Capturing Warning Signals to Prevent Accidents

Three Preventable Major Accidents

I was in South Korea over the Halloween weekend this year and woke up to the tragic news of the Crowd Crush Accident in the Itaewon District of Seoul.

The outcome of the event was devastating with a total of 156 dead and many more injured. Almost all the victims were teenagers or in their twenties, and two-thirds were women. All with their life ahead of them.

With my work focused on preventing severe injuries & fatalities, my first question was is if this was an incident that could have been prevented.

What is striking with the Itaewon accident, as well as many other tragic accidents, is the signals provided in advance of the event. Based on the available news reporting, there was a call made to the police already around 18.00 on October 29th saying that there were too many people in the narrow streets of Itaewon and warning that an accident could happen. The police received 10 similar calls during the evening, the last coming in at 22.15, just before the start of the crowd crush. Why didn’t these calls lead to more police resources being sent? Why was the crowd control process, which South Korea is very good at, not being deployed?

There are many possible responses to these questions, the calls might have been received by different operators with no system in place for consolidation, or maybe there was a reluctance to move resources away from the political demonstration happening at the same time in other areas of Seoul. These questions will be investigated, and measures put in place to ensure that next time the response will be different. For the young people that died, and their families and friends “next time” provide little consolation.

Looking at other large accidents, the pattern is the same, with many signals available, but not sufficient actions are taken to prevent the accident from happening. Take, for example, the Beirut Port Explosion in August 2020, where 218 people died and 300.000 became homeless. In this case, authorities had received repetitive warnings about storing ammonium nitrate in an urban area and the risk of an explosion but had not acted. Was the lack of action a question of how and by whom the warnings were transmitted? Or were there maybe unclarities in roles and responsibilities? Despite huge press coverage, it is still unclear, at least to the broader public, why the ammonium nitrate wasn’t moved to a safer location.

In the BP Deepwater Horizon Explosion and Oil Spill in 2010, 11 people died and 17 were injured. In addition, 780.000 m3 of oil was discharged into the Gulf of Mexico making this one of the largest environmental disasters in world history. BP ended up paying more than $60 billion in criminal & civil penalties and other costs.

The same day as the accident happened, BP and Transocean (owner & operator of the rig) executives visited the oil rig to celebrate a safety record, 7 years of operation without any lost time injuries.

In the case of the Deepwater Horizon accident the warning signals were not as clear cut as in the Beirut Port explosion or in the Itaewon Halloween crowd crush, nobody had called or made a report to say that the probability of an accident was high. Instead, there were many smaller warning signals that were ignored or misunderstood.

The investigation after the accident also concluded that groupthink and lack of psychological safety prevented people from speaking up.

The Itaewon crowd crush, Beirut port explosion, and BP Deepwater Horizon are all terrible accidents with enormous press coverage. Each one has had a significant impact on how health and safety is managed in the public space and inside organizations.

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Capturing Warning Signals to Prevent Accidents

People involved in Health & Safety know that most accidents are possible to prevent, when searching the internet the number that comes up is that 99% of accidents are preventable. In an organization as well as in society, the ambition needs to be to develop processes and systems to rapidly 1) capture warning signals, 2) transfer warning signals to the appropriate organizations, and 3) take action on the warning signals. The actions then need to be 4) verified to ensure that the intended results are achieved. The better these processes are executed the more accidents will be prevented.

Imagine knowledge about incidents as an Iceberg. Fatalities and serious injuries are known throughout the organization. The actions taken to prevent the same from happening again are many times shared and, hopefully, implemented throughout the organization.

A large portion of the Incident Iceberg is below the waterline and not visible. Here resides the knowledge about what happens in the daily operations, minor injuries, unsafe conditions, unsafe acts, and near misses, i.e., pre-accident warning signals. This knowledge is dispersed among individuals. The more of this knowledge that can be transferred to organizational knowledge, the more preventive actions can be put in place and the fewer injuries an organization will experience.

The challenge is how to move a maximum of dispersed knowledge to organizational knowledge.

Having had the opportunity to work with many organizations which have implemented pre-accident warning systems the aim of this article is to discuss the main areas that need to be addressed when creating a pre-accident warning system and how to avoid the most common mistakes.

From Where are the Warning Signals Coming?

