Great Safety Performance is No Accident! · 2018. 2. 4. · Great Safety Performance is No...

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© Copyright 2017, VelocityEHS. Do not distribute without authorized consent.

Great Safety Performance

is No Accident!_______

Overcoming Common Incident Management Mistakes

Presented byPhil Molé, EHS Expert, VelocityEHS


LEARNING OBJECTIVES• Understand the importance of incident management

• Understand hazard identification (job hazard analysis)

• Learn strategies for effective corrective action management

• Identify the most common incident management mistakes

• Learn best practices for developing and implementing an effective incident management program

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THE IMPACT OF WORKPLACE ACCIDENTS CAN BE HUGE!

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2

4

6

8

10

12

14

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Overexertion Falls (samelevel)

Struck by Falls (lowerlevel)

Otherexertions

Roadwayincidents

Slip or trip,without fall

Caught in Repetitivemotions

StruckAgainst

Total worker’s compensation costs for the top 10 causes of disabling workplace injuries (United States, 2012)

COST ($ M

ILLIONS)

CAUSE OF INJURY


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52%Average # of Compensation Claims

87%Average Lost Time Per Claim

80%Average Cost of Claims

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PLANNING YOUR INCIDENT MANAGEMENT PROGRAM


INCIDENT MANAGEMENT PROGRAM ELEMENTS

Incident Management

Job Safety Analysis (JSA)

Incident Response

Corrective Actions

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JOB SAFETY ANALYSIS


JOB SAFETY ANALYSIS (JSA)There are four basic steps to performing a job safety analysis (JSA), as shown here:

1. Job Selection

2. Job Task Breakdown

3. Hazard Identification

4. Corrective Action Planning

Let’s take a closer look at each of these steps.

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JSA STEP 1: JOB SELECTIONSelecting the job to be analyzed may sound simple, but it is a vital consideration when employers have limited time and resources to analyze all of the various jobs associated with their operations.


JSA STEP 1: JOB SELECTIONGenerally, JSAs should be prioritized according to the following criteria:

1. Jobs with the highest frequency or severity of incidents/injuries

2. Jobs with the highest potential for injury/illness

3. New jobs and processes where hazards have not yet been fully identified

4. Recently modified jobs and processes

5. Non‐routine jobs where workers may not have high awareness of hazards

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JSA STEP 2: JOB TASK BREAKDOWN

• “Tasks” are the individual steps required, in sequence, to complete a multi‐step work process, or “job”

• Break each job into a clearly defined sequence of individual tasks. Avoid defining tasks either too narrowly, or too broadly!

Generally, a job should contain no more than 10 individual tasks. If your JSA exceeds this number, consider separating the job into two or more separate phases.


JSA STEP 3: IDENTIFYING HAZARDSHazards should be identified soon after the job task breakdown. Review the sequence of tasks one at a time, and ask questions such as:

• Are there pinch points?

• Is there potential for slips/trips/falls?

• Are chemicals used? Which ones?

• Is there a potential for lifting strains?

• Is there a potential for cuts/lacerations?

(Not an exhaustive list, of course)

Employee involvement is the key to success!

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JSAs CAN REDUCE INCIDENTS!JSAs (also known as Job Hazard Analyses, or JHAs) can be an effective means of reducing workplace incidents. OSHA has published guidelines on the creation and use JSAS here: https://www.osha.gov/Publications/osha3071.pdf

© Copyright 2017, VelocityEHS. Do not distribute without authorized consent. Incident Response

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INCIDENT RESPONSE: TRAINING



• Ensure all employees at all levels understand incident response procedures and are prepared to respond

• Improper response procedures can compound an incident’s severity! (Tianjin)

• Employers should have a comprehensive written emergency response plan, which should be easily accessible

• Training provided must account for language and educational diversity of workforce – should be “in a manner and language” employees understand

• Don’t just provide training – verify it was understood!

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Regularly scheduled safety meetings provide a good opportunity to reinforce incident response procedures.



