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Behavioral Based Safety Understanding of Behavior Safety Many Companies have spent a lot of time and effort improving

safety usually by addressing hardware issues and installing safety management systems that include regular (e.g. monthly) line management safety audits. Over a number of years these efforts tend to produce dramatic reductions in accident rates. Often, however a plateau of minor accidents remains that appears to be stubbornly resistant to all efforts to remove them. Although, many of these are attributed to peoples carelessness or poor safety attitudes, most of these are triggered by deeply ingrained unsafe behaviors.




Undesired event, which, under slight different circumstances, could have resulted in harm to people, damage to property or loss to process. TWO TYPES OF HAZARD UNSAFE ACT- A violation of an accepted safe standard which could permit the occurrence of an accident. UNSAFE CONDITION- A hazardous physical condition or circumstance which could permit the occurrence of an accident.

If no control measure is applied, it will lead to accident.





INCIDENT is defined as any event ranging from a near miss, through first aid to fatality. The situation all companies should be striving for is to have work group performing a 100% safe behavior levels. This would give the best chance of eliminating incident.

Behavioral Based Safety (BBS) get a company beyond workplace audits and inspection, past the policing role and closer to really knowing how much your workforce understands their work practices, procedures, conditions and behaviors that cause people make mistakes. BBS is a proactive process that helps to get changes in a work group safety behavior levels before incident happen. All incidents are preceded by some kind, e.g. a worker fall off a ladder was not secured. Both of these individual are individual behaviors. BBS seeks to change the persons mindset, habits and behaviors so that these at risk behaviors will no longer be performed. As a results the worker will no longer fall off the ladder. It is built on the fundamentals of Antecedent Behavior Consequence (ABC) Behavior model. This is a behavior change model that can be used to change ANY behavior, not just safety. It can help operators behavior (thanking the Operator for taking the sample on time is a clear encouraging consequences for the desired operations behavior). Childrens behavior (being allowed to stay up an extra hour is a clear encouraging consequences for good behavior by a child). Pets Behavior (the treat given after a dog does a trick is a clear encouraging consequences). ABC behavior model is not complicated; its application in a company does not require a new organization chart or structure. The ABC behavior model and a BBS process can be integrated with existing structures, organization procedures, safety and health program. What is Behavior based Safety? Behavior Based Safety is a term used for programs focused on changing the behavior of workers in order to prevent occupational injuries and illnesses. BBS Focuses on what people do, analyzes why they do it, and then applies a research-supported intervention strategy to improve what people do. History Behavior Based Safety originated with the work of HERBERT WILLIAM HEINRICH at the Travelers Insurance Company in the 1930s and 1940s. Heinrich conducted research on thousands of insurance and injury/illness reports written by corporate supervisors. The reports blamed the workers, so called Man Failure, for 73% of the accidents

Heinrich revised this figure upwards to conclude that 88% of industrial accidents could be blamed on workers. Heinrichs data does not tell why the person did what they did to cause accident, just accident occurred. He came to the conclusion that roughly 90% of all accidents are caused by human error. This conclusion became the foundation of what BBS has come to be today. BBS addresses the fact that there are additional reasons for injuries in the workplace; environment, equipment, procedures and attitudes. Heinrich claimed that accidents result from Undesirable traits of character passed along through inheritance and the fault of workers who commit unsafe acts. Management-side safety professionals have based their work on Heinrichs faulty theories ever since. Criteria for Behavioral Safety Program It involves significant workforce participation It targets specific unsafe behaviors It is based on observational data collection It involves data driven decision-making processes It involves a systematic, observational, improvement intervention It involves regular focused feedback about on-going performance It requires visible on-going support from managers and front-line supervision.