The first thing to think through is the sources of warning signals. With technological development many of the early warning signals today, and even more in the future, will come from technology.

It is easy to imagine that crowd build-up will be detected by technology in the future and allow timely crowd control measures to be put in place to avoid incidents such as the Itaewon crowd crush. In the case of the Beirut port, the explosion might have been possible to avoid if fire/heat detection, alarm, and sprinkler systems, the technology available today, had been used. For the Deepwater Horizon case, technology already provided early warning signals showing the build-up of pressure below the oil rig, but these signals were ignored.

Another important source of information is people. In public spaces, people providing pre-accident warning signals can play a key role. In organizations, mobilizing the employees in the quest to identify and report minor injuries, unsafe acts, unsafe conditions, and near misses will have a very significant impact on identifying risks and preventing accidents.

This article is focused on leveraging the knowledge of the organization’s employees.

1. Employee Hazard & Near Miss Reporting Program

Putting in place a pre-accident warning program in an organization can be structured as an Employee Hazard & Near Miss Reporting Program including reporting of unsafe conditions, unsafe acts, and near misses. ?If these are not acted upon, they can lead to severe injuries/fatalities or environmental damage. This type of program is built on the willingness of employees to contribute. To make this happen employees need to experience psychological safety, i.e., whatever they report will be valued by their supervisor and the overall organization. Under no circumstances should employees receive disciplinary actions for reporting.

A psychologically safe work environment takes time to create and to begin with it is important to show early adopters of the program that the organization appreciates their contribution.

Here the individual supervisors play a critical role; to encourage reporting, taking action on the reports, and recognize the employees reporting. Middle and top management involvement in the recognition process is also key to getting the program off the ground and sustaining it.

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2. Taking Action on Employee Reporting

The employee reporting process adds a lot of value in itself; it makes employees significantly more aware of the safety hazards around them and it also increases individual accountability since many of the hazards can be removed by the reporting employee.

Despite this, any employee reporting system that doesn’t include a disciplined follow-up will fail. The first reason for this is that a portion of the hazards reported will not be possible to resolve by the employee himself, for these cases the expectation of the employee is that someone will quickly take action and remove the hazard. If this is not happening, employees will become disengaged and not continue to report.

The second reason it is essential to have close monitoring and follow-up of the employee reporting system is that it is a “treasure trove” for the organization to know what hazards are encountered by its employees. This is new knowledge that provides essential input to an organization’s risk management system. Removing the hazards that employees can’t resolve themselves, will continuously lower the overall risk in the organization.

In addition, we need to verify the relevant Risk Assessment considering the new knowledge. Did we miss something in the Risk Assessment? Do we need to expand/modify the Risk Assessment? Tying the Incident Management process to the Risk Assessment process creates a Continuous Improvement Loop.

I’ve seen two distinguished models for the follow-up of employee hazard reporting. One is when all the reports go to the EHS Manager / Officer, and this person is responsible to take action on the hazards not removed by the employees themselves. This model can work in small organizations or when each site has an assigned EHS person.

The second set-up is when the reports go to the employee’s immediate supervisor. The immediate supervisor then takes action or contacts the appropriate people in the organization so that action is taken.

I believe that an organization should have the ambition to implement the second model.?Employee safety is the responsibility of the supervisor and having a constant safety dialogue between employee and supervisor via employee hazard reporting will further strengthen this accountability.

In the second model, the EHS organization also needs to be closely involved in employee hazard reporting, particularly in identifying and acting on high-impact hazards. A high-impact hazard is a hazard that could, if not acted on, lead to severe injuries/fatalities or serious environmental damage.

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3. Providing Feedback to the Reporting Employee

Above we discussed the importance of employees feeling that their contribution via employee reporting is valued by the company. One way of accomplishing this is by providing the employees with both individual and collective feedback.

The individual feedback would be in the form of a thank you for hazards reported and resolved by the employee. For hazards that need others to take action, it is essential that the employee is informed about what action has been taken and the outcome of that action.

The collective feedback could be done in the immediate workgroup with a review of all the hazards reported and a discussion of the actions taken. Other ways to provide feedback could be through a monthly Newsletter providing an overview of hazards reported and the actions that have been taken.

