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#1 Posted : 14 April 2008 12:21:00(UTC)
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Posted By R Joe Does the HSE's focus on sensible health and safety and risk control, and objections to 'risk aversion', make the Du Pont mantra any less relevant or difficult to square? Would the average man in the street see risk aversion and 'all accidents being preventable' as the same thing? Are H&S practitioners who believe that all accidents are preventable risk averse? Any thoughts?
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#2 Posted : 14 April 2008 12:34:00(UTC)
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Posted By Smiff DuPont operate factories, with secure boundaries and they are should be able to exercise control over everyone and everything in the working environment. If all risks are subject to appropriate controls it may be possible to prevent all accidents. Also, you will hear "zero-accidents" in any American company, and a Senior Risk Manager of an American Corporation told me why; he said it is advice from the legal dept and helps fighting claims. If you talk of reducing accidents, or meaningful targets like in 18001, you have made a statement to the workforce and lawyers that you will continue to injure people and therefore cannot defend claims when someone does get hurt, for whatever reason. It's culturally very different over that pond.
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#3 Posted : 14 April 2008 12:42:00(UTC)
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Posted By Dave Merchant To be picky over legal semantics, no 'accident' is preventable as by definition an accident is "some sudden and unexpected event taking place without expectation, upon the instant, rather than something that continues, progresses or develops; something happening by chance; something unforeseen, unexpected, unusual, extraordinary, or phenomenal, taking place not according to the usual course of things or events, out of the range of ordinary calculations; that which exists or occurs abnormally, or an uncommon occurrence." If it's unexpected it can't be prevented as you can't take precautions against it. If something is anticipated it's not an accident when it happens (which is why the HSE rarely use the word, and prefer to cage their responses with words such as "incident" or "event"). Some incidents are preventable of course (you can't die in a train wreck if you never go within a mile of the tracks), but with everything else it's simple a case of reducing the probability to the point it's *as good as* impossible. A 1 in 20 billion chance of being hit by a falling camel while eating cheese is good enough for most people to forget about it, but it's not zero and never can be, so long as there are (a) people eating cheese (b) camels (c) planes The problem is that most people don't understand how statistics work when you're talking about very large ratios.
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#4 Posted : 14 April 2008 12:46:00(UTC)
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Posted By willhiem i suppose the whole thing about 'are all accidents preventable' is, it leads you to think about is there such a thing as 100% safety? I'd have to agree with dave's point above!
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#5 Posted : 14 April 2008 13:38:00(UTC)
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Posted By Sally The other side of 'sensible health and safety' is that occasionally people will get hurt and we as a society will need to accept that. We already accept that 314 people were killed on Scotlands roads in 2006 (don't know UK figures). We try to reduce it but we don't do the one thing that would dramatically reduce it which is take away private cars because we don't think the cost is worth the outcome. We need to be more realistic about what health and safety is about. It isn't about trying to prevent cut fingers and bruises and scraps or even the occasional broken bone. It's about trying to prevent deaths and serious injuries. I sometimes wonder if we concentrated on the really high risk rules ie wear and attached your harness at 6 floors about the ground and worried less about the very minor ie architects must wear gloves on building sites people would pay more attention and more lives would be saved.
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#6 Posted : 14 April 2008 14:31:00(UTC)
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Posted By willhiem Sally, That’s true, and the example you give is pretty good, but on the other hand if you can prevent someone getting dermatitis then you are doing your job and sad to say its also saving the employer from possible legal action. Yes it is better to focus more on the inherently dangerous activities but you could also argue that its about improving peoples lives as well, no one wants to be breaking fingers / bones etc. At the end of your working day everybody wants to come home as they left, if that can be done no matter how small you're on the right track. You could spend all day waiting and supervising people so they all attach their harnesses while meanwhile down below you could have a G.O. using a consaw with no gloves / eye protection, ear defenders and no training, think of what could happen to them, cuts / dermatitis / respiratory problems / eye problems / hearing damage. That’s the reason risk assessment techniques are so important. and how risks are classified.
