1 1 Reducing Injuries through the Identification of At-Risk Behaviors BY: David G. N. Stonhill Idaho National Laboratory Fire Department Idaho National Laboratory, Idaho Executive Development An applied research project submitted to the National Fire Academy as part of the Executive Fire Officer Program August 2005
2 2 CERTIFICATION STATEMENT I herby certify that this paper constitutes my own product, that where the language of others is set forth, quotation marks so indicate, and that appropriate credit is given where I have used the language, ideas, expressions, or writings of another. Signed:
3 3 Abstract Research was conducted because the INL Fire Department wanted to reduce recurring slip, trip, and fall injuries, but had not identified what behaviors were placing firefighters at risk. The purpose was to identify behaviors placing firefighters at risk for slip, trip, and fall injuries. A descriptive research method was applied to a literature review, interviews, process reviews, and questionnaires in specific areas of inquiry: industry data, methods of behavior evaluation, and current risks to firefighters. Research concluded that slip, trip, and fall hazards are the most common workplace hazards and at-risk behavior is a common cause. Where at-risk behaviors are present, an error precursor exists. Where an at-risk behavior and a hazard are present, a greater potential for injury exists. Both conditions were found to coincide in the work performed by INL Firefighters, placing them at-risk for slip, trip and fall injuries. Recommendations included: continuing to evaluate work using hazard identification and mitigation processes, surveying firefighters to determine the type and frequency of at-risk behaviors, and increasing participation and training in error precursor recognition.
4 4 Table of Contents Abstract... 3 Introduction... 6 Background and Significance... 8 Literature Review Procedures Limitations Results Discussion Recommendations References Appendix Table 1 INL Fire Department Job Safety Analysis Table 2 INL Fire Department Accident and Injury Data Table A3 INL Fire Department Accident and Injury Data Table A4 DOE Contracted Fire Departments Questionnaire Results Table A5 Regional Fire Departments Questionnaire Results Table A6 INL Firefighter Error Precursor Frequency Questionnaire Results Figure 1 INL Historical Injury Data Figure 2 INL Monthly Illness and Injury Report... 12
6 6 Introduction It is an organizational imperative for fire departments to establish a goal of eliminating accidents and occupational injuries by developing and implementing a health and safety program (National Fire Protection Association 1500 [NFPA] 2002). In establishing this program, a fire department must evaluate the hazards exposing firefighters to potential injuries and implement a system to control the risk exposures. Risk is defined in NFPA 1250 (2000) as the measure of probability and severity of adverse effects that result from exposure to a hazard. The management of risk is accomplished by developing methods to avoid, prevent, reduce, or segregate hazards in order to reduce the organization s risk exposure. Where risk cannot be completely eliminated, an organization must accept and shoulder the potential cost, or finance their risk exposure through insurance (NFPA). The Idaho National Laboratory [INL] Fire Department, like many other organizations exists in a business environment where there is competition for limited budget dollars and the need to utilize available funding more effectively. The maxim do more with less has become more meaningful to fire department administrators in recent years. In this fiscally lean environment, it is imperative that non value added expenses and avoidable costs are identified and eliminated. In spite of the financial impact of non-emergency related injuries which Leigh (2000) estimates to be 85% of overall cost burden, the majority of fire departments focus their risk management efforts primarily on emergency related injuries. The National Institute of Occupational Safety and Health [NIOSH], which is responsible for tracking and investigating
7 7 firefighter deaths does not keep statistics on non-fatal firefighter injuries (NIOSH 2004). Statistics on occupational injuries are maintained by the Occupational Safety and Health Adminstration [OSHA], but it is the responsibility of each fire department to classify and report injuries (Title 29, Labor, Code of Federal Regulations [CFR] 2004 Section, ). According to the National Institute of Standards and Technology [NIST] (2004), this data is often incomplete or difficult to obtain. The Idaho National Laboratory [INL] Fire Department has experienced recurring firefighter slip, trip and fall injuries during non-emergency operations (INL, 2005). The injuries are resulting in lost productivity and increased compensation costs. These injuries are believed to be a result of preventable at-risk behaviors. The problem is: the INL Fire Department wants to reduce these recurring slip, trip, and fall injuries, but has not identified what behaviors are placing firefighters at risk. The purpose of this research is to identify behaviors present during non-emergency work which places firefighters at risk for slip, trip, and fall injuries. 1. What national or industry data exists on behaviors placing workers at risk for slip, trip, and fall injuries? 2. What methods of evaluation exist to identify behaviors placing workers at risk for slip, trip, and fall injuries? 3. What methods of evaluation are being used by similar fire departments and in comparable industries to identify behaviors placing firefighters at risk for slip, trip, and fall injuries?