INCIDENT RECORDING AND INVESTIGATION

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INCIDENT RECORDING AND INVESTIGATION

• Neutralize immediate hazard & begin investigation. Witnesses to incidents must report them immediately

• Report close calls, too

• Early start to investigation = faster resolution


INCIDENT RECORDING AND REPORTINGRemember:

• Report certain serious incidents to OSHA

• Report recordable incidents on OSHA 300 and 301 forms and included on the 300 A summary

• Report “near misses”/”near hits”

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OSHA INCIDENT RECORDING & REPORTING REQUIREMENTS

Revised OSHA incident reporting requirements for all facilities.

(As of 1/1/15)

All employers must:Report any fatalities within 8

hours

Report work‐related amputations/loss of eye AND all in‐patient hospitalizations within 24 hours



All recordable incidents must be recorded on the OSHA 301 form or its equivalent within 7 days!

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OSHA’S FINAL RULE TO IMPROVE TRACKING OF WORKPLACE INJURIES AND ILLNESSES (ELECTRONIC RECORDKEEPING)• Requires certain employers to electronically submit their injury and illness information

• An employer’s procedure for reporting work‐related injuries and illnesses must be reasonable and not deter/discourage employees from reporting

• Mobile incident reporting apps enable barrier‐free reporting following an incident

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SAFETY INCENTIVE PROGRAM REQUIREMENTS UNDER THE RULE

• Employers must not create incentive programs that deter/discourage injury/illness reporting

• Incentive programs should encourage safe work practices and promote worker participation


INCIDENT INVESTIGATION

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THE INCIDENT INVESTIGATION PROCESS

1. Call the right people to begin investigation

2. Secure the area where incident occurred

3. Gather witnesses

4. Interview involved worker(s)

5. Interview all witnesses

6. Take photos/videos

7. Complete investigation report

8. Use results to improve systems/procedures

9. Ensure follow‐up on corrective actions


THE INCIDENT INVESTIGATION PROCESS

2015 revisions to OSHA’s incident reporting standards require employers to document, at a minimum:

• Establishment name

• Location of the work‐related incident

• Time of the work‐related incident

• Type of reportable event

• Number of employees involved

• Names of the employees

• Contact person & phone number

• A brief description of incident

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THE INCIDENT INVESTIGATION PROCESSWho? What? When? Where? How?

• The answers to these questions are needed to determine the “root causes,” or underlying reasons, why an incident happened to prevent a recurrence. Good root cause analysis should reveal systemic issues


ROOT CAUSE ANALYSIS

• What we can “see”: the symptom of the problem

The underlying cause, aka the “root”

Don’t mistake symptoms/effects with underlying causes!

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ROOT CAUSE ANALYSIS FOCUSES ON CONTINUOUS IMPROVEMENT


REVISING YOUR JSAs

Ideally, after an incident you should revisit the JSA to evaluate the relevant job tasks

Make sure employees areaware of JSAs!

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CORRECTIVE ACTIONS


CORRECTIVE ACTIONS• Once you’ve performed an incident investigation, re‐evaluated the relevant JSA and generated incident reports, it’s time to develop and initiate corrective actions (CAs)

• These are the measures you will take to prevent, or at least minimize the potential for its recurrence

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DEVELOPING CORRECTIVE ACTIONS• Developing good corrective actions is not as easy as it may seem

• The process depends on how accurately problems are identified. The stress of dealing incidents sometimes leads people to “fix” problems before they understand root causes

• Must overcome preconceptions about “what needs to be done,” and instead, go as deep as is necessary to eliminate the cause


DEVELOPING CORRECTIVE ACTIONSGeneral guidelines:• Employee involvement – to ensure the solutions will work

• Address all root causes identified

• Be sure to include corrective actions for the JSA, if applicable

• The most effective corrective actions are those implemented at the design level

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THE HIERARCHY OF CONTROLS

Elimination/substitution is the best option, when possible. All other solutions create a barrier to the hazard but leave the hazard in place.


PRIORITIZING CORRECTIVE ACTIONS

IMPACT

Very Low Low Medium High Very High

1 2 3 4 5

PROBABILITY

Very High 5 5 10 15 20 25

High 4 4 8 12 16 20

Medium 3 3 6 9 12 15

Low 2 2 4 6 8 10

Very Low 1 1 2 3 4 5

RISK PRIORITY MATRIX

Not All Hazards Are Equal!• Unless you’re extremely lucky, you’ll probably have more than one corrective action to manage at a time!

