Exploring the organisational preconditions for occupational accidents in food industry: A qualitative approach

Safety Science 45 (2007) 355–371 www.elsevier.com/locate/ssci

Exploring the organisational preconditions for occupational accidents in food industry: A qualitative approach Christina Stave *, Marianne To¨rner National Institute for Working Life, Department of People, Technology, Organisation, Box 8850, S-402 72 Go¨teborg, Sweden Received 13 October 2005; received in revised form 22 May 2006; accepted 6 July 2006

Abstract The continuing high frequency of occupational accidents in the Swedish food industry calls for new approaches to better understand the underlying factors. In the present study, 54 accidents involving hand injuries were investigated from the operators’ perspective, to explore the organisational preconditions. In-depth interviews were conducted with operators and their supervisors, and 24 of these interviews were analysed using the grounded theory method. The core category ‘safety as a process’ was identified encompassing the perception of the process of the accident at operative level and organisational preconditions that increased the risk of occupational accidents. These preconditions were open factors: deficiencies in technical/physical environment and work organisation; and concealed factors: insufficient communication and learning, a high level of responsibility in combination with low control, conflicting goals and a gap between procedures and practice. These preconditions lead to risk acceptance, resignation towards improved safety and normalisation of risk. Through the analysis a five-step hypothesis was empirically generated. Ó 2006 Elsevier Ltd. All rights reserved. Keywords: Occupational safety; Accident; Organisational factors; Injury risk; Food industry; Qualitative analysis

*

Corresponding author. Tel.: +46 31 501642; fax: +46 31 501610. E-mail address: [email protected] (C. Stave).

0925-7535/$ - see front matter Ó 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.ssci.2006.07.001

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1. Introduction The food industry is a branch in which there is high risk exposure, e.g. through the use of sharp tools and working in close contact with machines, and the frequency of occupational accidents is high. Accidents reported to the Swedish Labour Market No-fault Liability Insurance (AFA-TFA) in 2001 showed an annual frequency of accidents causing long-term (>30 days) sick leave or permanent disability of 6.3 per 1000 food industry employees (Forsblom et al., 2005). This may be compared to the overall frequency of accidents of that severity of 2.4 among Swedish workers for the same year. Attempts to increase efficiency have led to the creation of larger and less labour-intensive units. These changes affect organisational practices and work systems and can if not properly planned have a negative effect on safety. The present study investigated three sub-branches of the food industry: red meat, bakery and dairy products. One large company from each participated. The subbranches were selected on the basis of their high accident frequency, even by food industry standards. The companies studied encompassed a wide range of tasks, from manual butchers’ tasks, production/packing along an assembly line, and maintenance and repair work to warehouse work and transportation. The degree of automation varied depending on the product, as did the complexity of individual operators’ work. There were differences in the operators’ educational requirements but pay was generally low. In a parallel study Willquist (2003) found that the participating companies addressed safety primarily from a technical perspective, using passive risk control in the form of physical barriers or protective equipment, and that the organisations lacked a systems perspective on safety. The engineering approach to safety emphasises the development of reliability and systems modelling, with only limited attention to the complexities of the human issues involved (Pidgeon, 1998). Since the technical approach has proved to be insufficient, the interaction of humans in a socio-technical context needs to be further explored by means of a social or organisational psychological approach, aiming at detecting preconditions within the organisation that result in an unsafe working environment or unsafe actions. Organisational factors influencing accidents are more often studied in organisations where the consequences may affect third parties or larger groups rather than individual workers. Relatively little research has focused on actors in interactive practice at specific sites (Summerton and Berner, 2003). ‘‘Operational safety is not captured as a set of rules or procedures, of simple empirically observable properties, of externally imposed training or management skills, or of decomposable cognitive or behavioural frames. . . how to operate safely, is a property of the interactions, rituals, and myths of the social structure and the beliefs of the entire organisation, or at least of a large segment of it.’’ (Rochlin, 1999, p. 1558). The focus should here be on environment and organisation and not on individual factors, i.e. on a meso- rather than a micro-level. 1.1. Aim The aim was to explore the organisational preconditions for occupational accidents from the operator’s perspective, complemented by the supervisor’s view, in order to find general patterns across branches, tasks and individuals. The goal was to understand

