MEMORANDUM

TO: Greg Busch, Interim Chief Risk Officer (CRO) UA State Wide
FROM: Danielle M. Dewey, Project Manager
SUBJECT: Measuring and Improving Safety, Learning from Accidents and Near Misses
DATE: November 22, 2016
CC: Brad Gilbreath, Ph.D.

As part of the upcoming 2017 Risk Management Effectiveness Initiative a request was
put out for volunteers to investigate and inform the department of Environmental Health, Safety,
and Risk Management with weekly memos. This is the fourth in a series. In the preceding week
I have spent time on the subjects of Measuring and Improving Safety, and Learning from
Accidents and Near Misses. While these subjects may seem a daunting amount of work, I
believe it is important to consider the quotation commonly attributed to Peter Druckard: What
gets measured, gets managed. (Gilbreath, Video: Measuring and Improving Safety). Due to the
diverse nature of the various units within the University of Alaska System, I will utilize broader
subjects so as not to discount any of them. The following are my observations and
recommendations for best practices:

Measurement. We can talk about safety programs as much as we want but without
measurement we have no true way to gauge performance. The United States Department
of Energy suggests the development of the following three tiers: 1) Mission and Vision,
2) Safety Objectives, and 3) Performance Measures (Janicak, 2003) and implementing
performance measures following their development. The above should not be
challenging, as I mentioned in my blog, many professionals are comfortable with these
tools in various functions and may use them in their regular work activities (Dewey,
Contribution 7). There is an eleven step generic process available for measuring
performance within a framework: 1) Identify the Process Flow, 2) Identify Critical
Activities To Be Measured, 3) Establish Performance Goals or Standards, 4) Establish
Performance Measurements, 5) Identify Responsible Parties, 6) Collect Data, 7) Data
Analysis, 8) Compare Actual Performance to Goals, 9) Corrective Action, 10) Make
Changes to Meet the Goals, and 11) New or Modified Goals (Janicak, 2003).

Both qualitative and quantitative measures are important for a full picture, not everything
can be measured numerically. Quantitatively, Those numbers get crunched and that data
is used for the team to see what needs to be focused on next. (Lincoln). These
numbers should show all three types of indicators; trailing, current, and leading. All of
this information can be worked into a dashboard as they do at Shelby Lincolns
organization along with many others. Frequent meetings such as occur in conjunction
with Fred Meyers safety committee (Gardiner) would be a prime time to overview these
metrics.
Improvement. The University of Alaska System is a large one, comprising of many
campuses with many units and colleges within those campuses. While the study
Improving safety in small enterprises through an integrated safety management
intervention is directed at small enterprises that does not mean that we cannot apply
those lessons to our organization. It may also be conducive to review the additional
studies of medium and large size enterprises that the authors produced (Kines, Andersen,
Andersen, Nielsen, & Pedersen, 2013). To successfully improve safety, there has to be
management buy in and support, this is true regardless of the specific subject or
organization.

The Safety toolbox included in the Journal of Safety Research article is a valuable
resource no matter the size of the organization. I propose that we utilize the safety
perception survey included in that toolbox and administer it through the university wide
email system. This would be helpful in providing a picture of our safety culture
organization wide and also show any areas that may need special focus. At the smaller
unit levels, implementation of a recurring read and sign serving to highlight
organization specific issues as is done at Fred Meyers (Gardiner) would be extremely
beneficial and a way to keep safety in the forefront of everyones mind.

Accidents and Near Misses. Its important to learn from accidents and near misses in
your organization. Its important to learn from accidents and near misses in your
industry. (Gilbreath, Video: Learning from Accidents and Near Misses). Its important
to learn from accidents and near misses in your life. (Dewey, Contribution 8). Accidents
are going to happen regardless of the actions we take to eliminate them, whether at work,
home, or play. What we can do is implement steps to reduce them as much as we are
able. One way to do this would be to have a digital system for employees to report
accidents as well as near misses. We have to ensure that employees will not feel the
potential for reprimand as a result of their reporting and also make a concerted effort to
reduce the personal embarrassment that comes with what are frequently termed Stupid
mistakes [, or] Im glad no one saw me do that (Davies, 2004) accidents. An effective
way to accomplish this would be to make the reporting confidential. Anonymous is not
advised because it removes the possibility for follow-up. This system would help to
identify what technical, environmental and human factors underpin 'stupid' mistakes
(Davies, 2004) and armed with this information we can do our best to minimize impact
and occurrence.

