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Selling safety in a risk taking culture by shifting the focus of safety management....

March 1, 2006  By Pulp & Paper Canada

Selling safety in a risk taking culture by shifting the focus of safety management.


Non-routine work – Paper Mill Maintenance


Fatalities, such as the one outlined in the PPHSA Industry Alert bulletin (see sidebar), are rare events these days in Canada’s mills. What is so devastating to this mill’s morale is that it has an excellent sustained safety record. This case is a classic example of the conflicting messages that safety performance incident statistics can deliver. How can a mill with a total recordable (medical cases) rate of close to world-class performance of one or less, still have a fatality? This example is becoming more the rule than the exception these days. Enterprises continually reduce overall recordable incident rates by reducing high frequency/low severity types of accidents by working with the large amount of root cause data compiled from investigations of such types of incidents. However, they seem helpless when it comes to stopping the high severity/low probability accidents for which there is very little documented causal data.

Global Problem: Fatality and severe injury reduction is stalled

Occupational health and safety experts around the world are perplexed by this problem. In the June 2005 issue of Occupational Health and Safety magazine, U.S. safety expert Fred A. Manuele reported:

“From 1973 to 2001, according to the National Safety Council’s Injury Facts, 2003 Edition, the total occupational injury and illness rate for private industry dropped 50 percent — from 11.3 to 5.7. In the same period, the incidence rate for Total Lost Workday Cases (lost time injuries) decreased only 18 percent — from 3.4 to 2.8 (p60).

Significant data pertaining to occupational deaths also can be found in Injury Facts, 2003 Edition. From 1992 to 2002, the death rate per 100,000 workers dropped from 4.2 to 3.6, only a 14 percent reduction; the number of deaths has remained fairly constant — 4,965 in 1992 and 4,900 in 2002 (p49).

In several organizations with which I have been involved in the past few years, the incidence rate for lost work days with days away from work has leveled off, or increased. Also, the number of fatalities in some of those organizations has increased. As an indication of concern over the occurrence of serious injuries and fatalities, ORC International, an entity with a membership of about 125 of the Fortune 500 companies, has formed a task group to study the causal factors for such incidents.

And in another article in the February 2003 issue of Professional Safety titled “Severe Injury Potential” Manuele asks:

“Can Serious Injury Potential Be Identified?

To a considerable degree, the answer to this question is yes. One can identify the types of work which produce many accidents that result in serious injury; then, the relevant hazards in that work can be addressed on an anticipatory basis. Although data in support of this premise is limited, it is persuasive. For example, in the second edition of Safety Management, Dan Petersen wrote:

“If we study any mass data, we can readily see that the types of accidents that result in temporary total disabilities are different from the types of accidents resulting in permanent partial disabilities or in permanent total disabilities.

Effecties or fatalities. The causes are different. There are different sets of circumstances surrounding severity. Thus, if we want to control serious injuries, we should try to predict where they will happen. Today, we can often do just that. Studies in recent years suggest that severe injuries are fairly predictable in certain situations.”

He describes some of those situations as invovling:

* unusual, nonroutine work; (in both production and/or non-production departments)

* nonproduction activities;

* sources of high energy;

* certain construction situations.

These are just a beginning point. A long list could be made which would more extensively specify the areas where severity is predictable.

The author remembers two additional excellent examples of high-severity, low-frequency fatalities in the early 1980’s.


Non-routine work – Paper Mill Maintenance:

