Chapter 13 Prominent Case Studies Using Strategic Safety Measures Safety Wisdom: The absence of injuries does not equal the presence of safety; you’re not controlling the process if you just measure outcomes. Paul Woerz Numerous organizations have reaped the benefits of well-planned and effectively implemented leading measures for safety. Safety professionals can learn lessons for application from these cases regarding what to do, and in some cases, what not to do. The cases overviewed here are mostly model cases that offer innovative and powerful concepts, as well as methods that can be used in various industries. When possible, this chapter will present the following for each case study: the initial driver for change; the results of change; status; how the results were accomplished; and any lessons learned for application. Since each industry, organization, and site is unique, safety measures should be customized – taking into account the context of each specific setting. Readers are encouraged to identify those things they believe would work for their organization, modify as needed, and leave behind those concepts or methods that don’t appear useful for their situation. Who are the Safety Thought Leaders? The authors prefer to view notable safety accomplishments as a product of team efforts rather than the result of any individual safety ‘hero.” Nonetheless, there are individuals cited in this chapter that are arguably heroes, but are, at a minimum, Thought Leaders in Safety. One can see that these individuals have given deep thought and analysis to making improvements in safety. They have developed some highly innovative and creative approaches. These Thought Leaders have contributed to the field and provide safety professionals with proven concepts to consider for application at their own organizations.
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Cases and Safety Thought Leaders covered in this Chapter include: Case 1: Using Leading Measures for Driving Compliance and Fatality and Catastrophe Prevention – Paul Woerz Case 2: Leading Measures Process at Large Brewery – Anne Bevington. Case 3: Executing Leading Indicators in the Petroleum Industry – Jack Toellner Case 4: Using Leading Measures to Advance Behavioral Safety Efforts – Dominic Cooper Case 1: Using Leading Measures for Compliance in High Hazard Processes
This Case Study was reported by Paul Woerz, former Global Director of EHS at a high hazard, worldwide company with thousands of employees Paul Woerz was honored in 2005 with a Lifetime Achievement Award from his alma mater at Indiana State University. At the celebration dinner one of the authors engaged in conversation about safety performance, and Paul indicated that using leading measures was the best thing they developed in safety for his segment of the company, which employed tens of thousands of employees. During the late 20th century, the safety culture at Paul’s organization had been highly developed and influenced by top leadership. The primary focus of the organization was on lagging safety measures. In the 1980s and 1990s it was highly unusual for an organization to measure its management and overall performance with metrics focused primarily on safety. It is still unusual. This focus on safety measures positively influenced the organizational culture and resulted not only in a reduction in incident rates but to great success in profitability and the bottom line for the company. Unfortunately, in spite of the organizational focus on safety, there were one to two fatalities per year that occurred in Paul’s company. This was unacceptable to Paul and he was searching for a way to be more proactive and prevent these fatalities in his group. He believed the way to accomplish this was to eliminate risks and exposures wherever possible whether by behavior or by engineering means. In the early 1980s, Paul was asked what Leading Measures they had for safety. His answer then was “Safety Audits.” All of the remaining measures were lagging. This question focused Paul’s attention on the potential impact of using Leading Measures for Safety, and he later developed and used the Leading Measures process described here. This case is relatively basic in design, yet it’s important to recognize that the consequences can be profound. Paul asks, “What are you doing to prevent fatalities?” Part of the answer includes behavior and compliance, especially when involved with high hazard processes. When there is a potential for fatalities to occur, organizations need to ensure 100% compliance with the target programs. These target processes are the ones that involve a risk of causing severe injuries or fatalities.
