EHS incidents can be painful for injured employees, the environment and your organization’s bottom line, but incident management software and reporting systems don’t have to be a pain point for you.
Safety and environmental disasters rarely occur because of a single event or incident, which is why it’s critical to adopt incident management software or reporting system that identifies root causes and protects your business from future occurrences.
Ask a group of people what caused the Titanic to sink and most will say, “An iceberg.” If one person in that group is a risk or safety manager, he or she might respond that the Titanic tragedy was caused by a series of events—management failures, poor-quality construction, employee errors/lack of training, poor planning and either failure to track incidents or the inability to analyze incident data in a meaningful way—that ended with the sinking of the ship.
“Rarely does a single event cause a tragedy. It’s a cascade of events … there were problems lying in wait,” Gordon Graham, who spent 30 years with the California Highway Patrol and now is an attorney who educates and lectures about risk, told a conference audience several years ago (ISEA Executive Summit, Orange County, CA, 2013). “That ship was doomed long before it was built, designed, or hit the iceberg.” According to Graham, almost every bad outcome is preventable.
So how do we prevent these bad outcomes? As indicated by Graham and others, just meeting compliance with regulations and following procedures cannot prevent a bad outcome.
In the Intelex Insight Report “The Deepwater Horizon: Learnings from a Large-Scale Disaster,” authors Scott Gaddis and Graham Freeman discuss a technical issue—the failure of the blowout preventer to contain the flow of hydrocarbons that eventually ignited and destroyed the rig, killed 11 workers, and created an environmental disaster in the Gulf of Mexico—but also note that, “The emphasis on saving time and money over safety and managing risk manifested along a wide spectrum of organizational failures.”
Organizational failures included poor communication between managers, teams, employees, and third-party contractors; a lack of standardized procedures; badly written and organized safety manuals; little differentiation between mandatory and optional procedures in some cases; and a lack of reporting about unsafe conditions and organizational failures because employees feared management reprisals.
“Failing to manage safety procedures and processes in an organization will inevitably lead to tragedy at some point in the future. In complex systems, small failures will aggregate with connected failures in other parts of the system and eventually grow into crises. Every organization must therefore be sensitive to minor deviations and fluctuations that provide evidence of cascading failure,” wrote Gaddis and Freeman.
“Small failures,” in reality, are the incidents that should be documented by incident management systems in incident reports.
1. What Is an Incident?
Generally, an incident is an event or situation that causes disruption to the organization: an employee is injured or killed, property is damaged, an environmental release occurs (can be contained within the facility or travel outside the facility), security is breached, third parties are harmed (for example, a hospital patient is harmed as the result of malfunctioning medical equipment) and/or products are damaged.
Any serious loss should be investigated promptly and thoroughly. Multiple people/departments in your organization will have an interest in the outcome of an incident investigation and possibly will play a role in the thorough investigation of incidents. Loss of any kind impacts an organization. The suffering of employees and their families, the cost of work-related injuries and equipment loss, liability and lost production time cause concern all the way up to the executive suite. Such losses also point to deficiencies in the safety management system (SMS) that need to be corrected.
An incident also is an event that could have injured or killed an employee, caused property damage, caused a toxic release, etc.
Any incident with a potential for a serious loss points out the same deficiencies in the SMS: the causal factors that make the incident occur. The severity of the actual loss in each event often is a matter of chance.
How often have you barely avoided a car accident and thought, “I got lucky.” In reality, your “luck” was the result of good defensive driving skills on your part, on the part of other drivers, or even because of accident-avoidance systems. The loss and the risk may vary according to very slight differences in circumstances.
So, the practical approach is to investigate every accident and incident to evaluate the loss potential. Then, investigate high-potential incidents and accidents in depth to allow adequate control of the problem. Each organization must define what losses and potential losses are significant to its resources, its employees, and its public relations.
2. Employers Have a Legal Obligation to Report Serious Employee Injuries and Fatalities
OSHA requires employers with more than 10 employees to keep a record of serious work-related injuries and illnesses. (Certain low-risk industries are exempted.) Minor injuries requiring first aid only do not need to be recorded. (OSHA, https://www.osha.gov/recordkeeping/). OSHA requires employers to submit injury and illness Recordkeeping Forms 300, 300A and 301. The records must be maintained at the worksite for at least five years. Each February through April, employers must post a summary of the injuries and illnesses recorded the previous year. Also, if requested, copies of the records must be provided to current and former employees or their representatives. OSHA defines a “recordable” injury or illness as:
- Any work-related fatality
- Any work-related injury or illness that results in loss of consciousness, days away from work, restricted work or transfer to another job
- Any work-related injury or illness requiring medical treatment beyond first aid, or
- Any work-related diagnosed case of cancer, chronic irreversible diseases, fractured or cracked bones or teeth or punctured eardrums.
