Managing beyond zero: how to sustain an HSE IN THE LATE

Managing beyond zero: how to sustain an HSE
program near ultimate goal of zero incidents
By Kent Van Eaton and Curt Cranford, Grant Prideco
1970s, we can recall safety meeting discussions centered on the lost-time injury rate (LTIR). At the time,
we had never heard of total recordable injury rate (TRIR).
However, it didn’t take long until the LTIR became so low that
it was obvious an LTIR focus would not allow us to continue to
improve. We began to consider a broader spectrum of injuries.
So we took on TRIR as the indicator of success.
Over the last 20 years, we have made significant progress
in continuing to reduce injuries in the workplace. And, once
again, we’re reaching the point where analysis of incidents
producing recordable injuries no longer provides the information we need to reach our ultimate goal of zero injuries. It is
time to start managing beyond zero. It’s time to take a fresh
look, put new interest in what is happening in our workplaces
that can be corrected to stop every injury.
For most of us, the rallying cry used to achieve improvements
over the last 20 years was to “engineer the hazards out of the
workplace.” This was highly effective, and its application can
be seen time after time in almost every activity in the workplace, at home or in the community. This engineer-based technique will continue to serve us well, but we do not believe it
will get us to our ultimate goal.
An employee performs a peer-to-peer observation at Grant
Prideco’s drilling products division in Singapore. Peer-to-peer
reviews in this system of observation are requested by the person to be reviewed, not the person doing the reviewing, which
removes interpersonal relations and personal control issues.
The method we choose next must take into account two realities that have actually resulted from our success to date. First,
as we successfully apply the engineering-based approach to
reduce hazards, the hazards that remain become increasingly
difficult to distinguish, infrequent in occurrence and possibly
only momentary in existence. To battle these hazards, we must
strengthen our employees’ ability to recognize these less obvious situations that might hurt them.
The ability to see, envision, feel and sense the hazard must
be honed to the point that it is an actively conscious mental
process running in the background at all times. For example,
highly skilled athletes sometimes say “the game slows down”
for them as they rise to a high level of skill. It is this actively
conscious sense of the game that makes this “slowing” possible
at the same time the moment-to-moment details of the game
are actually getting faster.
The second of these realities can be seen in the pure mathematics of the calculation of TRIR. A TRIR of less than 2 means
98 out of 100 are not getting hurt. It is clear that a lot of people
are doing things right — but a lot is not enough. No one can
be left out. This means we must have an approach that builds
total participation to a meaningful level as a part of the plan.
First, we’ll focus on developing a sensitivity to hazards. The
ability to see the hazard may be thought of as awareness, or
a sense of awareness. Humans naturally have a keen sense
of awareness, but, over the years, as we have engineered
hazards out of our lives, that sense has become dulled. For
example, modern highway design has greatly reduced the
hazards of driving. Who would have thought we could take so
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A team performs a risk assessment — identifying the job steps
and the hazards associated with each step — at Grant Prideco’s
Reed Hycalog division in Singapore.
many hazards out of operating an automobile that we could
feel comfortable talking on a cell phone while driving at 65-70
mph? Similarly, in industry, proper machine design, guarding,
computerization, robots, ergonomics and other similar safety
engineering applications have made workplaces much safer
than 30-40 years ago. Fortunately, the dulling of our sense of
awareness can be reversed.
We are always uncomfortable with the term “awareness” — it
is greatly overused as the cause of all that is wrong in our
facilities. The operator was not paying attention; the employee
was careless; she did not have her mind on what she was
doing. Awareness or lack of awareness are used countless
times as the causation factor in many incident analyses. In this
article, we’ll use the term “seeing” rather than awareness. We
will discuss building a keen ability to “see” the hazards in your
workplace rather than to be “aware” of those hazards.
cally any situation, are easily communicated with simple
language, and can be the basis for the “seeing” techniques
discussed below.
A second concern is we’re making safety too complex. We
have hundreds of programs, all of which are meant to help,
but confuse the employee with buzz words and phrases. Here
are some examples: STOP, The 7 Habits of Hand Safety, CBIs,
Behavior-Based Safety, JSAs, JHAs, Cause Mapping, Systemic
Causation Analysis Technique, TakeTwo, SafetySmart, PHAs,
etc. All of these have value, but the point is that we need to
simplify the language. We must ensure that our employees
understand the continuum of our safety effort so they see how
the tools address the issue of keeping them from getting hurt.
