Even though most workplaces are clearly not the same as an Olympic sports facility, there are “lessons to be learned” from this tragedy for occupational health and safety professionals.  

• Arguing whether the individual hurt was at fault is not productive.  As the Georgian President Mikheil Saakashvili stated – “…no sports mistake is supposed to lead to a death.”  When individuals die as a result of workplace incidents, the sentiment is the same.  Blaming the worker is just as counterproductive as blaming an athlete.
• Consideration of ”human factors” is both critical to preventing injury and more difficult and complex than it initially seems. 

What are those complexities?

First, consideration of human factors must consider each person as an individual.  Unlike machines, humans are not identical.  Each person is unique in size and statue, physical capabilities and emotional responses.  Protecting all workers means protecting each individual.

Second, there is a relationship between the consideration of human factors associated with a task and the development of the competency needed to perform that task.  Much of the disagreement expressed about the luge crash has focused on the skill and experience of Nodar.  The same issue is often a factor in industrial accidents – inexperienced workers have a higher accident rate.

Finally, our view of what is an acceptable risk evolves over time.  In a recent blog post on www.motorsport.com, Max Mosley, the former president of Formula One’s governing body, is quoted as saying “The International Luge Federation is where Formula One was 40 years ago – the whole mindset is wrong.” 

© ENLAR® Compliance Services, Inc. (2010)

Many organizations partially address this requirement by establishing an ergonomics program in order to address physical human factors.  Only a few organizations explicitly address mental human factors as a part of their hazard identification and risk assessment. 

Yet, mental human factors are very real and can be just as important as physical human factors.  In some cases, they are even more important.  For example, when one is driving a car, factors that reduce mental acuity – such as talking on a cell phone – are typically much more significant than physical capabilities.  The dangers of being distracted while driving is important enough that the first Distracted Driving Summit was held last fall and the U.S. Department of Transportation has set up a Distracted Driving website. 

The human brain has been described as having “a very large hard drive but limited random access memory (RAM).”  As demonstrated by our proficiency at trivia games and success in answering questions on quiz shows like Jeopardy, the human brain is capable of storing a great deal of information.  On the other hand, studies show that most people have difficulty remembering more than 7±2 items at a time in short term memory.  Our mental processes were developed for a very different environment than we find ourselves in today.  In the past, our modes of information delivery moved much, much slower with significantly fewer “inputs per minute.”  

Yet we design work environments as if this mental limitation does not exist. 

We expect individuals to work at full capacity in environments with multiple stimuli.  We set up equipment lines so they are efficient for the machines but terrible environments for the people who have to work there.  We design work processes and work shifts as if mental limitations do not exist.

Unfortunately, when accidents do occur – which they inevitably will – we blame the individuals involved and tell them how “bad” they are. 

I’m not sure if this is silly, sad or tragic but it sure is NOT a sound management system approach.

© ENLAR® Compliance Services, Inc. (2010)

They loved it.

That should be great – right?

Well… The problem with an “approved strategy” is that now someone has to implement it.

This is a common issue that arises when an organization establishes an occupational safety and health management system.  The company tasks a team that sets up the framework for the OHSMS, someone writes up the procedures to match the conceptual framework and objectives are established for the various improvement initiatives that have been envisioned.

Then comes implementation – “doing what you say you are going to do.”  This is often the hard part.

For success – you need BOTH strategy and implementation.  

• If you have strategy without implementation, you may have great plans but the organization will get no benefits from the strategic planning (the “dusty manuals” syndrome).
• If you have implementation without strategy, you will have action but are likely to miss the mark and end up doing the wrong things well (the “ready, fire, aim” syndrome).

For a good discussion of the important of getting it right and doing it right – check out the following blog post – Strategy IS Execution.

© ENLAR® Compliance Services, Inc. (2010)

Many organizations use the start of the year as a time to review their OH&S management system objectives and set new ones.  If their OH&S programs are lagging in their implementation, new approaches or new assignments are considered. 

This is also a good time to address all that PAPER – either physical paper or electronic paper.  This includes all those completed hazard evaluation forms, inspection checklists, excel spreadsheets, meeting notices and minutes, e-mails with various interested parties, incident investigations, corrective action reports,….

When I help develop record control processes and procedures for an organization, one of the concepts I try to incorporate is the inclusion of record schedules with record breaks and scheduled clean-out days. 

A record schedule is a document that defines how a record is to be kept, how long it needs to be maintained in an active storage location and when it should be destroyed.  U.S. EPA has an informative discussion of the purpose and use of record schedules on its web site. 

