Robert Pater, SSA/MoveSMART Director
Professional Safety (February 1996): 20-23

If you are like many safety professionals, you already have too long a list of frustrations that just won't go away. Besides the ones you commonly hear about--regulations, organizational dysfunction, mounting workload, unrealistic expectations--add "accident repeaters." Even with an otherwise strong safety record, it seems that a small percentage of employees account for a disproportionate share of injuries. These "frequent flyers," as one Fortune 50 company calls repeaters, seem immune to the limited arsenal of interventions managers have traditionally employed, ranging from firing, threats, discipline or forced counseling. For many organizations, firing repeaters doesn't work due to legal, contractual or other reasons; similarly, screening them out of the hiring process may run you afoul of ADA.

But, as Stevie Wonder sings, "problems have solutions." Of course, he--and I--don't promise an effortless pill that solves repeater headaches. But a systematic approach can prevent initial incidents from turning into repeat problems, interrupt continuation of accident clusters, and break the chain of long-standing accident patterns. In addition, in this day of lots to do and limited time and resources, it is possible to craft such a system to simultaneously strengthen organizational safety culture.

The Problem

Although there has been little recent validated research in the field on "accident repeaters," the concept of repeat accidents has been discussed in the literature for some time. (1) This phenomena has also been described as "accident propensity," "accident magnetism" or "accident proneness." Sass and Cook suggest "The 'accident proneness' thesis has been with us since the early 1900's." (2)

The concept of accident proneness, which implies blame for repeat accidents on workers' lack of awareness, skills or experience, "has no empirical foundations" according to Sass and Cook.

But many safety professionals believe accident repetition--a series of near-misses, re-injuries or otherwise unrelated accidents that occur to the same person--is a real phenomena. Anecdotally, many safety professionals have confidentially suggested a Pareto distribution at work: that 20% of employees account for 80% of all accidents. The safety director of a large aluminum smelter reports a sharper phenomena, "approximately 30% of our accidents are caused by 3% of our workers."

Further anecdotal information shows that, while some few workers have a chain of accidents for a period of time, they seem to move out of this "repeater" pattern--and others move in to account for multiple incidents.

Schulzinger (3) states "The evidence indicates that, when the period of observation is sufficiently long, the 'small group of persons who are responsible for most of the accidents' is essentially a shifting group of individuals falling in and out of the group."

If you truly wish to break the chain, rather than just moving some current "repeaters" out of the multiple accident category, begin by shifting your paradigm from "accident repeaters" that focuses on the negativity of injured employees to that of "accident repetition." In the Accident Repetition (or Multiple Incident) model, emphases are on perceiving the three factors affecting repetition, on shared responsibility for safety and change and on future prevention rather than past blame.

Words have power to set attitudes that in turn translate into behavior. Educate people that repetition, not "accident repeaters" is one of your concerns; that select people are not natively clumsy; that anyone can learn to improve. Often coworkers are the worst taunters of "accident repeaters." Help everyone support those who've been hurt, not make things worse (or set negative attitudes that "Joe is an accident waiting to happen.")

Traditional approaches for dealing with "accident repeaters" have ranged from:

1. Solving the problem in advance--somehow setting up screening procedures to prevent hiring those destined to have repeat accidents.
2. With already existing repeaters, using some kind of threat or discipline--"You better not have any more of these occurrences!"
3. Also with existing repeaters, a counseling intervention--"What is going on in your life that leads to these incidents?"
4. Giving up in frustration--"There's nothing we can do about it."

Unfortunately, each of these approaches have been somewhat unsuccessful. Some organizations find it legally or contractually difficult to screen out repeaters. In addition, they often don't have effective criteria that enables them to determine in advance who might be prone to repeat accidents.