There are great safety techniques and tools out there that you
can and should adopt. However, we must be careful to do so in
a systemic and well-communicated plan.
For developing the skill of “seeing,” we prefer to use a very fundamental technique that has been around for decades, but we’ll
use it in a different way. You may be familiar with the analytical
technique of classifying injuries, or potential injuries, into event
types (caught on, struck by, etc). We can take these events,
recast them as the hazards that can hurt us, and utilize them
as a simple and effective way to observe our workspace. Simply
put, we look for places in our workplace where we might be
caught, come into contact, strike, fall or overexert ourselves.
Suddenly, the vast world of ways things can go wrong or
ways I can get hurt reduce to five keywords – caught, contact, strike, fall, overexert. These are applicable to practi-
Here we will outline a system of observation techniques that
we developed. None of these techniques are new, but you may
have never associated them with techniques that utilize the
skill of “seeing” the hazards in the workplace. These techniques build employees’ skill of sensing the hazard, making
them increasingly capable of finding the danger before it
causes injury.
Technique 1: risk assessments
The fundamental baseline risk assessment is the most formal
of the set but is important to setting the stage properly for
sustainable performance, solid training and efficient operation. Risk assessment teams identify the job steps and hazards associated with each step. For this discussion, the job
safety analysis is the relevant portion of the risk assessment.
Using the five keywords (caught, contact, strike, fall, overexert) greatly focuses the work. For new processes still being
designed, it helps the developers to visualize the hazards. On
existing processes, it gives a common language and sets a consistent level of detail that people often struggle to establish.
Additional skill enhancement comes from diversity of “seeing.”
What I “see” teaches you to “see” different things, and what
you “see” teaches me. The most effective risk assessmentbased “seeing” development comes from a diverse team of
operators, engineers, management, maintenance and other
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experts. The insight of these stakeholders not only creates a
higher quality assessment but provides each team member an
opportunity to “see” hazards from someone else’s point of view.
Technique 2: workplace inspections
In formal scheduled workplace inspections, most of us use a
checklist or some other guidance to assist the people doing the
inspection. This activity is a wonderful “seeing” skill development process. We encourage people to inspect areas familiar to
them and areas that are not so familiar. This will improve their
ability to “see” more effectively. Many items on the inspection
checklist deal directly with the five hazards. For example,
are there hoses or cords across the walkway? This is clearly
related to the hazard fall. Other items may not be as obvious,
such as a fire extinguisher inspection. In this case, encourage
employees to connect the inspection with the hazard the equipment is protecting, in this case, contact with heat.
Technique 3: 5x5
The 5x5 is an informal risk assessment
for employees to apply when the nonroutine job or task comes about. These
non-routine activities contribute an
inordinate percentage of injuries as they
are generally unpredictable in timing
and short-lived in duration. Some piece
of equipment breaks down, some tool
is missing, something unusual happens
that creates a situation where employees are doing unfamiliar tasks in what
generally is a time-sensitive, high-stress
Yes, there is a risk of poor-quality reviews and buddy-buddy
protection, but it goes away when the employees see that management is not using the tool in a negative fashion. Peer-topeer reviews also develop trust between teammates that goes
far beyond safety and health issues.
We advocate using the JSA portion of the risk assessment
as our critical behavior checklist rather than creating one in
the tradition of the BBS process. If we are not capturing the
critical behaviors in our risk assessments, we are not doing
the risk assessment properly. That document should be the
standard way to do the job, and it should
define how to do that job safely. By using
the risk assessment in this way, we show
The 5x5 technique is to quickly think
consistence in our safety system, provide
through the task and ask yourself:
great training for employees, get a risk
How could I be caught? How could I
assessment audit, and get continual
improvement in the quality of our risk
come into contact? How could I be
struck? How could I fall? How could I
overexert? The exercise takes 30-60
seconds for beginners, but experienced employees can do it on the fly
while performing the job.
