Learning from Potential Serious Injuries and Fatalities

Over the past century, there have been many changes in how companies manage their safety systems. Although fatalities were common and accepted as part of doing business in the 1920s, great strides were made throughout the following decades to reduce or eliminate unsafe conditions. Over time, safety measures continued to increase among various sectors, which led to a decline in serious injuries and fatalities. In the nearly five decades since the Occupational Safety and Health Act was signed into law, workplace deaths and reported occupational injuries have dropped by more than 60 percent, according to a January 2012 white paper published by OSHA.

And yet serious injuries and fatalities (SIFs) and potential serious injuries and fatalities (PSIFs) continue to afflict companies across a wide range of industries. When a company experiences a SIF event, safety consciousness usually increases. However, when a PSIF incident occurs, some company leaders do not know where or how to take action to strengthen the company safety culture against future risk.

One solution to this problem is for leaders to consistently use an incident decision tree or assessment questions to determine PSIFs. Each PSIF incident should be treated as an actual event, and a thorough incident investigation should be conducted. The main objective in an investigation is to recognize and diminish precursors – existing conditions that are known to increase the risk of an incident – in order to avoid a future SIF or PSIF.

Once a company has set and is using standard criteria for SIFs, an incident-related injury can be properly classified on a consistent basis. On the other hand, because a PSIF doesn’t result in a serious injury or fatality, determining when a situation is considered a PSIF may require the keen judgment of a safety or operations professional. This may be needed if, for example, a worker uses a grinder without the required guard and receives a small laceration due to loss of control. Could this injury have been more serious? Should it be classified as a PSIF, which would require a more in-depth investigation? If you answered yes to these questions, then you understand the significance of the PSIF process. The next two questions should be, how many other workers are using a grinder without a guard and why?

Safety System Integration
Existing safety systems that companies use may include safety observation processes, site audits and near-miss reporting. These system components can be integrated into a PSIF process, during which PSIFs are identified via observable and non-observable precursors. Precursors can lead to a high-risk situation if management controls are absent, ineffective or not complied with; if the precursors are permitted to continue or repeat, they could reasonably result in a serious injury or fatality. Examples of precursors include a worker who is unfamiliar with conducting a critical task; unexpected equipment conditions; and lack of a work practice or procedure to safely complete a task. A PSIF can occur at any moment, in any area of activity. Merging the act of precursor identification with site audits, for instance, will aid in the reduction of PSIFs, injuries and near misses.

There have been incidents that never occurred due to the effectiveness of PSIF investigations and complete follow-through of communications with frontline workers. Bulletins, face-to-face discussions and creating videos to share information are steps organizations have taken to reduce SIFs and PSIFs. When these types of incidents are given visibility, they boost employee awareness in a variety of areas, including hazard recognition. Reporting near misses is another key component in the SIF-PSIF prevention process. Cultivating a culture that is open to receiving these reports without repercussions will promote an organization’s commitment to reducing SIFs and PSIFs.

Once a company has implemented a SIF-PSIF program, SIF and PSIF incidents must be tracked and analyzed in order for the program to be effective. To make progress with any program in an existing safety management system, metrics must be developed to discover increases and decreases in risk over time.

It’s no secret that workers still have SIFs and PSIFs that could have been prevented. When PSIFs are properly investigated, assigned corrective actions and lessons learned are shared, then a company can better identify precursors and mitigate or eliminate the risk and occurrence of SIFs and PSIFs.

About the Author: Richard J. Horan Jr., CSP, CUSP, is a corporate safety director for Blue Bell, Pa.-based H&M Shared Services Inc., a Henkels & McCoy Group company. He has 37 years of experience, including work as a frontline mechanic, senior safety professional and safety manager providing risk solutions. Horan is past president of the Philadelphia Chapter of ASSE and a member of AIHA. He holds a master’s degree in safety sciences from Indiana University of Pennsylvania.