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Incident Management By Bernd Freibott

Sustainable Safety Management


Incident Management as a Cornerstone
for a Successful Safety Culture

I
ncident management is nothing new at all. accidents from repeating, to diminish the danger to
Historically seen, the birth year of occupa- which employees are exposed and to reduce the risk of
tional health and safety is probably 1811, when operations.
DuPonta producer of explosives along the This methodology in the beginning was bound to
Brandywine River in the U.S.established the be reactive and was very far from becoming proactive
first safety rules for operations in its production plants. safety management. The next essential step toward
All kind of play or disorderly fun is prohibited, read a safer work environment was to better understand
a notice posted by the companys French immigrant what the reasons are for accidents to better grasp the
founder E.I. du Pont de Nemours on New Years Day, nature of the causes of and the action chains that lead
1811. Seven years later, he banned to accidents.
alcohol from the site after an explo-
Studies have shown sion killed 40 people and injured Causes of Incidents & Accidents
that many accidents his wife Sophie. The accident was
attributed to a DuPont foremans
Certainly, the last 200 years of safety management
have not been without effect. Safety regulations and
are not the conse- drinking. safety management strongly diminished the number of
Still, a series of major explosions incidents in many industries, and protective equipment
quence of a major in the early decades of the 19th cen- and safety measures reduced the impact of accidents,
danger or hazard, tury occurred and drove the DuPont leading to fewer accidents, less serious incidents and
family to strive for more safety fewer fatalities.
nor do they hap- regulations and measures and to But still, incidents and accidents happen, and
pen due to missing diminish the operative risk of their
production plants and the personal
people still get hurt and sometimes die from accidents
at work. Everybody knows the major incidents that
safety regulations risk for their employees. have happened in the last years, with grave environ-
As often is the case in occupa- mental consequences and with workers hurt or killed.
or safety equip- tional safety and health, major acci- The Deepwater Horizon oil rig catastrophe is just one
ment. A great dents and incidents must happen prominent example. Beyond these major incidents with
to make things change. Consequent- great publicity, the incident numbers are much dimin-
number, if not the ly, the lessons learned from inci- ished, but it also seems that on this diminished level,
majority, of acci- dents were the main basis for
evolutions in safety management.
they have reached a kind of low barrier.
So why do these incidents happen even though more
dents happen as And for a great part of the indus- and more companies strive for a zero-accident environ-
ment? The reason is not obvious, but a closer look can
the consequence of tries around the world, this is also
todays reality. help. Studies have shown that many accidents are not the
minor lapses and Nonetheless, for the next 100 consequence of a major danger or hazard, nor do they
to 150 years, it was considered an happen due to missing safety regulations or safety equip-
usually of not just inevitable collateral effect of any ment. A great number, if not the majority, of accidents
one lapse, but operations that accidents would
happen and that people would be
happen as the consequence of minor lapses and usually of
not just one lapse, but the sequence of minor failures.
the sequence of injured. For example:
The 20th century saw the im- 1) An employee is in a certain work area for the first
minor failures. provement and spread of physical time, and by chance, he has not had the relevant safety
safety measure and procedures, and instruction obligatory for that work area.
the last 50 years have seen the evolution of safety man- 2) Due to the new work environment, he forgets to
agement systems as systematic approaches to safety. affix a safety hook properly on his gear.
In the context of safety management systems, 3) On that day, accidentally, the supervisor is not in
incident management has been one of the major trig- place, and no replacement has been nominated yet.
gers for improvement and changes. The objective was 4) The worker has not had the obligatory occupa-
essentially this: something that has happened should tional health check, including a check for being free
never recur, and everything should be done to prevent from dizziness.
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What does this mean for a proactive
Figure 1 incident management? The obvious
Cheese Slice Model message is this: Learning from real
incidents and accidents is only a small
part of what is needed. It is like chip-
ping off little pieces from the top of an
iceberg. It will have an effect, but the
change will not be great. The first chal-
lenge is to get a better understanding
of what is happening in the company,
what is the reality.
