Safety First! Or is it?

     Many organizations adopt the “Safety First!” mantra, but what does it mean?  The answer, of course, differs from one organization, person, or situation to another.  If an organization’s leaders truly live the mantra, its meaning will be consistent across time, situations, and parties involved.  It will also be well-documented, widely and regularly communicated, and supported by action.
     In short, the “Safety First!” mantra implies that an organization has developed a safety culture.  However, many fall far short of this ideal; often it is because leaders believe that adopting the mantra will spur the development of safety culture.  In fact, the reverse is required; only in a culture of safety can the “Safety First!” mantra convey a coherent message or be meaningful to members of the organization.

Safety Vocabulary
     All those engaged in a discussion of safety within an organization need to share a common vocabulary.  The definitions of terms may differ slightly between organizations, but can be expected to convey very similar meanings.  The terms and descriptions below are only suggestions; each organization should identify all terms necessary to sustain productive discussions and define them in the most appropriate way for their members.
     An organization with a well-developed safety culture will be relentless in identifying hazards in the workplace.  A hazard is an environment, situation, or practice that could result in harm to an individual or group.  Examples include elevated work platforms, energized electrical equipment, and chemical exposure.  Many hazards exist throughout the typical workplace; each should be evaluated for the feasibility of elimination.
     Risk is the likelihood that a hazard will cause harm and the extent or severity of that harm.  “High-risk” endeavors are usually considered those that exhibit a high probability of severe or extensive harm.  Defining categories of risk can aid in prioritizing mitigation and elimination efforts.
     An accident is an occurrence of harm – usually physical – to an individual or group.  The effects of an accident may be immediate, as in the case of a fall, or protracted, as in the case of radiation exposure.  A near miss is an occurrence that could be expected to cause harm, but the individuals involved are fortunate enough to avoid it.  An electrical arc within an open panel that does not seriously shock the technician working on it is a near miss that demonstrates the importance of personal protective equipment (PPE).
     PPE is the last line of defense against injury.  It is a broad term that includes any device used to protect an individual from harm, including safety glasses, ear plugs, hard hats, insulating gloves, steel-toed shoes, cut-resistant garments, face shields, retention harnesses, and breathing apparatus.  PPE that is adequately specified and properly worn can reduce the risk of an activity, but cannot eliminate it.  It can prevent or reduce injury in many cases, but provides no guarantee.  At best, PPE can turn an accident into a near miss.
     Accidents, near misses, and property-damage events are often called, collectively, incidents.  Use of this term is convenient for ensuring an investigation occurs, regardless of the type of event.  The difference between a near miss or property-damage event and an accident is often pure coincidence or good fortune.  These are not reliable saviors; they should not be expected at the next incident.
     Dangerous behavior includes activities that can be expected to result in an incident.  Examples include driving a loaded forklift too fast without checking for traffic at intersections, failing to remove combustible material from an area before cutting or welding equipment is used, and carelessly handling dangerous chemicals in open containers.  Behaviors develop for various reasons; it could signal a lack of training, complacency, or malicious intent.  In any case, corrective action must be taken to correct the behavior before an incident occurs.
 
Elements of Safety Culture
     The steps required to develop a safety culture are not particularly difficult to understand.  They may be difficult to implement, however, because they require a deep commitment of decision-makers to prioritize safety over other concerns.  When pressured to meet production requirements or cost-reduction targets, managers can be tempted to abandon safety-focused initiatives that they perceive as threats to the attainment of other metrics.  Commitment at the highest levels of an organization is required to prevent the sacrifice of safety to competing objectives.
     A common theme among discussions of organizational programs is documentation.  Developing a culture of safety, like so many other initiatives, requires a significant amount of documentation.  The value of documentation transcends its functional attributes; it provides evidence of commitment of the organization’s leadership to treat safety as its highest priority.  Documentation replaces verbal attestations and platitudes with “rules of the road,” or expectations of conduct at all levels of the organization.
     Documentation can become extensive over time.  At a minimum, it should include:

• Hazard identification:  descriptions of exactly what makes an operation, machine, place, etc. potentially dangerous.
• Risk assessment:  for each hazard, evaluate the likelihood and severity or extent of harm.
• PPE required:  specify the personal protective equipment prescribed to protect individuals from known hazards.
• Training requirements:  define all training required for an individual to remain safe from known hazards.
• Work instructions:  detailed procedures to ensure safe practices in routine work.
• Maintenance instructions: detailed procedures to ensure safe practices in non-routine work.
• Assessments:  reviews and evaluations of program effectiveness.

