During the recent Pulp & Paper Safety Association (PPSA) meeting in San Antonio, TX, a call to action panel discussed the possibility of what could be seen as a sea change in the safety arena: to stop using the recordable incident rate as the be-all and end-all of how to judge safety performance. The panel was chaired by Joy Ausman, Clearwater Paper, Matthew Kanneberg, WestRock, and Paul Bierly, Domtar, but it must be said they were speaking for the entire board of directors of the PPSA, which has been discussing this issue for more than a year.
Low recordables do not signify a good or bad mill. The industry needs to learn to move beyond TRIR. It may not be a true indicator of the mill of 2019 compared to the mill of 1955. It is still required by law, so mills will continue to collect the data, but as the panel members pointed out, the difference will be in how the industry uses this data.
What follows is PPSA’s call to action text.
For many decades the industry has made great strides in improving safety results. The industry safety journey has moved from a laissez faire approach, through focused compliance, prioritization, adopting a caring and values methodology and today—amidst a true understanding of science—a human organizational performance approach. Our efforts and successes have been immeasurable and many of us are on the cusp of greatness, but one critical challenge remains.
There is a seemingly unshakable obstacle that impacts all industry, a self-induced barrier in how we use lagging metrics—our failures—to evaluate and compare our performance.
More specifically, and certainly the worst, is the use of the Total Recordable Incident Rate (TRIR) to grade, compare, and incent not only our organizational performance, but the performance of individuals. Our industry is not alone in this challenge. While a number of organizations within the pulp and paper industry have moved past this barrier, the prevalent cloud of its past misuse remains ingrained in our culture.
For those in the safety profession, the challenges faced regarding this very specific number have been daunting and exhausting to say the least. While it is recognized this regulatory measure provided useful statistical data to the Department of Labor, it is likely OSHA forefathers never anticipated the albatross the TRIR rate would become, or that it would become one of the most hijacked, misused, and manipulated statistic of all time. For safety professionals charged with interpreting a recordable injury, the statistic became one of the murkiest interpreted of all measures, even though its criteria are very black and white.
One of the most disillusioning statistics in recent years is the false premise of what was believed to be an indicator of a strong safety performance—the Holy Grail: a sustained period of zero recordables. However, when analyzing site serious injury and fatality (SIF) incidents, recent studies have identified no correlation in SIF occurrence between locations with low TRIR and those that experienced higher incident rates. Yes, you are reading that correctly. Over time, facilities that have zero or low incident rates are experiencing SIFs at a rate comparable to sites with higher TRIRs.
This is significant in light of many of our organizational systems that focus attention and improvement methodologies on facilities with higher TRIR. By design, we have removed the focus from facilities with few or zero recordable incidents. In reality, instead of using TRIR to manage our safety efforts, we should be measuring a site’s organizational capacity and the strength of their risk management systems. Simply put, what we incent, grade, and compare must be our capacity and system strengths versus relying on our self-reported, OSHA mandated, documented failures.
Let’s test this philosophy with a comparison of how this data is commonly used today. Answer the following million-dollar question: Given organizations with similar population, risks, and resources, which of the following three sites is safest when comparing their 2017 OSHA TRIR rate: Site A: 3.45 TRIR; Site B: 0.00 TRIR; or Site C: 0.98 TRIR?
If you believe the question is in fact a trick one, it may only be because this article has prepared you for what is a reality. It is simple to illustrate the influence and manipulation that occurs intentionally and unintentionally every day. For the purposes of this analysis, we are going to assume all three sites are not intentionally manipulating the numbers. So, what is your answer? If you have been relying upon TRIR, as many have for the last decades, you will likely lean toward Site B as the best performing site in safety and Site A as the worst. This may appear obvious because the higher ratio of injuries to employee hours indicates more medical treatment is occurring at site A than B. If your answer is that you do not have enough information, you are on the right path to understanding the intent of this article. But for the consummate safety professional and thoughtful leader, the answer is very quickly “The TRIR rate alone gives you little to no understanding of the site’s safety performance capabilities.” To understand why, let’s look at some additional context about each site.
