AUDITING REDUCES ACCIDENTS BY ELIMINATING UNSAFE PRACTICES

J. Alan Collinge
Shell International Petroleum Co. Ltd.
London

Auditing for unsafe acts can remove the basic causes of accidents through the adoption of a proactive approach to safety. The process of auditing for unsafe acts is aimed at eliminating unsafe situations and practices by a method of constructive dialogue between managers and workers.

One of the major objectives of the process is to change the cultural attitude toward safety so that it is viewed as a personal responsibility of each member of management, supervision, and the workforce.

SAFETY POLICY

In large organizations like the Royal Dutch/Shell Group, it is common to see policy statements concerning the health and safety of employees and people associated with the business, such as contractors. In recent years, such organizations have also placed emphasis on statements related to protecting the environment.

Policy guidelines for Shell companies are unambiguous:

Health. The companies conduct business in such a way as to avoid harm to the health of employees and others, and to promote, as appropriate, the health of employees.
Safety. Companies work on the principle that all injuries should be prevented and actively promote the high standards of safety consciousness and discipline that this principle demands.
Environment. Companies pursue progressive reductions of emissions, effluents, and discharges of waste materials known to have a negative impact on the environment, with the ultimate aim of eliminating those discharges.

Shell companies aim to provide products and services which, when used in accordance with supporting practical advice, will not cause injury to or undue effects on the environment.

The companies also promote the protection of environments that may be affected by their activities and seek continuous improvement in the efficiency of natural resource and energy usage.

Shell companies' safety performance over the last 25 years-in terms of lost-time injury frequency (LTIF) rate-has shown a steady improvement, but reducing the number of accidents continues to be a challenge for management (Fig. 1).

In 1984 it became clear that, to produce a substantial overall improvement, a more structured approach to safety management was needed.

Shell recognized that, in those companies where good performance or a substantial improvement in performance had been achieved, a major factor in that improvement was the personal, visible intervention of management. In addition, safety was treated in the same way as other primary business objectives such as production, efficiency, and cost management.

In 1985, this philosophy was embodied in a set of principles which formed the core of a safety initiative called the Enhanced Safety Management (ESM) program.

ESM PROGRAM

Experience has shown that companies successful at managing an effective safety program have a number of essential features in common. These features are shown in Table 1.

An analysis of Shell accident reports showed that more than 80% of all injury accidents were caused by human behavior, or more specifically, by unsafe practices.

Often, the risk of major accidents is assessed from a technical standpoint. Sophisticated engineering designs are introduced to minimize the chance of major catastrophes occurring. In the oil industry, such risk assessment techniques are widely used.

While it is vital to improve facility and engineering safety standards continually, the larger human failure factor offers the greatest scope for reducing the occurrence of accidents.

Jim Thomen, a former Dupont Co. safety consultant and plant manager, in his book "Leadership in Safety Management" said, "A workplace is neither safe nor unsafe, nor does it possess varying degrees of safety between these two extremes. It is people who are safe or unsafe, or more or less safe.

"It is the behavior of people, not a characteristic of the workplace, that determines the degree of personal injuries, or damage to health, the environment, or property. I have never encountered an injury or instance of damage to health, the environment, or property that was not the result of human behavior."

This thought-provoking statement suggests that human factors must be addressed if safety risks are to be minimized.

The Shell ESM program therefore aims to produce a sustainable and ongoing improvement in safety performance by influencing the behavior of people in the organization, from top management to process worker.

This system of safety management has produced immediate and substantial improvements at Shell, but its longer-term success depends on the acceptance of the philosophy by all employees.

Certain key tools, such as auditing for unsafe acts and conditions, can be used to invoke this safety philosophy.

It may be tempting to view these tools as the complete solution. But experience has shown that there are no "magic buttons." If initial success and motivation is to be sustained, there are no alternatives to a well-founded safety management program and organization that permeate all levels of a company.

Early experiences with ESM have confirmed that:

A very high proportion of accidents resulted from individuals' unsafe acts.
Existing audit programs focused almost entirely on facilities and systems rather than on individuals' working practices.
In many cases safety management efforts were reactive rather than proactive, driven by poor accident statistics rather than aimed at accident prevention.