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What was the Primary Driver for Using Leading Measures? Preventing fatalities was the most urgent concern in this large segment of a major corporation. Over a period of 20 years, Paul received several calls that another fatality had occurred. As a result of this, Paul decided to adopt leading measures as a forecast for risk and fatalities. The overriding purpose for developing and using this plan was to measure the activities to intercede or intervene before adverse events occurred. Essentially, the organization began measuring the process rather than putting all of the focus on the outcome. Paul notes that leading measures are gauges of your processes. He asks, “Which process measure would you take out? If there’s one you would take out, then it’s not needed.” More importantly he says, “You’re not controlling the process if you just measure outcomes.” What Resulted from the Focus on Target Processes? Following the implementation of Leading Safety Measures, Paul’s segment led the organization in all lagging safety indicators. Most importantly, after experiencing 18 fatalities over 20 years in the company in total, his segment of the company went almost 10 years without a fatality. A quick analysis indicates that 6 or 7 fatalities could have been expected over the 7 years, based on the history of the previous 20 years. However, there were zero fatalities experienced and this is an amazing result considering the immediately preceding history. Furthermore, the fact that this segment of the organization focused on leading indicators and led the organization in lagging safety indicators suggests a correlation between the application of leading indicators and the positive results (lagging indicators). How did the Organization Measure Their Process? Since fatalities are typically not very common, it can be challenging for organizations to be proactive in preventing them. Employers and employees may interpret the “absence of injuries as the presence of safety.” Paul believes in the adage that “the absence of injuries does not indicate the presence of safety.” Paul also asks questions about safety performance. He notes, typically, when you ask about safety performance, you will be given outcome numbers such as injury rates. For Example:
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What to measure? Your risks. Which risks? The most severe risks. Example: 100 machines in the machine shop and 55% of them are properly guarded. Paul drills down and asks the following questions:
1. Is there risk? 2. If compliance increases to 75% – Is there less risk than before? 3. Will it eventually lead to an injury? 4. Is this acceptable to you? 5. What about 95% compliance? 99%? Is there still a risk? Is this acceptable to
you? Paul expanded from this simple example to target the context of the fatalities that were occurring at his organization. The context for fatalities included the following “Big Four.” The Big Four for Safety in Paul’s Division There were four categories where the fatalities and serious injuries were occurring in Paul’s division. These involved a failure to follow the procedures for lockout/tagout, fall protection, mobile equipment, and confined space entry. The following are some of the elements that were measured with the expectation that there would be 100% compliance. Lockout/Tagout
1. The % of equipment specific isolation procedures written 2. The % of employees found following LO/TO procedures 3. The % of tags and locks properly placed by each employee on the job 4. Was verification to assure de-energization done by each person who applied
locks and tags? Fall Protection
1. The % of employees at elevated levels that are properly wearing fall protection harnesses at required heights
2. The % of roof access permits completed as required Mobile Equipment
1. The % of employees wearing seat belts as required 2. The % of pre-use inspections documented prior to use of the vehicle 3. Are any vehicle/pedestrian interface issues present? 4. Are any loads being lifted or raised over employees?
Confined Space Entry
1. The % of monthly calibrations completed and documented 2. The % of pre-use bump tests conducted and documented 3. Were space specific entry procedures reviewed and followed prior to entry?
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4. The % of confined space permits fully completed 5. Are all entrants listed on the permit? 6. Are spaces equipped with signage regarding permit required?
Compliance – Doing the Basics Right When Consequences are Great Paul determined that in order to prevent major incidents and fatalities, the segment of his organization MUST expect and achieve 100% compliance in these four areas. Because the potential consequences were so great, if an employee was found to be violating one of the Big Four Safety procedures they were disciplined and sometimes discharged. In some instances, the employee’s immediate supervisor was also disciplined or discharged. This proved the company was serious about the safety process, and deviation from their standards would not be tolerated. Deviation from safety standards should not be tolerated when the potential consequence is a fatality or disabling injury. Who Were the Observers? Observations could be made by anyone at anytime. It could be a co-worker, a supervisor, or a safety professional. The percentage of safe compliance was tracked on a monthly basis, and 100% safe work was the expectation. Specific Example The section above is about compliant behavior. This example is about an administrative control that Paul recommended for his segment of the company. Paul’s Question: “What are you doing to prevent fatalities?” Paul put together a Fatality Prevention Team. He recommends when possible, “Don’t manage the risk, eliminate the risk.” Paul’s division experienced a fatality in Italy – an employee was run over by a large Fork Truck. They asked Paul if he wanted to take the same actions in the US they took in Italy as a result of the fatality. For example, they recommended marking the floor for pedestrian traffic and increased forklift inspections, etc. Paul said “No” – they were already doing those things in the US. He notes, “More of the same stuff does not make us safer…” Instead, Paul recommended:
• Take the fork trucks out of operation (they removed 65% of the fork trucks in his division – over 500 trucks).
• Instead of fork trucks, use hand trucks and walk-behinds. • One plant of 800 workers went totally fork-lift free – they reduced the exposure
for this risk to zero.