SITE A: 3.45 TRIR
• In 2015, the site initiated and rolled out a comprehensive leadership approach using human organization performance methodology. Its primary goal was a reduction in SIFs and to identify precursors and eliminate high risk gaps.
• The site only tracks TRIR for annual reporting purposes for OSHA. It does not use TRIR for a goal, performance bonus, incentive, comparison, grade, or as a measure of safety excellence. Leaders view a soft tissue recordable that was caught early as a positive indicator, believing that an employee may receive medical treatment resulting in a recordable, but likely preventing a rotator cuff surgery in the future.
• In addition to an experienced and competent 20-year industry safety professional, the site has a general manager that experienced a site fatality early in his career after having a string of three years without a recordable incident.
• The site’s key safety goals for 2017 were:
− Complete separation of powered industrial trucks and pedestrians in all areas of the site, not just allowing a focus on warehouse traffic. To accomplish this, a site logistical study was conducted, engineering controls were put in where the two types of traffic overlap, significant management system improvements were implemented, and auditing of those systems is ongoing.
− A significant capital project kicked off modernizing the site’s 40-year-old rewinder where countless SIFs had occurred sporadically over a four-decade period.
− Trend analysis indicated 50 percent of the injuries experienced were soft tissue related, so an industrial athletic trainer was contracted to target early intervention, implement a proactive ergonomics focus, and conduct a significant amount of wellness training.
• The site had six recordable injuries.
− A back injury resulting in 16 lost days from an employee slipping down wet stairs.
− A hand laceration resulting in three stitches received from an unforeseen nail on a shipping container.
− Employee visited athletic trainer (AT) with soreness in lower back. AT provided cold/heat therapy and prescribed stretching exercises to expedite the recovery. Based on the exercise treatment the injury was a recordable.
− An employee slipped and fell in the parking lot. Site leadership immediately took the employee to the doctor to be evaluated. X-rays indicated there were no breaks, but to help reduce swelling, the doctor prescribed a 600-mg anti-inflammatory medication. The site had 400-mg over-the-counter (OTC) doses in their first aid room, but the site leaders long ago had abandoned the need to manage medical care or “self-doctor.” Instructions were not provided to persuade the doctor from giving prescriptions or a need to ‘manage’ around an injury to avoid a recordable record. The fact that the employee was taking 600 mg of ibuprofen versus 400 mg had no impact on the root cause of the incident or the ability to prevent it. Site leadership did not believe that they knew better than a doctor on care management and to do so would be contrary to every mission, value statement, or vision policy posted on conference room walls across their job site.
− An employee visited the AT after being assigned a new job where they had to lift material above their head many times a shift. The employee spoke of moderate muscle pain in the shoulder and upper arms. The AT noticed that certain new muscles were being used and needed to be strengthened to help the employee avoid pain and tearing. The AT gave the employee resistance bands and showed the employee how to use the bands to strengthen the muscles required for the new task. The AT also gave OTC ibuprofen. Because the AT provided resistance bands, which equated to exercise instructions needed to strengthen and condition, the treatment was recorded because it was not on the OSHA list of first aid.
− An employee had an allergic reaction to a bee sting in the woodyard. The employee missed the next day of work to recover and to allow swelling and discomfort to go down.
SITE B: 0.00 TRIR
• The site had two years without a recordable injury. The site’s safety professional was new, and the general manager was very involved in the determination of recordable injuries. The general manager required the safety professional to be in the exam room every time someone sought medical treatment. They had several workers’ compensation cases, but would always manage to eliminate the need to record anything based on the general manager’s own interpretation of the recordkeeping requirements.
