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Safety Science 47 (2009) 479480

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

Why safety performance indicators?


Andrew Hale
Delft University of Technology, Safety Science Group, Delft, Netherlands

Andrew Hopkins paper (2008) is a thought-provoking challenge want to avoid the harmful effects happening, if possible, especially
to the safety community (both researchers and practitioners) to get if they are lethal or even more catastrophic. Rasmussen (1997) dis-
our ideas sorted out as to the purpose and functioning of safety cussed this point when he categorized different activities and their
indicators and key performance indicators (KPIs). He shows very requisite safety management regimes. Relying on reactive (lagging)
clearly that neither the Baker report (2007) nor the HSE guidance indicators to guide action is the x and y approach, as opposed
document (HSE, 2006) does that. In particular the HSE documents to that now universally regarded as essential for the major hazard
presentation and use of the Reason model sows extra confusion. I industries, which need to predict and act before the disastrous
agree with much of his criticism, but I feel he could have dealt with event occurs. Even in the traditionally reactive industries, the need
or emphasized a few more points which I discuss below. for leading indicators is becoming better recognized, as companies
try to move towards greater excellence (Hudsons proactive or gen-
Purposes erative states Parker et al. (2006)). In a study that I have recently
completed (Hale, 2008a,b) into the success of safety improvement
It seems to me important to start such a debate by asking what interventions in 16 companies, one of the characteristics of the
we need and use such indicators for. There seem to me to be three companies which showed success, in terms of signicant drops
different uses: in accident rates, was that they had KPIs for their managers which
were not only directed towards lowering the accident or absence
1. Monitoring the level of safety in a system (whether that is a rate, but also at driving up the intermediate indicators such as re-
department, a site, or an industry). This answers the question: ports of dangerous situations and their resolution, use of protective
is the level of safety OK as we are now managing things, or equipment, conduct of toolbox meetings and observation rounds
should extra action be taken to improve it? This requires data during which they discussed good and bad practice with the work-
which shows reliable and valid trends in safety. The indicators force. This illustrates the need for a variety of indicators for pur-
do not need to be causally linked to safety outcomes, as long poses 2 and 3 (action and motivating), including both leading
as the correlation is and stays high and the numbers are big and lagging. It is also necessary that the leading indicators can be
enough to show trends. shown to correlate with the lagging ones, as this provides the proof
2. Deciding where and how to take action if the answer to ques- to managers (regulators and workforce) that they are valid.
tion 1 is that action is needed. This requires indicators deeper
in the system showing the state of those causal links to the Models
harm which have been proven to exist (or at least are strongly
believed), so that we know (or believe) that manipulating them A related topic is the need to have clear, explicit and well-artic-
will result in the system becoming safer. ulated models forming the basis for dening and using indicators.
3. Motivating those in a position to take the necessary action to The HSE guidance document (HSE, 2006) fails badly in this respect
take it. This requires indicators which those persons see as and is therefore confusing. The document uses the Reason model
being relevant and as being inuenceable by themselves, either (1997), but presents it with the idea that an indicator is leading
directly or indirectly, and which show a response to actions or lagging in respect of the working of a barrier or Swiss cheese
within a time span that ts their management and decision slice, rather than the much more commonly used denition that
timescales. it leads or lags the occurrence of harm, or at least the loss of control
in the scenario leading to harm. It then confuses matters further by
Hopkins paper seems to concentrate primarily on the rst and using one reference point in its gures and the other in the text, as
third uses and less on the second. It is for the second that the terms Hopkins indicates. The distinction which the document makes be-
lead and lag indicators seem to be most relevant. For monitoring tween nding a non-functioning barrier, such as a relief valve, in a
and motivating that distinction is perhaps of lesser concern, or at routine test, as opposed to it failing when challenged in practice by
least other criteria such as the need to have enough numbers to a developing scenario, is an important one. A company would
show reliable trends are more important. However, for taking pre- much rather nd the former than wait for the latter to happen,
ventive action the indicators need by denition to be before the as that means one step nearer to a major failure before corrective
event and in a causal pathway leading to it. Good companies also action is taken. However, the distinction between the two is not

0925-7535/$ - see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2008.07.018
480 A. Hale / Safety Science 47 (2009) 479480

