Safety Management

Peer-Reviewed

Fatality Prevention
Findings From the 2012 Forum
By Jan K. Wachter and Lon H. Ferguson

A
2-day fatality prevention forum showcases and breakout sessions. The
was held in late October 2012 to breakout sessions served to document
examine the nature and cause of actual best practices used to prevent fa-
fatalities in the workplace and recom- talities and serious injuries (FSIs) as they
mended prevention strategies. It was relate to one of these areas:
a natural extension of the 2007 Fatality •leadership and organizational attri-
Prevention Forum (Cekada, Janicak & butes;
Ferguson, 2009). The 2012 forum had •developing a risk profile;
these objectives: •effective risk assessment method-
1) Identify practical approaches a fa- ologies;
cility can use to develop a risk profile. •managing the contractor/contracted
2) Recognize the most effective lead- services risk;
ership styles and organizational attri- •effective control for high-risk tasks.
butes necessary for a fatality prevention
effort, including (but not limited to) Presentation Highlights
training, root-cause analysis and em- Several key themes emerged, as re-
ployee engagement. flected in the findings presented in se-
3) Determine the role of human perfor- lect presentations (Fisher, 2012; Krause,
mance concepts in preventing fatalities, 2012; Newell, Comingore, Murray, et
especially as it relates to human-systems al., 2012).
integration and the recognition/elimina-
tion of error precursors.
4) Evaluate the influence of a person’s IN BRIEF
perception of risk, the required mental •Indiana University of Pennsylvania, in cooperation with
and physical aspects of the task, latent Alcoa Foundation, DuPont Sustainable Solutions, Edison
conditions and performance modes as Mission Group and U.S. Steel, hosted an international 2-day
they relate to fatality prevention. forum to study the nature and cause of workplace fatalities,
5) Discover best practices, innovative as well as to recommend prevention strategies.
technological concepts and tools that •Three key findings emerged:
have the potential to transform the abil- 1) A new measure, the fatalities and serious injuries (FSI)
ity to identify, assess, mitigate or elimi- potential rate, is being advocated for use in measuring an
nate the risk of fatal and life-altering organization’s risk for having FSIs.
injuries. 2) To reduce FSIs, organizations need to identify, under-
6) Identify areas of future safety re- stand and control the precursors of all incidents that have
search and public policy that could drive the potential to cause FSIs.
significant improvement in the ability to 3) Management of risk associated with FSI precursors
predict and prevent fatalities. must occur at the task level—individual tasks must be ana-
These objectives were met through lyzed and controlled for their FSI potential.
a series of presentations, best practices

Jan K. Wachter, Sc.D., CSP, CIH, is an associate professor in the Lon H. Ferguson, Ed.D., CSP, is a professor of safety sciences at
Safety Sciences Department at Indiana University of Pennsylvania IUP and chairs the university’s Safety Sciences Department. He holds
(IUP). He hold a B.S. in Biology, an M.S. in Environmental Health, a B.S. and an M.S. in Safety Sciences from IUP, and an Ed.D. from
and an M.B.A. and a Sc.D. in Environmental Health from Univer- University of Pittsburgh. Ferguson is currently vice president of BCSP
sity of Pittsburgh. He also holds degrees in theology. Before joining and is a member of ASSE’s Educational Standards Committee. He is
academia, Wachter was employed by Fortune 100 companies and the a past recepient of ASSE’s William E. Tarrants Safety Educator of the
U.S. Department of Energy. He is a professional member of ASSE’s Year Award. Ferguson is a professional member of ASSE’s Western
Western Pennyslvania Chapter and a member of the Society’s Aca- Pennsylvania Chapter and a member of the Society’s Academics
demics Practice Specialty. Practice Specialty.

www.asse.org JULY 2013 ProfessionalSafety 41

 Figure 1
The New Paradigm
High  potential     However, the study also showed that
Precursors   Outcomes  
events   the traditional triangle is not accurately
Unmi�gated  high  risk   predictive (Krause, 2012). In other words,
situa�ons   Near  misses   not all injuries have FSI potential (or the
Accidents  
same FSI potential). A reduction of inju-
High-­‐risk  event   Serious  injuries     ries at the bottom of the triangle does not
combina�ons   Injuries   and  fatali�es  
necessarily correspond to an equivalent
Exposures   reduction of FSIs. Of the 300 sampled in-
High-­‐risk  ac�vi�es   juries, 64 had the potential to be FSIs.
