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Investigation of Causative Factors Associated with Summertime Workplace Fatalities

Executive Summary

Introduction

The apparent increase in the number of workplace fatalities during the summer months in New Zealand has raised concerns among health and safety organisations as well as the general public. An important step towards achieving a goal of 'Healthy people in safe and productive workplaces' is to first establish through statistical analysis whether the seasonal summertime peak in fatalities does, in fact, exist and, if so, what industrial sectors and geographical regions are most responsible for it. Ultimately, the Department of Labour seeks to identify the major causal factors of workplace fatalities and to establish effective preventative strategies.

This study has been carried out to investigate the perceived seasonal trend in workplace fatalities and to identify the factors that are associated with it or have a contributing effect on occurrence.

Aims

There were two principal aims of the project: The first was to confirm whether or not a seasonal trend exists for summertime workplace fatalities both for nationwide occurrence, and for industries and geographical regions; the second was to identify the major causal factors for the workplace fatalities particularly during the summer season. In order to achieve these aims the following specific objectives were identified:

  • Identify and confirm the trend of workplace fatalities over the past several years.
  • Identify and confirm the seasonal trend of workplace fatalities in terms of their occurrences nationwide, and with different industries and regions.
  • Identify the potential contributing factors for summertime fatalities, including the environmental factors, sociological factors, workplace factors, and individual/personal factors.
  • Verify contributing factors by independent evidence.
  • Develop the profiles of contributing factors for summertime workplace fatalities and identify potential intervention strategies.

Scope of the study

This study focuses on workplace fatalities in New Zealand and uses Department of Labour data only. Department of Labour provided the researchers with a database of 365 workplace fatality records from 2000 to 2005 inclusive. It was appreciated that while this data set might appear to be relatively small for the scale of analysis to be conducted, it was the most reliable data set available at the time of the study and was considered sufficient to obtain some good indications regarding the objectives of work. The fatality data set was sorted for any possible recording errors and/or record duplications. As a result, a total of 362 Department of Labour fatal incident records were identified to be usable for further detailed analysis.

Other types of incident data such as Accident Compensation Corporation (ACC) data and serious harm data were used as a reference for comparison purposes only; further detailed analysis of those data was beyond the scope of this study.

Methods

Nationwide workplace fatality data from Department of Labour databases, covering the past six years (2000 to 2005 inclusive), were statistically analysed to investigate annual and seasonal trends (by industry, region, workers' age, employment status, and other variables). The analysis included 362 fatal incidents. The data were coded using the ANZSIC (Australian New Zealand Standard Industrial Classification Codes) system for the detailed analysis by industrial sectors. It should be noted that the ANZSIC system classifies the 'Agriculture, Forestry & Fishing' as one industry sector and this report uses this as a standard classification (and sometimes 'agriculture' for short), however, Department of Labour data do not cover fishing.

Data normalisation was carried out as necessary and when a reliable denominator was available. This reduces or eliminates the potential bias of incident occurrence due to the variation of some 'risk exposure' factors, such as the change in total population of the workforce over time.

In addition to analysis of the existing data, the fatality investigation reports were reviewed in order to determine the factors that contributed to incident occurrence.

Semi structured interviews were conducted in order to identify issues that may be associated with a summer peak in work related fatalities. Interviews were held with Department of Labour investigators, advisors and engineers, and many industry experts, including representatives from Business New Zealand and the Council of Trade Unions. In addition, a very broad and detailed literature review was conducted to uncover any independent evidence in support of workplace factors, environmental factors, sociological factors, and personal/individual factors that might contribute to seasonal variations in fatality rate. Preliminary analyses of the serious harm data were conducted in order to investigate similarities in trends between the fatalities and the serious harm data sets.

