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Safety Science 92 (2017) 225–231

Contents lists available at ScienceDirect

Safety Science
journal homepage: www.elsevier.com/locate/ssci

Methodology of improving occupational safety in the construction

industry on the basis of the TWI program
Katarzyna Misiurek a,⇑, Bartosz Misiurek b
Faculty of Civil Engineering, Wroclaw University of Science and Technology, Plac Grunwaldzki 11, 50-377 Wroclaw, Poland
Leantrix sp. z o.o., Hubska 60/3, 50-502 Wroclaw, Poland

a r t i c l e i n f o a b s t r a c t

Article history: The article presents the way of using the Training Within Industry (TWI) program, derived from manu-
Received 12 July 2016 facturing processes, in the construction industry in order to improve occupational safety. The origin and
Received in revised form 23 September meaning of the TWI program and its relation to the philosophy of Lean Management is also described. The
article shows how a preventative approach to ensuring safety has developed over the years. It has been
Accepted 30 October 2016
Available online 9 November 2016
proved that human errors, and not technical problems, have the greatest impact on the occurrence of
accidents. After literature surveys, three main root causes of human errors were defined and include: a
lack of or poorly led training, badly defined and developed work standards and also a lack of supervision
Training Within Industry
of employees. The statistics of fatal accidents in construction and manufacturing industries over several
Construction site recent years in the UK were analyzed. It has been noted that in the construction industry the average
Lean Management accident level is much higher than in the manufacturing industry. Conclusions were used to develop a
Occupational safety methodology of improving occupational safety in the construction industry. The developed methodology
is based on the selected components from the TWI program and contributes to the elimination of prob-
lems associated with the three main root causes of human errors.
Ó 2016 Elsevier Ltd. All rights reserved.

1. Introduction Bullet Problems with machines or apparatus (Machine).

Bullet Human error (Man).
Accidents are a major problem in various industries as well as in
everyday life. Ensuring occupational safety is a problem that is It is widely considered that the stabilization of processes is
widely described in literature. Accidents have an impact not only achieved by the elimination of the 4 M problems (Eaton, 2009, p.
on the victims themselves, but also on their adjacent surroundings 82; Birolini, 2004, p. 76; Pascal, 2007, p. 29; Gopalakrishnan,
(Hallowel, 2010). Moreover, accidents contribute to economic 2005, p. 204). This stabilization also refers to occupational safety,
losses for the employer in the form of additional costs and and the problems that occur in such a situation can be seen as
employee absences from work. Accidents are a significant problem hazards.
in the construction industry. The report presented by the National A pioneer in the field of research in the area of occupational
Safety Council (Injury Facts, 2015) of the US shows that in 2014 safety was Heinrich (1959), who assigned the causes of accidents
about 5% of all employees in the US worked in the construction to two main categories:
industry. This sector is thus responsible for approximately 20% of
all fatal accidents at work in this country. Bullet Human error (Man).
The root causes of accidents in all fields of human activity can Bullet Technical and organizational problems (Method, Mate-
be categorized into 4 main areas (4 Ms) (Lewandowski, 2000; rial and Machine – 3 M’s).
Runkiewicz, 2006; Spath, 2011):
Heinrich stated that in the category of human error (Man), the
Bullet Bad work methods (Method). most important factors which cause accidents are associated with:
Bullet The use of bad materials or components (Material). physical or mental unsuitability, a lack of attention or carelessness,
a lack of appropriate training and also supervision. Petersen
⇑ Corresponding author. (1982), when conducting extensive research in the field of safety,
E-mail addresses: katarzyna.misiurek@pwr.edu.pl (K. Misiurek), bartosz.misiur- which was based on earlier works of Heinrich, proved that people
ek@leantrix.com (B. Misiurek). are the direct cause of most accidents. However, the main respon-

0925-7535/Ó 2016 Elsevier Ltd. All rights reserved.
226 K. Misiurek, B. Misiurek / Safety Science 92 (2017) 225–231