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One could say that Paul practiced a form of “tough love.” He would let the sites know in no uncertain terms, what he believed needed to be done. However, these were things that needed to be done to stop the fatalities. Lessons Learned about Measuring Compliance The authors believe there are valuable lessons safety professionals can apply from this case, especially for those who work in high hazard industries. 1. You must measure the process if you expect exceptional outcomes. 2. Although it may be a hard sell for the safety professional, it’s important to remember that whenever possible, eliminating an imminent risk is superior to controlling it. 3. It is reasonable to expect 100% compliance for those operations that have and could lead to fatalities and serious injuries. It is better to lose an employee (and their supervisor) due to a lack of compliance than to lose them because they became a fatality statistic. 4. Safety professionals can learn to practice the technique of asking important and smart questions that get people in organizations reflecting on how to reduce and eliminate exposures and risks. We learned about asking smart questions from Paul Woerz. A similar concept supporting the art of asking questions that help people reflect on safety is from Fred Manuele; Fred advocates the overarching role of the safety professional is one of a culture change agent (Manuele, Ch. 6) Case 2: Leading Measures Process at a Large Brewery This case illustrates a number of innovative concepts that could prove useful to companies in various industries. These concepts were developed into a Safety Management Process (SMP) by Anne B. who was the EHS Manager at the time. Anne was not satisfied with any of the common approaches for enhancing safety management such as Total Quality Management or Behavior-Based Safety. There were elements in each of these approaches that she liked, but she didn’t care for the overall approach for her organization. Anne called the process the Safety Management Process or SMP. The SMP was used to proactively measure the safety process and to ultimately drive safety performance. Some of the key benefits of the SMP included the following:
• It was used to track proactive safety participation, team safety initiatives, compliance training, and injury rates in one combined SMP score based on a 100-point system.
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• It was a powerful process to engage employees in safety and get them proactively participating to drive safety performance in an industrial facility.
• The hypothesis that employee participation would drive safety performance was an underlying principle of the SMP system and was piloted first in the Packaging Department, which involved over 500 employees.
• The safety activities were tracked at the employee level, which provided control at the employee level.
• It was a process that gave employees line ownership for safety. • The SMP measures emphasized the safety process and de-emphasized injuries
and illnesses. • The process was based on 85% proactive measures and 15% reactive measures.
The points breakdown involved these four categories: 1) Up to 60 points (or 60%) for active, individual participation in safety; 2) Up to 20 points (or 20%) for team projects and group safety activities; 3) Up to 5 points (or 5% credit) for taking all required compliance training; and 4) Up to 15 points (or15%) were based on the outcome of injuries and injury rates. A little detail about each of these categories follows: 1. Individual Safety Participation. Individual participation was a broad category that defined safety participation in many ways. Some of the concerns that Anne had about formalized safety observation processes were that they were often too bureaucratic, cumbersome, or difficult to sustain over time. SMP built in the opportunity for employees to be creative and flexible in how they would participate in safety. The list of options was rather extensive and the fact that employees had a choice on how they would participate in safety was a key element to the success of the Safety Management Process. Employees were expected to be involved in five individual safety participations per month, thus the opportunity for 12 months multiplied by five safety activities per month gave the possibility for up to 60 points per year. 2. Team Safety Initiatives. The team safety initiatives were similar to the individual participation because teams could choose the safety issue or concern they would focus on during each quarter of the year. The brewery used a team approach for production, so team safety was not a big departure from the norm. Team initiatives could be simple or complex and involve ergonomic fixes or engineering re-designs. Points for Team Safety Initiatives were based on five points credit per initiative, multiplied by four quarters each year, for possible 20 points annually. 3. Compliance Training. Although Compliance Training was only worth 5 of the 100 points, it was highly sought after because the Team would not get the 5 points credit until 100% of the team took the required compliance training. Once a team earned the five points, it remained for the year so it encouraged employees to take all required
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compliance training early in the year. To illustrate the power of this approach, Bevington stated: “(The Organization) went from less than 40% compliance training completion rate in 2001, to a 99.8% completion rate in 2004 with the help of SMP.” 4. Traditional Incident Rates. This category was scored based on the plant performance for the year versus the established goals for the team performance for the month. Since incident rates were de-emphasized to 15% of the total scores, teams could still score points for safety activities even if the department or plant was not meeting its overall goal. This encouraged teams to continue working to win even if an injury had occurred. Having the ability to win was considered another key component in the success of SMP. Results. According to Anne, the hypothesis that proactive employee involvement in safety would result in fewer injuries held true.
• SMP turned the word safety into a normal conversation piece throughout the organization and not simply an injury rate number.
• Leadership was also score carded against SMP. They were measured and held accountable for supporting safety.
• SMP brought a high level of visibility and focus to safety performance across the organization.