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#7 Posted : 14 April 2008 14:35:00(UTC)
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Posted By Buzz Lightyear This is a great thread because it tries to get to the heart of what H&S is all about. Re Sally's comments, a while ago I would have definitely disagreed with you re just concentrating on saving lives because of the accident pyramid - you know the one that says for every 1000 minor injuries, there are 100 over three day, 10 major and 1 fatality. I was taught years ago to focus on the 1000 minor injuries to prevent the one fatality. However, I have found that in social care where I work, minor injuries tend to involve scratches, hair pulls etc. Whereas, deaths tend to involve completely different incidents - such as scalding in baths or falls from hoists. So, the principle of the accident pyramid does not work. I think the example given re architects wearing gloves is interesting. I suspect it is based on setting an example rather than protecting the architect's hands?
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#8 Posted : 14 April 2008 14:56:00(UTC)
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Posted By Tabs All accidents are preventable given a couple of things: 1. the accident can be imagined 2. enough financial resources are put behind preventing it Using examples given above, alternative forms of transport exist to allow you to stay a mile away from trains, and trains are stopped a mile back while you cross tracks. People eating cheese are always housed in camel-proof locations. I doubt we will ever have the finances or the public will to become accident free. Oh, and I like the accident triangle comment, but I think it is supposed to point to culture and sorting out the small things tends to lead to big things being sorted too.
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#9 Posted : 14 April 2008 15:56:00(UTC)
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Posted By Raymond Rapp All accidents are not preventable, even the HSE recognise this fact. It is at best an ideology, well intended but impossible to to achieve or sustain. One may strive for zero accidents but the reality is the reduction of them and their severity. Learning from previous accidents and incidents is more important to prevent recurrence. I believe the recognition that accidents and incidents will occur is at the heart of good health and safety management. I am happy to leave the theories with senior management and their mission statements. I live in the real world. Ray
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#10 Posted : 14 April 2008 16:02:00(UTC)
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Posted By willhiem now maybe my understanding of risk aversion is a bit out of place but the more i read 'Would the average man in the street see risk aversion and 'all accidents being preventable' as the same thing? Are H&S practitioners who believe that all accidents are preventable risk averse?' the more confused i get?? its not making sense to me!
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#11 Posted : 14 April 2008 17:25:00(UTC)
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Posted By Merv Newman I'm not risk averse. But I do believe in knowing and managing the risk. I presume we are talking about injuries at work ? (I tend to avoid the word "accident" as it DOES have connotations of chance) Many people work where high risks exist and cannot be engineered out. If the safety management system is functioning correctly then those risks have been identified and assessed and safe systems of work put into place. As said above, DuPont works within a tightly controlled system. To not work safely, to not evaluate risks, to not follow the rules is, for a DuPont employee, unthinkable. So the mantra is relevant WITHIN DuPont. They try to teach their methods to other companies (costs a bit) Very often it works and injury rates come down. But don't expect instant miracles even from their highly professional, grossly underpaid consultants (I can say that 'cos I were one)It took them about 200 years to get where they are now. Steady progress and "evolution not revolution" is the best way to go. So don't panic. Merv
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#12 Posted : 14 April 2008 18:10:00(UTC)
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Posted By Guderian All accidents are not preventable. Mathematical probability theory will answer that. Something that will definetley happen P = 1 Something that can't happen = 0 As we cannot be sure that within any safety system that we have truly covered/predicted and mitigated against ALL accidents (including freak truly random events) the P can never = 0. Therefore all accidents are NOT preventable, P might = 0.000000000001 etc, but the fact remains, you have not prevented all accidents or the possibility of an accident. Indeed the law doesn't call for P=0, its SFAIRP, as we all know, hence why the acceptability criteria for accidetns is set out in the HSE document 'R2P2' and the associated ALARP criteria. Hence the Dupoint theory is nonsense, that is not to say that is not a desirable aim. The game we are in is sensible/proportionate risk management.
