Serious Injury and Fatality Prevention

How a fatality changed a company

A colleague of mine died at work in 2006. He was engulfed by grain outside of a large storage tank. I remember receiving the phone call, arriving on scene to see his body lifted into the back of the coroner’s vehicle, and his wife kissing him on the cheek for the last time. I also remember seeing his young children at the funeral and thinking how they would never really understand what a great dad they had and how he loved them.

Prior to my colleague’s fatality I believed my employer had one of the industry’s leading safety programs. We had a robust safety management system as well as comprehensive auditing and employee training programs. In reality what we thought was an effective safety program was focused on the wrong thing. We knew we had to change our ways so that this type of incident never happened again.

We assembled a team to lead our “safety improvement initiative.” We also identified that we needed outside help. The first call we made was to a consulting company that specialized in helping companies get to the next level. They developed a company specific engagement strategy, and we hit the ground running.

After their initial analysis, the consultants identified that we were focusing our efforts on preventing minor injuries, such as recordables, instead of Serious Injuries and Fatalities (SIFs). Data from the Bureau of Labor Statistics indicates that the number of workplace fatalities over the past two decades has increased while the number of non-serious injuries has decreased. Prior to the fatality, we believed that focusing on preventing non-serious injuries would reduce the potential for SIFs. Based on the data, we quickly learned that this strategy was ineffective.

Changing Focus

Prior to the fatality, our auditing methods were focused on regulatory compliance and conditions rather than identifying SIF precursors. While unsafe conditions should be addressed, SIFs are most likely to occur when a worker comes in contact with a hazard during a routine or non-routine task. An effective and often overlooked method to identify activities with SIF potential involves engaging employees in conversation about the hazards they face. We accomplished this by conducting employee interviews and using employee focus groups.

We asked employees what activities they performed that cause fear and anxiety or could seriously injure or kill either them or a coworker. The answers to these questions identified activities with SIF potential, such as permit required confined space entry, jobs requiring complex lockout/tagout, loading railcars, handling hazardous chemicals, and non-routine maintenance activities.

Our conversations with employees established trust and allowed us to better understand their concerns. This was not something we were accomplishing through our traditional approach to auditing. Engaging employees also established a sense of urgency leading to immediate rather than delayed action to eliminate, control or reduce hazards in their work environment.

We learned a great deal from our SIF conversations with frontline employees. After, we shifted gears to addressing the SIF precursors. We used the hierarchy of controls methodology to address each precursor. Prior to the fatality, we often used less effective strategies, such as personal protective equipment or administrative controls. Our focus shifted to using elimination, substitution, and engineering controls where feasible. We also delivered a course on job hazard analysis (JHA), with a focus on the hierarchy of controls, to frontline supervisors and managers. Implementing the JHA process was important for sustaining our SIF identification efforts longer term.

Identifying SIF precursors through employee focus groups and implementing the JHA process were two of the most important strategies we used to prevent SIFs.

In addition, we delivered educational courses to the company’s supervisors and managers on leading with safety, feedback and recognition, collaboration, and accountability. We also revamped our near miss reporting process with a focus on incidents with SIF potential, defining our vision for safety, and identifying the behaviors at each level of the organization that would support this vision. These behaviors eventually became part of the company’s performance evaluation process. We wanted each employee to understand that safety was part of their job.

If you are looking to make a shift at your organization, consider starting with employee engagement. Simply form small groups at each facility or business unit and ask employees what they do on a routine or non-routine basis that makes them nervous, causes concern, or could seriously injure them or a coworker. I wish we had asked these questions sooner. It might have saved a life.

Joe Mlynek is president and safety and loss control consultant for Progressive Safety Services LLC, Gates Mills, OH; 216-403-9669; and subject matter expert for Safety Made Simple, LLC, Olathe, KS.