There also are special recording criteria for work-related cases involving needlesticks and sharps injuries, medical removal, hearing loss and tuberculosis.
Beyond the legal obligation of reporting an injury or fatality and including those reports as part of your incident reporting system, you also should include near misses—situations where no injuries or property damage occurred but that could have resulted in a worse outcome—as well as adverse events, such as those that cause harm related to medicine or medical devices, and “no harm” events (like the “small failures” and “minor deviations” documented in reports about the Deepwater Horizon disaster).
3. Incident Reports Are a Powerful Tool
An incident report is the foundation that is used in the investigation and analysis of an event or series of events. Reports should identify the root cause of an event and corrective actions taken to eliminate the risks involved and prevent similar events.
One of the most powerful tools in the toolbox of any EHSQ professional is a timely, accurate incident report. These reports document incidents that caused injuries to employees or damage to property, as well as “near-miss” incidents that could have caused injury or property damage. Incident reporting and management empowers EHSQ professionals to capture, track, investigate and report on all incidents and near-misses, including injuries and illnesses, spills, property damage, security breaches, employee misconduct and vehicle incidents.
Over the past few years, there has been a significant transition away from injury-based/compliance-based programs to the development of safety management systems that provide for continuous improvement and focus on risk reduction.
In a presentation at the EHS Today Safety Leadership Conference in 2016, Pamela Walaski, CSP, CHMM, director of health and safety for GAI Consultants Inc., cited a 2014 Rand survey that compared the fatality rate in the UK with that in the United States. The fatality rate in the UK is one-third the rate of the United States overall and one-quarter the rate in construction. “Lower rates are associated with management attention to safety and a risk management approach. Put time and energy into risk management [rather than compliance],” Walaski counseled.
Effective incident reporting and risk management systems allow you to do the following:
Describe the incident in question.
Police understand that five witnesses to a crime or accident can have five different opinions about what happened. None are necessarily incorrect, but were viewed from different perspectives through different eyes and experience. Thorough investigations into workplace incidents—like those at accident scenes outside the workplace—can help organize seemingly conflicting evidence and arrive at an accurate picture of what really happened.
Discover the real cause or causes.
As we’ve learned with many incident investigations, the underlying cause or causes might not be what you see on the surface. Just like an iceberg, there’s more than meets the eye. If the real cause or causes are not identified, then the investigation and any corrective actions potentially are a waste of resources. It’s like treating symptoms without curing the disease.
Determine the risk of the incident occurring again.
What is the likelihood of recurrence and the potential for major loss? These two factors are critical in determining appropriate corrective action.
Develop adequate controls to minimize or eliminate the cause of the incident.
A thorough investigation should determine the true cause of the incident and will dictate appropriate controls to ensure the incident does not reoccur.
Define and track trends.
Few incidents are truly isolated events. When your incident reports are analyzed, you should be able to identify trends. Once trends are identified, talk to employees, supervisors, and managers. They might have been concealing or ignoring issues, or they might have reported issues but corrective action wasn’t taken.
Demonstrate concern for employees who are injured or who witness incidents where injuries occurred to coworkers.
“That could have been me” is a thought that occurs to many people who witness accidents. You don’t want your employees thinking: “That could have been me and it might be me tomorrow.” Prompt, objective investigations reassure employees that their wellbeing is important, and that the organization does not want a repeat of that incident.
4. Best Practices for Incident Reporting and Management
An incident report is the repository for all the essential information about an incident. Incident reports should do the following:
- Be as accurate, objective, specific and detailed as possible – Information, including correct dates, times, names, and contact information of witnesses, is crucial to creating an incident report your organization can use to rectify a problem, process failure, or hazard. “Just the facts” should be the mantra as you create an incident report. Opinions don’t matter; facts matter. If there are differing accounts about what occurred, include them. If you take a statement from a witness or victim of a workplace accident, make sure you quote them accurately and note that it is the opinion of the person being quoted.
- Be as complete as possible – Make sure you determine and accurately report who, what, where, when, why and how. Include contact information and statements from victims and witnesses and include the names and contact information for team members who will be conducting the investigation into the incident. If someone needs to reference that report in the future because a similar incident occurred, will they find the information they need to propel their investigation?
- Be as graphic as possible – A picture tells a thousand words, so include photos, diagrams, illustrations, etc. You cannot have too many photos of the injury or accident scene. Include illustrations or diagrams from machine manuals as well if there’s a possibility that something was not built or maintained correctly or malfunctioned.
- Have sign off from everyone involved in the incident, such as the victim, witnesses and managers – They should agree, in writing, that the report is accurate to the best of their knowledge and that if they were quoted, those quotes are accurate.