Human Error. This is a term, or a version, that many use in their everyday lives whether
they are actually considering the reason behind doing so. "Simply stating that something
happened due to 'human error' is not an explanation; it is the start of a process of
investigation, not a conclusion - except in the broadest sense." (Davies, 2004). What
needs to be determined is whether the management and the University of Alaska
department of Environmental Health, Safety, and Risk Management are operating under
the new view of human error, or the old antiquated view. The old view essentially denies

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 that any fault lay with the system, the only fault is that of the human element using the
system. The new view focuses on what in the system caused the human element to err.
We should always be judicious in our actions, and review the full picture. Both systems
and humans can be unsafe and prone to entropy; you don't need to elevate either one to
the status of safe territory (Danielson).

We need to operate under the assumptions of the new view, creating an organizational
culture that blames its members is not going to benefit the organization, likely the
opposite. We should not simply assume that we are operating under the new view
because it is new. Many organizations still operate under the old view and inherited
systems, as one may find in an almost century old institution, frequently systems that are
inherited have been in practice for many years, [and] could use a fresh pair of eyes that
do not have any ties to their creation. (Wright). This taskforce is a prime opportunity to
be that fresh pair of eyes.

To support the new view argument, we should consider the local rationality principle
which states: "People do not come to work to do a bad job. What people do and decide
has to make sense to them (i.e. it has to be locally rational) given their knowledge, their
perspective, their understanding of the situation at the time, otherwise they would not do
it." (Dekker, 2003). If we can provide systems that are responsive to the repair of deeper
issues that cause human error then we can move toward reduction of that error.

I propose that the next step is to utilize the recommendations resulting from the 2017
taskforce to ensure that the University of Alaska system is best prepared to measure and improve
our safety and learn from our accidents that do occur and our near misses. We should review all
systems already in place annually, and add any new systems we develop to the annual review
process. We should implement an accident reporting system as discussed above. Employees
should be able to access a dynamic safety dashboard, this should be accessed through use of our
employee network logins. This dashboard should, as stated in The Nonprofit Boards Role in
Mission, Planning, and Evaluation, be a road map and benchmarks to measure organizational
effectiveness because the performance measurements identified through strategic planning are
key indicators of organizational performance. (Butler, 2012). We want to continuously improve
our safety, the best way to do this is to measure our outcomes and learn from our mistakes.

Thank You,

Danielle M. Dewey

Danielle Dewey
Project Manager, TAACCCT
Mineral Industry Research Laboratory
Institute of Northern Engineering
University of Alaska Fairbanks

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 Sources of Further Information
Butler, L. (2012). Chapter 1: Understanding the Role of Dashboards. In L. Butler, The
Nonprofit Dashboard: Using Metrics to Drive Mission Success (pp. 5-7). Board Source.
Danielson, J. (n.d.). Contribution 8.
Davies, J. (2004, July). Learning from Mistakes. The Safety & Health Practitioner, pp. 34-
36.
Dekker, S. W. (2003). Accidents are Normal and Error Does Not Exist: A New Look at the
Creation of Occupational Safety. International Journal of Occupational Safety and
Ergonomics (JOSE), 211-218.
Dewey, D. (n.d.). Contribution 7.
Dewey, D. (n.d.). Contribution 8.
Gardiner, J. (n.d.). Contribution 7.
Gilbreath, B. (n.d.). Video: Learning from Accidents and Near Misses.
Gilbreath, B. (n.d.). Video: Measuring and Improving Safety.
Janicak, C. (2003). Chapter 2: Safety Performance Measurement. In C. Janicak, In Safety
Metrics: Tools and Techniques for Measuring Safety Performance (pp. 7-18). Government
Institutes.
Kines, P., Andersen, D., Andersen, L. P., Nielsen, K., & Pedersen, L. (2013). Improving
safety in small enterprises through an integrated safety management intervention. Journal of
Safety Research, 87-95.
Lincoln, S. (n.d.). Contribution 7.
Wright, E. (n.d.). Contribution 8.