8 8 4. What behaviors are present in the non-emergency work performed by INL firefighters which are placing them at risk for slip, trip, and fall injuries? Background and Significance The INL Fire Department was established in 1948 to provide firefighting capabilities at the Atomic Energy Commission site on the Snake River plain desert in southeastern Idaho. Since its inception, the Fire Department has grown to become a comprehensive emergency services delivery organization. Covering approximately 888 square miles the INL is now the nation s premier environmental and nuclear energy research laboratory. Battelle Energy Alliance [BEA] is the maintenance and operations contractor for the Department of Energy with the responsibility for providing and directing resources and capabilities to support the nuclear energy and national security missions of the INL. BEA leads a diverse consortium including Babcock and Wilcox Technologies, Inc., Washington Group International, the Electric Power Research Institute, and an alliance of university collaborators led by the Massachusetts Institute of Technology. As part of the $4.8 billion contract, an award fee is established based upon several key performance measures. The amount of fee earned by the contractor is directly tied to implementing the DOE vision and accomplishing the requirements described in the contract s statement of work. To guide implementation, the DOE provided 18 explicit statements of vision of which one was the contractor shall work in a manner that is safe to workers, the public, and the environment (INL, Maintenance and Operations contract, 2005, DE-AC07-05ID14517).
9 9 The primary way of demonstrating the contractor s performance toward meeting this goal is to put controls in place and to establish performance metrics. Any time an accident occurs at the INL it is investigated, reported, and followed up with corrective actions to prevent recurrence. The INL has a formal procedure for conducting the investigations in accordance with the reporting requirements established by OSHA (2004). The scope and applicability of this requirement is to ensure worker safety and to protect facilities and the environment through the identification, analysis, and mitigation of safety and health hazards (INL, 2004). During the 1990 s, the employee injury rate at the INL climbed steadily. Viewing this trend, the INL identified the need to develop a stronger commitment to improving safety. In 1994 the INL adopted the Total Safety Culture program and a year later entered into a cooperative safety oversight program with OSHA (Voluntary Protection Program [VPP], 2004). Both of these programs are credited by OSHA to have a core emphasis on developing a commitment among workers to be responsible for their own safety and the safety of others. (see Figure 1).
10 10 Figure 1 INL Historical Injury Data INL Historical Injury Data 16 Total Safety Culture Voluntary Protection Program Year Source: INL ES&H Summary Report Recordable DART Total First Aid and Recordable The commitment of all INL workers to the new safety culture was challenged on July 28, During routine maintenance on a 5,500 lb. Carbon dioxide total flooding system, a sudden and unannunciated release trapped 13 workers. Eight workers were able to escape, three were rescued by other plant workers, and two were removed by the INL Fire Department. During the pre-job briefing, one of the workers questioned the need to physically remove the control heads from the CO2 system, and he was assured that the isolation of power to the control heads was adequate. Of the 13workers, one was fatally injured and several others sustained life threatening injuries (Department of Energy [DOE] Office of Oversight, Environmental Safety and Health [ESH], 1998).