4. Broad Safety Sharing Throughout the Organization

In larger organizations with many sites, it is essential to put in place a process to share the hazards & near misses reported and injuries that have occurred together with corrective actions taken. The reason is to spread the lessons learned at one site to all other sites and employees in the organization.

Often the preparation for the sharing of hazards and injuries is done by the central EHS group and distributed electronically or via announcement boards to the employees. A best practice is then for supervisors to pick up the safety shares and discuss them with employees during toolbox/pre-shift safety meetings.

To be manageable this process requires filtering, not all hazards, near misses, and minor injuries would add value being shared to all sites. Often the filtering is done based on if there is a risk for severe injury or if there is important guidance to share with employees to avoid future accidents.

In addition to the safety shares going to all employees, an effective process is for the operational managers to discuss the root cause(s) of the high-impact hazards, near misses, and injuries and what is being put in place to prevent these from happening again. It is important to have a process in place to verify that the corrective actions have been put in place at all the organization’s sites.

Recently I worked with an organization that through hazard reporting discovered that several bolts holding the overhead crane in place had become loose. There was a high probability that the overhead crane would fail under load, with very serious potential consequences to employees (and property). This unsafe condition was shared with all the organization’s sites and each site was asked to check its own overhead cranes. It turned out that two other sites had the same problem.

The organization’s overhead cranes are all inspected annually by an external, certified inspection company and verified each quarter internally, despite this thorough approach, the crane bolts at three sites were loose which meant a serious safety risk. The employee hazard reporting combined with corrective actions and a good safety-sharing process allowed this safety risk to be removed. To ensure that the same issue will not happen again, the quarterly inspection process has now been amended with a crane bolt check (before this step was only included in the annual external inspections).

5. Employee Hazard & Near Miss Reporting Processes and Systems

The launch of an employee reporting program requires good preparation. Hazard and Near Miss reporting & Management processes need to be developed. In organizations with many employees having an IT system with both reporting and workflow functionality is required.

It will be easier to engage employees in the reporting if there is an easy-to-use reporting system (e.g. Mobile App) with the possibility to attach photos/videos to explain the issue. Avoiding free text fields and favoring pre-populated categories will both enable the data analysis and make it easier to fill out for employees.

When the employees have done their reports, they should arrive automatically to the supervisor. If the employee has already removed the hazard and if there is nothing else to be done or discussed, the supervisor will close the case. On the other hand, if action still needs to be taken, the supervisor either takes action or forwards the case to the appropriate entity. The workflow system should ideally include escalation capability, i.e., if the supervisor hasn’t taken any action within a defined time, the case would be sent to the immediate manager (this usually is enough for the supervisor to take the required action). Another very important system capability is the feedback loop to the employee, if the system automatically provides the employees with feedback about the supervisor’s action, a lot of manual work is avoided.

Most systems would have an analytics module that would automatically consolidate the employee hazard and near-miss reporting metrics, e.g., how many reports, what type of reports, the number of reports still open, etc.

With a large volume of hazards and near misses reported it is also possible to do data analyses and identify weaknesses in the overall health and safety system.

The employee reporting process and IT system need to be developed with input from employees/managers and piloted with a small group of employees before the full launch. This allows potential issues to be fixed together with a smaller group and avoid the broader organization from potentially being disengaged by a process /system that is having multiple issues.

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6. Program Launch

Having a good launch plan and flawless execution of the plan will increase the chances of rapidly getting the reporting system off the ground.

A key success factor is to engage with all levels of management/supervisors in advance of the full launch to ensure their support and full buy-in.

I’ve seen several organizations launching employee reporting programs without engaging the direct supervisors in advance. Omitting this step very likely leads to a less-than-optimal launch and put the success of the program in jeopardy.

Doing a hazard recognition workshop with supervisors/employees as part of the launch is very beneficial. Often people working in the same environment every day get so used to the hazards around them that they do not notice them anymore. Therefore, spending ? day to first discuss what hazards could be present in the operations and then actually going out and looking for actual hazards is often an eye-opener. Commonly participants in this type of workshop think that we will find a handful of hazards and are surprised to see that the actual number of hazards found is significantly higher.

7. Governance and Objectives

To be successful with any program or initiative within an organization, strong governance is essential.

