The Evolution of Safety Auditing

There are many ways that safety programs are audited and evaluated. There are some that are internal to the organization or site and there are others that are used external. Some companies use the idea of intra-site auditing where safety people from other sites perform a documented audit on another site. Year-over-year there are rotations among all the sites. The other choice is the organization chooses to hire an external auditor on a contract to perform these evaluations. There are also opportunities to leverage the organization’s loss prevention or insurance company to assist with performing or coordinating audits.

As a safety professional, it is easy to enter a site an find multiple unsafe behaviors or conditions. From a strictly technical standpoint, there are always opportunities for improvement. The reason an audit should be conducted is to get an idea of where the total compliance attitude sits on the organizational scale. Getting lost in the trees and forgetting that the forrest exists does not create benefit.

Regardless of how an audit is performed, there are some basic items about an audit that gives indications about the performance of the audit team, the site behavior, and the organizational culture. I have created a scaled list of how an audit should give insight to the organizational compliance.

Poor performance = few findings. High complexity

When a site is still developing the audit should be focused on big ticket items like: creating a lockout program, training employees on hazard communication, performing personal protective equipment surveys, and creating written programs. Inundating the site with lists and lists of detailed items is not helpful in this phase. They should be focused on simply developing programs. It is the idea that something is better than nothing. The natural cycle of continuous improvement will help the details become addressed.

Medium Performance = high findings, low complexity

When a site has become the typical performing organization, the transition begins to see more punch list style items. Depending on the overall performance of the site, this will drive the number of those items. The major items of program creation are gone. In their place is a list of items that need to be completed to enhance compliance such as labeling specific bottles, updating placards, and

Good performance = Few findings, low complexity

One of the best auditors I know has three categories of findings that he creates as part of his process:

Nonconformities are findings where the program is not implemented or not followed

Deficiencies are where the program is in place but there are elements that are not up to the standard

Opportunities for Improvement are where the auditor finds ways that the program can be improved and is fully in compliance.

A good performing plant will be mostly focused on the opportunities for improvement. The complexity will be low, there will be minimal findings, and the goal is to keep the momentum rolling. The site has many good aspects of the program, but even a good program can go bad if it does not seek continuous improvement.

Overall, the process of auditing is value added when it is properly scoped, controlled, and helps create improvement in the process. The sake of auditing for auditing sake is overall a losing prospect. The audit program should have a governing policy and process that should be followed. There should be a defined outcome and mission statement for the audit. It is through planning and a focus on improvement that the audit program brings true value to a safety organization.

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The 5 Principles of Root Cause Analysis

I have been very fortunate in my career to have learned to perform 5-why or root cause investigation in various industries and using various techniques. This knowledge from automotive, Japanese automotive, food manufacturing, chemical, and nuclear as a facilitator of RCA has given me a very unique perspective of how an effective investigation is conducted. Across all the various methods and industries, I have found there are five very important aspects of RCA that a facilitator must have to drive a successful root cause and corrective action.

1) Time
Too many times, the RCA was just another item that had a very short deadline along with dozens of other items that everyone had to get done. What this led to was a fast and easy RCA. The team or sometimes individual would look for the obvious and easiest answer to the problem that was at hand. Many times this led to the answer of human error and to conduct a retraining of the process. This was fast, simple, and cost the company no money. This was the perfect way to close the investigation. The only problem is that the training was never sustainable because the team never had the time to really find the real root cause.

The best practice is for the management team to let the facilitator know that the most important task they now have is to really seek the true root cause. That is not only for the facilitator but for anyone who the facilitator will need to complete the investigation. If there are employees, supervisors, or even managers; they should be made available with ample time to work with the RCA team to answer and participate in the process. 

If time is not given to the team to do the task, the process will immediately breakdown. There may be corrective actions that are found and implemented, but they will be as short lived just like the time spent performing the RCA. Not to say that an RCA should take an unlimited amount of time, but it should be given the time priority of the team. It should be the priority to find and prevent the incident from happening again, especially when finding ways to keep people safe.

