ORCHSE proposes a six-step solution to achieve a fatality and serious incident-free workplace. It is a new risk model that creates a separate track for addressing serious hazards.
As the table below indicates, the solution relies on the same risk management steps, but employs a different approach to potential FSI exposures — a dual-path strategy for prevention. Processes are evaluated to identify precursors to FSIs. Once precursors are identified, different approaches are used for risk assessment and risk management.
This model emphasizes the need for a heightened sense of awareness and vulnerability in precursor situations:
- Safety professionals assess the current situation and set the stage for the technical and cultural shift required to address FSI risk potential.
Pros engage leaders to proactively shift focus from “outcomes” (often limited to tracking OSHA data) to the risks that drive them. Have leaders define an acceptable level of risk for the organization. This creates an important benchmark to identify and address serious hazards incompatible with acceptable risk. It also sends an important message to the workforce – leadership genuinely cares about their health and well-being. New levels of competence frequently must be established throughout the organization. Potential barriers to implementation, such as management system gaps, ineffective metrics, and certain aspects of the organizational culture relating to risk tolerance also must be identified and addressed. - Conduct an initial threat assessment to identify the most serious situations that are precursors to FSIs.
These hazards must then be inventoried, assessed, and managed. Related human and organizational factors that could activate or intensify the hazard or undermine controls also must be identified and managed. The inventory should be constructed on a task basis, populated by “critical tasks” – those that “keep you up at night.” Assessing tasks is critical. A certain number of FSIs are “one-offs,” not reflected in existing data. - Conduct a risk assessment and refine priorities for intervention. Take the “guesswork” out of risk assessment when the consequences of a bad guess may result in tragedy.
Identified precursors should be evaluated based on the potential severity of the hazard (severity), the degree of control (likelihood), and the number of workers exposed (magnitude). Related human and organizational factors that potentially activate or intensify the hazard or undermine controls should also be integrated into the risk assessment. The resulting Final Risk Assessment can be used to set priorities for FSI intervention and drive continuous improvement on two levels – hazard mitigation and underlying human and organizational factors. - Ensure adequate hazard control. Critical steps in the process – tasks where an incident could result in an employee being killed or seriously impacted – must be identified via task-based inventory.
Be proactive to ensure operational consistency in these steps. Promote the use of checklists for key aspects, and anticipate mistakes. No matter how hard we try, mistakes happen – it is part of the human condition. It’s risky to expose workers to serious hazards, provide lower level controls, and expect workers never to make a mistake. Critical steps should be “mistake-proofed” whenever possible. - Integrate human and organizational performance issues into the risk identification and abatement process.
Cultural and organizational norms, management policies and practices, process conditions, and human factors impact S&H performance – and the FSI rate. Flawed incident investigations and a culture that assigns blame and concentrates on the last factor in a chain of events leading up to the incident ignore these issues. It’s critical to incorporate human and organizational performance (HOP) issues into precursor recognition and assessment strategies. - Drive continuous improvement with Infrastructure, including management systems and metrics.
Cultural and organizational improvements are key to sustaining FSI prevention efforts over the long term. To sustain and drive continuous improvement, changes must be made in ongoing management system requirements, particularly regarding learning. Changes also must be made in the metrics used to measure prevention efforts and evaluate performance. Leading indicators can be developed to drive and assess key organizational and system improvements. And a relatively new trailing metric (largely developed by ORCHSE and adopted as a new Global Standard by ASTM) can be used to track outcomes for the more serious incidents.
Authored with Dee Woodhull, CIH, CSP and Rosemarie Lally, JD
