Draft agenda on managing critical risks (fatal and serious injuries) - otherwise referred to as FSII

1. Fatal and Serious Injury and Illness (FSI) Prevention
Appendix- ANSI Z10 Subgroup
INTRODUCTION
Fatal and serious injury and illness (FSI) prevention is the objective of every operational leader,
safety and health professional, supervisor, and shop floor worker. Yet with so many other
system drivers and success factors influencing performance, we forget about this primary
objective – Stopping life ending and/or life altering injuries and illnesses.
Ask your organization this question:
1. Does your organization define safety success by outcomes (Recordable Rates, Lost
Workday Rates, Fatality Rates) versus understanding the potential of fatal and serious
injuries/illnesses before the outcomes occur?
If you answered “Yes” to this question, your organization’s safety management system is not
focused on fatal and serious injury/ illness prevention and mitigation.
A FSI focus is safety differently because it uses data differently and breaks down the barriers to
reporting incidents whether it is with successful work, work that failed safely, or work that
resulted in an injury/illness. A FSI focus “shrinks” the focus from all injuries and injury free
events to those with potential to result in fatal or life altering injuries/illnesses.
Building FSI prevention into an occupational health and safety (OHS) management system
In every OHS policy, the protection and continual improvement for everyone working in an
organization or at a site is a key principle. This includes employees, contractors, temporary
workers, and visitors. So how can the policy statement words because actions? A company’s
policy is where the management system starts and ends and where FSI prevention and
mitigation must be embedded.
Many studies have found that occupational injuries and illnesses are decreasing, but reductions
of fatal and serious injuries are not on this same trajectory. It is also unfortunate that many
companies still believe in the Heinrich pyramid principle that implied reducing minor incidents
(bottom of the pyramid) will prevent major incidents (top of the pyramid). This is not correct.
A Fatal and Serious Injury/Illness is defined as a life-threatening, life-altering, or life-ending
injury.

2. Life-Threatening Life- Altering Life-Ending
An injury that needs
immediate emergency
response to sustain life
An injury resulting in
permanent loss or use of an
organ, body function or
amputation.
Fatality
A Fatal and Serious Injury/illness Potential is an incident that did not result the above but could
have if circumstances or controls were different.
Martin, Donald and Black,Alison,BST White paper - Preventing Serious Injuries and Fatalities (SIFs): a New Study
Reveals Precursors and Paradigms,2016 DEKRA insights. Originally appeared in Professional Safety magazine.
Conklin,Todd,PhD., Pre-AccidentInvestigation - An introduction to organizational safety’s press, 2015
Conklin,Todd,PhD., Workplace Fatalities - Failure to Predict - A New Safety Discussion on Fatality and Serious
Event Reduction.CRC press 2017.
Know your data
All locations collect and analyze injury and near hit/miss (injury free) data. FSI injuries/illnesses
(FSI ACTUAL) are easily found in the data because these are the horrible injuries or life ending
events that have occurred. These are unfortunately lost workday injuries or even worse a
fatality.
What is harder to uncover in the data is the FSI incidents with the POTENTIAL (FSI Potentials)
to cause life ending and life altering injuries and illnesses. These can range from injury free, first
aid, medical treatment, restricted or lost work day. The outcome of these incidents should not
be the focus and it does not matter. Because the outcomes are typically less hurtful, these

3. potentials often go unnoticed or worse yet, companies think they were lucky (Whoosh). Luck is
not part of any Occupational Health and Safety management system.
Use your data
Using data means it is important to capture the right data, a.k.a. know about incidents that did
not result in a bad outcome. Transparent reporting of incidents must be part of the management
system needed to embed FSI. Without this, the data set will not be complete.
Leaders must want to hear about incidents with potential for fatal and serious injury and illness.
They must respond appropriately and want to learn if the incident resulted in less harm because
a control/defense was effective or if it was just luck. This questioning leadership moves all
towards exhibiting behaviors that support operational excellence and not an ostrich effect.
Most data collected as part of floor inspections focus on physical hazards and regulatory
violations/compliance and fail to address social, risk and organizational issues that influence
“work as done” which often increases the level of risk. (see new View Section). A strong FSI
process, helps uncover this and moves the organization to improved performance by helping all
level of leaders focus on the key issue when walking the floor or conducting inspections.
The major concepts from this Appendix on FSI:
● Focus on potential consequences of situations and incidents not just actual
consequences/outcomes.
● Utilize mitigation techniques, as well as, prevention techniques to prevent FSIs. (prevention -
preventing an event, mitigation - minimizing the consequences of an adverse event (fail safe)
● Traditional approaches to safety often focus exclusively on personal safety ignoring process
and system safety. FSI includes both system and process safety elements.