In the early 1980s, at a northern Quebec mill, a mechanic, trouble-shooting a paper machine winder drive jam, was killed when he fell through a slot in the floor under the winder into a running broke beater. The slot was covered by a sheet of aluminum (bib) to prevent the broke beater from splashing wet pulp on the sheet on the winder. He had done this diagnostic work before but for some reason did not take proper precautions to lockout equipment (beater) and cover the broke slot in the floor. At the coroner’s boisterous televised inquest into the fatal incident, the mill safety coordinator was crucified by the coroner in front of 100 or more spectators as being incompetent because he had not identified this slot as a hazard. The coroner recommended to the Crown that the company be charged with criminal negligence. Preliminary hearings before a judge for admissability of the coroner’s allegations established that at numerous companies paper machines at this and other mills belonging to the company, no one, including line employees and winder operators, ever identified this slot in the floor as a major hazard. This, despite a card-based hazard reporting system available to all employees for this purpose. The judge dismissed the criminal neglicence charges as being unfounded. At this point the author realized that hazard identification was a job for the entire workforce (all employees) and not just a few safety specialists. However, employees need to develop the skills and practices to be able to detect hazards on a daily basis. Also, if simple, effective pre-task planning and risk assessment practices had been used by maintenance technicians for maintenance work, including maintenance diagnostic and trouble shooting work, this tragedy might have been prevented.


Unusual, Non-routine work – Sawmill Production:

In the early 1980s, at a sawmill near Mont Joli, QC, another fatal accident occurred at an unloading dock where tree length wood was being unloaded from trailer trucks by a caterpillar type of clam crane. Trees were removed by the crane and dropped into a boomed pond in a river and floated over to a jackladder on the other side of the river to feed the sawmill. There was only enough room for one truck to be unloaded at a time by the crane at the edge of the river. The crane was positioned at the rear end of the truck trailer. It would swing the clam 90 degrees from the truck to the river, drop the trees in the river and then swing back to the truck. A second loaded truck waited nearby for its turn to unload. When the unloading truck was empty, the driver pulled away to allow the next loaded tractor-trailer to back in for its turn. This is where the routine changed in this incident. The driver of the empty truck could not start his vehicle’s engine. He stepped out of the truck to advise the crane operator (over the engine noise) of the problem. He told the crane operator that he would get the waiting loaded truck to pull him out by attaching a tow chain to his stalled tractor from the rear end of the loaded truck. Once attached, the tow attempt started but the chain, very short in length, slipped off and the towing truck stopped. The space between the two tractor-trailers was only three or four feet. The crane operator, believing that this was not going to work, decided he would advance the crane and push the stalled vehicle out of the loading area. What he did not see was that the towing truck had backed the few feet in to the stalled vehicle so its driver could re-attach the tow chain properly. As he bent to attach the chain again, the stalled vehicle driver was crushed between the t
wo trucks as the crane made contact with the stalled vehicle.

Predictible high severity situations:

The three cases cited above are all representative of the the so called predictable situations for high-severity injuries described by Dan Petersen. They all involve high energy sources (hydraulics, heavy material handling equipment, moving machinery, electric motors and beaters). They all involved either unusual, non-routine maintenance work (Cases 1 and 2 ) and/or routine production work (Case 3) that was interrupted by a breakdown that changed the routine or a “best practice.”

OHS Management Systems are not perfect:

Over the last 20 years, global thinking on safety has stressed the theory that accidents are caused by inadequate safety management systems for detecting and eliminating hazards at the source of their creation. This is fine in theory but the reality is that it works to some degree, but not totally. The conclusion is that there is no such thing as “zero” risk at the point of risk where the worker interfaces with the workplace and the task-at-hand. There is always some residual risk that remains (either residual or newly introduced by ‘at-risk’ behaviour, whether voluntary or involuntary). This is not to say that OHS Management Systems (OHSMS) are ineffective and should be rejected. They are, in fact, effective – but are not perfect – due to economic, technical, administrative, practical and other reasons. What OHS Management Systems need is better feedback from line employees who are closest to the risks as to the types of system failures that are occurring, in order to be able to correct these failures and continually optimize the OHSMS.

Ideally, safety management sytems would provide the upstream filters to detect and remove all hazards before they reach the point of risk where the line employee interfaces with the task to be performed. However, in reality, it is very difficult for even the best of safety management systems to foresee and plan for every such situation. All of the best job safety analyses and inspections and standard procedures developments are not going to filter out every one of these unforeseen situations. These are system failures. Those hazards that leak through the filters are known as residual hazards. In addition, many hazards are introduced downstream from these filters or right at the time the task is being performed. Supervisors are not going to be present 100% of the time to observe residual hazards/ risks and/or at-risk behaviours, or to coach safe behaviour by the employees who perform the tasks.