According to Krause (2012), FSIs are
Note. Adapted from “New Perspectives in Fatality and Serious Injury Prevention,” by T. disproportionately related to certain types
Krause, 2012, presentation at Fatality Prevention Forum 2012, Coraopolis, PA, USA. of activities and to certain types of safety
controls. For example, most incidents as-
In the new Theme 1: New Paradigms, Models, sociated with operation of mobile equip-
paradigm, all minor Frameworks & Tools for FSI Prevention ment or watercraft, or working under suspended
injuries are not A new framework for FSI prevention is being ad- loads are considered to be FSI type activities. Based
the same. Injuries vocated to resolve a common issue for leading com- on such analyses, FSI precursors (i.e., unmitigated
of differing sever- panies in the area of safety performance: Recordable high-risk situations that will result in a serious or
ity have differing and lost-time injury rates are declining steadily, but fatal injury if allowed to continue) can be identified
underlying causes, fatality rates are level or increasing (Krause, 2012). that will inform intervention strategies.
and reducing seri- This is contrary to what has long been presented An example of a precursor is an employee work-
ous injuries requires in the safety triangle—that minor injuries predict ing on the bottom of an elevated vessel with no ap-
a different strategy serious injuries and that by controlling the causes proved place to secure a lanyard. Other examples
than reducing behind minor injuries, serious injuries will also be of activities that may have high proportions of pre-
minor injuries. controlled. According to Krause, an FSI prevention cursor events are mobile equipment (operation and
study involving several organizations was conduct- interaction with pedestrians), confined space entry,
ed to develop a model to understand and prevent jobs that require lockout/tagout, lifting operations,
FSIs. Using data from participating companies, working at height, caustic liquor handling and man-
these questions were studied: Is the traditional safe- ual handling. Situations that may have high propor-
ty triangle accurate descriptively? Is it predictive? Is tions of precursor events include process instability,
it possible to develop intervention principles, crite- significant process upsets, unexpected maintenance,
ria and methods to address FSI events? unexpected changes, high-energy-potential jobs
The study found that the triangle is accurate and emergency shutdown procedures.
descriptively (e.g., one fatal incident occurs every Based on these findings, Krause (2012) argues
x times when a serious incident occurs) (Krause, for a new paradigm (Figures 1 and 2). The old par-
2012). Implications of the triangle’s descriptive va- adigm holds that 1) all low-severity injuries have
lidity are that it provides an accurate description of the same potential for serious injury; 2) injuries of
the quantitative nature of incidents and provides differing severity have the same underlying causes;
insight that informs prevention strategies. It means and 3) one injury reduction strategy will reach all
that a single incident has significance (i.e., single kinds of injuries equally (e.g., reducing minor inju-
incidents inform people about the system). ries by 20% will also reduce major injuries by 20%).
In the new paradigm, all minor injuries
are not the same (Krause, 2012). However,
Figure 2
specific subsets of low-severity injuries
An Enhanced Paradigm are associated with FSI precursors. Also,
injuries of differing severity have differing
underlying causes, and reducing serious
injuries requires a different strategy than
Fatalities   reducing minor injuries. To reduce serious
Potential   injuries, one should use precursor event
serious   data drawn from sources such as incidents,
Lost-­‐time  
incidents   injuries   a nd   injuries, near-misses and exposures. The
fatalities   old paradigm could be shifted by focusing
on managing and classifying events ac-
Recordable     cording to their potential for serious inju-
incidents   ries based on precursor events indicating
unmitigated high-risk situations. This shift
First-­‐aids/   is predicted to lead to greater focus on pre-
near  misses   venting serious injuries, ultimately result-
ing in lower rates of such injuries.
Note. Adapted from “Best Practices Showcase: Exxon Mobil Krause (2012) proposes a five-step plan
Corp.,” by G. Murray, 2012, presentation at Fatality Prevention to prevent FSIs:
Forum 2012, Coraopolis, PA, USA. •Step 1: Educate the organization on
the new paradigm for FSIs.
42 ProfessionalSafety JULY 2013 www.asse.org
 •Step 2: Institutionalize the use of an FSI rate evaluated based on the hazard’s potential sever-
(also known as the FSI potential rate). This rate is ity, the degree of current control and the number
the number of fatal injuries, serious injuries and of workers exposed. Related human factors and
recordable injuries with high potential (for FSIs) organizational deficiencies are also evaluated and
divided by hours worked. Data on the rate should integrated into the risk assessment. The result is a Greater
be gathered for the previous 2 to 3 years, then final risk score that can be used to set priorities for focus must
monthly into the future. It should be given high
visibility throughout the organization. The critical
FSI intervention.
This approach also drives continuous improve-
be placed
importance of the FSI potential rate is that it gives ment around hazard mitigation and helps man- on different
visibility to FSI performance as a leading and lag- agement address key underlying factors that could aspects
ging indicator; it enables new research needed to
develop intervention strategies; it enables root-
create problems. A new safety cultural assessment
tool is also being advocated; it examines organi-
of error,
cause analysis of large numbers of potential FSI zational characteristics that may contribute to the including
events; and it sets the stage for predictive analytics. likelihood of an FSI. organiza-
•Step 3: Integrate findings from the FSI study
with existing safety systems. Some examples include
This integrated approach also includes new
approaches to risk mitigation that provide a
tional fac-
incident investigation, observation and feedback, framework for determining appropriate layers of tors that
pretask risk assessment and data analysis systems. protection (LOP) (Figure 4, p. 45). Occupational lead to
•Step 4: Develop mechanisms for the ongoing
identification and remediation of FSI precursors.