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#13 Posted : 14 April 2008 20:29:00(UTC)
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Posted By R Joe Merv I’d be genuinely interested to know more about your - and others - Du Pont experience particularly in the light of Guderian’s view of the Du Pont theory – presumably you advised clients strongly that ‘all accidents are preventable’? As a point of clarification, when Du Pont say ‘all accidents are preventable’ do they mean that all accidents have a cause which can, therefore, theoretically be prevented, or do they mean that all accidents can indeed be prevented? I’d also be interested to know how Du Pont define an accident – does the frequently mentioned paper cut count, and if so do they believe that all paper cuts can be prevented? Similarly, do all slips and trips resulting in some sort of injury count, and if so, can they all be prevented? Presumably accident includes harm and ill-health, so how do work related MSDs fit in to the theory? RJ
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#14 Posted : 15 April 2008 18:28:00(UTC)
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Posted By Merv Newman R Joe The definitions may have changed a bit as they are/were based on OSHA definitions of injury levels. I left DP 15 years ago and haven't really needed to keep up with OSHA Lost Workday Case (LWC)- one or more days absence due to an injury at work. Restricted Workday Case (RWC)- no absence but unable to perform normal work Medical Treatment case (MTC)- an injury requiring the attention of a medically qualified person First Aid Case (FAC) - a minor injury which could be treated by a nurse or first aider. Note if "nurse" level treatment is required more than once e.g. heat treatment of a muscle strain, then the incident is bumped up to MTC level. The first three categories are reportable and thus called "Recordable Injuries" putting them on a fairly equal level of seriousness. DuPont sites are now compared on a "recordable" basis. MSDs require treatment at least at the MTC level and would normally end up, at least, as a RWC. "paper cuts" do count as they should be reported, treated as required and reported. And there are techniques for knocking up reams of paper without getting cut. My wife was taught them in the print trade at the age of 16. PPE was not provided. The DuPont philosophy is that every injury/incident has a cause. If an injury or an incident occurs then an effective investigation will reveal the cause(s). An effective action plan will lead to elimination or control of the causes. Do that enough times, generalise the action plans and you will gradually eliminate whole classes of accident causes. Thus every injury and (controllable) incident is preventable. Eventually. I put "controllable" in brackets as a number of causes may bo outside of management control. "Injury causing slips and trips ?" Yes, of course they count and yes, you can eliminate them. Pay attention to floors and staircases - their condition and cleanliness. Teach people to look where they are putting their feet. Walk, do not run. HOLD THE HANDRAIL. The one injury I had during 10 years on a 500 employee site was to an employee who slipped on an icy path. Actions : * the accompanying supervisor had previously noticed the icy patch and had only given a verbal warning. He got a written disciplinary letter. Both I and the production manager got severe telling-offs as we should have done more to "increase the awareness" of the supervisor. * Contractors were put on emergency alert to clear walkways as soon as it started snowing * We eventually (two years later) installed covered walkways between main buildings. Going on a bit (but you did ask) Management responsibility is taken very seriously. The above injury occurred at 03.30 Monday morning. The supervisor called the ambulance and then called me. I followed the ambulance through the gate. (fortunately the habit of not wearing pyjamas allowed some savings on personal response time) At 4AM the IP left in the ambulance and I called the plant manager. He was on site 15 minutes later (I didn't ask about his pyjama habits) While waiting for him the supervisor and I made sure that the injury site had been made safe (salting the path which should have been done at least an hour previously) At about 4.30 AM the plant manager and I made a tour of the site to verify that there were no other icy patches. At about 5AM the plant manager started to call HIS line management. The President Directeur Général of DuPont France in Paris. The Director of DuPont Europe in Geneva and the President of the DuPont company in Wilmington Delaware. I also called the European HSE Consultant (also in Geneva) He was on site at 9 AM. That is the procedure within DuPont : in case of serious injury or probable material loss, inform your line management within 24 hours. I think the President of DP (100 000 employees) got about 30 of those calls last year. And I dare say he had a few words to say. That was in 1984. I can still give you the names, the dates and the times as that was about the most traumatic event I experienced in 16 years of plant safety. And the only LWC. Just lucky or just good planning ? I think it was Jack Nicklaus who, hearing a spectator call on of his shots "lucky", replied "Right. And I find that the more I practice the luckier I get" Regards Merv
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#15 Posted : 15 April 2008 19:54:00(UTC)
