Too many companies throw money at canned programs instead of investing in the one group best equipped to lead them to safety and operational excellence. Truth is, everything they pay for in a BBS program that has any positive effect on their safety they could do themselves for free.

1. Back on Track
Bringing the Relationship
Back to Safety
Erick A Arceneaux CSP

2. Ditch the BBS
 Behavior Based Safety brought you to this point
 However, it can go no further
• There is an absolute limit to the benefit of
documented observation
• As your incidence rate decreases, it takes more &
more observations to provide the same data points
(diminishing returns)

3. The Methodology is Flawed
 BBS is rooted in outdated theory & faulty
assumptions
• Operant Conditioning (B.F. Skinner)
 Works well for rats and pigeons
 Not so much with people
• The ~90% Fallacy
 An urban legend has popped up that about 90% of
all accidents are the result of actions by people
 This has never been statistically proven in ANY
reputable study

4. Herbert Heinrich
Herbert Heinrich was an employee of
Travelers Insurance in the 1930’s.
His book, “Industrial Accident Prevention,”
was for years considered the seminal work in
Industrial Safety.
He based the key concepts of the book on
research into workplace accidents gathered from
insurance claims and supervisor incident reports.

5. The Triangle
 By far the most popular element of every BBS
program is the concept of the “incident triangle,”
which is a direct result of Heinrich’s work
• However, his original data was lost & has never been
successfully reproduced
 His original findings, as stated before, were
based off insurance claims & supervisor
accident reporting
• The historical figures are “300 Near Misses, 29 Minor
Injuries, & 1 Major Injury”

7. The Domino Theory
Heinrich’s other contribution to BBS
Posited 5 Dominoes in accident causation
• Social Environment & Ancestry
• Fault of Person
• Unsafe Act or Condition
• Accident
• Injury
As each domino fell, it triggered the next in
sequence
• Therefore, to stop the sequence one simply had to
eliminate a domino

8. Case Studies

9. 1991Tyson Foods Hamlet and
North Little Rock Fires
Overview
The morning work shift of employees at the Imperial Foods Processing Plant in
Hamlet, North Carolina, had just begun when a fire occurred, at approximately
8:15 a.m., on September 3, 1991. The rapid spread of heavy smoke throughout
the structure ultimately resulted in 25 fatalities and 54 people being injured in
varying degrees. Of the people who died, 18 were women and seven were
men.
- U.S. Fire Administration/Technical Report Series
Chicken Processing Plant Fires
Hamlet, North Carolina and North Little Rock, Arkansas
USFA-TR-057/June/September 1991
- Lessons Learned, p. 10
“Establish a “worry free” line of communications for industry employees.
Although it has not been acknowledged firsthand and was told only through the
media, reports have surfaced that workers inside the Hamlet Plant were afraid
to say anything about safety conditions due to fear of being fired.”

10. 2005 BP Texas City Refinery
Explosion and Fire
CSB Investigation report detailed several issues with the refinery’s
organizational and safety culture, including:
“Serious safety failures were not communicated in the compiled reports. For
example, the “2004 R&M Segment Risks and Opportunities” report to the
Group Chief Executive states that there were “real advancements in improving
Segment wide HSSE [Health, Safety, Security & Environment] performance in
2004,” but failed to mention the three major incidents and three fatalities in
Texas City that year.”
- CSB Final report, Section 9.3.2, page 149

11. “A central component of the BP Texas City approach to safety was its
behavioral programs, which had been in effect in some form since 1997. The
program, based on observations of BP workers and contractors engaged in
work tasks, was designed to provide immediate feedback about observed
hazards and activities that did not conform to refinery safety policies. In a
2001 presentation, “Texas City Refinery Safety Challenge,” BP Texas City
managers stated that the site required significant improvement in
performance or a worker would be killed in the next three to four years. The
presentation asserted that unsafe acts were the cause of 90 percent of the
injuries at the refinery and called for increased worker participation in the
behavioral safety program. A new behavior initiative in 2004 significantly
expanded the program budget and resulted in new behavior safety training
for nearly all BP Texas City employees. In 2004, 48,000 safety observations
were reported under this new program. This behavior-based program did
not typically examine safety systems, management activities, or any
process safety-related activities.“
- CSB Final report, Section 9.3.6.3, pages 153-154