The 5x5 technique is to quickly think
through the task and ask yourself, “How
could I be caught? How could I come into
contact? How could I be struck? How
could I fall? How could I overexert?” These 5 questions are
the source of the first 5 in the 5x5. Going through the process
of asking the questions is the first of the second 5. Number 2
in the second 5 is “Why am I doing the job in this manner? Is
there a better way with less hazards?” Next, we dig deeper
into how I or someone else would be hurt. This leads to how we
are going make the hazard less likely to injure us. And, finally,
how are we going to protect others.
When employees first learn this technique, it is about a 60-second exercise. After a few tries, they can do it in 30-40 seconds.
Experienced employees find they can do it on the fly, so to
speak. They are going through the exercise in their head as
they approach the job.
Lastly, we use our normal system of
observation and reporting, using documents that have already been produced
for other processes, and we make use
of training that we do as a part of our
normal safety skills development. There
are no organizational requirements or
administrative needs beyond our regular observation process and system. The peer-to-peer reviews
are integral to work and blend into the daily activities on the
floor. They fit within the system, maintaining the consistence of
Technique 6: process audits
The process audit is the most advanced tool in the system,
but it is powerful and an excellent “seeing” skills enhancement technique. It complements the peer-to-peer view but is
procedure-focused rather than task-focused. It is also a team
process so a variety of viewpoints are in play.
The general observation process is the informal version of the
workplace inspection. Once again, we advise the use of the five
hazards to focus the “seeing” process. Where the 5x5 focuses
on a particular task, here the employees observe their environment and the activities and conditions within it. Using the
caught, contact, strike, fall, overexert method with it will direct
the “seeing” toward how you can get hurt.
In a process audit, a team of employees go to each department
or a cross-section of departments and audit a specific safety or
environmental process. They judge how well that department
is implementing and utilizing the process. Processes such as
lockout, welding and cutting, forklift safety, PPE, elevated work
and chemical handling are reviewed thoroughly. The procedure
provides the stimulus for what the team members are looking for, which allows the team members to become excellent
“seers” as they observe and interview employees during the
audit. Employees who are involved in the audit also benefit as
they point out the methods they use to carry out the procedure.
Technique 5: peer-to-peer reviews
This technique takes its roots from the behavioral-based safety
(BBS) observation process. However, it is designed differently
to overcome three distinct problems in the traditional BBS
This system of observation techniques offers a multitude of
approaches to train and educate employees and to rebuild the
natural ability to sense danger. The methods are both formal
Technique 4: general observations
observation process. Peer-to-peer reviews are requested by
the person to be reviewed, not the person doing the reviewing.
This reversal in approach removes issues related to interpersonal relations and personal control. The employee being
observed can ask anyone he or she wants to do the review.
Best buddy, worst enemy – they decide. They control when the
observation is done. They control which task is observed. This
control greatly reduces the fear and discomfort we have seen
in the original BBS approach.
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and informal, specific and general, task-oriented and processoriented, and individual- and team-based. The variety works to
enhance the overall “seeing” skills of the employee. It provides
interest and acceptability by offering control and variability
while building the same skill set. Yet, by using the five hazard
focus of caught, contact, strike, fall and overexert as the basis
of observation, the system remains consistent and comfortable
to the employees and supports what really counts to them –
not getting hurt.
Additionally, the system uses documents and other administrative systems already in use so there is minimal, if any, increase
in cost or resources.
Finally, using the five hazard focus makes the system simple
enough that everyone can contribute. There may be a need for
higher-skilled facilitation in the formal risk assessment, but
beyond that, anyone can do a reasonably good job evaluating if
there is a caught, a contact, a strike, a fall or an overexertion
hazard in front of them.
The second reality we identified is that although a TRIR of
less than 2 means a lot of people are doing things right, it’s
not our goal of zero incidents. To get there, no one can be left
out. Everyone must practice and hone their sense of danger. To
succeed, every employee must participate. Getting this to happen is the trick.
Before we try to generate participation, let’s step back
and look at principles of human behavior and performance
improvement research.
