Heinrich Deconstructed

Transcription

1 Heinrich Deconstructed (and reconstructed!) A Safety Revolution in Progress Presented at CSSE 2012 Professional Development Conference, Niagara Falls, Canada September 11, 2012 Wayne Pardy - Quality Plus Inc. 1

2 Some brief historical context Heinrich s Causation Theory: the Ratio Heinrich professed that among the direct and proximate causes of industrial accidents: 88% are unsafe acts of persons. 10% are unsafe mechanical or physical conditions. 2% are unpreventable (i.e. acts of God). Wayne Pardy - Quality Plus Inc. 2

3 Krause took this further In the majority of cases from 80% to 95% - accidents are caused by unsafe behavior. This statement emphatically does not mean that the injury is the employees fault. Source: The Behavior-Based Safety Process Krause, Hidley & Hudson Wayne Pardy - Quality Plus Inc. 3

4 Dupont went even further still 10 year study across all DuPont sites 96% of injuries resulted from unsafe acts and poor work practices Dupont, 1986 Wayne Pardy - Quality Plus Inc. 4

5 And Difford has gone even further still Whilst generally supportive of Heinrich (1941), Difford presents the case to revise Heinrich s finding that 88% of accidents result from unsafe acts and proceeds to logically adjust that figure to 98% Keith Scott, Chairman International Institute of Risk and Safety Management Wayne Pardy - Quality Plus Inc. 5

6 Are Difford and Heinrich wrong? While there have been many critics of Heinrich, it is worthwhile to note that Heinrich's 88% has been dismissed and criticized, but not refuted Difford on LinkedIn (EHSQ Elite) Wayne Pardy - Quality Plus Inc. 6

7 So What? According to Manuele, Heinrich s... ratios have had the greatest impact on the practice of safety How? It has also done the most harm Why? Since it promotes preventive efforts being focused on the worker, rather than on the operating system. Heinrich Revisited: Truisms or Myths Wayne Pardy - Quality Plus Inc. 7

8 Borderline unethical? A Manuele colleague who is disturbed by safety professionals who reference Heinrich premises as fact, says, It is borderline unethical on their part. Source: Wayne Pardy - Quality Plus Inc. 8

9 Manuele s bottom line The premise discussed here (unsafe acts of workers) are the principle causes of occupational accidents are wrongly based and cannot be sustained by safety practitioners. Source: Wayne Pardy - Quality Plus Inc. 9

10 Manuele s call to safety professionals Stop using and promoting these premises Dispel these premises in presentations, writings and discussions; Apply current methods that look beyond Heinrich s myths to determine true causal factors of incidents. Wayne Pardy - Quality Plus Inc. 10

11 Enter Paul Difford and Redressing the Balance (2011) Accident causation There are many who believe that management or organizational failures are the root of all accidents. Wayne Pardy - Quality Plus Inc. 11

12 Redressing the Balance, 2011 Management failures cause all accidents - Myth Reason s Swiss Cheese Model and Bird s management failure model - Disproved The so called Organization Accident - Myth Petersen s multiple causation theory - Disproved Heinrich s Accident Causation Theory - Empirically and logically valid with modification Wayne Pardy - Quality Plus Inc. 12

13 Redressing the Balance supported by: Ten year study about current models of causation 114 books 56 publications and papers 18 UK, EU and USA case studies, and 10 web site references Wayne Pardy - Quality Plus Inc. 13

14 The management failure movement Petersen, Bird, Reason, et. al. Compelled into absurdity and the categoric denial that workers have either right, inclination or opportunity to exercise free-will in the workplace For them, error and violation are always the consequence of managerial or organizational failings Wayne Pardy - Quality Plus Inc. 14

15 A perspective on Heinrich s 88% A common, if not convenient misinterpretation is that this in some way equates to a theory that blames front-line workers, but that is not the case Source: Difford, 1998 Wayne Pardy - Quality Plus Inc. 15

16 HSE (UK :1) The nature of accident causation has changed with engineering failures no longer being a major feature in many accidents It is now largely behavioral with human failings being a significant part of the causes of most accidents. Of these, knowingly deviating from approved work practices represents a large proportion of incidents involving some form of human error. This form of human error is often termed violation. Wayne Pardy - Quality Plus Inc. 16

17 Interesting! Where is the body of literature, empirical data and research that supports multiple causation theory, management failure and organizational accident perspectives? We re still waiting. Wayne Pardy - Quality Plus Inc. 17

18 Some perspective - What is a Causal Factor? (in my world) Mistakes or failures that, if corrected, could have prevented the incident from occurring or would have significantly mitigated its consequences Source: TapRoot : Changing the Way the World Solves Problems. P. 77 By Mark Paradies and Linda Unger Wayne Pardy - Quality Plus Inc. 18

19 What does a causal factor look like? Was this a mistake made, or was something done wrong, or What equipment failed or did not work as intended? NOTE! Wrong does not indicate blame. It is simply a statement of fact. Wayne Pardy - Quality Plus Inc. 19

20 Causation considered Why do so many automatically default to the organization or system when an accident happens? Why is it not the person s accident? Why is it someone else s accident? These questions have no notion or reference to blame in them... therefore there should be no notion or reference of blame in your answer. Source: Difford. P. 175 Wayne Pardy - Quality Plus Inc. 20

21 Management or Organizational Failures? Workers were asked who they thought was best placed to reduce the chance of them having an accident? Themselves 70% Other workers, Supervisors Management & Unions (30%) Are those 70% of respondents out to lunch? Source: Hale and Perusse (1977) citing McKenna Wayne Pardy - Quality Plus Inc. 21