• Prioritize addressing corrective actions based on risks, considering severity of potential incident and the potential number of employees affected

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MANAGING CORRECTIVE ACTIONSCorrective actions must be managed from conception to completion. Remember:

Assign them to the right people

Make sure those assigned CAs understand expectations, due dates

Track CAs to ensure completion

Verify and review CAs when completed

Communicate results to others – what worked well, what needs improvement?

Adjust CAs as needed


CORRECTIVE ACTIONS AND EMPLOYEE “BUY‐IN”• Effectively and efficiently completing corrective actions and communicating results helps earn employee “buy in”

• Earning employee participation and tapping into it is the key to success

• Your employees are your most important resource for driving your incident management system and your entire EHS culture!

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When you have an effective EHS management system, you’ll do more than just maintain compliance. There are many potential benefits, as seen in this chart.

BENEFITS OF EFFECTIVE EHS INCIDENT MANAGEMENT PROGRAMS

43%

28%

7%

6%

16%

Top Benefits of Effective Workplace Safety Programs Cited by Financial Decision makers (percent of respondents)

Increased productivity

Reduced costs

Greater retention of employees

Better employee morale andgreater job satisfaction

Other


INCIDENT MANAGEMENT MISTAKES: JSAS

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COMMON MISTAKES WITH JSAS

1. Making the task breakdown too detailed

2. Making the job breakdown so general that tasks are indistinguishable

You need to find the “happy medium” between these two mistakes!


COMMON MISTAKES WITH JSAS

3. Not involving employees in the process

4. Doing JSAs, then filing them away

Employees need to be involved in the process, and aware of how to access them!

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INCIDENT MANAGEMENT MISTAKES: INCIDENT INVESTIGATION & ROOT CAUSE

ANALYSIS


COMMON GENERAL INCIDENT INVESTIGATION MISTAKES1. Not talking to all of the right people2. Not giving enough weight to testimony of injured employee3. Belief that delays in reporting injury justifying “disowning” responsibility

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COMMON GENERAL INCIDENT INVESTIGATION MISTAKESOne of the biggest reasons for incident management failure is use of an incident reporting system that is too difficult or complex.

Effects:

1. Delays investigation, affects quality of investigation

2. Discourages reporting in the first place3. Interferes with response to incident –

prolongs hazard4. Affects quality of corrective actions5. Might expose you to fines from OSHA


“FRAMING” MISTAKE – MISCLASSIFYING INCIDENTS

Update the previously

recorded injury or illness record, if

necessary.Don’t create a new

record

Record

1) Did the employee experience an injury/ illness?

Yes

4) Does the injury or illness meet the general or the specific additional recording criteria ?

Yes

2) Was it work‐related?

Yes

3) Is event or exposure a new case?

Yes

Don’t Record

No

No

No

No

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WHAT IS WORK‐RELATED?• Presume Work‐Related if, and only if:

– Event or exposure in the work environmentIS the cause of the injury or illness

– Event or exposure LED TO significant aggravation of a pre‐existing condition• Sidewalks• Employee parking lot• Landscape, etc.

• Geographic Presumption of Work Environment:– Defined as any establishment/other location where 1 or more employees

are working or present as a condition of employment, including:• Physical locations • Employee working away from primary work establishment still carries geographical presumption (some exceptions apply)

• Geographical presumption may also include exterior of the establishment

1) injury/ illness?

2) Work‐related?

3) New case?

4) Meet recording criteria

Proceed


EXCEPTIONS TO WORK‐RELATED9 Main Exceptions Include – 1904.5(b)(2):1. Present as member of general public 2. Symptoms arise solely from non‐work event / exposure3. Voluntary participation in wellness program or

recreational activity– Wellness/ Fitness programs (exercise class, baseball)– Medical (donating blood, flu shot)

4. Eating/ drinking/ preparing food for personal consumption5. Personal tasks outside working hours6. Personal grooming/ self‐medication for non‐work‐related condition/

intentionally self‐inflicted incident7. Motor vehicle accident while commuting

– Parking lot– Access roads

8. Common cold or flu9. Mental illness

– Unless licensed professional confirms work‐relatedness

Additional Travel Exceptions ‐ 1904.5(b)(6)

1) injury/ illness?

2) Work‐related?

