First a confession:  The title of this blog isn’t original.  I hope that Eldeen Pozniak, my safety professional friend from Saskatoon, Canada won’t mind my shameless adaptation of the title she used for a recent speech at the Pacific Rim Conference in Honolulu, Hawaii.  Not only is it a catchy title, but her speech was excellent.  If you ever get a chance to hear Eldeen speak don’t miss the opportunity.

Focusing Your Fleet Safety Program

Recently, I was a speaker at the ASSE Southwest Chapter PDC in Dallas.  It was a good experience that allowed me to hear several good presentations, and one of which I want to share.  Rob Fulenwider of the Texas Department of Transportation topic was DOT safety, but was much better than the title implied.  First, he provided an update on recent Federal Motor Carrier Safety Administration rules and what to expect from enforcement.  Of course there were horror stories to get everybody’s attention, but then he shifted gears and presented a proactive approach to crash prevention.  Mr. Fulenwider is a good speaker and continued by asking a question.  ”What do you think causes the most crashes?”  This was a great open-ended question that sparked open conversation with the audience as they told him what they thought the answer is and he proceeded feedback.

His purpose in all this was to set up his presentation of the fundamentals of fleet safety and how focusing on the basics can pay off.

1.  Speed.  The saying goes that “Speed Kills” and it’s true.  All things being equal, if we teach drivers about controlling their speed and how to recognize when they are going too fast for traffic conditions or the weather, we will have more time to react.  Reaction time is a key element that ties back to all forms of distracted driving.  When speeding, or going to fast for conditions, even the most minor distraction can take away the margin for error leaving you no way out.  It doesn’t matter what defensive driving program you teach, focusing on controlling speed will provide the biggest dividend.

2. Distance.  Here we are talking about following distance.  By maintaining  a cushion between you and those ahead of you increases your ability to see approaching danger, as well as have time to react.  Distance also applies to those to your sides.  Creating space for an emergency manuever is important and without developing a distance cushion to the side and rear we don’t have sufficient distance to react safely.  Try to maintain a 4 second cushion between you and the vehicles traveling ahead, and if possible at least 2 seconds between you and the vehicles in other lanes.  These both can be difficult to maintain, but through active involvement  and feedback from the drivers the distance margin can become habit.

3.  Conditions.  Though we talked a little about traveling to fast for conditions, there is more to consider.  Conditions relate to anything in the environment that can have an effect on safely driving or maneuvering the vehicle.  Though most of us think about weather conditions, the overall condition of the road surface, or night driving conditions and visibility, what about the potential for animals entering the roadway, especially at night.  By maintaining the correct speed for actual or potential conditions, slowing down when necessary and maintaining proper distances will greatly increase our ability to react and steer clear of danger.

4.  Left-Hand Turns.  Intersections are dangerous enough, but when you add the action of a left-hand turn across traffic you increase the risk dramatically.  Almost any fleet safety professional will tell you that crashes at intersections are one of the most common occurrences.  The most common proximate causes include: following too close and rear-ending the vehicle in front, or side-swiping one in the next lane when trying to avoid rear-ending, and misjudging the speed of oncoming traffic and attempting a left-hand turn in front.  Teaching drivers to eliminate all left-hand turns and always slowing down at intersections greatly reduces risk.  Beyond teaching the avoidance of left-hand turns to drivers, you will also want to talk with those who construct the routes.  Have them work to build in right-hand turns into the routing system whenever possible (which is always!).

