The Role of the Supervisor in Accident Prevention
| Principal Investigator(s): | John H. Lewko (Laurentian University)
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| Co-Investigator(s): | Jose A. Blanco, (Blanco Mialhe Association); Robert J. Flynn (University of Ottawa); David W. Gillingham (Dublin Institute of Technology); Donald W.Hine, Kenneth C. Teed (Laurentian University); Nancy E.Lightfoot (Northeastern Ontario Regional Cancer Centre)
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| Sponsoring Institution: | Laurentian University |
Objective
With the understanding that eliminating ‘repeat’ accidents reduces injury and provides a blueprint for prevention this project aimed to engage personnel in an evolutionary process to improve, develop, and maintain accident/incident prevention strategies and systems. The project was designed and developed to facilitate learning by researchers, managers, supervisors and workers from review of existing accident/incident reports and the related preventive responses within the organization’s own database. The involvement of interested partner representatives as active participants ensured that any new practices arising as a result of this project would be relevant and feasible in the workplace. As a result, the likelihood that these practices would be applied towards obtaining the desired result of effective accident/incident prevention would increase.
Method
Based on the premise that all repeat accidents/incidents leave a ‘trace,’ analysis of these traces was undertaken in order to identify the factors contributing to the accidents/incidents and the fit of the preventive responses. The interplay of the two distinct processes of understanding these factors and acting upon them in an appropriate way necessarily improves understanding and enhances prevention of the accidents/incidents that recur.
With this in mind, a three stage action research model was followed. The structure of this model directed activities towards organizational change, making senior management safety intentions more explicit and aligning field personnel’s actions with such intentions. The three stages were:
- making the available database useful and helping improve future databases
- using the database to capture and clearly present meaningful patterns through conventional and unconventional analyses
- involving field personnel in both the identification of contributing factors and the development of effective prevention strategies and engaging the manager as the pivot.
In line with the belief that involvement in the process of searching for and acting upon patterns in repeat accident/incident occurrence leads to improved prevention, three of our industrial partner’s preventive factors were selected: Basic Cause, Risk Assessment, and Preventive Actions. Conventional and unconventional analyses of the selected preventive factors were used in order to facilitate their presentation in a form that would engage members of the organization, leading to consideration and discussion of the significance of the pattern and the appropriateness of the action responses. Subsequently, partner representatives initiated independent research into contributing and preventive factors and felt motivated towards actively improving their organization’s safety management system.
Results
The action research process was designed as the critical agent of change. Working together to both identify recurring accidents/incidents and their contributing factors, and to assess the appropriateness of the preventive responses, effectively transferred successful research strategies from researcher to personnel. Ownership enabled organizational personnel to use these research strategies as an important source of improvement for the organization’s safety management system. Key lessons and outcomes arising out of the action research process include:
- repeat occurrences point to failures of the Safety Management System
- the safety intent of the manager defines the context for prevention and influences the handling and disposition of repeat occurrences
- the design of the accident investigation report may show occurrences as unique although they might be repeats
- excess information can mask patterns and conceal opportunities for prevention
- conventional statistics pinpoints focal areas, while understanding patterns leads to appropriate action
- risk assessment of all occurrences must be consistent
- safety actions must align with contributing factors and their causes
- as the driver of the Safety Management System, the manager is the pivot for change
- the ‘safety intent’ of the WSIB and the Ministry of Labour influence how local organizations administer their Safety Management System.
These lessons and outcomes provide evidence of how pervasively ‘management human factors’ influence prevention activities. This suggests that, in order to ensure that the project responds to local conditions and requirements while maintaining scientific integrity, use of an action research model must incorporate:
- willingness to adapt project design to meet local needs and conditions
- strategies for a shift in project ownership from project management team to organizational personnel
- establishment of ‘stop rules’ for terminating project activities.
Some challenges were faced during the course of the project. For example, re-composition of the database was a larger task then anticipated and the project had to cope with a number of key personnel changes, a period of work stoppage within the organization and a union/safety restructuring. During the span of contact of this project, the company pursued a number of other safety initiatives. Despite these challenges, the findings of this project provided the focus for the improvement of the data collection and interpretation and for the prevention initiatives that were adopted.
The project demonstrated that new opportunities for prevention exist even in the historical records of incident reports of highly competent prevention oriented organizations, such as our industrial partner. That was only possible because our Safety Association partner collects and maintains a comprehensive record of occurrence data within their industry.
That opportunities for prevention can be found in leading safety companies suggests major prevention opportunities for the industry as a whole. Revealing such opportunities may require a policy environment that motivates the Provincial Safety Associations and their industrial partners to improve the quality and collection of data, responding to the evidence of “management human factors” and exploiting the rumbles in their own data.
Lessons learned and strategies developed and applied while conducting this project are portable to other companies and industries, including the WSIB and the Ministry of Labour, who may recast their policies in support of the prevention improvement process outlined in this project. This project report provides an outline of a step by step process for the use of available data to search for patterns within the families of recurring accidents/incidents, to evaluate the related preventive responses and to engage working personnel to assist organizations in their goal of improving prevention.
For more information:
jlewko@laurentian.ca
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