5. Incidents Can Be Painful (But Incident Reporting Sosftware Shouldn’t Be)
The creation of incident reports, which are a vital component of any incident management system, does not have to be difficult or confusing. Incident Reporting Software empowers you to capture, track, investigate, analyze and report on all incidents and near-misses, including injuries and illnesses, spills, property damage and vehicle incidents.
“Intelex’s Incident Reporting Software is sensibly designed as a means to this end: log basic incident details, facilitate an investigation, conduct root cause analysis, assign corrective actions, see claim information and provide all relevant documentation in one centralized location built with efficiency, accountability and visibility in mind,” said Trevor Bronson, Director, Portfolio Strategy, Intelex.
Previously, Bronson worked as an EHS practitioner to achieve improved EHS compliance and performance at organizations such as utility company PPL and automotive manufacturer Tesla Motors. According to Bronson, there are “tactical pain points of incident management.” These include the following:
Recording the incident: Obtaining the correct incident form, avoiding duplicate entry, gathering details rapidly, getting the key information and alerting relevant parties. According to Bronson, Intelex’s Incident Reporting Software addresses this pain point through the use of configurable incident forms, forms responsive to incident type, mobile functionality and automatic alerts.
Investigating the incident: Keeping the investigation organized, following a schedule, investigating at the scene and using document control. Software should provide a “dedicated workflow for investigations and a document repository with the ability to attach images,” said Bronson.
Follow up: Low visibility into action item success, visibility into trends and combine EHS data with other operational data. As an EHS professional, said Bronson, you want to be able to “easily monitor trends, conduct audits to ensure CAPAs are working and search for further improvements.”
Corrective and preventative actions (CAPA): Organizing actionitems, conducting risk assessments, scheduling tasks and ensuring timely task completion. Intelex can help you create and assign tasks directly in incident workflow, set configurable escalations for overdue tasks and monitor completion timeliness, Bronson noted.
Internal/external reporting: Tedious to collect and organize the right data, data may be siloed, reporting is not automatically formatted and inability to schedule regular reports. “Click-button report to [regulatory agencies such as] OSHA, create scheduled internal reports and customizable report formats” make it easy to collect, organize and report data, said Bronson.
Analysis of the incident: Data cannot easily be compared, inferior data quality across entries, conducting RCAs and third-party integrations. Data-embedded business intelligence, easy integration with external BI tools, customized dashboards and embedded RCA tools allow for thorough and accurate analysis of incidents, Bronson observed.
In addition, he noted, role-based access and perspectives provide the people who need to see and use incident data with the correct data for their role, whether they are the VP of EHS, a supervisor or a frontline worker. According to Bronson:
- Executives are provided high-level views, select KPIs, the ability to drill down into specific information and automatic reports.
- Supervisors see all tasks, all due dates, the results from specific sites and select KPIs, and have the ability to create reports and analyze and action trends.
- Frontline workers can see their specific tasks and due dates, look at metrics for their site and access and submit forms.
“The hardest part of incident management within an organization isn’t creating the management framework itself, it is executing it in a manner that ensures timeliness, accuracy, compliance, and continuous improvement,” said Bronson. “Without a proper tool, resources will be wasted gathering data, entering it in multiple locations, hunting down data for reports, and following up on CAPAs.”
Incident Reporting Software and Incident Management Linked to Operational Excellence at SUEZ
Since adopting the use of Intelex’s EHS Incident Reporting Software in 2015, SUEZ North America has transformed incident reporting, enhanced employee engagement, improved its safety culture and ultimately, reduced injuries. (Learn more about SUEZ’s journey to operational excellence here.)
SUEZ’s use of Intelex has been a major contributor to the company bringing its Days Away Restricted or Transferred (DART) rate down by 24 percent in the past four years, from 2.14 in 2014 to 1.63 in 2018, and its Workers’ Compensation Experience Modification Rate (EMR) down by 41 percent since 2009 (1.05 to 0.62).
SUEZ North America contracts with numerous clients to operate their water and wastewater plants. This requires managing facilities of different ages and stages in building and equipment maintenance, supervising and engaging employees who have not received comparable training and aligning often varied safety missions and cultures. Accurate incident reporting and data management is key to improving health and safety for workers and satisfying maintenance and operations demands at the many facilities SUEZ manages.
Initially, the company used spreadsheets to capture, report, analyze and correct hazards. As its client list grew and new software and technology became available, SUEZ realized a paper-based approach to incident management had become cumbersome and ineffective.
“We couldn’t keep track of the paperwork. We had five different versions of everything,” Kanwer Khan, Vice President, Environmental Compliance, Health, Security and Safety for SUEZ North America, revealed.
Now, SUEZ utilizes Intelex’s EHS Incident Reporting Software for capturing, reporting, analyzing and correcting hazards. Every employee has access to the software and most of the workforce has smart devices through which they can report hazards.
“Intelex has been a life saver for us,” said Khan. “I don’t know what we’d do without it.”
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