between leading and lagging, but between degrees of leading. In 3. Sensitive: does it respond to changes in what it is measuring
other words there is a continuum (represented, for example in with sufciently large changes in the indicator to become sta-
the bowtie model (e.g. Ale et al., 2005)) from extreme leading to tistically signicant over a reasonably short time?
extreme lagging, with a break either at the commencement of 4. Representative: does the set of KPIs cover all of the aspects
harm, or the loss of control. which are relevant?
What perhaps contributes to the confusion is that models such 5. Openness to bias: can it be manipulated to show a better score
as Reasons, or the original domino model of Heinrich (1931) which without changing the underlying situation it is supposed to be
it resembles, compress two dimensions into one. Those are a time measuring?
dimension (essential for showing causation) and a categorisation 6. Cost-effectiveness: does it cost more to collect the data than
based on causal type (unsafe acts, unsafe conditions and underly- would be lost without the indicator to assist decisions?
ing management decisions). Rasmussen and Svedung (2000) disen-
tangle these two dimensions in their accimaps, labeling the second Exactly how these criteria should be operationalised will de-
as the different system levels. However, their diagrams also show pend on the purpose of the indicator. For example, one purpose
that it is only possible to preserve the strict time dimension within of collecting incident data is to detect whether there are signicant
one given system level at once. The causal inuence at a higher things which could go wrong, but which we have missed in our risk
system level from an event earlier in the time sequence, may post- assessment (new scenarios). This can be recognized on the basis of
date an inuence at that same higher system level from a later one incident, if the potential consequences are great enough and
event in the accident scenarios time sequence. The events and cau- Hopkins criterion of large numbers would not be relevant
sal factors modelling of the MORT approach (Johnson, 1973) has (Koornneef, 2000).
the same problem. Indicators moving to the left along the time axis One of the greatest problems with indicators which are used in
become more leading, but also as they radiate out along the indi- practice as the basis of rewards or punishments, as Hopkins dis-
vidual pathways leading at right angles up the system levels, but cusses in the last section of his paper, is that managers learn to
the time relation between those different individual pathways fur- manipulate them and so contribute to the false sense of security
ther up the system levels is lost. that the Baker report sees as characterizing BP at Texas City. One
There are other criticisms which can be leveled at the gures in solution to this is to change the KPIs at intervals, so that they have
the HSE document, but these go beyond the topics of this debate. to start the manipulation process again. The way of looking at indi-
cators advocated in this contribution and, in fairness, in the HSE
Useful indicators document and the Baker report, shows that there are a vast num-
ber of potential indicators, at least of leading ones, between which
In conclusion, I agree strongly with Hopkins that it is vital for an the changes can be rung.
indicator to be valid and to have enough instances occurring that it
is sensitive to change and will show trends. However, I think he References
dismisses too lightly the distinction between leading and lagging
(in relation to the loss of control and the occurrence of harm). Ale, B.J.M., Bellamy, L.J., Cooke, R.C., Goossens, L.H.J., Hale, A.R., Roelen, A., Smith, E.,
Counting the numbers of dead and permanently maimed in a 2005. Development of a causal model for air transport safety. In: Proceedings of
the EMECE05 American Society of Mechanical Engineers International Congress
poorly performing system, such as the construction and sheries
November 2005. ASME.
industries in most parts of the world, and many more industries, Baker, J., 2007. The Report of the BP US Reneries Independent Safety Review Panel.
such as the mines, in developing countries is a good indicator of Hale, A.R., Guldenmund, F.R., 2008a. Evaluatie van de verbetertrajecten van het
programma versterking arbeidsveiligheid (Evaluation of the Improvement
safety in that it tells clearly that action is needed. However it does
Projects of the Programme for Strengthening Occupational Safety). HASTAM
not tell what action to take, and we would much rather action had Ltd, Maldon UK.
been taken on indicators before all those deaths resulted. Hale, A.R, Guldenmund, F., Oh, J., van Loenhout, P., Booster, P., Oor, M., 2008b.
We therefore need to agree clearly on what we need indicators Evaluating the success of safety culture interventions. In: Proceedings of the
International Conference on Probabilistic Safety Assessment and Management,
for, and recognize that there are a number of generic reasons, Hong Kong. May.
which I set out above, and many detailed ones within those. We Heinrich, H.W., 1931. Industrial Accident Prevention. McGraw Hill, New York.
then need to set out criteria for what makes a good indicator for HSE (Health and Safety Executive), 2006. Developing process safety indicators: a
step-by-step guide for chemical and major hazard industries. Shefeld. HSE.
each of those purposes. We could do worse than take the standard Koornneef, F., 2000. Learning from Small-scale Incidents. Ph.D. thesis. Safety Science
generic list of requirements for measuring instruments in science: Group. Delft University of Technology.
Johnson, W.G., 1973 MORT-The Management Oversight and Risk Tree. ERDA SAN
821-2, Idaho Falls.
1. Valid: does it measure what we want it to measure? Is correla- Parker, D., Lawrie, M., Hudson, P., 2006. A framework for understanding the
tion enough, or do we need the link to be causal? This includes development of organisational safety culture. Safety Science 44 (6), 551562.
using rates which take account of exposure when counting Rasmussen, J., 1997. Risk management in a dynamic society: a modelling problem.
Safety Science 27 (2/3), 183213.
things such as accidents.
Rasmussen, J., Svedung, I., 2000. Proactive risk management in a dynamic society.
2. Reliable: does it give the same measurement when used by dif- Swedish Rescue Services Agency. Karlstad, Sweden.
ferent people on the same situation, or on different occasions by Reason, J.T., 1997. Managing the risks of organisational accidents. Aldershot.
Ashgate.
one person on that same situation?

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