• The site has several key metrics around TRIR rates to include incentives for achieving zero recordable incidents within a department. The site provides a steak dinner for department teams that are able to work a year without a recordable incident. In 2016, the site presented jackets to all employees for experiencing a year with zero recordables.
• The site truly and sincerely shares a message that the company cares about employees and that their efforts in safety are to drive injury-free results and get their fellow workers back home safely. The general manager is well respected, truly cares for the employees, and is recognized by the company as a good and solid leader.
• One of the site’s key system gaps is its limited capacity around incident investigation and root cause analysis skills. And frankly, with such good incident rates they have not had much practice. Though they do have many near misses, some serious, they are not performing a deep dive or rooted cause review. They have recognized from an online benchmarking seminar that tracking near misses is important, therefore one of their annual goals was to collect more. And just like all other safety incentives, they have taken it seriously and increased near miss reporting by 300 percent in 2017.
• The site’s annual plan aligned closely with the corporate goals:
− Lower hand lacerations
− Improve near miss reporting and tracking
− Track employee involvement in Behavior Based Safety programs
• Shortly after posting their second consecutive 0.00 incident rate for a calendar year, on February 12, 2018, the site had an SIF occurrence. An employee’s arm was pulled into a nip and amputated at the shoulder. After company safety professionals investigated, rooted issues in Management of Change (MOC), allowing increased access to the hazard and a 1960s era equipment design allowing an exposed in-running nip were identified.
SITE C: 0.98 TRIR
• The site has a very old school general manager who has always gotten results with a punitive approach to safety discipline. Of the last five employee reprimands for safety, four were given after an injury had occurred.
• The site had only two recordable incidents—both were SIF classified injuries:
− A maintenance employee sustained multiple broken bones after a fall from an elevated work area while trouble-shooting an issue at 2 a.m. that was causing down time. The employee was disciplined for not following the written fall protection program.
− An employee received 30 stitches when he walked around a blind corner in a warehouse and his upper thigh was struck by the forks of a powered industrial truck. “Employee inattention to surroundings” was identified as the root cause.
• The site has many of the best written policies in their company, but they are almost verbatim to the OSHA standards and are a statement of policy—not a management system. The policies are well communicated, employees have access, and are typically linked to employee misconduct after an injury.
• The site has very little employee engagement, and attendance at the central safety committee meeting has been nicknamed the “root canal hour.”
Provided the site scenarios and only a little more information, it’s clear that evaluating safety by TRIR alone is misguiding. What appears to be the worst performing site (A) has the mature culture and more system capacity than both of the other locations. Site B would have likely received the least attention in a typical comparison. However, the site has a lot of low hanging SIF potential precursors that could be identified by basic safety evaluations or root cause analysis of their serious near misses. But because there were zero recordables, senior leaders instructed resources to attend to other sites with higher TRIRs.
The site with the TRIR performance in the middle (site C) most likely had the poorest safety culture. They appear stuck in the Dark Ages with a philosophy that discipline had a positive impact on safety, which resulted in a cause and effect culture where incidents were not reported, management was not trusted, and employees rarely became engaged.
You likely predicted the skewed results of each site based on the start of this article. But if you believe that these three scenarios do not represent real life situations and are extreme scenarios used to prove a point—you are wrong. Chances are you’re lucky to not have had the hard-earned lesson of the site leader who stood on the edge of a gravesite in the company of a spouse and children of a deceased employee. Who has the lowest TRIR, how our TRIR compares to others, or if we receive a bonus attributed to a TRIR is inconsequential if we continue to have SIF incidents. Sadly, at a micro level, the incident rate does not have the significance we once thought it did. And the gut realization that all of the collective effort, energy, and manipulation used to manage that number to zero took our eye off the real goal and continues to do so today.
