Construction StoryBuilder; an instrument for analysing accidents and exchanging measures in the construction industry

Transcription

1 Construction StoryBuilder; an instrument for analysing accidents and exchanging measures in the construction industry Adri C.P. Frijters Arbouw / P.O. Box 213 / 3840 AE Harderwijk / The Netherlands / Frijters@arbouw.nl Martijn Mud, Remco Hakhoff RPS Advies/ P.O. Box 5094, 2600 GB Delft / The Netherlands mar Summary A relatively high number of industrial accidents occur in the construction industry compared to other industries. Certain types of accidents occur regularly and do so in line with specific accident scenarios. Each accident and near-accident offers an opportunity to learn lessons with a view to preventing reoccurrence. Many companies currently act on this individually. They maintain their own, independent system and apply their own methods. In doing so, they seem to encounter difficulty in registering all incidents and analysing them systematically. This leads to companies acquiring insufficient knowledge of accident scenarios which occur in their industry and within their own company. This paper describes the development of an instrument. The instrument has been created to record, report, register and analyse accidents with a view to comparing accident statistics throughout the industry and exchanging measures between companies. This will boost the learning process from accidents within individual companies and within the construction industry as a whole. It is essential that accidents can be registered and investigated quickly, simply and clearly. The tool must fit in with the individual companies modus operandi and match the Safety Index (Dutch TR- Method) set up by Arbouw Foundation. This process started by conducting an inventory of the current methods used for reporting, investigating and following up on accidents. Next, a registration and investigation process was determined which can be used to draw up an accident analysis. The next phase looked at how Storybuilder fits in with the desired registration and investigation process. The third phase entailed a selection of scenarios. We subsequently looked at the extent to which these scenarios could be linked to the Safety Index. The direct use of Storybuilder models with the current professional interface requires a high level of training. In order to make this suitable for use in the construction industry, sections have been rewritten and specific options (such as choosing the correct scenario) have been constructed slightly differently. The next phase was to draw up a functional specification for the instrument. This specification was used to create a mock-up with several functioning elements. The logical next step is to construct a prototype version of the instrument. A database can be created by using this system as a pilot for several months. This will also allow us to consider adding elements to the instrument, such as linking underlying causes and standard solutions. 1

2 Motivation Almost all companies in the construction industry have their own system for dealing with incidents. This also applies to service providers which support companies in improving safety performance. Moreover, in small and medium-sized companies these systems are only used for a very small number of incidents. The result is a lack of comparable data. An industry-wide survey or comparison is therefore impossible. In order to be able to learn from accidents and prevent their reoccurrence, it is essential that companies are capable of quickly charting their own failing barriers and underlying causes in a clear and accessible manner. These underlying causes and lessons learned from other companies can subsequently be used to take well thought-out and efficient measures. The objective of this survey is to draw up a functional specification for a system of registration, analysis and follow-up on accidents which can be used throughout the construction industry. The system will record comparable analysis results, which will enable measures to be exchanged and trend analyses to be made at both company and branch level. This will boost the learning process in the construction industry. The parameters for designing a system of accident registration and analysis are: With the aid of a minimum number of questions, an analysis is conducted of the direct and underlying causes of an accident, so that companies can get straight to the heart of the matter. The questions in the report are written such that they are comprehensible to those working in the construction industry. The questions can be answered by anyone with the minimum of instruction. It must fit in with the method used in the Safety Index. It must fit in with the Ministry of Social Affairs and Employment/Labour Inspectorate s Storybuilder methodology. It must fit in with the modus operandi and structure of construction companies. It must provide the opportunity to conduct trend analyses within the construction industry. It must enable composition of a standard report for external use (e.g. report to the Labour Inspectorate). It must fit in with the applicable norms and laws and legislation, such as ISO 9001, OHSAS and Safety, Health and Environment Checklist Contractors (SCC, in Dutch VCA). Methods and techniques Six phases were used to reach a functional specification for a uniformly-applicable system of reporting, analysis and follow-up on accidents in the construction industry (see figure 1). 2

