Criticism of Behavioural Safety programs...the case against

FIXING THE WORKPLACE, NOT THE WORKER A WORKERS' GUIDE TO ACCIDENT PREVENTION
by Bill Hoyle Oil, Chemical and Atomic Workers International
PO Box 281200
Lakewood, CO 80228
phone 303-987-2229

Introduction

"Safety First", "Think safety", "Take Two", "Wear Your Safety Glasses" and "Safety is Everyone's Responsibility". These are a few of the many safety slogans found on banners and posters in most industrial facilities. What all these slogans have in common is that they send the message that accident prevention is primarily the responsibility of individual workers. When is the last time that you saw a safety banner directed at management such as "Preventative Maintenance First", "Engineer It Safe" or "Safety Before Profits"?

Health and safety are definitely important concerns for workers today. They have seen far too many injuries, fires and explosions taking place. Since accident prevention has been defined by management as an individual worker responsibility, it is often a subject of employee involvement programs. The most wide-spread employee involvement safety programs are based on behavior modification. These programs use workers and supervisors to watch and document the behaviors of workers on safety observation forms. The goal is to reduce the OSHA recordable injury rate by changing the behaviors of workers. Companies selling these programs include Du Pont, Behavioral Science Technology, BST, and others. These programs sometimes include the popular buzz-words: quality, cultural change, team work, jointness and empowerment. They promote union participation and sometimes include new full-time jobs for union representatives who help administer the program. The union often creates a name for their local program. Management may even agree to not use discipline when unsafe behavior is observed.

Programs such as BST can be popular with local union committees in plants where they have been implemented. One reason for this advocacy is that people believe that worker errors such as not wearing protective equipment are a central safety problem. many unionists are convinced that behavior modification programs really work. The OSHA recordable rate often does go down. Union members believe that a safer workplace has been created.

It can be argued that the primary thing that has usually changed is that the reporting of injuries has been reduced.However, even if the injury rate is actually lowered, this is a very inaccurate indicator of overall workplace safety, especially in the oil and chemical industries. These plants have a very low OSHA injury rate yet the number of disasters has sky-rocketed.

The basic premise of behavior modification programs is that the primary cause of accidents is worker error. This blame-the-victim concept provides little opportunity for effective accident prevention. Behavior modification does not focus on the fundamental safety problems that we face in the continuous process industry. For example, it does not address the need to change the dangerous contractor system or the unsafe practice of running plants far beyond their safe design limits.

OCAW has developed a powerful new program for making fundamental improvements in health and safety. It is called the Triangle of Prevention Program, TOP. Our safety program centers on fixing the workplace, not the worker. This is done through creating effective safety systems. A strong process safety management program is one part of a systems approach to health and safety. Examples of safety systems include the safe design of processes and equipment, proper maintenance and inspection, and having effective procedures and training programs.

Accidents and Worker Error

In the early hours of April 26, 1986, operators at a nuclear power plant were conducting a test of their emergency systems. Power was reduced to below 25%. This unexpectedly caused an explosion and the meltdown of the reactor core. Two of the operators involved were killed along with 30 of their co-workers. Thousands of people were exposed to harmful levels of radiation. The operators and supervisors who survived were blamed for the accident and five of them were sent to jail. Another example of operator error was documented in government reports and the case was closed. The name of the accident site is now synonymous with disaster, Chernobyl.

Years later with the fall of the Soviet Union a different version of the accident emerged. The reactor had inherently dangerous flaws in its design. Operating manuals did not warn of an instability safety problem associated with running the reactor at low power. Today, newly issued operating procedures prohibit operating the reactor below 25% power.

When you read a newspaper account of an industrial accident it will almost always conclude that the cause of the accident was worker error. In a society largely based on individualism the idea that worker mistakes are the primary cause of accidents rings true with most people. There is no denying that workers make mistakes. However, in every industrial accident there are almost always several management safety systems involved which may not be readily apparent.

At an OCAW represented plant in Salt Lake City, a process operator was burned when sulfuric acid splashed on him while drawing a routine sample. Management blamed the worker for causing the accident by failing to wear a face-shield, acid suit and other personal protective equipment (PPE). Management issued a bulletin threatening discipline against anyone not wearing all their PPE. Co-workers of the injury victim did not like seeing their friend blamed and knew that it was common practice to not wear all of the hot and awkward acid gear when taking samples. However, they conceded that he should have been wearing more PPE in order to avoid the accident.

Further investigation by the Joint Health and Safety Committee found that there was more going on in this accident than a mistake by a worker. The procedure for collecting sulfuric acid samples was to hold an open cup under a bleed valve on a pressured line on the acid pumps. The acid sometimes splashed out of the cup which made wearing PPE necessary. The committee recommended that acid sampling points should be redesigned to eliminate the potential for splashing altogether. One simple way to do this was to sit the sample container in an enclosed sample box with a glass door where the valves could be operated outside the box. This would eliminate the exposure and the need to wear most of the cumbersome PPE.

