Professional Documents
Culture Documents
Safety Science
journal homepage: www.elsevier.com/locate/ssci
UNOCHAPEC (Regional University of Chapec), Rua Quintino Bocaiuva, 390-D, Chapec, SC, CEP 89801-080, Brazil
DEPROT/UFRGS (Industrial Engineering and Transportation Department, Federal University of Rio Grande do Sul), Av. Osvaldo Aranha, 99,
5. andar. Porto Alegre, RS, CEP 90035-190, Brazil
b
a r t i c l e
i n f o
Article history:
Received 12 June 2008
Received in revised form 8 November 2008
Accepted 21 November 2008
Keywords:
Health and safety management systems
Resilience engineering
Health and safety audits
Manufacturing industry
a b s t r a c t
This article introduces a method for assessing health and safety management systems (MAHS) that has
two innovative characteristics: (a) it brings together the three main auditing approaches to health and
safety (HS) the structural approach (which assesses the system prescribed), the operational approach
(which assesses what is really happening on the shop-oor) and the performance approach (which
assesses the results of performance indicators); (b) it emphasizes the resilience engineering perspective
on HS, which takes into consideration four major principles (exibility, learning, awareness, and top management commitment). Such principles underlie seven major assessment criteria, which in turn are
divided into items (e.g. hazard identication from a resilience perspective is an item that belongs to
the criteria of production processes). The items are sub-divided into statements, which are the requirements that should be assessed based on interviews, analysis of documents and direct observations.
Within the 112 requirements proposed, 38 of them have clear links with at least one out of the four resilience engineering principles adopted. The remaining requirements are based on traditional assumptions
underlying the so-called best practices of HS management. The results of the assessment for each item
are expressed by a score on a scale of compliance with the established requirements, ranging from 0%
to 100%. The specic score within that scale is obtained from tables used to assess applications for the
Brazilian national quality award. The MAHS was tested in a case study that was carried out in a factory
that manufactures automobile exhaust systems, located in Brazil.
2008 Elsevier Ltd. All rights reserved.
1. Introduction
Health and safety (HS) management best practices are well
known among the leading companies in the area. Nevertheless,
best practices are generally not applied systematically but rather
normally amount to fragmented actions, in addition to which the
companies which use them have reached a performance plateau
(Amalberti, 2006; Mitropoulos et al., 2005).
Thus, advances are needed in terms of concepts and methods to
ameliorate this state of affairs. The traditional HS management
best practices analyze people, technology and the work context
separately by means of focusing on a sociological, technological
or organizational approach. The socio-technical approach brings
these ways of focusing together and emphasizes their interfaces,
and thus furnishes an analysis which is closer to the complex reality of mutual interactions and adaptations between people, technology and work (Clegg, 2000).
* Corresponding author. Tel.: +55 51 3223 8009; fax: +55 51 3308 4007.
E-mail addresses: costella@nostracasa.com.br (M.F. Costella), saurin@ufrgs.br
(T.A. Saurin), lia@producao.ufrgs.br (L.B. de Macedo Guimares).
0925-7535/$ - see front matter 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ssci.2008.11.006
though some studies use neither the label of CSE nor RE, such as
that by Montagna and Ferrari (2006).
The challenge for HS management in the context of RE is to
draw up prevention strategies which adequately address complex,
dynamic and unstable systems. In particular, strategies are needed
which adequately take account of system variations which cannot
be totally foreseen at the design stage. Therefore the challenge is to
construct dynamically stable systems, with a view to ensuring that
adaptations, despite their being necessary at any given moment,
allow for the system to remain under control (Hollnagel, 2006).
Although RE has been mostly studied in the context of complex
systems of high risk, such as in the aviation, petro-chemical and
nuclear power industries (Hollnagel, 2006), its concepts also tend
to be benecial for manufacturing industry, especially for medium-sized and large industries positioned in highly competitive
supply chains, such as the automobile sector. This occurs since
manufacturing also possesses characteristics of complex systems,
such as high interdependence between processes (most strongly
felt in environments of just-in-time production), the huge number
of variables and various trade-offs to be managed (Christoffersen
and Woods, 1999).