12. “BP’s approach to safety largely focused on personal safety rather than on
addressing major hazards. BP Group and the Texas City officials almost
exclusively focused on, measured, and rewarded reductions in injury rates and
days away from work rather than the improved performance of its process safety
systems. BP had process safety systems in place in its Group management
system and at Texas City, yet in the wake of the merger with Amoco, the
resulting organizational changes to safety management led to a de-emphasis of
major accident prevention.”
- CSB Final report, Section 9.3.7, page 155

13. 1988 London Clapham Junction
Railway Accident
“The appearance was not the reality. The concern for safety was permitted to
co-exist with working practices which we had seen from Chapters 7 and 8 were
positively dangerous. This unhappy co-existence was never detected by
management and so the bad practices were never eradicated. The best of
intentions regarding safe working practices was permitted to go hand in hand
with the worst of inaction in ensuring that such practices were put into effect.”
- Anthony Hidden, Investigation into the Clapham Junction Railway Accident, Chapter 17, page163

14. So What Do We
Do?
If BBS is not the answer,
then exactly what is?

15. Launch a Relationship-based Safety
Model
 Actually go out & talk to workgroups
• Identify challenges & find solutions with the people
best equipped to tell you what is not working
 Foster relationships with Line Employees
based on trust and respect
• No surreptitious monitoring and “point in time”
checklists
• People are more than the sum of observed behavior

16. Launch a Relationship-based Safety
Model
 Actively listen
• Ask direct questions
• Solicit their input & graciously receive their answers
 Treat Line Employees as part of the solution
 Recognize that most issues have generational
or cultural roots
• New employees learn the ropes from those already
there
• The “unwritten rules” are ever-present

17. Form Task Teams
 Locate Subject Matter Experts (SMEs) within &
outside the company
• Utilize SMEs to facilitate discussion, not dictate terms
 Directly involve Line Employees
• They have practical knowledge that is invaluable
• If a person knows & understands the reason behind
a policy, standard or procedure, they are far more
likely to follow it
• A personally invested employee is a motivated AND
productive employee

18. Form Task Teams
 Include Line Supervisors & Managers, as their
perspective on operations is helpful
• Gives everyone the sense that “we are truly all in this
together”
• Reinforces collaborative supervision rather than
declarative
 Include support personnel as appropriate

19. Craft Task-based Policies,
Standards and Procedures
 Focus on what you are trying to do rather than
how to do it
 Use the task team concept to write PSP
 Make all data on the PSP open & available to
the team
 Don’t drive the process -- let it evolve
 Set clear limits, and let the teams go from there
 Have a clear & documented methodology for
approval, review, revision & ranking

20. Review and Revise
 Establish & rigorously follow a review process
for those new PSP's
• Include the Line Employees in the review process
• Establish a documented policy regarding review &
revision
• Follow that policy
 Encourage all employees to revise using the
“red line” throughout the year
 Use the task team concept to conduct periodic
documented reviews of all PSP
• Clearly define the period for each one
• Document & track the changes

21. Audit Early and Often
 Audit your processes often
• Include self-audits by employees within their
respective work areas
• Encourage participation in more formally structured
audits
 Make your people feel like they are part of the
solution
 Concentrate on “fixing the problem” rather than
“fixing blame”

22. Communicate
 Encourage & foster direct communication
between Senior Management & Line Employees
 Ensure that the message sent is the message
received, from top to bottom
• Be clear
• Be concise (skip the “lingo”)
• Be honest
 Listen to your people
 Instill the concept that it is more important to
get it right than to be right

23. Above All Else
Take the decisions
regarding acceptable risk
out of the field