First is human behavior. Dr E. Scott Geller, a pioneer of
behavior-based safety, wrote that engaging people is facilitated
when they are in a positive state of mind, have clear goals and
feel empowered to achieve those goals. He speaks of creating
a sense of personal control and optimism. Next, set specific
goals that the person can clearly understand, are meaningful
and can be tracked. Now, provide a tool they believe will work
to achieve the goal, and they will get on board.
Dean Spitzer, in his recent book, “Transforming Performance
Measurement: Rethinking the Way We Measure and Drive
Organizational Success,” explains why performance measurement should be less about calculations and analysis and
more about the crucial social factors that determine how well
the measurements get used. He encourages us to ask such
questions as: How well do our measures reflect our business
model? How successfully are they driving our strategy?
So I asked myself: To get to zero incidents, are we measuring
the right things? I decided that, many times, we are. But we’re
not framing the measurements in the manner Mr Spitzer suggests.
We have already discussed a series of observation techniques,
many of which are surely already in use at your companies.
You might measure and analyze them, maybe even use them
for advanced leading indicators such as closure rate of actions
to address root causes of incidents or ratio of near-misses
to at-risk condition observations. But we can get more out of
these measurement if we can incorporate human behavioral
and performance improvement principles. We would like to
recommend a methodology for doing this that will get the high
level of participation needed to build “seeing” skills.
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The method is a system based on using a fully integrated
safety management system with an emphasis on proactive
activities to eliminating injuries. Its primary working tool is a
score card that tracks an employee’s participation in activities
defined by the management system. The goal is to provide a
system that motivates employees to get involved and take ownership in safety training and activities.
These activities include the previously discussed techniques
— general observations, 5x5’s, process audits, peer-to-peer
reviews, risk assessment reviews, workplace inspections, as
well as other proactive opportunities such as mentoring, individual safety plans, safety committee membership, safety and
toolbox meetings, and incident analysis.
It is also designed to encourage support of the system from
supervisors and managers, as the collective accomplishments
of their employees are measured as a component of their
achievement. This collective process is repeated up the entire
management chain, providing even the CEO with a score indicating his or her involvement and ownership.
The concept is that each employee has a score measuring his
involvement in HSE training and activities. Each employee
starts with a given score, say 65. They gain points by completing specific activities and lose points by violations of procedure
or failures to report.
Points are assigned to each activity, for example, completion
of training, attendance at safety and toolbox meetings, etc. A
higher number of points could be assigned to activities that
you might have a need to strengthen in order to encourage
involvement in those areas. A reduction in points is assigned
to specific violations, like failure to wear proper PPE or to
lock out equipment. No points should be assigned to an actual
injury or property damage to avoid the claim that disciplinary
actions are taken for getting hurt or damaging property.
Supervisors and managers gain/lose points based on both
individual involvement and involvement of their employees.
They gain points by leading their group to higher individual
employee scores and lose points on violations by their
Recognition is given to employees above 90 points. Additional
recognition might be given for those above 95, for example,
given a free pass that could be used if they have a violation.
Employees with scores between 80 and 90 are neutral, and
they are the beginning of non-participants. Focused effort and
communication with these employees should take place to
understand why they are not participating.
Employees with a score below 80 are placed on verbal notice.
If they fall below 70, a written notice is issued. If the employee
takes no action and his score goes below 60, he would be
placed on probation. An employee with a score below 50 would
be in serious risk of termination.
Employees gain points by doing proactive activities that
improve the performance of themselves, their colleagues and
the facility. The more advanced the activity or the more commitment required by the activity, the more points they earn.
Mentoring a new employee, for instance, might be worth 5
points. For quality control, a mentor might lose points if the
employee he’s mentoring has a violation.
For other activities requiring less effort and commitment,
points can be dependent on actions such as submitting “good,
quality” observations.
The point structure can be set to emphasize specific areas.
Maybe 1 point is given for every 2 near-miss observations rather than the 1-for-5 ratio for other kinds of observations. Or, if a
series of risk assessments is needed for a new process, you get
volunteers by offering double points for that month.
Points gained are good for one year from the date earned.
