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The following is an analysis of the safety and health program at Plant XYZ and some recommendations for improvement.


  • Records are suspect for the following reasons:
    • Numbers are not sequential
    • Cases are not in order, indicating reporting is lax and late.
    • Several cases are marked as ongoing. It is not clear what this means and may indicate that the cases were not initially reported.
  • How much higher will the real rates be once reporting is accurate?
  • There appear to be injuries related to lack of personal protective equipment.
  • There appear to be ergonomic issues at the facility.
  • The injury/illness rates are very high, indicating poor safety performance.
  • Is there a near miss or first aid log?
  • Where are the Workers’ Compensation first reports of injury?
  • The percent of recordables to lost time cases should be in the range of 10:1 (Heinrich’s accident pyramid); based on 8 lost time cases, this company should have had a lot more recordables, i.e., approximately 80, not the 18 recordables that they had. (There may be under-reporting.)

Behavioral Analysis of Incidents:

  • 6- Line of fire
  • 5- Personal protective equipment - gloves & washing resin off
  • 3- Personal protective equipment - eyes
  • 3- Overexertion
  • 2- Eyes forward & housekeeping
  • 2- Improper tool use
  • 2- Improper tool selection
  • 1- Lockout/tagout

Accident Investigations:

  • Not all cases were investigated.
  • Investigations set blame and determine no root cause.
  • Managers don’t value doing the investigations.
  • Lessons learned not generalized nor used proactively.
  • There are lockout/tagout issues which should be investigated.

Safety Committee Minutes:

  • There is no top management commitment at Plant XYZ.
  • Mixed messages are sent by opening the meeting with a production message instead of safety concerns.
  • Only managers are part of committee.
  • The message is : "Let’s clean up for annual fire department inspection" instead of: "Let’s find out how we are doing."
  • The company offers monetary incentives to keep rates and reporting down.
  • The safety and health program lacks sophistication - e.g., safety posters.
  • Supervisors not enforcing safety rules except when someone gets hurt.
  • Smith sees the purpose of accident investigation as filling out reports.
  • Culture is very poor and does not encourage safe behavior; rather, it encourages unsafe behavior and blames employees when something goes wrong. Employees won’t participate as a result of fear. There is low trust and credibility, and probably poor communication within the organization.

Organizational Roadblocks:

  • Poor communication;
  • Low trust;
  • Low credibility - managers don’t walk the talk;
  • Lack of consistency;
  • Blame;
  • Misuse of downstream measures;
  • Not everyone involved -no buy in;
  • Lack of cooperation between groups - no team play;
  • The company culture doesn’t value safety;
  • Production pressure - alignment issues;
  • Safety and health program lacks clear purpose and direction;
  • There are no clearly defined roles and responsibilities for safety at all levels;
  • Reward/incentive programs are disincentives;
  • Time;
  • Fear;
  • Peer pressure;
  • Lack of integration with other processes i.e., production and quality; and
  • Lack of top management commitment and involvement.

Overall - Plant XYZ should implement the following:

  • Accurate reporting,
  • Near miss reporting,
  • Root cause incident investigations,
  • Involve employees in incident investigations,
  • Involve employees in the safety committee,
  • Establish problem solving and process improvement processes for the safety committee,
  • Safety culture assessment,
  • Comprehensive safety and health audit,
  • Personal protective equipment program,
  • Ergonomics program,
  • Realignment for safety and health - production vs. safety priorities,
  • Establish S&H planning process,
  • Institute a lockout/tagout program,
  • Clearly define roles and responsibilities for safety,
  • Restructure incentive programs,
  • Establish good safety performance measures,
  • Define the value of safety and related processes for managers and for employees and get buy-in, and
  • Establish communications and trust with employees.
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