sibility in the prevention of accidents lies with the management the three root causes outlined above. It can therefore be assumed
site. Moore (2004a,b, p. 180) noted that management, in order to that an employee’s bad attitude to work is not the root cause but
improve safety, should focus mainly on improving work organiza- is only an indirect cause.
tion through, among others: In considerations regarding the provision of occupational safety,
the issue of automation should be raised as it nowadays occurs in
Bullet Education and training of employees; both the manufacturing and construction industry. Modern auto-
Bullet Employee involvement in self-improvement; mated machines intend to replace the work of a man. Regarding
Bullet Defining standards and procedures; the ensuring of occupational safety, the risk of human error is
Bullet The process of auditing; reduced because a human’s work is replaced by the work of a
Bullet Elimination of the root causes of problems; machine. On the other hand, a man has to operate complicated
Bullet The process of continuous improvement; automated processes, which changes the places of potential acci-
Bullet Building of a culture orientated on occupational safety. dent events. This problem is dealt with by Leveson (2004), who
believes that a lot of accidents blamed on human error could more
Nowadays, technological solutions are more and more often accurately be labeled as resulting from a flawed system and inter-
assumed to be able to effectively prevent the occurrence of human face design. These conclusions are relevant to one of the root
errors. In the area of industrial production, fault-resistant solutions causes of human error defined in this article - the bad design of
known as Poka Yoke (in Japanese it means preventing uninten- the method of performing work. Leveson (2004) notes in her article
tional human errors) (Misiurek, 2016) are being created. These that the problem of safety in the man - machine relationship is a
solutions aim to implement tools and methods into the manufac- challenge for engineers, who when designing machines should
turing process that protect against the occurrence of a human not only pay attention to the setting of the operating parameters,
error, which thereby result in both the reduction of the accident but also take into account the organizational aspects related to
rate and also improved quality. Liker (2004) notes, however, that the operation of such machines by operators.
such measures only reduce the possibility of mistakes; therefore
companies should primarily be focused on building an organiza-
tional culture by increasing employee awareness of safety. Rother 2. The analysis of the accident rate in manufacturing and
(2009) emphasizes that the organizational culture in the area of construction industries
assuring occupational safety should be primarily focused on the
development of the consciousness of employees and not only on Manufacturing and construction industries are the main
the implementation of Poka Yoke solutions. However, Rother also branches that contribute, to a large extent, to the revenues of
admits that such solutions bring measurable benefits. They should most countries in the world (United Nations Department, 2007).
be considered as a supplement to the system, and not the main Both of them are vulnerable to accidents due to their scale, num-
part. Likewise says Dekker (2002), who believes that technical ber of employees and also difficult working conditions. Therefore,
solutions do not eliminate the possibility of error, but just move it is crucial to improve safety in these industries. Monitoring and
them to another location or change their form. In his work he con- analyzing trends in the rate of fatal injuries is helpful in assessing
siders the difference between categorizing root causes of accident the safety improvement process. Such statistical analysis is car-
events to one of the following areas: human error or system error. ried out by the Healthy and Safety Executive (HSE). Since 1981
He clearly states that human error is a symptom of trouble deeper the HSE has continuously analyzed the rate of fatal injuries (per
inside a system. Dekker (2002) calls this approach as: ‘‘New view of 100,000 people) in enterprises in the UK. Fig. 1 shows how its
human error”. He also notes that a statement of human error is not value changed in the period from 1981 to 2013 among employees
the end and that it is just the beginning of a search for a root cause hired in companies from manufacturing and construction
of an accident event. In a similar vein, this problem is raised by industries.
Hansen (2001). He wrote that it is crucial that the reduction of It can be concluded from Fig. 1 that in both the presented indus-
human errors from processes takes place with the identification tries the rate of fatal injuries has a downward trend. However, this
and elimination of their root causes. As a result of literature ratio is still significantly higher in the construction industry. The
research, the three main root causes of losses occurring in the area conducted analysis is confirmed by literature studies, in which it
of human errors (Man) were listed as follows (Wilson et al., 1993; is widely recognized that in most countries the construction indus-
Hansen, 2001; Dekker, 2002; Montillaud-Joyel, 2006; Beke, 2011; try is a branch of industry in which the largest number of accidents
Hill, 2012; Chiarin, 2013; Mukherjee, 2006; Conner, 2011; occur (Abudayyeh et al., 2003; Mohan and Zech, 2005; Fredericks
Misiurek, 2016): et al., 2005; Fang et al., 2006; Carter and Smith, 2006; Hinze
et al., 2006).
Bullet Non-compliance with the work standard by an operator The reason for the difference in the value of the accident rate
due to the bad design of the method of performing work ratio which is shown in Fig. 1 is not associated with a higher com-
(e.g. a lot of hazards, bad ergonomics, etc.), despite the plexity of processes in the construction industry. However, manu-
fact that the sequence of work (method) was deter- facturing processes include operations mainly related to: welding,
mined correctly; casting, thermo-chemical treatment, work in very high tempera-
Bullet A lack of or poorly conducted employee training; tures etc. These operations are commonly considered to be danger-
Bullet A lack of the process of monitoring and auditing of ous. In the construction industry accidents are most commonly a
employees after conducted on-the-job training. direct cause of (Ministerråd, 2003):

