University of California Risk Summit 2011

Integrating Safety into Operations

A Systems-Thinking Approach

Janette de la Rosa Ducut, Ed.D.

Summary
A systems-thinking approach to safety allows consideration of more complex relationships between safety-related events. This
approach provides a way to look more deeply at why accidents occurred. A system can consist of the interaction between people
(man), their machines (equipment), and the environment. The environment is where conditions for unsafe acts, unsafe supervision, and
organizational influences on safety can be discovered. Knowing one part of a system enables us to know something about another part.
Using systems theory encourages us to adopt a systems perspective (avoid linear, unidirectional, causation) and focus on
interrelationships and processes that produce change (avoid cause-and-effect chains).
The 1986 Space Shuttle Challenger accident and University ergonomic injuries provide specific examples of the consequences
resulting from systemic breakdown. You can integrate safety into operations through the identification and prevention of overall
structures, patterns, and cycles that contribute to injuries and death. This presentation provides an overview of accident investigation
and organizational characteristics; that highlight the powerful role that structure takes in driving (safety) behavior.

For more information

View the course materials used for this presentation online at http://ehs.ucr.edu/safety/systems

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Accident Investigation
The Swiss Cheese model by James Reason

The Swiss Cheese Model of Accident Causation suggests that systemic failures, or accidents, occur from a series of events at different
layers of an organization. A system is similar to slices of Swiss cheese. There are holes which represent opportunities for failure, and
each slice is a layer of the system. When holes in the layers line up, a loss (or accident) occurs. Each layer of the system is an
opportunity to stop an error; the more layers, the less likely an accident is to occur. The major layers of a system are: Unsafe acts,
Conditions (for unsafe acts), unsafe Supervision, and influences of an Organization. Below are selected examples of each layer
(NOTE: This is not a complete listing).

Errors
Decision
Improper procedure
Misdiagnosed issue
Wrong response
Exceeded ability
Inappropriate act
Poor decision
Skill-based
Failed to prioritize
Inadvertent use of
equipment
Omitted step in procedure
Ignored checklist item
Poor technique
Overcontrolled the situation

Violations

Failed to adhere to brief

Failed to use equipment
Violated training rules
Used an unauthorized
approach
Used an overaggressive
maneuver
Failed to properly prepare
Not current / qualified for task
Intentionally exceeded limits
of the equipment
Unauthorized actions

Perceptual
Misjudged
Spatial disorientation
Visual illusion

Unsafe Acts of people can be loosely classified into two categories: errors and violations (Reason, 1990). Errors generally represent
the mental or physical activities of individuals that fail to achieve their intended outcome. Decision errors represent intentional
behavior that proceed as intended, yet the plan proves inadequate or inappropriate for the situation. Skill-based errors occur when
people operate without significant conscious thought. Perceptual errors occur when ones perception of the world differs from reality;
typically when sensory input is degraded. Violations, on the other hand, refer to the willful disregard for the rules and regulations that
govern the safety of work. They can be habitual by nature, as well as atypical actions.

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Substandard
Conditions

Substandard
Practices

Adverse Mentality
Channelized attention
Complacency
Distraction
Mental fatigue
Get-home-it is
Haste
Loss of situational
awareness
Misplaced motivation
Task saturation

Human Resource Management

Failed to back-up
Failed to communicate /
coordinate
Failed to conduct adequate
brief
Failed to use all available
resources
Failure of leadership
Misinterpretation of
information

Adverse Physiology
Medical illness
Physiological incapacitation
or impairment
Physical fatigue

Personal Readiness
Excessive physical training
Self-medicating
Not rested (tired)

Physical/Mental limitations
Insufficient reaction time
Visual limitation
Incompatible
intelligence/aptitude
Physical inability

Conditions for unsafe acts of people can be categorized into two categories: substandard conditions people, and substandard practices
of people. Substandard conditions of people involve adverse mentality or mental states (stressors and personality traits), adverse
physiology (conditions, such as illness, that preclude safe work), and physical / mental limitations (when work requirements exceed
the basic sensory capabilities of people at the) . Substandard practice of people, on the other hand, refer to human resource
management (poor coordination among employees), and personal readiness (when people are not at optimal levels when they show up
for work).

