4 Understanding the Challenge National Council on Compensation Insurance (NCCI); 2005, 2006, 2009Frequency of WC cases is down, greatest reductions for less serious injuries.Cases valued at $50,000 or greater, the reduction is about 1/5 of that for less costly cases.And they don’t happen very often….knock on wood
6 Understanding the Challenge BST & Mercer ORC 2011 study along with 7 global companies, Shell Oil, Exxon Mobile, CargillDon Martin BST, ASSE Fatality and Severe Loss Prevention Symposium Nov 2013Thomas Krause, Co-founder of BST, ASSE Denver meeting 2012Safety Professional Myths:Unsafe acts by workers are the principal causes of occupational accidentsReducing accident frequency will equivalently reduce severe injuries
7 Dislodging Safety Myths Reducing accident frequency will equivalently reduce severe injuries.H.W. HeinrichPioneer in field of accident prevention, 1930’s – 1960Misinterpretation of termsMajor injury – any case reported to insurance carriers or to the state compensation commissionerMinor injury – scratch, bruise or laceration such as commonly termed first aid caseNo injury or Near Miss – unplanned event that resulted in no employee injuryFred A. Manuele; Reviewing Heinrich, Dislodging Two Myths From the Practice of Safety. ASSE Professional Safety October 2011
8 Dislodging Safety Myths Heinrich’s pyramidMisinterpretation of termsMajor injury – any case reported to insurance carriers or to the state compensation commissionerMinor injury – scratch, bruise or laceration such as commonly termed first aid caseNo injury or Near Miss – unplanned event that resulted in no employee injury
9 Dislodging Safety Myths Heinrich’s premises is…“the predominant causes of no-injury accidents are, in average cases, identical with the predominant causes of major injuries, and incidentally of minor injuries as well”
10 Dislodging Safety Myths Many safety practitioners have misused this information or have been misinformed300 unsafe acts, 29 serious injuries, 1 fatalityBased on these definitions, there is no Severe Injury or Fatality detailed in the original pyramidDo not understand the context or the definitions of the Heinrich pyramid terms
11 Dislodging Safety Myths Unsafe Acts of workers are the primary causes of occupational incidents.Single point failure…worker is at faultIndustrial Accident Prevention: A Scientific ApproachPsychology in accident prevention is a fundamental of great importancePsychology is at the root of sequence of accident causesOriginal source data and references unavailableUnited Electrical, Radio & Machine Workers of America
12 Dislodging Safety Myths Heinrich’s Causation Theory88% unsafe acts10% unsafe mechanical or physical conditions2% are unpreventable“man failure is the heart of the problem”“unsafe acts, unsafe tools and willful disregard of instruction”“In the occurrence of accidental injury, it is apparent that man failure is the heart of the problem; equally apparent is the conclusion that methods of control must be directed toward man failure”“man failure” not defined; however, in the case to support controlling man failure, Heinrich cites personal factors such as unsafe acts, using unsafe tools and willful disregard of instruction.
13 Dislodging Safety Myths Columbia Accident Investigation Board (NASA 2003)Accident investigations do not go far enoughIdentify a technical cause and connect it to “operator error”Limits the investigationtypical corrective actions – fix technical error, retrain worker
14 Dislodging Safety Myths “The team did not identify any single action or inaction that caused this incident. Rather, a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces came together to allow the initiation and escalation of the accident”BP Deepwater Horizon
15 Dislodging Safety Myths Unsafe Acts of workers are the primary causes of occupational incidents.Reducing accident frequency will equivalently reduce severe injuries.False sense of securityInsufficient incident investigationsMisdirected preventionLack of focus and recognition of other causesMyths have resulted in…False sense of security, reduce minor injuries = and proportionate decrease in serious injuriesPrevention efforts focused on the employeePrevention efforts focused on technology or equipment (a new alarm, a new switch, a new interlock…)Insufficient incident investigationsLack of focus and recognition of other causesManagement decisions,Organizational culture,Safety systems,Prevention through designFred A. Manuele; Reviewing Heinrich, Dislodging Two Myths From the Practice of Safety. ASSE Professional Safety October 2011
16 Descriptive Perspective Safety pyramid is generally accurate from a descriptive perspectiveFatalitiesLost Time InjuriesRecordable InjuriesNear Miss Events
17 Predictive Perspective A reduction in injuries at the bottom of the triangle does not correspond to a proportionate reduction in SIFs21% of injuries have SIF potential (BST research)We need to focus resources and attention on the 21% of injuries that have SIF potential. If we don’t, the causative factors that create potential SIFs will continue and we will eventually have an SIF.