11 11 The dramatic event became a wake-up call for every worker at the INL. Suddenly, working safely was no longer a simple slogan or an abstract idea; it had taken on the names and faces of the lost and forever changed their coworkers. One of the corrective actions from the resulting DOE accident investigation identified in its report was the requirement develop an environment where continuous safety improvement is a way of life (DOE, ESH, 1998). To know where one is going, requires a realistic assessment of where one is and objective goals to direct one s efforts in getting there. To provide this, the INL is evaluated by DOE against industry performance and its own past performance. The frequency and severity of injuries are combined into a day-away, restricted, or transfer (DART) case rate (Title 29, Labor, CFR, 2004 Section, ). This data is quantified for comparison as the number of reportable cases per 200,000 hours worked. Three comparative measures are then used: 1) Bureau of Labor Statistics Average 2) DOE average 3) the company established DART performance goal (see Figure 1). Since the June 1998 accident, the INL has successfully implemented several programs to improve the overall safety environment and reducing the overall DART rate. These initial programs specifically targeted people and processes because that is where the most gain could be made towards improving overall safety. These programs include integrated safety management (DOE, 1996), worker applied safety program (Huntsman, 2004), and achievement of the VPP star status (INL, 2005). Each organization at the INL must continually strive to prevent injuries thereby contributing to the overall company safety goal. To provide individual performance feedback to each organization, BEA compiles and distributes a monthly injury/illness report. The report in
12 12 Figure 2 includes individual organization performance measures reflected against an overall performance goal along with a current trend line. Since the beginning of fiscal year 2005, the INL Fire Department has experienced 5 non-emergency slip, trip and falls injuries. During a review of performance feedback, this category was identified as being 30% higher than the INL occupational injury rate and was the leading cause of injuries among firefighters (see Figure 3). Overall slips, trips, and falls were representing 50% of all occupational injuries. A comprehensive list of INL firefighter injuries in provided in Table A3. Figure 2 INL Monthly Illness and Injury Report DART Case Rate By Organization February through May BLS Avg. 2 Dart Case Rate DOE Avg..58 Performance Goal 0 B000 C000 D000 E000 F000 G000 H000 I000 J300 Fire Department J000/J100/J400 A000/K000/L000 Total Organization Within the fire service, payment tied directly to performance is relatively unique to privately contracted fire departments like the INL Fire Department. Aligning incentives requires competitive forces to be strong where many players vie for a piece of the total market.
13 13 Competitively bid contracts for service allow the customer to define quantitative metrics which firmly establish agreed upon performance (Byrns & Stone, 1993). Figure 3 INL Occupational Injury Rate BEA Total Occupational Cases by Type of Incident February through May 2005 Contact with Temperature 3% Overextension 20% Struck By 27% Body Movement/Position 7% Contact W/Hazardous Substance 7% Struck Against 10% Slip/Trip/Fall 20% Repetitive Computer Related Work 3% Caught In/Under/Between 3% Although public fire departments are not subject to these types of contractual controls, the fire service still has a relevant need to focus its attention on its accidents and injury rate. Industries with a very public face can be destroyed or severely tarnished by catastrophic accidents even if they have good safety records. In their collective work on process safety guidelines, the Center for Chemical Process Safety of the American Institute of Chemical Engineers (1994) point out that public faith and trust in an entire industry can be eroded so severely, it can jeopardize their existence and forever stain their reputation. (Dekker, 2005) gives some supporting examples of how errors can lead to tragedy which in turn leads to public mistrust: Bhopal India, Three Mile Island, Chernoble, and the Space Shuttle Challenger disaster.