Supervised
Inadequately

Failed to provide guidance

Failed to provide oversight
Failed to provide training
Failed to track
qualifications
Failed to track performance

Planned
Inappropriate
Operations

Failed to Correct
Problem

Failed to correct document

in error
Failed to identify an at-risk
worker
Failed to initiate corrective
action
Failed to report unsafe
conditions

Failed to provide correct

information
Failed to provide adequate
time (for briefing)
Improper staffing
Task not in accordance with
rules/regulations
Failed to provide adequate
opportunity for rest

Violations of
Supervisor

Authorized unnecessary
hazard
Failed to enforce rules and
regulations
Authorized unqualified staff
to work

Unsafe supervision can be categorized into four areas: supervised inadequately, planned inappropriate operations, failed to correct
problems, and supervisory violations. When people supervised inadequately, there is a general failure to provide the opportunity to
succeed. When those in charge planned inappropriate operations, personnel are generally put at an unacceptable risk (i.e., improper
pairing of team members). When supervisors failed to correct problem(s), there are known unsafe conditions that allow to continue
unabated. Finally, violations of supervisor(s) occur when there is mismanagement of assets, followed by a tragic sequence of events
by people under those supervisors.
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Resource
Management
Human
Selection
Staffing
Training
Monetary / Budget
Excessive cost cutting
Lack of funding
Equipment / Facility
Poor design
Purchase of unsuitable
equipment

Organizational
Climate
Structure
Chain-of-command
Delegation of authority
Communication
Accountability for actions
Culture
Norms and Rules
Values and beliefs
Organizational justice

Organizational Process
Operations
Operational tempo
Time pressure
Production quotas
Incentives
Measurement / Appraisal
Schedules
Deficient planning
Procedures
Standards
Clearly defined objectives
Documentation
Instructions
Policies for hiring/firing/promotion
Oversight
Risk management
Safety programs

Organizational influences are the fallible decisions of upper-management that directly affect supervisory practices, conditions, and
actions of people. Resource management encompasses the realm of organizational-level decision making regarding the allocation
and maintenance of assets (i.e., people, money, and equipment/facilities). Organizational climate refers to a broad class of variables
that influence worker performance (i.e., the working atmosphere). Organizational process refers to decisions and rules that govern
everyday activities within an organization (operational procedures and oversight programs to monitor risks).

Integrating Safety
Research has indicated that low-accident companies differed from high-accident companies because they
possessed the following organizational characteristics:

Strong senior management commitment, leadership, and involvement in safety

Closer contact and better communications between all organizational levels
Greater hazard control and better housekeeping
A mature, stable workforce
Good personnel selection, job placement, and promotion procedures
Good induction and follow-up safety training
Ongoing safety schemas reinforcing the importance of safety, including near miss reporting
Acceptance that the promotion of a safety culture is a long term strategy requiring sustained effort & interest
Adoption of a formal health and safety policy, supported by adequate codes of practice and safety standards
Communication that health and safety is equal to other business objectives
Thorough investigations of all accidents and near misses
Regular auditing of safety systems to provide information feedback and continuous improvement

Source: Cooper, D. (2001).Improving safety culture: A practical guide. Hull, United Kingdom: Applied Behavioural
Sciences.
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Case Study
Imelda Marcos is experiencing pain in her wrist, after heavy use of a standard mouse. The pain began a week
ago when their company website went down, and her supervisor asked to her work day and night to bring it
back up quickly. After a week, Susie received an award for returning the website back to its original state, in a
short amount of time. Shes been through ergonomics training, and had her workstation evaluated by an
ergonomist one year ago. However, there have been recent budget cuts, furloughs, and layoffs which prevent
her from comfortably asking for more resources to deal with the pain. Soon, Imelda files a workers
compensation claim, citing tendonitis and median nerve compression caused by her employment. She indicates
shes used a standard mouse safely for the past 20 years. You are the person responsible for conducting the
accident investigation.

Questions

1. What are 3 questions you would ask during the accident investigation?
2. What are 3 corrective actions you would take?

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