FSIs may continue to occur because decision mak-
ers incorrectly apply the hierarchy of controls to
intentional
These include longitudinal analysis, predictive an- corrective actions, often relying on lower-order and unin-
alytics and discovery conversations. For example, controls. During incident investigations, causality tentional
87% of FSI cases studied had underlying precur-
sors/preconditions/root causes that were discover-
may have focused on personal safety accountabil-
ity and decision making; this can result in overap-
behaviors
able from interview-based observations. plication of administrative controls (e.g., updated that contrib-
•Step 5: Develop and validate an intervention procedures, retraining) instead of higher-order ute to FSIs.
strategy. This can be accomplished by identifying controls such as elimination, substitution and engi-
the intervention group, gathering baseline FSI rate neering design/redesign. Also, a focus on mitigat-
data, designing and implementing an intervention ing the exposure should be embraced in the overall
plan, and tracking FSI rate data to measure effec- strategy for preventing FSIs.
tiveness (Krause, 2012). The framework supports developing a compen-
The Mercer ORC Fatality and Serious Injury Pre- dium of control options for FSI prevention. These
vention Task Force (Newell, et al., 2012) also stud- control options include management of change
ies evolving concepts in FSI prevention and has guidance, prevention through design options,
proposed a new model that creates a dual track for engineering (postinstallation or design) controls,
addressing risk (Figure 3, p. 44): one track for less administrative/procedural controls and adminis-
serious personal safety hazards and another track trative/task-based controls.
for hazards with FSI potential. Aspects of error are incorporated into this frame-
The new model emphasizes the need for a work. However, the model creators believe there is
heightened sense of awareness and vulnerability a basic misunderstanding of human error, fueled
in precursor situations. The approach is also task- by flawed incident investigations that frequently
based. Multiple hazards are evaluated for each task focus on affixing blame and concentrate on the last
with points being assigned for each hazard. Haz- factor in a chain of events leading up to the inci-
ard severity rating combines different hazards with dent. Consequently, organizational factors
related human factors and organizational deficien- that contribute to serious incidents are frequently
cies to develop a full understanding of the risk. Al- overlooked or misunderstood. Greater focus must
though combined for risk assessment, the different be placed on different aspects of error, including
hazards and underlying factors are disaggregated organizational factors that lead to intentional and
to implement and track corrective actions. unintentional behaviors that contribute to FSIs.
A framework and tools for implementing this Empirically speaking, effective techniques for min-
model are available. An integrated workbook ap- imizing error must be identified and tested, and an
proach to FSI prevention is being advocated. This incident investigation tool that incorporates per-
includes a new model for identifying precursors to formance modes (Wachter & Yorio, 2013) and key
FSIs. Precursor data may vary by industry, employ- underlying factors is being developed.
er, business unit and even site. Therefore, com- New checklist tools for conducting more in-
panies should begin looking for FSI precursors by formed incident investigations are available as
examining their own data and creating an inven- well. A checklist approach ensures operational
tory of their own serious hazards. Underlying con- consistency in key steps in the process, particu-
ditions that could activate or intensify the hazard larly since memory and judgment are unreliable.
should also be factored into the hazard inventory. Checklists remind people about the necessary,
The integrated workbook approach also includes most important and critical steps. If used correctly,
a new risk assessment model that determines checklists are precise, efficient, focused and easy to
likelihood by degree of control, not by estimates use, even in the most difficult situations (Newell,
based on past experience. Precursor hazards are et al., 2012).
www.asse.org JULY 2013 ProfessionalSafety 43
 Figure 3
Dual-Path Strategy for Prevention
procedure steps greatly increases the error
Risk   Risk   rate of the step (Fisher, 2012). Misleading
Assessment:   Mi�ga�on:   information is incorrect information, but it
Low  
F(x):  Severity    +   Low  to  Middle  
Severity   is not easy to detect and to avoid the er-
Experience-­‐ Order    from  
Exposure  
Based   Control  
ror traps it creates. It may involve missing
Likelihood     Hierarchy   critical steps to execute a task or miss-
ing critical references. The most effective
Hazard   ways to discover misleading information
Recogni�on   are walk-throughs of procedures and full
Risk   scope verification of procedures.
