Supervisors’ After Incident Review Training Program

1. You’ve carefully thought out all the angles. You’ve done it a thousand times. It comes naturally to you. You know what you’re doing, its what you’ve been trained to do your whole life. Nothing could possibly go wrong, right??? Think again!

3. Supervisors’ After Incident Review Training Program

4. “Safety is usually a continuous fight with human nature……Understanding this point will lead to less victim-blaming and fault-finding…. Instead, we’ll be more able to find factors in the system that can be changed in advance….” Dr. Scott Geller, “Working Safe”Chilton Press 1996

5. Safety Is Just “Common Sense”! • How many of you agree with this statement? • Is there more to safety than common sense? • What is it? • Let’s test your common sense!

6. Common Sense Test • How long did the 100 Years War last? • In which month do the Russians celebrate the “October Revolution”? • From which animal do we get catgut? • Where do Chinese gooseberries come from? • In which country are Panama hats made? • What is a camel hair brush made of?

7. Common Sense Test • What kind of creatures were the Canary Islands named after? • In what season does Shakespeare's “A Midsummer Nights Dream” take place? • From which material are moleskin trousers made of? • How long did the 30 Year War last?

8. Objectives • Safety is more than “common sense”. It requires: • Knowledge of Operational Risk, Hazards and their potential severity. • Understanding how our behavior “works” in relation to loss-producing incident causation. • Learning to recognize behaviors that accept risk and how to reduce some of the factors that cause them. • Incorporating behavioral considerations into your Incident review and cause analysis.

9. Introduction THE HIDDEN COSTS OF ACCIDENTS Direct Costs Medical Compensation Time lost from work by injured Loss in earning power Economic loss to injured employees family Lost time by fellow workers Loss of efficiency due to breakup of crew Lost time by supervision Cost of breaking in a new worker Damage to tools and equipment Time that damaged equipment is out of service Spoiled work Loss of production Spoilage- fire, water, chemical, etc. Failure to fill orders Overhead costs (while work was disrupted) Miscellaneous- There are over 100 other items of cost that appear one or more times with every accident Indirect Costs (Hidden Costs of Accidents)

10. Introduction THE LOSS-PRODUCING PYRAMID • 1 Serious Injury • 10 First Aid • 30 Property Damage • 300 to 600 At-Risk or Near Miss

11. Changing our Perspective

12. Purpose of Program To Prevent the “Next Incident”

13. Fundamental Attribution Error • Why a method must be followed: • “The tendency is to blame the person rather than the system in which these people are acting. In complex systems, different people placed in the same structure tend to behave in the similar ways. When we attribute behavior to personality, we lose sight of how the structure of the system shaped our choices.”

15. Definitions • Risk • Any activity, thing, person, material, etc. that has the potential to cause harm or damage. All human endevors have some element of Risk(s)! • Hazard • Any activity, thing, person, material, etc. that increases the probability of injury or damage. • Control • Any action, procedure, protocol, method, item, that prevents or lowers the possibility of a loss.

16. Introduction Accidents versus Incidents • Accident: AN UNPLANNED AND UNDESIRED EVENT WHICH MAY RESULT IN INJURY AND/OR PROPERTY DAMAGE, Loss-Producing Incident THE UNPLANNED NEGATIVE RESULT OF THE COMBINATION OF PERSONAL BEHAVIOR, MENTAL AND PHYSICAL CONDITIONS, ENERGY SOURCES AND TASK(S) REQUIREMENTS.

17. Traditional “Accident” Investigations • Who? • When? • What? • Where? • How? • WHY ? Gathers Data

18. Why? • This is the hardest part of the review; and also the weakest! Why? • The “Why” is the behavior of both the person and the system they work within! • It’s the piece least understood!

19. CONTINUOUS RISK IMPROVEMENT PROCESS

21. Program Steps Review the proper steps in conducting an incident review, they include: • Determine if “proper” first-aid has been delivered • Secure the scene • Identify incident “causal” factors • Seek solutions to prevent a reoccurrence

22. Injury/Illness/Damage Reports Review all incidents : • Familiarize yourself with all incident investigation forms • Complete all sections of the form and provide useful answers* • Turn-in forms to Human Resources within 24 hours • *Defining Solutions may take longer - Assure all claims data is turned in.

23. Beginning the Process • Receive call • Form Team or Assign • Gather Forms, Materials • Camera, Tape Measure • Guidelines

24. Guideline & Compliance Issues Why do we review? • To ensure compliance to Risk Management guidelines and to OSHA regulatory standards. • Do we comply? • If not, how do we get to full compliance?

25. Incident Review - Beginning“Get the facts” • When - Immediately • Where - At the scene • Why - To gather evidence to identify cause(s) • How - Interview involved parties, witnesses, and survey “actively” physical equipment, materials, workstations, vehicles, facilities, and etc. • Recommend - Corrective action to prevent recurrence

26. Has “Proper” First Aid Been Delivered? • Determine the extent of the injury or damage. • Assist with medical first-aid care if you have the proper certification. • Accompany the injured to a designated medical care facility. • If the injury is severe, call for system assistance or Emergency Medical Services (EMS). • Call Human Resources to report the incident. Complete all primary reports within 24 hours. Solutions may take longer! • Arrange for property/vehicle damage assessment.

