1. Explain the Five Why technique, and describe how this technique can be used in incident investigation to identify potential causes that may tie to deficiencies in processes and management systems rather than mistakes made by workers?
Your response must be at least 75 words in length
2 Compare and contrast the concepts of macro and micro thinking as they relate to safety and health management in the workplace. Which is more in alignment with the safety management systems approach and why?
Your response must be at least 75 words in length.
3. Appraise the concept of organizational culture and its relationship to successful implementation of safety management systems.
Your response must be at least 200 words in length.
4. In the conclusion to Chapter 8, Manuele states that top-level decisions largely cause potential for human error, and this impact spreads through the entire organization. Please examine this statement with respect to how it aligns with the tenets of the safety management systems approach to produce desired results.
Your response must be at least 200 words in length
BOS 3651, Total Environmental Health and Safety Management 1
Course Learning Outcomes for Unit II Upon completion of this unit, students should be able to:
7. Examine management tools necessary to implement effective safety management systems.
7.1 Compare and contrast macro and micro thinking as it relates to safety and health management.
7.2 Examine ways the prescribed components of safety and health management systems work together to produce desired results.
Course/Unit Learning Outcomes
7.1 Unit Lesson Chapter 5
Unit II Assessment
Unit Lesson Chapter 2
Chapter 21 Unit II Assessment
Required Unit Resources Chapter 2: Organizational Culture, Management Leadership, and Worker Participation
Chapter 5: A Primer on Systems/Macro Thinking
Chapter 8: Human Error Avoidance
Chapter 21: The Five Why Problem-Solving Technique
In this unit, we will take some time to explore traditional methods of thinking about and managing safety. There is a great deal of history in the field of safety and health, and a number of researchers and
academicians have contributed over the years to add to the body of knowledge. As in many fields o f study,
however, we have come to learn new things and rethink some of the things we thought we knew. In this lesson, we will consider some of the ideas that have been around in the field of safety for many years. Then,
we will compare and contrast these ideas with current observations and findings.
Serious injuries and human error are important concerns in any accident prevention effort. The costs and other consequences created by injury and property damage accidents dictate the need for changes that will
ensure a reduction in their occurrence. Discussing serious injuries and human error in this unit will better
prepare us to tackle the details of safety management systems and ANSI/ASSP Z10.0-2019 in subsequent units. After all, reducing injuries and illnesses is the key point of having a safety and health program in the first
place. Developing and applying a systematic approach in an effort to experience such a reduction certainly seems like a worthwhile endeavor.
In the course textbook, Manuele (2020) challenges the notion that if we eliminate all the minor injuries, the severe injuries will be taken care of as well. The accident pyramid concept first proposed by H.W. Heinrich in
the 1930s has been embraced by safety professionals for decades and essentially proposes that there is an exponential relationship between the number of non-injury incidents, minor injury incidents, and major injury
UNIT II STUDY GUIDE
Serious Injury Prevention and
Human Error Reduction
BOS 3651, Total Environmental Health and Safety Management 2
UNIT x STUDY GUIDE
incidents. Essentially, the accident pyramid theory predicts that for every 300 non-injury incidents such as a
piece of channel iron falling and just missing an employee’s foot or a forklift almost toppling a pallet of stacked product onto an unsuspecting employee that there will be 30 minor injuries and one major injury. The
implication here is that if an employer focuses on the avoidance of non-injury incidents and minor injury incidents, major injury incidents can be avoided.
Manuele (2020) presents some compelling evidence that perhaps the safety and health profession should place more focus on the top of the pyramid rather than the bottom, however. His research has demonstrated
that incident frequency may have been reduced over the past several decades, but severity has not decreased proportionately. He also shows that serious injuries most often occur in non-routine and
nonproduction activities. In reality, this theory also seems to align with what can be observed by researching
occupational fatality facts. Occupational fatalities often result from non-routine tasks performed by employees who often are unaware of the risks involved with the task.
The domino theory is just as the name implies, a theory that Heinrich (1931) proposed back in the 30s. Over
the years, many have used this as a basis for their safety efforts to try to predict why injuries occur. However, in the course author’s experience, near misses, first aid cases, and other potential loss producing events are
not captured in this theory, leading the course author to question this theory.
Speaking from experience, the course author has seen many safety professionals use an interpretation of the
theory to show a relationship between injuries and the theory. However, as a safety professional develops their craft in the safety arena, one starts to question these types of theories versus what is practical and real.
Contrary to Manuele’s findings, however, most occupational safety and health professionals tend to focus most of their prevention efforts on routine and production activities. A typical checklist of a given safety
professional, for instance, may involve items such as updating injury and illness records, respirator fit testing, arranging to have an area of a facility monitored for air contaminants, and preparing for an upcoming
hazard communication training event. Meanwhile, unbeknownst to the safety director, employees are using a forklift to load steel I-beams onto a flatbed truck parked on the street because the overhead crane broke down
in the loading bay. Added to this situation is the fact that the forks on the forklift do not quite reach to the
middle of the flatbed, so the shipping foreman had to conspire with the welding department to fashion fork extensions out of channel iron. This non-routine situation has all the trappings of a potentially serious accident
waiting to happen.
