In Measuring Safety Part 1, we reviewed the drawbacks of focusing solely on the measurement of safety outcomes absent understanding and tracking operational processes and events that are predictive of a safe workplace. In Part 2 of the series, we are going to dive deeper into the implications of this thinking by reviewing “Serious Injury Fatality” (SIF).
Serious Injury Fatality (SIF) – Breaking it down
The concept is not new. Workplace fatalities have been the object of preventive corporate policies and regulatory scrutiny for decades. Before my interview with Todd Conklin during Pre-accident podcast, however, I had only seen the abbreviation of “SIF” online.
Being an avid reader and learner, I began my Google search on the SIF-phenomenon which revealed many sources on the topic: White papers, several documents by Fred Manuele, and a YouTube video for learning on the subject. Though my search was not an exhaustive literature review on the SIF subject, it did provide enough reading for reflection, with better questions and new thoughts to share on the topic for discussion.
If you are where I started my Google search, you are most likely unfamiliar with SIF as a subject matter onto itself. To start your learning journey, I suggest an easy introduction through this SIF Clip on YouTube by Dominic Cooper.
If you are familiar with SIF, we invite you to share your knowledge and thoughts in the comment section below.
During my learnings, I became concerned that it was not only being positioned as a “New Paradigm” but also as a new panacea for the safety professional. I developed a more nuanced opinion.
From my readings, I have come to understand that SIF emerged over the past decade because it was identified that while incidents leading to minor injuries have shown serious improvements, accidents leading to serious injuries and fatalities have shown less. This phenomenon was counter to Heinrich’s dictum that attacking minor accidents would cascade upwards to reducing major accidents. In practice, this was found not always to be the case.
Interestingly, these insights are from individuals who promoted and sold a form of Heinrich’s triangle for years, with behavioural programs based on a theory that preventing slip, trips, and falls would then prevent blow-outs. They were now finding that it, in fact, did not do so in every case.
Part of their studies included Donald K. Martin’s and Alison A. Black’s Preventing Serious Injuries & Fatalities paper, where seven multinational corporations that contributed cases with the conclusion that companies need to change their ways to prevent these fatalities. The creation of a new program to implement was borne into the safety world of measurement. It contained four components:
- Educate on the new model,
- Measure SIF as a category onto itself,
- Develop processes to identify and mitigate precursors, and
- Integrate with existing safety systems.
Is SIF our new Safety Panacea?
Many questions remain. To begin, is new insight and study necessary? When looking at Figure 4 in the Preventing Serious Injuries & Fatalities paper, one may wonder if it looks as ‘alarming’ when you draw both lines on the same scale. This is a slightly suggestive presentation of numbers.
Further, we can answer the question by breaking it down into several discrete queries:
- How reliable are the numbers? One would expect fatality numbers to be more reliably recorded than less serious accidents.
- How does the ‘trend’ look from a larger historical perspective? For example, what if we started examining trends from pre-1993.
- What about changes in larger contexts? Consider technological developments, access to markets and learnings from former Soviet bloc countries, and the movement of production to low labour cost countries.
- How about the problem that it becomes harder to improve something the better it is? Reviewing the leveling of the fatality rate in Manuele’s 2013 paper, it is undoubtedly easier to move from 10 to 8 than it is from 5 to 3.
This brings us to a larger question: Is SIF really new?
Returning to Heinrich’s work, it is worth reflecting on the application of the Triangle in practice versus challenging the theory itself. Because the Safety Triangle has become part of mainstream safety practice, it may be worth considering adding to the framework and thinking through its practical application versus discarding it and attempting a new, more complex framework.
Andrew Hale’s paper on the subject in the early 2000s offers a nuanced discussion of the subject. His conclusion states: “We should not think in terms of comparing major and minor injuries, but of understanding accident scenarios. We should compare completed and uncompleted accident sequences.” In other words, we need to stop comparing 125 strained ankles to 11 fatalities. Start to step back to look at the scenarios. Then you might use observations of slippery surfaces and uneven stairs to prevent the former, and irregularities in your drilling process to prevent the latter.
Erik Hollnagel shares in his book “Barriers and Accident Prevention” this corrected interpretation of the Triangle. Instead of waiting for a serious accident or fatality you have many prior frequent opportunities to learn. These opportunities are also less costly than the accidents themselves because the experience is direct and the consequences smaller. There is one important condition, however: “In order for this approach to be effective, it is necessary that the study is confined to the minor incidents and near misses that are directly related to accidents at the top of the pyramid”.
SIF corrects some of the problems related to the traditional interpretation and application of Heinrich’s Triangle including the belief that reporting past outcomes will somehow be predictive of future prevention. The SIF approach includes a variation of the Safety Triangle by looking at processes and events that did have serious injury and fatality outcomes and those incidents without serious outcomes that nonetheless had the potential to lead to these terrible outcomes.
The SIF framework is a clear improvement from the traditional collection of all incidents followed by a simple sorting based on severity of outcomes. Still, I believe it does not go far enough because this still does not distinguish in terms of scenarios and thereby can hinder more effective preventive measures. In my next Blog post next month we will have a look at some other challenges.