Given that all control systems tend to deteriorate over time or
become obsolete as a consequence of changes, the continuous performance measurement is essential for HS management, whether
or not under the RE paradigm. Such measurement can occur at different levels, such as individual workstations, individual management processes or at the level of the HS management system
(HSMS) as a whole. A particular type of measurement, which is
dealt with in this study, is auditing. In fact, auditing goes beyond
measurement, since it explains performance and builds on measurement to identify gaps between current and desired performance, to identify where there are problems and needs, and to
provide information that can be used in developing actions plans
to improve performance (Chiesa et al., 1996). The European Foundation for Quality Management (EFQM, 1995) adds that auditing
means a comprehensive, systematic and regular review of an organizations activities and results referenced against a model of business excellence.
Currently, the structural approach is the one most used to audit
HSMS, as it is based on the analysis of documents which prove that
the organization is meeting certain HS requirements which it itself
has dened or which are dened by standards, like OHSAS 18001
(occupational health and safety assessment systems). The structural emphasis is typical of most current safety audit tools, and is
concerned with assessing if there is a documented HSMS (Ahmad
and Gibb, 2004). As to the operational approach, it veries if the
documented HSMS has in fact been implemented in practice, by
means of observations and interviews with the companys operational and management staff. There is also the approach of auditing
by performance, based on analyzing the results of normally reactive performance indicators (Cambon et al., 2006).
The literature indicates a series of limitations to the existing
models for auditing HSMS, such as (Bluff, 2003; Le Coze, 2005):
(a) non-specication of the context in which the HSMS implicit
in the models is valid or more effective; (b) focus on relation to
imminent risks of accidents, so giving little importance to the latent hazards to HS in the long term; (c) the items assessed are static, with there being no guidelines for their continuous adaptation
to the dynamic conditions of modern work environments this is
partly a result of not making explicit what HS principles underlie
the audit model; and (d) strategic and cultural dimensions which
interfere in HS management are not considered.
Although there are no models for auditing which explicitly embrace the principles of RE, some studies have re-interpreted models which originally did not take account of RE, with a view to
verifying the extent to which its principles were indirectly borne
1057
in mind (Hale et al., 2006). Other auditing models, such as the Dupont system for process safety management (Dupont, 2006), focuses on behaviour-based safety. This has been criticized for not
emphasizing the capacity of workers to adapt and for not having
an impact on incidents which occur without there being any safe
or unsafe behaviour by workers on the shop-oor (Hopkins,
2006). Other auditing models do not adopt explicit assumptions
about what HS management philosophy should underpin the system, as for example ISRS international safety rating system (Eisner and Leger, 1988), CHASE complete health and safety
evaluation (Chase, 2006) and MISHA method for industrial safety
and health activity assessment (Kuusisto, 2001).
Considering this context, this study aims to present a method
for assessing HSMS (MAHS) with the focus on RE. Such a method
takes account of the three main approaches to auditing HSMS
and was tested in a case study in a factory which manufactures
motor vehicle exhaustion systems. Even though the MAHS might
be considered as an audit tool, according to the denition of an
audit that was previously given, the A of the acronym MAHS
stands for assessment rather than auditing. This choice was made
since the term audit is often narrowly interpreted as looking for
non-compliance with and deviations from regulations and standards, such as OHSAS 18001.