This idea about the reality within
a company with respect to safety, safe
operations and safe behavior is not
entirely new. In 1931, H.W. Heinrich,
an assistant superintendent of the
Engineering and Inspection Division
of Travelers Insurance Co., published
his book Industrial
Accident Prevention,
Figure 2 Heinrich, which included his
empirical finding known
Bird & Conoco Philips Marine as Heinrichs Law.
Pyramids with 1-10-30-600 Ratios His law states that in
a workplace, for every
accident that causes a
major injury, there are
29 accidents that cause
minor injuries and 300
accidents that cause no
injuries (Heinrich, 1959).
In 1969, Frank E.
Bird Jr. drilled even
deeper in a study of
industrial accidents, dur-
ing which he analyzed
more than 1.7 million
accidents reported by
297 companies (Bird
& Germain, 1996). The
Result: The worker becomes dizzy working in a essential finding was that
high place, loses hold, slips out of the wrongly fixed for every reported major injury (fatality, disability, lost
safety hook and falls to his death. time and medical treatment), there were 9.8 reported
The important message of this hypothetical scena- minor injuries. For each major accident with lost time,
rio is that none of the single lapses alone would there were around 15 accidents requiring medical
have caused a fatal accident, but the combination of treatment and 30.2 property damage accidents. Diving
minor lapses created a safety gap that led to major deeper during this extensive study, Bird found that
accident. below those real accidents, there was a bottom layer
A classical image for this phenomenon is the cheese of around 600 near misses or incidents that might have
slice model. The cheese slices represent protective caused injuries or a major accident. Overall, these find-
layers or controls, such as safety regulation and man- ings are usually depicted in a pyramid with a 1-10-30-
agement, fit-for-work checks, supervision, protective 600 ratio.
equipment and so forth. Only where these protective In 2003, a ConocoPhillips Marine study further
layers failholes in the cheeseis there a latent dan- demonstrated the large difference between serious
ger. And only when all layers fail, when there are holes accidents and near misses (ConocoPhillips Marine,
or safety gaps along the stream of action, can an acci- 2003). The studys core message was that for each
dent with major impact happen. single fatality, there must be assumed a hidden bot-
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tom end of the pyramid of 300,000 at-risk behaviors. The importance of the human
At-risk behaviors are defined as any activity that is not
consistent with safety programs or with training on interface cannot be over-
machinery, such as bypassing safety components on
machinery, eliminating safety steps in the production
stated. In any holistic EHS
process and so forth. approach, the individual
The natural consequence is that proactive safety
management and incident management cannot com- must be considered as a key
placently analyze accidents and real occurrences but factor for the success of an
rather must strive for transparency, creating visibility
on what is below the surface. This means not just chip- EHS management system.
ping off the top of the iceberg, but really getting to
know the iceberg and tackling it from below.
Alongside expert users, such
as industrial hygienists, occu-
Incident Management as the
Principal Pillar of Preventive Safety
pational health practitioners
Incidents today are not the consequence of major and the like, many other
dangers, but rather the result of chains of minor lapses.
The first step toward an improvement is, therefore, to stakeholders need to
gather all information about what is happening within be involved in EHS.
the companyto collect information on every kind of
hazard or safety-related misconduct.
A very important factor in this context is the human
factor. Human behavior, with its inherent nature and
Reporting All Safety-Related Incidents
flaws, with its fallibility, is one of the key sources of
One of the first steps when setting up proactive
hazards and, inevitably, of incidents and accidents.
safety management is to define what kinds of incidents
The surveillance and monitoring of human behavior
or occurrences are to be collected.
is at the core of behavior-based safety (BBS), which
At the top of the list are still all incidents and acci-
focuses on what people do, analyzes why they do
dents. It remains a core function of incident manage-
it and then applies a research-supported intervention
ment to register all real incidents and accidents, create
strategy to improve what people doand must be seen
all relevant reporting and statistics, execute incident
as a discipline within the wider range of organizational
investigation and root-cause analysis, trigger corrective
behavior analysis (Geller, 2004; Grainne). A modern
actions and safety measures and in this way make sure
incident management approach that incorporates infor-
that the same things cannot happen again.
mation gathering about any kind of hazard must also
The next step after this core activity of incident
include data on all kinds of unsafe behavior or behav-
management is to capture in some way all available
ioral failures.
information on all kinds of hazards that occur and that
Having so far dwelled on what to capture and pro-
are not considered in the industrial hygiene and risk
cess within incident management, we come to the next
assessment processes. These can be physical hazards
issues: how to ensure a near-to-complete capturing of
caused by assets and also operational hazards caused
all relevant information and whom to involve.
by the operative processes or by the way of doing
things. These hazards are in the nature of the plants,
operations, assets and activities of the company. Whom to Involve?