• Injuries dropped over 50% after the implementation of SMP. Lessons Learned from SMP and Employee Engagement: 1. Safety is a team effort. Safety is like the proverbial saying that a chain is only as strong as its weakest link. It is recommended that a part of an industrial site’s safety measures include measures of the team or unit together. 2. Employees need to be meaningfully engaged in order to optimize safety performance. Another way to put it is line ownership for safety is state of the art. Ownership for day to day safety should not be on the safety department, or solely on leadership, but primarily on line workers. This case illustrates a powerful way to give employees line ownership for safety in a way that is pleasant and motivating. 3. A simple but powerful method to increase employee participation in safety is to give employees the choice on how they will be involved. The options can be part of a pre-determined list of meaningful safety activities and employees can choose those activities that are consistent with their personal passions and strengths. The customized activities that are personally chosen by individuals are consequently more motivating, and may be perceived more positively than mandatory edicts.
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There are techniques, lessons and ideas from this case study that can be adapted at organizations in various industries. Perhaps no organization would do things exactly the same way as in this or other case studies, but the ideas and lessons can be modified and customized for specific contexts. Case 3: Executing Leading Safety Indicators in the Petroleum Industry ExxonMobil Development Company (EMDC) introduced leading safety indicators on the Hoover/Diana Gulf Platform Project in 1998. Safety Thought Leader Jack Toellner established safety measurement systems that resulted in some remarkable successes for the organization. From Jack Toellner’s ASSE SeminarFest presentation in 2006, the EMDC approach to pursuing an injury and illness free workplace included the following four elements:
• Build Culture • Implement/Improve Systems • Optimize Planning • Maximize Communication
Leading Indicators was one of the best tools the organization had for impacting safety performance. Toellner briefly explained the two types of safety indicators in the following manner:
• Leading Indicators = Prevention (Safe Behaviors) • Trailing Indicators = Injury Management
Toellner analyzed and pointed out a number of key points about the fundamentals of safety metrics. Examples of some his key points include: Key Point #1 – We inherently measure and steward those things that are important to us. Key Point #2 – Safety Metrics should have a positive slope. If you do more of it, or you do it better, then you have a more positive impact on safety performance. Key Point #3 – Safety Metrics should be business line or site specific. What one site needs to improve upon may be different than what another site needs to work on. Remember, “Ownership is everything!” Key Point #4 – Safety Metrics should not be competitive. The numbers are not more important than the outcome. Key Point #5 – Safety Metrics should not be complex. Complexity increases the chance of error and miscommunication. Key Point #6 – Safety Metrics should be tied to measurable individual, team, and system safe behaviors.
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Of particular interest to safety professionals who are making decisions about selecting leading indicators for measurement, Toellner developed the following five key questions for identifying and selecting leading indicators:
1. What are the key processes linked to your site’s safety success? 2. Are these processes measurable? 3. If you do more leading measures (or improve the quality of them) will safety improve? 4. If you don’t steward them, is the rate likely to drop? 5. If the rate drops will performance decline?
The Gulf Platform Project This case involved the construction of an oil platform in the Gulf of Mexico. Keeping workers safe was a real challenge because there were a number of issues for the project:
• The workforce was relatively inexperienced; • There were 1200 workers in a small area and at multiple heights; • The cost and schedule were competing for priority with safety; and. • Safety was a new value for many on the site.
Another key point that Toellner makes is that organizations can’t focus on everything at once. He recommends targeting three to five safety measures on a project. The following are the five leading indicators chosen, based on the selection criteria noted:
Leading Indicator #1. Effective Score of Barricade Performance Leading Indicator #2. Relative Quality of Morning Safety Meetings Leading Indicator #3. Average Housekeeping Score Leading Indicator #4. Job Safety Analysis Leading Indicator #5. Safety Walkthroughs Performed by Management.
These five leading indicators were selected as the priority for safety in the Hoover/Diana project. Barricade performance was important because of the heights workers were conducting their work. The score was based on the percentage of barricades that were in place, with the goal being 100%. Workers could fall to lower levels, or possibly worse, they could fall into the gulf. Preventing tools from being knocked off the edge of a platform to lower levels was also an objective of barricade performance. Morning safety meetings were evaluated for quality because of the importance of addressing safety issues and keeping the workforce aware of hazards.