Likely   Risk   Mi�ga�on:   The fifth trap involves conflicting in-
Precursor   Assessment:   High  Order     structions—actions required by procedural
to  Fatality   F(x):  Severity  +   from  Control   steps that are contrary to the normal ac-
or  Serious   Control-­‐based   Hierarchy;   tions a worker expects or formats that
Injury   Likelihood   Layers  of   seem to be different to the user. Fisher
Protec�on   (2012) notes that procedures can be a solid
3  
offensive weapon for reducing error if pro-
Note. Adapted from “Best Practices Showcase: Introducing a Global Fatality Prevention cedure writers are taught to avoid these
Strategy—Progress to Date, Kimberly-Clark,” by D. Jacobi, 2012, presentation at Fatal- traps and users are taught how to deal
ity Prevention Forum 2012, Coraopolis, PA, USA; and “A Model for Fatality and Serious with them before they produce an error.
Injury Prevention,” by S. Newell, R. Comingore, G. Murray, et al., 2012, presentation at
Fatality Prevention Forum 2012, Coraopolis, PA, USA. Best Practices Showcases
Several organizations also shared in-
sights related to their best practices.
The traditional Theme 2: Managing Error Traps
Heinrich model in Procedures & Processes Fatality Prevention: Barriers to,
and supporting Fisher (2012) offers keys to improving work Enablers of & Lessons Learned
principles have methods and instructions using a human per- Shockey (2012) shared Alcoa Inc.’s historical
been determined spective improvement approach to managing the challenges in its fatality prevention journey. He rec-
to be descriptive, causation of injuries. This approach includes un- ommends that companies focus on several factors:
but not predictive, derstanding the major error traps in procedures 1) supervision with a widening span of control;
in nature. and processes. Fisher explains that the fit, form 2) tendency to view people as a constant rather
and content of instructions have a marked effect than as the biggest variable in the equation;
on fatality prevention. 3) reliance on single LOP where the risk is high,
He points to five major error/procedure traps. deviation potential is high and the ability to ob-
The first trap relates to making field decisions serve is low;
when a procedure user must make a decision with 4) failure to recognize that fatality exposures ex-
little or no guidance for doing so (e.g., if a user ist at the task level;
needs to decide what to do out of multiple options 5) risk perspective being biased and limited by
without guidance, has to determine whether cer- personal experiences or a narrow band of the oth-
tain conditions exist or whether certain sections of er’s experiences;
a procedure are applicable). Decisions made in er- 6) ability and capacity to manage and keep up
ror-prone situations have a field error rate 11 times with the rate of change at all levels;
higher than that of a well-written step. 7) rapid loss of institutional knowledge about
The second trap is physical or mental difficulty. historical fatalities and risks.
For example, an employee is told once how to do According to Shockey (2012), specific enablers
something (e.g., in training, via memo), and now have made a difference in Alcoa’s fatality prevention
the individual must remember to use it and how to journey. He notes that it begins with leaders who
do so correctly. Or, perhaps the employee has been are emotionally committed and are made acutely
told earlier (in precautions, limitations or procedure aware of fatality potentials within their sphere of in-
steps) and now must determine when to apply it. fluence. Alcoa management challenges paradigms
Physical difficulty includes difficult tasks, unneces- and expectations of what is an acceptable risk, then
sary or unreasonable tasks, or tasks easy to shortcut. develops tools to identify and recognize catastroph-
The third trap is multiple actions (including em- ic potentials. These potentials include patterns of
bedded actions) in procedures, such as three or latent conditions and at-risk actions, exposures as-
more actions in the same step, actions in a note, sociated with specific time frames, exposures asso-
caution or warning statement (real or embedded), ciated with sources of energy and exposures where
or actions in the precautions, limitations and pre- people are likely to be present.
requisites section. Alcoa’s strategy is to test, reinforce and manage
The fourth trap is using vague terms and mislead- high-risk exposures daily. The company has devel-
ing information. Vague terms include verbs such as oped a specific plan focused on fatality prevention
“determine” and “review,” adjectives such as “suffi- in which its fatality prevention standard (“We val-
cient” and “periodically” and phrases such as “when ue human life above all else and will manage risks
directed.” Use of double-negative statements in accordingly”) sets the expectation.
44 ProfessionalSafety JULY 2013 www.asse.org
 Figure 4
Layers of Protection Guidelines
The integrated
approach also
includes new
approaches to risk
mitigation that
provide a frame-
work for determin-
ing appropriate
layers of protection.

Note. Adapted from “Best Practices Showcase: Alcoa Inc.,” by J. Shockey, 2012, presentation at Fatality Prevention
Forum 2012, Coraopolis, PA, USA.

