Applying cascade effect principles to mitigate workplace safety risks
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This document discusses applying cascade effect principles to mitigate workplace safety risks. It emphasizes that simple cause-and-effect thinking is not enough to dramatically improve safety and that cultural factors must be addressed. It provides tools to analyze organizational culture and processes through surveys, Venn diagrams, and war games to identify weaknesses in safety practices and perceptions at different levels. Addressing systemic cultural and process issues, rather than individual factors, can help create a truly safe work environment.
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Applying cascade effect principles to mitigate workplace safety risks
- 1. APPLYING CASCADE EFFECT PRINCIPLES TO MITIGATE WORKPLACE SAFETY RISKS Presented by David Patrishkoff President – E3 - Extreme Enterprise Efficiency® President – ICER – The Institute for Cascade Effect Research®
- 2. CASCADE EFFECT THINKING CONCEPTS CAN IDENTIFY SELF-INFLICTED SAFETY ISSUES Negative Reinforcing Feedback loops Identify Tipping Points The Perfect Silent Storm Address Internal Systemic Risks Identify Slow Burn or Creeping Risks Negative Causal Loops Expose Trojan Horse Risks Solicit Unspoken Talk Rules • Simple Cause and Effect Thinking cannot dramatically improve safety performances • More effective Cascading Safety Management concepts are required to create breakthrough safety improvementsIdentify Hyper- Connected Risks Facilitate Cascading War Games Conduct Cultural Health Surveys Bait-Bubble-Burst Effect Address Seemingly trivial but threatening interconnected issues
- 3. ORGANIZATIONAL CASCADES AND FEEDBACK LOOPS 1) Negative Reinforcing Downward Spiral 3) Maintain the Status Quo 4) Rapid Positive & Disciplined Intervention 5) Positive Reinforcing Virtuous Circle 2) Waste time by just Addressing the Symptoms 1 2 3 4 5 5 Types of Feedback >>>>>>> Loops to Leadership >>>>>>>
- 4. HOW 56 INTERNAL CULTURAL RISKS AND BEST PRACTICES CAN IMPACT YOUR SAFETY PROGRAM Transform These 56 cultural risks (left) have been at the core of the most serious safety disasters in history. Each risk can be countered by the appropriate Best Practice (right). Weak cultures cannot support a healthy safety program.
- 5. 10 OF THE MANY DISASTERS USED TO ESTABLISH THE CASCADE EFFECT PRINCIPLES 1. The Iroquois Theater Fire in Chicago, 1903 - 605+ deaths 2. Sinking of the Titanic, 1912 - 1,502 deaths 3. The USS Indianapolis Sinking, 1945 - 880 deaths 4. Banqiao Dam failure, China, 1975 - 171,000 deaths 5. Union Carbide gas explosion, India, 1984 - 3,787+ deaths 6. NASA Space Shuttle Challenger Loss,1986 - 7 deaths 7. Alaska Airlines Flight 261 Crash, 2000 - 88 deaths 8. Petrobras 36 Oil Rig sinking, 2001 - 11 deaths 9. NASA Space Shuttle Columbia Loss, 2003 - 7 deaths 10. Deepwater Horizon Oil Spill - 2006 - 11 deaths
- 6. HOW MANY OF YOU FEAR FOR YOUR LIFE BY GETTING ON A US COMMERCIAL AIRPLANE?
- 7. HOW MANY OF YOU FEAR FOR YOUR LIFE WHEN YOU GO TO WORK EACH DAY?
