As a safety professional, you are or will be engaged in the process of solving safety management system problems for your employer or client. It's important to have a general understanding of the basic steps involved in acquiring adequate skills. This module will look at the basic steps in problem-solving and some proven techniques to efficiently and effectively solve your organization's safety management system challenges.
Solving Safety Problems
Solving safety-related problems centers around two key strategies:
Solving surface-cause problems. Eliminating/reducing unique hazardous conditions and unsafe work behaviors representing the surface causes of accidents.
Solving root-cause problems. Improving inadequate or missing safety and health programs, policies, plans, processes, procedures, and practices representing the root causes that contribute to hazardous conditions and unsafe behaviors.
1. Solving safety-related problems centers around which two key strategies?
a. Solving surface-cause and root-cause problems
b. Reporting hazards and behavior problems to management
c. Having a zero-tolerance and total commitment approach
d. Removing affected workers and controlling hazards
As with any process, there are a number of required steps involved to ensure a successful outcome. Let's examine the five steps every problem solving task should involve.
Step 1: Understand the problem
Describe the observable/measurable conditions and behaviors. They represent the "signs and symptoms." of the problem.
Determine the nature of the problem. For example, the problem may involve inadequate leadership, poor management, or defective equipment.
Determine the scope of the problem. Does it affect individuals, groups, departments, the facility, the company, or the industry?
Write a descriptive problem statement. Problem statements should be operational. That is, they should be expressed using measurable/observable terms. For example; "There has been a 50% increase in the number of strain/sprain injuries in the warehouse over the last six months." The group must reach a consensus on the problem statement.
Determine priorities. If more than one problem exists, which one should we solve first? It's important that the group, not an individual, determine the most important problem to work on.
Step 2: Discover the cause(s)
Analyze the problem. Break the problem down into component parts. Some simple techniques: Circle key words. Accident investigation - Develop a sequence of steps.
Ask questions. Ask who, what, where, why, when, and how to get to the source or root cause of the problem.
2. Which of the following is a descriptive problem statement?
a. We have seen a number of OSHA violations
b. We must reduce the number of injuries this year
c. Unsafe behaviors are occurring due to lack of common sense
d. We have had a 50% increase in the number of injuries this year
Develop specific primary and alternative solution strategies. Focus on elimination/substitution, engineering controls, administrative controls, or personal protective equipment to correct corrective actions.
Focus on improving the system. Revise written programs, policies, plans, processes, procedures, and practices to improve the safety management system.
Determine resources and responsibilities. Physical and human resources will be required for most corrective actions and system improvements.
Design specific primary and alternative solutions. Developing alternative corrective actions and system improvements will give management choices and a feeling of control over the outcome.
Establish appropriate timelines. The sooner, the better, of course, but it may be impossible to correct or improve immediately in some instances. Generally, you might promote the following schedule: Serious impact - immediate or as soon as possible. Minor impact - within 30 days.
Step 4: Sell the solution
What is an effective recommendation? You'll learn more about submitting a recommendation that "sells the fix" in the next module. When recommendations are not acted upon, it may be that the supervisor does not have enough information to decide and act right away.
To speed up the process and improve the approval rate, the presenter should anticipate the supervisor's questions. The more pertinent the information you give, the higher the odds are for approval.
3. Why should you develop alternative solutions when proposing recommendations?
a. Alternatives give management choices
b. Alternatives make your solutions look good
c. Alternatives give you the control, not management
d. Alternative solutions are always better
Your work in problem-solving is not done once you have gained agreement on the solution. In fact, your problem(s) may just be starting.
Implementing solutions to safety management system problems requires an understanding of change and transition.
Change. Change is external. Change may involve a new boss, new procedures, or new products. The change will not succeed unless each affected employee transitions internally.
Transition. Transition originates within each affected employee. It's a psychological process of adapting to externally imposed change. It involves changes in thinking, beliefs, behavior, and performance.
According to William Bridges, Managing Transitions, there are three phases of transition that all employees must complete before a successful change can occur:
Phase One - Letting go. Ending the old order. Unfreeze old behavior. Acceptance.
Phase Two - Adapting. Searching for a new identity. Limbo. Neutral zone. Learning new behaviors.
Phase Three - Grabbing hold. A new beginning. Refreeze new behavior. Acceptance.
4. Which of the following terms is defined as an internal psychological process of adapting to externally imposed change?