“When experienced workers are involved in accidents, it is common to think ‘he should have known better.’ This apparent paradox may affect the nature of both product design and workplace safety training, the authors state, concluding that ‘the only truly viable long-term strategy for increasing workplace safety lies in combining normal safe design, guarding and warning strategies with the fostering of an increased understanding among workers of the actual risk involved in their activities.'”- Packer Engineering, Professional Safety, September 2004.

So what’s the remedy?

This leaves a last option to permit safe work with residual hazards present — one that we call “goaltending” by the line employee(s).

First, all line employees have to become better at residual hazard detection and planning the tasks they perform (the point of risk or man/work interface) to ensure safe and productive execution. In particular, they must become skilled at adjusting to the unusual. Those are the sudden changes in the work situation and task, whether working alone or as teams when no supervisor is present. These employees need to become knowledgable in performing rapid risk assessments and safe task planning so that they can control the new hazards introduced into the task at hand, a form of on the spot change control, without necessarily stopping the work, which will always remain as the last resort. Management’s responsibility is to provide the continuous commitment, support, training, resources, encouragement and, above all, the opportunity for this to happen, in good times and bad. This initiative puts risk assessment activity much closer to the point of risk where it is performed by those closest to the risk and who are probably best positioned to detect it.

Second, the eyes of every single employee are needed to detect hazards, not just those of a limited number of safety and technical experts. These experts would be put to best use by releasing them to focus on the detection of those high risk hazards that the line employees do not have the expertise to recognize. On a daily basis, line employees could feed back information on unfiltered hazard (system failures) that they detect so that the upstream safety systems or filters can be corrected and over time reduce hazard detection/control burden at the point of risk. This residual hazard burden would be considered a very efficient, real time indicator of safety performance, especially if it declines drastically over time. It would be extremely useful in providing feedback for continual improvement to the elements of the OHS Management System.


These initiatives stand an excellent chance of improving the control of high severity/low probability accidents at the point of risk by line employees until that magic day when OHS Management Systems are perfect at removing every single possible hazard before they reach the point of risk.

John E. Little can be reached at jelittle@videotron.ca

Copyright PPHSA 2005, All Rights Reserved

The purpose of this industry ALERT is to promote safety, reduce accidents, and is for information purposes only. Although the description of circumstances is real, this PPHSA Industry ALERT does not reflect legal commentary nor is it meant to assign legal responsibility to any person or firm.

Photo(s) & Incident Report submitted voluntarily.

For further information please contact PPHSA.

P: (705) 474-7233 / F: (705) 472-8250


Draining of a Hydraulic Cylinder Proved Fatal

The following is an extract from an Industry Alert issued in August , 2005, by the Pulp and Paper Health and Safety Association (PPHSA) of Ontario concerning a fatal accident which occurred in a Canadian mill:

A worker was fatally injured while assisting tradesmen to isolate and drain a hydraulic cylinder that was part of a series of four cylinders used to move wood chips in a chip storage bin.

The cylinder was isolated from the other three by removal of the hoses from the hydraulic oil feed lines. The feed lines were capped to prevent oil from draining from the rest of the system. Plugs were loosely fitted to the cylinder hoses to prevent the spray of oil while draining the remaining oil from the cylinder. The remaining three cylinders were then activated to retract the extended piston from the isolated cylinder and to drain the oil. The plugs provided enough resistance to allow pressure to build within the cylinder and hoses, causing the threads on the loosely fitted plug and fitting to fail. The hose suddenly recoiled as the pressure released — striking the worker — and resulting in fatal injuries. The investigation uncovered that the hydraulic systems create tremendous pressures and restrictive devices such as plugs can restrict the flow of fluid causing the system to be stressed to failure.


Restrictive devices such as plugs or caps must not be used to control the discharge flow of hydraulic oil when attempting to drain or stroke a hydraulic cylinder. The fluid must be allowed to flow freely without restriction.

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