Revisit Heinrich Triangle and apply TQM principles for world-class safety - NEW

What do our injury rates tell us? Should we expect recordables to repeat themselves if we stay the course? Why do anything different if our recordable rates are consistently better than the industry average?

Unfortunately, a well-performing 1,000-employee site industrial manufacturer — with perennial recordable rates of under 0.7 — learned the hard way after three fatalities within six months. Your safety culture — whatever condition it’s in — isn’t something that takes care of itself.

It’s one thing for a company to plateau after consecutive years of strong performance, but it’s quite another to hit the wall with three fatalities. It can happen to any company. But how?

With the benefit of hindsight, the easy answer is that the company had been lulled into complacency by the appearance of good safety performance based on “downstream” injury data. But after extensive investigation, the company found a less visible defect: a safety culture that often said one thing, but did another. There was also an “acceptable level” of injuries, most of which happened to be minor. Despite thorough root cause analyses and the implementation of corrective actions after every incident, the numbers never really changed.

The organization found that nearly 60% of the minor injuries could easily have been major incidents with only a small change in circumstances. Worse yet, about 30% had the potential to have been fatalities with similar minor situational variations. It became clear that the “downstream indicators” fell short in the manufacturer’s ability to effectively manage safety. The downstream indicator-focus lulled them into a fatal safety culture flaw . . . complacency.

Ultimately, the manufacturer concluded it had too many unseen variables and circumstances — too many potential risks that went unnoticed. After all, its only criteria for safety performance were downstream indicators — with the lion’s share of emphasis on the recordable rate.

Revisiting the Heinrich Triangle
Enter the “Heinrich Accident Triangle,” the diagram used to point out that many unsafe acts and conditions lead to numerous minor injuries, which lead to a lesser number of major injuries, which — based on the law of averages — inevitably lead to a fatality. Not only does the triangle give us a fatalistic perspective on the probability of severe injuries, it smacks of surrendering to the forces that be . . . and accepting the status quo.

What can we do?
Let’s break it down by starting with the base: the foundation beneath the injury triangle. It has to be solid, fully fortified with compliance programs, observations, mechanical integrity, and new employee training that’s carried out correctly, credibly, consistently, and with appropriate frequency. The manufacturer with the three fatalities had all of these items in check. They addressed them well and were proud of their OSHA knowledge. The company also addressed extraordinary risk circumstances such as open flame and potential energy require special care (e.g., supervised burning permits, supervised lock out/tag out, etc.). So far, so good.

If you’re already looking at what gets built into the foundation, good. To incorporate even a little bit of a safety-culture approach, it’s necessary to look at the realities in the work place that can’t be observed. Ask, What’s “inside the head” of all those involved? Do front-line workers believe in our processes? Do they feel our approach to protocol and processes protect them and keep them safe? Are the company precautions sufficient? Do your foundational safety processes go well beyond the standards of compliance and observation systems?

As long as you’re asking the tough questions, you’re headed toward a safety performance level that delves beyond the regular activities, the visually apparent, and rules-based safety. You’re nearing a culture of world-class safety — where management, supervisors, and employees have a wider view of safety and understand how it impacts the overall success and condition of the company. The shift to safety accountability and its well-thought-out, value-added, frequent safety activities and responsibilities is a gigantic step toward a safety culture transformation.

Involvement and buy-in can make or break a culture in transition. Safety accountabilities and a culture transformation without involved people at all levels isn’t enough; a vibrant the sustainable evolution depends on buy-in from upper levels of management, continuous improvement teams, and total quality management mechanisms (e.g., Six Sigma).

Continuous Improvement Teams
Similar to the world of manufacturing process control, companies are increasingly adopting a wide range of checks and balances, activities and reports, and metrics and rewards. These are the mechanisms that enable safety improvement teams to address a particular area for improvement: the idea is to completely flesh out safety processes that will eliminate hidden causes of injuries. All levels of personnel are involved in developing the solution . . . therefore, all have buy-in and ownership. This is not a “drop in” solution like compliance training. Instead, it’s developed, owned and “lived” as a minute-by-minute, day-by-day way of doing things. It’s part of the organization’s DNA stake in safety.

One key lesson in understanding how to break through your safety performance plateau is to revisit the Heinrich Triangle. When you do, remember to eliminate the unsafe acts and conditions by utilizing the rock solid foundational process of continuous improvement teams, which get people involved. This is what it takes to eliminate all the potential errors before becoming an inevitable part of Heinrich’s probability “build up.”

According to a 1988 Univ. of Minnesota “safety culture” study led by Dan Petersen, Ph.D. and Charles Bailey, Ph.D., there are at least 20 statistically validated safety management processes that must be solid (if not error-proof) before an organization is able to achieve a lasting zero-incident safety culture (see list below).

The 20 Safety Categories as measured by CoreMedia Safety Perception Survey:

Accident Investigation Goals for Safety Performance Quality of Supervision
Alcohol and Drug Abuse Hazard Correction Recognition of Performance
Attitude Towards Safety Inspection Safety Climate
Awareness Programs Involvement of Employees Safety Contacts
Communication Management Credibility Supervisor Training
Discipline New Employees Support for Safety
Employee Training Operating Procedures

There’s no reason to wonder if the recordable rate will remain good — or lucky. It’s imperative that companies identify and carry out a systemic approach that works for them … as long as it empowers employees with safety-culture ownership. Just as the quality revolution focused on eliminating chance errors from the product equation, you can use the same principle and approach to remove chance injuries from your organization’s safety culture.

Michael M. Williamsen, Ph.D., is director of consulting services of CoreMedia Training Solutions, a Portland, Ore.-based safety products and services company. Williamsen has more than 30 years of business change management experience with companies such as Frito-Lay Inc., General Dynamics and Standard Oil. He earned his Ph.D. in business from Columbia Southern University.

For more information about CoreMedia and its safety culture solutions, go to or call 800 537-8352.

CoreMedia Training Solutions
1771 NW Pettygrove St., Portland, OR 97209
Toll-free: 800.537.8352

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