14 14 The fire service itself has had its own tragedies where error has played a part: Roseburg, OR Wildland firefighters, Westmoreland, NY training fire, and the World Trade Center (NIOSH, 2005). So what do these catastrophic events have to do with firefighter slips, trips and falls? Is it reasonable to compare them in the same category of significance as the aforementioned catastrophes? It is, if one understands that there is the slow, yet persistent rate of occurrence that conceals their impact. It is, if everyone could be affected and share in what is usually manifested only upon the injured firefighter and his or her family. It is, if one understands that all of society is burdened with the cost of slip, trip, and fall injuries which is masked by that which is seemingly so insignificant, that we collectively shoulder the burden of increased insurance, workers compensation and taxes. The connection between these extremes is in the fact that most accidents and the resulting injuries involve human behaviors or the things people do. It is human actions that determine whether the consequence will be intended or unintended. When we examine those behaviors which have been observed to yield unwanted consequences, we will find commonality. The behaviors which put firefighters at risk for slips, trips and falls, are the same root behaviors causing other firefighter injuries. The recent rise in firefighter fatalities is a grim reminder that we are victims of our own at-risk behaviors. The goal of this research project is to go beyond the environmental conditions of the firefighters occupation and to identify the human behaviors which are putting them at risk for injuries. Because behaviors are what people do, it is expected that one can observe and measure
15 15 the at-risk behaviors present and then teach firefighters where the error traps exist in their work so they can identify and prevent them. Fire officers in the National Fire Academy s Executive Development course are challenged to become change agents within the fire service by applying proactive approaches to risk reduction (United Stated Fire Administration [USFA], National Fire Academy [NFA], 2005a) Supporting this challenge, the NFPA (2000, 1021)specifically defines the health and safety job performance requirements for fire officers at all levels. Officers must poses the specific knowledge and skills to identify at-risk behaviors and be capable of taking action to prevent reoccurrence. Using behavior modification, fire officers can empower their personnel to become aware of the behaviors which put themselves at-risk and teach the methods for improving their own safety and health. Descriptive research will be used in this applied research project consisting of: a review of literature examining national and industry data on behaviors placing workers at risk for slip, trip, and fall injuries; a description of methods used to identify behaviors placing workers at risk for slip, trip, and fall injuries; a description of methods used by similar fire departments to identify behaviors placing firefighters at risk for slip, trip, and fall injuries; and what behaviors are present in the non emergency work performed by INL firefighters which are placing them at risk for slip, trip, and fall injuries. Literature Review Data on Behaviors placing workers at-risk for slip, trip, and fall injuries Industry Injury Data
16 16 According to the Department of Labor [DOL] Bureau of Labor Statistics [BLS] (2005), the nation s recordable injury and illness rate has declined to its lowest rate since the BLS started recording worker injuries in the 1970 s. According to the Acting Assistant Secretary of the Occupations safety and Health Administration J. L. Snare (2005), the decrease is attributed to targeting resources where they will have the most impact. OSHA requires all injuries that result in loss of consciousness, restricted work activities or job transfer, days away from work, or medical treatment beyond first aid to be reported (Title 29, Labor, CFR, 2004 Section, ). Further, required data must be reported using OSHA form 300 which includes data specific to the injury sustained by the employee. This reporting requirement provides a means for OSHA to establish comparisons among different types of industries. Occupational injury data may not be accurate. According to the research of Leigh, Markowitz, Fahs, and Landrigan (2000), agencies charged with gathering statistical data do not receive data on government workers and from businesses that intentionally underreport. This underreporting results in accident and injury data that is artificially low. According to OSHA (1995) 4 out of the top 10 most commonly cited workplace hazards have the potential for causing a slip, trip, or fall injury. The research of Leclercq (2005) indicates that slips, trips, and falls are a common cause for injuries among all occupations, representing more than 20% of occupational accidents with the most commonly occurring injury being bone fractures. In his analysis of accident rates Dekker (2005) points out that most industries that have achieved high levels of safety within their operations, such as the air transportation industry,
17 17 have not been successful in completely eliminating all errors. Even with accident rates as low as 1 in 10,000,000 the inability to reduce accidents to zero appears unachievable. This barrier to reducing accidents beyond a certain point is supported by Dekker also cites Amalberti (1996), who calls the inability to eliminate all errors which cause accidents a magical frontier as error rates asymptotically approach zero. Firefighter Injury Data NFPA 1500 (2002) defines an occupational injury as an injury sustained during the performance of the duties, responsibilities, and functions of a fire department member. Occupational firefighter injuries are placed into five major categories: (1) responding to or returning from an emergency, (2) fireground, (3) non-fire emergency, (4) training, and (5) other on duty. Firefighter occupational injury data for 2003 shows that 18% of fire department member injuries were categorized as other on duty. If training injuries are added which constitute 9%, and the 7% which are attributed to returning to and from incidents, the number comprising the non emergency category rises to 34% (Tri-Data Corporation, 2004). Due to the demanding work performed by firefighters, NFPA 1582 (2003) sets standards requiring firefighter be in top physical and mental condition. Therefore, the significance and severity of injuries have a lower threshold to cross before impacting the organization, and last for a longer period of time. NFPA 1582 requires firefighters to report all injuries which could affect their ability to safely perform their essential job tasks to the fire department physician. Further, NFPA 1582 requires that a medical evaluation be performed for all occupational injuries in compliance with OSHA standards and that these evaluations be used to detect any underlying work-related problems.