4. SYSTEM THINKING THROUGH A FSI LENS (Plan Do
Check Act)
Plan – Build FSI potentialinto reporting and incidenttracking process
Building a reporting culture for FSI Potential events means a location or business has a FSI
Decision methodology that outlines what incidents have FSI potential for the work environment.
In a lagging indicator focused environment, it is easy to talk oneself out of reporting because
nothing bad happened and it was not a recordable. Outlining a FSI Decision methodology builds
consistency in reporting and allows for more transparency. Now of course, leaders must
respond to this new reporting appropriately and embrace the data they are now receiving. If
leaders are not trained on FSI and this new reporting, they will believe more bad things are just
starting to occur.
Steps to Building “FSI Decision Logic/Profile” and FSI Tracking Process:
Step 1 - Review at least 3 years of existing data. During this review focus on the “what
occurred” not the outcome of the incident. If there is a credible outcome or likelihood of a life
altering or life ending injury, pull it aside for further review.
Step 2 - Bucket the incidents from this review into hazard categories and type of event. For
example, Hazard categories like: Different Level Falls, Same Level Falls, Electrical, Mobile
Equipment, Lock/Tag. Verify, Fixed Rail, etc. and Type of Event like: Fell greater than 4 feet/1.2
meters, Shock, Dropped Load. See example below:

5. .
These buckets will become your FSI profile. These are your life-saving focus areas! It is not
rocket science because most heavy industry will have similar hazard categories and types of
events.
Step 3 - For any event reported, train EHS and leaders to ask if this event had credible potential
to cause or actually resulted in a Life Threatening; Life Altering; or Life ending injury/illness.
(Note this step is important because your data analysis will not pick up everything. Always ask
this question!)
Step 4 - In an incident tracking system, build in a flow path to track the FSI Potential events that
allows trending and tracking of control effectiveness (Control effective- worked; Control
ineffective; Control not in place).
Step 5 - Require EHS teams and learning teams to focus on FSI events corrective actions and
controls; not all events. Shrinking the focus to the FSI profile allows for better investigations,
learnings, and corrective actions.
Step 6 - Educate leadership and EHS personnel on FSI concepts and requirement for
transparent reporting. If leadership is not properly trained, they will believe safety is getting
worse and you could lose your job.
FSI Roles and Responsibilities
To act on FSI in the management system, clear roles and responsibilities must be outlined and
understood. Goal conflict must be recognized and countermeasures put in place. This is
discussed in the New View section. Example roles and responsibilities with FSI focus:
Leadership (Executives, Business unit leaders, Plant managers)
1. Resource the organization with the capacity to improve safety and health. Believe
“Safety is not the absence of injuries but the capacity to fail safely for FSI events”.
2. Accept that humans (all levels of the organization) will make errors.

