HSE makes paper progress
Chris Dyer reports on a sectoral initiative that cut major injuries by a quarter and could have a wider application.
In the mid-1990s, the major injury rate in the paper industry exceeded that of construction, with 10 mills accounting for about one-third of major injuries in the industry. This was difficult to explain on the basis of hazards, and there was a consensus within the industry that it was linked to standards of safety management and culture.
In 1996, prompted particularly by the Graphical, Paper & Media Union (GPMU), the HSE's Paper and Board Industry Advisory Committee (PABIAC) decided to sponsor research to test this hypothesis and investigate both the high injury rate and apparent disparity between mills. Following an initial investigation, which found that standards of safety culture and safety management were variable and generally inadequate, the PABIAC drew up a programme for halving rates of reportable injuries over three years. (The rate of fatal and major injuries in the paper industry was twice that of UK manufacturing generally.) The PABIAC initiative was launched in April 1998, and sought to:
The HSE has recently published a report on research that it commissioned to assess the initiative.1 The research, which began in May 2001, examined safety culture and safety-management systems, which are covered in this feature, and techno-logical risk, which varied little during the study.
SAFETY CULTURE
The research found there were significant improvements in safety cultures over the period of the initiative (see box 1). Although weaknesses were still noted, these were less prevalent.
Mills with good safety cultures typically had accepted definitions and standards of safety-related behaviour. Employees understood what was required in terms of safety performance, understood the rationale for safe systems of work and personal protective equipment and complied with these systems. They also knew the consequences of failing to comply, such as increased risk of accidents or disciplinary action.
Several mills had tried to improve safety attitudes and behaviours through behavioural safety initiatives, but these had rarely been successful. The report concludes that behaviour-based safety is not an appropriate mechanism to improve safety culture until basic levels of safety management and safety culture have been achieved.
Line management and supervision was a continuing problem and was recognised as central to improving safety culture. A common pitfall was the failure to get supervisors to "buy-in", a critical factor in achieving safe attitudes at all levels. The application of pressure on those with supervisory responsibilities can also prove counter-productive without support and training.
The better mills, with successful line management buy-in, had recognised the need for workforce involvement and consultation. "Effective means of communication" was raised as one of the significant elements of a good safety culture. The impacts of poor communication were varied, and included "missed opportunities", where shopfloor personnel had recognised problems or solutions that had not been followed up.
Safety belief and commitment
An organisation-wide belief in safety was an important element of safety culture. It was manifested in various ways, for example a belief that accidents are preventable and can be controlled by safety initiatives. In good safety cultures, all levels of staff exhibit these beliefs. But there were also instances of accidents being described by managers and staff as inevitable, disillusionment or frustration with the "latest safety initiative" on the shopfloor and perceptions of safety as an unattainable goal.
Management in mills with a poor safety culture perceived workers as lacking common sense. Workers tended to be aware of this as a postulated reason for high injury rates, and were fundamentally opposed to the idea that they would put themselves unnecessarily at risk. Nevertheless, perception plays an important part in this argument; workers at many of the mills displayed a "macho" attitude towards hazards seen as inherent to the job.
All mills appeared to be committed to improving their safety performance and achieving the PABIAC objectives. Where safety culture was lacking in fundamental areas, mills tended to recognise their failings and were striving to improve, making a good start with an awareness of the difficulties and the time required to turn around a mill's safety culture.
SAFETY MANAGEMENT SYSTEMS
Standards of safety management significantly improved over the period of the initiative, particularly the "measure", "audit" and "review" elements from the HSC's core framework, HSG65, which were not evident at the outset (see box 2). An important element of a good safety management system (SMS) was how it used organisational learning elements such as audit data, accident and near miss root causes and accident statistics.
Training was important at all mills. Many attributed to this to the PABIAC initiative, though some also cited downsizing and multi-skilling programmes as drivers. Two main types of training were included: generic safety training, including NVQs; and more specific training, either routine skills renewal by the mill, or to provide competence in a new area. The specific training was driven by the need to increase the diversity of employee skills due to company changes.
Most mills had recognised the inconsistency in the "sitting with Nelly" approach to worker training, moving towards induction according to working procedures and a more systematic process of competence checking. Shortcomings included: a lack of methods for ensuring that people could safely carry out their jobs; reliance on individuals recognising the limits of their competence; poor linkages between safe systems of work and risk assessment within training; and reliance on informal assessment methods.