The Committee then broadened the investigation to look at all of the sample points in the plant. It was discovered that sampling points for dozens of different hazardous materials were unsafely designed and were unnecessarily exposing workers. The Committee initiated a new program to have sample points throughout the plant redesigned to eliminate or minimize exposures.

Behavior modification programs are the least effective way to prevent accidents because they focus on the narrow issue of correcting worker mistakes. In the acid burn accident, behavior modification programs would only seek to reinforce the need for workers to wear PPE. The Health and Safety Committee investigated the injury using a fix the workplace, safety system approach. The Committee saw that the worker's injury was a symptom of a problem with the facility's chemical sampling system. By focusing on fixing the workplace, the Committee was able to take accident prevention to a much higher level than is possible by using behavior modification.

The Center for Chemical Process Safety, CCPS, of the American Institute of Chemical Engineers is an industry sponsored publisher of widely used safety guidelines. They state that:
"An Axiom of incident investigation is that process safety incidents are the result of management system failure... Of course, many causes of incidents can be attributed ... to equipment breakdown or operator error. However, experienced incident investigators know that such specific failures are but the immediate causes of an incident and that underlying each such immediate cause is a management system failure, such as faulty design or inadequate training. It is from identifying the underlying causes that the most benefit is gained." (Technical Management of Chemical Process Safety, CCPS, pages 113-114)

James Reston of the University of Manchester adds that:
"Rather than being the main instigators of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking." ("Preventing Accidents at Oil and Chemical Plants" by Najedin Meshkati, Chemical Safety; November, 1990)

Yale University Professor Charles Perrow explains:

"Finding that faulty designs were responsible would entail enormous shutdown and retrofitting costs; finding that management was responsible would threaten those in charge; but finding that operators were responsible preserves the system..." ("Preventing Accidents at Oil and Chemical Plants" by Najedin Meshkati, Chemical Safety; November, 1990)

What the Insurance Companies Know About Oil and Chemical Plants

Insurance companies that cover oil and chemical facilities keep extensive records about the safety of these plants. These insurance companies have millions of dollars in policies at risk. Their records show that during the last 15 years safety in the oil and chemical industries has gone out of control. The number and the scope of disasters has greatly increased. The most notorious of these disasters took place at Phillips Chemical Company in Pasadena, Texas in 1989 when an explosion killed 23 people, injured 232 and did nearly $1 billion in damage.

Industrial Risk Insurers has explained that there has been substantial growth in the inherent hazards of oil and chemical plants due to profit driven decisions being made by management. This includes use of higher pressures and temperatures, more toxic and unstable chemicals, increased congestion of plants and equipment to save on piping, energy and instrumentation costs. Studies published by Marsh and McLennan show that the majority of property losses in oil and chemical plant accidents are due to mechanical and design failures, not operator error.

A leading European based insurance company, Swiss Re, explains that petrochemical plants "have reached a level of complexity beyond the ability of current techniques and organizational structures to control them safely." (Chemical Week, August 5, 1992, page 33) OSHA's John Gray Report determined that increased use of less trained and experienced contract labor has seriously compromised safety in the petrochemical industry. Also, there are far fewer shutdowns scheduled to perform essential safety repairs and inspections. Many plants are running at rates of production beyond the safe design limits of the equipment. Corporate reengingeering and other downsizing programs have eliminated thousands of jobs and increased overtime while targeting record production goals.

Amoco Oil Company boasted in 1994 that they have been running their refineries at 104 percent of capacity. (Amoco Torch, November 14, 1994) This is like riding in an over-loaded elevator or flying in a corded airplane that exceeds safe weight limits. When a pilot allows this situation, they are fired. When a corporate CEO does the same thing on world scale they get a bigger bonus.

In the name of competitiveness, oil and chemical plants are increasingly managed and engineered in a high risk and unsafe manner.

Is Your Safety Being Downsized?

Cost-cutting mania is sweeping through corporate America. No one's job is safe from consultant's latest snake-oil proposals for reengineering and increasing profits. Spending on health and safety is not immune from the budget slashing ax. In the plants, corporate managers often tell workers that no expense will be spared in maintaining a safe workplace. Workers are told that safety is a win-win, non-adversarial issue which is in the mutual interests of both management and labor. meanwhile, these same corporations are using their vast wealth to lobby the Congress to eliminate health and safety regulations and enforcement in the name of world competition and cost-cutting.

Corporate reengineering also has deadly consequences beyond the plant gate. It has even hit the medical care system. At the University Community Hospital in Tampa, Florida, one patient had the wrong leg amputated and another died when their respirator machine was turned off by mistake. Clearly, doctors and nurses made serious errors, but these errors were set-up by a medical care system that is being downsized. An investigation report by federal and state government agencies found that these incidents were caused by "assembly-line surgical care, the hospital's dramatic under-staffing and the use of poorly trained, poorly supervised nurse replacements." (Unhealthy Care, The Nation, May 8, 1995, page 620)

What is a Safe Workplace?