Outcomes from a Well Planned & Implemented Behavioral Safety System 1. 2. 3. 4. 5. 6. 7. 8. 9. Lower numbers of accidents or incidents, near-misses and property damage. Improved levels of quantified safety behaviors Reduced accident costs. Maintenance Acceptance of the system by all concerned Generality Regular and rapid follow-up Increased reporting of defects, near misses, accidents etc. Increased skills in positive reinforcement

Why do people behave unsafely? People behave unsafely because they have been hurt before while doing their job in an unsafe way: Ive always done the job this way being a familiar comment. This may well be true, but the potential for an accident is never far away as illustrated by various accident triangles. How can we stop unsafe behavior? Why not engineer out hazard? Eliminating Hazards by engineering them out or introducing physical controls can be effective way of limiting the potential for unsafe behavior. While successful in many instances, it

does not always work, simply because people have the capacity to behave unsafely and override any engineering controls. How can we stop unsafe behavior? Why not change peoples attitude? Although positive safely attitudes are important and very desirable, the link from attitude to behavior change is very weak. This can be explained by the fact that a single attitude comprises of at least three components: thinking (cognitive), feeling (emotional), and the intention to act on it (commitment) How can we stop unsafe behavior? Why not change peoples attitude? Additional, a single attitude is usually linked with a set of other related attitudes. Logic dictates, therefore, that attempts at attitude change must target each individual component of each individual attitude, for each single employee. In practical terms this is nigh on impossible. Fortunately, the link from behavior change to attitude change is much stronger If people consciously change their behavior they also tend to re-adjust their associated attitudes and belief systems to fit the new behavior. This occurs because people try to reduce any tension caused by a mismatch between their behavior and attitudes. Behavior change, therefore, tends to lead to new belief and attitude systems that lead to the new set of behaviors. How can we stop unsafe behavior? Punish people until they behave safely? These approaches emphasize the use of discipline and punishment to discourage unsafe behavior, while safe behavior is largely ignored. This often results in the opposite to that intended. The reason for this is quite simple: The effectiveness of punishment is dependent upon its consistency. It only works if is given immediately, and every single time an unsafe behavior occurs. How do we use this knowledge to help improve safety Behavior? Any safety environment initiative which relies almost exclusively on line managements effort is less likely to be as successful as one that empowers and enables the workforce itself. Accordingly, behavioral safety approaches are very much driven and shaped by the workforce, in conjunction with line management. In this way, the workforce is given responsibility and authority for identifying, defining and monitoring their own safe and unsafe behaviors, as well as setting their own safety environment targets. DOES IT WORK? Because the behavioral approach differs considerably from traditional ways of improving safety, a question commonly asked is Do these ideas work in practice.

Overwhelmingly, the answer is YES. Psychologists from around the globe have consistently reported positive changes in both safety behavior and accident rates, regardless of the industrial sector or company size. Typical Results Include: 40-75 percent reductions in accident rates and accident costs year on year 20-30 percent improvements in safely behavior year on year Greater workforce involvement in safety Better communications between management and the workforce Ongoing improvement to Safety Management Systems Greater ownership of safety by the workforce More positive attitudes towards safely Greater individual acceptance of responsibility for safety.

Known Implementation problems with Behavioral Safety These mainly arise because of attempts to short cut the process due to perceived time pressures, from attempts to minimize the resources required, or from bad advice received from an inexperienced behavioral safety consulting company. Common Problems that often arise include: Lack of workforce buy-in. This normally comes about because the management team, without consultation, has imposed the system on the workforce. The observation checklists are not targeting the accident causing behaviors. This usually occurs because the accident records have not been analyzed correctly. The unsafe behaviors have not been defined with sufficient precision. This is a very common problem with many behavioral safety systems. Such items assume everybody knows what the correct procedures are, and often they do not. The behaviors on the checklists are not acceptable to the workforce, as they have not been consulted about them. Again a lack of consultation about the behaviors on the observation checklists with those who are to be observed is too common. Safety improvement target-setting meetings or Kick-off meetings are not conducted properly. Common problems include insufficient preparation; the sessions are held in noisy locations; there was insufficient time set aside for people to express their views; it is held at an inconvenient time meaning that people are unable to attend; and one or two vocal individuals hijack the sessions to air their grievances about what management has traditionally done or not done in relation to safety. A lack of ongoing management support. Management do not see themselves as a part of the problem, and therefore do not see what they have anything to offer.

The person components consist of the following:




Attitudes represent our covert feelings of covert feelings of favorability toward an object, person, issue, etc. Attitude developed over time by being exposed to the object directly (experience) or through receiving information receiving information about the object (training). People often behave unsafely because they have never been hurt before while doing their job in an unsafe way. Ive always done the job this way Being a familiar comment. This may well be true, but the potential for an accident is never far away. Behavior Based Safety is based on four key components: A behavior observation and feedback process; A formal review of observation data; Improvement goals, and Reinforcement for improvement and goal attainment. 1. Behavioral Observation and feedback This is one of the most important components of the process, Observations provide direct, measurable information on employees safe work practices. Employees are observed performing their routine task. The observer documents both safe and unsafe behaviors.

