Process Safety – The Heinrich Model of Behavior

Catastrophic incidents happen to safety-conscious people for the same reason some children get pulled alive from a collapsed building–the law of probability. At any given time, place and situation some people will be lucky, others not. However, while we can’t ensure good luck, we can significantly reduce how much luck we need. How? By considering the nature of risk, risk literacy and applying the underlying principle of Heinrich’s triangle.

If the odds of someone working at height being momentarily distracted while not clipped on and falling are 100,000 to 1, and this applies to 10,000 workers once a week, then we will lose about five workers every year. The wider the bottom of the triangle, the wider the top becomes. Halve the base numbers, halve the incidents.

Either way, though, it’s easier to predict numbers than names. If we do lose five workers in this way, then over a 10-year period most will be those who take the most chances, but a couple will be those who took very few.

Experience doesn’t necessarily help. Fear provides adrenaline-directing attention and focuses the mind. However, exposure to any environment will increase complacency and reduce fear.

Although we should encourage employees to be alert, this has an upper limit due to limitations on concentration, which varies depending on the current task. Tired, stressed, hungover, or slightly over-confident, and it’s likely to be worse.

The best strategy is to move the task up the safety hierarchy by designing out the risk, e.g., replacing all high windows with self-cleaning ones. Instead of reminding workers to “be careful where you stand,” whenever possible, make it impossible for them to stand in a dangerous position.

In some cases a design solution isn’t possible, but we should check and avoid getting comfortable with a “standard risk.” Thinking it’s “just part of the job” is the enemy of continuous improvement.
This leads to Heinrich’s principle and the need to defend a common criticism: Proactively working the triangle bottom means behavior. However, we all know that a conversation that starts: “Can I talk to you about your behavior?” rarely ends well!

Over-simplistic programs work from the principle that, as culture is in essence “the way we do things around here,” then a focus on front-line behavior is a culture change program. If that’s the extent of the program, then the criticism is justified.

We shouldn’t just focus on PPE, line-of-fire and slip/trip issues. What about supervisor behaviors such as toolbox talks and board-level strategy meetings?

It can’t be stressed enough that a cultural approach must address these high-level activities. Many don’t, however, and often even the most well-meaning observation and intervention-based behavioral programs irks workforce representatives.

The famous “one minute manager” stresses how we must get out and about and “catch a person doing something right” to praise, reinforce, and embed that behavior.

Used stand-alone and with the tone slightly wrong, it’s easy to recall that classical conditioning started with Pavlov and his dogs – “sit, wait, roll-over … good boy.”

Quoting Heinrich: “No matter how strongly the statistical records emphasise personal faults or how imperatively the need for educational activity is shown, no safety procedure is complete that does not provide for the correction or elimination of physical hazards.” Indeed, emphasizing this aspect, Heinrich devoted 100 pages of his classic work to the subject of machine guarding.

A key reason even safety conscious and experienced workers get hurt is they work in a culture where management spend their efforts encouraging the workforce to “be careful” (or worse–behave!) rather than analyzing the cause of the behavior and designing it out.

It wasn’t that BP Texas City pursued an active strategy to keep process safety under control through a low LTI rate; they simply sleep walked into a vulnerable position because they took undue reassurance from strong personal safety scores. That’s just a lack of holistic risk literacy.

Similarly a major cause of Piper Alpha was that the permits were signed off blindly. However, offshore permits require housekeeping are acceptable before they can be submitted. Analysis of the housekeeping would have highlighted a weakness in the permit system. A patchy safety culture manifests itself in many ways, but all come from the same primary source.

In his study of Texas City, Andrew Hopkins described a culture in which only good news travelled up. Despite cuts, assurance was taken from LTI that rates remaining low. The behavioral safety team there didn’t cause the explosion – the culture of aggressive cost cutting, sloppy thinking, and poor listening at the very top did.

Only the day before the Macondo explosion in the Gulf of Mexico, there was a VIP site visit that covered falls from height thoroughly. Again, this conversation didn’t cause the explosion, it was the VIPs skipping straight past the critical process safety issues about pressure readings with an “Everything OK?” question that begged a “Yes, boss” response.

The safety culture had many strong aspects, but there was a blind spot regarding process safety caused by an absence of incentive levers (present for production and personal safety). The mindset was robust questions about process issues suggested a lack of trust (it “just wasn’t done” – which is the very definition of a culture).

Drilling “kicks” are a good example: on the Deepwater incident, though personal safety was well monitored, nobody was really monitoring the likelihood of a blowout. In hindsight, it’s alarming that few companies collected data either about the number of “kicks” they experienced or the speed with which they are identified.
In-depth conversations are much harder than PPE checks, that’s why they happen less often. It takes more effort. However, as Hopkins said, it makes no sense for experienced managers to chat only about personal safety and miss the opportunity to “deep dive” into process safety.

Halving poor handovers, weak communications,
simplistic decisions, or mindless “tick-box and file” audits will reduce the number of process safety incidents too. Heinrich’s basic underpinning principles remain the same:
Analyse and act.