This keeps the score dynamic and requires employees to continue to participate. To keep employees from “loading up” their
scores with a flurry of activities in a short time then stop doing
anything, a limit can be set on the maximum number of points
that can be received in a given time period. You have almost
total control over the scoring tool so you can build it to fit your
The tool can be designed so that it cascades up through the
organization and helps to create a clear tie of group performance to the success of supervisors, managers, directors,
vice presidents, presidents and CEOs. For example, if a
supervisor’s group has an average score above 95, they get
5 points. If it is above 90, maybe they earn only 2 points.
Awarding points to the boss for group performance encourages that boss to support and promote participation by his
The tool is designed to motivate employees to get involved and
take ownership in their safety training and activities. However,
it also provides a standardized methodology for defining and
consistently applying the human resources group’s progressive
disciplinary response to HSE failures by employees, supervisors and managers. The beauty of the tool is that the employee
knows exactly how they can recover and avoid this negative
This tool also matches principles of building a positive state
of mind. All of the activities mentioned above can be done by
every employee given normal training. No one is forced to do
anything except accept the consequences of their own lack of
The loss of points in this system comes from violations or
failures to do what the employees know are required. Point
reductions are based on identified violations from observations, audits and the incident analysis process. All of our incidents are reviewed and analyzed to some degree depending on
potential, and violations are fact-based and specific.
Recognition is built into the system, and people and teams are
rewarded for doing well, so self-esteem is enhanced. Finally,
employees feel more and more optimistic about themselves,
their team and the facility as improvements become apparent.
Care must be taken when issuing point reductions so as to not
create distrust. A good measure to track is to strive toward
7-10 positive points for every negative point. The idea is to win,
not to lose.
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Point reductions, like point awards, are assigned with consideration of impact. More serious violations, such as making
safety devices inoperative, cost 10 points. Conversely, allowing
an at-risk condition to exist in your workspace would cost an
employee — and maybe their supervisor if he was aware of the
condition — 1 point.
Let’s see if we have met our original realities. First, we said we
need people to be highly skilled at “seeing” how they can get
hurt. We have outlined a series of observation techniques, all of
which develop the skill to “see” the hazards around us. Within
those techniques, we have given the employee the easy-to-use
5x5 tool. We have formal and informal, specific and general,
task-oriented and process-oriented, and individual- and teambased techniques. By using the five hazards of caught, contact,
strike, fall and overexert as the basis of all observation techniques, the system remains consistent and comfortable for the
employees and supports what really counts to them – not getting hurt.
Next, we realized we must have very high, almost total, participation by employees. The scoring tool provided uses the
principles of human behavior to accomplish this. It is a Specific
Motivational Achievable Relevant and Trackable (SMART) way
to increase individual involvement and ownership of employees
in safety training and activities. There is clear guidance on
what to do to achieve success and recognition. Participation by
every employee is required in order to maintain their acceptability to the organization. But they are in control of that participation, therefore make the choice for themselves.
We have used guidance from performance improvement leaders to ensure that our measurement system is less about calculations and analysis and more about the crucial social factors
that determine how well the measurements get used. The process focuses on learning and improvement from measurement
yet also ties directly to the strategy we are trying to drive.
We are placing increasing importance on measuring leading
indicators that are proactive and preventative and reducing
our reliance on the measurement of lagging indicators such
as injury and property damage. Additionally, we have the right
people having the right measurement discussions about things
that affect them on a daily, even moment-to-moment, basis.
Our task was to develop a very high, almost total, participation
by our employees who are highly sensitive to nearly invisible
hazards. Have we done it? We think we are well on the way.
A full version of this article is available online at www.drilling
About the authors: Kent Van Eaton and Curt Cranford are HSE managers for Grant Prideco. Mr Van Eaton holds a BS degree in chemical engineering from the University of Tennessee. He has 24 years of
experience in HSE in the petrochemical, energy, specialty chemicals,
pharmaceuticals and building materials industries. He received his
Certified Safety Professional certification in 1991. Mr Cranford holds
a degree in chemistry from Kansas State University. He is an environmental, health & safety professional with over 20 years of experience
in the energy and manufacturing sectors and has also worked as a
principal consultant assisting companies in many industry sectors.
He holds several certifications, including certified hazardous materials manager and registered environmental manager.
This article is based on a presentation at the IADC Drilling HSE Asia
Pacific Conference & Exhibition, 26-27 February 2008, Kuala Lumpur.
March/April 2008