Threat, discipline or counseling interventions seem to work in some companies for a short time but have the shortcoming of labeling workers as deficient. This often results in the negative side effects of reduced employee morale. And like the myth of Pygmalion, it may actually help create the self-fulfilling prophecy of repeat incidents. Further, thinking of a worker as the source of the problem makes it less likely the organization will search for other, more salient sources of accident repetition. As Sass and Crook stated, "Blaming the victims for accidents is...fruitless, since it does not provide impetus for the elimination of hazardous conditions." (4)

Ironically, some safety professionals have suggested that accident repetition is somehow related to lack of involvement on the employee's part. Seeking to involve workers seems a natural part of breaking the chain of repeat accidents. But it seems inherently difficult to invite involvement (forcing involvement is self-defeating) while thinking of the employee as messed up.

Experience shows involving everyone in preventing repeat incidents can make a major difference. Never give up. The sources of accident repetition can be controlled--if you start by looking for them in the right places. Here are some approaches, strategies and techniques that have helped reduce repeat accidents in a range of organizations.

Different Kinds of Repeat Incidents

Start by identifying different kinds of "repeaters." We have been able to distinguish 5 kinds:

1. Exposure--workers who have a higher degree of potential risks associated with their jobs. An example might be an employee who's job requires repeated heavy lifting.
2. Cumulative--employees who experience wear down from cumulative trauma. Often physical job stresses (or off the job activities) lead to progressive illnesses or reports--each of which may be reported as separate incidents.
3. Re-injury--sometimes an injured part of the body is weakened. This can lead to reinjury of the same area, to the same or a more acute degree.
4. Referred injury--Injury in one part of the body can lead to problems in another area. For example, a foot injury can affect how weight is distributed over the foot when walking, which in turn can lead to a change of gait and potential knee pain. Also, many people with lower back pain have discovered they modify their posture in an attempt to alleviate pain; this shift in spinal alignment can lead to neck pain.
5. "Random"--where there are apparently no patterns detectable in accident repetition.

Profiles of "Repeaters"

Our interviews and work with companies such as Anheuser-Busch, Schlumberger, Alcoa and many others suggest employees who have repeat injuries don't come in only one texture:

• Proud, tough repeaters often don't report "minor" pains and pride themselves on working through difficulties.
• Some work harder than others and therefore may be at risk of greater physical stressors.
• Fatigued workers may endure longer shifts, increasing workloads or forced overtime.
• Distracted employees may have work or personal concerns that reduce their safety awareness.
• Uninvolved people may not pay attention to safety procedures or care about doing things the safest way.
• Unappreciated workers are often angry and their attention is expended on dwelling on what they should rightly be receiving.
• Some don't report all or some incidents. This may be due to pressure they receive from their peers, supervisors or managers. Some organizations report that safety incentive award systems may have the unforeseen result of reducing accident reports. Not reporting means hazards are still working in the system, like a cobra lurking undercover.
• Some are angry at their supervisors and may have accidents because to some degree they wish to make their supervisors look bad. It is critical to define in advance what an incident is prior to determining who are "repeaters."
• Some employees are looking to bail out of work to receive workers compensation payment. I suggest this percentage of employees is often overly focused on by managers and is a smaller group than most think. The safety manager of a municipal school board says of repeaters, "the number of abusers is very few."

A New Paradigm

If accident repetition only happened to disgruntled or uninvolved employees, there might be more merit to the 'accident repeater' concept. If you change your paradigm to accident repetition, rather than thinking of accident repeaters, you will be able to consider and adjust to the three factors that propagate the chain of accidents:

Human Factors

• Prior injuries may lead to future ones (cumulative or weak spot).
• Physical condition. Being out of shape can make sprains or strains more likely. Slower reaction times may make it more difficult to recover from changing risks.
• Use of medication that has side effects on balance, judgment or reaction time (these may include common medications sold over the counter).
• Body mechanics that leave a person poorly balanced, overextended or not able to effectively apply strength. For example, working with your elbows abducted more than 10° from the body ("winged") greatly reduces strength and dexterity, while increasing the likelihood of upper limb cumulative trauma. It's amazing how infrequently people work within the natural design mechanics of their body.
• Learning style. Some people learn slower than others. Some learn best by doing (kinesthetic learners), yet receive training based upon lecture, which is most effective for auditory learners.
• Pace. Some work faster than others. This may leave them more vulnerable to cumulative or acute injuries.
• Self-image. If a person sees herself as accident prone, she may be less likely to make needed adjustments to avoid repetitive injuries, taking a fatalistic view of her safety.
• Age. As we age, there are normal effects on our bodies. Our need for illumination increases, ability to tolerate heat lessens, muscle strength lowers. Not making intelligent accommodations will put a person at greater risk of injury. But it is possible to overcome most of these effects through a combination of awareness and planning.
• Change. Experiencing a certain degree of life changes may be associated with injuries. Levenson and Hirschfeld wrote, "In addition to experiencing more life change than the average person,...the industrially injured workers were having increasing difficulties in health, work, social, and financial areas." (5)
• Emotional disruption. Depression may be associated with injuries in that strong emotional states may overshadow risk awareness or adversely affect motivation to prevent injury. (6)
• Stress. Mental stress narrows attention span, resulting in tunnel vision. This adversely affects awareness and may be a contributing factor in accidents.

Task Factors

• Job design. Jobs that are overly repetitive, forceful or static may lead to increased concentration of forces on smaller parts of the body more prone to cumulative breakdown.
• Workstation layout. Distance of the workstation from the person affects the amount of force he or she must apply to do a task. Even a slight increase in distance of a task from a workers center of gravity is a major factor in back injuries.
• Lighting. Illumination adequate for a 22 year old worker may be inadequate for that same worker who has been on the job for 20 years. According to the National Safety Council, an average 65 year old needs fifteen times more illumination to see the same object with clarity as an eight year old.
• Exposure. Some have jobs with greater environmental risks.
• Climate. Exposure to the elements can also make a job more hazardous. These need not be outside jobs. They may include: working at a loading dock, crossing a leaf-strewn parking lot or frequently walking between buildings also qualifies here.
• Pacing. For example, some studies suggest machine-paced jobs may be associated with greater incidence of lower back pain.

Organizational Factors

• Management expectations about reporting injuries play a strong role in whether non-recordable incidents and near-misses are utilized to engineer or train out potential repeat injury risks.
• Medical management. In our experience, medical management frequently is a weak spot in the prevention of multiple incidents. In fact, it is often part of the problem. Poor diagnosis of early cumulative trauma symptoms often lead to expensive re-injuries. Not knowing real job tasks may lead to poor alternative or "light"duty recommendations. For example, workers with lower back pain are frequently provided seated "light duty" jobs, even though lumbar spine pressure is typically worsened by sitting.
• Training. Inadequate training handicaps workers attempting to do a job safely and efficiently. New employees who are not provided strong initial training pattern their work behaviors after a more experienced peer. Unfortunately, this "model" may be using poor body mechanics themselves or making adjustments to a prior injury he has but the onlooker doesn't.
• Personal Protective Equipment. Is equipment provided in appropriate sizes for workers? In sufficient quantities? Near enough to their tasks so the PPE will be easy to use?
• Level of staffing. In these challenging times, employees are often working thin and hard. Inadequate staffing levels may make it difficult for employees to recover from physical work stresses and lead to a series of injuries.
• Accident investigation. Is your organization's accident investigation system one of witch-hunts and war-fare? Are people tacitly blamed for any accident so they become naturally defensive about honestly exploring factors that could prevent future injuries to themselves or others?
• Regulations. What internal procedures and external standards affect jobs? How effectively are these communicated to employees? Are they explained so workers can understand without minimum defensiveness?
• Stress. How well does the organization help employees manage stress and change? Is stress deemed as a non-issue or sign of weakness that employees are expected to ignore? Is an Employee Assistance Program provided?

Helping Current "Repeaters"

Certainly, if you have a group of people currently caught into the chain of repeat incidents, it is critical to have a plan to help them.