The first key to using a record schedule is organizing your records in a way that makes complying with your record retention requirements as easy as possible.  This usually means using record breaks – usually defined points in time when you start a new file. For example, rather than filing all of your records pertaining to a particular topic randomly in one file folder (physical or electronic), you file them by year so you can move an entire year’s worth of records to a different location (off-site storage or electronic archive) at one time. 

The second key to using a record schedule is actually setting aside a time for moving old records out of active storage locations and getting rid of unnecessary records in accordance with your organization’s record retention policies. 

Although this often appears to be an unimportant mundane task to “put off to another day” it is important to the smooth functioning of your OHSMS. 

So, schedule your record clean-out day today.  By the way, wear comfortable clothes and order a pizza.  It will make the job easier.

© ENLAR® Compliance Services, Inc. (2009)

This is not easy.  Often, the root cause investigation ends with a determination along the lines of “Joe screwed up.”  We play the blame game.

Why?

There have been a number of reasons advanced for this and most of them are probably true – at least in part.

Last week, a colleague lent me his copy of Dan Gano’s book – Apollo Root Cause Analysis.  This book sets out a different way of approaching root cause analysis by focusing on defining a problem in terms of both the action and the conditions that caused the particular effect you are analyzing.  For example, you don’t get a fire (an effect) unless you have an ignition source (an action) as well as two conditions (fuel and oxygen at the right concentrations).  Remove either condition (fuel/oxygen) or the action (ignition) and the effect (fire) does not occur.

What I liked most about the book, however, was not the root cause methodology advanced in the book but the explanation of why we so often fall into the blame game.

In a word – storytelling.

As humans, we have a long tradition of storytelling.  It comes naturally to us.  It is how we have transmitted information for generations.  Everyone likes a good story.

Integral to storytelling is identifying your actors – answering the question “who” is central to telling a good story.  As Gano points out in his book, most incident reports provide a prime example of storytelling.  The initial focus is typically on who did what.  Unfortunately, for purposes of root cause analysis, storytelling sets us up for failure because it keeps us focused on the story – who, what, where and when – rather than focusing our attention on identifying the causes of an incident. 

So when you are investigating an incident or nonconformity, tell your story.  It is, after all, human nature and likely irresistible.  But when you start your root cause analysis, put the story aside and take the “who” completely out of the analysis.  Remove the names and strike the identifiers.  Instead, focus your attention on the actions and conditions that lead to the situation (effect) that you are investigating.

© ENLAR® Compliance Services, Inc. (2009)

So – What is Timely?

Neither OHSAS 18002 nor the dictionary (my primary sources for interpreting the OHSAS 18001 requirements) provides much help. 

OHSAS 18002 does not explicitly discuss this particular requirement of the OHSAS 18001 standard.

The dictionary isn’t particularly helpful either. It defines timely as – “well-timed, in time, occurring at a suitable time, opportunely“. The legal dictionary definition is “falling within a prescribed or reasonable time.”

As a practical matter, there are several components to a “timely” incident investigation –

•  “The CSI Factor” – As in the TV show CSI, you will want to do your immediate investigation of an incident (who, what, when and where) while the facts are fresh – before memories fade and “the evidence” disappears.
• Dealing with Imminent Risks – Hazards that are imminent risks (e.g. defective ladders, broken guards on operating equipment) need to be addressed immediately.
• Preventing Future Injuries – Since the primary purpose of incident investigation is prevention of injuries, the root causes of an incident (why and how) need to be determined and addressed before another similar incident occurs.

An investigation does not need to be completed all at once in order to be timely.

An incident investigation is often done in two stages:

1. Initial information collection – preserving the evidence
2. Root cause analysis – determining what the evidence means

The initial of collection of information about the incident usually needs to be done quickly. The root cause analysis typically takes more time.

So what do you think? Let me know by completing the survey below or posting a comment.

© ENLAR® Compliance Services, Inc. (2009)

Not true. 

As this video points out, at some point more information simply makes us stupid.

This is an important point to remember as you are establishing, implementing and maintaining your OH&S management system.  As you are developing your procedures, programs, forms, inspection sheets, training programs, meeting minutes, e-mail updates…… remember that the human brain only has so much capacity. 

Use it wisely.

© ENLAR® Compliance Services, Inc. (2009)

Why is that OH&S management system manuals so often repeat the language of the OHSAS 18001 standard – isn’t that redundant?

Yes and No.

