The New View of Safety (Safety-II)
The New View of safety, also called Safety-II, came about in the late 1990s and 2000s. During this time, practitioners and academics in the safety field began to question the effectiveness of the traditional safety management practices described above.
Although the rate of workplace illnesses and injuries had been reduced from 11.0 in 1973 to 6.1 in 2000 (representing recordable injuries per 100 workers), fatalities had not been reduced to the same extent.
In fact, the average occupational fatal injury rate in US industries has hit a statistical “plateau,” stuck at 3.4 since 2008 (R. Gantt, “Safety Differently – A New View of Safety Excellence,” Session 590, ASSE Proceedings, Feb 2015.
So industry leaders and insurers began to ask why all of the money invested in safety staff, equipment and procedures, training and safety audits had not virtually removed every hazard and prevented every injury by now?
Why did so many “Drive to Zero” safety programs have such minimal results?
As illustrated above, traditional safety practice tends to be backward-looking and based on responding to failures like injuries and lost days. Accident analysis focuses on behavioral and system failures that result in injuries or process interruption.
Although the effort put into understanding “what went wrong” and trying to fix it is effective in preventing the recurrence of the exact same failure (assuming the corrective actions selected are effective long-term), focusing solely on preventing recurring failures precludes an understanding of 99.99% of the other actions that do not result in accidents.
In other words, safety staff often spends time looking at the wrong things.
The Flaw in Heinrich’s Triangle
The concept that serious accidents occur after a finite number of minor accidents (i.e. the Injury Pyramid Theory) was developed by H.W. Heinrich in “Industrial Accident Prevention: A Scientific Approach”(1931).
“Heinrich’s Pyramid” as it came to be called, can be found on safety posters in company break rooms worldwide; and the belief that by eliminating minor injuries and unsafe conditions, the major breakdowns and catastrophes would be avoided has launched a thousand corporate safety initiatives.
Unfortunately, Heinrich got it wrong, since some of the worst industrial accidents in recent times—the Challenger explosion, Deep Water Horizon disaster, the Texas City Refinery fire, etc.—have happened within organizations with OSHA VPP status and below industry average injury and illness rates.
Clearly, minor incidents and major catastrophes were not statistically linked as common sense, as Heinrich’s theories would indicate.
According to the U.S. Chemical Safety Board’s analysis of the Texas City refinery explosion, “BP Texas City explosions was an example of a low-frequency, high-consequence catastrophic accident. Total recordable incident rates and lost time incident rates do not effectively predict a facility’s risk for a catastrophic event.”
Beyond Anticipating and Correcting Failures
Recognizing that the nature of organizations and work processes has become so complex and interrelated that conventional approaches to hazard analysis are no longer up to the task of anticipating and correcting likely failures, a new approach is clearly needed.
“Safety and risk in a complex system are not a matter of controlling, governing, standardizing, and understanding individual components. So-called system accidents (Perrow, 1984), while rare, are caused by the interactive complexity of the system itself…System accidents result from the relationships between components, not from the workings or dysfunction of any component part.” (Dekker S, The Safety Anarchist, p. 134 (2018)
This includes actions and inactions of workers who are part of an increasingly complex process. Although a worker may make a “mistake” to start a chain of events, it’s the system design and operating characteristics that determine if the consequences will be catastrophic or minor.
The New View Explained
“New View” safety programs are not based on checking the usual compliance boxes that traditional safety management is built on. Since many companies embrace New View principles after having used a conventional approach for many years, they already have the compliance-driven, audit-based, highly bureaucratic structures in place.
The goal in these companies is to increase the effectiveness of the safety effort and to reduce injuries and hopefully guard against those low-probability, high-impact catastrophic accidents.
Breaking down some of the bureaucracy and emphasizing employee operational knowledge over the “expert” knowledge coming from the Safety and Quality departments is a first step.
Some broad principles of the new safety approach are listed below: (Todd Conklin, Pre-Accident Investigations, 2012)
- Safety is not the absence of accidents; safety is the presence of defenses.
- Humans are born to make mistakes.
- Employees come to work wanting to perform their jobs well.
- Workers don’t cause failures (failure is built into the system).
- Workers are not problems to be fixed, but solutions waiting to be found.
- After an accident, you can blame and punish or learn and improve.
This approach places a high value on employee knowledge and focuses on communications between the shop floor, safety department, production, and quality.
Allowing employees to influence work processes and use their knowledge to drive system improvements is the key to New View Safety Management.
With Safety-II, safety staff concentrates on the 99% of worker actions that result in positive outcomes and use the occasional incident or failure as a learning opportunity to understand how the system failed and what might be done to make predictable failures have less severe consequences.
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