The dominant model of safety in the country says that an injury free workplace is a safe workplace. Therefore, a low OSHA injury recordable rate demonstrates that a workplace is safe. Having zero worker injuries is a worthy goal, but creating a safe workplace requires much more. IN 1994, an OCAW represented facility in Ohio celebrated the fact that they had gone two million work hours without a lost work day injury. A major fire on the crude unit which had occurred during the award-winning period did not detract from the safety record. No one was seriously hurt in the fire.

At a huge Texas plant, a release and fire caused hundreds of citizens living near the facility to seek medical treatment for possible exposure to hazardous materials. But since no workers were injured, the plant's safety record remained unblemished.

In the majority of potentially catastrophic chemical releases and fires there are no OSHA recordable injuries. Often the only thing that prevents fatalities and injuries is luck. The wind direction was favorable or workers had just left the area before an explosion. When we measure safety by using the injury rate we get a very distorted view of actual safety conditions in our plants.

The primary theory used to explain the causes of industrial accidents is that mistakes by workers are responsible for virtually all accidents. This is the foundation on which health and safety programs have been based for decades. Therefore, the ultimate goal of corporate safety programs and local union safety committees is generally, the same, to have zero worker injuries. safety attention focuses on finding ways to get unsafe workers to change their ways. Companies like DuPont and Behavioral Science Technologies are hired to help fix the problem of worker behavior.

Workplace safety is measured by only one statistic, the OSHA recordable rate. Based on this statistical yardstick, continuous process industries continue to be among the safest industries in the country and are getting safer. Many plants have celebrated working millions of hours without a lost work day accident. While all eyes are on the OSHA recordable rate, releases of hazardous materials, fires, mechanical breakdowns and near misses are not included in the safety statistics.

OSHA's John Gray Report found that use of injury rates to determine workplace safety is "wholly inadequate" and inaccurate. An article published by the National Safety Council explained that injury incident rates "aren't always a reliable indicator of safety performance." (Safety and Health, January 1994, page 72)

While having a low injury rate, the oil and chemical industries are actually among the most dangerous industries in the country and they are getting more dangerous every year.

Safety Systems: The Key to Fixing the Workplace

A safety system can be defined as the use of management programs which proactively identify and eliminate or control hazards. This beings in the conceptual phase e of process units and equipment and continues throughout the life of the process. Major safety systems include the following:

Process and equipment design

Mitigation devices (relief valves, etc.)

Warning devices (alarms)

Mechanical Integrity

Procedures and training

Human factors

All these systems are important in order to have a safer workplace. However, some systems are far more effective than others in their ability to maximize opportunities for prevention of disasters and injuries. The most important safety system is the design system. This is the only system in which primary protection takes place. For example, by designing a process to use lower pressures, temperatures and less toxic and reactive chemicals, the potential for disaster and injury has been effectively reduced by the use of inherently safer equipment and materials. Another example is the design and use of unique couplings for the connection of nitrogen, air, steam and other hoses. Good design techniques like the use of unique couplings are the most effective way to eliminate the potential for accidents.

All of the other safety systems provide secondary prevention by reducing the probability or severity of an accident. Good maintenance, inspection and training programs are important, but they will not make unsafely designed equipment safe. Take for example a series of three heat exchangers which have been installed on top of each other without a safe way to access the valves on the top exchanger. Operators assigned to take the top exchanger out of service are instructed to wear fall protection harnesses while they climb up on the slippery lines and valves. The harnesses will not prevent a dangerous fall. At best the harnesses will reduce the severity of injuries suffered from a fall. In congested process units which often do not have safe anchor points for fall protection, a harness may be of little real help. Effective prevention of injuries in this example requires that exchangers are not stacked on top of each other or that permanently elevated work platforms are installed so that the equipment can be safety accessed.

Behavior modification programs assume that the workplace and its safety systems are designed and maintained safely. Insurance industry research shows that this is not the case. Behavior observation programs actually function as a means of convincing workers to adapt their behaviors in order to keep unsafely designed equipment running. Rather than focus energy on changing unsafely designed equipment such as on the stacked heat exchangers, behavior modification programs concentrate on getting workers to adapt themselves to the unsafe equipment by wearing fall protection harnesses or other personal protective equipment.

Treating Workers As Good as The Pipe: Understanding Human Factors

Human factors involves considering the worker element in the design of equipment and technical systems so that they will be safe for workers. For example, a process hazard analysis will insure that valves are installed so that a compressor can be isolated. However, these valves will be of little use in an emergency if they are placed in hard-to-reach locations or if an operator's job tasks in an emergency do not allow time to close the valves. This is one reason why OSHA requires that each process hazard analysis examines human factors.

