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                                                   A Proven Process Improvement Model      33


                            process as a top priority throughout the organization. Ideally, the develop-
                            ment and implementation of improved safety management processes should
                            be driven by top management. Top management leadership helps assure that
                            sufficient resources are available for implementation and thus increases the
                            probability of favorable recognition for performing the required work.
                               Nevertheless, lack of a clear upper management mandate to implement
                            an improved incident prevention process should not be an insurmountable
                            barrier for the supervisor who desires improvement. In fact, it is relatively
                            common in companies of all types and sizes to find organizational units
                            within the company that are “islands of excellence.” In these units, the lead-
                            ership and commitment of the supervisor is at such a level that achievement
                            of outstanding results is not dependent upon the boss’s strong, visible sup-
                            port. These managers find a way to implement an improved safety process,
                            because it is simply “the right thing to do.” Supervisors and managers at
                            each level of the organization need to recognize that they are considered
                            “top management” by their subordinates, and each level of management
                            must assume a strong leadership role.
                               Application of the serious incident prevention process model ensures
                            that management’s investment of time and resources will yield the desired
                            results.

                            Element 2: Involve Employees

                               Full employee involvement is essential to leveraging the organization’s
                            limited resources, capturing vital employee knowledge, and facilitating em-
                            ployee ownership of the process. The full benefits of employee involvement
                            are achieved only when employees have leadership roles in all aspects of de-
                            veloping, implementing, maintaining, and improving the serious incident
                            prevention process.
                               The process model provides effective techniques for leveraging the
                            power of employee involvement in accomplishing the work required to pre-
                            vent serious incidents.


                            Element 3: Understand the Risks
                               Success in any endeavor requires knowledge of potential risks. Without
                            a firm understanding of the risks, pitfalls are identified only after they
                            occur, a “fly-crash-fix-fly” cycle.
                               With the nonroutine nature of serious incidents, the focus must be on
                            what can happen rather than what has happened in the past. The argument
                            that a unit has been operating 10 to 20 years without problems must be
                            granted only limited consideration in evaluating the potential for a future in-
                            cident. Past incidents involving Flixboro, Bhopal, and the  Exxon Valdez
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