18 Things We Need to Do Identify potential SIFs Prevent SIF events Define SIFsIncident reports & injury logsSIF Decision treePrevent SIF eventsAudits, Inspections, SOPs & JHAManagement controls, Life Safety Rules,Educate organizationInform about SIF exposuresReport SIF near miss events
19 Identify SIFs - Define Define Serious injury Define Precursors Life threatening - one that if not immediately addressed is likely to lead to the deathSevere burnsEvent that requires CPRLaceration / cut with significant loss of bloodDamage to brain or spinal cordLife altering injury - one that results in permanent or long-term impairment or loss of use of an internal organ, body function, or body part.Head injuriesAmputationParalysisFractured bonesBrain / spinal cord injuriesDefine PrecursorsHigh risk situation in which management controls are either absent, ineffective, or not complied with and in which the result could be a serious injury or fatality
20 Identify SIFs – Injury Review Teams Injury logs, incident reportsSIF Decision TreeLimited EH&S & Risk Management Professionals to follow up on injuries, where do we focus our time and effort?
22 Injury Logs & SIFs First Aid Only A vehicle mechanic was cleaning the residue and dirt from the top of a garbage truck, slipped and bruised his elbow.The top of the truck is 12 ft off the ground and there was no fall protection in place to prevent the worker from falling off the vehicle to the concrete below.An Administrative Assistant tripped and bruised their elbow when their shoe caught on a loose portion of the carpet.
23 Injury Logs & SIFs Near Miss An electrician was working in an attic installing new wire. The worker became light-headed and was taken outside to fresh air. No lost time or recordable injury occurred and he returned to work.A flooring contractor was using a solvent to strip away old mastic from the concrete floor below the attic. Vapors from the mastic remover concentrated in the attic, the electrician became light-headed and partially fell through the sheetrock ceiling becoming wedged between two beams.
24 Other incident logs Property damage A forklift operator was unloading supplies for the Dining Hall. They were backing up going approximately 5 MPH, struck a pedestrian walkway guardrail and damaged it. No pedestrians were in the walkway.
26 UC SIF Potential UC 2010 – 2014 (April 30) 188 Claims of $150K or greater21 SIF exposures~ 11% have SIF potential4 of top 10 highest incurred costs, SIFs2012 = #1 Fall from roof – 8 ft (over 5.5 million total incurred)2013 = #3 Vehicle incident (2.2 million)2009 = #4 Vehicle incident – employee hit by vehicle (1 million)2014 = #8 Fall from aerial lift (600K)
32 Educate the Organization Dislodge the MythsTraditional Safety triangle is accurately descriptive, but not accurately predictiveIncident investigations must go beyond single point failure of workerDefine SIFs, review challenges, potential impactsInform Senior Leaders of SIF exposuresDevelop SIF metrics & report
33 Summary Recognize the Challenge Dislodge Safety Myths Identify potential SIFsPrevent SIF eventsEducate organizationRecognize the ChallengeIdentify potential SIFsIncident review teamsSIF Decision tree, Reactive and/or ProactiveIncident investigationsPrevent SIF eventsTargeted Audits, Inspections & JHA’s, ProactiveManagement controls, Life Safety Rules, Hierarchy of Controls, Integration with ISEMEducate organizationDefine SIFsInform about SIF exposuresReport SIF near miss events to Senior LeadersFrequencySeverityMeasure potential to SIFs
34 Don’t be the Turkey The event is a surprise The event has a major impactIn hindsight, the event could have been predicted