In the United States, the term "ergonomics", is typically used to refer to the physical aspects of work while "human factors" is used to encompass both the physical and mental issues. Like every other major safety system, the human factors system has several sub-systems. These include equipment lay-out, workload and staffing levels, shift schedule, overtime and behavior. In order to effectively address these important safety issues, each plant needs a written human factors program. Many plants have large staffs of engineers who perform extensive calculations on piping and other hardware so that the process will run safely. While the hardware receives lots of attention, little thought is given to human factors. During oil or chemical plant shutdowns for repairs called turnarounds, workers may be assigned to work 12 or more hours a day for a month or longer without a single day off. Companies apply tight restrictions on the maximum safe process limits for the protection of piping and other hardware. But when it comes to scheduling unlimited and unsafe amounts of overtime, workers are treated far worse than the pipe.

The Center for Commercial Process Safety, CCPS, has created a list of questions for auditing human factors programs. Sample questions include: (Guidelines for Auditing Process Safety Management Systems, CCPS, page 104)

Do control and display layouts minimize the chance for operator error...?
Are there design standards that specify proper layout?
Is there adequate space to access system elements for normal operations and maintenance?
Have the psychological and physical demands of the job been considered for both routine and emergency operations?
Have shift work and overtime schedules been designed to minimize operator fatigue and stress?
Have environmental conditions such as noise, temperature and illumination been considered?
Have employees made modifications to existing systems that would indicate failure to apply human factors principles in the original design?
Have employees received training in human factors?

The CCPS explains that a human factors program is an essential component of every process safety system. However, a CCPS survey of selected large company's process safety activity revealed that five out of seven companies did not have a human factors program.

While many companies do not address human factors safety, they give a great deal of attention to one of its sub-systems. That is worker behavior. Most industrial safety departments concentrate their efforts on behavior modification. Their focus is on worker observation, Job Safety Analysis, slogans, posters, prizes, accident score boards, and bonus pay programs.

Changing worker behavior is one of the least effective methods for accident prevention. Workers make occasional errors because they are human. There is a natural error rate for even the most highly trained and drilled work force. This is recognized whenever a process hazard analysis such as a HAZOP is performed. It is always assumed that if valves can be operated in the wrong order or at the wrong time that this will happen sometime. Therefore, the hazard analysis concerns itself with the design of a process where it will remain safe even when a worker makes a mistake. Examples of this concept include the use of relief valves, check valves, redundant controls and automatic shutdown systems.

No amount of behavior observation will create an error-free, injury-free workplace. The Chemical Manufacturers Association explains in a CMA publication that "enlightened managers realize that... most mistakes are committed by skilled, careful, productive, well-meaning employees...Human error is a natural and inevitable result of human variability in our interactions with a system." (A Manager's Guide to Reducing Human Errors, CMA, pages 4 and 5)

Entering the Era of Process Safety Management

In 1984, thousands of people were killed when a toxic chemical was released from a Union Carbide plant in Bhopal, India. Afterwards, a safety movement in this country forced Congress to pass the Emergency Planning and Right to Know Act in 1986. The 1989 catastrophic explosion at Phillips Chemical plant in Pasadena, Texas along with other disasters, further pressured Congress to include in the 1990 amendments to the Clean Air Act a requirement that OSHA and the EPA establish disaster prevention regulations.

OSHA issued the Process Safety Management Standard in 1992. This law recognizes that the key to safety in the oil and chemical industries is to require a fix the workplace, safety systems approach. Elements of the Standard include process hazard analysis, mechanical integrity, management of change and incident investigation. OSHA mandates that employees and their unions are consulted by the employer on each of the 14 required elements of the Standard. How is focusing on fixing the workplace and safety systems different from the way that continuous process industries has been functioning for decades? Let's take the example of a pump failure which caused a fire. Traditionally, the failure mode would be identified. For instance, it would be determined that a bearing failed. A new bearing is installed and the pump is put back into service. The incident would be treated as an isolated case and would not trigger a broader review of facility safety programs.

In a fix the workplace framework, when a pump fails it is recognized that the thing that actually broke down was the plant's mechanical integrity program. The most important thing to examine is not the pump bearing. The key for prevention of future similar incidents requires examining and changing the mechanical integrity system. Therefore, attention focuses on issues such as why the pump vibration monitoring program did not detect a problem with the bearing. If vibration monitoring had detected a problem, why had the pump been kept in service and run until it finally failed. The repair history of the pump would be examined to see if it has had similar failures before. If so, there may be a design problem with the pump and similar pumps in other areas of the plant.

Examining Du Pont

Basketball players want to "be like Mike", Michael Jordan. Many corporate safety programs have as their goal to be like Du Pont. While many companies try to get down to a good OSHA recordable injury rate of 3.0 per 200,000 work hours, Du Pont advertises that their rate is only 0.033. Du Pont's programs include "Take Two" and "STOP". Their premise is that worker behavior is the safety problem in industry. Du Pont sells the following formula for safety:

All injuries and occupational injuries can be prevented

Working safely is a condition of employment

96% of injuries are caused by unsafe acts

The Du Pont Safety Training Observation Program, STOP, uses an observation data sheet to monitor and change unsafe worker behaviors. The five areas that are observed include personal protective equipment, proper use of tools, body position, following procedures and reactions of people. Observers are warned in the STOP guide for supervisors that "an unsafe act is always committed by a person, not a machine. A skilled observer looks at everything in the workplace, but concentrates on people and their actions."

