Examining Accident Causation: After-the-Fact and Before-the-Fact Approaches

LOST CONTROL PROGRAMS Chapter 4

Examining Accident Causation • There are two basic approaches to examining how accidents are caused; after-the-fact and before-the-fact. After-the-Fact • This approach relies on examining accidents after they have occurred to determine the cause and to develop corrective measures. Evaluation of past performance uses information derived from accident and inspection reports and insurance audits. Before-the-Fact • This method relies on inspecting and systematically identifying and evaluating the nature of undesired events in a system. The method is called critical incident technique.

Critical Incident Technique • The critical incident technique measures safety performance and identifies practices or conditions that need to be corrected. • To obtain a representative sample of workers exposed to hazards, management selects personnel from various departments of the plant. • An interviewer questions a number of workers who have performed particular jobs within certain environments. They are asked to describe only those existing hazards and unsafe conditions they are aware of. • Management then classifies incidents into hazard categories, and identifies problem areas. • The investigative team can also analyze the management systems that should have prevented the occurrence of unsafe practices or the existence of unsafe conditions. The procedure needs to be repeated because the worker-equipment-environment system is not static.

Safety Sampling • Also called behavior or activity sampling, safety sampling is another technique that uses the expertise of those within the organization to inspect, identify, and evaluate hazards. • This method relies on personnel - usually management or safety staff members - who are familiar with operations and well trained in recognizing unsafe practices. • While making rounds of the plant or establishment, they record on a safety sampling sheet both the number and type of safety defects they observe. A code number can be used to designate specific unsafe conditions. • Safety personnel or managers should make observations at different times of the day, on a planned or random basis in the actual work setting, and throughout the various parts of the plant. • In a short time, they can easily convert observations to a simple report showing what specific unsafe conditions exist in which areas and what supervisors and foremen need help in enforcing good work practices.

Definition of Hazards • A workable definition of hazard is any existing or potential condition in the workplace that, by itself or by interacting with other variables, can result in deaths, injuries, property damage, and other losses. This definition carries with it two significant points. First, a condition does not have to exist at the moment to be classified as a hazard. When the total hazard situation is being evaluated, potentially hazardous conditions must be considered. Second, hazards may result not only from independent failure of workplace components but also from one workplace component acting upon or influencing another. For instance, if gasoline or another highly flammable substance comes in contact with sulfuric acid, the reaction created by the two substances produces both toxic vapors and sufficient heat for combustion. • Hazards are generally grouped into two broad categories: those dealing with safety and injuries and those dealing with health and illnesses. However, hazards that involve property and environmental damage must also be considered.

Effects of Hazards on the Work Process • In a well-balanced operation, workers, equipment, and materials are brought together in the work environment to produce a product or to perform a service. • When an accident interrupts an operation, it sets in motion a different chain of events and carries its own price tag. • An accident is an unplanned, undesired event, not necessarily resulting in injury, but damaging to property and/or interrupting the activity in process. • An accident increases the time needed to complete the job, reduces the efficiency and effectiveness of the operation, and raises production costs. • If the accident results in injury, materials waste, equipment damage, or other property loss, there is a further increase in operational and hidden costs and a decrease in effectiveness.

Controlling Hazards: A Team Effort • Traditionally, most managers have relied only on their safety and operations on people to locate, evaluate, and control hazardous situations. Accident and hazard reduction requires a team effort by employees and management. Example of how several departments and employee teams can work together. • The engineering departments can design facilities to be free of uncontrolled hazards and provide technical hazard identification and analysis services to other departments. Their designs must comply with federal, state or provincial, and local laws and standards. • Manufacturing departments can reduce hazards through efforts such as effective tool design, changes in processes, job hazard analysis and control, and coordinating and scheduling production.

Controlling Hazards: A Team Effort… • Quality control can test and inspect all materials and finished products. It can conduct studies to determine whether alternate design, materials, and methods of manufacture could improve the quality and safety of the product and the safety of the employees making the product. • Purchasing departments can ensure that materials and equipment entering the workplace meet established safety and health standards, and that sufficient protective devices are an integral part of equipment. They should circulate information received from suppliers to line management and workers about safety and health hazards associated with workplace substances and materials. • Maintenance can provide planned preventive maintenance on electrical systems, machinery, and other equipment to prevent abnormal deterioration, loss of service, or safety and health hazards. • Industrial relations often administers programs directly related to health and safety.