Further, there are accidental hazards, such as latent In the beginning of the history of safety manage-
dangers caused by malfunctions or damage of assets or ment, safety was in the hands of line management.
by safety gaps in the operations. Examples are a dam- Managers were responsible for the safety of their
aged electric plug, a damaged ladder or a consumed coworkers, and general managers were responsible for
safety rope. safe operations. The evolution of safety management
After the real incidents and accidents and the real techniques and methodologies brought the creation of
hazards, it is then important to collect all information the role of the safety engineer, the expert with respect
about any kind of near misses or nearby accidents. to safety. Different safety roles were created, such as
Although these near misses do not have a real impact, hazardous substance managers, industrial hygienists,
they are just as valuable a source of information as real safety engineers and so forth. But still there was mana-
accidents, and it is important to derive the right lessons gerial responsibility for safety.
from them. In other words, having just escaped the This has changed. With the rise of safety culture
accident, one should make sure to prevent similar situ- concepts and BBS management, individual employees
ations from happening. have become the focus. This means that all workers
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should consider themselves responsible for their own With these requirements for successful incident
and their coworkers safety. Know-how about safety management, we come without fail to a discussion of
is spread more widely within the workforce to create a incident management within the context of an environ-
strong sense of common safety management. This is a mental health and safety (EHS) strategy, with all its
collaborative safety approach. implications and dependencies.
For example, companies with an active safety cul-
ture promote keeping an open eye for safety-related Incident Management in a Wider Context
issues within the corporation to address safety-related Incident management involves many stakeholders
issues, proactively address coworkers and create and aspects, from initial reporting to safety manage-
awareness. Employees are more and more motivated ment to legal reporting. Any approach to setting up a
to drive safe behavior and to actively talk with their successful incident management must take into con-
coworkers when they see latent dangers or unsafe sideration the whole range of stakeholders and aspects.
behavior. An isolated approach is bound to fail. It is therefore a
Modern incident management must consequently crucial prerequisite to analyze incident management in
meet the needs that arise from this approach. Most the overall context of EHS and in the context of inter-
importantly, any safety management concept must nal and external dependencies, within the corporation
include everybody in the company. Everybody needs and outside.
to become to a certain degree his or her own safety
Incident Management within EHS:
engineer. Everybody needs to have access to the right
A Complex Reality
information and to the right tools. This means, for
As mentioned, it is important for the design and
example, that an incident management solution should
setup of a proactive safety culture driven by a modern
have the tools for everyone to report hazards, near
incident management system to analyze the dependen-
misses and unsafe behavior. Consequently, these tools
cies and interdependencies within the greater picture of
need to be tailored for nonexpert users and for occa-
EHS, with all its facets.
sional users. Usability and suppleness of an incident
EHS has various centers of competence and activity;
management application are crucial for user acceptance
we might call them functional areas. And these func-
and for the successful setup of appropriate tools and
tional areas, such as hazardous substance management
processes. (HSM), industrial hygiene (IH), occupational health
(OH), environmental compliance
and reporting and so on, have a
great interdependency. Process
Figure 3 flows across and information
flows between these areas. The
Links Between Functional Areas various links between both the
Within EHS & Between EHS & Other functional areas within EHS and
between EHS and other units
Units of the Corporation of the corporation are shown in
Figure 3.