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Posted By Merv Newman Sorry, just had to pause to watch "The Great British Menu". Back to the plot. OK, so someone is quoting statistics and probability theory at me. "All accidents are preventable" Remember that I am discussing a controlled situation and excluding those events outside of management control. "outside of control" does NOT include earthquakes, floods, volcanic eruptions or lightning strikes. Exposure to those events is foreseeable and controllable. And you could try to lobby for a ban on the air transport of camels. Probability theory. You need a time element in there. What is the probability in any one year that an employee will suffer an injury of LWC gravity ? On a European basis that is about 0.05 (5% roughly)(or one per employee every 20 man years) One injury per shift with 50 shifts worked per year (yes, I know it is less than 50 but lets make the calculation easy) and the probability is 0.001, once in a thousand years. DP had about 30 for 100 000 employees. 0.0003/year They are not there yet, they admit. But the overall trend towards zero is good and they are convinced that they will get there. The same trend and attitude is also good for lower injury categories. In ten years I had one LWC, two RWC, no MTC and about 250 FACs. For 500 employees. Let me change the argument. "No injury is acceptable" "of course it isn't" I hear you say. But it is to many. Managers tend to accept a certain level of injuries "industry average", better than average", "half the industry average", "a bit (or much) better than last year" and so on. These attitudes cause the "plateau" phenomenum. Injuries run at a certain, acceptable, level for a while, just until the company decides that that level is no longer acceptable. (costs, legislation, image, legal problems) so they make a bit more noise, employ a consultant or start kicking bums. These actions drive injury levels down to an "acceptable" level. Management experiences collective sighs of relief and relax. After a few, two or three years on the new, acceptable plateau the rates start to rise again. So they repeat the same, previously successful, actions hoping to repeat the previous success. But this time they usually decide to do it louder and harder. They make a lot more noise. They employ even more expensive consultants and they reallyreally kick bums. Hard. ([reference removed] sometimes find that they are now replaceable)(watch out for the plateau people. Get it before it gets you) So what is your company's comfort zone on injury rates ? "better than average" ? Or "better than DuPont" ? Last point. "Sensible proportionate risk management" How much does a large, successful company get fined nowadays ? Hundreds of thousands of pounds. Installing covered walkways cost about £60 000 plus ongoing contractor snow clearing costs. Much more economical AND kept you dry going to the canteen. May I rest my case here and go and watch "University challenge : the professionals" It's so much easier on the brain. Merv
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#16 Posted : 15 April 2008 21:08:00(UTC)
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Posted By Safety Dave Merv, Thank you for that, it's truly inspiring stuff. Most if not all companies I've dealt with who pay lip service to aiming for zero injuries just don't cut it by comparison to DP (even those implementing STOP!). The next time I hear someone tell me they are aiming to create a genuine safety culture and "get to zero" I'm going to show them your post and say - "are you this committed? - well are you punk?!?"
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#17 Posted : 16 April 2008 00:04:00(UTC)
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Posted By Guderian So now the goal posts have been moved to only count 'controllable' (by management)accidents - that makes life a bit easier - but it certainly does not equate to 'all accidents are preventable'. Sorry haven't got time to give a long answer - but with the best will in the world, there will be still 'human factors' accidents - lapses/errors etc - sorry can't be bothered to look up the precise definitions right now (HSG 48 I think about Human Factors?), but suffice to say human errors still occur in even the best trained/motivated people - for this I would cite pilots/aviation situations etc. Therefore probability theory still holds true - you can never truly be sure that you have covered all accident scenarios. So while the chance may tend to be infinetly small 0.0000000000001 etc or how many 0's u wish to put in before the 1, it will NEVER be 0. Therefore the Dupoint theory falls down or you accept the modified definition of 'all accidents are preventable' to achieve an artifical 0.
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#18 Posted : 16 April 2008 00:14:00(UTC)
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Posted By Guderian To give an extreme example - it is not unusal for aircraft to crash because of bird strikes/bird ingestion in to engines etc. In theory these crashes can be prevented by either (and in theory are under management/human control - which gets around the modified Dupont criteria) 1) Stopping flying 2) Building much stronger/fault tolerant aircraft/engines 3) A different method of propulsion, not affected by bird ingestion 4) Cull all birds 5) Persuade all birds to keep clear of aircraft None of which are likely to happen in the near future. Therefore the probability of a crash from a bird strike remains a risk, hence P does NOT = 0, hence some accidents remain non-preventable. DuPont theory falls. However most of us accept the risk of flying because of the benefits it brings to us as individuals and as a society.
