BERNARD M. TELATOVICH, P.E., J.D. Kenneth Martin CONSULTING - - PowerPoint PPT Presentation

PRESENTED BY:

BERNARD M. TELATOVICH, P.E., J.D. Kenneth Martin

CATCH IT! ---------------------------THE SEMINAR

PRESENTED BY:

BERNARD M. TELATOVICH, P.E., J.D. Kenneth Martin

S T D

CATCH IT! ---------------------------THE SEMINAR

Owner/President -Consulting Services & Investigations, LLC – A forensic engineering firm. Vice President of Engineering -Benchmark - A civil engineering, traffic, and surveying firm.

University of Alabama at Birmingham, School of Engineering

• M. Eng. Candidate 2015 in Advanced Safety Engineering and Management

University of Florida, College of Law Juris Doctorate (J.D.), May 1993 Lehigh University B.S. Civil Engineering, June 1985 Louisiana Sate University Certified Occupational Safety Specialist University of Florida Accident Reconstruction and Highway Safety Northwestern University Accident Reconstruction Training University of North Florida (IPTM) Computer Accident Reconstruction /Simulation

Designing out Error Provocative Environments & Liability Issues in Implementing or not Implementing PTD Standards

Introduce the ANSI/ASSE Prevention through Design (c0nsensus) Standard (Z 10) Heinrich’s Safety Theories Hierarchy or Controls Risk Analysis and Risk Assessment Application of PtD in the Workplace Application of PtD in Litigation Related Matters

• “Without changing our patterns of

thought, we will not be able to solve the problems we created with our current patterns of thought.”

• WHO SAID

THIS? Albert Einstein

2008 – NIOSH declared a major initiative to develop and approve a broad, generic voluntary consensus standard on PREVENTION THROUGH DESIGN that is aligned with international design activities and practices.

WEBSITE : www.cdc.gov

Scope:

Defines minimum requirements for OHSMS

Purpose:

Management tool to reduce risks of

• ccupational injury,

illnesses and fatalities

Application:

Organizations of all sizes and types Includes Contractors

IS Z10 the Trojan Horse in Safety?________

ASSE – ANSI Z590 PtD

• -Generic voluntary consensus

standard

• -American National Standards

Institute (ANSI)

• -Need for an ANSI accredited

standards development organization

• -American Society of Safety

Engineers (ASSE)

National Society of Professional Engineers’ Code of Ethics:

− Engineers shall hold paramount the safety, health, and welfare of the public −

American Society of Civil Engineers’ Code of Ethics:

− Engineers shall recognize that the lives, safety, health and welfare of the general public are dependent upon engineering decisions…

• 1. SAFETY
• 2. HISTORY
• 3. WHO is TO BLAME?
• 4. What did Heinrich Say?

By way of New Matter it is averred: Plaintiffs claims are barred or limited by the applicable Statute of Limitations. Plaintiffs claims are barred or limited by the provisions of the Pa. Comparative Negligence Act, 42 Pa. C.S.A. §7102. Plaintiff assumed the risk of her alleged injuries. Plaintiff fails to state a claim upon which relief may be granted. Plaintiff's injuries, if any, were not factually caused by any activity or failure to act on the part of answering defendants. Answering defendant was not negligent. Answering defendant breached no duty

• wed to the plaintiff.

Answering defendant had no notice, actual or constructive, of the alleged dangerous and/or defective condition identified in plaintiffs complaint, the existence of which is specifically denied.

The plaintiffs injuries were caused by third parties over whom answering defendant had no control or right of control. Plaintiffs alleged accident could have been avoided had plaintiff taken an alternate route. Plaintiffs claims may be barred and/or limited by a failure to mitigate damages. Plaintiffs claims are due in whole or in part to an act or acts of commission or

• mission of persons, parties or entities other than Answering Defendant

and over whom Answering Defendant had no control or right of control. If answering Defendant owed a duty of care to Plaintiff, said duty was not breached or violated.

PLAINTIFF MAY BE INJURED, BUT THEY CANT SUE US BY LAW! PLAINTIFF WAS IN OUR FACILITY/LOT, BUT ASSUMES THE RISK!

