Recognizing Predictive Indicators for Fatalities and Serious Injuries

1. Recognizing Predictive IndicatorsforFatalities and Serious Injuries Fred A. Manuele, CSP, PE President Hazards, Limited

2. What I Will Comment On A phenomenon Statistics on fatalities and serious injuries Debunking a myth

3. What I Will Comment On • Fatality–serious injury characteristics • Significance of organizational culture • The business climate, and culture • A mechanism for an internal study

4. What I Will Comment On • Improving incident investigation • Making gap analyses • A “near hit” data gathering system • The need for a different mind set

5. The Phenomenon • Reliance on traditional approaches to fatality prevention has not always proven effective. This fact has been demonstrated by many companies, including some thought of as top performers in safety and health, as they continue to experience fatalities while at the same time achieving benchmark performance in reducing less-serious injuries and illnesses.

6. The Phenomenon • ORC Worldwide: 140 Fortune 500 companies • Data gathering system on fatalities and life threatening incidents • We, collectively, do not know enough about causal factors

7. Statistical Indicators – Fatalities • National Safety Council – Accident Facts (Now Injury Facts) • Bureau of Labor Statistics – National Census of Fatal Occupational Injuries

8. Statistical Indicators – Fatalities No. of Number of Fatality Workers Year Fatalities Rate in 1000s 1941 18,000 37 48,100 1951 16,000 28 57,450 1961 13,500 21 64,500 1971 13,700 17 78,500 1981 12,500 13 99,800 1991 9,800 8 116,400 2001 5,900 4.3 136,000

9. Statistical Indicators – Fatalities • From 1941 through 2001 • Employment increased over 280% • Number of fatalities – down over 67% • Fatality rate – reduced over 88%

10. Statistical Indicators – BLS ReportsAll Fatalities – All Occupations Number of Fatality Year Fatalities Rate 2001 5,900 4.3 2002 5,524 4.0 2003 5,559 4.0 2004 5,703 4.1 2005 5,702 4.0 2006 5,703 3.9

11. Statistical Indicators – BLS ReportsAll Fatalities – All Occupations • Relate 2002 to 2006 • Number of fatalities increased 3.2% • Fatality rate stayed the same • Why did the number of fatalities increase? • Why did the fatality rate not continue the downward trend in previous years?

12. Statistical Indicators – BLS ReportsFatality Rates – Selected Occupations Industries 2005 2006 Mining 25.6 27.8 Transportation/wrhsing 17.6 16.3 Construction 11.0 10.8 Utilities 3.6 6.2 Wholesale trade 4.4 4.8 Manufacturing 2.4 2.7

13. Statistical Indicators: BLS • Lost-Worktime Injuries and Illnesses: Characteristics and Resulting Time Away From Work • Table 10 – Percent distribution of nonfatal occupational injuries and illnesses involving days away from work – Private Industry

14. Statistical Indicators: BLS Percent of days-away-from-work cases involving these numbers of days 1 2 3-5 6-10 11-20 21-30 31 or more 1995 16.9 13.4 20.9 13.4 11.3 6.2 17.9 2005 14.3 11.6 19.0 12.7 11.5 6.5 24.2 % -15.4 -13.4 -09.1 -6.0 +1.8 +4.8 +35.2 Change from 1995

15. Statistical Indicators • You can not conclude from the BLS data that the number of incidents resulting in severity has increased • You can conclude that incidents resulting in severity are a larger segment of all lost time injuries

16. Statistical Indicators • National Council on Compensation Insurance • The Remarkable Story of Declining Frequency—Down 30% in the Past Decade • Also down in Canada, France, Germany, UK, Japan

17. Statistical Indicators • National Council on Compensation Insurance (2005 paper) • Decline in the frequency of smaller lost-time claims is larger than in the frequency of larger lost-time claims

18. Statistical Indicators 1999 to 2003, in 2003 hard dollars Value of Claim Frequency Declines 1. Less than $2,000 34% 2. $2,000 to $10,000 21% 3. $10,000 to $50,000 11% 4. More than $50,000 7%

19. Debunking a Myth • A barrier • Reducing injury frequency will equivalently reduce incidents resulting in severe injury

20. Debunking a Myth • Many safety practitioners believe and profess that efforts concentrated on the types of accidents that occur frequently will also address the potential for severe injuries.

21. Debunking a Myth Jim Johnson: “I’m sure that many of us have said at one time or another that frequency reduction will result in severity reduction. This popularly held belief is not necessarily true. If we do nothing different than we are doing today, these types of trends will continue.”