Management Support • To coordinate the organizational and departmental efforts, a program of loss control is necessary as part of the management process. Such a program provides hazard control with management tools such as programs, procedures, audits, and evaluations. • A loss control program establishes facility-wide safety and health standards and coordinates responsibilities among departments. For example, if one department makes a product and another distributes it, they share responsibility for hazard control.

Safety Management and Productivity Improvement • The process of identifying and eliminating or controlling hazards in the workplace is one way of making the best use of human, financial, technological, and physical resources. Optimizing these resources results in higher productivity. • Loss control, like productivity, quality, costs, and personal relations, is a strategic process. To be effective, it must be integrated into the day-to-day activities. • An accident interrupts the production process, not only increases the time needed to complete a production task, it may also reduce the efficiency and effectiveness of the overall operation and increase production costs.

Determining Accident Factors • the organization should first determine the major factors likely to cause loss of control. Then identify the location;importance; and potential effects. • Control measures can then be introduced to help reduce risk and potential losses. Factors responsible for accident losses may be identified by either inspection or detailed hazard analyses. • The control measures may be some type of process innovation or machine safeguarding, personal protective equipment, training, or administrative change.

Worker-Equipment-Environment System • Those professionals involved in establishing effective loss control programs must understand the interrelationships in the worker-equipment-environment system. Worker • In any worker-equipment-environment system, the worker performs three basic functions: (1) sensing, (2) information processing, and (3) controlling. • As a sensor, the worker serves to monitor or gather information. • As an information processor, the worker uses the collected information to make a decision about the relevance or suitability of various courses of action. • The third function, control, flows from the first two. Once information is collected and processed, the worker keeps the situation within acceptable limits or takes the necessary action to bring the system back into an acceptable or safe range.

Evaluating an accident of these three functions can pinpoint the causes • Did the error occur while the worker was gathering information as a sensor? • Was the worker able to gather information accurately? • Did the error occur as a result of faulty information processing and decision making? • Did the error occur because an appropriate control option was not available or because the worker took inappropriate action? In order for the system to move toward its production objectives, the employee must perform work effectively and avoid taking unnecessary risks.

Evaluating an accident of these three functions can pinpoint the causes……. Equipment • Equipment, the second component in the system, must be properly designed, maintained, and used. • Hazard control can be affected by the shape, size, and thickness of tools; the weight of equipment; operator comfort; and the strength required to use or operate tools, equipment, and machinery. • These variables influence the interaction between worker and equipment. Other equipment variables important in hazard recognition include speed of operation and mechanical hazards.

Evaluating an accident of these three functions can pinpoint the causes… Environment • Special consideration must be given to environmental factors that might divert the comfort, health, and safety of the worker. Emphasis should be placed on factors such as: • layout: the worker should have sufficient room while performing the assigned task • maintenance and housekeeping: • sufficient illumination: poorly lit areas increase eyestrain and also the chance of making an accidentcausing mistake • temperature, humidity, noise, vibration, and control of emission of toxic materials.

ACCIDENT CAUSES AND THEIR CONTROL • Close examination of each accident shows that it can be attributed, directly or indirectly, to an oversight, omission, or failure of the management system regarding one or more of the following three items: • unsafe practices or procedures; either the worker or another person • situational factors, for example, facilities, tools, equipment, and materials • environmental factors, such as noise, vibration, temperature extremes, illumination. • If an sufficient line management hazard control system is properly designed for the organization's workers, equipment, and environment, then the possibility of accidents occurring in the workplace is greatly reduced.

Unsafe Practices or Procedures An unsafe practice often is a deviation from the standard job procedures. Examples of such actions include: • using equipment without authority • operating equipment at an unsafe speed or other improper way • removing safety devices, such as guards, • using defective tools. • Unsafe practices also can be a deviation from safety rules or regulations, instructions, or job safety analyses. When implementing a hazard control program, emphasis should be placed on the countermeasure.