PLAINTIFF FAILED TO STATE A CLAIM UPON WHICH RELIEF CAN BE GIVEN WE DIDN’T CAUSE THE PLAINTIFF’S INJURY IT WAS SOMEONE ELSE.

WE ARE NOT NEGLGENT, WE HAVE NO DUTY TO THIS PERSON HERE. BUT, IF WE HAVE A DUTY, WE DID NOT BREACH OUR DUTY.

WE NEVER-EVER-EVER KNEW THIS WAS A DANGER OR HAZARD! OTHER PEOPLE (3RD PARTY) CAUSED THE INJURY .

BLAME PLANTIFF – THEY DIDN’T MITIGATE THEIR DAMAGES. PLAITNTIFF SHOULD NOT HAVE BEEN WALKING IN THIS AREA.

Are these the defenses you want to state in your answer and new matter?

Organizational factors Operational factors Cultural factors

ROOT CAUSES

1.

Scope, Purpose and Application

• 2. Definitions

3.

Management Leadership and Employee Participation

• 4. Planning

5.

Implementation and Operation

• 6. Evaluation and Corrective Action
• 7. Management Review
• 8. Appendices

√ THERE IS A FIXED RATIO BETWEEN SERIOUS AND LESS SERIOUS INJURIES √ ALL TYPES/SEVERITIES OF INJURIES HAVE THE SAME UNDERLYING CAUSE √ SAFETY COMMUNITY ADOPTED AND VIEWED INJURY PREVENTION THROUGH THE PARADIGM OF HEINRICH AND HIS SAFETY TRIANGLE.

300 No injury accidents 29 Minor Injuries 1 Major injury √ Unsafe acts and unsafe conditions were at the root of all injuries. √ You must work at the base of Triangle to prevent injuries. √ Reducing the frequency rate of minor injuries will lead to a corresponding reduction of major injuries.

WAS HEINRICH CORRECT?

WAS HEINRICH CORRECT?

A pioneer in the field of accident prevention, employed by Travelers Insurance Company. Authored “Industrial Accident Prevention, A Scientific Approach”--- in 1931, 1941, 1950, and 1959. Accident Triangle Theory 88% of accidents  are human error-blame the worker—train better—warn..etc.

The most persistent of Heinrich’s concepts were: a mathematical relationship exists between the numbers of accidents of similar types and their severity; the most common cause of workplace accidents is unsafe acts of employees; and reducing the overall frequency of workplace injuries will produce an equivalent reduction in the number of severe injuries. These are the basic foundations of many current safety programs such as Behavior Based Safety; Zero Harm (or zero anything) and so forth which are vigorously promoted by consultancies and adopted by firms and safety professionals.

• Fred A. Manuele, P.E., CSP, is

president of Hazards Limited, which he formed after retiring from Marsh & McLennan where he was a managing director and manager of M&M Protection Consultants. His books include Advanced Safety Management: Focusing on Z10 and Serious Injury Prevention, On the Practice of Safety, Innovations in Safety Management: Addressing Career Knowledge Needs, and Heinrich Revisited: Truisms or

• Myths. A professional member of

and former board member of ASSE, NSC and BCSP

2013 Roger Brauer Lifetime Achievement Award Recipient

• “Don’t blame people for problems caused by the

system” Dr. Deming

“

FROM HEINRICH TO ANSI Z 10

THE LESSONS LEARNED FROM HEINRICH (TRIANGLE) HAVE BEEN VALUABLE TOOLS TO DRIVE THE IMPROVED HSE CULTURE RESULTING IN GREAT REDUCTIONS IN INJURY RATES. HOWEVER, NEED TO BE AWARE OF LOW FREQUENCY HIGH SEVERITY RISKS…………………………EXAMPLES

FROM HEINRICH TO ANSI

LANNY FLOYD UAB EGR 601

Don’t blame people for problems caused by the system.

• DR. SCOTT GELLER

Behavior is an outcome of a number of cultural factors, including work climate, the relevant equipment, the work process and the management system.

ANSI/ASSE Z590.3-2011 :

“Addressing occupational safety and health needs in the design and redesign process to prevent or minimize the work related hazards and risks associated with the construction, manufacture, use, maintenance, retrofitting, and disposal of facilities, processes, materials, and equipment.”

