protection

Written by Kevin Doffing 08 August 2015

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On May 1, 2015, OSHA issued a final rule Standard 29 CFR 1900.1200, Confined Spaces in Construction.  This standard was initially scheduled to become effective August 3, 2015, however, the agency is postponing full enforcement of the new standard until Oct. 2, 2015.  This delay is in response to requests for additional time to train, and acquire the equipment necessary to comply with the new standard. 

Although there are similarities to the general industry confined space standard, this rule intends to address the particular safety concerns of the construction industry.  MSA has prepared a technical brief OSHA 1926.1200 Confined Spaces in Construction:  What to Expect From the New Standard to help customers learn more about the new standard and similarities/differences as compared to the general industry standard.

For additional information on confined space solutions, visit www.MSAsafety.com or contact Customer Service 1-800-672-2222.

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5 Must Haves for a Successful Safety Incentive Program

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Oil & Gas

Written by Kevin Doffing 08 August 2015

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          Safety incentive programs are a hot button topic in the health and safety community. Every manufacturer and field service company dreads seeing their employees injured and jobs delayed due to preventable accidents. Having to go back and fix a job a second time always takes more time than doing the job right the first time. But how do supervisors and managers balance the demands of a production schedule or the needs of the customer with ensuring a safe work environment? The answer is the most ambiguous or cliché of terms in the health and safety profession: A Safety Culture. Starting or changing an existing safety culture at a company is a huge endeavor. A safety incentive program is a great way to get the ball rolling or to shake up an existing safety culture. Here are five must haves for a successful safety incentive program would be:

            1. Make a Goal

You’re starting a safety incentive program because something has gone wrong; usually a recordable injury or a near miss has made you realize that something has to change. Set a goal that corrects the deficiency in work practices or attitudes among workers. For instance, if you’ve had a recent rash of incidents involving fork lift accidents, make your goal to eliminate those accidents. What’s it worth to the company to eliminate these accidents? Knowing how costly these accidents are means you also know how valuable a successful safety incentive program is to the company and to management.

    2. Measure and Report Results

Make sure that you can document improvement or decline along the way to your goal. You need numbers to validate the incentive program to workers and management. The simpler the method of record keeping, the better; don’t make a new position or hire just to keep up with the safety incentive program. As one industrialist once commented, “The company bureaucracy should not grow to meet the needs of the growing bureaucracy.” Find the people that have the most to gain from a successful program in the short term and get buy in from them to support record keeping. Let’s be honest, if you’re reading this, then you’re that person. If you can’t convince yourself record keeping is worthwhile, good luck convincing anyone else to follow the program.

Once you’ve started tracking results, make sure that there’s a way to regularly report and inform the entire company of the program’s progress. If you don’t have a regular safety meeting, this is a good reason to start one. Make sure to make this as a positive and succinct meeting as possible, 15-30 minutes at most. Make a board that displays results in the break area. The results of the safety incentive program should not be a secret.

    3. Focus on Leading Indicators

What you measure is as important as how you measure and report it. Don’t focus on lagging indicators of safety, instead focus on leading indicators. For the forklift example, you absolutely would not want to use accidents as the indicator you track. Yes, that’s your ultimate goal of eliminating incidents, but if you only measure accidents after they’ve happened a funny thing will occur. Accidents will continue to happen, but no one will report them. That’s how equipment mysteriously gets demolished and someone says, “It was like that when I found it.” Don’t encourage your workers to act and sound like three year olds.

Instead focus on leading indicators, the things that prevent accidents in the first place. For instance measure training and maintenance compliance. Has everyone received a recent update on their forklift training? When was the last time the preventive maintenance inspection was performed? Were those inspections checked by a supervisor? Who attends the most safety meetings? Measuring leading indicators will make you proactive in preventing accidents instead of being reactive to accidents that have already happened. Measuring leading indicators makes it easier to reward good behavior, whereas measuring lagging indicators usually mean punishing bad behavior. I’ve never heard of anyone getting a reward for having an accident or reporting a near miss. Usually that just results in paperwork, training, and long talks that discourage responsible reporting.

    4. Avoid Financial Rewards

The point of a safety incentive program is to lead with more carrot than stick and reward rather than punish. Stay focused on the positivity of improving leading indicators and resist direct financial rewards. Of course everyone likes money, that’s why people leave their family and go to work every day. However, it’s harder to get buy in from management when there’s a potentially large price tag associated with a safety incentive program. You don’t want to pay people to do the right, safe thing, you want to encourage and promote that behavior.

Make sure to identify individuals that are responsible for improving leading indicators in your new safety meetings. You can even put their picture on the wall and update it monthly. I’ve always found that an extra half day or full day of paid time off does wonders for morale when goals are met. Management might see this as a financial burden but often the employee is unusually productive before and after paid time off, and little to no production is lost. The workers that go above and beyond to take care of their equipment and look out for their co-workers are usually your strongest and most reliable workers. Have those people lead training or meetings; this is a good opportunity to develop leadership skills among your best and allow them to shine in front of others. That recognition and trust is priceless in the eyes of someone who has spent years doing the right thing without reward or recognition. Don’t tarnish that behavior by paying for it, because if you ever stop paying then you might just lose what you already got for free.

    5. Get Management Buy In

It’s been touched on previously, but if the company management doesn’t buy into the safety incentive program then no one else will either. Leadership by example is always a key to success in any business. If the shift supervisor or company owner is willing to jump on a forklift to drive without going through a pre-operating checklist why expect different from anyone else? Often senior leadership in a company has spent years or decades in their industry and knows the right thing to do, but are so familiar with the day to day activity that they neglect the basics. This isn’t because they’re lazy or forgetful, but because they don’t see themselves as prone to an accident. You could argue that they’ve been around long enough to see that accidents happen to anyone at any time, but that isn’t the most compelling argument. Instead leaders need to realize that everyone is watching them whether they like it or not. If they skip one step in safe operations, then the new guy watching from across the shop floor is going to skip 10 things the next time he uses that piece of equipment. Leading by example isn’t about what’s best for the leader; it’s about what best for the people that they lead.

Safety incentive programs most often have gotten a bad reputation not because of bad intentions, but rather poor execution. Be flexible as you begin and be responsive to worker attitudes. Don’t be afraid to use that carrot and reward employees by having good food or snacks at safety meetings; remember to use the carrot more than punish with the stick. Often times improving one indicator or achieving one goal causes other unintended issues. Be ready to address those issues and when you accomplish your goal, keep up the momentum and identify the next goal. Beginning or changing a safety culture is difficult, but is worthwhile for employee safety and the prosperity of the business. A safety incentive program is the best place to start; keep these steps in mind as you go. Good luck.

Kevin Doffing
Sam’s Safety Equipment
This e-mail address is being protected from spambots. You need JavaScript enabled to view it




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