3 figure 1 The six activities in the investigation Phase 1: inventory of current and desired situation Charting of the current and desired reporting, analysis and follow-up process Phase 2: assessment of the Storybuilder method In this phase, an assessment is made of whether, and if so how and where, the Storybuilder method matches the desired process. Phase 3: selection of Storybuilder models Not all models in Storybuilder are applicable to the construction industry. The Storybuilder models will be adapted where necessary so that the relationship with the factors from the safety indicators is clear and that the models are specific to the construction industry. Phase 4: from models to comprehensible questions In this phase, the selected scenarios are translated into comprehensible questions for analysing accidents. Phase 5: practical test In this phase, a mock-up of an interface is created and tested within five companies. 3

4 Phase 6: drawing up functional requirements In this final phase, the functional requirements for a software instrument are drawn up, using input from the companies which participated in the practical test. Results Phase 1 was conducted at ten companies. Visits were paid to six of these and at four companies only the procedures were inspected. All the companies are SCC** and ISO 9001 certified. None of these companies hold an OHSAS certificate. Within the framework of laws and legislation, certification or industry agreements, companies are obliged to process and provide a minimum amount of data. To this end, the Occupational Health and Safety Act and European legislation, Safety, Health and Environmental Checklist Contractors, BS OHSAS and ISO 9001 were analysed and translated into design requirements for the instrument. Construction companies generally have a no-nonsense mentality. This is where their strength lies and a great deal of effort is put into creating a fine, one-off product. Many issues are seen as side-issues or irritating and, especially in the event that there is no provision for repetition of the process, an evaluation such as an accident investigation is allocated a low priority. Action is usually taken in the event that a serious incident occurs on the construction site. At the companies surveyed, no near-accidents and only a few accidents were reported. The interviewed company KAM (quality, health & safety and the environment) coordinators explained that foremen or the project manager on the construction site mostly report accidents which also need to be reported to the Labour Inspectorate. A large number of subcontractors are also used. The interviewed KAM coordinators indicated that accidents involving personnel from other companies are not reported and registered by them. They work under pressure of time and with limited budgets, whereby reporting, investigating and following up on accidents costs time and money. Employees think that accidents not involving physical injury, or only minor injury, do not need to be reported. For instance, a concrete block which falls when no-one is in the vicinity is not viewed as an accident and is not reported. Victims and others involved are given no direct, personal feedback. This discourages employees from reporting any subsequent incidents. One of the conditions for a sound and thorough analysis is to correctly and objectively describe the investigation facts. With this analysis it is important that all relevant facts are collected and nothing is omitted. This is done in an iterative process. Each cycle comprises the following phases; reporting, factfinding, analysis, report, introduction of improvements and continuation of improvements. These phases have been assessed in practice and compared to the ideal implementation. The result shows no difference between current practices and the ideal situation for reporting. However, the other phases are not ideal. When fact-finding, in most cases there is no classification of sort, type and/or scenario. In the case of analysis, little attention was found to be paid to the underlying causes. The report is usually poor and incomplete with respect to content and its distribution to people. Any victims or the person doing the reporting are often overlooked. Improvements are often restricted to technical measures, while underlying causes are poorly inventoried and therefore often not included. Continuation of improvements and exchange within the industry are not included. Phase 2, the assessment of fitting StoryBuilder in dealing with accidents within construction companies and exchanging collective information, has yielded no difficulties. 4