- 8. US COMMERCIAL AIRLINE DEATHS VS. TEXAS WORKFORCE FATALITIES? There were more workforce fatalities in Texas, in 2013, than airline passenger deaths on US Commercial Airlines in the last 15 years, including the 9/11/2001 high jacking and crashing of 4 commercial jets. • 2013 Texas Workforce Fatalities: 508 • 2000 – 2014 (15 years) US Commercial Airline Fatalities: 474 1-5 1 February 12, 2009: Continental Flight 3407 Beech 1900; Charlotte, NC, which killed 51 people in New York 2 August 27, 2006: Delta Connection (Comair) CRJ-100; Lexington, KY: 49 perished 3 January 8, 2003: US Airways Express (Air Midwest) 2009, with 21 fatalities 4 Sept 11, 2001: Four high-jacked and crashed jets, total of 265 airline passengers perished 5 January 31, 2000: Alaska Airlines MD83; near Pt. Mugu, CA with 88 fatalities
- 9. Charts: http://www.tdi.texas.gov/wc/safety/sis/fathomepage.html FATAL OCCUPATIONAL INJURY DATA - TEXAS
- 10. Charts: http://www.tdi.texas.gov/wc/safety/sis/fathomepage.html FATAL OCCUPATIONAL INJURY DATA FOR 2013 - TEXAS • Most fatal work hour: 1-2 pm • Most fatal day : Mondays & Wednesdays • Most fatal month: August, then April • Most endangered age group: 45-54, then 25-34 • Most endangered gender: Males, 20x the # of Females • Biggest cause: Transport Incidents
- 11. NONFATAL OCCUPATIONAL INJURY AND ILLNESS DATA, AND INFORMATION BLS PROGRAMS http://www.tdi.texas.gov/wc/safety/sis/nonfatalhomepag.html 2009 to 2013 drop in US private sector injury / illness rate = 8.3% (2.1% / year) 2009 to 2013 drop in Texas private sector injury / illness rate = 10.3% (2.58% / year)
- 12. EXAMPLE OF A NEGATIVE TOP-DOWN CASCADE THAT CAN PROVOKE SERIOUS SAFETY ISSUES No Learning Feedback Loops
- 13. NEW USE FOR AN OLD TOOL (THE SWOT): CASCADING SAFETY SWOT ANALYSIS • On a top level, a SWOT (Strengths, Weaknesses, Opportunities & Threats) is a general tool that yields general results • However, it can be improved to supplement other Safety improvement initiatives
- 14. • A SWOT can be quite effective when conducted for each element of the organizational cascade that deals with Safety processes • A Safety Culture is only as strong as the weakest link in the Cascade SWOT THE HEALTH OF YOUR SAFETY CULTURE CASCADING SAFETY SWOT ANALYSIS
- 15. SWOT THE HEALTH OF YOUR SAFETY CULTURE • A SWOT analysis should be conducted at each level in the organization, candidly and anonymously • It’s important to identify and analyze any differences in safety program perceptions at various levels • The doomed NASA Space Shuttle found that engineers perceived 10X the risk levels of managers
- 16. CULTURAL SAFETY SYSTEM SURVEY • Part of a 56 question cultural survey that can be used to measure the health of a safety program • This survey should be conducted at all levels and in different departments
- 17. 0 1 2 3 4 5 A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 K1 K2 K3 K4 K5 K6 K7 K8 K9 K10 K11 Q1Q2 Q3 Q4Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Q14 Q15 Q16 Q17 Q18 Q19 Ja1 Ja2 Ja3 Ja4 Ja5 Ja6 Ja7 Ja8 Ja9 Jo1 Jo2 Non-Management Score Mid-Management Score Top-Management Score Target Score Risk (1) to Best Practice (5) Brainstorm / Survey Scores EXAMPLE OF SPIDER CHART RESULTS FOR THE CULTURAL SAFETY SURVEY These scores were quite different between the 3 levels of management and the differences shown here were statistically significant (p- values < 0.05)
- 18. VENN DIAGRAM EXAMPLE: AGREEMENT AND DISAGREEMENT IN THE SAFETY CULTURE WEAKNESSES • This Venn diagram shows the differences and similarities between 3 different levels in opinions about key weaknesses that in their safety culture • Such differences in opinions and risk perceptions can lead to an ineffective safety management efforts Leadership Non-Management Mid-Management It is not taken seriously No accountability for procedure violations The company acquisitions did not integrate different safety cultures Common Perceptions No time is taken for proper training Other priorities are much higher than safety, such as getting the job done on time Different departments have different safety guidelinesSafety is just a slogan with few actions to back it up Everyone thinks it’s just the safety managers job and not theirs
- 19. STRESS TEST / WAR GAME YOUR PROCESSES & CULTURE TO FIND SAFETY BLIND SPOTS
- 20. SAFETY PROCESS ISSUE IDENTIFICATION AND MITIGATION TOOLS Pictorial Process Risk Analysis Risk Stream Mapping
- 21. A WEAK CULTURE CAN DISABLE THE BEST SAFETY STRATEGY • “Culture eats Strategy for Breakfast, Operational Excellence for Lunch and Everything Else for Dinner” • Quote from MIT Professor Bill Aulet, derived from the original quote by Peter Drucker Hello, My Name is CULTURE A healthy Work Culture: The best foundation for an effective Safety Strategy
- 22. DON’T BLAME THE PEOPLE!!! BLAME THE FLAWED PROCESSES & CULTURE
- 23. GOOD PEOPLE + BAD PROCESSES AND / OR CULTURE = BAD RESULTS • If you put GOOD PEOPLE in a BAD PROCESS & Culture, the process and Culture wins… Every time… • High Reliability Organizations (HROs) that put great emphasis on a high performance culture, have excellent safety records Good People Bad Processes and / or Culture >>>>>
- 24. SUMMARY • Simple Cause and Effect logic cannot create breakthrough safety improvements • True safety issue root cause analysis must address “many seemingly trivial but interconnected issues” and not just 1 or 2 “silver bullets” • A High Performance Work Culture can help create a safe work environment • Measure the cultural health with unique cascading cultural health surveys and address the weak links • Common Employee Surveys are too often “Feel good” exercises that do not address cascading systemic issues • Address weaknesses in the system and processes that compensate for human weaknesses and “bad days” at the office