There is, first of all, the chain
of links between HSM, IH and
OH. HSM deals with the materials
that constitute a certain element
of risk for the company, employ-
ees and environment. The same
materials become an integral part
of the exposure profiles in IH as
soon as people are exposed to
them. The exposure profiles with-
in the IH health risk assessments
(HRAs) and information from
human resources (HR) together
form the basis for medical proto-
col planning in OH. A clear link
also exists between waste manage-
ment and HSM since hazardous
substances often end up as waste,
and this waste often must be
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handled as a special form of hazardous substance. As A successful incident manage-
such, it constitutes an exposure for coworkers involved
in waste handling. Moreover, it is important to state ment system must first
that HSM is closely intertwined with the material
flow within a company from the outset, from the sub-
provide the tools and means
stances point of purchase until it leaves the company to measure the success of the
as a product, part of a product or waste.
Waste management is also connected to purchasing system (such as development
and material management to a certain extent in terms of of incident numbers and dash-
the procurement of waste disposal services and the stor-
age of waste. Furthermore, the financial dimension of boards), but it must also have
waste disposal is also of crucial importance since waste
management costs contribute to overall material costs and
monitoring functionality
may in fact influence purchasing decisions with respect to ensure the efficiency of
to alternative substances. As a result, it is necessary to
link this component with cost accounting and financial the inherent processes
accounting. Waste management also incorporates a cer- and activities.
tain degree of environmental compliance, such as legal
reporting with respect to appropriate waste disposal. obtained from purchasing or material management so the
The functional area of incident or accident manage- relevant emission figures can be calculated.
ment with hazard reporting/near-miss reporting incorpo- Finally, the importance of the human interface can-
rates a range of integration aspects. The aftermath of an not be overstated. In any holistic EHS approach, the
incident often brings numerous other functional areas into individual must be considered as a key factor for
play, including claims management, disability manage- the success of an EHS management system. Alongside
ment and return to work. Injuries and subsequent medical expert users, such as industrial hygienists, occupational
treatment necessitate the involvement of OH, with infor- health practitioners and others, many stakeholders need
mation about the injuries and first-aid treatments that are to be involved in EHS. Various hierarchies of manage-
needed as input for incident reporting. ment exist, each with different information require-
Of particular importance is the link between inci- ments ranging from very condensed and exception-trig-
dent management and IH as a principal trigger of inci- gered C-level reporting down to a managers view of
dent prevention since the incidents, hazard reports and his/her team members exposures, OH planning, safety
near-miss reports are a key starting point for corrective training and so on.
actions and measures designed to make work areas Finally, of particular importance, one must consider
safer. A link also exists between the areas of disability all employees and contractors as a wholeevery-
management, HR and OH. Reintegration strategies for body who is active in the company. It is a generally
coworkers with restrictions are compiled in coopera- accepted fact that the top level of safety awareness can
tion with reintegration managers, HR and OH along only be achieved by incorporating everybody into the
with additional input from IH, such as information EHS concept. In other words, everybody must be a
about exposures in alternative work areas. HR is inter- part of the EHS world. This can be achieved uniquely
linked with any functional area in EHS related to the by involving all individuals, via self-service portals
workforce, that is, any area that deals with safeguard- for EHS as well as employee information centers
ing employees. with information about exposures, safety regulations,
Parallel to this HR integration is a link to third-party PPE, planned and executed medical protocols and so
management since whatever applies to in-house employ- on. Transparency and inclusion are the first and most
ees also applies to external employees, such as contrac- important steps toward achieving an excellent behav-
tors. It is also possible to draw a direct link between IH ioral safety culture. And for a successful holistic EHS
and plant maintenance with regard to the corrective mea- approach, it is essential to make the integration of
sures that must be triggered as a follow-up to HRAs and people a core element of the EHS strategy from the
incidents. very outset.