Developing solutions to surface cause problems may occasionally require different tools and techniques than those required to solve root cause problems. So, let's review the problem-solving tools and techniques that help address surface causes and then shift gears to discuss problem-solving for root causes.
But first, let's look at the following scenario and use it as the context within which we will discuss problem solving in each of the two areas. Carefully read the following accident scenario and
then reference it to answer the questions that follow:
Unguarded rotating drum with nip points.
Bob was a new hire employee working as a clean-up person in the finish department of XYZ, Inc's particleboard plant.
On his first day of work, he received an initial classroom orientation on company policies from the personnel department.
He was also introduced to his new supervisor, who gave him a walk-around tour of the plant.
Since his supervisor didn't have time to fully brief Bob on his new job, he was then given some simple initial duties to accomplish.
He was busy cleaning up around the floor under the return belt of a conveyor connected to a large piece of machinery and noticed a jammed piece of wood. He removed a guard covering pinch points on the conveyor belt and reached in to remove the wood.
Bob's glove got caught in the return drum nip point, and he was drawn into the machinery. Bob's hand was severely injured and required surgery.
XYZ, Inc. has a mod rate of 1.5, which is worse than average for the industry. Unfortunately, this incident was not a total surprise to the company. Most of their OSHA 300 Log recordable accidents have resulted from injuries to employees within their first six months on the job.
What's a MOD Rate? The Experience Modification Rate (MOD) compares a company's workers’ compensation loss (claims) experience with other companies of similar size and type in the same industry within a state. The MOD rate reflects a company's safety record and affects its insurance premium.
If the MOD Rate is higher than 1.0, the employer's accident experience is worse than expected. Insurance premiums will be higher than the average for similar companies within the industry.
If the MOD Rate is below 1.0, the employer's experience is better than expected. Insurance premiums will be lower than average for companies in the industry.
Watch the NCCI video above to get more information on MOD Rates. Just remember, your goal is to get that mod rate below 1.0!
5. What does a company's experience modification rate (MOD Rate) of 1.5 indicate?
a. The company's workers' compensation claims experience is better than average
b. The company's accident frequency record is higher than normal
c. The company's workers' compensation claims experience is worse than average
d. The company's injury severity record is worse than normal
Getting the Facts: Who-What-Where-When-How Analysis
Good analysis will uncover the roort causes.
This traditional analysis technique is primarily used in accident investigation to determine the accident's surface cause(s). Surface causes are the unique conditions and behaviors that contributed to or caused the accident.
The technique simply asks a series of initial who-what-where-when-how questions to determine the basic facts. The questions that ask who, what, and how are the most important to discover the surface causes of accidents. When used with the 5-Why analysis we'll discuss in the next section, you'll be able to identify root causes.
Click on the buttons below to see examples of each of the question types.
Who is getting hurt? Are individuals or groups getting hurt over and over, and is it the same kind of injury?
Are only new employees getting hurt?
Are forklift and truck drivers having accidents?
Are most of the accidents happening to our younger or older workers?
Is there an obvious trend that tells who is getting hurt?
What actually caused the injuries? This question looks for the
basic cause of the physical trauma to the body. This might be best answered
determining trends in the following accident types:
Struck by: A person is forcefully struck by an object. The force of
the contact is provided by the object. Example: Struck by a falling object.
Struck against: A person forcefully strikes an object. The person provides
the force or energy. Example: Running up against a wall.
Fall from elevation: A person slips or trips and falls to a level below
the one he or she was walking or standing on. Example: Falling over the edge while shingling the roof.
Fall to surface: A person slips or trips and falls to the surface he
or she is working or standing on. Example: Fall due to slippery floor.
Contact with: A person contacts a harmful substance or material. The
person initiates the contact. Example: Contacting electricity.
Contact by: Contact by a substance or material that, by its very nature,
is harmful and causes injury or illness. Example: Acid splashes on a person's
Caught on: A person is somehow caught on an object that is either moving
or stationary. This may cause the person to lose his or her balance and
fall, be pulled into a machine, or suffer other harm. Example: A person
is dragged into a machine because loose clothing is caught on a conveyor
Caught in: A person is trapped or otherwise caught in an opening or
enclosure. Example: A person's arm is stuck in a printing machine when
it starts up and causes injury.
Caught between: A person is crushed, pinched, or otherwise caught between
a moving and a stationary object, or between two moving objects. Example:
Person is crushed between moving crane and wall.
