Page 182 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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Reinforcement and Corrective Action 151

Organizations should always strive to implement fail-safe practices.
When conducting incident investigations it must be recognized that the
identification of human error is a beginning point for the investigation, not
the ending point. Evidence from incident investigations supports a conclu-
sion that serious incidents are more often the result of error-prone situations
or conditions rather than error-prone people. When errors do occur they are
quite often related to human conditions that are extremely difficult to con-
trol—i.e., short-lived mental states, such as preoccupation or distraction,
and errors of omission that the employee did not intend to make. 7
From a practical perspective, avoidance of many problems will remain
dependent upon the prudent and disciplined actions of individuals at the op-
erational point of control. Prior to loading hazardous materials, for exam-
ple, tank car loaders must ensure each tank car bottom outlet valve is fully
closed. Such basic requirements are part of the fundamental performance
expectations for tank car loaders. In this situation, like many others in the
workplace, precise action is needed on a repetitive basis to avoid high-con-
sequence events.
Failures to close bottom valves prior to starting flow should be ad-
dressed through the organization’s coaching process. The focus must be
on making tasks and conditions less error-prone and on employees help-
ing one another to develop safer work habits through behavioral-safety
techniques. However, managers must also recognize that some individuals
are less suited than others for performing repetitive work without errors.
Thus, individuals who have been coached but retain a tendency to start
flow without closing bottom valves should be isolated from safety-sensi-
tive jobs.
Corrective action, like reinforcement, is important in maintaining the
constancy of purpose required to sustain serious-incident-free operations.
The first objective of corrective actions should be to achieve inherently
safer operations through changes that are not dependent upon perfect ad-
ministrative or operating systems for success. Employees with active own-
ership of the incident-prevention process and managers who maintain a bias
toward constructive improvements, rather than fixing blame, are factors that
promote implementation of effective corrective action. When the potential
consequences of performance failures are severe, the focus must be on im-
plementing solutions capable of withstanding the passage of time. Effective
management of the serious incident prevention process requires the appro-
priate integration of both positive reinforcement and proactive corrective
action into the workplace environment.