The Research Process
During my career, the topic of the Safety Pyramid came up many times with references to many opinions on the notion of Safety Pyramid, and it was used as a scare tactic when incidents occurred because of the senior managers’ actions who could state that they had too many incidents.
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I chose the topic of Accountability and the notion of Safety connected with it was the topic in which I became interested while working. Before starting the classes Topics in Occupational Health and Safety, I worked with the team of Safety Professionals and we had a conversation about the number of incidents. Thus, we were heading for a near miss. I decided to see if there was any more information about the Safety Pyramid and its relevance.
There were a lot of articles and books about the safety pyramid with various opinions on its relevance today. I found very few journals that referred to the Safety Pyramid, but the few ones that I found were very informative and interesting to read. Most of the readings that I found were written within the last few years so the information was rather new and relevant to the modern Safety Culture.
Sources of Information
I was able to obtain the most information from the articles in OH&S magazines. These articles were current and relevant to the information I was seeking. I also examined the information from the books mainly related to Safety Culture, and I was able to take that information and combine it with the other information that I have found earlier to make the other authors’ arguments stronger. The most difficult task was to obtain the information that could be relevant to the subject from the peer-reviewed journals which I was looking for in the various databases.
In your opinion, is the Safety Pyramid relevant to today’s safety culture?
Many times you will see great companies that received accolades for their safety performance only become crippled by a workplace fatality or you can see other companies with horrible safety performance without the record of a major incident or fatality. If it were as simple as a math equation, I would hope we would have figured it out by now (S. Tait, personal communication, September 21, 2011).
In your opinion, why do so many safety professionals promote this theory?
It is an easy theory to believe in it as something that has been around since 1930. There was a small amount of data and research presented, and it seemed to fit the needs. Now companies have built their safety programs around this theory. Saying that we are wrong and shifting the focus is not an easy task. We also have to ask the construction management to get a new way of thinking that holds them more accountable than they were required to in the past (S. Tait, personal communication, September 21, 2011).
Does this mean that Behavioural Based Safety Programs are not as effective as we are inclined to believe?
Behavioural Based Safety Programs are rooted in the belief that human behavior causes accidents, it is in turn that fact on which Heinrich’s Safety Pyramid theory is also based. Spending all your time and effort in the pursuit of fixing one persons or group’s behavior, we may see a reduction of minor injuries and near misses, but we do not see the Loss Time Injuries and fatalities go down (S. Tait, personal communication, September 21, 2011).
“Injury statistics in recent years revealed that while minor injuries have declined steadily, serious injuries remained the same, casting doubts on the validity of the Heinrich Safety Triangle concept” (Johnson, 2011).
Today, many safety professionals heard about and possibly were trained according to the concept that was pioneered by H.W. Heinrich in the 1930s. His concept of a Safety Loss Pyramid (1-10-30-300) has been used to help managers and supervisors to examine the relationship between fatalities, serious injuries, first aid, and near misses; or analyze injuries causation as the split between 88% unsafe acts and 10% unsafe conditions (Manuele, 2002; Manuele, 2010). But how does this theory add up? Does this theory just help us to find an easy way to explain incident causation or add value to this? If we as safety professionals follow this theory, can we prevent serious incidents?
In his The Standardization of Error, Stefansson pays attention to the fact that people can accept much information they receive without references to credible evidence (Stefansson, 1928). “When studies show that a supposed fact is not true, dislodging it is difficult because that belief has become deeply embedded in the minds of people and, thereby, standardized” (Manuele, 2010).
Herbert William Heinrich
Herbert William Heinrich was born in 1886 and was an American industrial safety pioneer in the 1930s. Heinrich worked as an Assistant Superintended of the Engineering and Inspection Division of Travelers Insurance Company; he published his book Industrial Accident Prevention, A Scientific Approach in 1931.
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Today, Heinrich’s empirical finding is discussed as Heinrich’s Law. According to this law, for each significant injury, there can be 29 accidents. Thus, these accidents cause minor injuries. 300 accidents do not cause any injuries. Many researchers agree that Heinrich’s work can be discussed as the basis for the Behaviour-based safety theory. This theory states that as many as 88% of all workplace accidents can be caused by unsafe acts when 10% are unsafe mechanical conditions, and 2% can be unavoidable accidents.
