Private Sector risk management methods may help counties separate the forest from the trees when it comes to workplace accidents / By Maria Sprow

It’s 10 p.m. on a Frida y night whe n a dispatcher radios in a domestic disturbance complaint to a new sheriff’s deputy. The deputy responds in a hurry, speeding along the rural country roads to the address, when suddenly, his patrol car leaves the roadway and strikes a tree, resulting in life-threatening head and neck injuries.

It’s one thing to ask what happened, or how it happened, or even why it happened. But asking the preliminary questions rarely fully answers the larger questions that safety and risk management experts are asking more and more: what was the root cause of an injury, and how can it be prevented from ever happening again?

“The beauty of root cause analysis is, if one is done well, it’s going to uncover a lot of issues that may need to be addressed,” said Mike Strawn, who oversees the safety and loss control training services for the Texas Association of Counties. “There are things that you wouldn’t normally think about that are safety concerns.”

TAC recently held a series of regional workshops on how to identify the root cause of injuries. Attendees learned how to differentiate between unsafe acts and unsafe conditions, about the different psychological factors that cause a person to put themselves unnecessarily into unsafe conditions or behaviors, and to understand that most injuries have multiple causes. The workshops focused on injuries in law enforcement, but root cause analysis could be used in any county department, Strawn said.

“A lot of this comes from safety professional journals, the conferences we go to and the professional development we have,” Strawn said. “It’s our task to take the cutting-edge tools being used in the private sector and adapt them to be applied in the public sector.” Many private sector industries, including the petrochemical and space exploration industries, take a root cause approach to limiting accidents and injuries.

“The businesses that use a regular root cause analysis approach are the businesses that you hear go a million man hours without an accident,” Strawn said. “They have zero tolerance for accidents, so when one happens, it’s a big deal.”

Why ask Why

One way to identify the root cause of an accident is to look at the sequence of events and continue to ask ‘why’ that event took place until the question ‘why’ can no longer be asked, then take a look at the event prior to the accident and ask ‘why’ that event happened, until all the events that lead to the actual accident have been thoroughly investigated.

Someone performing a root cause analysis will know they have succeeded when all ‘why’s have been sufficiently answered and when an action can be taken that would permanently affect the root cause of an accident, thereby hopefully preventing similar incidents from occurring in the future.

Some investigations tend to focus too much on just one cause of an accident – a technique that can shift the focus from why something happened toward who’s to blame. That’s not what safety prevention is about.

According to the Root Cause Analysis Handbook, published by ABS Consulting, “most organizations don’t get beyond human error or equipment failure level without a structured (root cause analysis) program. They are able to correct one problem, at least temporarily. But they fail to dig deeper to generate permanent solutions.” So, a deputy slams his patrol car into a tree. What was the root cause?

In order to gather information about the first “whys” – why did the deputy’s patrol car hit the tree and why was the officer injured in that accident – an investigator would need more information. They would need to see the injury and crash reports filed by the officer, talk to the officer personally and review any personnel or training files on the officer.

An investigation at the scene of the accident may reveal that the deputy had been speeding, that there was standing water on the road at that time, and that the accident occurred after a curve in the road. Why was the deputy speeding, why was there standing water in the road and why did the accident occur after a curve in the road? A conversation with the officer may reveal that he felt the need to get to the scene of the domestic disturbance quickly – there had been recent criticism in the newspaper about the department’s slow response time, and the deputy was far from the incident when the call came in – so he had, in fact been speeding. Maybe the deputy had been on an unfamiliar road, and he hadn’t known about the sharp curve, and maybe the deputy had been having a problem with the vehicle – the headlights weren’t bright enough and it was difficult to see the water on the road. A look at the deputy’s personnel files may reveal that he is a new officer with a history of speeding and wrecking vehicles who has not had any vehicle or driver training. Now, why are the department’s response times slow? Why was a deputy so far from the incident scene dispatched to that scene? Why weren’t the headlights bright enough for the deputy to see the water on the road? Why was a deputy hired when he had a history of wrecking vehicles and why did he never receive driver training? Maybe the department’s response times are slow and the deputy was dispatched to that scene because the sheriff’s department lacks the funds to have more officers, or because it’s having trouble recruiting enough officers.

That’s a complicated problem, but it’s one of the root causes of the injury. A root action would be to somehow hire more deputies, or to change the locations where deputies patrol so they aren’t spread so far apart.

But back to those other whys – the standing water, the curve, the headlights, the hire, the lack of training. Maybe the water was on the road because there isn’t proper drainage in the area. Maybe the deputy wasn’t aware of the curve on the road because there wasn’t proper signage visible. Maybe the headlights were dim because the vehicle’s maintenance wasn’t up-to-date, and the car hydroplaned because the department had switched to a new brand of tires. Maybe the department’s hiring and training policies should be reconsidered. This is root cause analysis: it’s not one single trail of whys leading to one final answer, but possibly several or many branches of questions stemming off a single incident.

Each of those branches should have a root action that the county could take to help prevent future incidents: putting up a warning sign before the curve, implementing new sanctions for employees who don’t abide by policies, formalizing the hiring process to include background and driving record checks, starting up a needs assessment program in order to ensure that employees are provided appropriate safety training. The Whole Safety Tree

Utilizing root cause analysis is just one step county leaders can take to develop an effective safety culture that reduces the county’s workers’ compensation claims and costs.

Reducing workers’ compensation claims and costs is important on many levels – not only does it save taxpayer dollars when premiums are lowered, but having too many on-the-job injuries impacts staffing, reduces workers’ moral, leads to lawsuits, lowers the operational efficiency of a department and can lead to resident dissatisfaction, if, for some reason, an injured worker leads to lengthening the amount of construction time for a road project or a bystander is somehow injured during an arrest.

