SafetyInsights.org

This paper evaluated whether investigations findings and corrective actions were influenced over time by a national focus on Prevention Through Design (PTD) and the Hierarchy of Control (HoC).

That is, they’re comparing investigations prior to and following a particular time point (2007) for differences in what causes are attributed (e.g. active or latent failure types) and what types of corrective actions are assigned. 249 investigation reports from seven organisations were evaluated.

Note: I’m using a lot of direct quotes since I can’t put it better than the authors did.

Providing background:

• The years 2005 – 2007 seem significant in demarcating a possible shift in safety-related decision making, given that, in the US at least, the ANSI Z10 standard was approved in 2005
• Manuele also noted a transition in the practice of OHS ~2005, with greater emphasis on the HoC, HAZID, risk assessment and design of the workplace and work methods
• Taken together, these examples and more “signifies a shift is what is being written about and read by safety professionals” over time, but noting that the HoC isn’t new (dating back to the 1920s in the area of industrial hygiene and since the 1970s in safety via Haddon)
• Prior work from Culvenor concluded that it was “easier for organizations to
• solve problems using lower-order controls, whereas higher-order controls are sometimes difficult to develop and implement, even though they have the ability to fundamentally change the work”
• Moreover, Culvenor maintained that “higher-order control solutions are often brushed away as being far-fetched”
• One challenge with higher-order controls is that “investigators are usually so close to the job that their main objective is to correct the immediate technical faults that caused the incident and get the plant back on line; putting the world right is not their problem”
• Work from Manuele suggests that causal factors for low probability/high consequence events are “seldom represented in the analytical data on accidents that occur frequently”, with perhaps ergonomics incidents being an exception,
• And Manuele also observes “many incidents resulting in serious injury are unique and singular events, having multiple”, complex causal factors that may have technical, operational systems or cultural origins”
• Thus, “it may be that if organizations tend to solve OSH issues with lower-order controls they will impact frequency but not severity”
• Lower order controls may influence individual and group behaviour at one point, but might also “mask management and systemic deficiencies that will eventually result in an infrequent yet severe incident”

Results

Key findings were that investigations before 2006 and 2008 to 2014 had some key differences:

1. Incident causes categorised as either latent or active failures have not statistically changed over the time periods
2. Risk reduction recommendations in investigations had slightly changed to include more higher-order controls, but this wasn’t statistically significant
3. Elimination was the only control where a statistically significant change was observed

Discussing the findings, while it appears that slightly less active failures are being attributed in investigations, and there is a slight increase in the percent of latent failures being identified, neither were statistically significant.

However, diving into specific datapoints yields more insights. For one, the use of elimination as a solution to OHS issues was found to have statistically increased over the two time periods. In 2006 and earlier, 2% of solutions were identified under elimination, compared to almost 11% of solutions from 2008 onwards.

Substitution and engineering weren’t statistically significant between the time periods.

For lower order controls, no significant difference between the time periods was observed. However, they found that administration controls were recommended in nearly 88% of all investigations.

In this dataset, investigations “were focused largely on single causes and single solutions”. An average of 1.05 failure types and 1.3 solutions were specified in the investigations. This could be a limitation since a body of evidence surrounds incidents having multiple factors and multiple learning opportunities.

Another study from the lead author found “6.6 causes and factors identified per incident during a thorough research process compared to 1.2 causes and factors identified by the case study organization”. A maritime review of incident reports also found that organisational factors were under identified, compared to sharp end/worker factors.

Taken together, the authors wonder whether “safety professionals are stuck in an administrative control mind-set” and whether the “safety profession [is] stuck at the sharp end?”. Another view is the ease of targeting training, updating procedures or worker behaviour, such that these facets are “likely within [safety professionals’] sphere of influence”.

That is, they wonder whether an incident investigation is “more closely aligned with [an investigators’] sphere of influence than the hierarchy of controls?”.

Here they suggest that the “organizational view of the safety professional’s role must evolve and be upgraded”. This evolution can be seen, in part, with the proposed relationship they provided between the ability to incorporate higher-order controls into work and design based on the lifecycle of a product, process, service or technology, based on Szymberski’s 1997 work.

Authors: Behm, M., & Powell, D. (2014). Professional Safety, 59(02), 34-40.

Study link: https://foundation.assp.org/docs/ASSEF_SHE_Problem_Solving_Higher-Order_Controls_14.pdf

LinkedIn post: https://www.linkedin.com/pulse/she-problem-solving-higher-order-controls-ignored-ben-hutchinson-1cw7c