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The ABC of your workplace incident, did you see the root cause coming!

Everyone has incidents at work some large some small and hopefully in the Abyss of the event you are talking about the ABC of the events and how you as a company plan to make them better or eliminate them plus some of the root cause events.Whenever there’s an incident, whether the result is a fatality or a broken plate or anything in between, someone is sure to ask: “How did it happen?”

The answer should always be the same: “It didn’t happen; it was caused.” And it’s almost always possible to trace it back to somebody—or several somebodies—who fell down on their job somewhere along the line. Either they did something they shouldn’t have done, or they failed to do something they should have done.

Incidents on the job don’t “just happen,” either. They are caused by the actions or inactions of one or more people.

Just as people cause incidents to happen, they can prevent them from happening. That’s the reason for the safe work practices we have established and the posted list of safety rules. But no work practices, rules, training, or equipment can prevent an incident from happening. You do that. You follow the lockout-tagout procedure; you leave machine guards in place; you tag and report a damaged tool or wire; you wear your safety glasses or bump cap. Remember that when you’re tempted to take a shortcut or break the safety rule “just this once” or “just for a minute.” That one minute could be exactly when the incident doesn’t “happen” but is caused.

Mark Twain once said, “It is better to be careful 100 times than to get killed once.” What does this tell us? Workers are not taking the proper precautionary measures before working, or they are simply too lazy to be bothered with it. After all, they do their jobs everyday right? Why do they need to waste their time with tedious things like inspections and precautionary measures? Well, considering the above statistic, there should be an ample amount of evidence to convince lazy and neglectful workers to start paying more attention to correct safety measures based upon your PRIMARY  ABC overview.

No matter how attentive and conscientious you are about observing health and safety rules on the job, the potential for workplace injuries is ever-present. Not only can these injuries put employees at risk of hospitalization — or even death — it also can impact insurance rates, reduce productivity, increase workers’ compensation claims and affect company morale. Team vigilance at all levels is critical in maintaining a safe environment and preventing incidents from happening.

While no company wants to see its employees maimed or killed, it goes without saying that every company is interested in saving money.  And with the bottom-line being what it’s all about, companies are hyper-aware of the expense attached to safety programs.  Safety costs money.  Money for structural integrity, money for regular maintenance, money for machine guards, money for ergonomics, money for training.

Companies are nothing if not inveterate cost-cutters, and accordingly, safety programs are going to cost money.  Not when their lives depend on it and ignore the triggers of the incidents like

Fatigue

If someone is pushed — or pushes herself — beyond reasonable limits to stay on top of workload, the results often are physical and mental exhaustion.

Stress

Job security, finances, health issues and anxiety about personal relationships all factor into the stress equation. When an employee’s mind is too distracted by real or perceived threats, he is not only more likely to make mistakes that could cause injury but also invites an increased risk of a heart attack, stroke or hypertension.

Slips

Office kitchens and break rooms are common places for slips to occur because of the number of liquids that get splashed there and are subsequently not cleaned up. Linoleum, hardwood and tile flooring surfaces are particularly hazardous after they have been mopped or waxed. Another consideration is the type of footwear worn by employees.

Trips

Items left sitting out in a high-traffic corridor, extension cords that are not properly taped down and carpeting that has come loose all are contributors to tripping employees and sometimes causing more than just stubbed toes. Poorly lit hallways and stairs are danger spots, too, because they obscure the ability to see what is underfoot.

Toppling Objects

If tall pieces of furniture such as bookcases and filing components are not securely anchored, an earthquake could cause them to pitch forward and dislodge their contents, putting nearby workers in peril. Workplace injuries also can be caused by heavy objects such as supplies and file boxes that are stacked on high shelves and are shifted precariously to the edge each time they are put back or the structure gets bumped.

Hazardous Materials

Protective clothing, eye wear and gloves are mandatory for employees whose jobs require them to be around hazardous materials, chemicals and toxic waste. Slip-ups in these rules can result in burns, explosions, respiratory diseases, blindness and skin infections.

Repetitive Motion

Carpal tunnel syndrome is a common occurrence for workers engaged in repetitive motion activities that put pressure on the median nerve, causing numbness and pain in the fingers, wrists and hands. Typists, key data operators and beauty salon employees are at particular risk for developing this excruciating condition.