But in order for root cause analysis to be effective, a county must be willing to make an investment – especially financially, since the process demands that something be fixed or changed. TAC Law Enforcement and Loss Control Specialist Steve Chalender said the cost is normally offset by the potential cost-savings of not having to pay future workers’ compensation claims.

The average Texas county workers’ compensation claim, he said, is about $3,500 – though they can cost much more. If a deputy hits a deer in the road, causing damage to the patrol vehicle, and the solution is to purchase deer guards for the fleet of vehicles, that decision should be weighed against how much it costs to replace a totaled vehicle, how long it takes to replace or repair damaged vehicles, the impact to the department if it is short a vehicle, and the cost of a workers’ compensation claim, should anyone be injured in a future accident.

In the end, the solution to a problem may be less expensive than the problem itself.

“You can give some outlandish reason for not doing something, but you know, play the numbers,” Chalender said, giving one example with two counties. In County A, which Chalender said was not taking steps toward building a safety culture, the county had an annual payroll of $3,307,329 and its workers’ compensation premium was $214,363. County B, because it was taking an proactive approach to safety, had an annual payroll of $3,329,114 but a workers’ compensation premium of just $63,955 – meaning that its safety culture was saving it roughly $150,000 a year off its premium. Another step to lowering workers’ compensation claims, safety experts said, is to understand workers’ behavior. Most injuries are caused by a combination of both unsafe conditions – addressed by root cause analysis – and unsafe actions. If a manager has a good idea of why his or her employees are behaving unsafely, they run a better chance of modifying the behavior.

“Our behaviors are very much affected by our values, our habits, even our state of mind at the time of an incident,” said Ernesto Galindo, a safety and loss control specialist at TAC.

For instance, if employees are getting their fingers smashed in an elevator, the cause is two-fold: the elevator is broken, and employees are trying to hold the doors open for others – an act of kindness toward coworkers made by those who value time or friendliness but do not take personal safety into consideration.

“That’s a preventable injury,” Galindo said of the smashed fingers. “Look at what motivates a person to be safe or unsafe in the workplace.” A person’s values, intentions and behaviors aren’t always consistent, he said, adding that surveys have indicated that 90 percent of employees believe they should caution coworkers when observing them perform unsafe actions, but that only 85 percent are willing to step in and only 60 percent said they actually do step in when observing such behaviors.

“Why not intervene?” Galindo said. “The difference is that if something affects them directly, they will intervene … if it doesn’t, they let the other guy deal with the consequences.” He added that an organization will achieve a safety culture once there is a management system in place that stresses safety as an important value and emphasizes each person’s personal responsibility for their own safety, as well as for their coworkers safety. Employees in such a culture – where those who perform their job safely are positively reinforced – are more likely to actively care about their coworkers and stop unsafe behaviors.

Employees – particularly those in high-risk positions, such as road and bridge workers and law enforcement officers – must also be trained in how to assess the severity of risk involved in any situation, including those that happen on the fly.

Safety specialists use what is called a risk assessment matrix, or a threat level, to determine the source and nature of the potential dangers involved in an action or job function. The risk assessment basically takes into account the likelihood that an event will occur and places that against the severity of such an event – an event that is likely to occur and would cause fatalities should it occur is given a critical threat level, whereas events that are unlikely to occur and would probably only result in an employee needing first aid is given a slight threat level.

Larry Boccaccio, a loss control expert at TAC, said the most important thing to remember about risk assessment is that a situation’s threat level changes as the situation changes. While it’s important to have a routine in place while operating heavy equipment, perf o rmi n g a traffic stop or dealing with hazardous substances, employees must be willing to modify their behavior according to each event’s variables.

While protocol is important, “you have to follow the signs that something is different,” Boccaccio said, adding that, for a sheriff’s deputy performing a traffic stop, the risk involved during one stop may be higher or lower than the risk involved during the next stop. A traffic stop involving a car with tinted windows at night should be assessed differently than a traffic stop during the day, since the officer’s tools won’t help him or her see into the car at night.

The same principle can be applied by an employee who helps residents at the clerk’s office. Employees should assess the threat level of each client; a resident who comes in smiling is an unlikely threat, but one who comes in with an angry glare and begins waving papers around may end up injuring someone. Understanding and awareness of the threat level associated with any given situation should allow the employee and county to control risks and prevent injuries, safety experts say.

“When I say safety, that means everybody gets home with all our fingers and toes,” Galindo said. “If someone is not going to get behind the safety culture, eventually you need to wheel them out.”

A More Formal Investigative Process Steps to Root Cause Analysis

1. Identify the injury and damage caused by the event.
2. Identify the incident that caused the injury or damage.
3. Identify the events that lead to the injury-causing incident.
4. Identify any hazardous acts or unsafe conditions that occurred during those events that could have lead to or contributed to the accident that occurred.
5. Analyze at the causal factors involved in an incident:
   • the use, availability and design or flaws of any tools or equipment being used;
   • the hazardous conditions, physical environment, personnel habits and specific tasks involved with the job at hand or the actual work environment at the time of the incident;
   • the capabilities, job knowledge, safety skills and precautions of the involved employee; and
   • the department’s housekeeping, hazard control, history of similar injuries, safety inspections and other management issues.
6. Create a detailed list of the analysis findings.
7. Determine which causes can be successfully controlled to prevent a similar accident from occurring in the future.
8. Implement solutions to those accident causes that can be controlled.