It uses recognized management system principles in order to be compatible with quality and environmental management system standards such as the ISO 9000 and ISO 14000 series. The standard also draws from approaches used by the International Labor Organization’s (ILO) guidelines on Occupational Health and Safety Management Systems and from systems in use in organizations in the U.S. The design of ANSI Z10 encourages integration with other management systems to facilitate organizational effectiveness using the elements of Plan-Do-Check-Act (PDCA) model as the basis for continual improvement. PDCA was popularized by Dr. W. Edwards Deming, and is used as a framework by most management system standards

ANSI/AIHA Z10 – (2005) 2012:

VOLUNTARY CONSENSUS STANDARD

The design of ANSI Z10 encourages integration with other management systems to facilitate organizational effectiveness using the elements of Plan- Do-Check-Act (PDCA) model as the basis for continual improvement. PDCA was popularized by Dr. W. Edwards Deming, and is used as a framework by most management system standards

ANSI/AIHA Z10 – (2005) 2012: PLAN-DO-CHECK-ACT

• 1. Pre-operational stage, which includes pre-planning,

specification, design, prototyping, and construction processes.

• 2. Operational stage, where hazards and risks are

identified and evaluated and corrective action is taken through either redesign initiatives or by making changes in work methods to prevent incidents or exposure.

• 3. Post incident stage, where investigations are made
• f incidents and exposures to develop the causal

factors, which will lead to the correct interventions and acceptable risk levels.

• 4. Post operational stage, when the demolition or

reusing/rebuilding operations are undertaken.

ANSI/ASSE Z 590.3:

Introduce the ANSI/ASSE Prevention through Design (c0nsensus) Standard Heinrich’s Safety Theories Hierarchy or Controls

• I. Widely supported in the

professional community.

• II. They describe the order that

either should be followed or must be followed when choosing among

• perations for controlling health and

safety hazards. WHY ARE THEY IMPORTANT?

SAFETY IS CULTURE DRIVEN and MANAGEMENT ESTABLISHES THE CULTURE The major key to success of any standard, program, or process is _____{please take a guess} _________

The answer is: MANAGEMENT ‘S COMMITMENT

APPENDIX G HIERARCHY of CONTROLS (ANSI Z10 SECTION 5.1.2, 2012) This hierarchy is intended to provide a systematic approach to eliminate, reduce, or control the risks of different

• hazards. Each step is considered less

effective than the one before it. It is not unusual to combine several steps to achieve an acceptable risk. The types of hazards employees are exposed to, the severity of the hazards, and the risk the hazards pose to employees should all be considered in determining methods of hazard elimination or control.

Section 5.1.2 (ANSI Z10 SECTION 5.1.2, 2012) 5.1.2 Hierarchy of Controls The organization shall establish a process for achieving feasible risk reduction based upon the following preferred order of controls:

• A. Elimination;
• B. Substitution of less hazardous materials,

processes, operations, or equipment;

• C. Engineering controls;
• D. Warnings;
• E. Administrative controls, and
• F. Personal protective equipment.

Section 5.1.2 (ANSI Z10 SECTION 5.1.2, 2012) Feasible application of this hierarchy of controls shall take into account:

• The nature and extent of the risks being controlled;
• The degree of risk reduction desired;
• The requirements of applicable local, federal, and state statutes, standards

and regulations;

• Recognized best practices in industry;
• Available technology;
• Cost-effectiveness, and
• Internal organization standards.

While not every company has implemented PTD or ANSI Z10, the hierarchy of controls is not a new concept. It has been around in industrial hygiene since Hamilton (1929) and in safety since at least Haddon (1973). Michael Behm and Demetria Powell

1938 ANSI

The hierarchy of controls is also found in the “consensus” standards written by committees meeting under the auspices of the American National Standards Institute (ANSI) and its predecessor, the American Standards Association. The Association’s 1938 standard for protective equipment did not require any particular “hierarchy of controls, ” but the attached commentary noted:

It is obviously better to remove the hazard, when this is possible, than to protect the worker against it [using personal protective equipment]. Thus, in granite cutting it is preferable to remove the dust by an exhaust system rather than to allow it to contaminate the air, and then to protect the worker against breathing the dust. . . . This code does not attempt to specify how various industries shall be conducted, with respect to avoiding hazards, but points out the method of protecting the worker where the hazard has not been eliminated by other means (15).