Additional documentation may be deemed necessary as the culture matures.  Specifically, conducting safety program assessments may reveal the need for additional procedures or other refinements of the documentation package.
     Several other characteristics must be present to sustain a successful safety culture; chief among them is effective communication.  Reports of incidents and safety metrics must be viewed as communication vehicles, not the sole required output of a safety program.  This means that incidents are investigated, not merely reported.  Root causes must be found, addressed, and communicated, updating members’ understanding of the hazards they face.
     Communication must also be open in the opposite direction.  Team members should be provided a clearly-defined channel for communicating safety concerns and suggestions to those responsible for implementing changes.  This hints at another critical element of safety culture – security.  If team members fear reprisal for reporting issues, safety and morale will suffer.  Each member should be encouraged to activate this communication channel and given the confidence to do so whenever they see fit.
     All incidents – accidents, near misses, and property-damage events – should be investigated with equal intensity.  Non-accident incidents are simply precursors to accidents; thorough investigation provides an opportunity to prevent future accidents or other incidents.  Open communication and investigative responses are needed to ensure that incidents – near misses, in particular – are reported.
     Non-routine work is a significant source of workplace incidents.  When maintenance and repair personnel are rushed to release equipment, the risk of injury increases proportionally to the stress they feel.  Failing to provide ample time to perform non-routine tasks carefully and thoroughly increases risk to maintenance and operations personnel.
     In their haste to return equipment to service, technicians may take shortcuts or fail to strictly adhere to all prescribed safety procedures, increasing the risk of an incident.  Once the equipment is returned to service, shortcuts taken could reduce its reliability, precipitating a catastrophic failure.  Such a failure may cause injury of operators or a near miss in addition to property damage.  A culture of safety allows sufficient time for non-routine work to be performed carefully and to be thoroughly tested before equipment is returned to service.
     Similarly, excessive time pressure on investigations of issues, training, or production can lead to stress, shortcuts, and distraction.  All of these considerably increase the probability of an incident occurring.  No one should have to rely on luck to avoid injury because the pressures to which they are subjected make an incident nearly inevitable.
     In a mature safety culture, culpability of individuals will be assessed according to the type of error committed.  If a blameless error – one that “could happen to anyone” – is committed, or a design flaw that invites misinterpretation is discovered, efforts should be made to mistake-proof the system (see “The War on Error – Vol. II:  Poka Yoke”).  If dangerous behavior or intentional violations cause an incident, disciplinary action may be taken.  Other considerations include an individual’s safety record, medical condition, and drug (prescription, OTC, or illicit) use.
     To ensure consistent treatment of all personnel (no playing favorites), an evaluation tool, such as Reason’s Culpability Decision Tree, shown in Exhibit 1, can be used.  Administered by an impartial individual or small group, the series of questions will lead to consistent conclusions.  Responding to each type of error with predefined and published actions will further support the team’s perception of procedural justice.

     While Reason’s Culpability Decision tree will likely lead to a majority of responses requiring no punitive action, it is preferable to a “no blame” system.  A no blame system provides little opportunity to correct patterns of behavior, even when negligent or reckless.
     A culture of safety espouses a continuous improvement mindset.  In this vein, periodic reviews should be conducted to evaluate the effectiveness of the systems in place to ensure safety.  Over time, equipment degrades and is often modified or upgraded, changing the characteristics of its safe operation and maintenance.  Operators and technicians come to recognize previously unidentified hazards and may develop well-intentioned work-arounds.  A periodic review reminds personnel of the communication channels available to them and allows the documentation and procedures to be updated to reflect the current condition of the system.
     Results of routine health screenings should be included in these reviews to assess the effectiveness of prescribed PPE and documented procedures.  In addition to vision and hearing checkups, individuals should be examined for signs of repetitive stress or vibration-induced disorders.  They should also have the opportunity to discuss their stress levels and overall well-being.  It may be possible to identify negative trends before conditions become debilitating.  Preventive measures can then be implemented to safeguard employees from injury.  One of the simplest responses to many work-related issues is to schedule task rotations.  Doing so reduces the risk of repetitive stress disorders and errors caused by complacency or boredom.
 
     Organizations that have mature safety cultures prioritize the well-being of their employees, customers, and community.  The evolution of an organization can start with one person.  You shouldn’t expect it to be easy or fast, but doing what’s right is timeless.
 
     For assistance in hazard identification, risk assessment, developing procedures, or other necessities of safety culture, leave a comment below or contact JayWink Solutions directly.
 
References
[Link] “A Roadmap to a Just Culture:  Enhancing the Safety Environment.”  Global Aviation Information Network (GAIN), September 2004.
[Link] The 12 Principles of Manufacturing Excellence.  Larry E. Fast; CRC Press, 2011.
[Link] “The health and safety toolbox.”  UK Health and Safety Executive, 2014.
 
Jody W. Phelps, MSc, PMP®, MBA
Principal Consultant
JayWink Solutions, LLC
jody@jaywink.com