What truly matters is the elimination of serious, fatal, and life-changing injuries. Of course no one wants any injury, including those requiring minor care. Therefore, we should investigate with rigor and put in controls to prevent their occurrence. But it is paramount that when given our risk, the challenge of fast paced technology, increased turnover from an aging workforce, limited resources, and the drive to become more competitive, we must focus on the higher risk first and not waste time on engaging and distracting our limited resources on managing and manipulating a number that does not indicate safety performance on a micro level. In certain instances, such as early intervention of soft tissue injuries, a recordable incident may be a positive metric of holistic prevention.
Let’s focus on some industry comments in recent years.
A recently hired senior operational leader: I transferred from an industry competitor that was very focused on Human Organizational Performance and human factors and the company had long since abandoned the internal use of TRIR. Within the first month of working for my new company, I heard that CEO wanted to be at the top of the industry related to TRIR. I understand he wants to be competitive, but believe he demonstrated a failure to understand what TRIR was designed to measure. (I’m) very frustrated to take a step back in safety philosophy and I’ve now come to recognize that many of our senior leaders really don’t get it.
A facility general manager: I’ve always felt like the emphasis we put on TRIR was hypocritical. At times when we were really working hard on safety, focusing on engagement and management systems, I was still getting tons of pressure from senior leaders to do more because we had a few recordables, none of which were serious. Then at other times, when I had a zero, no one bothered me. It felt good to be out of the spotlight, but eventually we started getting complacent and had more serious near misses, but no one was looking at those. As I have matured as a leader, I have ensured I have strong safety resources, good employee engagement, and all my leaders working on high risk systems. I deflect the focus on TRIR from the outside away from our employees and just do the right thing. But I still have that TRIR looming over my head with no real consideration to what I am really doing on site. I also have a really hard time getting capital money just for safety when there is no return-on-investment. The corporate group hammers me for a few minor recordables, but when I explain I need capital to update aging hazardous tanks, their safety hammer vaporizes.
MANY OTHER EXAMPLES OUT THERE
If you have been in a site safety or key leadership role for more than a decade, it’s almost certain you have heard or lived these examples. And to be kind, we have left out many examples of misuse and manipulation of TRIR where the decision was unethical and willful and often affected the potential to receive awards and monetary bonuses. The saddest part of all is that these decisions were self-inflicted using a TRIR measure that was never intended to be used at a micro level. And, in most cases where the number was manipulated, there was an unintended cause and effect—one where leaders at all levels had no intention of creating a barrier and certainly cared about people and an improvement in safety. Whether it’s unintended or willful, in order for true and effective safety practices, systems, and culture to grow, the practice must stop.
Reliance on a TRIR rate can be an emotional topic. As such, it is imperative to summarize the critical talking points and identify the key call to action.
• The challenge with TRIR is not a pulp and paper challenge; is an in inherent barrier in all industry. However, our goal is to move our industry past this barrier and to be the leader of all manufacturing related to solid safety results and continuous safety improvement.
• In the majority of cases where TRIR has been used improperly to incent, compensate, grade, and compare our safety strengths, there was no ill intent. The motivation has been to help drive safety improvement. For most of the last two decades, awarding pizza parties, jackets, and other incentives was a benchmarking best practice to help drive better safety performance. We have all done it; we were all trying to help. But as TRIR rates dropped off, improvement in the number of SIFs has flatlined for more than a decade.
• This article does not diminish the importance of a site which has sustained zero recordable incidents. Low incident rates can be a positive indicator, especially when the rate consists of low-severity cases. Rather, the message is to ensure that our industry understands that solely relying on TRIR may lull one into a sense of complacency, missing SIF precursors that might exist. In addition, this article serves to demonstrate ways in which a hyper focus on TRIR can be a potential barrier to understanding authentic safety performance. This may cause leaders to waste time and energy, or worse, exercise poor judgement in the interest of protecting the site from outside consequences when they experience recordable injuries.