The employee is then provided positive feedback on the safe behaviors and nonthreatening feedback on the unsafe behaviors. They are also provided with suggestions on correcting the unsafe behaviors. 2. Formal review of observation Data The data is then analyzed to determine the employees (or departments) improvement in the safe behaviors. It can be looked at as an overall percentage. Example. If there were 20 items on the checklist and the worker performed 17 of them safely, then he would get a score of 85% safe. The improvement between observations could be graphed and displayed for employees to view. When the graphs shows improvement between observations could be graphed and displayed for employees to view. When the graphs shows improvement, it provides positive reinforcing feedback to employees. 3. Improvement Goals Setting improvement goals increases the effectiveness of feedback and the success of the behavior-based safety process.

4. Reinforcement for improvement and Goal Attainment Management must provide immediate, positive feedback to reinforce safe behavior. Rewards can be an effective means of reinforcing goal attainment. Behavior Based Safety Process Step 1 Identify the behavior required to obtain safety performance Step 2 Communicate the behavior and how they are performed correctly to all employees. Step 3 Observe the work force and record safe/unsafe behavior and intervene with workers to give positive reinforcement when safe behaviors are observed. Provide coaching/correction when unsafe behavior are observed. Step 4 Collect and record observation data. Step 5 Summarize and analyze observation data.

Step 6 Communicate observation data and analysis results to all employees. Step 7 Provide recognition when safe behavior improved. Step 8 Change behavior to be observed or change consequences as appropriate. Step 9 Communicate any changes to workforce If people see the value of wearing their seatbelt then they are more likely to actually wear it. If people think that smoking is bad for their health, then they will quit. Industrial safety. Is a serious subject both in its consequences and its costs. What is the most effective way to motivate people? Readiness Indicators There are five conditions that dramatically increase the likelihood of success: 1. 2. 3. 4. 5. Effective leadership Established safety systems and processes Safety involvement teams Organizational style Measurement and accountability

LEADERSHIP ___ Leadership commitment to safety is active, visible and lively ___ A clear and inspiring vision has been established for safe performance ___ safety is viewed and treated as a line management responsibility. ___ Safety is clearly perceived as an organizational value on the same level with productivity and quality. Systems and Processes ___ Supervisors and workers partner to find and correct systems causes of incidents. ___ Communication systems are abundant, effective and flow well in all directions. ___ Training systems deliberately and systematically create competency for the right people at the right time.

___ Safe Operating procedures and policies are clearly defined and communicated. Involvement ___ Workers are skilled at problem solving and decision making. ___ Labor and Management work together to address safety systems issues. ___Team Orientation achieves involvement and cooperation. ___ Innovation, participation and suggestions are encouraged at all levels. Organizational Style ___Trust and openness are the norm ___Positive reinforcement is used regularly. ___ Bureaucratic obstacles are removed ___ There is formal and informal recognition for great performance at all levels

Increased efficiency Increased productivity Increased morale Increased Profitability

Why Behavioral based Safety? 1. 2. 3. 4. 5. 6. 7. 8. 9. Safety is about people Compliance is not sufficient Consequences drive behavior Motivating Performance feedback Truly proactive Broad awareness Deep involvement proven effective Transcends workplace safety

Shift persons attitude n the right direction and behavior will follow

SUPERVISOR TRAINING OBSERVATION PROGRAM (STOP) OBJECTIVE 1. To improve safety performance by making skilled focused Observation of people A sustained Habit by all levels of supervision. Specifically, The objective in STOP training is to become a _____________________________ by focusing on _______________ in order to eliminate _________________.

Focused Observation -Directing your attention exclusively to watching an employees safety and health-related work habits. Total Observation LOOK above, below, behind and inside LISTEN for vibrations and unusual sounds SMELL for unusual odors FEEL for unusual temperatures and vibrations

Line Responsibility -Set the standards for your organization Both self-respect and the respect of others are important to every member of your organization USES/APPLICATION of 6 PRINCIPLES OF STOP 1. 2. 3. 4. 5. 6. All injuries and occupational illnesses can be prevented. Safety is a line-management responsibility. All construction and operating exposures can be reasonably safeguarded. Line Management has a responsibility to train employees to work safely. Preventing injuries and incidents is good business. Working safely is a condition of employment.

