Safety Incident Reporting. Sarah Bogner, Contra Costa Water District ASSP Bay Area Safety Symposium March 7, 2019

Transcription

1 Safety Incident Reporting Sarah Bogner, Contra Costa Water District ASSP Bay Area Safety Symposium March 7, 2019

2 Agenda Incident Reporting Basics Why reporting matters Near misses and why they re important Barriers to reporting and how to overcome them Recognizing and correcting hazards Case Study - Incident reporting system at CCWD Comprehensive reporting system Corrective action management and tracking

3 What is an incident? What is a near miss? All incidents/events involve people and some type of action Incident: An unplanned, undesired event that hinders completion of a task and may cause injury, illness, or property damage or some combination of all three in varying degrees from minor to catastrophic. Unplanned and undesired do not mean unable to prevent. Unplanned and undesired also do not mean unable to prepare for Crisis planning is how we prepare for serious incidents that occur that require response for mitigation. Near Miss: A subset of incidents that could have resulted in injury, illness or property damage, if given a different set of circumstances, but didn't. Only a fortunate break in the chain of events prevented and injury, fatality, or damage. Also knowns as a close call or a near hit

4 The problem with accidents Accident: Definition is often similar to incident, but supports the mindset that it could not have been prevented. An accident is the opposite of the fundamental intentions of a safety program, which is to find hazards, fix hazard, and prevent incidents. When we accept that accidents have no cause, we assume that they will happen again.

5 Why do we need to report safety incidents and near misses? Near misses are free warnings and opportunities Prevent the little stuff before it becomes big stuff Share improvements and best practices as they develop (recognition) Leading indicator of potential safety management problems Capture sufficient data for statistical analysis, correlation studies, trending, and performance measurement (improvement over baseline). Required as part of our Injury and Illness Prevention Program (IIPP)

6 Why do we need to report safety incidents and near misses? Provide opportunity for employee participation, a basic component of a successful safety management system. Create an open culture whereby everyone shares and contributes in a responsible manner to their own safety and that of their fellow workers. Show care and respect for employees Create a safer work environment!

7 Top Reasons Employees Don t Report Near Misses 1. Fear Afraid of being reprimanded or disciplined for actions that led to the incident. 2. Embarrassment 3. Difficulty Co-workers are viewing the incident with humor instead of seeing the hazard. If everyone is laughing, how serious could it be? They don t know how to go about it. They don t know they should go to the supervisor or what form to use. 4. Bureaucracy They don t know they are supposed to report near misses. Too much trouble to fill out those forms and/or attend meetings

8 Top Reasons Employees Don t Report Near Misses 5. Peer pressure Pressure from co-workers to keep quiet so nobody gets into trouble. Under pressure to maintain a clean incident record because the team will win a prize. 6. Loss of reputation New employees wanting to make a good impression. 7. It s easier not to 8. Lack of interest from the organization The work culture says suck it up and don t make a big deal out of it. Last time they tried to talk to the supervisor about something, they were belittled or disregarded. 9. Perceived as pointless Think nothing will be done to fix the problem

9 Examples of Poor Reporting Culture Chernobyl nuclear meltdown (1986) Modified test conditions, rather than report problems prior to meltdown NASA Challenger Disaster/Explosion (1986) reports from technical experts were ignored in favor of meeting launch deadline DuPont Phosgene Gas Release (2010) three different chemical releases in 33 hours. First two were not addressed before third release killed one worker.

10 Developing a reporting program 1. Leadership must buy-in to the reporting culture 2. Non-punitive 3. Mechanism to anonymously report 4. Encourage employees to report solutions, not just problems 5. Follow-up on every incident to identify root causes This demonstrates that you want to know about events and it is worth employees time to participate. 6. Report back to the employee and broader group of affected employees 7. Results and corrective actions are a mechanism for training, feedback, and continuous improvement

11 Developing a Reporting Program Employee Participation is Vital Employees are uniquely positioned to provide information on hazards and changing working conditions. Create policies and procedures that clearly explain near-miss reporting Make the reporting system easy to understand and use Promote a culture of reporting with the support of all managers and supervisors Train all employees on the reasons near-miss reporting is necessary Provide incentives for workers who report incidents

12 Developing a reporting program Actual consequences Positive reinforcement Negative reinforcement Perception of consequences Significance magnitude and impact Timing immediate or future Consistency certain or uncertain Consequences with strongest impact on behavior are SOON, CERTAIN, and POSITIVE

13 Correcting Hazards Without this piece, the hazard reporting system will become ineffective. First, must identify the root/contributing cause(s)

14 Hazard Correction Cause Determination Basic Causes Indirect Causes Direct Causes INCIDENT Policy & Procedures Unsafe Acts Slip/Trip Fall Personal Injury Environmental Conditions Unsafe Conditions Energy Release Pinched Between Property Damage Potential/Actual Equipment/Plant Design Human Behavior

15 Correcting Hazards How do we know which things to fix first? How do we know when it s safe? Safety freedom from danger or harm Is anything free from danger? No, but we can reduce the risk. Better definition a judgement of the actability of risk. Risk measure of the probability and severity of a hazard to harm human health, property, or the environment.