Of course, in contrast to the risks being taken in our I -beam loading scenario, routine production activities tend to include lengthy periods of time, which increase the risk of some sort of incident occurring on the
production line. If we are not experiencing serious injuries in these routine operations, however, maybe we
have them under control and should focus more of our efforts on the non-routine tasks that are more likely to result in a serious occupational injury or illness.
It is important to implement safety management systems that support identification of the unknowns. Consider
the forklift loading process scenario described above, for instance. Does it seem reasonable to assume that
an organization with a well-developed safety and health culture that embraces occupational safety and health as a core value of the organization would avoid such a scenario?
Hopefully, your response to the question above is yes. Organizations that put forth an exemplary effort to
create a culture where employees automatically consider the safe way of getting things done, rather than automatically considering shortcuts, tend to avoid the risks inherent in performing actions that are not well
thought out. It is unlikely that employees of an organization with an exemplary safety program would have
come up with a solution of loading I-beams from the street using job-made fork extensions on a forklift. Integrating well-designed safety and help management systems into the day-to-day work culture helps to
alleviate the likelihood of individuals performing non-routine tasks without first analyzing hazards. In such an organization, incident reporting is encouraged, and incident investigations are thoroughly analyzed in order to
identify root causes. Identifying root causes, of course, goes much further than simply finding something or
someone to blame and typically ties causes back to flaws in the management system rather than worker behaviors. That is to say that worker behaviors and faulty equipment might contribute to a given accident and
even be identified as direct causes. Well-designed safety management systems, however, take incident investigation a step further to identify why individuals engaged in unsafe behaviors or why faulty equipment
was allowed to be faulty.
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Manuele (2020) also discusses the fact that many
errors have roots in processes and procedures outside the employee’s control. He states that while
the human condition cannot be changed, the working conditions of people can. That is not to say that
people cannot learn to avoid situations that may
result in injury or illness, but that human behavior is influenced by many factors. This concept is what
gave rise to the behavior based safety (BBS) movement in recent years. Originally focused on
identifying and correcting unsafe behaviors, BBS has
grown to include examination of outside influences that cause people to make specific choices. Safety
professionals need to understand at least some of the psychology that affects choices and decisions.
For example, if workers are rewarded for completing a task in a specific amount of time, they may be more
likely to disregard safe procedures that add time to
the process. Decisions made at the top levels of management have a significant effect on unsafe
behaviors and the resulting incidents.
The key point is not to explore the nuances of how best to conduct an incident or accident investigation, but
rather to point out that the safety management systems approach is different from the typical compliance- based approach to safety. Employees are treated differently with respect to the roles they play supporting the
safety culture, and the way safety is managed is very different as well. Management approaches are also typically well informed, and such organizations typically stay abreast of research and resulting changes in
occupational safety and health theory and practice. ANSI/ASSP Z10.0-2019 is useful in that it provides a framework for safety management that shifts the focus from individual behavior, specific hazards, or any
single process to a system that integrates all social and technical aspects of accident and injury prevention.
Using this socio-technical model, we become more aware of the interdependence of all the parts and begin to understand that they cannot be separated from each other.
Heinrich’s pyramid theory presented early in this unit lesson is not the only long -standing occupational-safety-
and-health-related theory that has been re-evaluated in recent years. There are others, and many of the long- standing theories certainly warrant thought and provide useful starting points for more contemporary thought.
Looking past the prevailing paradigms, however, is important for any field that wants to continue to move
forward. For the last several decades, the safety management systems approach has garnered a great deal of attention and has been successfully implemented in many organizations, and this different approach to
management will certainly continue to be improved in in the future.
Heinrich, H. W. (1931). Industrial accident prevention: A scientific approach. New York, NY: McGraw-Hill.
Manuele, F. A. (2020). Advanced safety management: Focusing on Z10.0, 45001, and serious injury prevention (3rd ed.). Wiley. https://bookshelf.vitalsource.com/#/books/9781119605409
Palmer, A. (1942). AlfredPalmerRamagosa [Photograph]. Wikimedia Commons. http://commons.wikimedia.org/wiki/File:AlfredPalmerRamagosa.jpg
Suggested Unit Resources
In order to access the following resource, click the link below.
The article below is a suggested resource that can provide further insight into safety and human error.
If too much emphasis is placed on completing
tasks quickly, workers may be less likely to follow
all safety precautions that add extra time to their tasks.
BOS 3651, Total Environmental Health and Safety Management 4
UNIT x STUDY GUIDE
Reason, J. (2000, March). Safety paradoxes and safety culture. Injury Control & Safety Promotion, 7(1), 3–14.
Learning Activities (Nongraded)
Nongraded Learning Activities are provided to aid students in their course of study. You do not have to submit them. If you have questions, contact your instructor for further guidance and information.
If you have access to your organization’s injury/illness records, sort the records from the past 3–5 years according to the severity of the incident (use days away from work or worker’s compensation costs), and look
for trends in the types of operations where the most serious incident occurred. How does your data compare with Manuele’s list of activities where serious injuries occur on page 137 of the course textbook? If your
findings are different, what could be a reason for the difference?
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