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#19 Posted : 16 April 2008 00:30:00(UTC)
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Posted By Guderian Merv Your comment regarding a time element to the probability issue is irrelevant - what you are saying is that the risk is low over time, but NOT 0. Regardless of the time span we are talking about, P = 0 will never be reached. So once again, it may well be 0.00 + loads of 0's other then 1, but it is still NOT 0 (10^-100000000 etc). It may well be very close to 0 in terms of human experience/working life of a factory etc, but not 0. You have 2 logical states - no accidents or accidents. 'No accidents' P = 0, 'accident' P = 1 You can't have 0.5 of an accident. You have had an accident or you haven't! WHich is why the probability view point is so powerful in dispelling the DuPont theory
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#20 Posted : 16 April 2008 05:46:00(UTC)
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Posted By SB MCD Gents WOW - the award goes to this thread for boring me to death. You all need to take a chill pill..........
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#21 Posted : 16 April 2008 08:05:00(UTC)
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Posted By Gabe Realistically, all accidents are not preventable. In reality. However, the current madness for H&S will definitely harm certain aspects of society and industry. Business may struggle financially trying to achieve unrealistic targets for H&S. Schools are already affecting our childrens lives with really stupid rules under the guise of H&S - banning conkers, tamer school trips. We need to pull ourselves back a little from this unthinking application of H&S and focus more on where we can actually affect change. If the architect is not wearing gloves...well, you dont die from Dermatitis...but make sure that bugger six floors up is taking all the precautions! Just a thought.
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#22 Posted : 16 April 2008 08:23:00(UTC)
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Posted By Safety Dave In short, of course all accidents are not preventable - as Donald Rumsfeld almost said - there are known knowns, there known unknowns but its the unknown unknowns that can't be legislated for and a lot of the "silly" accidents that remain after the preventable ones have been dealt with are unknown unknowns. As mentioned by others - it generally comes down to the predictability and probability of risk. After that you've got the individuals good (or bad) safety habits (improvable) and their reflexes (probably not that improvable!!)
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#23 Posted : 16 April 2008 16:11:00(UTC)
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Posted By Sally Rather than asking if all accidents are preventable we should be asking if it is desirable to prevent all accident. I work in a schools environment and many of our accidents are of the tripped over own feet, or fell playing tig, bad tackle in football etc. Do we stop playtime or do we accept that sometimes children get hurt?
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#24 Posted : 16 April 2008 22:14:00(UTC)
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Posted By Al.. 1) All incidents resulting in injuries are (individually) preventable; 2) We will have a target of zero incidents resulting in injuries; 3) It will be unacceptable for us to have even one person injured while at work. (1) is a pretty reasonable statement - cannot fault the logic of it. (2) is good inspirational stuff for the troops before they go over the top into the factory - always makes sense to aim high (or in this case low) (3) is nonsense - it requires zero risk and we can only get that if we close down and all go home. It's all rhetoric but if it gets the accident rates down to reasonable levels who am I to knock it. The problem comes when the message gets lost or misunderstood, rather like religion, but let's not go there.
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#25 Posted : 17 April 2008 15:28:00(UTC)
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Posted By Brando I've worked for organisations who have followed the "all injuries are preventable" mantra and worked for others who gladly seem to accept minor knocks and bumps and find the "all injuries" mantra a nonesense. The first company went several years without a single RIDDOR. And had a low rate of minor injuries. Didn't do it over night and had to put a lot of effort into it but they showed results. The second have regular RIDDORS and god knows how many minor injuries to contend with. If we don't strive to prevent all injuries we will fail ( and we have accepted that we will fail before we begin ). Same as quality - you aim for zero defects. You know you will get some but this must never become an accepted state. Brando
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#26 Posted : 17 April 2008 15:37:00(UTC)
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Posted By Rob T This also apart from the fact that many minor incidents/accidents (whatever) are not reported by Du Pont staff because they are worried about the Draconian responses Du Pont put in place. As regard to holding the hand rail on stairs (and apparently not being allowed to take two steps at the time - I'm 6"3' and one step on some steps is more hazardous!) is concerned, they should just get a life. Even the RA regs state that you don't have to assess for things associated with every day life. No - not all accidents are preventable and never will be unless we all become robots. Human factors mean that we are able to think about other things when we are walking which means at times we are not so observant. If you aim for the impossible you will never reach your goal - so I refuse point blank to set a target of nil. I always aim to improve on the previous years figures and if that achieves a nil then all well and good - but of course one accident the following year means a 100% increase on your stats. Anyway that's my point of view - nobody has to agree with it but it is a point of view which is in line with the HSE telling people not to be risk averse.