Bodily reaction: Caused solely from stress imposed by the body's free movement or assumption of a standard or unnatural body position. Example: Person bends over to plug in a tool and strains back.
Over-exertion: A person over-extends or strains beyond the ability to lift,
lower, push, pull an object. Example: Person strains back while lifting
Over-exposure: Over time, a person is exposed to harmful
energy, such as noise, heat, toxic chemicals, or hazardous atmospheres.
Example: Person loses consciousness due to lack of oxygen.
Where are workers getting hurt?
Are they getting hurt while doing their regular job, or are they working for another department when they get hurt?
Are workers getting injured more in certain departments or workplace areas, like the maintenance shop or on towers?
Are workers only involved in accidents in particular facility locations, like the warehouse, high traffic areas, or the parking lot?
When are workers getting hurt? Look for trends if employees work in shifts.
A particular time of the day. Early or late in the work shift?
A particular day of the week. Mondays? Fridays?
A particular week of the month. Just before payday? Last production
A particular month of the year. December?
A particular quarter of the year. Last fiscal quarter?
A particular season of the year. Just before hunting season?
A particular business cycle. Just before annual report?
How was the worker injured? This question is directed toward hazardous
conditions and unsafe work practices.
Were hazardous materials, tools, or equipment used?
What personal protective equipment was the worker not using?
Are work shifts too long?
Were workers using unsafe practices?
Are workers getting hurt as a result of factors within or outside of work?
Are workers getting hurt as a result of factors the employer controls, or can't control?
6. Which of the following is an example of over-exertion?
a. A person strains his shoulder when trying to lift a heavy object
b. A person loses consciousness due to a lack of oxygen
c. A person bends over to plug in a tool and gets dizzy
d. A person is splashed by acid on the face
This technique is used once you have asked the who-what-where-when-how questions we discussed in the previous section. In this technique, we list each of our analysis findings, and then we continue by asking "why" at least five times for each of the findings. Doing this will help us eventually arrive at one or more root causes contributing to the accident.
Let's apply the who-what-where-when-how analysis technique to an accident summary statement to determine surface causes and then use the 5-Why analysis to determine the accident's root causes.
Finding: Bob, a new hire in the finish department, was injured as he attempted to remove a jammed piece of wood from a conveyor belt under a large piece of equipment.
Who got hurt? Bob, a new hire.
Why? Bob was the only worker available to do the job. Why? The shift was understaffed. Why? Management has reduced staffing. Why? Sales have decreased in the last two quarters.
Why? Increased competition.
What was he doing? Removing a piece of wood jammed in a conveyor belt.
Why? Bob thought it was his job, and his supervisor expected it. Why? Bob was not properly trained or briefed by the supervisor. Why? The supervisor did not train or properly brief Bob. Why? The company does not have electrical safety training, machine guarding safety, or lockout/tagout procedures.
Why? The company does not have a formal safety training program.
Where did the accident happen? Within energized equipment in the finish department.
Why? The wood had jammed the conveyor within the energized equipment. Why? The wood had slipped through the side of the belt into the pulley system. Why? The conveyor system does not have adequate guarding along the length of the system. Why? The conveyor system is has been used for 40 years and did not have proper guarding when purchased.
Why? Guards were not mandated by standards when purchased.
When did the accident happen? At 3:00 am on the mid-shift.
Why? That is when the wood became lodged in the conveyor system. Why? The equipment was not being monitored during the mid-shift. Why? The mid shift was understaffed. Why? The company has difficulty hiring workers for the mid-shift.
Why? Employees receive no incentives for working the mid-shift.
How did he get hurt? His hand was caught and pinched by an incoming nip point on the moving conveyor.
Why? The conveyor was in operation when Bob attempted to remove the wood. Why? Bob did not perform lockout/tagout before removing the guard and reaching into the conveyor belt area. Why? Bob did not realize he needed to deenergize the equipment before removing the wood. Why? Bob did not receive machine guarding, electrical safety, or lockout/tagout training.
Why? The supervisor did not ensure Bob received proper training before the assignment.
As you can see, the first set of questions get at the surface causes for the accident. Once we know what directly caused the injury or illness, we begin to ask why to arrive at the root causes. Remember, each time a why-question is asked, a deeper root cause is uncovered. To get to the deep root causes, ask why at least five times.