The author made his conclusions with references to thousands of accident reports by managers who are inclined to see the problem in workers’ causing accidents without further detailed investigations (Reason, 1997). The data that Heinrich used was not wrong; Heinrich only accurately reported no credible data as far as causation was concerned (Johnson A., 2011; Manuele, 2010).
Frank E. Bird Jr.
The other researchers attempted to build their investigations on Heinrich’s theory over time, including Frank E. Bird Jr. Frank E. Bird Jr. was born in 1921; in 1969, he became the Director of Engineering Services for the Insurance Company of North America. He was interested in Heinrich’s theory and made his calculations. He analyzed 1,753,498 accidents reported by 297 companies representing 21 different industrial groups and reflecting over 3 billion working hours. Bird’s data represented that for every major injury there were 9.8 reported minor injuries (requiring first aid treatment), there were 30 accidents, and 600 incidents or near misses. Accidents are used only to describe a situation in which there was an injury. This theory is often referred to as the 1-10-30-600 relationship (Roughton, 2008).
Today, with such diverse worksites many companies try to put their own ‘brand’ on the Safety Pyramid (Ringen, Seegal, & Englund, 1995). There are no two companies today which have the same ‘pyramid’. For instance, in 2003, the study was conducted by ConocoPhillips Marine “by demonstrating a large difference in the ratio of serious accidents and near misses” (Roughton, 2008). According to ConocoPhillips Marine, for every one fatality there are 30 Lost Work Days; 300 Recordable Injuries, 3,000 Near misses (estimated), and 300,000 At-Risk Behaviours (estimated).
Heinrich and Bird were both insurance guys and their pyramids did not predict, but only gave figures for risk exposures at the time of their analysis, just the same as any other pyramid that can be created today (Bird incident pyramid true or false, 2011; Janson, 2009). ConocoPhillips Marine Pyramid and your companies’ pyramid may look the same today, but some major incidents or fatality can alter the ‘pyramid’ tomorrow.
Today’s Safety Culture
Have safety professionals become fatalists? Do we believe that every incident that occurs could result in a fatality or a loss time injury? Do all incidents have the same potential outcome? A worker who falls off a railcar and the extent of the injuries he/she receives as a bruise on the elbow is compared to another worker who walked through a doorway and his elbow came in contact with the doorframe which resulted in bruising. The worker walking through the doorframe suffered from the highest potential of injury in the situation, but the worker falling off the railcars could feel much worse. The risk potential was higher.
Thus, if you can prevent someone from hitting his or her elbow in a doorframe, you cannot prevent a fatality from occurring. Situations need to be looked at separately because no one can review the statistics about which injuries had a higher potential to cause any harm (Corbett, 2004; Ritwik, 2002).
What do the statistics say?
Krause states that “we’re blind to the indicators of fatality. We’re looking at the wrong information” (Krause as cited in Johnson, 2011). Moreover, “that scenario – of good recordable rates and then a big event that’s bad – happens over and over”, and Krause says with adding that senior executives often wrongly regard a serious or fatal incident as a fluke that “being able to tell that makes all the difference in the world because if you’re having a lot of events that are potentially serious, the likelihood that you’re going to have a serious event is very high” (Krause as cited in Johnson, 2011).
According to Yan Lau, senior manager of OHS policy, “employment and immigration with the Government of Alberta, says safety statistics in the province show a similar trend as in the U.S. – from 2006 to 2010, the lost-time claim rate fell by 37.3 percent, while during the same time fatalities rose from 124 to 136” (Johnson, 2011). He goes on to accentuate “that injuries differ greatly in their potential. Most injuries are caused by over-exertion and affect the musculoskeletal system” (Johnson, 2011). The sprains and strains can be discussed as a majority of injuries that tend to be lost-time injuries and “could not end up as fatalities” (Johnson, 2011).