Lifting

Many back injuries and pulled muscles that occur in the workplace are the result of picking up something that is too heavy, not bending the legs, not asking a partner to assist or trying to lift or hold a heavy object above the shoulders.

Workplace Violence

Despite increased security measures and limiting office access to individuals who have a legitimate reason to be on the premises, innocent victims are often involved when estranged spouses, disgruntled former employees or even total strangers with a vendetta show up with an intent to commit harm. Managers and workers must likewise stay sensitive to suspicious mail or packages, phone threats and evidence of any security violations.

Collisions

Opening a door too quickly or turning a corner too fast are the frequent setups for unintended collisions with co-workers. While it may not be with enough force to knock one or the other unconscious, the potential for injury escalates if there are hot liquids, sharp implements or heavy objects involved. Leaving file drawers pulled all the way out is as dangerous at shin level as chin level, especially if a co-worker won’t see it until the point of impact.

Shortcuts

Humans are notoriously lazy, so taking shortcuts is a rather common practice in all walks of life, not necessarily work alone. However, when workers take shortcuts at work, especially when they are working around dangerous machinery or lethal chemicals, they are only exposing themselves to a potential catastrophe.

Overconfidence 

Confidence is always a great thing to have, but there is also such a thing as too much confidence. When workers walk into work every day with the attitude that, “It will never happen to me”, they are setting an attitude that leads to incorrect procedures, methods, and tools while working. Be confident, but remember that you are not invincible.

Poor, or Lack Of Housekeeping

Whenever someone walks through your workplace, they can get a pretty good idea of your attitude towards workplace safety by just looking at how well you’ve kept up your area. Housekeeping is one of the most accurate indicators of the company’s attitude towards production, quality, and worker safety

The quickest way to get a job done is to do it right the first time. To do it right the first time, you need to make sure that you have any and all pertinent information relating to the task you will be performing. Workers who begin a job with just half the information, or half the instructions, are essentially doing the job while blind. Remember this; it’s not stupid to ask questions, it is stupid not to.

Neglecting Safety Procedures 

This is probably the worst thing that any employee at any level in the organization can do. Deliberately neglecting set safety procedures in the workplace doesn’t just endanger yourself, but it endangers the workers around you as well as the company as a whole. Casually following safety procedures doesn’t work either. You are paid to follow workplace safety procedures, not your own.

Mental Distractions 

Everyone has a life outside of the workplace, and sometimes life can take dips and turns that affect your emotions and your mood negatively. However, as harsh as it sounds, workers cannot let mental distractions from their personal lives affect their performance at work. Not only will they become less aware of their surroundings and less safe, but they will also become less productive, costing the company time and money.

Lack of Preparation 

You may have heard of something called Job Hazard Analysis (JHA). JHA’s are an effective method of figuring out the best way to work safely and efficiently. When workers begin a task without thinking through the process beforehand, or hastily start without any type of planning, they are setting themselves up for failure. Make sure you plan your work, then work your plan.

When we look into incidents, we must look at what has happened to identify causes.

We look at

  • what occurred just prior to the incident,
  • the series of events which occurred before the incident.
  • what happened this time different in some respect to what always happens?
  • why the difference this time?
  • are there regular risks being taken?
  • is the system inherently flawed?
  • are incidents and near misses happening as a result of an ineffective ‘system’?

 

Classifying Error

We try to ‘classify’ error.  We can do this by looking at:

  • Omissions– leaving something necessary out
  • Commission– doing something wrong or doing something right, in the wrong context
  • Extraneous activity– doing something extra within a task, which is harmful

So, it’s not all about disobeying the rules, nor is it all all about a freak piece of ‘bad luck’. It’s not about a faulty piece of equipment, although all of these can and do occur and can explain some incidents.

Task Analysis

There are, obviously, different types of task required of different people at work, each relying to some extent on the other.

Choice analysis – Human error

When considering human behaviour and performance, we acknowledge that people are not perfect and we all make mistakes.

This usually involves coming at the issue from two perspectives:

  • The individual and his or her characteristics, age, gender, type of learning style, risk taking tendencies etc, and
  • The perspective of the wider, organisational culture, management systems and prevailing climate, training given and reward systems in place

Within both of these sub-systems is the matter of the physical plant, machinery, upkeep of machinery and plant and housekeeping.