2. Resilience engineering
Resilience engineering is a paradigm for safety management
that focuses on how to help people to cope with complexity under
pressure to achieve success (Resilience Engineering Network,
2008). Due to this fact, a distinctive feature of RE is its emphasis
on understanding how success is obtained, how people learn and
adapt themselves by creating safety in an environment which
has faults, hazards, trade-offs and multiple objectives (Hollnagel
and Woods, 2006). Wreathall (2006) also associates resilience with
the ability of an organization to keep, or recover quickly to, a stable
state, allowing it to continue operations during and after a major
mishap or in the presence of continuous signicant stresses. Thus,
resilience includes both the property to avoid failures and losses, as
well as the property to respond effectively after these have
occurred.
The applications of RE are particularly suitable for high risk systems with complex characteristics, such as (Christoffersen and
Woods, 1999): (a) the high degree of inter-connection between
the components of the system, the consequence of which is the
very great difculty which the operator has to foresee the effects
of his actions and the rapid propagation of the errors; (b) uncertainty and variability. Under such conditions of complexity, the
attributes associated with RE grow in importance.
Considering that there is no one set of RE principles which is
widely accepted in academic circles and also that there are differences in the terminology adopted by different authors, for the purposes of this article, there was a need to endeavour to compile a set
of principles which would serve as a reference for the assessment
method now put forward. It is worth stressing that RE principles
may be used at any level of aggregating the cognitive system, ranging from the focus of a single worker at his workstation to the focus
of the organization as a whole. Thus, based on various studies (Rasmussen, 1997; Hollnagel and Woods, 2005; Hale and Heijer, 2006;
Wreathall, 2006; Saurin et al., 2008) four principles were identied
which have interfaces with each other and do not possess strictly
dened limits:
(a) Top management commitment: this implies demonstrating
a devotion to HS above or to the same extent as the companys other objectives.
1058
3. Research method
The selection of the elements assessed by the MAHS was made
based on the standards OHSAS 18001 and ILO-OSH 2001 (guidelines on occupational safety and health management systems), as
well as based on a review of the literature which covered three
areas: HSMS, RE and HSMS audits. An exploratory case study to assess a HSMS conducted in an agricultural equipment factory also
contributed to constructing the audit model. The elements assessed by MAHS can be classied into criteria and items. The former correspond to the large categories of assessment and the
items to the sub-categories, which, for their part, consist of the
requirements to be assessed. Thus, 28 items and seven criteria
were established.
Since the framework of the MAHS was dened, it was applied
and assessed by means of a case study, carried out over a 3 months
period in 2007. The case study took place in the Brazilian company
which is the market leader for replacing automobile exhaust systems. It was chosen because of the ease of access which the
researchers had to it, as well as on account of its size (450 employees) and integration with a highly competitive supply chain, which
were indicative of characteristics of complexity. The company produces exhaust pipes and accessories, such as protective caps,
crankcase guards, tow bars and trailers for motor vehicles, ranging
from automobiles to tractors. The main clients are the sales outlets
for spare parts for all models, there being 12,000 clients in Brazil
and Latin America.
Throughout 2005, 2006 and 2007, the company went through
nancial difculties as a result of an investment in a new line of
products that produced a disappointing return. This negatively
inuenced HS in terms of there being a shortage of resources for
the area. Despite this, the company holds an ISO 9001 certicate.
The workforce consists predominantly of men from the rural zone,
which requires substantial investment in training events.
The companys portfolio boasts more than 850 products, with
most of its components being manufactured in the same plant in
which the nal products are assembled. This contributes to the frequent change of dies and tools, to the existence of functional layouts and difculties in standardizing processes, which makes the
production process more complex.
Three examiners applied the MAHS in the case study: one of
them was the rst author of this article, who was designated as
the lead examiner (LE) and is a certied auditor of quality management systems by the Brazilian foundation for the national quality
award. The other two examiners were selected in accordance with
their knowledge of the area of HS. One of these examiners, deemed
examiner 1 (E1), is a civil engineer and was completing a specialization course in safety engineering. The other, deemed examiner
2 (E2), is a business administrator and was completing a masters
degree in industrial engineering with emphasis on ergonomics.
