• 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 per cent 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.)

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

• 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.

• 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.

• 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.

• 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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