For the Employee Hazard & Near Miss Reporting Program the governance entails deciding on what KPIs (Key Performance Indicators) to capture to measure the success of the program. For each KPI an overall target needs to be set and then broken down to managers, supervisors, and, for some KPIs, individual employees.

A key KPI for the program is how many hazards/near misses the organization wants to have reported by month/year. For someone that has yet to start working with an Employee Hazard Program having a target for the hazards / near misses can seem a bit strange and the question “Do you not want to have all hazards/near misses reported?” might be asked. The answer is yes, we would like to have as many hazards / near misses as possible reported and removed. The reason we need to set a target and break it down by group/employee is human nature and the fact that “what gets measured gets done”.

My recommendation is to break down the overall target to, at least, the supervisor level. Depending on the culture of the company and the part of the world where you operate, it might be appropriate to provide each employee with an objective for hazard / near-miss reporting and to measure if they have achieved this objective by the end of the period.

Some other interesting KPIs to follow is the how quickly “open” hazards are being closed and how many and what type of High Impact Hazards are being reported.

As discussed at the beginning of this article the objective of the hazard and near-miss reporting program is to increase employee engagement and to remove hazards to decrease the risk of severe injuries and fatalities. The increase in employee engagement and the constant dialogue around safety between employees – supervisors – managers, and leadership will gradually improve the organization’s safety culture. It is possible to measure this improvement in Safety Culture by doing surveys with employees. This can be done either by dedicated Safety Culture Surveys or by including a set of safety questions in the Employee Satisfaction / Insight Survey. The improvement in Safety Culture scores together with a decrease in minor & major injuries will be important indicators of the success of the Employee Hazard & Near Miss Reporting Program.

The KPIs selected for the Employee Hazard / Near Miss Program need to be made visible, discussed, and actioned throughout the organization. This requires dashboards available on different levels of the organization and shared through announcement boards in each facility. The Program and its KPIs need to be presented and discussed at all-employee meetings, department meetings, and workgroup meetings.

To get traction with the employee reporting program it might be a good idea to put in place additional recognition, e.g., an incentive program following the program launch.

The incentive program can either be individual, e.g., monthly recognizing the individual that reported the most hazard on a site with a small gift, or team-based e.g., inviting the workgroup to have the reported the most hazards for a team dinner. For the incentive program to be effective it needs to be well communicated, the rules need to be clear, and recognition provided frequently (monthly or quarterly).?The program and the results need visibility and discussion at the leadership level. To further increase employee engagement, it is important that the leadership shows that they care about the results with regular follow-ups and support if the intended results are not achieved.

Summary

Many serious accidents could be avoided if better pre-accident warning systems were put in place and the warning signals acted on in a structured and disciplined way.

This is the case for accidents impacting the public like the Itaewon crowd crush in October 2022, the Beirut Port explosion in August 2020 & the BP Deepwater Horizon oil rig explosion, and gigantic oil spill in April 2010. This is also true for accidents happening inside our organizations and impacting our employees.

The pre-accident warning system can take the form of Employee Hazard & Near Miss Reporting Programs. This type of program both increases the safety engagement and accountability of employees and removes hazards that could lead to severe injuries and fatalities. The Employee Hazard & Near Miss Reporting Program is therefore an important building block in any strategy aiming to improve an organization’s safety culture.

Designing a successful Employee Hazard & Near Miss Reporting Program is challenging and requires well-thought trough and executed processes, systems, and a launch plan.

The main areas to consider when launching an Employee Hazard & Near Miss Reporting Program are:

• How to encourage employees to report
• The roles and responsibilities of the direct supervisors, managers, and leadership
• Management of corrective actions
• Feedback loop to reporting employees
• Set up safety sharing throughout the company
• Selecting KPIs, setting targets, and monitoring.
• Governance through breaking down the targets to the workgroup/employee level. Regular reviews and rapid actions if desired results are not achieved
• Process design, system selection, and set-up, initial pilot, and full roll-out

Many organizations spend a significant amount of time developing and deploying Employee Hazard & Near Miss Reporting Programs without establishing governance and metrics. The probability of these programs being successful is low. Safety needs to be managed as any other important business, with disciplined governance and clear objectives at each level of the organization.

A well-managed Employee Hazard & Near Miss Reporting Program will significantly improve an organization’s safety culture and reduce injuries and incidents.

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