5.  Backing Issues.  Most of us can remember learning to drive and the difficulty we encountered when backing the family car or truck for the first time.  Our vision was limited, the direction we needed to steer was reversed, and we had some physical limitations.  Now as adults we still have difficulty backing out of the driveway, or a parking spot at the shopping center.  Experts say that the most common non-roadway incident comes from backing up.  Now we add in a large commercial vehicle with even more vision and maneuverability issues and we are asking for trouble.  The key lies in how we are training our drivers.  Always teach them to avoid backing up in the first place. But, with dock deliveries and other types of drop-offs it may not be feasible.  First it is important that they learn the dimensions of the vehicle and how to manuever in close quarters.  Next they need to learn how to use their mirrors and gauge distances.  This takes practice, so make sure they get the time necessary to master backing the vehicle.  Then teach them to always verify their pathway.  This requires them to exit the vehicle and to walk the route, assuring they know the path they will follow and any obstacles.  Using spotters to direct the driver as they back is the best method, but when not available taking the time to check the path will improve the odds.  Lastly, proceed slowly and with extreme caution.  Some experts also recommend honking the horn in the absence of a backup alarm system.

6.  Annual MVR Check.  I think it was Demming who said “past behavior is the best indicator of future behavior”.  Another key element in a good fleet safety program is a system that validates the safe driving behavior, such as a check with the state and making an MVR check.  CSA 2010 takes the pre-check to another level, but if your vehicles don’t fall in the heavier DOT classifications, an MVR check is a good place to start.  It is also recommended to institute a substance abuse program with random testing, along with regular driver safety education and observations.

Here’s where the +1 Element comes in.

New ANSI/ASSE Z15 – 2012 Approved

A comprehensive standard aimed at increasing commercial motor vehicle operations’ safety developed by the American Society of Safety Engineers (ASSE) was approved recently by the American National Standards Institute (ANSI). The revised ANSI/ASSE Safe Practices for Motor Vehicle Operations, Z15.1-2012, standard approved March 28 will be effective August 20. The practices in the standard are designed for use by those responsible for the administration and operation of motor vehicles as part of organizational operations.

According to the information on the ASSE website, ANSI/ASSE Z15.1-2012 calls for organizations to have a written motor vehicle safety program that defines organizational requirements, responsibilities and accountabilities for drivers and motor vehicle safety; to have a written safety policy that includes communicating management’s concern for the health and well-being of drivers throughout the organization; how to have a system of responsibility and accountability in order to ensure effective implementation of a vehicle safety program; a driver recruitment, selection and assessment program; orientation and training; a system in place to report to corporate executives major incidents, trends and safety performance, including the immediate reporting of major incidents to management; internal and external communications programs to be in place, (this includes contingency communications with the media); inspections and maintenance; regulatory compliance; and audits.

The revised standard provides guidance for occupant restraints; impaired driving; distracted driving; aggressive driving; journey management; and, fatigue. It also covers operational policies on vehicle business use; vehicle personal use; driver-owned/leased vehicles; and, for using rental cars. Further, the standard provides guidance for driver qualifications; vehicle management; and, incident reporting and analysis. Sample policy/acknowledgement forms are included within the Appendix of the standard including a business use policy, a personal use policy, and a distracted driving policy. The Appendix provides guidance on incident rates including various methods of calculation as well.

Fleet Safety Requires Focus

As we’ve discussed, Fleet Safety doesn’t just happen.  It requires vigilance and an ongoing commitment to driver education and team involvement.  Then, establishing the infrastructure and management systems outlined in ANSI/ASSE Z15 – 2012 will provide the muscle you’ll need to maintain a solid fleet safey program.  Safe Driving…..  And thank you to the ASSE for some of the content I’ve included above.  Please feel free to comment and share with others.  Thanks.

In my last post I wrote about a recent presentation on human error that I attended.  The speaker was Dan McCune, VP of Safety at Embry-Riddle University and Director of Trianing for HFACS, Inc.  Not only is Dan a very knowledgeable and entertaining speaker, but he is passionate about learning as a key element for safety.  His background is in military aviation, where he was exposed to extreme risk.  As he spoke, many of his examples illustrating human error and their source were either from his personal experience or that of others. A key take-away that I got from his talk was about the importance of an organizational culture that embraces learning from mistakes, hopefully before they lead to serious consequences. Moreover, sharing what has been learned with others to imporve the good for all.