5 Storybuilder was developed to analyse industrial accidents and to record these in graphic models (BowTies). The instrument was developed within the framework of the Ministry of Social Affairs and Employment s Improving Occupational Safety programme (VAV ). Storybuilder guides the person reporting the accident through a specific accident scenario and in doing so registers the course of events. Storybuilder defines the steps needed to reach an analysis of the causes. The two processes were compared in order to decide whether these steps can be fitted into the desired process. Where the desired process provides no structure in the investigation, Storybuilder can provide this structure in the analysis phase. This step in the process is therefore constructed in detail. The tasks and role of the person reporting the accident and the investigator can be allocated for each (sub) process in Storybuilder. Storybuilder can therefore be fitted into the current structure. The third phase comprised adapting and selecting the scenarios. On the basis of the link to the Safety Index and the survey of accident statistics, a selection was made from the available scenarios which should at least be investigated using the tool. A total of 36 accident models (scenarios) are available in Storybuilder. With a view to implementing the system in practice, the registered construction industry accidents were surveyed ( The accident statistics showed that 80% of all accidents can be investigated through the selection of only nine scenarios. The selection comprises the following scenarios: Falls from a height - roofs, upper floors etc.; Falls from ladders; Falls from scaffolding; Contact with other falling objects (buildings, scaffolding etc.); Contact with moving machine parts; Contact with objects falling from cranes including falling loads; Contact with projectiles; Contact with swaying objects/hanging loads; Contact with electricity. The Safety Index is an instrument in which six elements are tallied up as correct or incorrect on a cordoned-off section of the construction site. The Safety Index is formed by the ratio between the number of correct observations and the total number of observations. The index can therefore range from 0% to 100% and is simple to interpret. Those aspects which cause the highest number of incorrect scores remain visible. These problems can then be solved directly. A link between a scenario and an element in the Safety Index is not unique. Several scenarios and barriers may apply to an element from the Safety Index. Scenarios and barriers may also recur in several elements from the Safety Index. In the fourth phase, the scenarios in Storybuilder were converted into comprehensible questions. The use of Storybuilder models requires a high level of training. This conflicts with the parameters for the system. Although most sections can be asked directly via the completion of a form, there are also sections which are not as easily comprehensible. That is why during the fourth phase sections of these models were translated into questions for use in everyday practice. In this instance, the main thing is for the person (or people) reporting the accident to select the correct, most-applicable scenario and to select the failed task. This phase resulted in three main questions: the first preselects a number of scenarios and provides insight into the sort of accident, the second question results in insight into the type of accident (this is where the scenario is selected) and the third question provides insight into what went wrong, the actual non-functioning barrier. The questions are spread throughout the process and across the person immediately involved, the manager and the accident prevention officer. 5

6 Storybuilder compared with current process Role Process steps Data / aim Storybuilder steps Incident Victim Supervisor on site Incident call Name, telephone number, address, etc Bowtie selection Fact-finding Short description of facts Short description of effects Lost control event (LCE) selection Aim: Collecting data Barrier selection HSEQ - responsible Analysis Determining causes through own method Determining the failing tasks Aim: Advice on the prevention Determining of failing management tasks HSEQ - responsible Report Aim: Identif (direct) causes, giving advice Reporting Report to middle management and person reporting Aim; Providing facts and figures for management system Report to (middle) management HSEQ - responsible Action to improve Follow up: In company and branch Aim: Collection of data, solving direct causes Different types of input Follow up and registration 6