The firm systemically identifies risks by reporting, 9) Change management matters at all levels of
reviewing and analyzing past major incidents, in- the organization.
cluding those without injury, using a risk assessment 10) Organizations must capture institutional
tool to develop a fatality risk profile, and recording knowledge about hazards and risks to advance the
identified risks in a database. Workers (and contrac- next generation’s chance for success.
tors) are empowered to stop work if an unaccept-
able risk cannot be effectively reduced or controlled. Life-Changing Injury & Fatality Elimination
In addition, the company implements concepts such According to Williams (2012), over a 10-year
as LOP, improved causal factors analysis and a focus period, International Paper has experienced a sig-
on the high-risk tasks of the day. The company also nificant decrease in total injuries (56%), yet seri-
acknowledges the presence of human performance ous injuries have not declined proportionately
triggers and traps (“To err is human: look for it, plan (33%). To address this issue, in 2010, the company
for it, defend against it”) and uses human perfor- launched LIFE, a multiyear effort to identify and
mance tools in particular to defend against human mitigate the potential hazards and risks that lead
error (Wachter & Yorio, 2013). to FSIs. LIFE stands for life-changing injury and
The company also has institutionalized a lessons fatality elimination, and the organization has set a
learned program. Shockey (2012) shares these top LIFE goal of zero.
10 lessons from Alcoa’s fatality prevention journey: A LIFE incident is defined as a fatality, amputa-
1) Have a plan (roadmap). Knowing a company’s tion or an injury that results in 14 or more calendar
risk profile provides focus and direction to the plan. days away from work and involves organ damage,
2) Manage the exposures (predictive), not the concussion or other brain trauma, bone fracture,
outcomes. crushing injury, degloving, and/or serious second-
3) Senior leadership sets the tone. or third-degree burns.
4) Organizations cannot prevent fatalities with- The strategy has nine components:
out engaging those who perform the work. 1) Communicate effectively.
5) Developing workers’ hazard recognition and 2) Engage stakeholders.
risk assessment skills is essential. Actively looking for 3) Make safety a core value.
hidden potentials must be a daily, sustained focus. 4) Learn from past mistakes (called LIFE les-
6) Fatalities occur at the task level and are influ- sons).
enced by multiple causal factors. 5) Benchmark best practices.
7) Relying on a single LOP for high-risk tasks 6) Use manufacturing excellence tools, project
makes an organization vulnerable. teams and be data driven.
8) Individual perception of risk is often biased 7) Train and educate on LIFE (e.g., LIFE leader
and limited by personal experiences. guide, LIFE newsletter).
www.asse.org JULY 2013 ProfessionalSafety 45
 8) Change the way that safety performance is KCC is pursuing a dual-path strategy for preven-
measured (use leading indicators). tion based on risk assessment and mitigation (Figure
9) Be global (in terms of engagement). 3, p. 44). For low-severity exposure, risk assessment
To learn from past mistakes, LIFE lessons (a one- is a function of severity and experience-based likeli-
page summary of incident investigation findings hood; risk mitigation steps can be selected from the
and corrective actions) are distributed throughout low to middle order from the control hierarchy. For
the company. likely precursors to FSIs, risk assessment is a func-
According to Williams (2012), incident analysis tion of severity and control-based likelihood; risk
under this program has led to the creation of focus mitigation should involve LOP selected from the
areas based on their contribution percentage to LIFE upper levels of the control hierarchy.
events: machine guarding, 30%; falls, 27%; other KCC’s fatality prevention structure (Figure 5,
(e.g., primarily acute trauma due to material han- p. 48) has as its foundation a code of conduct, glob-
dling), 18%; motorized equipment, 17%; harmful al SH&E policy and a safety management system.
substances or environments, 6%; and driver safety, From this structure, the following activities are di-
2%. Project teams were formed to focus on these five rected to achieve zero injuries and fatalities: apply-
focus areas. For example, in the motorized equip- ing learnings from failures in safety systems and
ment focus area, several initiatives were conducted processes; mitigating recognized hazards through
or implemented in 2011: pedestrian safety training, adherence to robust internal standards; and build-
traffic flow risk assessments, motorized equipment ing SH&E capability through education and prac-
operator training and collision avoidance systems. tical training, including global rollout of employee
Results of adopting this strategy have shown and leadership-specific sentinel event hazard recog-
steady progress in reducing LIFE events over the nition training.
previous 2 years, Williams (2012) reports. One rea- A part of the implementation strategy is to con-
son the process has succeeded is that senior man- duct sentinel event training pilots for all business
agement views fatalities and fatality potential on a units and to revise its safety management system.
personal, individualized level. This entailed revising key safety performance stan-
dards that affect control of sentinel event hazards;
Controlling Sentinel Event Hazards a refocused scope of global management system
Since 1970, 125 employees have died on the job assessments on these performance standards; and
across all business units at Kimberly-Clark Corp. embracing sentinel event reporting (e.g., KCC has
(KCC) (Jacobi, 2012). From 1997 until 2009, KCC a dedicated input interface as part of global safety
experienced an average of two fatal injuries per reporting process).