In James Reason’s book, Managing the Risks of Organizational Accidents, he writes about how to “engineer a safety culture”. (First, I digress: not only do I highly recommend this book, but when you read it please pay particular attention to Chapter 9.)  In this chapter he discusses the Organizational Culture and that “A safety culture is not something that springs up ready-made from the organizational equivalent of a near-death experience, rather it emerges gradually from the persistent and successful application of practical and down-to-earth measures. Acquiring a Safety Culture is a process of collective learning.” Reason then goes on to discuss other business books about culture that support the notion that a strong organizational culture begets a strong safety culture. Tom Peters, in his book In Search of Excellence, writes that a strong culture is one in which all levels of the organization share the same fundamental goals and values. “In these companies with strong cultures, people that are way down the line know what they are supposed to do in most situations. This is because the handful of values that guide behavior are crystal clear.”

Reason’s focus on organizational culture, and the underlying factors that allow a strong safety culture, stresses the importance of not only removing barriers to learning, but narrowing in on how we react to situations. In safety, how do we react to a near-miss or worse, an incident with injury? All too often we focus on what happened or the individual behaviors that preceded the incident. By instinct we want to find the cause, place the blame, retrain, fix the person, etc.  However, this type of reaction throws cold water on learning and as Reason argues, results in a short-term fix, such as “write another procedure” and the “blame and train” response cycle. Though many safety professionals know this all too well, understanding what they can do to change managment systems or reframe long-held beliefs is less clear and can be very difficult.

Several books on human error, including Reason, Dekker and Marx talk about the importance of institutional learning by creating a positive and just culture. (I’ll save this for another post, but you all should read the book by Edward L. Deci “Why We Do What We Do”. It may change your thinking about behavior based safety.)   Reason’s book details several subcultures that work together creating one positive and productive culture.  These include a Reporting Culture, a Just Culture, a Flexible Culture, and a Learning Culture.  Here is where I will take you back to the presentation by Dan McCune.

In aviation safety it is critically important that pilots feel free to share and discuss everything related to flying and their performance. Though being a pilot requires knowledge, skill, physical ability and mental capability, each and every pilot will tell you that they really do not have command of the plane and situational control until they have a great deal of experience.  This translates to thousands of flight hours.  What happens over time while they are gaining this experience? They are making mistakes; many, many mistakes.  It is the job of the flight  instructor to help each pilot recognize and understand their mistakes.  From this they learn about their perceptions, misapplication of knowledge, what could be done differently, etc. But how does learning occur after they graduate and are on their own?  Pilots and the FAA have a system of near-miss reporting. It is a no-fault system that recognizes that if there are barriers to sharing and reporting, knowledge will be stifled.  This reporting philosophy extends beyond the pilots to the entire crew, controllers, ground service personnel and anyone who could impact safe flight operations.

McCune shared that at Embry-Riddle, whether in their school of aviation or any other part of the University, they have embraced an important and unique philosophy: “No disciplinary action will be taken for reporting a safety hazard, concern or near-miss situation”. They realize that for the University to have a true safety culture it must be open to learning and sharing experiences. The safety culture must include just and open reporting, without blame or consequenses, so it can learn what is has missed or didn’t know. (of course situations of willful misconduct are dealt with differently) From the new employee and student orientation where the President of the University makes it perfectly clear, to the day-to-day actions that support it, everyone learns that ”Event reporting is very important. Everything, without risk to you or anyone else, should be reported.”   To support this Embry-Riddle has a simple and respectful system for reporting, providing feedback and thanks to the reporting person.  They also have a data base for tracking and sharing information about near-misses, and always investigate each situation using the HFACS system. With over 700 reports this past year from their two campuses and no serious incidents it must be working.

In closing, here is a fundamental belief that I have learned about Near-Miss reporting.  If you don’t have it in your organization and it’s not resulting in many hundred reports each year, you do not have a culture that values learning from mistakes. Further you don’t have an organization that really understands the nature of human error and designing work to expect it.