Findings

This study has identified a number of findings, many of which are new and are supported by independent evidence. The key findings from the research are summarised below:

Seasonal trends of workplace fatalities:
  • While work related fatality rates fell consistently from 2001/2002 to 2004/2005, there was a significant upturn in the rate of work related fatalities during 2005/2006.
  • In the period from 2000 - 2005 the rate of workplace fatalities was higher in summer (December-February) and autumn (March-May) than throughout the rest of the year. While there appeared to be a clear peak in the number of fatalities that occurred in January the limited size of the data set meant that this could not be confirmed through statistical testing.
  • The increase in summertime work related fatalities, and to a large extent the increase in autumn work related fatalities, can essentially be explained by the seasonal variation in fatalities in the agriculture industry.
  • Within the agriculture sector, January has the highest workplace fatality rate, followed by April and October.
  • Male workers aged between 55 and 64 years have the highest incidence of work related summertime fatalities. This trend is applicable to all industries but particularly to the agriculture sector.
  • Male workers between 35 and 44 years of age are most likely to have a work-related fatal incident in the autumn. This trend is applicable to all industries, and in particular to the agriculture industry. Independent of season, older workers (aged 65 and above) are suffering the most effects from workplace fatalities.
  • The mid north region and the southern region are most affected by seasonal variations in the occurrence of work-related fatal incidents. In the northern part of New Zealand (northern and mid north regions), work-related fatal incidents involving employees tend to occur more in the summer; and in the southern part of the country (central and southern regions), work-related fatal incidents tend to occur more in the autumn.
  • There are two peak times when work-related fatal incidents are most likely to occur, one is late morning (between 10:30 and 12:30), and the other is mid afternoon (between 14:30 and 15:30). This trend is applicable for all industries, but is particularly relevant to the agriculture sector.
  • When time of day data are examined by season, work related fatal incidents in summer tend to occur in the morning time (from sunrise to noon); and work related fatal incidents in autumn tend to occur more in the afternoon (from noon to sunset).
  • Within the agriculture industry, 'Forestry and logging' is the sub-sector with the highest summertime fatality rate, followed by 'Horticulture & fruit growing'.
  • 52% of work related fatalities involved a vehicle. Vehicle rollovers accounted for 23% of total workplace fatalities investigated and nearly 40% of workplace fatalities in the agriculture sector. All-Terrain Vehicles (ATVs) were involved in only a relatively small percentage (approximately one quarter) of the vehicle rollovers recorded.
  • Human Error and procedural violations contributed to a large proportion of work related fatalities. The vast majority of human errors and violations can be prevented by improved equipment or workplace systems design. In 22% of the fatalities reported, a failure in design could be recognised, either by the investigator at the time or during subsequent review of the incident report.
Primary causes of workplace fatalities:

These 'primary causes' were recorded as being directly related to the death of the victims at the time when the incident occurred. These are the events at the moment when the incident actually happened. For the purposes of injury prevention, it is more important to understand what the main reasons (or contributing factors) were that lead to the fatalities recorded. This study has attempted to identify these contributing factors surrounding the workplace, the environment, the society and the people.

  • 52% of work related fatalities involved a vehicle.
  • Nearly 50% of the total workplace deaths from 2000 to 2005 were directly due to one of three causes:
    • The first and most frequent cause for work-related death is vehicle rollover (accounting for 23% of total workplace fatalities investigated).
    • The second cause of workplace fatalities is fall from height (accounting for 9.7% of total workplace fatalities investigated).
    • The third cause of workplace fatalities is fatal crush injuries accounting for 17% of total workplace fatalities investigated. Crush injuries involving a vehicle (non rollover) contributing 8.4%, and non vehicular contributing 8.7%.
Direct contributing factors to workplace fatalities:

Seven factors have been identified from the workplace fatality investigation reports as directly contributing to a high proportion of the fatalities that occurred during 2000 to 2005. They are:

  • Human error (>43.1%)[*]
  • Procedural violation (>27.7%)*
  • Poor/inadequate equipment/workplace design (22.1%)
  • Poor safety culture (11.7%)
  • Unsafe supervision 10.0%)
  • Lack of personal protective equipment (PPE) (8.7%)
  • Lack of experience (7.69%).

The research indicates that 'human error' and 'procedural violations' have contributed to nearly 70% of work-related fatalities over the past six years.

It is critical that the term 'human error' is properly understood. Identifying 'human error' allows us to ask why a person's decisions and actions made sense to them at the time. It should be seen as a symptom of other things that are wrong deeper in the work system. 'Human error' is not simply identifying the mistakes people make.