year, leading it to embark on a journey to reduce According to Jacobi (2012), a key strategy involves
the number of fatalities. communications such as global deployment of
A primary KCC message is that prevention of fa- e-newsletters, mini-posters and hazard bulletins for
talities requires some process for predicting their eight sentinel event hazard categories. Other com-
occurrence (Jacobi, 2012). An organization can- munication essentials are CEO and executive line
not identify the characteristics and causes of fatal of sight on measureable objectives, a dedicated in-
events until it measures and trends loss incidents tranet (SharePoint) site for tools (solutions), a web-
that, while not resulting in a fatality, could have. based reporting interface with database used for
The first key realization is that data analysis sug- trends, and a global communications plan linked to
gests that fatal and near-fatal events at KCC can message branding. From July 2009 to the date of this
be classified into priority groups (called sentinel writing is the longest period in more than 40 years
event hazards) with predictive power. Based on an without an employee or contractor fatality in a KCC
analysis of fatal and near-fatal events from 1999 to manufacturing facility or distribution center.
2008, KCC identified and categorized the following
sentinel event hazards: Best Practices Breakout Sessions
•contact with energy equipment (26.2%); Leadership & Organizational Attributes
•transportation (road) (16.7%); The first best practice focuses on leadership in-
•lift-truck events (14.3%); volvement in serious injury/fatality investigations
•falls (14.3%); and their follow-ups leading to the implementa-
•fires and explosions (9.5%); tion of corrective and preventive actions. In this
•electrical contact (arc potential) (7.1%); case, it entails a team process. A root-cause analy-
•confined space operation (7.1%); sis incident investigation begins immediately; the
•falling objects (4.8%). executive review team visits site within 2 weeks of
The second key realization is that addressing incident; the team reviews completed investiga-
fatalities is a different problem set and requires a tion report, as well as recommended interim and
different approach (Jacobi, 2012). The company long-term corrective actions; the team determines
recognizes that fatality elimination is a separate but application to other lines of business within the
parallel effort to injury elimination. This approach company; the team develops communications plan
is based on the research and publications of Manu- for sharing lessons learned; the team conducts pe-
ele (2008) and others who suggest that efforts to riodic reviews of status of corrective actions with
reduce incidents and using traditional measures of the business unit executive; and a senior executive
severity do not address issues leading to death. (e.g., EVP, COO, CEO) visits the site of the event
46 ProfessionalSafety JULY 2013 www.asse.org
 initially and 6 months after to increase active, vis- change processes, particularly for situations involv-
ible leadership. ing high-risk work systems, settings and activities.
Another best practice involves reducing risk Since innovation is fundamental to developing new
through pretask hazard assessments/prejob briefs, technologies, products and processes that sustain
in which senior management takes an active role in business growth, the addition of new technologies
high-risk area management. By taking a few min- or changes to familiar core business manufacturing
utes before performing tasks, potential hazards are operations often introduces new or unfamiliar haz-
identified and steps necessary for avoiding them ards. Process change must be managed to control
are outlined. Pretask hazard assessments increase
safety awareness, thus decreasing operational risk.
this risk.
A procedural checklist for risk management is
To prevent
Here’s the typical process: another best practice in use. It is important to eval- FSIs, an
1) Before performing work, supervisors and uate the quality of such checklists and compliance organization
workers meet to discuss the assigned task, its ob-
jectives and its hazards to clearly understand what
with their use in the execution of both routine and
complex high-risk procedures and tasks.
must look
to accomplish and what to avoid. Developing and consistently applying standard- at all of its
2) The briefing is a structured, risk-based review ized, valid and reliable quantitative tools for rou- incidents
of the work activity from a human performance
perspective to enhance workers’ situational aware-
tine assessment of organizational exposure to FSIs
at the site, process and task levels is also consid-
and assess
ness (mental model) before they start to work. A ered a best practice. The tool incorporates input their poten-
pretask hazard assessment/brief provides the op- from all major stakeholders as well as specialized tial for lead-
portunity to ensure understanding of the task’s
scope, limits, precautions, hazards and responsibil-
external expertise as appropriate.
The processes covered provide useful means of
ing to FSIs.
ities. It also provides a forum to ask questions and assessing risk profile pre- and postintervention
raise concerns, and to use operating experience to (e.g., introduction of controls), and reflecting se-
identify error precursors and flawed defenses. verity potential with and without controls. Initial
Another best practice involves leadership think- risk is assessed assuming no controls are present.
ing outside the box and emphasizes several factors: Potential risk is assessed assuming all listed con-
1) integrating safety/leadership in engineering trols are in place. The difference between these
and business curricula; 2) integrating safety in the assessments indicates the effectiveness of risk re-
strategic decision-making planning processes; duction (helpful in communicating the importance
3) preserving corporate memory; 4) allocating safe- of controls to employees and useful as an audit
ty capital; and 5) using risk tolerance screening. tool). Contractors should be required to implement
Improving management systems is another best similar procedures.