Examining Behavioral Science Technology, BST

The co-founders of BST explain their program in a book entitled "The Behavior-Based Safety Process, Managing Involvement for an Injury-Free Culture". The book says that behavior modification has proven itself in the treatment of alcoholism, drug addiction, neurotic, psychotic and other mental disorders. However, in industry "it has never really gained popularity and in some cases behavior modification has a poor reputation". The authors explain that "when behavior modification is presented incorrectly, it can be perceived as manipulative."

BST echoes the Du Pont premise that virtually all accidents have as their root cause the behaviors of workers. BST requires employees and union participation because it uses peer pressure as the vehicle for changing behavior. BST and corporations realize that the people who are the most effective in carrying-out the blame the worker program are the workers themselves and the union.

BST recognizes that selling behaviorism to workers has some problems. BST's co-founders complain that workers mistakenly "judge management commitment to safety by how quickly equipment and facilities are repaired and serviced...what they see are leaks and machinery without guards." The authors go on to say that:

"Workers are regularly around equipment that might seem unsafe to them. For this reason, maintenance has symbolic importance to workers. If the maintenance function is perceived as being unresponsive, workers are likely to think that they work in a place where management does not really care about safety."

The "problem" that concerns BST's founders is that workers understand that lack of repairs causes accidents rather than buying into the notion that only worker behavior causes accidents. Like the Du Pont STOP program, BST relies on the use of workers and supervisors to watch worker behaviors and to record what they see on observation data sheets. According to BST, the primary categories targeted for observation are protective equipment, tools, body use and following procedures.

Fixing the Workplace v. Fixing Behavior

How would a fix the workplace approach to safety differ form behavior modification in a typical job task in the oil or chemical industries? Let's take the example of a process chemical pipe which has developed a hole. A patch is being welded on the pipe while the surrounding process unit continues running. In the behavior modification model, the only thing of importance is the observation of how the welder performs their task. Is the proper welding hood, respirator, clothing and gloves worn? Does the welder stand in a safe and comfortable position? Does the welder stand in a safe and comfortable position? Does the welder have a hot work permit and fire watch? Is the welding equipment in good condition?

In a fix the workplace approach to the repair the starting point is that hot work on a running process unit in an oil or chemical plant is inherently very dangerous. It is recognized that issuing a permit or a good procedure does not make an inherently unsafe job safe. The permit and procedure only lessens the danger of the high-risk job. The most important safety question in any hot work job is how can the job be done without use of hazardous hot work? It is also recognized that PPE is the least effective method for controlling exposure to hazards.

In a fix the workplace framework, the most important questions to ask are very different than the questions asked by behavior modification programs. Fix the workplace questions would include: Why did the line fail? What is the historical record of failures on this piping system? Was the pipe engineered and installed properly? f not, what failed in the engineering and design system? Why didn't the inspection system detract the thin pipe prior to it failing? What needs to be changed in the engineering and inspection systems to prevent further similar failures? Can the line be repaired without use of hazardous hot work? Can the section of line be removed from the unit and repaired in the shop? Can the unit be shut down so that the repair can be done more safely.

Analyzing Job Safety Analysis

Another popular safety program is Job Safety Analysis, JBA. This program also relies on supervisor and workers observing job tasks and documenting what they see on the JSA form. JSA is often used to verify or create job procedures. Before beginning the JSA, the required personal protective equipment, PPE is listed on the top of the form. According to the National Safety Council, a JSA is divided into three steps. First, the sequence of basic job steps is listed. Next, the potential hazard of each step is recorded. Finally, a recommended procedure is listed.

How would a JSA work in the welding job example previously discussed? The required PPE would be listed first. Next, the steps needed to perform the repair task would be recorded and the hazards identified. Then recommendations are made. These might include more PPE, a different body position, or moving the fire watch to a better location. As you can see, there is little difference in what a JSA, Du Pont STOP or BST would look at in the welding job. All these safety programs are primarily focused on what the worker does or does not do. The much more important questions about fixing the workplace are not addressed.

The PPE Police

In all behavior modification programs the central thing that this looked for is the use of personal protective equipment, PPE. A favorite theme of management is to constantly tell workers to wear ever increasing layers of PPE. Workers are told that if they would wear all this PPE they would eliminate most injuries.

There are times when use of PPE is appropriate. These include emergency responses to releases of hazardous materials, during line breaking or while engineering controls are being installed. However, most use of PPE is due to exposures caused by poorly designed and maintained equipment or poor work procedures.

