A theory of incidents: You are your brother and sister’s keeper

Monday, June 03, 2013

Occupational health and safety expert Dr. Peter Strahlendorf talks about the Internal Responsibility System

Have you ever walked by a potentially hazardous situation – like a puddle on the floor – and done nothing about it? Perhaps you assumed it was someone else’s responsibility or maybe you spoke up and nothing was done. You’re not alone, according to occupational health and safety expert Dr. Peter Strahlendorf.

Dr. Peter Strahlendorf onstage presenting to conference audience on the Internal Responsibility SystemDuring a recent health and safety conference hosted by Workplace Safety North, Strahlendorf spoke with WSN about the Internal Responsibility System (IRS), along with other health and safety issues in Canadian and American workplaces. With degrees in biology, environmental studies as well as a doctorate in law, Strahlendorf has consulted in the areas of occupational and environmental health and safety since 1983, and is currently a professor at Ryerson University’s School of Occupational and Public Health.

Diagram of dominoes showing company roles in accident process
Who can cause an incident? Anyone.

The theory behind workplace injury, illness, or fatality is that they are symptomatic of a larger problem within the workplace system. There is a domino effect regarding responsibility, writes Strahlendorf in his 2001 article The Internal Responsibility System for Occupational Health and Safety Canada magazine.

If a worker makes a mistake and causes an accident, we can see how very often there was a prior failure of a supervisor to train, coach, observe, job plan, motivate, and so on. So, if the supervisor can be said to have caused the accident in part, then we can see that frequently the manager did not properly select and train the supervisor, or did not develop programs needed by the supervisor, or did not properly allocate resources or staff the workplace. 

Where the direct causes of an accident involve unsafe conditions, tools, machines, processes and structures, we can often bypass the worker and supervisor in our causal analysis and see the failure of the mid-level to senior manager to properly apply design standards or allocate resources.

Managers cause accidents; they just cause them in different ways than workers and supervisors. However many layers there are in an organization we can see a causal connection back to the accident. Presidents cause accidents. They can fail to lead, to set policy, to ensure a proper delegation of authority, to inspire a proper safety culture, to design a workable organizational structure or to allocate resources.

To really drive down risk…you would not just focus exclusively on the CEO because some accident causation chains will commence at stages later in the sequence. You would not focus only on the worker because the causes sometimes lie higher up. 

Who can cause an accident? Anyone. Who can take steps to prevent accidents? Anyone. Who should be taking steps to prevent accidents and exposures? Everyone. Who should be responsible for health and safety in the organization? Everyone. And that is the basis of the IRS in accident theory.

Source: The Internal Responsibility System by Dr. Peter Strahlendorf, OHS Canada, March 3, 2001

List of IRS values

The culture of safety, known as the Internal Responsibility System or IRS, is one in which each and every individual – from owner and CEO to supervisors and workers –  is responsible for health and safety on the job.

“Everyone at all levels takes the initiative on health and safety,” according to Strahlendorf. “As well, everyone is obligated to report unresolved concerns upward and to respond properly to the unresolved concerns of others.”


Artificial separation of safety from work

Reporting a health and safety problem instead of fixing it, Strahlendorf explains, is usually the result of poor labour relations and general misunderstandings in the workplace – typical symptoms of a poor Internal Responsibility System.

To demonstrate what the IRS is not, Strahlendorf shares a story about common workplace winter doormats. “I remember a workplace near Toronto where over a period of time people coming through the main lobby were reporting the wrinkled rugs as a trip hazard,” he says. “They’d walk through the lobby and go to their desk, go online to company sites and report this tripping hazard. I think there was something like 29 reports over this period of time and not a single one of those persons actually stopped to straighten out the rug – it was one of those rugs that, in the winter you tap your boots on as you’re coming in, so they kind of get wrinkled.  

“And that always struck me as really a clear example of a very poor safety culture where, ‘I work and someone else does safety, and my only involvement is to report’...that’s not the first thing you should do,” says Strahlendorf. “You should ask whether it’s something that’s already within your job, your procedure, the workstation; if you can solve the problem safely, do it. I’d say nine times out of ten that is the size of the problem – people see something that already belongs to them. So, yes, you’ve got to report things, but that’s not your first thought.” 

