‘The Exposures are in the Areas That We’re Not Looking at,’ Pitzer Says During Occupational Keynote


Itasca, IL — Safety leaders shouldn’t focus in on the holes in their “Swiss cheese” (safety systems) but rather the whole cheese before the holes begin to form.

That was one of the messages from Corrie Pitzer during the Occupational Keynote on March 4 at the virtual National Safety Council Safety Congress & Expo.

The CEO of global consulting firm Safemap International shared an example of a mine that had zero fatalities in 40 years. Above the 120 workers in that mine, however, was a potentially catastrophic hazard: The air intake was located near the diesel fuel tanks for the power generation plant.

“We must look at the cheese and not where the holes are,” Pitzer said. “The exposures are in the areas that we’re not looking at, not in the areas we’ve already seen.”

He described it as “risk atrophy,” and offered another example: organizations that focus on lost-time injury rates and other data instead of looking for potential hazards on the jobsite.

“They focus so much on the holes in the Swiss cheese model that they don’t see the cheese anymore,” he said.

Before the 1988 Piper Alpha disaster in the North Sea, managers of the oil rig never received any reports that anything was wrong. The incident, which killed 167 people, occurred six months after the rig won a safety award. Similarly, Pitzer added, the BP Deepwater Horizon disaster in 2010 occurred one day after the crew on the drilling rig was given a safety award.

Both were high-performing organizations, at least in the managers’ minds, that didn’t see the forthcoming catastrophic events.

The highest-performing organizations, Pitzer said, are ones that are “restless” and looking for lurking and latent indicators instead of leading or lagging ones. He gave seven attributes of “restless” organizations, including workers having the autonomy to challenge safety rules when needed.

As an example, Pitzer returned to the Piper Alpha disaster: Workers who followed the instruction to meet at a certain location when evacuating didn’t survive, while those who jumped into the ocean did.

“The last defense we have is the human being, the human operator,” Pitzer said. “The human being is incredibly capable. We can do incredible things when dealing with risks, responding to it. My fear is that, in safety, we are suffocating the operator, the supervisor, the front end of the business. We are suffocating them with procedures, bureaucracy, and we’re suffocating them with distrust.

“They are able and capable of incredible things, and we should unleash them. We should unshackle them, and we should allow them to be the strongest link in the safety chain.”

Source: National Safety Council

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