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#27 Posted : 17 April 2008 16:33:00(UTC)
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Posted By anon1234 Rob, If you had no incidents the previous year and one incident this year that is an infinite % increase not a 100% increase. One last year and two this year would be 100% ;}
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#28 Posted : 17 April 2008 16:39:00(UTC)
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Posted By anon1234 All incidents are preventable - however, you need to be able to identify the root causes to take appropriate action to prevent such incidents. This is sometimes extreemly difficult with hindsight, so therefore is unlikely to occur in all case prior to the incident, thus there will undoubtably be a certain level of incidents that occur. I think Merv and DuPont recognise this hence they may have much lower than industry averages but have not actually achieved zero. However, as another poster mentioned, if you don't aspire to achieving zero then you are by definition accepting performance which will not drive your incidents rate to the low levels they could be. Therefore whilst I don't subscribe to the theory that zero will be achieved, I do subscribe to the concept that you aim for zero as this will assist in ensuring you have done all you can to prevent harm.
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#29 Posted : 17 April 2008 17:13:00(UTC)
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Posted By Jay Joshi In my workplace we also have a "goal zero"--it refers to OSHA recordables, but our vision is that "nobody gets hurt" i.e. goes home unhurt. I feel this is an excelllent aspirational goal. I realise that not all support behaviour based safety, but we have implemented it on our site. The handrail example is classic--we are not trying to be patronising, but every little helps. In my view, one of the potentially hazardous activities that could lead to all manner of accidents/near misses is being distracted when using a mobile phone--not only in vehicles, but even whilst walking etc. Now, I will not include this in my risk assessment for slips, trips and falls as it is an everyday risk, but I will surely do something about it on our site by encouraging all not to "multitask"!
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#30 Posted : 18 April 2008 09:26:00(UTC)
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Posted By Brando A couple of people have mentioned the "handrail" example. Reminding people to use the handrails is good sense - we had a chap break both wrists when he fell down the stairs - he was not holding the handrails. Would you rather have broken wrists or hold the handrails? How many incidents are caused by people not using "common sense"? We really do have to hammer these points home until they become second nature. Brando
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#31 Posted : 18 April 2008 10:22:00(UTC)
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Posted By Safety Dave Common sense indeed, but it's complacency that we need to address really. Coming down the stairs is a good example - how many times in our lives (in work and outside of work) have we come down stairs with no problems whatsoever??? Millions I'd suggest, so our "common sense" tells us that this is a low risk activity and therefore we don't take the care we should when doing it. If you add to this the times that we stumble, or slip very slightly on stairs but no accident or injury occurs then you are left with an incredibly small number of times per person when a fall on stairs actually leads to a significant incident/injury. So it's not hard to understand that people become complacent about walking up and down stairs and therefore don't see the need to hold on to the handrail - the "I'm safe enough" attitude. A good start would be to get people to analyse their near misses - the times when they slightly stumble or slip but nothing happens, and then we need to get them to widen it out to not just slips trips and falls on stairs, but the fact that the same hazard (ie gravity) is responsible for hurting them lots of times in lots of situations but that, in effect,the mistake is the same wherever it happens - i.e. the lack of care leads to a slip, trip or fall which has led to them hurting themselves many many times in, but mainly outside of the workplace. Then people might start to realise that they aren't as safe as they think. As it is, simply telling people that they must hold the handrail because they aren't safe on stairs is, to an extent, counter-intuitive to their own life experience and therefore liable not to be readily accepted. I know that some workplaces have managed to create a culture where handrail holding is the norm, but I bet not as many who would like to!!
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#32 Posted : 18 April 2008 10:37:00(UTC)
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Posted By R Joe Merv, thanks for the Du Pont insight. I'd be interested to get some more feedback about any similar experiences from those who have used or worked with the Du Pont 'all accidents are preventable' approach.
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