How many times do you walk by?

What does it mean when the same health and safety issues keep cropping up month after month? There are plenty of examples where an item is noted on a monthly inspection checklist with recommendations to clean it up, says Strahlendorf and “if you go back and look at all the monthly reports in the last year or so, you’ll find the same item there every month. 

“So, every month, they note this problem and they recommend they clean it up – and they clean it up. Everybody feels they’re doing a great job, it’s all positive, but really that contravention or hazard is there 27 days out of 30 all the time. Nobody is saying: ‘Well, why are we seeing this there? Why aren’t the people in this area seeing it, recognizing it, or doing something about it?’

“You think you’re successful because you’re dealing with the observed contravention or hazard, but the real issue is why are you seeing it? You’re seeing the same thing repeatedly. It keeps coming up, well – why, why, why? You have to ask. If everybody’s supposed to be doing health and safety 100 percent of the time, how many people actually know that problem is there? How many times do they walk by? And, very importantly, why? 

Top excuses for avoiding workplace safety issues

The reasons we avoid dealing with a workplace safety issue are as varied as the workers says Strahlendorf as he runs through a laundry list of reasons for passivity: “You talk to people and they don’t feel it’s in their territory; they don’t feel it’s their responsibility; they think it’s someone else’s job; they don’t have enough time; somebody would get mad at them if they took the time to fix this problem; they would offend somebody if they raised this issue – there could be dozens of reasons why people don’t react to things they see in the workplace.” If you’re not addressing those problems, you’re contributing to the problems. Strahlendorf is adamant communication is the key, and encouraging openness about safety is at the heart of the IRS.

Pyramid diagram showing authority, responsibility, and accountability

“There’s a number of influences there, I think, in some workplaces it’s a labour-management thing. Health and safety isn’t separate from labour management. People think it’s subject to debate and argument between labour and management – not to say there isn’t some aspect of that. But if you think that way: ‘It’s management’s job,’ ‘I work and management is supposed to make this workplace safe for me’ – that leads people to think all they have to do is to report it to management or report it to the committee without actually doing it themselves. There’s an artificial separation of health and safety from work; the two are viewed as separate. 

“You sometimes see another influence. There are some – some – health and safety professionals selling themselves and the program: let me help you, bring me any problem you have. They’ve got to be careful about that because you could be encouraging people to unload their problems on you. So, these people – well-motivated, well-intentioned and very keen, may actually be undermining the health and safety engagement of individuals. 

“And, quite aside from the labour relations bias, even when it’s not there, you can see some people on health and safety committees – they don’t really understand the role of the committees, they think it is their job to find hazards and deal with complaints. They don’t really see their job as an advisor, consultant, watchdog, and auditor. And there are some reasons for that. 

“I remember in the 1990s, there was certified committee training that actually told committee members that you are the IRS and it is your job to find hazards for people. So all those people take that training, go back to the workplace and say, ‘Bring me all your problems.’ Then people unload on them and that becomes the accepted norm, ‘All I have to do is refer to them and they will take it from there.’ That’s how it began. Again, well-intentioned – it’s a misunderstanding that leads to less personal engagement rather than more.”

Poor safety indicative of other problems

Research has shown that a strong IRS correlates with a lower incident rate, which means improved productivity. “When we’ve done IRS audits before, the ones that have very bad scores turn out to be ones with lots of other problems, too,” notes Strahlendorf. “You’ve got bad labour relations, people not talking to each other for something that happened years ago; people carry grudges for a long time. They’re generally mad and resentful; you’re certainly not going to be engaged positively with other people...” 

“When you see an IRS that isn’t functioning well, it’s a set of people problems and those are problems about proper communication. Some people aren’t skilled or trained on how to interact with other people and they start right in an accusatory, blame-fixing way and put people on edge. So, there isn’t that trust and cooperation.”