1950

NSC.

In 1950 the National Safety Council began describing the hierarchy of controls. It recognizes that design, elimination and engineering controls are more effective in reducing risk than lower level controls such as warnings, training, procedures and personal protective equipment. Hierarchy of Controls

• 1. Elimination or Substitution
• 2. Engineering
• 3. Warnings
• 4. Training and Procedures
• 5. Personal Protective Equipment

The highest feasible level of control should be used to control every hazard. When high level controls are not feasible or do not adequately reduce risk, lower level controls such as warnings, training, procedures and personal protective equipment must be

• implemented. The hierarchy can be found in almost every competent manual on health

and safety.

NSC

National Safety Council’s Accident Prevention Manual (322), which lists the following “hierarchy”:

The basic measures for preventing accidental injury, in order of effectiveness and preference are:

• 1. Eliminate the hazard from the machine,

method, material, or plant structure.

• 2. Control the hazard by enclosing or guarding

it at its source.

• 3. Train personnel to be aware of the hazard

and to follow safe job procedures to avoid it. Prescribe Personal protective equipment for personnel to shield-them against the hazard.

United States Military MIL-STD-882D Much of the wording in the preceding hierarchies of control is comparable to that found in military standard system safety requirements. First issued in 1969 as MIL-STD-882, the fourth edition, issued in February 2000 is designated as MIL-STD-882D (U.S.

• Dept. of Defense).

Introduce the ANSI/ASSE Prevention through Design (c0nsensus) Standard (Z 10) Heinrich’s Safety Theories Hierarchy or Controls

Risk Analysis and Risk Assessment

What is the new view of human behavior? Z 10 – Z 590 – Military Standards –THE FUTURE The progression is slow- evolving, not revolutionary! Where the old view and the new view diverge! Who are the heavy hitters: DEKKER, MANUELE, DEMING, LEVENSON, WOODS…..

• System is basically Safe

(PAT YOURSELF ON THE SHOULDER)

• Erratic people undermine it! (YOUR DEFENSE)

BAD APPLE – Need to be controlled, punished, exiled

• System is not basically safe

– Human errors systematically connected to features of people’s

• tools,
• tasks
• organizational
• environment

• Find unreliable people or components

in otherwise safe system! Is this your best defense? Only Defense?

• Think that safety, once established,

can be maintained by keeping human and system performance within bounds. We trained them its their fault! The blew it! How dumb could they have been? No one did this in X Years? {SO ITS SAFE}

“Accidents are … the effect of a systematic migration of organizational behavior under the influence of pressure toward cost-effectiveness in an aggressive, competitive Environment— Rasmussen (DRIFT INTO DANGER)

WHAT IS WRONG WITH THIS PHOTO?

WHAT IS WRONG WITH THIS PHOTO?

Some (most) people don’t care enough about safety to be safe Some (most) people don’t know enough about safety to be safe These people are the primary cause of accidents!

“Underneath every seemingly obvious, simple story, there is a second deeper story. A more complicated story. The second story is inevitably an organizational story, a story about the system in which people work.” SYDNEY DEKKER

It is a choice: See Human Error s the cause of trouble in otherwise safe

• systems. So stop looking as soon as you have found a

convenient “human error’ to blame!

The best way to intervene is at the contextual level Safety is best measured by its presence (i.e. success) People are usually reliable and are the source of safety and success

Latent Conditions

Latent Conditions

Latent Conditions

Active Conditions

Failed or Absent Defenses

Unsafe Supervision Preconditions for Unsafe Acts Unsafe Acts

Accident & Injury

Active versus Latent Failures (Reason, 1990)

Human Error is not a cause of failure. Human Error is the effect of a deeper trouble:

Human Error is not Random. It is systematically connected to features of peoples tools, tasks, and operating environment. Human Error is not the conclusion of an investigation, it is the starting point.

TO ERR IS HUMAN. TO FORGIVE- DESIGN

Alphonse Chapanis – Father of Human Factors Engineering

WHO SAID THIS?

QUESTIONS