Worker observation programs are the best method for management's policing of PPE use. Local union representatives who are urged to become safety observers are usually promised that discipline will not be used when PPE violations are observed. Union locals often consider this promise to be a progressive step. But while discipline may be kept out of the observation process, the blame the worker for accidents system which includes discipline remains firmly intact.

For union members, behavior observation programs inhibit solidarity among the workforce. Workers are assigned to watch, analyze and document what your fellow workers do right and wrong. In behavior observation programs, the primary safety problem that needs fixing is the conduct of your union brothers and sisters. Workers do not like having the boss or anyone else looking over their shoulder. Rather than focusing worker attention on organizing collectively to fix the workplace, behavior based programs have workers target each other for individual change.

Another problem for management is that workers hate PPE. Workers do not hate PPE because they are lazy or forgetful. They hate it because they are smart. PPE is often hot, very uncomfortable and awkward to use. It often creates additional hazards. Vision and communication may be impaired. Increased stress may be put on the heart and lungs. It is the least effective way of protecting against hazards. Reliance on PPE to protect you from toxic materials is like relying on a bullet proof vest to protect you from a firing machine gun. Real protection requires stopping the machine gun fire. This is why OSHA requires that exposures should be eliminated by use of engineering controls whenever feasible and that PPE should only be used as a temporary measure or as a last resort.

During a shutdown of a catalytic cracking unit at an oil refinery in Utah, dozens of workers suffered eye injuries due to the sand-like catalyst blowing around the unit. The design of vessel clean-out activities did not include the adequate control of catalyst dust clouds. Rather than redesigning clean-out operations to better contain the catalyst, management issued a new rule that everyone must keep goggles on their heard-hats ready for use.

Management has two reasons for handling safety problems by requiring more PPE. First, it is the cheapest way to deal with the problem. Redesigning equipment or work procedures usually cost more money than PPE. Secondly, reliance on PPE transfers responsibility for safety from management onto workers.

Safety Observation and Management by Stress

Watching and recording in detail how workers do their jobs is nothing new. Since early in the century, followers of Taylorism's scientific management ideas have been doing time-and-motion studies of workers using a stopwatch. This piece of the management by stress programs has been especially despised by workers. Modern management by stress programs have replaced the hated stopwatch with incentive bonus awards for workers who speed-up production. Since one of the ways to improve safety is to slow down the pace of work, incentives for speeding-up work conflict with the incentives for improving safety.

Another tool in the management by stress arsenal is using team concepts and peer pressure to blame and shame workers in order to modify their safety and other behaviors. The federal government convened the Dunlop Commission to study improving teamwork and cooperation between management and labor. One of the studies used by the Commission argues that corporations should:

"develop an environment of positive peer pressure by instilling a sense of guilt and shame in workers...Workers who do not respond to shame n\must be weeded out or converted...Practices like quality circles and work teams may be just as important for their cultural effects on team spirit and for the opportunities they create for workers to monitor each other as they are for the specific work task that take place in teams." (Working Smart, A Labor Notes Book, page 151)

The Case of Accident Prone Andy

In every plant there is always at least one worker who has the reputation of being a hazard to themselves and others. Let's call this person Accident Prone Andy. Some corporate safety consultants subscribe to the theory that a handful of unsafe workers are responsible for a significant percentage of all accidents. Behavior modification programs will give lots of attention to Andy. He will be encouraged to change his ways. Maybe he will work safer. If he continues to have accidents, the discipline program will be used. If that still doesn't work, Andy might be fired.

Anther way that corporations deal with the notion of accident prone workers is to attempt to not hire them by using screening programs. One such program is BST's Job Candidate Profile. BST promises employers that by purchasing this personality profile test, accident prone workers and other problem employees can be weeded-out. BST curiously warns that their "good" employee screening test is only appropriate for hourly workers, not for management staff.

So what kinds of "safety" questions does the BST test ask? Here are a few examples which the prospective worker is asked to agree or disagree with:

The police should be given more power.

This country needs higher moral standards.

There is too much crime today.

The old-fashioned values are best.

It is hard to tell from questions like these whether management and BST are looking for safe workers or if they are recruiting for a conservative political organization.

If the theory of the accident prone worker is true, then by modifying or firing and by not hiring all the Andy's we will have finally created a safe workplace. But is this true?Will there be fewer fires and explosion caused by thin piping systems and by poorly maintained pumps and compressors? Will there be less welding done on running process units? Will contractor companies start giving equal training to their workers to that received by employees of the host company? Modifying or firing all the Andy's leaves intact the unsafe safety systems which need to be changed in order to create a truly safer workplace.

Belief in the idea that a few unsafe Andy's cause most accidents is widespread. But in reality, every on of us is an Accident Prone Andy at various times in our lives. We are distracted by marital or family problems. We may be unable to get a decent nights sleep. We are having medical problems. Or sometimes we just have a bad day or week for any number of other reasons. All these conditions are absolutely normal human behavior. We do not need to be modified. The safe design of equipment and process units assumes that workers will have occasional bad days and will make mistakes. When the workplace is designed and maintained safely, we don't need to fix or fire the workers.