‘No problem’ is a problem

“It’s very difficult to talk about causes of an accident or why some hazard or contravention’s been there for some time without getting into who’s at fault. Our brains are wired that way, I guess,” Strahlendorf adds. “Those are all skills, and you actually have to confront the issue about speaking up. People in groups are often silenced for a number of reasons. They don’t speak up. You have to confront the reasons why they won’t speak up, you want people to speak up.

Diagram of IRS process

“I’m reminded of an accident – an airplane accident – where they had the transcript from the cockpit of an Asian airline and there were some cultural differences there. You could hear the subordinates – the co-pilot and navigator – trying to tell the pilot – the captain – there was a problem maybe you should look at. They didn’t come right out and say: ‘You’re headed into the side of a mountain,’ ‘You’re wrong, we need to change course,’ because they couldn’t culturally challenge the superior in the organization, whereas, in a different culture, people would be more inclined to speak up. 

“Sometime supervisors think that everything’s fine – nobody’s bringing any problems to them. The little slogan, ‘No problem is a problem’ – if people aren’t bringing issues, then they aren’t engaged. There’s always something to talk about in terms of reducing risks, it’s part of the role of the supervisor to encourage people to speak up.”

Go ahead, make my workplace safe

Asked if the American mentality about safety and legal liability has an influence on the Canadian workplace, Strahlendorf replies, “I think there’s a different safety culture in the United States. They have a different philosophy on enforcement there. OSHA [Occupational Safety and Health Association] inspectors tend to be kind of Clint Eastwood about their role; they’re not very much into education and promotion. 

“I think, at least historically, they come to your workplace, they leave, and you’ve got about a million dollars’ worth of orders to comply with. Whereas, I think, in Canada, the idea is – under the IRS – it’s your job in the workplace to find problems and fix them. It’s the inspector’s job is to make sure you have a good IRS.

"When the inspector sees something, it’s a symptom or sign that the IRS isn’t working. I think if you’re waiting for the government inspector to tell you what to do, then essentially you’ve transferred initiative to somebody outside the workplace. 

“I’ve been down to the States and visited a couple of mines down there and heard people describe how the mining inspectors…behave very differently than inspectors in Canada. In essence, they come in and threaten people, and walk into the mine manager’s office and start opening up stuff and looking at stuff without discussion. 

“I think we’re ahead of the Americans in health and safety. You talk about a safety pause or safety shutdown – when a Canadian company operating in the United States does that, the American miners are shocked and surprised – at least, that was my experience at one plant.

“They don’t have a well-articulated Internal Responsibility System concept in the United States; it seems to me they certainly don’t use that expression. They talk about empowerment and engagement, but I think the IRS helps us because it gives us a clear definition, a clear framework to talk about personal options. 

History of personal responsibility for workplace safety

Chart showing IRS responsibilities

The idea of taking personal responsibility for safety in the workplace developed through a number of avenues, notes Strahlendorf. As early as 1972, there are some elements of the IRS in the Saskatchewan legislation, and in 1974, British legislation referred to a requirement for a company to spell out its “organizational arrangements” with regards to who was responsible for which aspects of health and safety. Also, ISO [International Organization for Standardization] management system models, strongly influenced by British standards, contain the idea of the IRS. 

By 1976, Ontario’s Ham Royal Commission into Safety in the Mines discusses the IRS in its report, which tabled health and safety responsibility according to organizational structure – from company owner right down to the individual worker. The health and safety legislation that came into effect in Ontario in 1979 was based on Ham’s vision of the IRS and how it could be monitored and maintained. Strahlendorf notes, “It is highly unlikely that we would be using the phrase ‘internal responsibility system’ today were it not for the Ham Royal Commission.”

Leading the way in workplace health and safety

Canada and the IRS are leading the way in workplace health and safety, and this culture of safety helps improve the bottom line by clarifying expectations, responsibilities and communication around hazards that may impede production.

The IRS is everyone in an organization working together mutually committed to eliminate or control workplace hazards; in other words: a safety culture. Think of it as a gut instinct – to look out for yourself and your co-workers. When something doesn’t look or feel right in terms of safety, your ‘danger’ alarm bells should be ringing. The safety culture code of honour says, “Treat others the way you would want to be treated,” so look out for each other and speak up about safety.



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