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Housekeeping and job safety analyses were important to prevent fires, eliminate slip and trip hazards, and to make sure the workforce was on the “same page” regarding the safety procedures for each task. Interestingly, Toellner noted in one of his workshops that when the Leading Indicator #5, safety walkthroughs, were first begun the workforce had a somewhat negative reaction. It was often met with sentiments such as “here comes the safety cop again.” But, after the workers began to realize management actually cared for them and their safety, it became a powerful measure for impacting morale and safety perceptions. Toellner likened it to Scott Geller’s concept of Actively Caring for people. The walkthroughs were tangible activities where the organization could show by their regular, visible support and actions that they were actively caring for the workers and for their safety. This is a powerful concept that can shape the perceptions and culture at a worksite. Results from the Gulf Platform Case Study The outcomes, or lagging indicators for this case, were “seven times better than the industry average.” It was reported there were 2 million hours of work on the gulf platform with only one recordable injury. This is remarkable when one considers the high hazard context of the work and the additional challenges faced due to the relative inexperience of the workforce. The Formula for Safety Success? ExxonMobil Development Company (EMDC) has a philosophy that “Nobody gets hurt.” Safety is a core value, and they have analyzed and organized their safety management systems to accomplish this primary goal. EMDC incorporated a “Formula for Safety Success.” Based on a hypothesis that “safety is a mathematical fact” (see Toellner reference) the Formula for Safety Success maintained that “If you do it and do it well, you will get good results.” Here’s the “Formula for Safety Success” graciously shared by Jack Toeller:
Positive Energy x Efficiency = Results (Nobody Gets Hurt)
Positive Energy means the more you put into it, the better the results; Areas in which to sink positive energy include:
• Leadership, • Demonstrating Care, • Communication, • Training, and • Resources.
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To prevent “negative energy,” organizations should avoid initiatives that produce fear of failure and delegation of leadership. Efficiency implies the better you do it, the greater the chance it will be embraced by the team. It includes the following aspects:
• Alignment on Expectations, • Processes fit for Purpose, • Recognition of Risk, • Controls Effective (yet not overbearing),
and • Application of Lessons Learned.
Inefficiency includes elements such as Mixed Signals and Exceeding Organizational Capacity. Lessons Learned from Executing Leading Safety Measures at ExxonMobil The following lessons learned are adapted from Jack Toellner’s paper published by the Society of Petroleum Engineers on “Lessons Learned in Executing Leading Safety Indicators.” Lesson #1: You are not doing leadership teams a favor by giving them the answer. Ownership is everything! Toellner notes that safety professionals have a challenge in balancing the idea of “giving them the answer” versus “letting them discover the answer.” He believes you are not doing the leadership team a favor when you give them the answer. The principle behind this paradox is recognizing that “Ownership is everything!” Based on this recognition that “Ownership is Everything!” EMDC has a 2-step process for choosing Leading Indicators: Step #1 Solicit ideas from the Site Safety Steering Team; what do they think we need to work on; what is it the site should clearly be doing better or more of? Step #2 Solicit input from Site Management; what are they wiling to resource and support through visible leadership? Are they willing to hold themselves accountable with their management? Lesson #2: Choosing leading indicators is not a beauty pageant; we must focus on areas the team needs to Improve.
To prevent “negative energy,” organizations should avoid initiatives that produce fear of failure and delegation of leadership
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Toellner recommends that teams don’t choose to measure a process that is already being successfully executed, and end up essentially spending energy validating something that is already successful. Rather, “Leading indicators are not about showing just our best side (e.g., the beauty pageant), they are about recognizing our less flattering side where we need additional work, and then going and pouring energy into improving those areas of weakness.” Lesson #3: You may think you can, but you really can’t measure everything. To Be effective, one must prioritize. A common failure occurs when teams try to take on too great a challenge. There may be a belief that if several leading indicators are good, then more is even better! Organizational resources and capacity are not unlimited, and it’s important to recognize this fact by limiting the number of leading indicators being stewarded by an organization. An unintended consequence of making “everything important” is that essentially “nothing is important.” We can’t focus on everything at once. ExxonMobil’s experience suggests that a site should start with no more than four or five leading indicators. Toellner also recommends that sites avoid indicators and measurement processes that are too complex. Simplicity is important and simple measures that are meaningful are more likely to be supported by the workforce. He notes: “Sometimes in the safety business slow may be better if it leads to a higher level of acceptance and long-term success.” Lesson #4: Just because you can, doesn’t mean you should. Excel is not always your friend. You must present data in a fashion that the message is clear. Although Microsoft Excel is a wonderful tool, it isn’t always the best way to communicate what is important. Sometime a simple line graph with clear explanations can be more meaningful for employees. Lesson #5: Once a lagging indicator always a lagging indicator. Observation & Intervention programs are great, but they are not enough. Organizations must seek to impact culture and process long-term. Toellner claims that near miss reporting and observation & intervention (O&I) programs are important and add value when properly executed. Either of these is leading type behaviors, but if these are the only elements of your leading indicator programs then you may be missing high value opportunities linked to process and culture improvement. These two programs fall into the category of “Hazard Recognition” and ExxonMobil’s data analysis demonstrates that sites that embrace rigorous near miss reporting and/or O&I programs statistically perform better than those sites without O&I programs.