• It is not our intent to say not to measure TRIR. First of all, it is not our number to give and take. Secondly, it is a regulatory requirement. TRIR is likely not going away, and annually we must continue to report our numbers. But the first step in recognition of our misuse is simply to understand that the original intent of the TRIR was for macro statistical comparison of industries. It determined OSHA funding and was used for targeting regulation and resources.
• In reference to discipline, it is not the intent of this article to debate when and how discipline should be used. In some cases, it is necessary, prudent, and even referenced in OSHA standards in order to enforce compliance. The references within this article are used to illustrate the harm that unhealthy use of or the significant value some leaders believe employee discipline has on improving safety. Some have been applying discipline for decades with an iron fist. Where have the SIF improvement results been if it’s truly helpful? Appropriate discipline should be used where applicable, but only when human performance factors are weighed within the review of the incident, root cause analysis has been completed, and a true look in the mirror for shared just and fair accountability has been evaluated. It is critically important to have a far higher ratio of “pre-incident” discipline than “post-incident” discipline to ensure fewer barriers to incident reporting.
In conclusion, over the past three years, PPSA has systematically taken steps to remove our own recognition and awards programs that have targeted lagging indicators, and are replacing them with employee engagement, leadership, and management system best practice recognition. We will continue to do so, but now we implore all within the industry to join our cause, an industry call to action.
We ask all industry companies and supporting associations that are still using TRIR inappropriately to stop using TRIR measure to incent, grade, or compare a company, division, or site’s safety strength. Using the TRIR number to compare your company’s strengths against a competitor is not helpful, and just like the three site examples given, may falsely direct you to or away from benchmarking a better company. We encourage companies to track solely for its intended purpose and replace the lagging metric with high severity metrics and leading metrics that identify SIF precursors, measure employee engagement, and specifically target demonstrated leadership activities at all levels. This includes not using TRIR for monetary bonuses, prizes, or any perceived carrot that is dangled and then taken away when a failure occurs. Simply stop measuring performance by failures, and start looking at capacity and system strengths. Focus on high risk activities with continuous improvement in applying multilevel engineering and elimination controls. This includes removing location signage that indicates “days without an injury”—as that number increases, it often leads to suppressing incident reporting.
We ask industry senior leaders to seek to understand how misuse of TRIR has affected your company in the past and present. We encourage open debate in a non-threatening atmosphere where leaders at a site level can share the dynamics and influences when the measure is used inappropriately. Listen to your competent and trusted safety professionals who have worked in and around this barrier for decades. Collaborate with the human resources function to align performance management, recognition, and reward systems toward leading indicators.
For companies who have already abandoned this misuse and overemphasis, reach out to fellow competitors and help guide them to remove this self-induced barrier which can have an unintended cause and effect. For those most mature in our industry, share your testimonials regarding how you care about employees’ quality of life. Advocate the use of medical resources, early intervention of pain and discomfort, and err on the side of caution to ensure employees receive quality care directed by health care providers. Encourage colleagues to do all these things in good faith, even if that compassion comes with tipping the scales of compliance with a need to record even a very minor injury.
FINAL THOUGHT FROM A 25-YEAR SAFETY PROFESSIONAL
The day I can just care about an employee at the moment they have an issue (pain, medical concern, injury, or potential re-aggravation of a personal injury) and just help them get medical attention without the albatross of negative consequences hanging around my neck…I will likely go to my office, close the door and really just have a good cry. No one really understands how we are conflicted to always do the right thing when we could be admonished for providing reasonable care. Why can’t we provide a level of medical treatment that exceeds all abundance of caution while showing compassion for a fellow employee? The cost is inconsequential compared to the long-term credibility damage we cause when managing a case to avoid the OSHA recordable threshold. I am just exhausted playing the recordable game all these years.
THE PANEL WRAPS UP
In conclusion, the panelists said that performance should not be measured by failure. Start looking at capacity and system strengths. Allow employees to fail safely. Encourage a reporting culture. Safety is not the absence of injuries; it is the presence of defenses.