• Think about the barriers that exist and how you may get over or around them.
• Think about how your organization reacts to incidents or mistakes.
• Think about how your organization conducts incident investigations and what may be called root cause analysis.

If you see a culture that focuses on individual behavior, is quick to blame, stops short of looking for organizational solutions, adopts quick fixes, doesn’t encourage open discussion about problems and solutions, and
…… well you get it, you probably don’t have an organizational culture that can accept what it takes to have a true safety culture.

I apologize if this post has been a bit academic, or had the feel that I am preaching. Love it or leave it, I am passionate about this.   Developing an organizational culture that values information and knowledge sharing leads to success in safety. Having a robust system for near-miss reporting is an important element and one I hope you decide to implement if you haven’t already.

Thanks for reading and feel free to comment or share this with others.

About 3 years ago I began an in-depth study of Human Error Management, Human Performance, Cognitive Science and Prevention Through Design.  In the process it has become clear that we have not effectively learned how to create work processes and procedures that are error tolerant.  People will make mistakes and in fact are designed to process by trial and error as they go through their day.  Until we understand this fallibility and learn to create an environment and systems that allow our employees to have a bad day and still finish without injury, we will never take safety to the next level.  Recently, I had the opportunity to learn more about Human Error management, and want to share it with you.

Last week I attended a blockbuster PDC put on by the Northwest Chapter of ASSE.  The organizers did a great job of assembling top-notch speakers including Joel Tiegnes, Adele Abrahms and Dan McCune, the first keynote speaker.  Donna Heidel of NIOSH and their lead authority on the Prevention Through Design delivered the afternoon keynote.  With a number of other excellent local speakers the NW Chapter proved that by increasing speaker quality greater attendance would be achieved.  They set an all-time record by more than 100 participants!

The morning keynote and follow-up session by Dan McCune, VP of Safety for Embry-Riddle University and Director of Training for HFACS, Inc. was outstanding.  First, he provided an excellent discussion of human error and introduced the audience to a deep dive into the Human Factors Accident Causation System – HFACS.  Created by Drs. Wiegmann and Sheppell for the DOT/FAA, HFACS provides a taxonomy of analyzing incidents to find they key contributing factors beyond the actual human error.  The system goes beyond the root cause analysis that most safety professionals know and use.  The system allows the users to consider a number of additional factors, one being the “Normalization of Deviation”.  I have heard of this before from Todd Conklin, another noted speaker on human error and the design of work.  Conklin stress this two-way phenomena.  “Deviation” refers to the day-to-day variation from established work standards and procedures, better known as the way work is actually performed.  “Normalization” is just that; the deviation from the establish standard that has become habitual and is now the new standard for performing the given task;  the new normal.

In McCune’s discussion of Normalization of Deviation he was referring to violation errors, where accidents are easily blamed on the person who didn’t follow set procedures.  However, to be a violation you must pass the “3 Question Rule:  1) was there a standard or established procedure and was the employee aware of and trained to perform to that standard?  2) did the organization know that deviation was occurring?  3)did the organization intervene and enforce the rule or redirect the deviation from the procedure?  If you cannot answer Yes to all three, there is not an enforceable violation.

As we learn more about organizational control and process management as it relates to human error, we can see clearly how performance expectations and methods must be checked regularly to assure that normal deviation is acceptable and not setting up significantly increased risk.

Conklin uses a graph to illustrate the problem of deviation, especially in work where the level of risk fluctuates.  During a work activity exposure to hazards can vary, so if the worker takes short cuts for the sake of increased productivity, the risk of injury often increases.  Put simply, the margin for human error and resulting negative consequences is reduced.  Among his many suggestions, McCune believes that regular worker and supervisor job reviews, together with an active near-miss reporting system can effectively limit deviation and decrease the risks involved.

That’s enough for now, but next post I will cover more about McCune’s thoughts on Near-Miss Reporting.