7. What is the purpose of the 5-Why analysis?
a. To properly identify those at fault
b. To discover the surface causes
c. To determine the root causes
d. To comply with OSHA requirements
Mind Mapping, or "Instantaneous non-linear cognitive deduction utilizing spatial forms in a two-dimensional plane." (huh?) Seriously, mind mapping merely draws circles and lines to help you quickly think about and categorize ideas, problems, concepts, subjects, and just about anything else. Mind mapping is successful because it takes advantage of the brain's natural ability to categorize ideas quickly in an unorganized manner.
Look at the mind map to the right. At the center we write the problem. Next, think of the factors that are more obvious causes for the problem. This works best by letting your subconscious do the work while you watch TV or work on another project. Next, take a look at each factor listed and ask why the cause exists.
Using this technique, you will be able to take any topic, project, or problem and quickly determine related categories of processes, procedures, topics or events.
Click to Enlarge
Once the mind map is complete,
it is merely a matter of reorganizing the information into the more common "outline" format.
Another tool similar to the mind map is called the Fishbone Diagram or "Cause and Effect Diagram. Basically, it's just a mind map using a different form. The diagram illustrates this. The
"Effect" describes the problem. Possible causes are listed under one of several categories that you determine. Generally, these categories might be people, materials, equipment, environment,
methods, or procedures.
8. In the fishbone diagram above, the head of the fish represents the effect, and the bones represent the ________.
a. possible solutions to the effect
b. possible causes of the effect
c. factors that identify the effect
d. factors that prevent the effect
You are probably familiar with this problem solving technique. Brainstorming can be used by individuals or groups quite successfully to quickly develop a list of possible solutions to problems. There are six basic and unalterable rules for brainstorming that set it apart from other problem-solving procedures. They are:
Define the issue. Make sure everyone is clear on the problem you are going to brainstorm.
Critical non-judgment. Defer judgment on any idea that is expressed. This even includes encouraging comments to others or qualifying phrases attached to your own suggestions.
Organized chaos. The session should be as freewheeling as possible, with each person voicing whatever ideas come to mind - - no holds barred. Ideas may be expressed in a rapid, machine-gun fashion. Don't limit creativity.
Similar originality. Participants are encouraged to hitchhike or piggyback on the ideas of others. When one person's suggestion sparks an idea by another, it should be instantly
expressed. Lots of "ah-ha's"...
Quantity, not quality. The more ideas, the better. The goal of brainstorming is to get as many ideas as possible. Evaluation and elimination can be accomplished later.
Brief summary statements. Don't go into great detailed explanations of your idea. You want the recorder to have time to write down all ideas as team members think
9. Which of the following is NOT one of the six primary rules of brainstorming?
a. Clearly state the problem
b. Go for quality, not quantity
c. Defer judgment on ideas
d. Piggyback of the ideas of others
The survey is an excellent problem solving tool to help identify the perceptions of many employees. What they perceive is their reality, so it's important to understand what they think. Safety committees and coordinators can gain valuable information about the safety management system with this technique. To help ensure the survey is effective, do the following:
1. Gather a team. Best if led by trained employees.
2. Determine who you are going to sample. All departments should be represented. Randomly select from three groups: managers, supervisors, and employees.
3. Decide how you are going to conduct the survey. Keep it simple and confidential. Use computer software or manual system.
4. Tell everyone why you are conducting a survey. This is a critical step. Explain clearly. Express the importance of the survey. Explain who is involved, what the survey is about, how it is being administered, and why it's important.
5. Conduct the survey. The key to high participation is a quick response. Honor confidentiality and reward participation.
6. Summarize the results. What are the perceptions of each of the three groups: managers, supervisors, and employees?
7. Meet directly with the top decision-maker to discuss the results. This helps reduce misunderstanding and is more likely to get top management buy-in. It also bypasses gatekeepers who might revise the results or prevent the results from being heard.
We've discussed a sampling of some common problem solving techniques, but there are many others available that can help you and the safety committee quickly arrive at solutions to apparently complicated problems that might surface. We want to encourage you to continue to explore all available methods.
10. Why is it important to discuss the results of a survey with the top decision-maker?
a. Increase personal power
b. Less likely to get top management support
c. Takes less time to get results
d. Bypass the gatekeepers who might revise results
Check your Work
Read the material in each section to find the correct answer to each quiz question. After answering all the questions, click on the "Check Quiz Answers" button to grade your quiz and see your score.
You will receive a message if you forgot to answer one of the questions. After clicking the button, the questions you missed will be listed below. You can correct any missed questions and check your