Due to the disparity of knowledge about RE among the examiners,
the LE fostered a levelling up of these concepts using the MAHS
assessment instrument which was fully discussed. The three examiners took part in all the stages of the case study jointly. Taking into
1059
2 Production
processes
3 People
management
Fig. 1. Association between the items of the MAHS and the principles of RE and OHSAS 18001 elements, with additions from ILO-OSH 2001.
Worker participation
Continual improvement
Management systems
integration
Procurement e contracting
Management review
Audit
Performance measurement
and monitoring
Accidents, incidents,
nonconformances, and
corrective and preventive
actions
Records and records
management
Operational control
Documentation
Consultation and
communication
Objectives
OHS Policy
Awareness
Flexibility
Learning
Top management
commitment
RE principles
1060
1061
Evidence sources
Operational
Items
Performance indicators
analysis
Documentation and
records analysis
Structural Performance
Direct observation
1062
of external environment factors) and, at most, ve sources of evidence (for example, hazards response from RE perspective).
Fig. 2 also indicates that the MAHS reconciles in a balanced way
the structural and operational approaches, given that 25 of 28
items adopt both the sources of evidence linked to documentation
(typical of the structural approach) as well as the sources linked to
interviews or direct observation (typical of the operational
approach).
in the margins of the scoring table, from which one obtains the corresponding percentage.
Should there be characteristics in distinct score bands, one
should always opt for the lower score band. For example, when
we consider the following performance for a given item in relation
to the focus: the management practices are adequate for most of
the requirements of the item (line C); almost all the practices are
rened (line E); meeting almost all the requirements is proactive
(line E); innovation is present in some practices (line E). In this
case, the score will be determined by line C, given that in the lines
above, at least, one of the factors would not be met. It is worth
stressing that that the coverage of each assessment factor should
be determined in accordance with the note in Fig. 3: some (less
or equal to 50%), most (greater than 50%), almost all (greater than
75%) and all of them (100%).
Dissemination,
continuity and
integration
Suitability,
proactiveness,
refinement and
innovation
Management practices
presented are
disseminated in some
areas, processes,
products and/or by the
pertinent interested
parts.
Continued use in some
management practices.
No evidence of
integration.
Management practices
presented are
disseminated by most of
the main areas,
processes, products
and/or by the pertinent
interested parts.
Continued use in most
of the management
practices.
Some evidence of
integration.
Management practices
presented are
disseminated by the
main areas, processes,
products and/or by the
pertinent interested
parts.
Continued use in
almost all management
practices.
Presented most of the
evidence expected from
integration.
Management
practices presented are
disseminated in almost
all areas, processes,
products and/or by the
pertinent interested
parts.
Continued use in all
management practices.
Presented most of the
evidence expected
from integration.
Management
practices presented
are disseminated in all
areas, processes,
products and/or by the
pertinent interested
parts.
Continued use in all
management
practices.
Presented all
evidence expected
from integration.
10%
30%
50%
70%
90%
100%
10%
30%
50%
70%
80%
90%
Management
practices presented
are not disseminated.
Use not reported.
No evidence of
integration.
10%
30%
50%
60%
70%
70%
10%
30%
40%
50%
50%
50%
10%
20%
30%
30%
30%
30%
0%
0%
0%
0%
0%
0%
Notes: Coverage: some (less or equal to 50%), most (more than 50%), almost all (more than 75%) and all (100%).
Fig. 3. Framework of the Brazilian foundation for the national quality award for assessment of the factors in focus and being applied.
1063
Table 1
Scores obtained in the case study, in accordance with the items of the MAHS.
Items of the MAHS
Score (%)
1.4
1.5
2.4
3.2
4.3
2.1
3.1
5.1
5.3
6.1
6.5
1.2
6.4
1.1
2.5
7.1
1.3
1.6
2.2
2.3
4.1
4.2
4.4
4.5
5.2
6.2
6.3
7.2
70
70
50
50
50
40
30
30
30
30
30
20
20
10
10
10
0
0
0
0
0
0
0
0
0
0
0
0
Average score
20
1064
reliable and full information, which limits the participants understanding of the safety performance, and consequently, of the
causes of the problems. It is worth stressing that critical analysis
of HS is analyzed supercially by top management as part of the
critical analysis of the quality management system.