3) New case?


Don’t Record

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NEW CASES• If employee has not previously experienced a recorded injury or illness of the same type that affects the same part of the body

OR

• If employee previously experienced a recorded Injury or illness of the same type that affects the same part of the body BUT had recovered completely

1) injury/ illness?

2) Work‐related?

3) New case?


Proceed


“FRAMING MISTAKE”: OVERLOOKING TEMP & CONTRACTED WORKERS

Injuries or illnesses experienced by contractors & temporary employees may or may not be recordable for you, depending on whether you supervise their work on a day‐to‐day basis, or if the other employer provides that supervision.

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“FRAMING” MISTAKE: FIRST AID VS. MEDICAL TREATMENT• First Aid (Non‐Recordable)

– Use of non‐prescription medications at non‐prescription strength – Administering tetanus immunizations– Cleaning, flushing or soaking wounds on the surface of the skin– Use of wound coverings such as bandages, Band‐Aids™, etc.– Use of hot or cold therapy– Use of any non‐rigid means of support

• Elastic bandages, wraps, non‐rigid back belts, etc.

– Use of temporary immobilization devices while transporting an accident victim

• Splints, slings, neck collars, back boards, etc.

– Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister– Use of eye patches– Removal of foreign bodies from the eye using only irrigation or a cotton swab– Removal of splinters or foreign material from areas other than the eye, by irrigation,

with tweezers, cotton swabs or other simple means– Use of finger guards– Massages – Drinking fluids for relief of heat stress

1) injury/ illness?

2) Work‐related?

3) New case?


Don’t Record


OSHA’s Recordkeeping Rule

Workers’ Compensation Law

“FRAMING MISTAKE”: RECORDABLE CRITERIA VS WORKERS COMP

According to Section 1904.0 of the Standard, having an OSHA Recordable Incident does NOT necessarily mean:

• An employer was at fault

• An OSHA Rule has been violated

• An employee is eligible for Workers’ Compensation

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ROOT CAUSE ANALYSIS MISTAKES: CASE #1An office employee who walks with a cane falls down in a section of hallway leading from the office area to a side door exiting to the parking lot, and winds up with a fractured elbow from the fall. This employee has known health and mobility issues, and you are not aware of any other employees who’ve fallen in this area.

Source: OSHA


IT’S EASY TO JUMP TO CONCLUSIONS, BUT….We investigate and find the hallway where the incident occurred is slicker and waxier than other areas. We’re surprised to hear that other employees have slipped and fallen, but hadn’t thought to report it. It seems that the floor is more slippery after floor cleaning visits from the maintenance crew.

There’s a new cleaning crew employee who ends his shift in that section then exits thru the parking lot door, so this section has not been getting dried as well as it should.

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SO THE DEEPER ISSUES ARE…

What first appeared to be cut and dried actually happened because of several deeper issues:

• Waxy hallways from improper cleaning technique

• Lack of proper cleaning procedure and methods to insure that new staff are trained properly

• Serious problems with knowledge about incident reporting, which prevented us from addressing the issue before a recordable injury could occur

• Lack of focus on raising awareness of safety among office personnel


ROOT CAUSE ANALYSIS MISTAKES: CASE #2As part of a plant beautification process, Management orders some topcoat and epoxy topaint the main walkways of the factory. During application of the coatings, employees complain about the fumes, and several need to go home due to complaints of dizzinessand nausea.

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WHY DID THIS HAPPEN?

Subsequent investigations reveal that the paint was never properly assessed by corporate EHS prior to being brought on‐site.

So, the big take‐away is “no more painting without proper review,” right?


NOT SO FAST….

OK, if we had that as a take‐away, we’d head off problems with future painting incidents….probably.

But what if years from now we need or want to *remove* the paint, and need to use paint stripper? What if we don’t paint at all, but get a new floor cleaner to make the concrete floors nice and shiny? Neither of these cases would involve painting, but both could introduce new hazards.

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THE DEEPER ISSUEWhy weren’t the paint and epoxy properly reviewed? Chances are, you probably have a procedure for reviewing hazards of new chemicals and processes when it comes to operations. But this wasn’t operations‐related.

So, one of the biggest real root causes is the lack of procedures or plans for assessing risks related to operations besides production ops.