18 18 It is estimated that the total cost to fire departments of firefighter injuries in the United States from both emergency and non-emergency related accidents is between $2.8 and $7.8 billion per year. This figure, which must be shouldered by the taxpayers paying for emergency services, includes workers compensation, lost productivity, and insurance costs. Injury prevention activities including accident investigation and reporting costs are alone estimated to be between $830 and $980 million per year (Tri-Data Corporation, 2004). According to the National Safety Council (2003), the average cost of wage and productivity losses, medical expenses, and administrative expenses in 2003 was $38,000 for each debilitating workplace injury. In the report commissioned by NIST performed by the Tri- Data Corporation (2004) NIST unequivocally supports the conclusion that data on firefighter injuries is neither comprehensive nor attributable to a qualified source. In their commissioned report on the economic impact of firefighter injuries the NIST points out that fire departments do not typically maintain adequate records to determine the extent and severity of firefighter accidents or how each is meeting safety goals (Tri- Data Corporation). Another potential weakness in the reporting scheme used by fire department which may work to obscure or underreport firefighter injuries is the National Fire Incident Reporting System [NFIRS]. Data on firefighter injuries are compiled on a Fire Service Casualty Form NFIRS-3. This reporting system, which is used as the primary tool for generating firefighter injury statistics, is invoked only for emergency operations as a module to the standard NFIRS Incident Report NFIRS-1 (United Stated Fire Administration [USFA] NFIRS, 2004) Therefore, injuries not precipitated by an incident response are not reported. Although specific data could not be found quantifying non-emergency injuries, emergency related accidents could be used as a predictor of non-emergency accidents. In their work on
19 19 accident prevention Heinrich and Peterson (1980) propose a relationship between the number of errors which occur and the number of significant events resulting in worker injuries. In Heinrich s triangle, for every 30,000 unsafe acts there were 3,000 near misses or first aid accidents, 300 recordable injuries, 30 major accidents, and 1 fatality. What methods of evaluation exist to identify behaviors placing workers at-risk for slip, trip, and fall injuries? Identifying Behaviors There are three elements working together in every process, determining whether the process will conclude satisfactory with the expected outcome or with unintended consequences errors. The National Academy for Nuclear Training [NANT] (2004) identifies the elements as the environment, the person, and the behavior. The environmental elements are defined by as the things in the work area such as tools, equipment, procedures and work control process. The person factor involves what is known and what is felt. Behaviors are what one does. In their work on behavior based safety, the Institute of Nuclear Power Operations [INPO] (2004) state that traditionally the environmental factors have been the focus of safety programs. However, to truly develop a safety culture, and achieve zero injuries, organizations must focus on behaviors. To promote behaviors throughout an organization that support safe and reliable emergency and non-emergency operations. According to Cacciabue (2004), human error has become a common cause for many accidents. He points out that this category is typically used to assign blame and is not conducive to finding a true explanation of the accident and properly determine corrective actions to prevent recurrence. To find true causes, investigators must look past the assignment of blame and determine why people did what they did. Cacciabue also points out that the term human error
20 20 is often used to describe people failing to recognize hazards which are readily apparent to others in hindsight. This failure is often caused by what is known as a loss of situational awareness. Attitudes have a powerful positive or negative impact in determining behavior. The NANT (2004) lists seven specific hazardous attitudes which contribute to situations where errors are likely to be happen. These attitudes are referred to as pride, heroic, invulnerable, fatalistic, bald tire 60,000 miles and haven t had a flat tire yet, summit fever we re almost there, and Pollyanna nothing bad will happen. Therefore, at-risk behavior cannot be evaluated completely without an assessment of the attitudes of the people involved. Since behaviors are what people do, they can be observed and measured. According to Dekker (2005) at-risk behaviors are