Still with regard to the principle of learning, two other opportunities have been wasted: (a) in the investigations of accidents,
since the company operates under the paradigm of the culture of
blaming the worker, which is felt to be insisted on during the process of investigation and (b) in the management of changes, a very
faulty process in the company, since it does not include alterations
in training or procedures should there be changes (for example,
technologies). Thus, changes occur and their impact on HS is perceived late on, which characterizes reactive learning.
5.2.3. Flexibility
Performance in relation to the principle of exibility is ambiguous. As an example of this, in 2006, at the request of the operator of
an overhead crane, members of the HS department inspected the
main supporting cable of the bridge and issued a report declaring
that there was the grave and imminent risk of the cable snapping,
and requesting the immediate stoppage of the equipment, without
consulting the production supervisors. This attitude generated
huge upsets in production on that day and friction between the
production and safety staff because the former were not consulted.
The positive fact of this example was that the safety staffs action
prevailed over the pressures from production staff. At the same
time, this was seen as a circumstantial event, since there are no
guidelines for managing the trade-off between safety and production. Although top management supported the stoppage decision,
they also held that there should be better communication between
HS and production.
Another ambiguity arises from the fact that, both in the procedures and in the discourse of the production manager, it is recognized that a very quick rhythm can generate accidents, although
there are no mechanisms to identify what characterises an excessive rhythm. For example, in the procedure of the pressing operation there is a recommendation not to accelerate production with a
view to making up for lost time after a stoppage, the aim of which
is to prevent accidents. In this example, at least under the structural approach, the principle of exibility is fairly well satised, because of not ceding to the pressures of production, in favour of
safety. Besides this, according to the representative from the production planning and control department, there are no individual
production targets in each workstation. There is only the concern
that the factory as a whole meets the global production targets.
The workers who declared that they did not feel pressurised into
attaining production targets conrmed this.
The deciencies already cited in the management of changes
also indicate that the company is not prepared to respond exibly
to the dynamic environment in which it nds itself. The lack of definition of responsibilities regarding HS is also detrimental from the
point of view of exibility, since, especially during emergencies, it
may not be clear what the channels of assistance are nor do those
who intervene feel obliged to act in favour of HS.
In operational terms, the lack of exibility is evident in the nonexistence of fail-safe devices in machines with the highest risks,
which would make the limits error-tolerant. According to a traditional HS approach, a factor which was emphasized by the managers interviewed was the consideration of requirements concerning
attention, concentration and discipline when selecting skilled
workers who operate machines of greatest risk, such as the presses
in the stamping department, the folding machines and milling.
Nevertheless, this criterion could be less important should the machines of greatest risk have fail-safe devices, as is the case of a single machine which has a system of sensors which switches the
machine off when something or someone gets close to the hazardous parts.
During the interviews with the managers, situations were also
reported of refusal to work on machines shortly after an accident,
as the member of staff was afraid. According to the production
manager, in this case, the worker was transferred to another function. Similarly, the company has demonstrated concern for staff
who presents health complaints, by immediately arranging for
them to have medical attention and transferring the worker to
activities with less risk of accident. These facts display the autonomy of production management to deal with aspects of HS, which
is one dimension of the principle of exibility.
5.2.4. Awareness
Although the examples of re-allocation of functions are positive
from the point of view of exibility, they are indicative of the lack
of meeting the principle of awareness, since they are evidence of a
belated awareness in which the workers and managers become
aware of the risk after tragic events. Another piece of evidence that
the principle of awareness is characterised by great reactiveness
arises from a change of attitudes with regard to safety on the occasion of hiring new welders coming from a large multi-national
company. Such welders were accustomed to wearing protective
spectacles under the welders mask and demanded that they
should only work under the same conditions. The company supplied the requested equipment, and the other welders, slowly but
surely, also began to use the same equipment. Currently, most
welders use this double protection, which occasioned the reduction of eyes injuries.