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However, the better leading indicator programs address not only hazard recognition, but also process and culture improvement. Near miss programs can be considered a leading indicator if they go beyond simply tracking and include an in-depth analysis that leads to incorporation of lessons learned. Case 4: Leading Measures for Advancing Behavioral Safety Efforts Introduction This food manufacturing company had been implementing Behavior-Based Safety (BBS) or Behavioral Safety for about 10 years at various locations throughout the organization. Although there had been some successes regarding reductions in injuries that appeared to be correlated to the BBS efforts, there were also some issues with the approach that needed to be addressed. The corporate and regional safety professionals wanted to continue BBS and contacted one of the authors to help them update and apply a more advanced approach to BBS. BBS has evolved using 3 distinct formats over the years. The first characteristic of BBS in the early years was mostly a “top-down” approach, with management making the decisions and calling the shots. This format was common during the 1980s. Then BBS evolved into more of a “bottom up” approach characterized in the 1990s and early 2000s allowing employees greater empowerment and authority in developing and making decisions about the approach. Dominic Cooper calls the third and most recent iteration of Behavioral Safety a “Safety Partnership” between management and employees. (Cooper, 5). This approach recognizes that it’s not just employee behaviors that are important, but management behaviors as well. An argument could be made that management behavior is more important than hourly employee behavior, because the leadership behaviors are leveraged and tend to have great impact. All three of these BBS formats are still practiced, depending on the organization. However, the Safety Partnership approach is the most promising because it is more inclusive regarding the meaningful behavior of all employees, including management employees. The food manufacturing organization had been using a combination of top-down and bottom-up approaches to behavioral safety. There had been a variety of successes depending largely on how well the approach was accepted and embraced by the various sites. On the other hand, the BBS process had grown stale and there were quotas for the number of observations and coaching sessions that participants were expected to complete each month. This quota system had resulted in a percentage of the submitted observations being perceived as low quality. These are sometimes called “pencil-
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whipping” or parking lot observations, and usually are not particularly meaningful or useful. Dominic Cooper – Findings from Research and Experience This is a relatively recent case and discussion here is related to the plans for improvement. The author drew upon numerous sources, including the ideas of the corporate safety team and passionate safety advocates within the company for developing leading measures for the Advanced BBS Process. However, the person whose ideas influenced the evolution of behavioral safety are from Safety Thought Leader Dominic Cooper. Cooper has documented case studies, lessons learned, and concepts for successful implementation and execution of behavioral safety in his book, Behavioral Safety: A Framework for Success. The foundation for the advanced approach to BBS was that the principles of this book would be applied to the approach. The following principles were applied for BBS leading measures:
• There would be a mix of leading and lagging indicators; • There would be a mix of type one and type two measures; • There would be a mix of measures for employees and for leadership; and • Primary measures would be limited in number from three to five
measures. The concept of type one and type two measures were influenced by the work of Terry McSween. Basically, type one measures are measures that identify and address practices that create the most exposure to injury, i.e., the work is being done safely. An example of a type one measure in BBS is “percent safe.” One might say that type one measures could be “considered a condition of employment,” especially for industries where failure to work safely could result in disabling injuries or fatalities. This is a slogan used by some companies, and working safely could be considered a condition of employment. Type two measures are designed to monitor and improve how well the behavioral process is functioning. Basically, these are the ways the safety process is supported. Type two measures are an expectation that employees (including management) will support the safety efforts, and they will be measured and held accountable for doing so. Generally speaking, type one measures more often concern employees while type two measures are primarily expectations for management. However, managers should be held accountable for type one measures – working safely – if they actually perform the work or are exposed to hazards; i.e., should wear the appropriate PPE, are in close proximity to the work being performed, etc.