7 In the fifth phase, a mock-up was built of the developed model. The mock-up for the practical test contains three screens in which the person reporting the accident (the foreman) and the investigator (KAM department) can process the data quickly and succinctly. Once the mandatory fields have been completed, such as the victim s personal details, information about the accident can be collected quickly and simply in just a few questions. The information can be added to during the investigation. This mock-up was subsequently tested at five companies and an inventory was made of requirements via an interview. 1st screen: Reporting When an accident has occurred, this is reported (digitally) on the construction site by the foreman or the project manager (together with the victim/person reporting the accident). After completing the first page, the foreman has sufficient information to report the accident to the Labour Inspectorate. With the aid of an inbuilt risk matrix, these initial data are used to decide what to do with the report. 2nd screen: Reporting/fact-finding In the next screen (Feil! Fant ikke referansekilden.), more detailed information is requested. The correct scenario is selected in two steps. The first step makes a selection from all the scenarios, while the second step selects the exact scenario. This means that the person reporting the accident never has to choose from more than eight scenarios. After selecting the correct scenario, the way in which the accident occurred is selected. (LCE / PSB) Next the failing barriers are identified; this is done via questions about the method of failure. As a step towards which management tasks failed, the person reporting the accident is asked how it could have happened. This is not done by literal questioning using the definitions in Storybuilder. The person reporting the accident is given the choice of a number of statements, all of which are related to management tasks. Finally, the person reporting the accident confirms his or her report and can print out or save a summary of the report for personal use. The next step, investigating the accident, lies with the responsible officer within the construction company, usually the KAM coordinator. 3rd screen: Investigation It is the task of the investigator to identify any failing system and to record these in the system. He or she is given the description of the accident and the failing barriers already selected. It is possible to add comments in an open field. With a view to SCC** certification, the registration of accidents needs to include how many fatal accidents have occurred and how many accidents led to hospitalization or lasting injury. This is often unclear when the accident is reported and that is why this can be added during the investigation. Depending on the selection of the type of absence, for administrative purposes, the number of days and the starting date can also be entered. The mock-up was demonstrated at five companies and several accidents were entered as examples for each company. During the demonstration, the various process steps were gone through and comments were requested from the system s intended user. A brief questionnaire of eleven questions was subsequently completed to evaluate the mock-up. Questionnaire results The questions varied from the practical use of the tool and the match with the current modus operandi to the question of whether the tool might be used in the company in future. Respondents could only answer with agree or disagree. 7

8 Disagree Agree Entering the basic data is easy Describing / entering the facts is easy The questions are comprehensible The classification of the basic causes is comprehensible The cause is easy to describe / select It is useful to generate an automated report I would like to be able to compare reports (anonymously) with other similar companies / activities I would like to share insight into solutions (industry / other companies) I would like to be able to consult a database of solutions for each scenario The digital tool fits in easily with our current modus operandi If the tool is made available (free of charge), I would use it Conclusions and recommendations Each accident and near-accident provides the opportunity to analyse it in more detail and to learn from it. The objective is to prevent a reoccurrence. However, the comparison of the companies surveyed demonstrates that there is a wide gap between the desired and current situations. Most companies seem to experience difficulty in registering all incidents. It was noted, for instance, that the person reporting the accident often receives no feedback, which does not provide sufficient encouragement for reporting accidents. The interviews and audits among construction companies also show that after an accident few underlying causes are identified and solved. There is often no clear system in place. Improvements often appear to be aimed at solving the symptoms. Companies use their own, varying analysis methods. None of the surveyed companies are in a position to effectively share knowledge of and insight into accidents and underlying causes with its peers. It is therefore not surprising that too little is learned from accidents. It is essential that accidents can be registered and investigated quickly, simply and clearly. We investigated whether the Storybuilder method could provide a solution here, and whether a link can be made to the Safety Index developed by Arbouw Foundation. A selection was made of the Storybuilder accident models relevant to the construction industry. It proved to be simple to link these to the Safety Index. 8

9 Storybuilder s structure also proved to be excellently suited to the current modus operandi of the surveyed construction companies. The method of asking conditional questions in an adapted interface guarantees a simple and effective reporting and analysis process. The gap between the current and desired situations can therefore be bridged via an adapted user interface and in particular adaptation of the way the questions are put into words for the construction industry. A mock-up was made of the desired reporting tool and this was tested for usability and match at several construction companies. This practical test demonstrated that the adapted Storybuilder method fits in well with the desired situation within the surveyed construction companies. Moreover, there are opportunities for matching existing Arbouw Foundation publications and instruments to the lessons learned from accidents. The industry-wide sharing of knowledge with respect to accident prevention and the sharing of experiences with peers via their accident analysis and measures is seen as a major added value. On the basis of the survey results of the desired situation for accident reporting, analysis and follow-up, and from the results of the practical test, a functional specification has been drawn up for the development of a Construction Storybuilder instrument. The Construction Storybuilder is to be developed further thanks to the results of this investigation. 9