Risk assessments
The quality of risk assessments varied hugely, both across and within mills. Elements of best practice included:
Poor practice included assessments that:
Risk assessments were more effective where employees were involved, and mills successful at risk assessment used shopfloor personnel to develop them. This fostered employee acceptance and use, both of the assessments and controls and of accompanying procedures or systems of work.
The practice of using assessments to "feed forward" into areas such as work statements and training needs was clearly identifiable within the mills where risk assessments were perceived as useful, and more than a paperwork exercise.
The process of developing, documenting and adhering to safe working practices was at various stages at the mills. As with risk assessment, safe systems of work require the involvement and ownership of those carrying out the work activities. Where involvement was gained through either a link to the risk assessments, or procedures developed through worker consultation, the safe systems were both used and praised as having greater relevance to tasks.
Reporting, investigation and improvements
Although most of the mills seemed to be focusing attention in this area to some degree, the overall rate of reporting could still be vastly improved, as could the methods of devising and implementing corrective actions. Critical to the effectiveness of reporting schemes is the role of investigation to identify root causes and implement corrective actions. The most effective schemes were those where all incidents were investigated with a team composed of management, safety reps and employees using some sort of root-cause analysis technique; the findings from the investigation were then reviewed by management and discussed at the appropriate safety committee. A culture of following up accidents and informing personnel of the outcome supported this effective process.
All mills had some form of reactive monitoring (even where this was only accident reporting), but only a few had systems for proactively seeking areas to improve. One method, which worked well, was a procedure whereby employees could fill in a form identifying action needed and suggesting a control method. Another method, with similar outcomes, was the creation of safety-dedicated teams, with each department charged with identifying its own areas for improvement. These processes all encourage workforce participation, improved communication and the maintenance of a proactive attitude to safety.
The main positive and negative issues associated with proactive monitoring are that involvement improves the quality of the process but that there is a danger that the process may simply generate a long list of maintenance items. The most effective mills carried out monitoring to ensure that improvement systems did not just generate lists of "jobs to do", and were also not misused as a method of "jumping the queue" on engineering tasks.
Experience highlighted the need to ensure effective feedback loops, since reporting "into a black hole" was hugely detrimental both to further use of the system and the perception of management efficacy. When issues were not resolved quickly enough, people became disheartened and systems fell into disuse.
Most mills developed a system for measuring and auditing performance, but this was rarely linked to whether or not systems were achieving the objectives. Most mills also lacked a fully developed review processes, although some did have a system for keeping action plans up to date.
INITIATIVE MAKES THE CUT
The researchers found that the fatal and major injury rate reduced across the paper industry by 26% over the three years of the initiative, ie 174 fewer people were killed or seriously injured during the initiative (the over-three-day rate fell marginally). The PABIAC initiative appears to have played an important role in this reduction. Improvements are still required to bring the paper industry into line with rates for UK manufacturing generally. Although the reduction fell well short of the 50% target set by the industry, it was achieved against the background of a difficult economic climate, staff reductions and a 30% increase in production.
The evaluation was carried out soon after the three-year point. This was too early to allow evaluation of the quantitative impact on injury rates, but it did provide a good qualitative picture of the effectiveness of the initiative.
Building on the initiative
The PABIAC followed its initiative with "PABIACtion" in April 2001. This set new targets, both tailored to the performance achieved by each company and designed to push the industry towards injury rates similar to those for manufacturing in general. The five-point action plan agreed by the industry's chief executives also stresses compliance with HSE guidance and cooperation between mills.
The new industry target is to halve the incidence rate for all reportable accidents over three years, from 2,783 per 100,000 employees at 31 March 2001 to 1,391 per 100,000 in March 2004. The HSE describes progress during the first year of PABIACtion as "steady", with the rate decreasing to 2,402 at 31 March 2002.
The PABIAC initiative succeeded because of a number of features that are specific to the paper industry but, with care, a similar approach could be adopted in other industries. If an analogous initiative were to be implemented in a larger sector, there might be a need to break it down into homogenous units with a common identity and representation, for example regional agricultural groups. Andrew Porter, chair of PABIAC, said: "We can now see that setting clear targets for accident reduction can work, even for a traditional industry like paper making, and we can learn lessons from this work that can be applied elsewhere."
1"The effectiveness and impact of the PABIAC initiative in reducing accidents in the paper industry", CRR 452/2002, HSE Books, ISBN 0 7176 2527 3, £30 or at www.hse.gov.uk/research/content/crr/index.htm , free.