6. 3. Drive transparency for incident reporting. Set metrics for FSI reporting; target 10%-20%
of all incidents to be evaluated for FSI potential. Challenge if reporting too low. Can you
imagine your leader asking “why am I not hearing about any incidents? “
4. Require prevention and fail safe controls for FSI profile work. Set metrics for improving
controls for FSI profile work.
5. Properly fund FSI controls in capital expenditure process.
6. When FSI Potentials or Actuals are reported, focus on system elements; not just the
worker in questioning the context of the event and learnings.
7. Challenge the organization to understand how successful work is done because
successful work embodies FSI potential.
8. Require all locations to have and maintain good housekeeping.
Supervisors/TeamLeaders
1. Require transparent reporting of incidents.
2. Know the FSI profile and controls for work performed in your department/area. Assist
with risk assessment of FSI profile in work area.
3. Conduct field verification of controls for FSI profile. Identify and correct where controls
are ineffective or do not allow for a safe failure. For example, a fork truck will have
prevention controls like a backup camera, blue spot lights, strobe light, and back up
alarm but when it hits a person what is the failsafe control? When there are no fail-safe
controls, leadership must know and work to build it into work as done.
4. Empower learning teams to understand the system aspects of incidents and
effectiveness of controls.
5. Utilize human performance skills.
6. Make good housekeeping a keystone habit in work area.
Employees/Contractors/Temporary workers
1. Report all incidents.
2. Help develop the FSI profile and controls (prevention and fail safe) for work as
performed. Assist with risk assessment of FSI profile.
3. Conduct field verification of controls for FSI profile.
4. Notify leadership of ineffective controls. Do not start work if controls not in place. Stop
work if controls become ineffective.
5. Use human performance skills.
6. Participate and/or lead learning teams to understand FSI events.
7. Make good housekeeping a keystone habit in work area.

7. Do – Learn from FSI events to prevent and fail safe
How an organization learns from FSI events (both Actuals and Potentials) is key. Transparent
reporting of events is the first step but to drive operational excellence, the organization must
learn from the events by either validating the controls worked or identifying what controls were
missing or ineffective. By shrinking the focus to the FSI profile, learning teams can spend their
valuable time and efforts on understanding these incidents and recommending corrective
actions that eliminate, prevent, or mitigate FSIs.
When FSI Actual or Potential events are reported, the learnings and recommendations from
these events become the key actions for your organization (the “Do” in your management
system).
In order to learn and improve, FSI events must be evaluated using a balanced approach:
Prevention and Mitigation
Risk assessments must focus on both sides of the scale. Organizations typically focus controls
and activities on Incident Prevention when in reality, humans and systems are fallible thus will
make errors. With this knowledge, organizations must also risk assess their FSI profile to verify
controls and activities are in place and verified.
Develop controls that mitigate (fail safe) and prevent. Start with your FSI profile. See example:

8. WoF means w orker on foot

9. Check – Verify FSI controls thru floorverifications and audits
(footnote ICMM as reference)
Verifying/checking controls and activities must be balanced, thus looking at incident prevention
and FSI prevention and mitigation.
Almost all organizations have a field or floor verification process. It is recommended that this
process be one that is “3 in a Row”. This means 1. plant leadership (or even
organizational/business unit leadership), 2. supervisors, and 3. employees/contractors all
assess compliance and controls. This “3 in Row” process helps see alignment or lack of
alignment.
Compliance with rules and standards is basic and required but what field/floor verification must
also assess is effectiveness of controls. Building employees/contractors; supervisors; and
leadership knowledge of controls is first step. Using the FSI profile, an organization must
develop controls that focus on prevention but also allow work to fail safe. Of course, elimination
of work in an FSI profile is the best hierarchy of control. For example, by eliminating the need to
climb a ladder to check a tank level by installing remote sensors or using a drone to verify level,
is the most effective (just verify the sensor or drone is operational during verifications).
Example of Field Verification checklist of controls for Cranes or Lifting operations in the FSI
Profile:
EHS auditing is a common approach to checking compliance and it should also be used to
verify controls in the FSI Profile. All organizations must have a process to check compliance

10. internally (self-assessment) and well as have an external audit on a 3-5-year basis (either third
party or company audit team). These audit are typically very broad and compliance focused.
First step is for the audit or self-assessment to verify the FSI Profile is part of the organization's
Health and Safety management system.
Test and verify the Health and Safety Management system by:
 Asking to see the FSI profile;
 Checking linkage of objectives to FSI reductions;
 Reviewing operational controls to validate they address FSI hazards;
 Examining how FSI controls are monitored and measured;
 Reviewing HS metrics for FSI linkage (transparent reporting, Tracking of FSI potential
events and corrective action closure)
 Examining the Management Review for FSI learnings and improvements.
To audit FSI prevention, the audit process must include verification of controls. An FSI audit is
really a risk based audit which works with operations to identify FSI tasks for onsite verification
instead an audit of compliance documentation. Developing a risk based audit approach instead
of typical compliance audit will focus in on the hazardous work occurring in the organization; not
all work.