In literature it is also stated that a bad attitude of an employee Bullet Slipping, stumbling or falling of an employee;
to work can be the cause of losses in the area of Man. Studies pub- Bullet An employee being hit by an object falling from above;
lished by Clayton (1919, p. 140) show that out of all the losses that Bullet A victim falling from a height;
arise as a result of actions in the area of Man, only 10% may result Bullet A man being hit by an object from the same height level;
from the bad attitude of an employee to work. Nevertheless, Clay- Bullet An employee falling down a hole;
ton notes that in many cases the bad attitude of an employee may Bullet Etc.
stem from a lack of commitment of superiors, which results from
K. Misiurek, B. Misiurek / Safety Science 92 (2017) 225–231 227

Fig. 1. The rate of fatal injuries (per 100 people) in the years 1981–2013 from manufacturing and construction industry companies in Great Britain. Source: Redrawn from
Wright (2014).

The causes of these accidents are related to poor organization of modern methods of managing manufacturing enterprises in their
work but do not result from the complexity of their operations. processes. Among these methods Koskela mentions, among other
These incidents can be prevented by the identification of threats things, Lean Management which is currently the most popular
and then an attempt to eliminate them. Therefore, it should not approach to the management and organization of manufacturing
be assumed that the higher value of the rate of fatal injuries in processes in the world (Yogesh et al., 2012). The term ‘‘Lean Man-
the construction industry results from the complexity of opera- agement” was first used by Womack et al. (1990) in order to
tions occurring there. describe the Toyota Production System (TPS). This system is cur-
The construction industry is commonly identified with prob- rently considered to be the leading system of managing organiza-
lems such as: tions in the world (Moore, 2004a,b). Literature research proves that
the TPS system was based on the American program of Training
Bullet a constantly changing situation in the workplace, Within Industry (TWI) (Dinero, 2005, 2011; Wrona and Graupp,
Bullet turnover of workers, 2006; Kato and Smalley, 2011).
Bullet a rapidly changing relevance of risks, The genesis of the TWI program dates back to World War II. The
Bullet etc. TWI program was directed mainly to masters, foremen and experi-
enced operators. Originally its objective was to master the skills of
The root causes of these problems should be especially associ- instructing employees, improve current working methods and
ated with a low level of management and organization of work. maintain good relationships with employees. After World War II,
The TWI program was originally implemented in companies that the TWI Job Safety program (Wrona and Graupp, 2006) started as
produced military equipment during World War II. At that time an additional program. The main idea of Lean Management philos-
the manufacturing industry struggled with similar organizational ophy and the TWI program was that processes, and not people,
problems as the construction industry currently does. Implementa- should be blamed for problems and accidents (Balestracci and
tion of the TWI program in those years in the production area gave Barlow, 1996). This is consistent with the approach promoted by
spectacular results as there was a number of problems to solve. Heinrich in the area of occupational safety, according to whom
Currently, the manufacturing industry is widely recognized as the management is responsible for the establishment of processes
the most effective branch of industry (Aziz and Hafez, 2013). in companies and the supervision over their compliance.
Nowadays, the efficiency index of manufacturing processes is at The TWI program aims to reduce human errors in the areas of
a level of 85% (i.e. World Class Overall Equipment Efficiency) and manufacturing processes and it also trains operating employees
is achieved over a long period of time by many manufacturing the four main following skills (Dinero, 2005; Wrona and Graupp,
companies (Misiurek, 2015). Standardization of work, which is 2006):
the foundation of most of the production systems in the world,
e.g. the Toyota Production System, translates into stability, and this Bullet How to transmit knowledge effectively while discussing
affects e.g. the reduction in the absenteeism level (Liker and Meier, what to do and how and why it should be done in such a
2007). The implementation of methods and tools that improve way as opposed to other ways (TWI Job Instruction);
organization of work in the construction industry should result Bullet How to improve work using a series of questions
in the elimination of the root causes of many problems, as was included in 5W1H1 methodology (TWI Job Methods);
the case with the production area. Bullet How to build relationships and solve problems in a team
(TWI Job Relations);
3. Causes of the lower level of the rate of fatal injuries in the
manufacturing industry in relation to the construction industry