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how accidents, risks and safety are constructed, interpreted, handled and communicated by actors in everyday practice. A deeper understanding was sought by exploring mesofactors from a micro-perspective, leading to empirically grounded hypotheses that would create a basis for further investigation. This study defines an accident as an event resulting in an injury. The term ‘accident’ is deliberately chosen since the focus is on the event and the conditions leading up to it, rather than on the resulting injury as such. Communication is here used as a general term for exchanging information. 2. Method Empirical grounding was of importance in this study, exploring practice and perceptions and from these moving to theories. In-depth personal interviews were chosen due to the sensitivity and complexity of the subject discussed. Analysing the story from the actors’ point of view and proximity to the operators’ voice was considered essential since new information, new relations or new meanings were sought for in already known facts. The interviews with the injured persons and their supervisors were qualitatively analysed, using the grounded theory method (Glaser and Strauss, 1967). It allows investigation of micro- to meso-level issues, processes concerning individuals as well as social processes in the socio-technical environment. Grounded theory produces theoretical models of individuals’ perspectives of a given phenomenon and the strategies they use to resolve or cope with the problem in a distinct and bounded context. The method is based on continuous comparison of theoretical constructs with raw data. Data collection and analysis, theoretical and simultaneous sampling, memo writing and analytical techniques lead progressively to more abstract analytical levels (Dellve et al., 2002). 2.1. Subjects The study was based on the approximately 20 most recent hand and lower arm accidents that had occurred in each of the three participating food-producing companies (red meat, bakery and dairy products, respectively). The study period was 1999–2001. The accidents had all been reported to the national insurance system as an occupational accident causing a hand injury, resulting in absence from work (44% >7 days). Eighteen injured operators from each company and their supervisors at the time of the accident participated in a personal interview. Those who dropped out did so for practical reasons and production demands. In all, 108 interviews were conducted representing 54 accidents. The mean age of the 54 injured interviews was 40 years (19–61 years), the mean job tenure was 12 years and 41% of the injured workers were women. From this initial sample (n = 54), a stepwise strategic sampling of ten accidents (20 interviews) was made in order to compare the narratives of operators of as much diversity as possible (different sub-branches, tasks, machine or tool interaction, gender, age, work experience and severity of the injury). Two additional accidents were thereafter theoretically selected, bringing the total to 12 (five accidents from the red meat company, four from the bakery company and three from the dairy company). The selection of interviews was made gradually and simultaneously with analysis until saturation was reached, i.e. when new information did not alter the results, in accordance with the

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grounded theory method (Dellve et al., 2002). The remaining 84 interviews provided a body of information that contributed to confirming or rejecting new data in reaching saturation. The mean age of the 12 interviewed operators selected for in-depth analysis was 41 years (28–60 years) and the mean job tenure 12 years. 50% of these operators were women. These 12 interviews, as well as the corresponding 12 supervisor interviews, were audio taped, transcribed verbatim and coded. 2.2. Data collection – the in-depth interviews The interviews lasted for approximately 45 min and were carried out between May and October 2001 at the companies at which the operators worked, using the union’s or the health department’s offices. None of the 12 operators were interviewed more than two years after the accident. The operator was interviewed first, and then the supervisor, in order to obtain a complementary viewpoint and additional information, and to counterbalance operator hindsight self-serving bias. The interview guide covered the following topics: – Perception and experience of the accident including both pre and post events and ideas about the underlying causes of the accident. – Conditions related to risks and safety. During the interview, the accident, in its context, acted as a concrete event through which the person could gain access to his/her own perceptions of situational and organisational factors. The interview started with questions on the place, date and time of the accident in order to assist recall. The first open thematic question was: ‘‘Tell me as much as you can about the accident, starting just before it happened’’. Follow-up questions were posed and drawings were made to complement and facilitate the dialogue. The second thematic question was: ‘‘What do you think was the underlying cause of the accident?’’ The dialogue now circled around direct and indirect factors affecting the accident, exploring the complexity and focusing on the process but avoiding the issue of blame. Finally, more general questions were posed about risks, safety and the work environment. The interview ended with a question on whether the interviewee had something to add. Efforts were made to create trust, since the question of guilt and failure may easily arise. 2.3. Analysis of data Data analysis was carried out in two ways: line-by-line coding and overview analysis. Quality was strived for by closely adhering to the method as described by Dellve et al. (2002). The purpose was to ensure that the categories identified fitted the problem studied and that the theories were able to explain, predict and interpret actions related to the phenomenon (Glaser, 1978). Credibility (internal validity) was ensured through the constant comparison of different aspects of data throughout the analysis process, and the theoretical model was considered valid when categories repeatedly emerged, were saturated and validated in data (Lincoln and Guba, 1985). The informants were guaranteed

