This material is for training purposes only. Its purpose is to inform Oregon employers of best practices in occupational safety and health and general Oregon OSHA compliance requirements. This material is not a substitute for any provision of the Oregon Safety Employment Act or any standards issued by Oregon OSHA. For more information on this online course and other OR-OSHA online training, visit the Online Course Catalog.

Module 6: DEVELOPING RECOMMENDATIONS

Introduction

An accident investigation is generally thought to be a reactive safety process because it is initiated only after an accident has occurred. However, if we propose recommendations that include effective control strategies and system improvements, we transform the investigation into a valuable proactive process that ensures similar accidents do not recur. In this module we'll explore tips and tactics for making effective recommendations that "sell" safety improvements.

Do it right!

Some employers may assign the responsibility for making recommendations to safety directors or maintenance supervisors. However, you, as the accident investigator, may be required to take on this very important responsibility. Consequently, it's a good idea to know where to start, and how to write strong proposals. One tip up front: If you find the responsibility is yours, be sure to get the help of experts if you're unsure how to proceed. Consultants in OROSHA or your workers' compensation insurer can be a great source for help.

What is an effective recommendation

To make sure recommendations are effective, we need to address effective control strategies that will eliminate or reduce the specific surface causes of the accident. We must also propose system improvements to missing or inadequate safety system components that contributed to the accident. Let's continue this discussion by taking a look at control strategies.

The Hierarchy of Controls

Hazard control strategies may be quite effective in eliminating hazards or reducing exposure. Effective corrective actions will include one or more of the following hazard control strategies:

1. Engineering controls. Sometimes the cause of an accident is corrected most effectively by removing or reducing the hazard, itself. This may be done in a number of ways, including:

Redesign the hazard out. Example - Fabricate a mesh guard to protect against exposure to moving parts.
Replace the unsafe item with a safe item. Example - Replace a poor quality grinder stone with a high quality grinder stone.
Enclose the hazard. Example - Place a hood over a source of noisy printer.
Substitute an unsafe item with different item. Example - Substitute a toxic chemical with a non-toxic chemical.

Engineering out the hazard is our top priority

Why is this control strategy our top priority? Engineering controls remove the hazard itself. We're somehow changing a thing/condition in the workplace. It has the potential to completely remove a hazard, and as we all know...we can't be exposed to a hazard if it does not exist. No hazard...no exposure...no accident.

It's important to note that the intent of OROSHA law is that the employer attempts to engineer the hazard out if feasible. For instance, if a machine is producing a noise level of 120 decibels, OROSHA expects the employer to first attempt to reduce the noise level to acceptable levels using an engineering control such as enclosure.

2. Management controls. Safety managers employ these control strategies to eliminate or reduce the frequency and duration of exposure to hazards. This is accomplished through:

Manage work practices. Effective design and implementation of safe work procedures and practices.
Manage work schedules. These strategies include job rotation, breaks, shift work, etc.

As you might have guessed, these control strategies are less effective in the long term than engineering controls because they do not remove the hazards, themselves. Rather, they attempt to reduce exposure to hazards by controlling human behavior - attempting to change "things we do or don't do." As long as employees "behave" or comply with the changed procedures or schedules, management controls work. However, it's "normal" for us to want to work in the most efficient manner. Sometimes safe work procedures are not perceived as most efficient...so we may not use them. Managers must diligently oversee and maintain management control strategies or those controls may become ineffective.

"Any system that depends on human reliability is inherently unreliable."

A. Block, Murphy's Law - Book Two

3. Personal protective equipment (PPE). Some jobs require PPE by law. This control strategy is used in conjunction with the other control strategies. It should not be used to replace them. When engineering and/or administrative controls don't adequately eliminate or reduce the hazard(s)of a task, PPE may be needed in addition to those strategies. PPE places a barrier between workers and the hazard. Remember, PPE does not eliminate or reduce the hazard itself, it merely sets up a barrier between you and the hazard. And, to be successful, it is highly dependent on safe behaviors.

The Hierarchy of Controls, when used separately or in combination, may be quite effective in eliminating or greatly reducing the probability of a similar accident recurring. However, to make sure long term risk reduction is achieved throughout the entire company, system improvements must be made.