22. DNV Consulting • Much has been said about the classical loss control pyramid, which indicates the ratio between no loss incidents, minor incidents, and major incidents, and it has often been argued that if you look after the small potential incidents, the major loss incidents will improve also.

23. DNV Consulting • The major reality however is somewhat different. If you manage the small accidents effectively, the small accident rate improves, but the major accident rate stays the same, or even slightly increases

24. Debunking a Myth • Recall Jim Johnson saying that: • If we do nothing different than we are doing today, severe injury trends will continue

25. Debunking a Myth • Jim’s view – supported by a world famous philosopher who said • If you keep doing what you did, you will keep getting what you got

26. Debunking a Myth • The world class philosopher • If you keep doing what you did, you will keep getting what you got • Dr. Lawrence Berra

27. Debunking a Myth • As the data clearly shows, frequency reduction does not necessarily produce equivalent severity reduction • Severity reduction requires specially crafted initiatives, focused on hazards and risks that present severe injury potential

28. A Different Approach Needed • The data requires that we adopt a different mind set, one that results in a particularly directed focus on preventing low probability, severe consequence events.

29. Characteristics of Severe Injuries Studies: Over 1,200 Incidents • A large proportion of severe injuries occur: • In unusual and non-routine work • Where upsets occur: normal to abnormal • In non-production activities • Where sources of high energy are present • In at-plant construction operations

30. Characteristics of Severe Injuries • Many accidents resulting in severity are unique and singular events, having multiple, complex, cascading technical, organizational or cultural causal factors

31. Characteristics of Severe Injuries • Largely, causal factors for low probability/severe consequence events are not represented in the analytical data on incidents that occur frequently, but such incidents may be predictors of severity potential if a high energy source is present

32. In the Studies Made • The quality of incident investigations, on average, was abysmal.

33. Predictive Specifics From Studies • Thirty-five percent of severe injuries were triggered by a deviation from normal operations – upsets • Over a 10 year period, 51% of fatalities occurred to contractor employees

34. Predictive Specifics From Studies • In three companies with a combined total of 230,000 employees, each company having very low OSHA rates, 74% of severe injuries occurred to support personnel

35. Predictive Specifics From Studies • Percent of severe injuries that occurred to non-production personnel in two other companies • Company A – 63% • Company B – 67%

36. Predictive Specifics From Studies • For companies with OSHA rates higher than industry averages, and in companies where there is heavy material handling or the work is highly repetitive, the percent of severe injuries occurring to production personnel was higher

37. Predictive Specifics From Studies • About 50% of major accidents involved powered mobile equipment: fork lift trucks, cranes, etcetera • Reviews of electrical fatalities indicate that, the design of the systems produced error-inducing situations

38. Predictive Specifics From Studies • Having effective management of change procedures would have greatly reduced major accident potential • Complacency and overconfidence was often a factor

39. Dan Petersen: On Severe Injuries • The mass data indicates that the types of accidents resulting in temporary total disabilities are different from the types of accidents resulting in permanent partial disabilities or in permanent total disabilities or fatalities

40. Dan Petersen: On Severe Injuries • The causal factors are different • There are different sets of circumstances surrounding severity • If we want to control serious injuries, we should try to predict where they will happen

41. A Study of Fatalities • UAW Data • Skilled trades people, 20 percent of population • Have 41 percent of fatalities

42. Corporate Culture and Safety • The physical cause of the loss of Columbia and its crew was a breach in the Thermal Protection System on the leading edge of the left wing. • In our view, the NASA organizational culture had as much to do with this accident as the foam.

43. Corporate Culture and Safety • Columbia • Organizational culture refers to the basic values, norms, beliefs, and practices that characterize the functioning of an institution.

44. Corporate Culture and Safety • Columbia • At the most basic level, organizational culture defines the assumptions that employees make as they carry out their work. It can be a positive or a negative force.

45. Corporate Culture and Safety • In every organization • “Values, norms, beliefs, and practices” are translated into a system of expected behavior that impacts positively or negatively on decisions taken

46. Corporate Culture and Safety • with respect to management systems, design and engineering, operating methods, and prescribed task performance—and how much risk taking is acceptable

47. On Major Accidents • James Reason – Managing the Risks of Organizational Accidents • Stresses the long term impact of inadequate safety decision making on an organizations culture

48. On Major Accidents • Reason: The impact of (top level) decisions spreads throughout the organization, shaping a distinctive corporate culture and creating error-producing factors within individual workplaces.

49. On Major Accidents • Donald A. Norman – The Psychology of Everyday Things • Most major accidents follow a series of breakdowns and errors.

50. On Major Accidents • Norman: In many cases, the people noted the problem but explained it away, finding a logical explanation for the otherwise deviant observation.