The difference between the ratios of the accident rate can result
mainly from the fact that manufacturing companies are much 5W 1H methodology relies on the asking of questions in a sequence (Shingo,
1989, p. 82):Why?, What is the purpose?, Where?, When?, Who? and How?. An
more focused on improving their processes (including processes approach, which is consistent with 5W 1H analysis, has been fully adopted by Toyota
which ensure occupational safety). Koskela (1992), in a published and was included in the TPS system as the main method for building the kaizen
report, emphasizes that construction companies should implement approach (from Japanese - continuous improvement) (Kato and Smalley, 2011).
228 K. Misiurek, B. Misiurek / Safety Science 92 (2017) 225–231

Table 1 understood human errors - including problems in the field of occu-

The impact of methods included in the TWI program on the elimination of the root pational safety.
causes of losses ascribed to human errors. Source: Own work. Explanation: X indicates
that the method can affect the elimination of a specific root cause.
The TWI program can have an impact on the elimination of all
the root causes of human errors. It therefore influences the reduc-
Methods Root causes of losses ascribed to human errors tion of the level of the accident rate of which human errors are
included in the
TWI program
Non-compliance with A lack of or A lack of a direct causes. The TWI program is universal because it can be used
the work standard due to poorly supervising in any area of human activity, and thus also in the construction
its bad design executed process
industry (Dinero, 2005). However, its implementation in the area
of the construction industry requires appropriate modification.
TWI Job X 4. The developed methodology of improving occupational
Methods safety in the construction industry which operates on the basis
of the TWI program
TWI Job Safety X X
In a preventative approach to safety management it is most
important to identify hazards (Heinrich, 1959). When a hazard is
Bullet How to identify and eliminate hazards in a workplace identified, it should be eliminated. It is the most effective preven-
and how to safeguard against them using technical mea- tative measure (see Fig. 2). If the elimination of a hazard is not pos-
sures if it is not possible to eliminate them (TWI Job sible, a technical measure, which will secure the hazard, should be
Safety). developed. The next action should be the designating of the speci-
fic hazard with a warning and the training of employees on meth-
Each of these skills were developed by a separate method of the ods of dealing with it. The least effective preventative tool,
TWI program. This program is a very effective way to eliminate the although important and reasonable, is seen to be personal protec-
root causes of human errors (see Table 1), and thus effectively tive equipment (PPE).
influence the reduction of accidents. The developed methodology of improving occupational safety is
The TWI program has been implemented in thousands of man- presented in Table 2. It is orientated to the reaction on hazards in
ufacturing companies around the world (Graupp et al., 2014). The accordance with the hierarchy of the effectiveness of remedial
program is universal because it is oriented to describe the work of measures shown in Fig. 2 and built on the basis of the TWI pro-
a man, not processes (Misiurek, 2016). The TWI program can thus gram. Each method from the TWI program is a separate tool. The
be implemented in all areas where there is human labor, including developed methodology extracts from these methods the most
the construction industry. The TWI program effectively translates important points that have an impact on improving occupational
into an improvement of all the key performance indicators of a safety, and can also be used in the construction industry.
company, as was demonstrated by research conducted after the The way of preparing a JBS is described in the second main step
Second World War among the 600 companies that implemented of the methodology (see Fig. 3). Regarding occupational safety, the
this program (Wrona and Graupp, 2006). For example, the Ameri- describing of key points in the JBS is crucial. Each key point is an
can Shipbuilding Company - Consolidated Steel Corp. from Orange identified hazard. The fewer key points in an operation, the less
in Texas attributed the following result to the TWI program over a chance of the occurrence of human error. It is important to elimi-
four year period (War Manpower Commission, 1945): nate key points, and if this is not possible, to facilitate their
Bullet Reduction in accidents 70%,
Bullet Increase in production 45%, 5. Conclusions
Bullet Reduction in tool breakage 75%,
Bullet Reduction in training time 78%, A preventative approach should prevail in the process of ensur-
Bullet Savings in manpower 45%, ing safety (Reis et al., 1999; Schneid, 2011). It is associated with an
Bullet Reduction of scrap 69%. early identification and prevention of accidents, and not a reaction
to accidents that have already occurred. Accidents are usually a
These studies show that the TWI program effectively translates direct result of human error. The key is to eliminate the root causes
into the elimination of most of the problems related to broadly of problems, as they generate direct causes. The three root causes

Fig. 2. Hierarchy of the effectiveness of remedial measures. Source: Own work on the basis of Heinrich (1959).
K. Misiurek, B. Misiurek / Safety Science 92 (2017) 225–231 229

Table 2
Methodology of improving occupational safety on the basis of the TWI program. Source: Own work on the basis of Heinrich (1959), Rother and Harris (2001), Dinero (2005, 2011),
Wrona and Graupp (2006) and Kato and Smalley (2011).