often the cause of injuries, either directly or indirectly. Therefore, it makes sense to focus attention on observing which behaviors are putting firefighters at risk of injury. If at-risk behaviors can be observed then we can intervene to change those behaviors and eliminate the risk. Factors Affecting Behavior Error precursors are defined as unfavorable factors, such as at-risk behaviors embedded in the job site that increases the chances of error during the performance of a specific task by a particular individual. There are four categories of error precursors which affect human behaviors. These categories are: task demands, human nature, work environment, and individual capabilities (NANT, 2004). Task demands are the factors which compete with or divide the necessary attention required for completing work. Task demands include: time pressures, high workload, simultaneous or multiple actions, repetitive actions/monotony, irreversible actions, interpretation requirements, unclear goals, roles, or responsibilities, and lack of or unclear
21 21 standards. Human nature refers to the common qualities that all people have. When people perform work, these qualities can have a negative impact on the ability to properly assess the level of risk people are being exposed to. The commonalities include: stress, habit patterns, assumptions, complacency/overconfidence, mind set, inaccurate risk perception, mental shortcuts or biases, and limited short-term memory. The work environment is the conditions and circumstances around people which influences behavior. The work environment includes: distractions/interruptions, changes/departure from routine, confusing displays or controls, workarounds/out-of-service instrumentation, hidden system/equipment response, unexpected equipment conditions, lack of alternative indication, and personality conflict. How well work is performed depends upon the capabilities of the individual performer. Individual capabilities are affected by: unfamiliarity with task/first time, lack of knowledge, new techniques not used before, imprecise communication habits, lack of proficiency/inexperience, indistinct problemsolving skills, unsafe attitudes, illness or fatigue, and general poor health (NANT). Where one or multiple error precursors exist, it creates what the National Academy for Nuclear Training (2004) calls an error trap. An error trap is a job or work task where there is greater opportunity for an error to occur due to the presence of one or more error precursors. The research of Cacciabue (2004) supports the assertion that accidents are a result of error prone situations more than they are of error prone people. Further, Cacciabue states that anticipating and preventing the occurrence of error prone situations is a sure way to ensure safer performance of work. Therefore, if error traps can be identified and eliminated, errors can be prevented.
22 22 Methods for Identifying At-Risk Behaviors At-risk behavior investigation is designed to expose concealed weaknesses that may contribute to accidents. Many methods for evaluating at-risk behaviors have been developed and are in use. What they have in common is that they are defensive in nature, meaning that they are used to prevent errors from occurring. It is essential that the correct behavior identification method is chosen based on the type of errors being exhibited. Errors can be placed into three categories which lead to the correct method to be used. Errors are skill-based, rule-based or knowledge-based. Skill based errors are made due to a lack of experience with performing the tasks. Rule-based errors result from the inability to correctly interpret information. Knowledgebased errors result from the lack of complete or adequate information (NANT, 2004). Many jobs are too complex or variable to analyze, therefore it is essential to break them down into component parts. According to Dekker (2005), the first step in identifying at-risk behavior is to break jobs down into individual job steps. Once each part is understood, a better understanding of the whole can be assessed. Additional benefit gained from this analysis is that it provides a step-by-step work control procedure which can be used to perform work in a consistent and repeatable manner where in each step, an assessment of the particular hazards are identified. To spot one s own mistakes is difficult. It is therefore essential that peers, supervisors, managers, and subordinates all be involved in the process of at-risk error identification (INPO, 2004). Worker-applied safety processes capture this need by involving all levels of workers and management to participate and lend their perspective (Huntsman, 2005). Cacciabue (2005)
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