One of my pet peeves in safety is emergency egress lighting.  From not having any to having some serious deficiencies in the setup and functioning of the lighting.  OSHA has failed to establish a minimum lighting intensity for this emergency lighting.  OSHA has established the brightness for EXIT signs, but when it comes to the egress path lighting OSHA has not QUANTIFIED its minimum...

“Very few unsafe acts will result in damage or injury. In a highly protected system, the probability that the consequences of an isolated action will penetrate the various layers of defense is vanishingly small. Several causal factors are required to create a ‘trajectory of opportunity’ through these multiple defenses. Many of the causal contributions will come from latent failures in the organizational...

The Entry Supervisor is an ABSOLUTE CRITICAL PATH in safely performing entries into PRCSs.  With that said, if entry supervisors simply attend the same training that everyone else attends, we have FAILED them.  We were asked to assist with a 2012 PRCS fatality incident where the abject failure of the facility to train its entry supervisors was undoubtedly the root cause of the tragedy. ...

What is an Injury & Illness Prevention Program (I2P2)?  It is a very basic, 8-element, safety management system (SMS).  It is OSHA’s attempt to fundamentally change from the complaince model to an SMS model to manage workplace safety and health.  OSHA has been talking about I2P2 for nearly 20 years and has faced relentless pushback from the industries.  But it is time...

We hear it all the time… “yes of course we have a safety management system.”  Then we ask one simple question, “can we see your OSH auditing plan for the year/3-years/5-years?”  The most common response we get is “OSHA does not require us to conduct overall workplace audits.”  That is true and it is also evidence that the facility does NOT have...

In his 1990 paper, The contribution of latent human failures to the breakdown of complex systems Jame Reason presented us with three classifications of organizations.  As usual, his work and results were spot on!  The three (3) categories are: Pathological organizations Calculative organizations Generative organizations When we read these descriptions, as well as what Westrum (1988) provided...

As the “safety culture” debate rages on, I came across this 2019 research paper that I found to be spot on.  Of course, those are my biases shining through as I believe all organizations have a culture; in fact, they will have multiple cultures.  So I am not one who subscribes to the idea that organizations do not have a “safety culture”.  I like to use the phrase...

At 3:00 p.m. on August 18, 2022, an employee entered an empty liquid propane gas (LPG) tank for servicing at an industrial equipment wholesaler facility. Earlier in the day, the employee approached a supervisor and stated that he wanted to enter the tank to spray a penetrating oil product on an internal valve to loosen it overnight so it could be worked on the next day. The supervisor told the employee...

There are many concepts related to the science and practice of human factors. However, from a practical standpoint, having a unified view of what we should be concerned about is most helpful when considering aviation maintenance human factors. An excellent way to gain this understanding is by using a model. For over a decade, “PEAR” has been used as a memory jogger, or mnemonic, to characterize human...

The HFACS model was designed to be a classification tool rather than a predictive tool. However, since its initial development, there has been a lot of interest on whether it can also be used as a predictive tool. That is, can it be used to inform us about which factors in preconditions for unsafe acts, unsafe supervision, and organizational influences predict factors within unsafe acts? A major assumption...

I posted an article today @ SAFTENG explaining his accident pyramid model and discussing some of his Domino model. This quote is his own words trying to use the lottery to explain his pyramid model. I think it is a very fitting analogy. “The machine is dangerous as man makes it so. It is the use of the machine—more correctly, the abuse of it—that creates danger. Nor is the appalling degree of...

Another article defending the work of H. W. Heinrich, Assistant Superintendent Engineering and Inspection Division, The Travelers Insurance Company.  I feel the need to explain how many have misstated Heinrich’s Accident Pyramid in this article.  His Accident Pyramid is probably his most famous piece of work and by far what most attribute to his work.  But in recent years, his...