Major steps of the methodology Key points in the methodology Reasons for key points
1. Selection of an operation to be 1. Operations which are significant in terms of potentially 1. For these operations there is a greater probability of human
applied in the methodology existing hazards (with many incidents potentially accidental) errors occuring
and complications (difficult operations) should be chosen first
2. Creation of a Job Breakdown Sheet 1. Specification of major steps in an operation 1. Major steps describe the method of work - what should be
(see Fig. 3) done. It is important to write down the procedure of an
operation in a major step (see Key Point no. 2.1)
2. Determination of key points in an operation 2. The way work is performed depends on its key points - how
a major step should be performed. Every key point informs
employees about a potential human error, and thus about the
risk of accidents
3. Specification of reasons for key points 3. Justification for the implementation of a specific key point
has an influence on the creation of an employee’s awareness.
When people understand why they have to do something in a
particular way, they pay more attention to the procedure
3. Conducting the process of 1. Use of the 5W1H approach 1. This approach initially focused on the elimination of key
eliminating and improving key points (including hazards), and then on their improvement
points (the method of performing 2. Use of the following questions: Why? and What is the 2. These questions aim to find ideas of how to eliminate key
work) purpose? for each key point points
3. Use of the following questions: Where ?, When ?, Who? and 3. These questions are focused on finding ideas of how to
How? for the key points for which there were no generated improve key points by changing the following: the place of
ideas for their removal their execution, time, people and procedure
4. Writing down ideas generated from the question session 4. Generated ideas are not yet solutions. They need to be
included in the 5W1H approach written down in order not to be forgotten. They should be
submitted for CBAa analysis
5. The implementation of the generated solutions in the 5. After the conducted CBA analysis, ideas that do not require a
method of performing an operation lot of effort and improve occupational safety should be
4. Preparation of warnings for each 1. Use of the One Point Lesson (OPL) 1. OPLs are a graphic method of presenting a correct and
safety related key point incorrect procedure. They should be written next to an
operation in order to continuously inform employees about
the most important hazards
5. Identification of necessary 1. Depending on demand in a specific operation 1. There should be individually selected personal protective
personal protective equipment equipment for each operation
6. Preparation of a JBS for a new 1. Taking into account the new standard of work, OPL and 1. The JBS should comprehensively describe the method of
method of performing an personal protective equipment work, but also contain warnings and information about
operation hazards. It is a document that will be used for on-the-job
training (see Major Step no. 7)
7. Training of employees in the new 1. Use of the TWI Job Instruction method 1. This method is widely recognized as the most effective
standard of work method of transferring practical knowledge. Training
according to it requires a prepared JBS. The method is based on
the transmission of knowledge in small enough parts for a
man to be able to remember
8. Maintaining the methodology. 1. Conducting regular audits 1. Regular audits in the area of work are one of the most
effective tools to maintain labor standards. Moreover, an audit
is a tool to identify problems and can be used as an
improvement tool because, on the basis of non-compliance,
remedial measures which influence the improvement are
Cost-Benefit Analysis – the investment/project’s efficiency assessment method taking into consideration all projected benefits and costs. Helps to predict if benefits
exceed costs (Brent, 2006).

Fig. 3. Job breakdown used in a TWI Job Instruction. Source: Based on Wrona and Graupp (2006) and Misiurek (2016).
230 K. Misiurek, B. Misiurek / Safety Science 92 (2017) 225–231

Table 3
The impact of the developed methodology of improvement. Source: Own work. Explanation: X indicates that the specific step of the methodology can affect the elimination of a
specific root cause.

The major steps of the developed methodology Root causes of losses ascribed to human errors
Non-compliance with the standard of work A lack of or poorly A lack of a
due to its bad design executed training supervision process
1. Selecting operations to apply in the methodology X
2. Preparation of a Job Breakdown Sheet X
3. Conducting the process of eliminating and improving key points X
(the way of performing work)
4. Preparation of warnings in the location of the occurrence of each X
key point related to safety
5. Identification of necessary personal protective equipment X
6. Formulation of the JBS for the new way of performing operations X X
7. Training of employees in a new standard of work X X
8. Maintaining of methodology X

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