Recommend system improvements

Missing or inadequate safety system components represent root causes for workplace accidents. Surface causes represent symptoms indicating system weaknesses. Therefore, every effort should be made to improve system components to ensure long term workplace safety. As we learned in the last module, the most successful accident investigator is actually a systems analyst: Not an easy task.

Making system improvements might include some of the following:

Including "safety" in a mission statement.
Improving safety policy so that it clearly establishes responsibility and accountability.
Changing a work process so that checklists are used that include safety checks.
Revising purchasing policy to include safety considerations as well as cost.
Changing the safety inspection process to include all supervisors and employees.

A little about behavior-based safety (BBS)

All of the proposals above represent "antecedents" or "activators" to behavior that serve to initiate appropriate behaviors. These changes in expectations must be clearly communicated to everyone through effective education and training to ensure behavioral changes are understood. Behavior-based safety, a type of formal observation process, is successful when the data gathering process is clearly understood by observer and observed, and the data collected is analyzed only to fix the system, not blame. Behavior-based safety is not usually successful if the process is, in any way, tied to discipline. The only consequences that work in BBS are positive consequences for making observations and being observed demonstrating safety leadership.

It's important to understand that once improvements have been designed and implemented, they then should be tied to accountability. Only effective consequences will ensure the changed behaviors are sustained long term. Remember, antecedents are likely to fail without effective consequences. We do what we do because of consequences...not antecedents. In other words...we do what we do, not because we're told to do it...but because we're going to (1) get something good, or (2) avoid something bad.

Bottom-line, behavior-based safety is another useful analysis tool that can be quite successful, when carefully designed, in helping the employer improve the safety management system.

Garbage In -- Garbage Out (GIGO)

When managers do not respond to a recommendation, it may be that they do not have enough useful information to make a sound judgment or take action. The GIGO principle -- "If you put garbage in, you'll get garbage out" -- that is commonly applied to data entry and computer programming, applies equally well to the process of making effective recommendations: Useful information must be presented to management so they are able to make correct decisions.

Proactive recommendations

To speed up the process and to improve the approval rate, we must learn to anticipate the concerns and questions that supervisors have when deciding what actions to take. The more pertinent the information included in the recommendation, the greater the likelihood for approval. To make sure you do provide good information, ask some important proactive questions.

Answer Six Key Questions

Answer the following six questions to help develop and justify recommendations.

1. Pinpoint the problem - What exactly is the problem?

What are the specific hazardous conditions and unsafe work practices that caused the problem? What are system components - the inadequate or missing policies, processes, rules that allowed the conditions and practices to exist?

2. What is the history of the problem

Have similar accidents occurred previously? If so, probability for similar accidents is highly likely to certain. What are previous direct and indirect costs for similar accidents? How have similar accidents affected production and morale? 3. Pinpoint the specific solution - What are the solutions that would correct the problem?

What are the specific engineering, administrative and PPE controls that, when applied, will eliminate or at least reduce exposure to the hazardous conditions? What are the specific system improvements needed to ensure a long term fix?

4. Who is the decision maker?

Who is the person that can approve, authorize, and act on the corrective measures? What are the possible objections that he/she might have? What are the arguments that will be most effective in overcoming objections?

5. Why is that person doing safety? It's important to know what is motivating the decision-maker. Is the manager doing safety to:

Fulfill the legal obligation? You may need to emphasize possible penalties if corrections are not made.
Fulfill the fiscal obligation? You may want to emphasize the costs/benefits.
Fulfill the moral obligation? You may want to emphasize improved morale, public relations.

6. What will be the cost/benefits if the recommendation is approved and the predictable cost/benefits if not?

What are the estimated costs and benefits of taking corrective action, as contrasted with the possible costs and harm that might occur if the hazardous conditions and unsafe work practices remain? What are the employer obligations under administrative law? What is the "message" sent to the workforce as a result of action or inaction?

The maintenance supervisor may be able to help you determine these estimates. Also, detail the costs associated with any training that might be required.

A simple cost-benefit analysis

A simple cost-benefit analysis assumes that there is a reasonable expectation that a disabling injury is likely in the foreseeable future (five years) when employees are exposed (place themselves within a danger zone) to a workplace hazard. The object is to contrast the relatively high cost/low benefit if the hazard is not eliminated, with the low cost/high benefit if the hazard is eliminated.