There are two basic ways in which you apply STOP on the job. Your ____________ and the joint ______________ that you make with your supervisor or STOP program leader. Part of STOP training is for you to make safety observations everyday as part of your regular work. By using the STOP techniques on the job, you can develop the habit skillfully observing, correcting, and preventing recurrence of unsafe acts and encouraging safe work practices.

As a member of line management, your job is to make sure that certain things are done and that they are done correctly. You are continually alert for problems in production, quality, ocst or morale. For these tours, you and your immediate supervisor should schedule a block of time in which you will concentrate exclusively on observing the people in your area of responsibility to see if they are working safely. Why does STOP train you to observe peoples work practices and to focus on peoples unsafe acts? Why not concentrate on unsafe conditions? Nearly all injuries are caused by unsafe acts. Unsafe act has been committed when a person does something that can cause an accident or injury. An unsafe act is always committed by a person, not a machine. A skilled observer looks at everything in the workplace, but concentrates on people and their actions. Every time an unsafe act is committed, some person is gambling with life or physical well-being. And, when an unsafe act is committed, there is never any guarantee that the gambler will not lose. Unfortunately, this may mean losing an eye or limb or a life. In a sense, unsafe conditions cause injuries, too, but many unsafe conditions are caused by unsafe acts. Therefore, all injuries resulting from unsafe conditions are originally caused by DU PONT LOST WORKDAYS INJURIES INCIDENCE RATE Du ponts lost workdays injuries incidence rate during a period of nearly 80 years shows that lost workday rate was 0.033 per 200,000 hours worked. Consider that the more than 3,000 people would have to work a full year with only one lost workday injury to achieve such an outstanding record. One of keys to Du Ponts safety success is the companys belief in the following principle: ALL INJURIES AND OCCUPATIONAL ILLNESS CAN BE PREVENTED. SUPERVISOR RESPONSIBILTY FOR SAFETY What is your responsibility for safety? How is your level of safety performance measured? Where should safety rank on your list of supervisory priorities?

Safety Morals Cost Quality Production

As member of supervision, you are held accountable for the safety performance you can expect from your employees is determined by the minimum standards you have established and maintained. You have established your standards when the standards are understood. You maintain your standards by making sure that they are followed.

When you seen an unsafe act and fall to take corrective action, you signal the people around you that your performance standards are low. The result would be the same if you did not see the unsafe act. In either case, by falling to correct the act you have condoned the act. The Safety Observation Card is not the only tool you use when applying STOP on the job. As you DECIDE,STOP,OBSERVE, ACT and REPORT, the two-sided Safety observation Card will help you through every step. The most crucial part of STOP TRAINING is on-the-job application. When you put what you have learned into action. You stop unsafe acts and prevent injuries. The Observation Checklist 1. 2. 3. 4. 5. Reactions of people Personal Protective Equipment Position of people (Injury Causes) Tools and Equipment Procedures and Orderliness

Making Safety Equipment Maybe, in the past, you have left safety to the professionals. Now you know that you should make safety equal to together major supervisory priorities; quality, morale, cost, and production. STOP training will teach you how. The STOP System Safety Observation Cycle is a tool that can help you make safety equal. Note that the first word in the Safety Observation Cycle is DECIDE. It all starts with you, the decision maker.






The only people you can observe completely are those who are nearby. Others are not close enough to be observed clearly. After you DECIDE to make safety observation, you take the second step in the Safety Observation , you take the second step in the Safety Observation Cycle: you STOP When you walk up to a new group of people, you should stop nearby and devote your complete and UNDIVIDED ATTENTION to observing the peoples work practices. STOP to observe for 10 to 30 seconds. If you find yourself in a situation like the one described, where people are in danger and their supervisor is not taking action, you have a responsibility to encourage the supervisor to act. Often, the best approach is to say, What if - ? In this situation, for example, you could ask the supervisor, What if something happens and those people are injured after youve been standing here, aware of the danger, and not doing anything to prevent the injuries? You can also ask yourself the same question: What if - ? To understand the importance of the second step, suppose you are walking through your area where all of your workers are required to wear all of your workers are required to wear safety glasses. As you walk past one man, you have the impression that he is not wearing his glasses. After a few steps, you turn around and look. IMMEDIATE CORRECTIVE ACTION What should you do if you observe a person committing an unsafe act? FIRST, you should STOP that unsafe act immediately SECOND, you should act to prevent unsafe act from being committed again. Before studying what you should do when you observe an unsafe act, remind yourself of What you should not do. When a person knows that his supervisor does not approve of his own behaviour but does not know why the supervisor does not approve, the person is likely to react to the supervisors presence. If a person has been reprimanded an unsafe act, and if no reason has been given for the reprimand, that person is likely to perform the act safely only when he knows that his supervisor is nearby.