When discussing incidents, it is impossible to ignore If we also take aspects of product safety and product
incident management for environmental compliance man- compliance into account in such a concept, we would
agement. This is particularly true during a leakage, outlet very likely discover even more interdependencies and
or spill that is harmful to the environment and subject to interactions that would need to be added to the solution
legal reporting obligations. With regard to regular emis- landscape setup for EHS.
sions, such as greenhouse gases, CO2 or other kinds of A final aspect which further compounds this com-
emissions subject to legal reporting, the necessary con- plexity is that most modern companies are part of a
sumption information about input quantities needs to be global economic system. Their customers, partners and
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contractors are international. Similarly, most industries
is the link to OH for first aid and the usual aftermath
are interwoven into a global system of plants and sub- of accidents with employees injured. First-aid activity
sidiaries in various countries and jurisdictions with dif-
must be triggered and reported on. However, there is
ferences in terms of language and culture. also the process of reintegration of injured employees
When seeking to design a successful global corpo- with restrictions. For example, during the return-to-
rate EHS strategy that will work for all regions and work process that follows an accident, OH practitioners
will adequately support all languages and local or are involved in close cooperation with HR, industrial
regional requirements, it is imperative that this inter-hygienists and incident managers.
national or global aspect be given sufficient consider- With this, we have automatically touched the area
ation. This is valid for the broader EHS view and also of HR and IH. The link with HR is very strong, reflect-
for consideration around the setup of a successful inci-ing the cooperation necessary with respect to people-
dent management as a subset of the EHS strategy. related accidents. The same is also valid for contractor
Essentially, all these aspects of interaction and inter-
management when third-party employees are involved
dependence point toward one crucial messagean iso- in incidents or accidents. Industrial hygiene, with all its
lated approach to any functional area of EHS is bound preventive activity, is based very much on the findings
to miss the target. of incident management, especially in case of preven-
tive proactive incident management.
Incident Management Also obvious is the link to HSM. Hazardous sub-
Within the Corporate Context stances are often involved in incidents or accidents.
Having come to that conclusion, it is clear that the For all activities around prevention, it is important
next step must be to illuminate all facets of incident to have a clear picture of what hazardous materials
management, including all connections, dependencies with what characteristics are where within the compa-
and interdependencies with other functional areas or ny. HSM also provides all safety-relevant information
organizational units. A wide range of those links are about the materials, from protective equipment to first-
apparent. aid treatment in case of accidents.
The first and most obvious links are those to other The link between asset management, fleet manage-
functional areas within the world of EHS. Above all ment and maintenance is also rather perspicuous, first
for the assets, machin-
ery, vehicles and
such that are involved
Figure 4 and for the subse-
Functional Areas Within a quent repair activity.
Additionally, with its
Corporation Affected By an Industrial preventive activity,
Accident or Environmental Incident incident management
drives maintenance
activity around assets
to improve their safety
by constructing pro-
tective barriers, using
safety switches or
speed delimiters and
so on.
Another important
link is the connection
with governance, risk
and compliancethe
area of corporate risk
management. It is
important to be able to
monitor hazards and
incidents or accidents
in incident manage-
ment and to under-
stand the connection
between these actual
occurrences and the
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risks that have been established In summary, it can be said that incident manage-
and assessed within the corporate ment is not an island, but highly intertwined with many
risk management to control those units, processes and activities within a corporation. An
risks and to match them with isolated approach, a point solution to fix some issue or
reality. a standalone tool may cover some aspects to a certain
Also important is the smooth degree, but any comprehensive approach to proac-
flow of information from incident tive safety management with an active safety culture
management to top management, requires a flexible and highly integrated solution that
such as C-level, and to company can meet the needs and fit the capabilities and qualifi-
representatives and legal units. cations of very different stakeholders within a holistic
If a major incident happens, the solution landscape for EHS.
public is today informed in near
real time. Journalists and media Incident Management:
reporters arrive on site nearly The Suitable Way Forward
simultaneously with fire brigades Anybody who faces the challenge of implementing
and ambulances. Company repre- an incident management solution in some way, includ-
A systematic sentatives and legal advisors therefore must be in line ing all various aspects and facets of such a solution
approach can have
different designs
with any major incident as quickly as first aid is called setup, will need a systematic approach or roadmap for
or granularities, to protect the corporation from inadequate statements the way forward.
but roughly there and reactions. This is of vital importance to shield the A systematic approach can have different designs or
are five principal
steps to keep in
company from avoidable legal persecution and to pro- granularities, but roughly there are five principal steps
mind; Problem tect the brand name. to keep in mind:
analysis, Process Another important facet of incident management is 1) problem analysis;
design, Integration
design, Solution
external and internal legal reporting. On one side, com- 2) process design;
setup, Flexible panies strive to have accurate internal monitoring (using 3) integration design;
deployment. dashboards) to monitor efficiency, in this case, efficien- 4) solution setup;
cy of safety processes and incident/accident statistics. 5) flexible deployment.