27. Secure the Scene • Ensure the incident scene is not disturbed. • Preserve vehicle, tools, equipment, and materials involved in the incident. • Identify and isolate witnesses. • Separate witnesses to limit discussion. Objective is unbiased observation of what happened. • Take photographs and measurements if possible especially if the scene must be disturbed. • Draw a diagram of the site and objects involved.

28. Gathering Data Interviewing the injured,witnesses or other “involved parties”: • Remain calm and be patient • Seek to comfort those involved • Ask questions that are neutral and not leading • Listen, seek facts not opinions • Thank all who participated • Don’t forget names, phones numbers, addresses, places of employment

29. Data Gathering Process • What am I looking at or for? • What’s the hazard? What types of energy were involved? • What control(s) are needed? • What or who else is at risk? • What could happen if we don’t change something? • What do we change? • Where do I get help?

30. Identify Incident Causal Factors When and Where: • Begin the review immediately at the scene. Why? • The injured party or damage is there • The witnesses are there • The material evidence is there • Factual data can be collect and interpreted

31. Identify Incident Causal Factors To gather evidence to identify incident causes • Seek answers to questions regarding: • behavior (skills, abilities, and one’s decisions) • environment (physical conditions of materials, tools, and equipment, and weather, etc.); and • management policies and procedures (rules, regulations, training, supervision, and maintenance, etc.)

33. Types of Behaviors • Risk Perception - “Forced” • Those behaviors that force the employee to perform the task in an at-risk manner. • Risk Assumption or Acceptance - “Influenced” • At-Risk Behavior in which there is some type of “reward” is considered an influenced behavior. • Risk Communication - “Unforced” • Those behaviors that appear to be simply an error by the employee.

34. Analysis of Incidents • Was Hazard out of Employee’s Control? • Unsafe physical conditions uncontrolled. • Implement Control, Avoidance or Transfer of Risk • Did a “Risk/Reward” influence behavior? • Risk taking more rewarding with Consequences of Risk. • Change Consequences of Risk-Taking - Reduce tolerance for risk. • Was incident due to simple employee error? • Risk was unknown or unrecognized • Review “Antecedents” and Risk Communication

35. Risk Perceptions • Knowing the Hazards that create a loss-producing condition(s)

36. What causes an Incident? • Contact with an “energy” source that is above the defensive or protective threshold of the Target of the energy source plus: • A conscious or unconscious decision by some person to continue to work or act while exposed to the Risk and it’s Hazard(s).

37. Let’s Take A Break! Back in 10 Minutes!

38. Categories - Energy Agents • Chemical - solvents, acids, etc. • Electrical - amps, voltage • Kinetic - falls, thrown items, movement • Thermal - hot, cold • Acoustic - noise • Biological - animals, insects, virus • Radiation - laser, sun

39. Control of Hazards and Risks • How severe could this incident have been? What was the true scope of potential loss? • Cause harm to our “brand” with negative public opinion? • Harm plant or facilities? • Harm a third-party or other personnel? • Create a regulatory issue? • If we don’t change “something”, will this type of loss-producing incident continue to occur? • What management action is needed to reduce the potential for the “next” loss-producing incident?

41. Control of Hazards and Risks • Is this a task or activity we should avoid doing in the future? • How do we change the process to avoid the risk? • Can changes in the task reduce its hazards? • Complete a Job Safety Analysis • Assure safety rules, procedures, protocols and personal protective equipment are in place • Is this something “new” that will continue to cause injury or damage? • Develop new risk evaluation and hazard control guidelines.

42. Principles Risk Perception and Communication • Did the Individual simply make a mistake or error? • Did Individual know the standards for performing the task without the injury/damage? • Review Training and Refresher Training • Review Training content and methods • Does the individual have any history of bypassing safety requirements or similar incidents? • Review Consequences of doing task unsafe • Any known personal, medical or other reasons for error?

43. Risk Assumption and Acceptance • Why we do what we do- • Risk-taking Decisions and At-Risk Behavior

44. BEHAVIOR • Understanding behavior • What it is vs. what it isn’t • What affects it! • How to affect behavior for everyone’s benefit!

45. People engage in At-Risk behavior because... • It enables them to get their job done- • “Do you want it done safe or done on time? • The perception of risk is low - • “Never happen to me……. • At-risk behavior is reinforced - • Risk taking is encouraged………. • They are not conscious of the at-risk behavior - • They don’t know they don’t know…...

46. Behavior Based Safety • The application of Performance Management principles to safety. • Antecedents - Defining of clear communications • Behavior - Clearly defined desired behavior • Consequences - Clear understanding of implied and direct consequences • Reinforcement - Emphasis on Positive • Measurement - Clearly defined metrics

47. Antecedents Behavior Consequences A-B-C Model prompts the person to act action - what the person actuallydoes what happens after the behavior

48. Behavioral Influence • How do you determine behavioral influence? ASK!

49. Behavior • Behavior is any observable, measurable act. Anything you can see or hear somebody do! • Attitude ?

50. Antecedent • An antecedent is any person, place, thing or event that precedes a behavior that encourages you to perform the behavior. • Training, orientation, rules, guidelines, protocols, signs, discussions, meetings, etc. are all antecedents.