16 Risk Matrix Probability vs. Severity

17 Contra Costa Water District Formed in employees Serves 500,00 customers in Concord Antioch areas of East Bay

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20 Contra Costa Water District 48-mile long canal provides water from the delta to the Concord area Central Valley Project contractor Los Vaqueros reservoir, built in ,000 acre-feet 886 miles of pipeline 40 storage reservoirs 31 pump stations 250,000 direct customers 250,000 customers through water CCWD delivers to local agencies

21 CCWD s Safety Culture Project 2008 two severe accidents involving employees Both directly the result of poor communication and near misses not being reported Management launched significant effort to improve safety culture and employee involvement Included reorganizing safety committees Greatly increased management support and employee involvement Added more safety infrastructure (e.g. paperwork) to better understand what was happening in the field 2016 safety perception survey identified the safety program and incident report had gotten too complex

22 CCWD Incident Reporting System So many forms! 1. Safety suggestion form 2. Safety recognition request 3. Initial injury form 4. Declination of medical treatment form 5. Supervisor s report of injury 6. Vehicle accident form 7. Near miss report So many tracking sheets! Facility Safety Tracking Injury Tracking (OSHA First Aids) Suggestion tracking Recognition tracking Monthly incident tracking How can we follow up or track our events this way? we didn t at least not well

23 Consequences of a bad reporting system Corrective action items get lost Employees and supervisors didn t know how to complete a report, so they don t ask If they report, there s no follow-up. Employees were discouraged from reporting again We weren t learning from our mistakes Focus on paperwork and the type of event, not what was actually on the paper

24 Building our incident reporting system District Safety Committee broke down our current system to determine: What were the primary frustrations or complaints with the system? Where were our road blocks? How can we build a reporting system that works with our agency structure, not against it. What most pertinent information do we need? What outcomes are we looking for?

25 Primary frustrations and road blocks Near Miss definition confusion. What is a near miss? Report form and submission process too complicated No independent way for employees to check the progress of corrective actions No point person to follow-up on events or get back to the original reporter Monthly safety tracking list was published with incidents for each month, and then cleared for the next month. No running tracking.

26 Building our incident reporting system Important features of our program included: Streamline paperwork Many ways to report One centralized corrective action tracking All reports go through one person (Health & Safety Manager) Reports can be easily shared across the District Emphasize reporting is non-punitive and directly helps employees

27 Safety Event Report New Safety Event report Reduces focus on type of event One page, easy to fill out Form available in several formats: Fillable word and PDF versions Printed forms located on every breakroom bulletin board Web form on staff website

28 Safety Event Report The Safety Event Report replaced 1. Declination of medical treatment 2. Supervisors injury report 3. Employee injury report 4. Spot recognition form 5. Safety suggestion form 6. Near miss report Many ways to file an event report Complete a paper form Complete the online form Call or supervisor Call, , or text Health and Safety Manager safety@ccwater.com Although the form is helpful, it is not required to report a safety event.

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31 Safety Event Report Process Supervisors after receiving a report: Review form to ensure completeness Add any additional information that may be useful Send a copy to Health and Safety Manager Health and Safety Manager after receiving a report: Enter information into safety event report tracking If follow-up is necessary, assign event to appropriate manager Typically follow-up plan will be due within one week Eminent hazards will require immediate follow-up Every event will be assigned to either a site safety committee or the District safety committee to track corrective actions When possible, the reportee will be informed on the progress and resolution of any corrective actions.

32 Safety Event Report - Tracking

33 Communication of Safety Events Directly to employee/work group that reported event Monthly District-wide safety newsletter Safety committee meetings

34 Results so far FY15 FY16 FY17 FY18 FY19 - YTD Closed Events - Total 27? Average Days to Closure? Events > 60 days to Closure? 20% 13% 6% 0 Closed on day reported? 32% 45% 58% 70% Open Events

35 Summary Incident reporting is critical to safety program success Take time to identify barriers to reporting and making a plan to address them Key to developing a comprehensive program is to evaluate what is/is not working with current system. Not always appropriate to keep adding on to your program, eventually programs need to be reevaluated and streamlined A thoughtful, inclusive approach to developing an incident reporting system will lead to success

36 Thank you! Sarah Bogner (925)