The analysis answers the following questions:

What are the potential costs to the company if the hazard is not eliminated?
What are the potential costs to the company if the hazard is eliminated?
How soon will the corrective action pay for itself?
What is our return on investment (ROI) if corrective actions are taken?

Example: If, during a safety inspection, you notice that an elevated platform area in a warehouse does not have a proper guardrail. You note that several workers work on the platform each day, and a well-used walkway passes directly under the platform. To construct a cost-benefit analysis for this situation you would answer the above questions as follows:

Average direct dollar costs for different types of accidents

To be effective, recommendations should be supported by a bottom-line cost/benefit analysis that contrasts the relative high costs of accidents against the much lower costs associated with corrective actions. Doing a cost benefit analysis is even more important when recommending corrective actions before an accident occurs.

According to the National Safety Council, which considers all industries nationally, the estimated 2000 average direct and indirect costs of a lost time injury is about $28,000, and a fatality averages $980,000. In Oregon, the direct costs to close a serious injury claim is around $10,500 and $300,000 to close a fatality claim.

Indirect costs, according to the NSC figures above average 1.6x direct costs. However, it's important to understand that indirect costs may amount to much more than this multiple with any single claim. Indirect costs can be as much as 2x to 50x direct costs...or more. Two things to remember in when estimating indirect costs:

The lower the direct cost, the higher the ratio between the direct and indirect costs. For instance, if someone suffers only minor injury requiring a few hundred dollars to close the claim, the indirect/direct costs ratio may be much higher than the NSC average.
Capital intensive operations, where large sums have been invested in facilities, realize higher and average indirect/direct cost ratios. For example, if someone is seriously or fatally injured on a oil-drilling rig, resulting in operations shutting down for a day or so, many thousands of dollars in lost production will result. In high capital intensive work processes, the expected ratio between direct and indirect costs may be 5x to 50x.
Labor intensive operations, where more investment is made in labor than capital assets, realize lower indirect/direct cost ratios. Someone may suffer a serious injury, but operations are not as likely to be significantly impacted. In labor intensive operations the expected ratio between direct and indirect costs may be 2x to 10x.

You can use these figures to demonstrate the benefits of taking corrective action.

What are the estimated costs to the company if the hazard is eliminated?

Costs: $1,500 needed to purchase and repair guardrail.

How soon will the corrective action pay for itself?

If a disabling injury occurs within the next 5 years, using National Safety Council figures we can estimate a direct/indirect cost to the company of approximately $28,000. Given the cost to purchase and repair the guard rail of $1,500. The corrective action will pay for itself in just 3.3 months ($1,500/($28,000/60 months)).

What is our return on investment (ROI) if corrective actions are taken? The ROI over the five year period will be $25,500 or 1,800 percent!

Last Words

Finally, it's important to provide alternatives to make it more likely that corrective actions will be taken. Your options might follow the logic below:

First option -- If we had all the money we needed, what could we do? Eliminate the hazard with primarily engineering controls. Additional administrative controls if required.
Second option -- If we have limited funds, what would we do. Eliminate the hazard with using work practice and/or administrative controls. Engineering controls if required.
Third option -- If we don't have any money, what can we do? Reduce exposure to the hazard with work practice/administrative controls and/or PPE.

It's important to remember that your employer should first try to engineer out the hazard if feasible before using administrative controls or PPE. Of course, some tasks require the use of PPE in accordance with Material Safety Data Sheet (MSDS) requirements.

Let's Review

26. (Fill in the blank) When making recommendations, we need to propose corrective actions ____ system improvements.

a. instead of
b. or
c. rather than
d. and

27. Engineering controls include all of the following except:

a. Substitution
b. Enclosure
c. Rescheduling
d. Redesign

28. Which control strategy is most effective in eliminating hazards?

a. Engineering Controls
b. Management Controls
c. PPE Control
d. Personnel Controls

29. All of the following are safety management system improvements except:

a. Writing a new safety policy.
b. Establishing a proactive incentive program.
c. Placing a guard on a table saw.
d. Revising an accident investigation form.

30. How does the "GIGO" principle apply to safety system improvements?

You are definitely over the hump! Only one module to go. You know what they say, "it's not over until the paperwork is done." In the next module we'll take a look at an effective format for reporting accidents. If you have any questions or comments, just drop me an email at email.

Have a great safe day!

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