1. Examine the real problem: ask "why?" Examine your assumptions about repeat incidents. Determine three kinds of contributing factors. Interview those who have had repeat incidents and solicit their expertise. Interview supervisors and managers for their opinions on causes and solutions to accident repetition. Ask your Employee Assistance Program staff for any trends they have spotted regarding causes of injuries. Involve your Safety Committee in planning possible interventions so they fit your culture and reduce resistance to change.
2. Define your targets. For example, some organizations define repeaters as those who have had three lost-time accidents or medical claims within a one year period. Other companies focus on employee in their top 10% of repeat incidents.
3. Plan Your Intervention. Decide which model you will use with "repeaters"--a counseling model, one that focuses on discipline or an education and training model. I recommend the last approach for lasting positive results, both with the current "repeaters" and their peers (who in their own ways will be monitoring what you are doing). Training and education should de-victimize and de-stigmatize "repeaters," help them understand different factors in multiple incidents, solicit their opinions and teach skills and techniques for assuming greater personal control of their own safety. Experience has shown a mix of attitude control, understanding multiple contributing factors in accidents, practical body mechanics and stress management can result in participants being ready to make a working plan that will help them get off the repetition merry-go-round. Initially pilot the program with a small group of "repeaters." It is critical they enjoy it and recommend the program to others.
4. Sustain it. Monitor and evaluate the pilot program to determine its effectiveness. Find creative methods for reinforcing the program in the attitudes and behaviors of participants. You might consider volunteer past "repeaters" become trained to help future "repeaters."

Organizational Strategies for Breaking the Chain

Don't stop there.

Make sure the Repetition-not-Repeater message is communicated to management and employee leadership throughout your organization. Help them take their fair share of the responsibility in multiple incidents.

Train everyone in the causes of accidents and effective methods for accident prevention. For example, no matter their condition, everyone can quickly learn simple techniques for improving balance and coordination.

Have positive accident investigation that is prevention-, not blame-, oriented. A good idea is to have accidents investigated by an employee-supervisor team.

Help workers and managers recognize signs of on-the-job stress. Supervisors can be trained to develop their antennae as the first line of organizational defense. Provide support and, above all, a vehicle for honestly listening to employee concerns. This may take the form of an employee assistance program.

Focus on both attitude and behavior.

Strengthen your medical management system. Assess its strengths and weaknesses, show health care professionals the range of real worker tasks and working conditions, set their expectations about preventing the different kinds of repeat incidents and continue to strengthen your relationship with them. Be sure to utilize them for ongoing feedback on your safety system in general and in accidents that may be "repeat" in nature (you can easily develop a feedback system where they can advise you and still maintain patient confidentiality).

Design tools and workstations to reduce cumulative forces and to help workers "un-concentrate" them--spread these stressors to larger muscle groups that are less likely to break down.

Think of providing your organization a range of options. Just as there is no one kind of "repeater," company cultures also vary greatly. Experiment with different strategies to see what might work for your organization. Determine if an outside source might be helpful or if you have already existing internal resources to spark needed changes.

Above all, have high expectations. Real change is happening right now in companies throughout the world. You don't have to settle for frustrating repeat accidents. By taking strategic control, you can help break the chain of multiple incidents.

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NOTES

1. Newbold, E.M., "Practical application of the statistics of repeated events, particularly to industrial accidents," Journal of the Royal Statistical Society 90 (1927).
2. Sass, R. and Crook, G., "Accident proneness: science or non-science?" International Journal of Health Services 11:2 (1981).
3. Schulzinger, M.S., "The Accident syndrome." Springfield, IL: Charles C. Thomas, 1956.
4. Sass, R. and Crook, G.
5. Levenson, H. and Hirschfeld, M., "Industrial accidents and recent life changes," Journal of Occupational Medicine 22:1 (January 1980).
6. Hirschfeld A. and Behan, R., "The Accident Process," Journal of the American Medical Association 186 (1963).