2) Access
The team must have the resources available to make the right decisions. Of course, there are some things that the team should not have to need to have access too. There are times, though, that the information is not provided in which they need to perform the work. 

Access is a very broad term, but it includes items such as data, recreation photos, ability to go see the area, ability to interview witnesses and read statements, and access to those who can aid in the investigation. I found in the chemical industry in particular that there were some key people who had strong knowledge in certain areas. It was those people that we needed access to so as to really understand the complexity or background of an issue.

The RCA team should be able to make requests and have those granted in a reasonable amount of time. It is important that the team and organization knows that the RCA team is to have access to what they need to find the best root cause.

3) Data
Data seems like a no brainer when it comes to performing a RCA, but too many times this is the part that is overlooked. I remember a metal assembly laceration that I was facilitating. The ruling thought was that too much weld oil had led to the part being dropped and causing the laceration. What we really found was that the rack that held the part was not built to specifications and had an awkward angle that led to the potential for a weak grip. We only got lucky and stumbled on that information when a maintenance person told us about the reported issues with that assembly.

We almost missed a key point of the RCA by assuming we already knew the answer. We were not seeking data. We felt we knew. That is why the data gathering step of any RCA is so important. Some of the data will be useful, some may not be. The key is that you will not know what is and is not useful until you have it all for evaluation. The team should have the data and be able to use it appropriately. 

4) Independence
One of the critical aspects of being an RCA facilitator is having independence to be factual and based in reality. Sometimes, it is hard to admit there is a problem with a system or process. The facilitator has to be able to report that without bias, without showmanship, without personal opinion, but with total certainty that it is the truth. I have seen good RCAs go bad when a management team wants to “review” them before publishing. These little tweaks to the process take away the credibility of the work and sometimes gloss over the real issues of the organization.

This is also a deeper topic about the culture of organization. Are you in an organization that wants to learn or are you in one that wants to blame?

High blame = low independence

High learning = high independence

The RCA facilitator has some influence over this, but this is really a much larger cultural process. It is necessary, though, to allow the process to freely flow. Once people see that the process clouded by political judgement, the faith is the process is lost. This creates a significant degradation in the RCA process and corrective actions that are effective.

5) Training/Expectations
RCA is not common sense and it is not something the people learn on the fly. It is absolutely necessary that RCA facilitators are educated on the processes and procedures of the organizations investigation expectations. In my experience, I have always asked to be trained in the company’s RCA process. Some use the fishbone, 8D, charting programs, is is-not, 5-Why, and others. Those who perform the process need to know what process to follow.

The best way to comply with the expectations is to write them in a procedure. This creates the standard for the way the RCA process should work and the standard that the process will be graded to. It sets the groundwork for having a strong team and being able to benchmark when there is turnover. It has always been a relief to be able to come into an organization and find a procedure to explain the investigation process. This helps in giving clarity and streamlines the training. The key is to assure that the program can be sustained. A procedure helps to do that.

RCA facilitation can be a complicated process. There are ways, though, to make it an easier and more efficient methodology. Through making sure that the basics are provided for the team, the process will then drive a good solution. The goal of any RCA facilitation is to learn, correct, prevent, and improve. It is through allowing the facilitator to have time, access, data, independence, and training that this can be accomplished.

We are asking the questions, but do we care about the answers?

As part of many safety audits, there are times where employees and supervisors are brought together to answer questions about safety programs, experiences, and feelings. The process is to ask open ended questions to draw out the employees to talk about what they are witnessing and experiencing in the workplace. The goal of these audit protocols should be to help the sites leadership see from the outside what the culture and people on the inside are creating. 

This process is perceived as an outside group taking a true interest in the goals and feelings of the people at the site. So the real question from these audit processes is: If we are asking the right questions and getting the true answers; what are we doing with the data?