McSafety Scoreboards

McDonalds restaurants have boasted on their signs that they have sold so many billions of hamburgers. Likewise, most large industrial plants display a prominently located McSafety scoreboard. The scoreboard tracks how many days have passed since a lost work day injury. Safety success is measured by how many million hours have been worked without an injury. Fires, explosions and toxic releases are not included on the McSafety scoreboard. If you get to a safety target, for example two million hours, everyone gets prizes such as a sharp safety award jacket. Gain-sharing and variable pay awards are also based on having low injury statistics.

Prizes and awards are behavior modification techniques called positive reinforcement. Safety consultant Thomas Smith explains that "the research shows that positive reinforcement is as bad as negative reinforcement. It's just a different side of the same coin. The ultimate goal is to control people."

May workers know that the scoreboard injury numbers are often the result of creative book-keeping and of assigning injured workers special light duty work while they heal. The numbers may be a fantasy, but the jackets are real, so complaints are kept to a minimum. Workers are also keenly aware of the powerful peer pressure to not report injuries. Reporting an injury means you will be blamed by your peers for taking money and prizes out of the pockets of your co-workers. Million-hour jackets, gain-sharing awards and safety scoreboards are a favorite part of management's behavior modification tool box. management recognizes that the problem behavior that they are most concerned with is to entice workers to think twice before reporting injuries.

Plant management has developed one scoreboard trick that the baseball team owners could learn from. McSafety scoreboards only list the score for the home team. Management just includes their own workers in the safety statistics. The visiting team, the contractor workers, do not get to have their performance listed on the safety scoreboard. According to a report issued by the EPA, over 30% of the hours worked in the petrochemical industry are logged by contract workers. (Rachel's Environment and Health Weekly, September 22, 1994) If management is truly concerned about safety and not just the numbers game, contractor injuries must be included in plant safety statistics.

Owning Up To Ownership

Corporations have a very clear idea of who owns and controls their businesses. management determines what is produced, what types of equipment and chemicals are used, how maintenance is performed and every other aspect of production. These are management's "rights" based on their representing the owners of the company. In exchange for shouldering the responsibility for the company's success or failure, top management may get bonuses worth millions of dollars. However, there is an important exception to management's monopoly on responsibility. In a word, it is accidents. When it comes to accidents, ownership and responsibility is swiftly passed down to the workers. This is one of management's favorite employee involvement programs.

Another area where corporations shirk their responsibilities is through the use of contractors. OSHA's John Gray Report is the most extensive study ever conducted on health and safety in the oil and chemical industries. The report found that in addition to cutting costs, a primary reason that corporations use contractors is to avoid the legal liability for these workers. The OSHA report recommended that legal responsibility for the health and safety of everyone working at a facility, including contractors, should be shouldered by the plant manager.

Behavior modification safety programs are a perfect fit for management's avoidance of responsibility for health, safety and accidents. When these programs refer to unsafe behaviors, they are referring to worker behavior only. In reality, the decisions of corporate CEOs, presidents, managers, engineers and supervisors are the primary factors in preventing accidents. When management runs process units beyond factory design limits, reduces preventative maintenance staff, crowds equipment together, hires poorly trained contractors and downsizes safety budgets, these unsafe management behaviors are ignored by behaviorist safety programs.

Workers do have important responsibilities regarding health and safety. These include the responsibility to report all injuries and near misses no matter how many prizes and bonuses are offered for non-reporting. Workers have an obligation to question inadequate work permits, procedures and training and to demand that these are done properly. Workers have a responsibility to not be pressured to cut corners when management is in a hurry to get a job completed. They are responsible to demand that engineering controls are used whenever possible rather than PPE.

Preventing Catastrophes

In the corporate model of safety, a low injury rate equals a safe workplace. Therefore, it is believed that preventing injuries prevents bigger incidents and disasters. This long held perception is not supported by the facts. The oil and chemical industries have very low OSHA recordable injury rates and their rates are getting even lower. At the same time, the number and seriousness of catastrophes in the industry has sky-rocketed. Union locals that focus their activity on Du Pont, BST, JSA and other worker behavior programs are missing important opportunities to protect workers, the public and the environment. These programs are ineffective in preventing disasters.

Take the example of the disaster that took place at Phillips Chemical Company in Pasadena, Texas. Behavior based programs would observe that the individual behavior of a contractor worker caused the disaster. In reality, it is widely recognized that the system of contractor maintenance was a primary cause of the catastrophe.

An important safety concept used in writing workplace emergency response plans is that you always prepare for the most serious types of accidents. By doing this you are able to most effectively handle safely the entire range of incidents from minor to catastrophic.

By focusing on disaster prevention and creating strong safety systems, union members can most effectively prevent injuries and create a safer workplace.

