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E34: The failure of critical controls in construction · Safe As Podcast

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  We invest so much in risk management, risk reduced
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  designs, protective equipment, engineered safeguards.
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  We design and implement these measures believing they'll form
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  a robust barrier between hazards and harm.
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  But then in a moment, despite all that effort in pursuit
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  protection, a serious injury or fatality occurs.
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  You left asking how how could that happen when the very
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  controls designed to prevent it were supposed to be in place?
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  Did the control fail or was the failure mine in my assumptions
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  or knowledge of how that control will function in reality?
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  Good day everyone. I'm Ben Hutchinson and This is
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  Safe as a podcast dedicated to the thrifty analysis of safety,
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  risk, and performance research. Visit safetyinsights.org for
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  more research. Today's study is from Salek,
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  Hassle and Katani from 2022. Titled Determining the
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  Reliability of Critical Controls in Construction Projects, It
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  analysed 10 years of serious and fatal Accident Investigation
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  reports from 4 international construction companies.
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  The main goals were to assess the reliability of the company's
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  critical controls and identify factors affecting that
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  reliability. The authors previously proposed
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  that the construction industry should focus more on risk
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  treatment like a critical control approach to prevent
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  fatalities, much like this happened in oil and gas and
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  mining. So what are critical controls?
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  Well, there's specific types of safety barriers that directly
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  prevent the unplanned release of energy that lead to major
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  accidents, directly prevent event consequences from
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  escalating, and types of unique controls with a specific
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  incident pathway. So, as noted in the paper,
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  regulatory data suggests that between 85 to 90% of fatalities
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  are events occurring from common high risk activities which have
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  controls already defined within the SMS.
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  That is, based on this data at least, most fatal and severe
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  incidents are less about novel situations and more related to
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  barrier reliability. Essentially, in the study, the
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  effectiveness of a control is simply the ratio of the number
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  of failures of the control when challenged compared to the
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  number of occasions the control was challenged.
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  Now, controlled reliability also depends on the type of barrier
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  and its interdependency on human action and the effectiveness of
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  the safety management system supporting the reliability of
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  the barrier. The paper has a detailed process
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  for how it measures this, which you can take out yourselves.
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  So jumping into the methods, the study collected 186 serious and
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  fatal event investigation reports.
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  A panel of four safety professionals analysed reports
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  and determined essentially their mechanisms of failure and the
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  critical control performance. The most frequent major accident
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  events included driving interactions, lifting operations
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  as in dropped loads, et cetera, uncontrolled energy release and
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  falls from height. So what did they find?
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  Well, regarding the critical control performance, overall,
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  the implementation of critical controls of course across all of
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  the major accident event categories averaged a mere 57%.
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  This means only 42% of the critical controls were assessed
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  as both implemented and effective.
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  On average, even when they were implemented, the effectiveness
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  of the critical controls averaged just 41%.
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  Mobile equipment and lifting operations had the strongest
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  critical control implementation rates.
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  Stored energy had the lowest implementation rate.
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  Overall, engineering control showed the strongest
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  implementation rates, likely because field personnel monitor
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  their integrity more often. Interestingly, while stored
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  energy critical controls had low implementation, they delivered a
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  higher rate of effectiveness when they were actually
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  implemented. Expanding on the findings, while
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  the study highlights some other critical issues, all four major
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  accident event categories were found to have a high proportion
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  of weekly or not implemented critical controls and therefore
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  were not effective in preventing the release of hazardous
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  energies. Critical controls that were
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  rated as weak, which is less than 50% reliability, were
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  deemed unreliable because they failed more times than the
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  critical control was effective. And with the critical controls,
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  there was a high reliance on human performance like operating
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  plants, vehicle inspections or maintaining inclusion zones and
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  these had a higher rate of failure.
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  This finding aligns with the hierarchy of controls,
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  emphasising the human reliant controls are generally less
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  reliable than engineered ones. So what do we make of these
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  findings? Beyond just highlighting the
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  importance of critical controls or barriers or direct controls
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  or whatever you call them, the authors stress the need to
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  consider individual and organisational factors that
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  directly impact a critical controls reliability.
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  This means we need to deeply consider how the controls are
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  designed, implemented, communicated, understood,
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  perceived and resourced. Crucially, need to understand
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  how people actually interact with the controls in the field.
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  This might involve deeper work in areas like safety, critical
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  task analysis or work domain analysis.
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  The study also emphasises setting people up to succeed.
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  For example, supervisors facing constant changes in schedules or
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  resources often couldn't complete the expected critical
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  control support activities. This is more than just measuring
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  involves a deeper nuanced understanding of real hazardous
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  work. This leads directly to
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  paraphrasing Stephen Kerr's famous statement.
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  There's a fully in expecting a you know, fully functioning
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  critical controls while under resourcing.
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  B the support training time and attention needed to make the
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  controls reliable. And while the lower mechanistic
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  reliability of human controls is well known, like in human
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  factors, this isn't a weakness. Humans excel in other areas,
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  providing the much needed adaptability and agility to make
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  our dysfunctional systems work. Quoting Decker, people finished
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  the design. So what were the limitations?
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  Well, it was a selective sample of performance failures, meaning
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  they only analysed events essentially where a control had
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  already failed. This means it doesn't represent
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  the reliability of these controls in normal non failure
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  conditions. It also didn't assess cultural
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  factors of broader commercial and delivery strategies.
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  That's it on Safe as. I'm Ben Hutchinson, please help
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  share, rate and review and checkoutsafetyinsights.org for
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  more research. Finally, feel free to support
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  Safe As by sharing a coffee link in the show notes.