In the report, 'human error' has been used to classify a variety of incidents where memory lapses, slips in behaviour or mistakes (e.g. misjudgements, misinterpretations, distraction errors, silly decisions, inadequate knowledge) have led to a fatality.

These slips, lapses and mistakes are only one part of the cause of injuries. A memory lapse may have occurred because a person was asked to do a task they had not done for some time. A slip in behaviour could have occurred as a result of fatigue. A mistake, such as a misjudgement, may have been made because the person making a decision was given incorrect information to base a decision on. A procedural violation could have occurred because of pressure to complete a task, resulting in a risky shortcut being taken.

The vast majority of human errors and violations can be avoided, or at least minimised. Consequently this finding demonstrates an area where significant improvements can be made. The research points to areas such as workplace systems design, training and workplace culture, where improvements could make a huge difference to incident, injury and fatality rates.

Other workplace factors likely to contribute to increased risk of work related fatalities:
  • Hours worked per day. (Applicable for all industries, and in particular for 'Dairy & cattle farming' within the agriculture industry).
  • Lack of recovery from fatigue. (Applicable for all industries, in particular for 'Agriculture, Forestry & Fishing', and for 'Construction').
  • Tight timescales/deadlines. (Applicable for 'Horticulture & fruit growing' sector within the agriculture industry).
  • Staffing levels. (Applicable for all industries, particularly for 'Horticulture & fruit growing' sector within the agriculture industry).
  • Amount of casual labour. (Applicable for all industries, particularly for 'Horticulture & fruit growing' sector within the agriculture industry).
The following environmental factors are likely to contribute to increased risk of work related fatalities:
  • Rain/wet days. (Applicable for all industries, particularly for the agriculture industry).
  • High temperatures. (Applicable for all industries, particularly for agriculture, 'Cultural, recreational & other services', and 'Manufacturing').
  • Longer hours of sunshine. (Applicable for agriculture, 'Cultural, recreational & other services', 'Manufacturing', and 'Transport & storage').
The following sociological factors are likely to contribute to increased risk of work related fatalities:
  • Increased consumption of alcohol. (Applicable for all industries, in particular 'Agriculture, Forestry & Fishing').
  • More tourists (and temporary workers). (Applicable for agriculture, 'Construction', 'Cultural, recreational & other services', and 'Transport & storage').
  • School holidays and public holidays. (Applicable for Agriculture, and for Manufacturing).
  • Daylight saving.
The following individual factors are also likely to contribute to increase risk of work related fatalities:
  • Gender (male workers, employees, and self-employed). (Applicable for all industries).
  • From the age, gender, industry, season, and time of day data combined it may be postulated that:
    • Male workers working in the agriculture industry, aged between 55 and 64, are most likely to have a fatal incident in their workplace during the summertime between sunrise and noon.
    • Male workers working in the agriculture industry, aged between 35 and 44, are most likely to have a work-related fatal incident during the autumn between noon and sunset.
  • Return to work after a long holiday[1]. (Applicable for all industries).

The Department of Labour's next steps

This study is the first step to improving the Department of Labour's understanding of the reasons behind workplace fatalities. This research highlights some initial areas of workplace health and safety practice in New Zealand which can be improved. The Department of Labour intends to take a positive approach to the findings, focussing on ways to raise awareness and promote direct action to reduce workplace fatalities.

The Department of Labour will focus on the following approaches to deliver information and guidance.

Emphasise the benefits

Focus on actions that will reduce the work toll. Identify the benefits of safe work practices and demonstrate that they outweigh the perceived costs.

Deliver messages locally

Awareness-raising will be accompanied by realistic and practical advice on how to improve health and safety in New Zealand's workplaces. Messages will be targeted and personalised to specific at-risk groups. Small-scale, low-key safety initiatives locally delivered will be an effective part of personalising safety messages.

Work together

The Department will develop collaborative approaches and partnerships for the delivery of messages. We will actively seek the support of others, industry representatives, business organisations, unions, and businesses to promote awareness and action in workplaces and the wider community.

[*] In an additional 16% of cases, an unsafe behaviour was identified that could have been either a human error or a procedural violation

[1] E.g. for a period of more than one week.