A proactive approach is therefore needed to remove the basic causes of accidents and to supplement the existing formal audit and inspection procedures with the structured implementation of unsafe act auditing.

UNSAFE ACT AUDITING

Unsafe act auditing is a process in which managers and supervisors get out into the workplace and observe people at work. And more importantly, managers can discuss with workers the aspects of safety that are fundamental to the maintenance of a safe working environment.

Organizations can have the most elegant written safety policies and procedures, but they are of little value if they are not understood or followed at the workplace level by people in the line organization.

The objectives of unsafe act auditing are:

To change the cultural attitude toward safety from one where...
- Unsafe practices are condoned
- Safety management is reactive, concentrating on statistics
- Safety is seen as an extra and not an integral part of the business
- Safety is seen as someone else's responsibility.
To one where...
- Unsafe acts and conditions are observed, identified, and removed
- Safety management is an integral and cost-effective part of business management
- Safety management is preventive and concerned with people
- Safety is accepted as a personal responsibility by each member of management, supervision, and the workforce.

Other objectives are:

To reaffirm and improve the accepted standards of safety.
To improve communication and understanding, and so contribute to a more-effective use of the total resources of the business.
To provide a more-sensitive indication of the underlying safety performance than is given by accident statistics alone.
To reduce significantly the potential for accidents in individuals' working practices, including both unsafe acts committed and unsafe conditions created.

In carrying out the process, the goal is to change the culture of the organization by observing and correcting the behavior of the workforce so that, over time, attitudes toward safety will result in a much-safer business.

One of the benefits of unsafe act auditing is the minimization of human risk factors. And anyone who has read the court of inquiry reports of the ship Herald of Free Enterprise capsizing and the Exxon Valdez grounding will recognize the significance of human factors in major accidents.

Also, recently in the United Kingdom there was a major rail accident that had its roots in a regular, but unsafe, practice. This accident might have been prevented by task observation and unsafe act auditing.

THE ICEBURG CONCEPT

When an iceburg floats in the water, the portion that is seen above the water line is only about one fifth of the volume of the iceburg; four fifths is below the waterline and unseen. An analogy can be made with accidents.

Often managers hear about only those accidents that have severe consequences, such as death or serious injury, or those where a person has received medical treatment.

Clearly, these accidents represent only the "tip of the iceburg." For every fatal accident in a company there are literally thousands of unsafe acts and practices (Fig. 2). So if the number of unsafe acts can be reduced, the iceburg will become smaller and the potential for serious accidents will be significantly decreased.

The process of unsafe act auditing is aimed at eliminating the unsafe situations and practices; not by a punitive or authoritarian approach, but by a method of constructive dialogue between manager or supervisor and worker.

AUDITING UNSAFE ACTS

In addition to understanding the need for recognizing unsafe acts, it is also necessary to discuss the techniques for successful implementation of an unsafe act auditing program.

First, the success of the technique depends on an open discussion of each individuals' performance in a blame-free atmosphere. In this environment, workers can recognize their unsafe acts and commit themselves to safer working habits.

For the process to be successful, it is important to develop a discussion technique that gives the people being audited an opportunity to think about the way they have been working. It is also necessary for those people to discuss in a nonconfrontational manner with the auditor, aspects of their jobs that are perceived as either unsafe or not being performed according to previously agreed-on procedures.

Good results depend on the understanding and trust of those being audited, as well as on the skills and attitudes of those performing the audits.

The auditing process involves five basic steps:

Preparation. Select a suitable area in the plant or workplace for the audit. The work area can be divided into sectors, which can be audited on a regular basis. Because the goal of the process is to begin a dialogue between those doing the audit and those being audited, each section of the plant selected for audit must be small enough to allow this to take place.
Observation. At the work area selected, stop for a few moments and observe peoples' activities, looking first for good safety practices, but also for the unsafe acts and conditions that may be occurring.
Discussion. Discussion is the key to success. Discuss with the workers how the job can be done more safely. Encourage the worker to discuss with the auditor the hazards of the job and the ways it can be done more safely. It is, of course, very important during the discussion to commend those safe practices observed.
Recording. At the end of the audit, record the unsafe acts and conditions. This record will assist in future discussions of plant safety, both informally during similar audit tours and formally at safety meetings.
Follow-up. Again, if commitment from the workforce is to be obtained, it is essential that, for any item discussed during the audit that requires some form of follow-up, a follow-up is carried out.