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anonymity in data presentation. Two persons independently analysed the first interview, starting the process of categorisation. The findings were evaluated during the analysis process by means of memos and discussions with a co-researcher. In order to avoid pre-theoretical assumptions, the literature review for this study was made after the data analysis. Confirmability (objectivity) is demonstrated by the direct quotations in the material. Transferability (external validity) was provided through the rich description, offering depth rather than breadth of information on the relevant phenomena. The fact that the analysis was done in three companies representing different branches of the food industry further enhances transferability. 3. Results A core category ‘safety as a process’ was identified encompassing two interrelated narratives linked to the two thematic questions. The first was the perception of the accident process (AP) at operative level. The second was organisational preconditions (OP) of a strategic character. Organisational preconditions affected the workers’ perception of the accident process and led to risk acceptance, resignation and overconfidence in their own ability. This was the fundament of ‘normal’ in which context the accidents occurred and safety was constructed and performed. The organisational preconditions consisted of open organisational preconditions (OOP) and concealed organisational preconditions (COP). From the process and preconditions a five-step hypothesis was empirically generated. Since the aim was to analyse the preconditions from the operators’ perspective, the hypotheses generated were mainly based on these interviews. However, in most cases the supervisors confirmed the operators’ stories but described the underlying preconditions from a broader organisational perspective. 3.1. The perception of the accident process (AP) The injury occurred at the interface between the operator and the physical environment. The organisational environment was manifested in part in the design of the physical environment, but also in rules, goals and culture. Disturbances that propagated through the chain of production affected the choice of working practices. These conditions were the standard, and were conditions to which the operator more or less adapted. At times, several simultaneous deficiencies had to be compensated for. This complexity was something the operator had learned to accept as normal. If the operator could foresee the risk, he/she attributed the accident partly to him/herself. The perceived accident process consisted of three steps: 1) before the accident everything was as usual, 2) the accident occurred without warning and 3) the operators’ reasoning about possibilities to foresee the accident and attribution of responsibility. (For greater detail, see Appendix A, Table 1.) 3.2. Organisational preconditions (OP) Organisational preconditions were the underlying factors enhancing the risk of an accident. They consisted of open and concealed factors. The description from open to concealed should be seen as a gradual difference from concrete and physical factors to more overriding and abstract factors.