It should be clear that you must take immediate corrective action whenever you observe an unsafe act, and it should be also clear that immediate corrective action, alone, is NOT ENOUGH. To improve the safety performance of the individual who committed the unsafe act to improve your areas safety performance, you must take action to PREVENT RECURRENCE. ALL INJURIES AND OCCUPATIONAL ILLNESSES CAN BE PREVENTED. Action to prevent it recurrence It means that you have taken action to prevent recurrence of an unsafe act from being committed again. You have done something to prevent a dangerous situation from occurring again. Your immediate corrective action will remove the danger for the moment, but only when your action to prevent recurrence will keep the danger from returning in the future. Because an unsafe act is always committed by a person, your action to prevent recurrence involves taking with a person. To prevent recurrence you: TALK WITH THE PERSON INVOLVED UNTIL HE OR SHE UNDERSTANDS WHY THE UNSAFE ACT IS HAZARDOUS. It is important to accept two basic principles when talking with people about their work practices: FIRST, people always act in ways that make sense to them. SECOND, given all the facts, logical people will make logical decisions. To prevent recurrence of an unsafe act, you may find it necessary to take further action after discussing the hazards of the act. For example, you may need to change existing procedures, conduct safety training for your employees, or order new supplies or equipment. Use your judgement: Your ACTION to prevent recurrence should FIT both the SITUATION and your ORGANIZATIONs POLICIES. If you help the person understands that it is in the interest of his own safety not to repeat the unsafe act you observed, the person will work more safely in the future, even when you are not nearby. Not only will his safety performance be improved, but the safety performance of your area will also be improved.

OBSERVATION PERSONAL PROTECTIVE EQUIPMENT Head Eyes and Face Ears Respiratory System Hands and Arms Trunk Feet and Legs


Hard hat, acid-resistant hood, hair net Safety Glasses, faces shield, splash-resistant goggles, Welders hood Earplugs, earmuffs Respirators, SCBA, dust mask, supplied-air hood Gloves: leather, chemical-resistant, heat-resistant, cut resistant, arm-guard Apron, safety belt, frame-retardant clothing, full body suit, coveralls Safety shoes, shin guards, chemical-resistant boots, rubber boots

There is another important reason for being alert for unsafe acts involving PPE. Experienced observers have noted that a person who does not wear adequate PPE often ignores other safe practices. In such cases, the unsafe acts are the results of the persons attitude.

The Observation Report What Information do you write on the Observation report? the unsafe act you observed your immediate corrective action your action to prevent recurrence your signature the date the name of the person who committed the unsafe act

Remember that the Observation Reports you complete on the job will be collected, analysed and used to coordinate your organizations efforts to eliminate injuries. They will also be used to discover what successes or problems you are experiencing as you apply STOP on the job. A FINAL CAUTION do not give your employees the idea that these reports are meant to get them in trouble. Be sure to let your employees know that your observation reports will not include names. Do not forget that your objective is to Help your employees work safely. Evaporative Unsafe Acts It would be convenient if people would stand still and give you plenty of time to observe their unsafe acts. They do not; their unsafe acts sometimes disappear or evaporate very quickly How can you stay alert enough to see unsafe acts before they disappear? Evaporative Unsafe Acts are unsafe acts that disappear very quickly. For example, a person can often add or adjust PPE in just 10 to 30 seconds. This type of unsafe act would be an evaporative unsafe act. Similarly, if a person can move from an unsafe position to a safe position in 10 to 30 seconds, he has committed an evaporative unsafe act.