During management system implementation, the constant repetition of the OHSAS 18001 language feels redundant.  You are referring to OHSAS 18001 constantly – in drafting procedures, discussing processes, creating forms and developing training programs.  You probably feel – “enough already with the arcane standards speak.”  Since you are so close to the initial drafting of the manual and other procedures, it is clear in your mind what the OHSAS 18001 requirements are and how you are planning to meet them.

As with most things, memories and associations fade with time. 

One of my favorite Christmas stories is that each year when we got together with my mother and my husband’s parents for Christmas, my Mother would start a question with “What year was it when we ….”  A lively discussion would ensue as we tried to remember exactly what year it was that we did some particular activity – “Was it 1997 or was it 2000?”  My mother has since passed away but we still discuss “What year was it when we …” at Christmas – and I am reminded of her presence.

A similar thing happens with your management system manuals and procedures.  Over time, people will forget both WHAT they need to do and WHY if you don’t actually include the requirements in your Manual.  The “shall clauses” in the OHSAS 18001 standard are unlikely to be remembered and may not actually be met if you don’t explicitly include them in your own OHSMS documentation.

One of the tests of the completeness of a management system manual is whether you can file the standard away (never refer to it again), and still have a management system that continues to be in conformance with the requirements of OHSAS 18001. 

In fact, the hallmark of a good internal audit program is that audits are performed against the organization’s own OHSMS documentation – its manual and procedures – NOT against the OHSAS 18001 standard.  Conformance with the OHSMS manual IS conformance with OHSAS 18001.

© ENLAR® Compliance Services, Inc. (2009)

At this meeting I gave a presentation – Challenges & Opportunities in Developing OHSMS Standards – that outlined five common barriers to implementing Occupational Health and Safety Management Systems.  Also giving presentations on this topic were Mike Seymour from OSHA and Barbara Braun from The Joint Commission.  Mike Seymour discussed the OHSMS guidance document that OSHA is currently in the process of developing and Barbara Braun discussed how the Joint Commission standards also include worker safety requirements.  As several of the attendees pointed out, there is a clear and obvious link between patient safety and worker safety.

The purpose of these presentations was to assist the HCSA Sector Council in developing implementation plans for the new National Occupational Research Agenda for this sector (currently out for public comment until the end of October 2009).  A key strategic goal in this agenda is promoting the use of OH&S management systems and improving safety culture in healthcare organizations.

The scary part of the meeting…

The critical issues that need to be addressed to protect health care workers – particularly as it relates to the H1N1 pandemic.  There was a great deal of discussion concerning the precautions that need to be taken related to providing proper respiratory protection - NOT JUST SURGICAL MASKS – and the current lack of hospital preparedness.  The importance of this topic was emphasized by the advisory issued by the Institute of Medicine yesterday that urges health care workers to use N95 respirators instead of surgical masks for protection.

© ENLAR® Compliance Services, Inc. (2009) 

The need to pay for preventive maintenance.

When we moved to Florida, we purposely choose to live in a neighborhood that did NOT have a golf course, community center or jointly owned “common areas.”  Instead, we choose a neighborhood that had a voluntary homeowners association – not a mandatory one.  A couple of years ago, a few neighbors wanted to “beautify” the neighborhood by putting up signs and installing landscaping.  They did so.  Then, because the plantings they put in were dying and you could not see the new signs at night, they wanted to add irrigation and lighting.  They did so.  Needless to say, once they realized that these things were costing money, there was an attempt to impose mandatory fees to pay for the on-going expense.  It didn’t happen.  These neighbors became upset when the rest of the neighborhood was not interested in paying for their neighborhood beautification efforts.

According to last Friday’s paper, the National Mall is slipping into a state of neglect. Apparently, ducks died last year of avian botulism because the water in a mall pool was so foul, the Jefferson Memorial is sinking into the mud and the soil is so compacted in places that grass can’t grow.  Yet, Congress has refused to provide funding to pay for the necessary upkeep.

What do these stories have in common? 

The failure to recognize that – “If you build it, you’ve got to maintain it.”

This is an important warning to keep in mind as you develop your OH&S management system. 

Whatever systems you put in place must be maintained –

• Documents need to be reviewed and revised
• Software needs to be maintained and updated
• Controls need to be inspected and maintained

All of this costs money.

Make sure you consider the long-term preventive maintenance costs before you put systems, software and controls in place.  If you can’t maintain them, you may only make things worse.

© ENLAR^® Compliance Services, Inc. (2009)