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3.2.1. Open organisational preconditions (OOP) Open organisational preconditions were deficiencies in (1) technical/physical systems and (2) organisation of work. The technical deficiencies encompassed the following factors: uncontrollable and inflexible technology, problems related to material and machines, dysfunctional premises, poor technical design, poor maintenance and constant repairs. The open preconditions concerning work organisation encompassed the following factors: production disturbances, high demands on concentration, high work pace and demands of the work, poor individual adjustment and production efficiency. These factors could be observed and were described by the operators as having a direct influence on the accident. They were considered a part of the normal working environment. (For greater detail, see Appendix A, Tables 2 and 3.) 3.2.2. Concealed organisational preconditions (COP) Concealed organisational preconditions were (1) insufficient communication and learning, (2) high responsibility but low control leading to stress, (3) incompatible conditions. These factors are embedded constructs of how risks, accidents and safety are perceived and handled, as well as how the work should be carried out and what should take priority. The operators found these factors less obvious and they influenced the understanding of and reasoning about underlying causes of the accidents in a more indirect way. (For greater detail, see Appendix A, Tables 4–6.) 3.3. Effects – risk acceptance, normalisation and resignation toward improved safety Experienced operators were aware of risks in the working environment. They accepted the fact that the environment was full of risks and that they had to be cautious at all times. Injuries were sometimes even accepted, as was a need for fearlessness. ‘‘The first day after an injury you are careful but it fades away after a week and you are back working at full speed again. It depends on your mental strength whether or not you get frightened’’. ‘‘The ones who are careless get shorter fingertips but that’s really no big deal’’. Several operators said that their accident could happen again. In many cases the company had not taken any measures, unless it was possible to mend or to construct a protective device. Operators became resigned to the fact that the only possibility to improve safety was to be more careful and try harder. This risk acceptance was a part of the ‘normal’ that preceded the accidents. A hypothesis in five steps was empirically generated from the open and concealed organisational preconditions for accidents related to the accident process. H1. The operator compensates for technical and organisational limitations/deficiencies at the point when the accident appears without warning, and the operator is injured. H2. Risks are covered and sustained by insufficient learning and communication. H3. Risks that are not detected or attended to have to be handled by the operator, who has little possibility to exert effective control. H4. There are conflicting goals and differences between procedure and practice. H5. Organisational preconditions lead to risk acceptance, resignation and normalisation of risks.

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AP Accident process

AP1 pre-injury “ There was nothing unusual ”

AP2 injury “It all happened so fast”

AP3 post-injury “Could not foresee the risk” or /and “Should have foreseen the risk”

OP Organisational preconditions OOP1-2 Technical & organizational systems

COP1 Communication & learning

COP2 Control & responsibility

COP3 Conflicting goals procedure/practice

Risk acceptance, resignation toward improved safety and normalisation of risks

Fig. 1. ‘Safety as a process’ presented as a loop model of the accident process, the influencing organisational preconditions and effects on operator attitudes. AP1-2 encompasses the conditions perceived as ‘normal’, in which the accident occurred without warning. Organisational preconditions (OP) were considered as open (OOP1–2) and concealed (COP1–3). The preconditions influence the workers’ perception of the accident process AP3 and lead to risk acceptance and resignation, in turn influencing the construction of normality.

Fig. 1 illustrates the core category ‘safety as a process’ represented by a loop model, showing how organisational preconditions were found to relate to the accident process, as perceived by the operators, and the effects of this on operator attitudes. 4. Discussion The grounded theory approach made it possible to discover the open or direct as well as the more concealed or indirect organisational preconditions for accidents. In grounded theory the researcher makes an interpretational analysis, not strictly seeking generalisations but aiming to reveal underlying principles that are likely to apply to similar situations (Tesch, 1990). A reader not entirely familiar with the situation under study may well feel him/herself at the mercy of the analyst. The provision of a sufficient amount of raw data must however be balanced with the need to avoid a text laden with context information and citations, which can distance the reader from the condensed conceptual content of the material. Nonetheless, it should be kept in mind that the grounded theory method is explorative, generating hypotheses to test in further research, as is the case in the present study. The issue of recall may be raised, since in some cases two years had elapsed between accident and interview. Recollection was found to be good, but Dekker (2002) warns for hindsight bias. The sense making of past performance tempts us to simplify and correct the reconstruction and to judge people for what they did not do but should have done. It is thus important to identify people’s goals, focus of attention and knowledge active at the time in order to understand why people did or did not do at the time (Dekker, 2002). The purpose in this study was not to objectively investigate accidents but to use the concrete experienced event to enable the interviewee to gain access to his/her perceptions and evaluations of preconditions influencing risk.