practice. Specifically, this entails using the strength- Some organizations apply personality inven-
of-defense matrix (e.g., prevention through design, tory methods for workers involved in high-risk
engineering controls, administrative/procedural work processes. This provides a basis for coaching
controls, administrative/behavioral controls) to as- decision-making strategies appropriate to the level
sess and manage risk. of potential risk. One assessment tool being used
In addition, the SH&E profession needs to iden- generates a safety insight report. This report inven-
tify a new set of metrics or measurements relevant tories a worker’s characteristics along a continuum
to FSI prevention. These metrics include: 1) mea- related to reasoning (open-minded vs. cautious;
suring precursors, such as employees observ- taking chances vs. being conservative; analytical
ing the risk, and using potential severity incident vs. intuitive), emotion (emotional vs. calm; overly
rates (whereby incidents are ranked based on their confident vs. coachable; impatient vs. patient), and
potential for ending up as a serious event in the personality (spontaneous vs. deliberate; expedient
future); 2) measuring engagement; 3) classifying vs. rule oriented; distractible vs. focused; impulsive
risks; 4) using raw numbers, not the rates; and vs. detailed).
5) assessing wellness indicators. These metrics dif- The basis of inventorying reasoning, emotional
fer from traditional lagging indicators, preventive and personality characteristics is that they influence
action tracking and serious event focus, including behaviors. Related to this practice is the idea to de-
fatality assessments. velop and apply methods for determining cognitive
and physical capabilities of individuals assigned to
Developing a Risk Profile perform high-risk procedures and tasks. An orga-
In this context, a risk profile is associated with nization would then reassign workers whose capa-
an organization’s exposure to FSIs. Risk profiles bilities do not fit high-risk task requirements.
should be determined by applying valid and reli- One other best practice involves the develop-
©istockphoto.com/thinkstock

able methods (e.g., measuring FSI potential risk, ment and reinforcement of the use of real-time
not risk of minor injuries, lost-time injuries) and hazard assessment reporting and rating forms.
techniques (e.g., providing consistent results if An example is the HIRAC-lite approach used for
applied by multiple people at the same time and nonroutine or infrequent tasks. A checklist, with
place). Risk profiles are determined at the site, pro- color-coded (red/yellow/green questions to iden-
cess, task and individual levels. tify hazards and controls, is provided on a pocket
Let’s highlight five best practices. The first deals card for use on the job site.
with evaluating the quality of management of
www.asse.org JULY 2013 ProfessionalSafety 47
 Figure 5
Fatality Prevention Structure
0  Injuries  
step level. Risk assessments typically are
conducted at the system, hazard and task
Vision   level, but rarely at the specific critical step:
 Global  Fatality  Elimina�on  Leader   systems hazard task critical step
LEARN   PREVENT   BUILD   A critical step is the unrecoverable step
in a task; if it fails, an FSI may result.
Mi�gate     Build  OS&H  
Apply  
recognized     capability       Managing the Contractor/
learnings  from  
Direc�on   hazards  through   through   Contracted Services Risk
failures  in  
adherence  to   educa�on  and   Several best practices aim to expand
safety  systems  
robust  internal   prac�cal    
   
contractors’ abilities to assess the risk they
and  processes  
standards   training   bring to a host employer’s site. It is also
noted that the prequalification process
does not always lead to selection of the
EHS  Management  System   best contractor due to the 1) need to se-
Founda�on  
Global  OS&H  Policy   lect less-than-perfect vendors; 2) limited
vendor pool; or 3) no choice on vendor
Code  of  Conduct  
selection. The knowledge/awareness gap
Note. Adapted from “Best Practices Showcase: Introducing a Global Fatality Prevention places both a contractor’s and an employ-
Strategy—Progress to Date, Kimberly-Clark,” by D. Jacobi, 2012, presentation at Fatality er’s workers at risk for FSIs since many
Prevention Forum 2012, Coraopolis, PA, USA. contractors perform work that occurs
during nonroutine operations or conduct
high-risk tasks that a host employer’s per-
KCC’s fatal- Effective Risk Assessment Methodologies sonnel are not qualified or do not wish to perform.
ity prevention An organization must address inherent risk at Some companies use tools that require contrac-
structure has as its various stages of work planning and execution. tors to perform a risk assessment before starting a
foundation a code This can be achieved using three different ap- job task in order to increase contractors’ level of
of conduct, global proaches: risk perception. Others believe a host employer
SH&E policy and a 1) systems-based approach that requires the or- should use contract mechanisms to manage con-
safety management ganization to assess and prioritize its safety man- tractor risk. The contract can specify controls that
system. From this agement system on an ongoing basis; flow directly from the scope of work. Most believe
structure, many 2) hazard-based approach that begins with the it is also essential to monitor contractors while on
other activities are hazardous characteristics of the materials, environ- site, since highest risk is present during work.