No known standard for safe job procedure exists. Countermeasure: Perform a job safety analysis (JSA) and develop a good procedure through job instruction training. • The employee did not know the standard job procedure. Countermeasure: Train in the correct procedure. • The employee knew, but did not follow, the standard job procedure. Countermeasure: Consider an employee performance evaluation. Test the validity of the procedure and motivation. • The employee knew and followed the procedure. Countermeasure: Develop a safer job procedure. • The procedure encouraged risk-taking, such as incentive pay for piecework. Countermeasure: Change the unsafe job design, procedure, or incentive program.

The employee did not follow the correct procedure because of work pressure or the supervisor's influence. Countermeasure: Counsel employee and supervisor; consider change in work procedures or job requirements. • Many accidents are the result of someone deviating from the standard job procedures, doing something prohibited, or failing to do something that should be done. • An important first step in loss control is distinguishing between worker error and supervisory error, then addressing what caused the system to break down.

Human error is reduced when • supervisors and workers know the correct methods and procedures to accomplish given tasks • workers demonstrate a skill proficiency before using the particular piece of equipment • the entire organization gives top priority and continuous regard to potentially dangerous situations and the corrective action necessary to avoid accidents. • supervisors provide proper direction, training, surveillance. The supervisor must be aware of the worker's skill level with each piece of equipment and process, and adjust the supervision of each worker accordingly.

Situational Factors • Situational factors are another major cause of accident. These factors are materials that make accidents possible, an unsafe operations, tools, equipment, and facilities. • Examples are, unguarded, poorly maintained, and defective equipment; ungrounded equipment that can cause shock; poorly arranged equipment, buildings, and layouts that create congestion hazards; Environmental Factors • The third factor in accident causation is environmental, that is, the way in which the workplace directly or indirectly causes or contributes to accident situations. • Environmental factors fall into four broad categories: human, chemical, biological, and ergonomic.

Human Factors • Noise, vibration, radiation, illumination, and temperature extremes are examples of factors having the capacity to influence or cause accidents and illnesses. • Operations on a machine lathe, for example, may produce high noise levels that prevent workers from hearing other sounds and weaken communication with others or may damage the workers' hearing over time. Chemical Factors • Classified under this category are toxic gases, vapors, fumes, mists, smokes, and dusts. In addition to causing illnesses, these often damage worker's skill, reactions, judgment, or concentration.

Biological Factors • Biological factors refer to those items capable of making a person ill through contact with bacteria, viruses, fungi, or parasites. Ergonomic Factors • Ergonomic factors refer to a persons capabilities, physical attributes and work habits that is accepted in the workplace.

Sources of Situational and Environmental Hazards • Employee contributions to situational and environmental hazards include disregarding safety rules and regulations by • making safety devices inoperative, • using equipment and tools incorrectly. • using defective tools rather than obtaining serviceable ones, • failing to use engineering controls such as exhaust fans when required, and • using toxic substances in unventilated areas or without proper protection.

PRINCIPLES OF LOSS CONTROL • Lost control is the function directed toward recognizing, evaluating, and eliminating, at least controlling, the destructive effects of occupational hazards. These hazards generally results from human errors and from the situational and environmental aspects of the workplace. • The primary function of a lost control system is to locate, assess, and set effective preventive and corrective measures for those elements harmful to operational efficiency and effectiveness.

PROCESSES OF LOSS CONTROL • The processes of an effective lost control program should be directed toward evaluating, eliminating, and preventing workplace hazards. • An effective lost control program has six steps or processes: • hazard identification and evaluation • ranking hazards by risk • management decision making • establishing preventive and corrective measures • monitoring • evaluating program effectiveness

Hazard Identification and Evaluation • This first step in a comprehensive lost control program is to identify and evaluate workplace hazards. These hazards are associated with machinery, equipment, tools, operations, materials, and the physical plant. • Hazard information also can be obtained from accident reports. Information explaining how a particular injury, illness, or fatality occurred often will reveal hazards requiring control. • Close review of accident reports filed in the past three to five years will identify the individuals and specific operations involved, the department or section where the accident occurred, the extent of supervision, and possibly the injured person's deficiencies in knowledge and skill.