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The following discussion relates the five steps of the empirically generated hypothesis to relevant theories and research. H1. The operator compensates for technical and organisational limitations/deficiencies at the point when the accident appears without warning, and the operator is injured. Although efforts were made to control the technical aspects of safety, this was not sufficient to prevent accidents. Consequences of the constant striving for efficient and flexible production may have resulted in preconditions in conflict with safety, for example reduced redundancy by cutting margins, increased work load and speed, less time for reflection and learning, which may lead to production disturbances and a priority of production (Rasmussen, 1997). The operator did not notice the risks, and one of the major problems was staying alert or maintaining control. Do¨o¨s and Backstro¨m (2003) found that the machine normally provides feedback, and the operator usually knows what to expect, so he/she may not be fully alert to the possibility of an unexpected accident. The operator detected and saw the accident as it occurred, i.e. in the man-machine interaction, but risks were embedded in the production process and the organisation. Reason (1990, p. 173) stated that ‘‘operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions’’. Do¨o¨s et al. (2004) recommended that latent failures should be managed at the levels of the work team and the organisation, and not as a problem of any single individual. Feyer et al. (1997) confirmed that the work organisation provided the circumstances in which latent events may lead to an accident. However, the weakness of the system does not become clear when the accident occurs, and the operator’s action is seen as the cause of the accident. If the operator could foresee the risk, he/she attributed the accident partly to him/herself. This was a finding that contradicts the theory of defensive attribution bias (Burger, 1981), which is the tendency of individuals to attribute the causes to external factors. The present internal attribution may be related to a need to affirm personal control, to sustain a belief that further accidents could thus be avoided (Hale and Glendon, 1987). These findings may also indicate an organisational culture where people are held responsible for foreseeable consequences of their actions, even if these were not intended. Giving information about previous accidents and risks influences attribution towards personal responsibility and acts as confirmation of foreseeability (Hale and Glendon, 1987). Present results also indicate that operators do not expect to be able to influence their surrounding work conditions. H2. Risks are covered and sustained by insufficient learning and communication. Learning is a key component of strategies to improve safety (Do¨o¨s and Backstro¨m, 2003; Pidgeon, 1998; Rochlin, 1999). The important goal of learning from incidents and accidents is a part of the integrated safety system (Pidgeon, 1998). The present results indicated that the companies in this study needed a better integrated system of organisational learning, better systems for retrieving information and analysing accidents, and a shift in focus from individual to organisational factors. Safety learning at the operative level could be more effectively incorporated and controlled, not only in introductory programmes but

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also on an ongoing basis. In developing skill, the operator may also learn unsafe behaviour, for example taking shortcuts. One way to promote safety is individual experimental learning through reflective observations, an ongoing interaction between action and reflection (Kolb, 1984). Pidgeon (1998) also identified organisational learning as reflection on practice in the form of monitoring, incident analysis and feedback systems. Safety management in the present organisations was however mainly practised through the principle of control. Do¨o¨s and Backstro¨m (2003) argue that participation and learning should complement internal control. Communication is the foundation of everyday learning and a necessity in an ongoing strategy for safety improvement. Poor communication of safety information affected the risk awareness, and risks that could have been detected and reflected upon were not shared. Social feedback encouraging safe behaviour can be a way to modify behaviour (Saari, 1990). Organisational culture may attribute risks and errors to the individual operator, which may result in little motivation to report incidents. It is of importance to avoid blame storming, but not to such a degree as to exclude a discussion of and reflection on work practices. The need for both learning and accountability increases simultaneously with the risk, but using sanctions to encourage safe behaviour may result in poor or incomplete information (Pidgeon, 1998). Parker et al. (2001) found that communication quality (sufficient, explanatory, and feeling free to speak your mind) was positively associated with safe working. When operators are excluded from playing an active role, vital information on risks will be lost, and risks may be covered and sustained. These ideas about communication and learning may conflict with the view of operators as being numerous, unskilled, replaceable and standardised, which is implied in the design of industrial settings. H3. Risks that are not detected or attended to have to be handled by the operator, who has little possibility to exert effective control. Communication and the implementation of safety measures in the organisations in this study were top–down. Residual risks that were not detected and managed by others were left to be exposed at the operative level. The question of politics and power is absent in many models and discussions of failures in organisations (Pidgeon, 1998). Shannon et al. (1997) found that factors associated with lower injury rates were: empowerment of the workforce; training for one’s workplace role; delegation of safety activities; and an active role in health and safety by top management. Our results showed poor employee participation in decisions affecting their work, inadequate information communication, lack of consultation, and feelings of being unable to create changes in one’s job. These factors are also commonly reported stressors among blue-collar workers (Cooper et al., 2001). The high responsibility for production goals stated by the operators, combined with little control over technical and safety systems, may have resulted in a latent feeling of stress, as was stated by the operators as an underlying cause of accidents. Both Karasek (1979) and Hackman and Oldhamns (1976) underlined workers’ perception of control as a major determinant of job satisfaction and stress. Accordingly, responsibility is a positive factor for motivation and satisfaction, but if responsibility for production is increased without extending control, stress will emerge. Control in combination with social support may help the individual to cope with the job demands and problems. Harris (1991)