On the other side are various legal obligations, such as
reporting injuries to legal bodies or insurance companies Problem Analysis
or informing environmental agencies about releases First, perform a detailed and concise analysis of the
(such as giving information to water protection squads). status quo, of the present situation, of the challenges
Last but not least for a company as economic unit and of the objectives that have been set for the new
is the financial aspect. What are the costs and col- approach to incident management.
lateral costs of accidents or incidents? What are the
costs of preventive measures and safety activities? Process Design
What amounts in compensation must be paid for clear- Based on step one, a detailed design should be done.
ing water or ground after major incidents? What are Such a design should not focus on functions, but rather
the potential savings due to safety measures? Which on processesprocesses that in many cases are cross-
organizational unit should be charged with the costs of functional and interdisciplinary. In case of incident
incidents or accidents? management, this becomes apparent when drawing up

Figure 5
Problem Analysis

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efficiency of the inherent
Figure 6 processes and activities.
Only based on this learn-
Safety Performance ing is it possible to drive
improvement.
Especially when a
company is coming from
a rather rudimentary
safety organization with
a rather reactive approach
to safety management, it
is important to have the
necessary insight into
the actual performance
to drive the evolution, to
come to a more systemat-
ic and managed approach
and in the final trans-
formation step, to cre-
atebased on experience
and insighta practiced
safety culture and proac-
tive safety management.
the flow of action and information from first reporting
until the final activities around investigation, preven- Summary
tion and so forth are closed. It can be said that incident management is far more
Integration Design than an administrative process around incidents or
Very quickly it also becomes visible where informa- accidents. On the contrary, it is a highly interactive and
tion is needed from which area, that is, where integration collaborative process, with many links and bridges to
needs exist between the functional areas. The previously other organizational units and functional areas. And as
discussed complexity of an EHS solution landscape and such, it must be a kind of backbone of an active safety
the many facets of incident management have shown that culturean approach to safety that not only enables
a high degree of collaboration, and consequently system processes and functions, but also facilitates evolution
interaction, is an important factor for success. and progress with respect to the safety of the operation.
It is the cornerstone for a learning organization with
EHS Solution Setup respect to safety and the core prerequisite for the pur-
The next step is the setup of a system or of process- suit of a zero-accident environment. x
es to facilitate the incident management activity. Given
the many very different stakeholder groups around References
EHS and incident management and their very different Bird, F.E. & Germain, G.L. (1996). Loss control
needs, it is obvious that to be suitable and acceptable, a management: Practical loss control leadership (revised
solution must have a certain degree of user orientation, ed.). Oslo, Norway: Det Norske Veritas.
adaptability and ease of use. Apart from the pure need ConocoPhillips Marine. (2003, Apr.). Safety pyra-
for the processes, the usability of the solution and its mid based on a study.
acceptance by the users are key factors for success. Geller, E.S. (2004, Oct. 1). Behavior-based safety:
A solution to injury prevention. Behavior-based safety
Flexible Deployment empowers employees and addresses the dynamics of
Last, but still of great importance, is the operation injury prevention. Risk & Insurance.
of the incident management solution, which should be Grainne, M.A. Behavioral safety from the con-
driven as flexible deployment. A key factor of success sumers perspective: Determining who really provides
for organizations today is to keep pace and to sustain behavior safety. Cambridge Center for Behavioral
momentum as a learning organization. Studies.
The basis for this process of learning and improving is Heinrich, H.W. (1959). Industrial accident preven-
the ability to monitor success and efficiency. A successful tion (4th ed.). New York: McGraw-Hill Book Co. Inc.
incident management system must first provide the tools
Bernd Freibott is the director of business development, Global
and means to measure the success of the system (such as Sustainability Services Hub, at SAP. He is also an ASSE member.
development of incident numbers and dashboards), but
it must also have monitoring functionality to ensure the
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