Ranking Hazards by Risk (Severity, Probability, and Exposure) • The second step in the process of loss control is to rank hazards by risk. Such ranking takes into account the result (the severity, the probability, and the exposure index). • The purpose of this second process is to address hazards according to the principle of "worst first." • Ranking provides a consistent guide for corrective action, specifying which hazardous conditions deserve immediate action, which have secondary priority, and which can be addressed in the future. Risk Assessment • When the hazards have been ranked according to all three criteria, the next step is to assign a single risk number or risk assessment code (RAC).

Management Decision Making • The third step involves providing management with full and accurate information, all possible alternatives, so managers can make intelligent, informed decisions concerning loss control. • Such alternatives will include recommendations for training and education, better methods and procedures, equipment repair or replacement, environmental controls, and – rare cases where modification is not enough – recommendations for redesign. • After management's decision-makers receive hazard reports, they normally have three alternatives: 1. take no action 2. modify the workplace 3. redesign the workplace

Establishing Preventive and Corrective Measures • After the safety team or others have identified and evaluated hazards and provided data for informed decisions, the next fourth step involves implementing control measures. • Controls are of three kinds: 1. administrative (through personnel, management, monitoring, limiting worker exposure, measuring performance, training and education, housekeeping and maintenance, purchasing) 2. engineering (isolation of source, lockout procedures, design, process or procedural changes, monitoring and warning equipment, chemical or material substitution) 3. personal protective equipment (body protection, fall protection, etc.).

Monitoring • The fifth step in the process of hazard control deals with monitoring activities to locate new hazards and assess the effectiveness of existing controls. • Monitoring includes inspection, industrial hygiene testing, and medical surveillance. • Monitoring is necessary • to provide assurance that hazard controls are working properly, • to ensure that modifications have not changed the workplace that current hazard controls can no longer function adequately, • to discover new or previously undetected hazards.

Evaluating Program Effectiveness • The sixth step is to evaluate the effectiveness of the safety and health program. • Evaluation involves answering the following questions. • What is being done to locate and control hazards in the plant? • What benefits are being received, for example, reduction of injuries, workers' compensation cases, and damage losses? • What impact are the benefits having on improving operational efficiency and effectiveness? • Evaluation must be adapted to • the time, money, and kinds of equipment and personnel available for the evaluation; • the number and quality of data sources; • the particular operation; and • the needs of the evaluators.

Among the criteria management can use to determine the effectiveness of its safety and health program effort are • the number and severity of injuries to workers compared with work hours; • the cost of medical care; • material damage costs; • facility damage costs; • equipment and tool damage or replacement costs; • the number of days lost from accidents.

ORGANIZING AN OCCUPATIONAL SAFETY AND HEALTH PROGRAM • The purposes of a loss control program organization are to assist management in developing and operating a program designed to protect workers, to prevent and control accidents, and to increase effectiveness of operations. Establishing Program Objectives • Critical to the design and organization of a safety and health program is the establishment of objectives and policy to guide the program's development. • If the organization has a joint safety and health committee, it could be the body chosen to set the program objectives.

Among the program objectives should be the following: • gaining and maintaining support for the program at all levels of the organization • motivating, educating, and training the program team to recognize and correct or report hazards located in the workplace • engineering hazard control into the design of machines, tools, and facilities • providing a program of inspection and maintenance for machinery, equipment, tools, and facilities • incorporating hazard control into training and educational techniques and methods • complying with established safety and health standards.

Establishing Organizational Policy • Once the objectives have been formulated, the second step for management is to adopt a formal policy. A written policy statement, should be available to all personnel. • It should state the purpose of the hazard control program and require the active participation of all those involved in the program's operation.

Responsibility for the Hazard Control Program • Responsibility for the safety program can be established at the following levels: • board of directors, chief executive officers, managers, and administrators; • department heads, supervisors, foremen, and employee representatives; • purchasing agents; housekeeping and maintenance personnel; • employees; safety personnel; • staff medical personnel; and • safety and health committees.