Observing the Positions of People When you observe people at work, you must ask yourself whether their positions can lead to injury. Is the person positioned close to a hazard? The key to observing positions of peoples of people in the workplace is the list of INJURY CAUSES. This list will help you to expect the unexpected. Using the list, you can foresee and correct situations that can result in injury if the unexpected happens. Remember also to use a questioning attitude.

INJURY CAUSES Striking against or being struck by objects Caught in, on, or between objects Falling at same level or falling to different level Contracting temperature extremes Contracting electrical current Inhaling, absorbing through the skin, or swallowing a hazardous substance Overexertion while lifting, pulling, pushing or reaching

For example, a maintenance man in your area is washing the floor with an electric scrubber. He has not inspected the cord on the scrubber and has not noticed that it is frayed. He is standing in water and his shoes are wet. He can be seriously injured, or possibly killed, if he contacts the bare wore or the bare wire contacts the water, In both cases he will receive electric shock. The maintenance man does not know that he is in danger. Unless you observe his work area carefully, using the list of injury causes and the observation checklist, checklist, you may not perceive the danger, either. First, to familiarize yourself with the list of injury causes, complete the observation checklist. Then mark the category in Positions of People (Injury causes) that will help you perceive the danger that threatens the employee in the previous example. Injury Causes Do people in your work area, lift, push, pull, or reach? Do they climb ladders? Do they handle hazardous substances? Do they walk from one place to another? In each of these activities or positions, there is the potential for injury. Your job is to recognize that potential and train your employees to recognize it, too.

Talking with Talking with a person is very different from giving someone a scolding or a talking-to. Talking with includes all of the following: Using a positive, non-threatening tone of voice adopting a questioning attitude listening to the other person exchanging ideas

Reactions of People People who understand and accept the importance of safe practices are more strongly motivated to work safely. The more safely the people in your work area, the more likely you are to succeed in eliminating injuries. When you demonstrate all three of these through your actions, you will be on the way to an excellent safety performance in your area. COMMITEMENT, CONSISTENCY, PERSEVERANCE COMMITMENT. You must show people in your area that you are concerned about their safety. Safety must be high on your list of priorities every day equal to quality, morale, cost and production. STOP techniques, like the techniques used in the Safety Observation Cycle, will help you put your commitment to safety in action. CONSISTENCY. Each time you observe an unsafe act you should correct it and act to prevent recurrence. If you walk past one person who is working unsafely but correct the next persons unsafe act, you will send the signal that safety is important only when you are in the mood to notice it. When you are consistent, however, the people in your area will see a pattern in your actions: a consistent pattern of commitment to safely. PERSEVERANCE. It is important for you to persevere and continue using STOP techniques and talking with people, making sure they understand and accept the safe practices needed for the jobs. Over time the people in your area will learn, through your perseverance, that your purpose is to help them work safely, rather than to get them in trouble. Until the people in your area are convinced that working safely is to their benefit, they may simply react to your presence. A QUESTIONING ATTITUDE Two questions are the keys to a questioning attitude? WHAT IF - ? What injuries can occur IF the unexpected happens? HOW - ? How can this job be done more safely? REACTIONS OF PEOPLE When you see people reacting to your presence, is that a good sign? YES and NO. It is good sign when it shows that they are becoming more aware of their unsafe acts. It is a bad sign when it indicates that they have not yet developed a good safety attitude.

People in your area may see unsafe practices simply as something supervision wants them to follow, rather than something for their benefits. Therefore, they may see hazardous acts as something to hide rather than something dangerous to themselves. If they have attitude, the people in your area are likely to REACT TO YOUR PRESENCE by stopping their unsafe acts inly when you are nearby. It is your responsibility to be alert for peoples REACTIONS because the reactions are CLUES to possible unsafe acts. REACTIONS OF PEOPLE 1. 2. 3. 4. 5. Adjusting or Adding PPE Changing Position suddenly Rearranging the job Stopping the job Attaching grounds or Locks

REMINDER When you enter a section of your area of responsibility, you look for the reactions of people first because you will have so little time to observe them. Next you look at peoples personal protective equipment and then their positions

INVESTIGATION When you observe a reaction, there are two things you need to find out. FIRST, was the person who reacted trying to hide or correct an unsafe act, or was there another reason for the reaction? SECOND, if an unsafe act was committed, what was it? Anytime a person reacts to your presence by attempting to correct or hide an unsafe act, it is important for you to discover what it was so that you can take action to prevent recurrence.