What happens if the findings are that the culture is broken and workforce is burned out? Is there blame assigned to the site or even worse to the HSE Manager? If the site is showing some real development with people and culture is the site rewarded and recognized? If there are real issues that come up that require resources or capital outside the sites ability, is the audit team helping support the work to get those resources allocated to the site?

Too many times (not only in audits) people are asked the questions, the data is collected, there is a presentation of the information, there are some short term exchanges on change and process, but there is not sustainable, culture focused, and appropriate solutions provided.  

What this is really about is if we are really ready to ask the questions. If the organization is ready to make the plunge and ask the culture questions, there has to be a method to address and create real solutions. As safety professionals, creating culture not only in the workforce but in the leadership and management is one of the greatest challenges. The answers are more important than the questions when it comes to building trust among the workforce. I once heard trust defined as empathy combined with action. The questions create a sense of empathy but the real challenge is turning that into action. And one could say that real empathy creates action. 

Creating a sense of trust in the workforce is one of the key components of Maslow’s hierarchy. Without trust, there is no basis for people to give the best. Without trust, there is no giving more than the minimal. Without trust, there is dysfunction to a higher degree. When we ask the questions and we act toward a solution, trust is created. We create a culture in which we can find solutions. We can create a culture where the questions are no longer as important as the issue are apparent as part of the dynamic continual improvement process. 

So when the audit comes to town, the questions are asked, and the answers are given; there must be a process to create solutions to the cultural needs. If the solutions are limited to a site or group and not evaluated on a inter-organizational level, there is a significant loss of sustainability and effectiveness.  

My Thoughts on the ASSE Interview with Paul H O’Neill

A week ago, the American Society of Safety Engineers hosted a Q&A session with Paul O’Neill. He is the former CEO of Alcoa and is recognized as a true safety leader. I would highly recommend seeing the interview if at all possible. It was quite a sobering experience of how easy he made safety leadership sound. There were a few items that really struck me as pertinent.

1) Before taking over as CEO, he asked himself, “what do you want to be remembered for?”

His answer was “safety.” I think of my own life and career and wonder what I will be remembered for. As a safety professional, I hope that people will see me as a strong advocate for worker safety. A few other attributes that come to mind are leadership, compassion, and fairness. I also look around at other managers and leaders and wonder what their answer would be to that same question. If we are truly being honest with ourselves, what would that answer be? What would others say we stand for? There are leaders whose answer would be leadership, profitability, innovation, or productivity. Are we really considering the human factor in these decisions and assuring that we protect the most valuable resource of any organization?

2) If you take care of the non-financial aspects of the business, the financial aspects will be there.

He was specifically talking about people. If you take care of the people in the organization, they will help the company take care of financials, quality, and productivity. This message highly resembles my postings on the Hierarchy of Safety Needs. Until the people of the organization feel their safety need has been fully realized. they will not progress to higher levels that drives true breakthrough skills that progresses the company. This philosophy also strongly resembles Toyota’s systems. As Toyota’s systems continue to be bench-marked, there is one clear idea that resounds: follow good processes, and the results will be achieved. Instead of driving the results, focus on the people and processes. They will help create organization success.

3) All safety issues will be corrected

He actually said that this statement scared his financial team. He stated that he could not expect people to believe in the message of safety if there were limitations to what they were willing to do to make the sites safe. This is definitely a lofty goal, and it did not happen overnight. There were processes and methods in place, but the issues were addressed and organization was transformed.

4) All incidents/injuries can be prevented

There is no such thing as an accident. There are measures that can always be taken to prevent injuries. I also found it interesting that he did not classify injuries as OSHA Recordables. He meant that near misses and first aid cases deserved swift, decisive, and focused attention. A first aid case is still someone who has been hurt on the job. It is not as severe, but it is still a person who has been hurt at work. His vision was not just an OSHA related goal, but one that was people and process focused.

Overall, I enjoyed the interview and found it to be very informative. His methods were not complex or difficult. They were focused on a few key principles that helped revolutionize his organization.