Statistics and numbers cannot differentiate between the same injury types and their risk potential (Krause, 2011). According to the Safety Pyramid theory, “the decrease of minor injuries (the large number at the bottom) leads to a proportionate reduction in severe injuries and deaths (the small number at the top)”, moreover, “statistics over the past 10 years have shown that minor injuries have steadily declined while the number of serious injuries and deaths has not changed” (Johnson, 2011). Krause and Lau also suggested that “companies track the number of events that they judge could have been serious or fatal as a metric separate from time-lost injuries” (Johnson, 2011).
Heinrich Vs. Safety Today
Heinrich believed that it was the worker behavior or acts that accounted for 88% of accidents. Heinrich did not see value in improving work systems and processes. There are many safety professionals today that are stuck in Heinrich’s frame of thinking even though there is a lot of information that has proved that his theory does not add up. BP celebrated 7 years of exemplary safety performance before the Deepwater Horizon Explosion on April 20, 2010. If Heinrich’s theory is correct then how can companies with great safety ratings have serious incidents or disasters large according to a scale as Deepwater Horizon Explosion?
During the investigation of the BP Deepwater Horizon Disaster it was found there was not one main cause, but many smaller causes that led to the ‘perfect storm’ that resulted in the worst offshore oil disaster in history.
If a company was to track high potential incidents and evaluate them separately from the lost time injuries, we can properly categorize occurrences and observations so that we can spot trends. Once these trends are identified, there must be actions to follow up to ensure that the action items are completed and effective to prevent the more serious occurrence.
Inspections should concentrate on both process safety as well as on observational safety. Past incidents have shown that there is no one root cause for an incident, but a range of plan missteps, process gaps, or engineering errors that can lead to an incident. Completing thorough inspections in multiple disciplines can assist in pointing out potential problems before they can do any harm.
The completion of an adequate incident investigation with an emphasis on finding route cause will be the key in preventing similar incidents from occurring again. If an operator commits an unsafe act, there is a human or operator’s error. But why did the error occur? This brings us to five why’s a method. This method involves asking “Why…?” five times to come up with the root cause as to why something happened. Questions may not be able to be answered on the spot and may require time to gather and analyze information.
The ability to find a root cause of why an incident or high potential near miss occurred will help put the proper actions into place to prevent a similar incident from occurring.
The shift in incident causation occurred since the time Heinrich first came up with his Safety Pyramid Theory. With that change, we can realize the root causes as to why incidents occur. If people are working unsafe, there are many layers as to why this occurs or what the problem is.
Being safety professionals, it is necessary to stop the occurrence of those unsafe acts which can be considered as the primary cause for many accidents. The reduction of the accident frequency can result in the further decrease of a severe injury. To complete the task, it is also significant to concentrate on the risk potential to prevent the incidents.
Corbett, D. (2004). Excellence in Canada: Healthy organizations – Achieve results by acting responsibly. Journal of Business Ethics, 55(2), 125-133.
Manuele, F. A. (2010). Reviewing Heinrich: Dislodging two myths from the practice of safety. Professional Safety, 7, 52-61.
Ringen, K., Seegal, J., & Englund, A. (1995). Safety and health in the construction industry. Annual Review of Public Health, 16, 165-188.
Manuele, F. A. (2002). Heinrich revisited: Truisms or myths. USA: National Safety Council.
Reason, J. T. (1997). Managing the risks of organizational accidents. London: Ashgate Publishing Co.
Stefansson, V. (1928). The standardization of error. London: K. Paul, Trench, Trubner & Co., Ltd.
Janson, E. (2009). Don’t miss the near miss. Shipgaz, p. 22.
Johnson, A. (2011). Were Herbert William Heinrich’s theories valid, and do they still matter? Safety + Health, p. 62.
Ritwik, U. (2002). Risk-based approach to near miss. Hydrocarbon Processing, p. 93.
Website Internet Addresses
Bird incident pyramid true or false. (2011). Web.
Johnson, L. (2011). Is the safety pyramid a myth? Study suggests new approach to injury prevention. Web.
Krause, T. (2011). Accidents just happen? Web.
Roughton, J. (2008). The Accident Pyramid. Web.