22 HSE (UK) 2002 & 2004 studies Violations were linked to between 70%-90% of accidents (2002) Problems stemming more from known violations than from lack of knowledge (2004) A Deadly Maintenance... 30% of the 739 deaths to which he refers could not possibly have been rooted deeper in management (1985) Wayne Pardy - Quality Plus Inc. 22

23 Management Failure School of Philosophy Based almost exclusively on the belief that a man is never the cause of his own behavior, i.e. that a man is never responsible for his own actions. On the one hand, Petersen stated that management invariably causes all accidents... Yet Petersen himself was even forced to concede: a painfully obvious and simple truth.. people, not things cause accidents (Petersen 1979:15) Source: Difford, p. 161 Wayne Pardy - Quality Plus Inc. 23

24 Bird & Reason Moved a million miles away from Heinrich s findings in order to claim (based on their own subjective re-labeling of things) that the cause of a man s behavior, without exception, is due to management or organizational failures Difford... P. 74 Wayne Pardy - Quality Plus Inc. 24

25 Difford If they are right that only management can cause an accident, then only management can prevent one since with no opportunity for sharp-end man to cause one, logic dictates that he cannot possibly have any opportunity to avert one either. Wayne Pardy - Quality Plus Inc. 25

26 I am not an animal! Management failure theory: Presumes a workplace full of mindless automatons devoid of any free will... such that, regardless of what anyone does, it will always be someone else s fault (i.e. attributable, ultimately and without exception, to management or the organization.) Source: Difford. P. 101 Wayne Pardy - Quality Plus Inc. 26

27 Can you or I control ourselves? For Difford and his supporters, the notions of so-called organization accident (Reason, 2004) and the organizational model of human error are pure fiction. They reply largely, if not exclusively, on the belief that workers (you and I) have neither right, inclination, ability or opportunity to exercise free will. Difford, P. 103 Wayne Pardy - Quality Plus Inc. 27

28 Difford s 10 year study At a stretch, error is behavior (Bogner, 2004)... But, it is not a system driven phenomenon insofar as it has not been found to be caused by the environment in the academic, epidemiological or multi-factorial sense. More often than not, it results from an individual s assessment of the environment s ability to either prevent or support the behavior that they are contemplating (Ajzan, 1991) Wayne Pardy - Quality Plus Inc. 28

29 How many dominos do we need? If Bird genuinely believed that management failures always cause accidents then there is no reason for his domino sequence to look anything other than the depiction below: Management failures Accidents Wayne Pardy - Quality Plus Inc. 29

30 So what are the challenges? Academics have confused themselves and each other over causation... That aside, the MCT (multiple causation theory) approach is extremely attractive to regulators and so it is not surprising that they force the philosophy into the H&S community. For now, they need to realize that people, not things, cause accidents and that something is seriously out of balance. Wayne Pardy - Quality Plus Inc. 30

31 Why Difford s work is unsettling for many in the safety community: It requires a questioning of the widely held belief that management or organizational failures are the root causes of most, if not all, accidents. There is, in fact, no such thing as an organization accident (it being an academically miscalculated invention). For some, all their rhetoric and money making ideas and programs are seriously challenged Wayne Pardy - Quality Plus Inc. 31

32 Challenges to the safety community Many have put too much on the line to even read Difford. It would mean a change in approach to a lifetime of what some safety practitioners have written and practiced. Many have said so much in support of management system failure theory of accidents, MCT and organizational accidents that they are now not able to save face if they in any way accept Difford s work/conclusions. Wayne Pardy - Quality Plus Inc. 32

33 Will anyone listen? The extent of the programming is such that many will be unable to change. Source: Difford in to W. Pardy Wayne Pardy - Quality Plus Inc. 33

34 So where does this leave us? We have 2 very distinct camps, both supported by their research/perspectives and theories They cannot co-exist Management failures, organizational accidents and multiplecausation theories of causation vs. Management cannot possibly cause all accident approach Wayne Pardy - Quality Plus Inc. 34

35 What to believe and why? Acts of God aside, (or more correctly, the unpredictable and uncontrollable consequence of natural phenomena) human behavior, irrefutably, will be the proximate cause of any preventable accident. OR Wayne Pardy - Quality Plus Inc. 35

36 Management or organizational failures cause all accidents What to do? Wayne Pardy - Quality Plus Inc. 36

37 You make up your own mind after considering the evidence (I m simply a messenger). Consider: Redressing the Balance (Difford) Heinrich Revisited: Truisms or Myths As well as the following The following links will be helpful: Wayne Pardy - Quality Plus Inc. 37

38 Final thought Don t be bullied by those experts who have a great deal to lose by maintaining their theory of accident causation (academics, consultants, regulators, etc.) Read and absorb all you can and then decide based on the logic, rationale and argument of your own research. Don t dismiss Difford outright, as some have done. Fear won t progress our efforts in causation. Do your homework, assess the evidence, and make up your own mind. Wayne Pardy - Quality Plus Inc. 38

39 So what? Why should I care? It will help us determine effective prevention strategies It will put our resources in the right place, for the right reasons It s about people let s emphasize what s important Alternatively, we ll continue to be polarized We ll have no accepted body of knowledge on causation Let s get our own house in order Safety is still in growth and pursuing maturity. How about you... What will you do? Wayne Pardy - Quality Plus Inc. 39