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Largely, type one measures are more prescribed, whereas, with type two measures, employees and management may be provided with choices about how they would be measured. With type two measures, employees and management choose how they can meaningfully support the safety effort beyond the basics of working safely. With these principles in mind, the following five measures for the advanced approach were developed. The first and fifth measures are leadership measures, while the second, third and fourth measures are primarily employee measures: Measure 1. Safety Leadership Scores This measure is self-managed and self-designed. Although it is a “soft” measure, it can have a great impact on performance. With the safety leadership scores, there are separately designed pinpoints (or specifically defined behaviors) selected by management and self-managed. The self-report criterion covers a weeks’ timeframe and includes a green light if the behaviors are conducted daily, such as four or five times in a week; a yellow light for the selected behaviors completed two or three times in a week, and a red light if the behaviors are done rarely or never. Behaviors are selected from a list of ways to support the safety process and include items such as:
• Performing safety walkabouts to discuss safety; • Ensuring the closeout of safety-related corrective actions; • Conducting safety coaching; • Promoting safety coaching; • Attending safety related training with the team; • Recognizing employees for working safely; • Providing at least one positive safety feedback; • Reviewing observation data and its importance in safety meetings; and • Activity participating in safety activities.
The completed checklist should be turned in weekly. Managers are encouraged to pinpoint three to five behaviors for their performance, since they can’t focus on everything at as part of managers’ annual evaluations. Measure 2. Quality of Observations One of the concerns with the past performance of BBS was related to the poor quality of observations. Since there were quotas for observations, a lot of observations had been conducted and turned in. Some of the observations were valuable and led to real
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improvements. On the other hand, many observations were glib and possibly even “fictitious.” Most safety professionals probably recognize that quota systems with required minimums can cause issues. Cooper explains it this way:
“For a variety of reasons, observations are not always conducted. Within ‘one- on -one, peer-to-peer’ processes it is common for management or the project team to overcome this by setting observation quotas. For example, each person will be observed, or will conduct an observation once a month, or quarter. Often this leads to a massive number of observation cards being handed in at the end of the quota period, most of which focus on the use of PPE or unsafe conditions. This should raise suspicions about their authenticity. It also indicates the process has become merely a numbers game. In my view, it is much better to target the quality of observations, as they are much more likely to reduce the incident rate.” (Cooper, 131-132)
Cooper notes that quality of observations is assessed by comparing percent safe scores (the next measure chosen below) for specific pinpoints to those identified in near-hit and incident records. As the reported percent safe scores increase the associated injuries should decrease. For example, if wearing eye protection is the pinpointed behavior, and if the percentage of wearing eye protection is reported to be increasing, then the associated eye injuries should decrease. If this negative correlation does not exist then there is some kind of problem. Another way to assess the quality of written observations is by having a steering committee or safety team review the detailed comments from observation cards and evaluate the quality. Items that could be reviewed:
• Did the observer focus on the behaviors previously pinpointed on the checklist? • Did the observation include feedback reinforcing safe behavior or addressing
needs for improvement (coaching)? It could be argued that there is little or no value to an observation without feedback.
• Did the dialogue lead to a precise solution? • Was a “way forward” agreed upon?
It should be noted that especially powerful solutions are tapped when the solution impacts the system, rather than just one or two individuals. Regarding the use of incentives to improve the quality of observations, there were some sites with safety teams that evaluated observations similar to the points listed above. The team chose two or three winners for the best quality observations. These winners won an all-expense paid trips to a national safety conference.
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Measure 3. Percent Safe Score This is the most common score used in BBS. The organization was already using percent safe scores and wanted to continue using percent safe as one of their five primary measures. This metric is the only type one measure of the five measures selected – the remainder are type two measures that measure the level of support for the safety effort. Percent safe is determined by the ratio of safe to unsafe behaviors. As noted, it is a type one measure because it directly reduces exposure to injury. It is most effective when it is trended over time. Initial observations are used as a baseline to compare future scores. Goals are typically set by each work area and scores are compared to each goal. The formula for Percent Safe Scores: Percent Safe = Number of Safe Pinpoints (Behaviors) Total Number of Pinpoints Observed Measure 4. Number of Feedback Methods Utilized In a section entitled “Limitless Feedback,” Cooper makes the following points:
“Feedback is the key to performance. Although feedback comes in many shapes and forms, it has to be specific, relevant, credible, frequent, timely and linked to action sources to be effective… Research shows that using three to four feedback mechanisms reduced twice as many injuries as those using only one or two.” (Cooper, 31)
The food manufacturing company defined the following four methods of feedback for the fourth metric:
1) One-on-one feedback with two-way dialogue; 2) Simple graphs, using goal-focused line or bar graphs; 3) Unit feedback in safety meetings, training sessions, toolbox and pre-shift meetings; and 4) Written feedback such as newsletters, bulletins, job performance reviews.
The scoring criteria for the number of feedback methods utilized includes a green light for using all four methods; a yellow light for using two or three methods of safety feedback, and a red light for using just one method. This metric appears rather simple, but the impact can be rather profound.