Housekeeping and Preventive Maintenance • Good housekeeping reduces accidents, improves morale, and increases efficiency and effectiveness. • When the workplace is clean and orderly and housekeeping becomes a standard part of operations, less time and effort will be spent keeping it clean, making repairs, and replacing equipment.

Preventive maintenance has four main components: 1. Scheduling and performing periodic maintenance functions 2. Keeping records of service and repairs 3. Repairing and replacing equipment and equipment parts 4. Providing spare parts control. Maintenance schedules can be set up on several different bases: • manufacturer's recommendations • age of the machine • number of hours per day the machine is used • past experience

Employees • Employees can observe safety and health rules and regulations and work according to standard procedures and practices. • They can recognize and report to the foreman or supervisor hazardous conditions or unsafe work practices in the plant. They can develop and practice good habits of hygiene and housekeeping. • They can use protective and safety equipment, tools, and machinery properly. They can report all injuries or hazardous exposure as soon as possible. • Employees can help develop safe work procedures and make suggestions for improving work procedures. Management should encourage employees to participate on safety committees.

Purchasing Agents • Those responsible for purchasing items for organizations are in a key position to reduce hazards associated with operations. • In maintaining standards of quality, efficiency, and price, the purchasing department must make sure that safety has received sufficient attention in the design, manufacture, and shipping of items. • Depending upon the company organization, other departments - such as safety, engineering, quality control, maintenance, industrial hygiene, and medical should indicate to the purchasing department what equipment and materials meet with their approval.

COMPANY SAFETY RULES • Report unsafe conditions to your immediate supervisor. • Promptly report all injuries to your immediate supervisor. • Wear hard hats on the job site at all times. • Use eye and face protection where there is danger from flying objects or particles, such as when grinding, chipping, burning and welding, etc. • Dress properly. Wear appropriate work clothes, gloves, and shoes or boots. • Never operate any machine unless all guards and safety devices are in place and in proper operating condition. • Keep all tools in safe working condition. Never use defective tools or equipment. • Report any defective tools or equipment to immediate supervisor promptly. • Properly care for and be responsible for all personal protective equipment. • Do not operate machinery if you are not authorized to do. • Do not leave materials in aisles, walkways, stairways, roads or other points of egress. • Practice good housekeeping at all times. • Do not stand or sit on sides of moving equipment. • All posted safety rules must be obeyed and must not be removed except by management's authorization.

Safety & Health Professionals (Loss control Specialists) • To ensure the effectiveness of the safety program, management usually places program administration in the hands of a safety director or manager of safety and health. • To administer a safety program effectively requires considerable training and many years of experience. • A safety program has many aspects: occupational health, product safety, machine design, plant layout, security, damage control, and fire prevention. • Safety profession combines engineering, management, preventive medicine, industrial hygiene, and organizational psychology. • It requires knowledge of system safety analysis, job safety analysis, job instruction training, human factors engineering, biomechanics, and product safety. • The professional must have extensive knowledge of the organization's equipment, facilities, manufacturing process, and workers' compensation, and must be able to communicate and work with all types of people.

THE SCOPE OF THE PROFESSIONAL SAFETY POSITION Functions of the Professional Safety Position • The major functions of the safety and health professional are contained within four basic areas. The major areas are: • Identification and assessment of accident and loss producing conditions and practices and evaluation of the severity of the accident problem. • Development of accident prevention and loss control methods, procedures, and programs. • Communication of accident and loss control information to those directly involved. • Measurement and evaluation of the effectiveness of the accident and loss control system and the modifications needed to achieve optimum results.

SAFETY AND HEALTH COMMITTEES The joint safety and health committee is responsible for: • actively participating in safety and health instruction programs and evaluating the effectiveness of these programs • regularly inspecting the facility to detect unsafe conditions and practices and hazardous materials and environmental factors • planning improvements to existing safety and health rules, procedures, and regulations • recommending suitable hazard elimination, reduction, or control measures • periodically reviewing and updating existing work practices and hazard controls • monitoring and evaluating the effectiveness of safety and health recommendations and improvements • compiling and distributing safety and health and hazard communications to the employees • immediately investigating any workplace accident • studying and analyzing accident and injury data.

Examining Accident Causation: After-the-Fact and Before-the-Fact Approaches