pursued to achieve ment or work site, considering the possible activi- Several methods can be used to identify, assess,
zero injuries and ties that may affect them and the consequences; mitigate or eliminate the risk of fatal and life-alter-
fatalities. 3) task-based approach that begins with a job, ing injuries. These include a process for mentoring
breaks it into specific tasks, identifies associated deficient contractors so that they can continue to
hazards, then assesses the risks. be hired. This is essential in environments where
During this breakout session, 16 best practices the contractor pool is limited or in countries where
were shared. Several of them adopt and/or adapt a a host employer may have no say in contractor
traditional risk matrix to qualitatively and/or quan- selection. In addition, some are empowering em-
titatively assess risk level as described in Appendix ployees to take responsibility for monitoring con-
F of ANSI/AIHA/ASSE Z10-2012, Occupational tractors while on site and providing methods for
Health and Safety Management Systems. A com- them to report unsafe practices and conditions to a
mon element throughout the best practices is a high contractor or host employer manager for correction
level of employee involvement in assessing risk. rather than allowing the behavior or condition to
Five practices identified to be best overall in ad- continue. Another practice involves in-person vis-
dressing risk at the systems, hazard or task level its by senior management to convey a strong mes-
had several common characteristics: sage about contractor performance expectations. 
1) an internal system to communicate lessons Due to the lack of consistent control measures to
learned across their organizations; manage known high-risk activities, some of which
2) status tracking of outstanding corrective or are known to result in fatalities, another approach is
preventive actions as a result of risk assessment to standardize required controls for both employees
activities; and contractors who perform tasks within the scope
3) targeted training being demanded; of a global safe-permit-to-work program.
4) high level of management/labor cooperation;
5) employee participation; Effective Control for High-Risk Tasks
6) risk assessment authority being delegated to Four of the top five best practices for control-
the appropriate level of management to ensure ling high-risk tasks utilize a risk assessment matrix,
process completion and success. color-coding (red/yellow/green), and a checklist or
Most participants recognized that many of these hazard pictogram methodology to address potential
best practices lack an effective tool for worker/ human performance issues specific to a worker’s
supervisor/planner risk assessment at the critical assigned task. Frontline employees are often in-
48 ProfessionalSafety JULY 2013 www.asse.org
 For More Information
Find more information about the 2012 Fatality Prevention Forum,
including PowerPoint files for all of the presentations and descrip-
volved in the internal development of the prejob
tions of best practices, at www.iup.edu/page.aspx?id=128336.
hazard recognition and evaluation tools. For each
Additional related information on the human performance
best practice that addresses the issue of worker risk
approach to managing organizational and human error can be
recognition and evaluation, training is mandatory to
found in Human Performance Tools: Engaging Workers as the Best
ensure that workers understand they have authority
Defense Against Errors & Error Precursors, by J.K. Wachter & P.L.
to stop any job recognized to be unsafe.
Yorio, Professional Safety, February 2013, pp. 54-64.
None of the best practices specifically addresses
the process of identifying and evaluating the critical
task (unrecoverable step) in a job process, which if it ee engagement is critical to identify and manage
fails has a high probability to result in a serious injury precursors (e.g., unmitigated high-risk situations,
or fatality. Effective risk assessment methodologies high-risk activities) that lead to high potential
could be developed to help work planners, schedul- events that lead to negative outcomes. Equally im-
ers, managers, supervisors, crew leaders and workers portant is senior management’s ability to see the
to identify the critical step(s) in a job packet and the specifics behind the typical rates reviewed at high
high-potential/high-severity hazard(s) associated corporate levels—that real people comprise these
with the critical step(s). Effective risk assessment rates, each with a different background story that
methodologies would evaluate the hazard, then needs to be heard and addressed.
eliminate or control the risk at an acceptable level. Several gaps in current knowledge and practice
require future research and discussion:
Conclusion 1) implementing a management system specifi-
The pressing issue for many industries is that cally for FSI;
while overall OSHA injury and illness rates have 2) defining and effectively using FSI leading in-
dropped dramatically in recent years, FSIs have not dicators;
experienced a similar decline. To address this di- 3) incorporating human factors (such as error
lemma, several themes were common among the proofing, literacy, training and qualifications, and
presentations, best practice showcases and break- fitness for duty) into management systems;
out sessions. The major theme was that to prevent 4) using safety considerations in strategic-level
FSIs, an organization must look at all of its inci- decision making;
dents and assess their potential for leading to FSIs. 5) making the critical step the next logical pro-
At this forum, many presenters and organizations gression in the risk assessment process. PS
advocated tracking potential FSIs as an important
new performance measure. This measure has both References
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www.asse.org JULY 2013 ProfessionalSafety 49