11. Act – Measure and respond to the right things to prevent FSIs
Controls must be in place that prevent and allow for safe failures based on the FSI profile. To
determine this, a risk assessment process must be in place.
Risk = FSI Hazard + Effectiveness of Control(s). In this example, the lion is the hazard and
the pictures illustrate the effectiveness of controls which determines risk of injury by the lion.
Traditional risk assessments look at Severity + Probability + Frequency. For FSI prevention,
frequency should not be considered because FSI actual events are infrequent. As discussed in
the Plan Section of this appendix, an FSI profile is first built on analysis of past events. Risk
assessments can be used to further define or refine the FSI profile. Using your location data
and risk assessment tool, an FSI risk registry can be developed. This FSI risk registry should
be at the task level. Start with your top 5-10 tasks so this does not become overwhelming. The
FSI risk registry should be a “living” document.
The effectiveness of controls is the most important aspect in the risk registry. A common tool
used for this is called a Bow-tie analysis. A bow tie analysis evaluates controls for a material
unwanted event (an FSI event) from a prevention and mitigation (fail safe) methodology. Bow-
tie methodology and software are available from numerous companies. Example Bow-Tie:

12. Utilize your organizations existing risk management tools but make sure the controls are
evaluated from a prevention and mitigation view point.
FSI Measurement
Measuring FSI potentials incidents is critical so mitigating and preventive controls can be put in
place. DEKRA Research has shown between 10%-20% of all incidents (including near
misses/near hits) typically have FSI potential. The key is how can this be measured so it does
not drive reporting underground. It is recommended to target an increase in reporting of FSI
Potential incidents to truly understand your organization FSI profile. Suggested metrics:
 Set an Upper limit (30%) and Lower limit (10%) control ban for FSI Potential incidents
(using all incidents as the comparison). In the example below, FSI reporting would be
classified as being “under reported” thus leadership should investigate reporting
practices and or understanding of FSI.
 Set a zero FSI Actual target – This is a lagging indicator but is necessary to keep focus
on FSI actual reduction and not just Total Recordable or Lost Work days. In the past,
Lost Work days were used to measure severity but in fact FSI Actual (life threatening,
life altering, or life ending) is a true measure of severity
4.8% 5.5%
3.1%
0%0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
2014 2015 2016 2017
FSI Reporting as a Percent of Total Incidents
FSI Incident Controls Limits <10% and > 30%
FSIA % of Total Incidents Under Reporting Out of Control

13. Once the organization is mature enough, and FSI Potential and FS Actual rate can be
calculated and targets set. FSI incidents can be tracked by FSI profile (LTV incidents, Falls,
etc.) so reductions or increases in these high-risk hazard areas visual. The key is not to
reach a reduced rate by under reporting FSI Potential incidents.
Reporting and measuring FSI is different than communicating FSI events. Set criteria for
communicating FSI Potential incidents. Not all FSI Potential incidents need to be communicated
or shared upward. Example criteria for communicating FSI P/A incidents:
- FSI potential or actual result in restricted or lost work day
- FSI potential or actual event that including major loss of production, property damage,
fire, or adverse media coverage
Martin, Donald and Black, Alison,BST White paper - Preventing Serious Injuries and Fatalities (SIFs): A New Study
Reveals Precursors and Paradigms,2016 DEKRA insights
CONCLUSION
An Occupational Health and Safety Management system must outline how an organization is
going to reach zero FSI actual incidents (not zero incidents but zero life threatening, life altering,
and life ending injuries and illnesses).
Use the Plan, Do, Check, Act system to build FSI prevention and mitigation into work as done.
The key aspects to FSI are:
● Focus on potential consequences of situations and incidents not just actual
consequences/outcomes.
●Utilize mitigation techniques, as well as, prevention techniques to prevent FSIs. (prevention -
preventing an event, mitigation - minimizing the consequences of an adverse event (fail safe).
● Traditional approaches to safety often focus exclusively on personal safety ignoring
process safety and system elements. FSI approach must include people, process safety, and
system elements.