Classification Packages

There are a number of different classification packages, which have been developed in order to assist in this area of activity.  Briefly, they are:

  • PHECA– Potential Human Error Cause Analysis and
  • SHERPA– Systematic Human Error Reduction and Prediction Approach

Both have manual and computer versions.  For instance, PHECA uses a system of prompts for task type and human errors:

  • Task – operation, maintenance, check, monitor, communication
  • Errors – Not done, part of it done, less than it done, more than it done, other thing (similar) done, as well as, repeated, sooner than, later than, miss-ordered

SHERPA links both task types and error types together to get a combined set of prompts but keeps error causes separately stored

It is important to distinguish between error types and underlying causes.

  • An ‘error type’ should be tied back to defined performance goals and thus a human task – i.e. blade only partly covered by guard.
  • Causes will be linked to the relevant underlying stage of the human action chain within a human information-processing model and classified into either a skill, a rule or a knowledge based error.

Examples of the causes of error are the following:

  • A wrong mental model– a person pictures the way something is best done and does it that way as it appears immediately the ‘right’ way, although it is not. The cause of this can be lack of training, lack of re-enforcement of training, out of date procedures, bad modelling
  • Risk tolerance– error occurring because a person believes that it’s worth it to have a few errors each week as it is made up for by the quicker way of working.  This is allowed occur due to poor supervision locally, insufficient training on safety, insufficient reinforcement, both positive and negative and lack of monitoring
  • Demand overload– error occurring because a person makes mistakes. The cause is obvious – too many demands, not enough supports and can be referred to as stress-related error

 

How to Change Human Behaviour

Two distinct approaches to changing behaviour in order to better manage workplace safety have competed for attention over the past decade.

The first of these approaches, behaviour-based safety, focuses on the identification and modification of critical safety behaviours.  This is a focused approach using the above method/sequence to classify behaviours which led or might lead to errors, regardless of whether incidents ultimately resulted. This approach emphasises how our behaviour is linked to workplace injuries and  incidents. The focus is on producing systematic changes in objectively defined behaviours. It uses Operant Conditioning (the use of consequences to modify the occurrence and form of behaviour) and Reinforcement Theory (shaping behaviour by controlling the consequences of the behaviour)as its guiding psychological principles.

The second approach, culture based approach, emphasises the more fundamental importance of the organisation’s safety culture and climate – how management practices and policies shape and influence safety behaviour and operations for effectiveness. With respect to safety, the logic of the culture change approach is that the organisation’s basic values in relation to safety hugely influence the level of effort and specific plans used within the organisation to manage safety.  Thus, these activities serve to shape the perceptions held by employees regarding the importance of safety. Their expectations regarding the importance of safe work practices, hazard control, incident reporting are thus set down. In contrast to behaviour change, culture change approaches to safety are more ‘top down’.

  1. First, a set of critical safety behaviours are identified. The focus is on identifying specific behaviours or work practices that result in or have direct potential for producing injuries or other losses. The targeted behaviours are most often behaviours performed by shop-floor or front-line personnel.
  2. Next, performance goals for the behaviours are determined, and the pertinent behaviours are observed or sampled over some time period.
  3. Some type of feedback or contingent reinforcement is then applied to increase the probability of desired behaviours and to decrease the probability of undesired behaviours.
  4. Results are tracked and feedback on performance provided to the relevant audiences within the organisation. Performance trends are recorded and/or plotted, and these data are frequently posted in conspicuous locations in the facility.

The typical implementation of the culture-based approach (which we recommend occur at the same time as the above) usually involves direct feed in to management.

Safety policies and practices can be assessed but only insofar as they fit with the organisation’s core values and assumptions regarding safety.

Collecting information about the availability of safety equipment and safety training, or about the status of hazard control activities, can set a baseline for drawing inferences about the safety culture, but it is not the same thing as assessing the culture directly. Following the assessment phase, most culture change programmes aim at an analysis and planning process to focus the organisation’s safety-related values and vision.  This includes identifying action priorities and implementation strategies for improving safety performance within the organisation.

Terry Penney

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