ROOT CAUSE ANALYSIS MISTAKES: CASE #3Your facility decides to implement a new uniform policy for all shop‐floor employees. One week after distributing the uniforms, a manual machinist gets part of his sleeve stuck in the machine, pulling his arm partially into the gears and luckily just scraping the skin. A first aid‐incident that could’ve been a serious recordable, even an amputation.

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THE OBVIOUS STUFF….Several things jump out at us right away. Clearly, there was a failure to properly risk assess the uniforms. If we’d risk assessed them, we would have seen (possibly) the risk for manual machinists, where loose/hanging clothing is a serious hazard. Likely, we thought of the uniforms as just being “clothes,” and of entirely lacking EHS considerations.


LOOKING A LITTLE HARDER…

We can start to ask related questions. E.g., what about other types of risks that we might have missed? E.g., are welders wearing these, and is the material fire‐resistant? And why did we miss that there might be EHS issues here, and how do we fix that?

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HERE’S WHERE HONESTY IS NEEDED

We can say that “failure to properly risk assess the uniforms” or “failure to have adequate risk assessment policies in place” might be a root cause. To be sure, it’s important stuff. But it’s not the whole story. Because the painful truth is, in this case, how could we possibly have made these assumptions if we had a good EHS culture, and sought employee input? Any manual machinist would’ve *told us* the risks, if we’d asked her or him.

So why didn’t we?


DEEPER ROOT CAUSES

Clearly, there is a deep underlying issue with the culture itself. Management does not seek the input of employees, and therefore cannot learn what they need to know. This can be fixed, but it will take effort on many fronts:

• Better communications to employees

• Actively seeking input from employees

• Sharing progress on corrective actions

• True prioritization of safety, e.g., “safety stand downs”

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TAKE‐HOME LESSONS

• It’s easy to jump to conclusions• We need to identify and avoid biases• Investigate programs, not

“behaviors!”• We need to do a thorough

investigation, and go wherever it leads

• We should *assume* there will probably be a system failure involved

• There is almost never just one reason for an incident!


INCIDENT MANAGEMENT MISTAKES: CORRECTIVE ACTIONS

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COMMON MISTAKES WITH CORRECTIVE ACTIONS

1. Not involving employees in the process

2. Not sharing details of corrective actions with employees, or other company reps


COMMON CORRECTIVE ACTION MISTAKES

3. Inefficient management of corrective actions – inability to start working on themas soon as possible has a catastrophic effect on entire program

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So, how do I create an incident management program that works and fosters employee buy‐in?


USE INJURY AND ILLNESS PREVENTION PROGRAMS (I2P2)

6 Keys to I2P21.Management Leadership2.Worker Participation3.Hazard Identification and Assessment

4.Hazard Prevention and Control

5. Education and Training6. Program Evaluation and Improvement

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OTHER RECOMMENDATIONS• Show employees their feedback makes a difference. Promote visibility

• Identify and remove barriers to participation, including difficult reporting procedures. Verify comprehension. (Note: helps ensure OSHA compliance, too!)

• Use technology resources to streamline and simplify tracking and management of JSAS, incidents and CAs. Having one system that manages all of them will help!

• Recognize and tap into the diversity of your workforce to improve in all facets of safety


EXAMPLE: IMPROVING RISK PERCEPTION

What do these two photos convey about risk perception?

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EXAMPLE: RISK PERCEPTION• Diverse employees possess diverse backgrounds and experiences that influence their perceptions of risk, and the level of risk they are willing to accept

• Use diverse risk perceptions to your advantage!

• Emphasize the importance of watching out for each other’s safety – that all of them are your best EHS resource!

• You’ll be able to “see” risks better than before, which improves your JSAs

• Employee involvement increases morale and “buy‐in!”

MAKE IT PERSONAL.

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SOFTWARE SOLUTIONS CAN HELP WITH:

• Reporting incidents, including mobile capability

• Managing incidents

• Developing and tracking corrective actions

• Tracking incident metrics

• Internal and external reporting

• Risk assessments/JSAs


QUESTIONS?Phil Molé

Email: [email protected]

Phone: 1.312.881.2252

Great Safety Performance is No Accident! · 2018. 2. 4. · Great Safety Performance is No...

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