Although, as has already been commented on, there is a systematic effort to train the workers, as well as there being a few channels
for their participation, the potential of these mechanisms to support
the principle of awareness could be better exploited. With regard to
the training, it does not tackle management skills, which would favour hazard identication and control, such as critical observation
of their own and their colleagues work, as well as communication
of hazards. As to participation, the existing channels do not include
opportunities for work enrichment, which would lead the worker to
get to know the nature of their activities in more depth.
Nor is HS planned from the early conception of products and
processes, whether because of the lack of support and release of resources by top management or whether because of the lack of
awareness of the hazards. There is a procedure relating to the
development of new dies and tools in the company itself, it having
been foreseen in this procedure that there was a need for approval
by the HS during a pilot test of the new pieces of equipment. Nevertheless, this posture is reactive for it does not require the participation of operators and safety specialists from the initial steps of
the design for new pieces of equipment.
6. Conclusions
The method for assessing health and safety management systems (MAHS) proposed in this article contributes to lling gaps
regarding the assessment of the HSMS. One of these gaps concerns
the deciency of the current audits of HSMS when it comes to reconciling the structural, operational and by performance approaches in a single audit model. Besides this, the MAHS also
contributes to adopting explicitly the focus of RE on HS. With regard to the practical application of the MAHS, what can be stressed
is its use to re-structure the HSMS, and its presenting the main positive and negative points as well as the action priorities. These are
assessed from a focus which, although still little known in the
industry, makes it possible for there to be wide-ranging assessment of the HSMS performance.
1065
1066
Appendix A
References
Extracts from the MAHS assessment tool
1.6 Top management commitment
Approach: operational.
Sources of evidence: interview with top management representatives (requirements a, b, c, d, e, f), interview with production
management representatives (requirements a, b, c, d, e, f), interview with representatives from the HS department (requirements
a, b, c, d, e, f) and interview with workers (requirements a, b, c, e):
(a) to highlight if top management participates in HS efforts and
interacts with the interested parties, thus demonstrating
commitment and seeking opportunities to develop the
HSMS (top management commitment and learning);
(b) to highlight if top management is aware of the satisfaction,
motivation and well-being of the workers (top management
commitment and awareness);
(c) to highlight if top management ensures there are resources
for HS (top management commitment);
(d) to highlight if top management shows concern for improving HSMS performance and if there is oversight regarding
the level of the safety performance indicators, especially
the proactive ones (top management commitment and
awareness);
(e) to highlight if top management demonstrates commitment
both to HS and other business functions, such as production,
marketing and sales (top management commitment);
(f) to check the position of top management with regard to the
management of the pressures of production in relation to
safety (top management commitment and exibility).
2.5 Hazard response from an RE perspective
Approach: structural and operational.
Sources of evidence: direct observation (requirements a, d),
analysis of the procedures relative to HS (requirements a, b, d, e),
interview with representatives from top management (c, d), interview with the production manager (requirements a, b, c, d, e),
interview with representatives from the HS department (requirements a, b, c, d, e) and interview with workers (requirements a,
c, d):
(a) to observe how the difference between real and prescribed
work is managed. To describe how the monitoring and modication of the HS procedures are carried out and how the
adaptations carried out by the workers in relation to the
HS procedures are managed (exibility);
(b) to highlight how the procedures indicate what the limits of
safe work are and how to detect faults and regain control. In
addition, to highlight what the mechanisms are so that the
limits are made visible, respected and/or error-tolerant
(exibility);
(c) to check how workers and supervisors on the shop-oor
have autonomy to take decisions which inuence safety,
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