# Thinking About Process Safety Indicators

*Hopkins · Safety & Error, Measurement & Method, Critique & Boundary · Safety Science · 2009 · Open access*

Hopkins explains how an organisation can watch its safety numbers improve while a catastrophe assembles itself underneath, and the mechanism he describes is the most consequential measurement failure in this map. His central distinction is between personal safety, the slips, trips, falls and cuts that produce lost-time injuries, and process safety, the integrity of the hazardous system itself, whose failures are rare but catastrophic. The two are routinely conflated, and the consequences are lethal. Esso's Longford gas plant had an impeccable lost-time injury rate while managing its major hazards poorly. BP's Texas City refinery, in the year before the 2005 explosion that killed fifteen people, had a recordable injury rate one third the industry average, and in 2004 the rate had improved so much that BP paid the whole workforce a bonus, an improvement achieved in a year that included three fatalities, two of them process-related. The site was, by its own instruments, getting safer as it prepared to explode. Hopkins traces how this happens: bonus schemes tied to personal-injury rates drive the reported rate down, both by encouraging genuine attention to minor hazards and by discouraging reporting, while the loss-of-containment events that actually predict disaster go uncounted and unrewarded. He notes drily that the airline industry would never make this mistake, since no one would take an airline's lost-time injury rate as evidence of how well it manages air safety, and warns that even the reform of adding process indicators to incentive pay must be handled carefully lest it produce attempts to manage the measure rather than to manage safety. For this corpus the paper is the bridge between the disasters cluster and the measurement cluster. It is Goodhart's law with a body count: a measure that becomes a target stops being a measure, the reassuring number silences the awkward signal, and each unreported small thing makes the next one harder to report, because it now contradicts an official story of excellence that leaders have come to believe. Published a year before Macondo, where executives were on the rig to celebrate seven years without a lost-time injury on the day it exploded, it reads as a warning that was available and unheeded. Its limits are those of a short analytical essay in a safety-science special issue: it argues from a handful of well-chosen disasters rather than from systematic data, and is sharper on the pathology than on the design of indicators that would not suffer the same fate. (Text drawn from the 2009 Safety Science paper, 47(4), pp. 460-465.)

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