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Measure 5. Percent Corrective Actions Completed This measure focuses on the number of corrective actions completed compared to the total number reported in a given time period- such as 30 days. The safety team chose >80% for green light, 60% to 70% for yellow, and <60% for red. The corporate office noted this one could be difficult to accomplish. The team made the following distinctions for this metric. First, the period of time would include a “rolling 30 days.” Secondly, the corrective actions that require engineering fixes or major expenditures would not be included as part of the metric, although they could be highly important and tracked under another system (outside of the BBS process). The theory is that as corrective actions are taken in a timely manner, the number of corrections needed should be reduced over time since many of them have already been addressed. Key Points about Leading Measures for Advancing BBS Efforts Although this case is new and results are ongoing, here are some strategies for applying these leading measures to behavioral safety: Key Point #1. Leadership behavior is the key to an effective behavioral safety effort. These 5 measures begin and end with measures for leadership. Leadership behaviors are the most important behaviors that impact safety performance. Key Point #2. Managers are given a choice on how they think they can most effectively support the safety process. Similar to the Brewery Case study where employees were expected to be involved in safety but were given a choice on how they would be involved. Similarly, management is expected to support BBS and safety, but is given a choice on how they will support the safety effort. Key Point #3. BBS processes can be made more efficient. The Organization practices a team approach to manufacturing at many but not all sites. Consequently, the safety approach is considered both personal and a team approach. The point is that the BBS process can be made more lean by utilizing one member per team as the observer, versus the former practice of having numerous BBS Observers. Key Point #4. One-on-one feedback skills can be enhanced. One of the factors impacting the quality of observations (or lack of quality) was that many employees either lacked the courage or the skills to give effective feedback to a coworker. A simple seven-step process was developed to aid employees in providing crucial safety feedback.
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A note about leadership reluctance to engage in leading safety measures. Quite often it appears that an approach that focuses on leading safety measures is not embraced by many organizations – while one segment forges ahead with positive results, other divisions may keep the same safety processes and continue to experience fatalities and serious injuries. It can be puzzling if no one asks what the successful division was doing to prevent fatalities, even though a particular approach may be highly recommended to others. Is it possible that an organization may perceive the approach as too much work? Or is due to a traditional resistance to change? CHAPTER REVIEW QUESTIONS
1. How did the necessity of the leading measures in Case Study #1 dictate the metrics that were tracked and emphasized? What limitations do you see with Case Study #1?
2. Name two innovative, cornerstone characteristics of Case Study #2.
3. Why, in Case Study #3, did ExxonMobil Development Company decide to
only focus on five measures of safety performance?
4. Compare the Case Study #3 with #s 1 and 2.
5. What do you think will the results of the plan discussed in Case Study #3? Why do you think that?
References Bevington, Anne M., Safety Management Process – Proactive Safety Metrics that Drive Performance in Manufacturing Facilities, Proceedings of the American Society of Safety Engineers Professional Development Conference, 2005. Conklin, Todd, Pre-Accident Investigations: An Introduction to Organizational Safety, Ashgate, 2012. Cooper, Dominic, Behavioral Safety: A Framework for Success, B-Safe Management Solutions, 2009. Gawande, Atul, The Checklist Manifesto: How to Get Things Right, New York: Picador, 2009. Geller, E. Scott, Actively Caring for People: Cultivating a Culture of Compassion, Make a Difference, 2012.
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Manuele, Fred A., Advanced Safety Management: Focusing on Z10 and Serious Injury Prevention, 2nd Edition, John Wiley & Sons, 2014. McSween, Terry E., The Values-Based Safety Process: Improving Your Safety Culture with Behavior-Based Safety, 2nd Edition, John Wiley & Sons, 2003. Toellner, Jack, Improving Safety & Health Performance: Identifying & Measuring Leading Indicators, Professional Safety Journal, September 2001. (pp. 42-47) Toellner, Jack, Lessons Learned in Executing Leading Safety Indicators, Society of Petroleum Engineers (SPE-168377), March 2014. Toellner, Jack, A Practitioner’s Approach to Utilizing Leading Safety Indicators to Drive Contractor Safety Performance, Power Point module for American Society of Safety Engineers SeminarFest, 2006. Weick, Karl E. & Kathleen M. Sutcliffe, Managing the Unexpected: Resilient Performance in an Age of Uncertainty, Second Edition, San Francisco: John Wiley & Sons, 2007. Wilson, Frazier, Personal Correspondence. Woerz, Paul, Personal Correspondence June 2006 and January 2014.