Reinventing the Yardstick: A Better Way to Measure Safety

Some union safety activists have long been troubled with blame the worker safety programs and giving out prizes for low OSHA injury rate statistics. A fundamental problem has been that there has never been another method for measuring safety success. The OSHA injury rate yardstick has been the only game in town. OSHA and the Congress have been guilty of dragging their feet on implementing a new safety measurement system. Recognizing that effective safety systems are the key to protecting health and safety, it naturally follows that what we should be measuring is safety system performance. OSHA's John Gray report recommended the following for a new safety tracking system:

Data collection on actual injuries and illnesses and the accidents, near-miss events, chemical leaks and releases, equipment failures, design flaws, operator errors, fires, explosions, and other workplace incidents that have the potential to cause serious injury to workers and communities.

With these ideas in mind. the OCAW has designed a new measurement system for tracking plant safety. It is called the TOP Rate. It consists of tracking the following incidents:

1. Hazardous material release reportable on the EPA's SARA 304 list or releases of more than 5,000 pounds of flammable material.

2. Fires, explosions or chemical spills that required an emergency team response.

3. Injuries or illnesses suffered by employees or contractors which are OSHA recordable or incidents which caused one or more members of the public to seek medical treatment.

The top Rate is calculated in a similar manner to the OSHA recordable injury rate. The annual number of reportable incidents is divided by the total hours worked in the facility and then is multiplied by 200,000. Take for example a plant with 200 employees who each worked 2,000 hours in a calendar year and which experienced 6 reportable incidents. Dividing the incidents, 6, by the 400,000 total hours worked, and then multiplying by 200,000 would result in a TOP Rate of 3.0.

What About Near Misses?

Many serious incidents do not result in fires or injuries, but easily could have been disasters. It is important that these near miss events are also tracked. The OCAW TOP initiative includes the new tracking program, use of a full-time union safety representative and training for all employees on process safety, safety systems and incident investigation. Too often, near misses go unreported because of fear of discipline or other negative consequences. In order to help encourage greater reporting of near misses, the TOP Rate statistics will not include near misses unless these incidents fall into one of the three categories described.

Determining the Root Causes of Incidents Using OCAW's Logic Tree Diagraming

The root causes of accidents and incidents almost involve problems in management safety systems. Typically, there are multiple system-based root causes in an accident. Another leg of the TOP program is the easy to use OCAW Logic Tree Diagraming method for identifying root causes. In the OCAW method, each fact that is found in an accident or near miss investigation is recorded on a 5 by 7 inch self-adhesive paper and placed on a wall. Use of the self-adhesive paper allows each fact to be easily moved around as the logic tree diagram is constructed. This type tree construction process is similar to that used by the National Transportation Safety Board.

Direct causal relationships are determined for each fact through the use of several questions found on the OCAW Logic Tree Diagraming Wallet Card. The card guides investigation teams through a two-step process. In the first step, all the facts that are necessary to have caused or allowed an event or condition to take place. The logic tree is continued downward until all of the safety system failures are identified. For more information on the TOP program contact the OCAW Health and Safety Department.

Conclusion

Creating a truly safer workplace requires looking at industrial health and safety in a fundamentally new way. After all, our entire society is based on blaming the victim. When millions of people are thrown out of work by an inherently cyclical economic system, the individual worker is told to get out there and solve your problem by finding a new job. If you don't find a new good job it is your fault.

We are told that the epidemic rise in the rate of cancer in our society is caused by our individual actions. That is, that we smoke and drink too much while not exercising and eating right. In contrast, it has been shown by scientists Barry Commoner, Dr. Samuel Epstein and others that the primary cause of the cancer epidemic is increased exposures to toxic industrial chemicals in our workplace and in our food and environment.

The solution to pollution is increasingly framed in terms of telling individuals to drive their cars less and to recycle more. The national focus on individual recycling concentrates our attention on the least effective area for actually reducing pollution. However, it is very effective in transferring blame and responsibility for pollution onto working people and away from corporations who create, control and profit from the system of pollution.

An article in OCAW's publication New Solutions reports that corporate downsizing and the management by stress system are contributing to increased smoking, drinking, drug use and violence. "If employers respond at all to this, they tend to respond in terms of increased surveillance, more drug testing, more ways of getting rid of you; or (they use)... the yoga and yogurt approach: quit smoking, eat bran and wear a condom. It's your fault and we can solve it by changing the individual rather than changing the workplace." (Work and Health in the Global Economy, New Solutions, Summer 1995, page 6, quote by Pat Armstrong)

The corporations and their consultants such as BST and DuPont say that workers are the problem that needs fixing in order to have a safe workplace. They claim that the behavior modification of individual workers is the solution. In reality, unsafely designed, maintained and managed workplaces are the primary problem.

The best way to prevent injuries, fires, explosions and hazardous material releases is by fixing the workplace, not the workers.

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