KEY ELEMENTS

The auditor must know what to look for when observing and remember that eliminating unsafe practices will reduce the potential for more-serious injury.

Unsafe acts may be violations of either written or unwritten common-sense safety rules and procedures, or they may be unsafe conditions.

Techniques employed by good observers include:

Stopping at a distance from the work location for a few moments to observe the work activity
Concentrating on people working, not on things
Being alert to unsafe practices that are corrected as the observer enters the work area (these include putting on personal protective equipment such as gloves or goggles and adjusting the work)
Systematically considering the actions of the people being observed
Looking at the positions of the people in relation to the jobs being performed
Noting the protective clothing being worn or not being worn
Looking at how tools are being used
Looking at the work area and equipment
Considering the rules, procedures, and operating instructions.

Observe with a questioning mind, asking "What if. . . ?," or "Why. . . ?" During the observations it is important to refrain from taking notes, as this can create distrust.

The aim of the discussion is for employees to participate in improving performance through recognizing and correcting their unsafe acts and the unsafe conditions they create.

Ways to achieve this objective will depend on individual situations and personalities, but some points to consider are:

Do not rush. Take time to put employees at ease.
Be open and direct, but not confrontational.
Question and discuss.
Do not lecture but keep listening and allow employees to identify hazards and volunteer improvements in working practices.
Guide the discussions, but do not manipulate.
Always commend good performance observed.
Make it a mutual learning experience for both line management and employees.
Help, do not blame. Audits should not normally result in disciplinary action, an exception being where conduct consistently violates safety rules.
Encourage employees to discuss safety concerns and offer ideas.
Make a note of employees' concerns and ideas and ensure that they are followed up and that the outcome is communicated back to the employees.
Do not leave the work area without discussing the observations with the employees, as such an omission is certain to generate unease and distrust.
Thank the employees for their participation.

Throughout the process be aware that the auditors' reactions and the standards that are shown to be acceptable will be critical to the continued raising of standards, which of course, is one of the key objectives of the exercise.

RECORDING

After the audit, the unsafe acts and conditions observed should be discussed by the observers. Further action items should be agreed on and the findings recorded. This enables the results of the audits to be consolidated and any specific and recurring problems to be discussed with the safety committee.

Shell has found that unsafe act auditing is an extremely powerful tool for stimulating positive action toward preventing accidents and improving the two-way flow of communications on safety matters at all levels.

However, used negatively in an environment of blame or discipline, its power can be damaging, provoking strong negative reactions from the work force.

It is vital that the implementation of the program employ a uniform system of communication, training, and verification, backed by a high level of visible management involvement.

Training in the techniques requires practice in small groups under the direct supervision of a competent auditor.

IMPLEMENTATION

Unsafe act auditing should be implemented on a structured basis from the top of the company. This is not simply a process that a supervisor and his foreman undertake in a plant at infrequent intervals, but rather a technique in which senior managers can and should be participants.

Unsafe act auditing also requires:

Each manager and supervisor to audit each direct subordinate in the line, on a planned schedule, following the line structure in the company
Time each week to carry out the audits
That techniques be cascaded down through the organization.

Modifying employees' unsafe behavior can only be achieved in the longer term by the belief throughout the organization that it is people who cause accidents. By adopting a participative approach to safety, not only are peoples' attitudes changed but also the safety culture of the organization is changed.

Managers, in writing safety policies and procedures, can only be certain that the procedures will be followed if they are prepared to spend some of their valuable time getting out into the workplace and convincing employees of the need for them.

It is not a new concept; it is "management by walking about," which the authors of "In search of Excellence" describe as one of the hallmarks of a successful company.

Managing safety is about policies and action; unsafe act auditing is about part of those actions. Ultimately however, in any organization, the level of safety achieved will be that demonstrated by the managers.