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suggested that the range of coping strategies could be determined by organisational values, culture and norms, in addition to the availability of coping resources (control, power and authority). H4. There are conflicting goals and differences between procedures and practice. Knowledge of what really happens at the operative level and what motivates those actions is necessary to improve safety (Dekker, 2002). In this study, factors conflicting with safety were not openly handled. Safety sometimes conflicted with production goals, technical and organisational demands and even operators’ demands. Do¨o¨s and Backstro¨m (2003) stated that production typically emerges victorious from such conflicts. Dekker (2003) highlights the gap between procedures and practice, underlining the fact that real work takes place in a context of limited resources and multiple goal pressures. If procedures are inadequate for coping with local challenges, scarcity, pressure and multiple goals, then informal work systems may emerge. Procedures describe how to do the job safely. Yet, adhering to all procedures can lead to an inability to get the job done. Instead of imposing work from the outside-in, it is important to understand work from the insideout. According to Dekker (2003), the goal should be to (A) monitor the gap between procedures and practice and try to understand why it exists (and resist attempting to close it by telling people to comply); (B) help people to develop skills to judge when and how to adapt (and avoid telling people to follow procedures). In the present study, the gaps between practice and procedures were not openly discussed within the companies. Many organisations or industries do not know, or want to know, about this gap (Dekker, 2003). A variety of workplace factors (communication problems, physical and/or hierarchical distance) obscure the gap. In this study some operators expressed doubts about higher management’s, but not supervisors’, concern for operator safety. The importance of management’s commitment to safety has been found in previous research (e.g. Pidgeon, 1998; Rundmo and Hale, 2003; Shannon et al., 1997). The organisational preconditions presented in the hypotheses above can be related to the latent conditions presented by Reason (1997) in his theory on organisational accidents. Active failures are unsafe acts with a direct impact whereas latent conditions lie dormant until they interact with local circumstances defeating the system’s defences. The latent conditions can contribute to a number of different accidents and increase the likelihood of active failures by promoting errors and violations. Reason (1997) stated that both individual and organisational accidents have their roots in organisational and managerial factors and are often caused by latent conditions. H5. Organisational preconditions lead to risk acceptance, resignation and normalisation of risks. Poor communication and learning, as well as a high level of responsibility with little control, contributed to passivity in the area of safety. In order to avoid risk, the operator had to improve his/her own control or concentration. Vaughan (2004) stated, that the perceived cause of a problem is the basis for the strategy of control. Results in the present study indicated that since the operator perceives low external control, he/she relies on him/herself and a change in his/her own behaviour, such as trying harder or being more

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careful in the future. If no actions to improve safety are taken by the company, individual commitment to safety management may be reduced and risks accepted. Pidgeon (1998) stated that the norms by which a risk is judged are continuously negotiated and re-negotiated through the working practice of the team. These negotiations may lead to risk acceptance if improvements in safety are not given priority. If the gaps between practice and roles, policies and safety standards are not acknowledged and dealt with, team or individual solutions will flourish. Dekker (2003) writes that deviance from the original rules becomes normalised and routine, as informal work systems compensate for the organisation’s inability to provide the necessary basic resources (e.g. time, tools, documentation with a close relationship to action). Organisational culture, structural secrecy and unclear communication of information were found by Vaughan (2004) to influence towards a normalisation of deviance, which in turn may lead to failures to foresee risks. In a study by Farrington-Darby et al. (2005) a normalisation of risk were also found to be a part of a negative safety culture. Dekker (2002, p. 372) stated, ‘‘Safety is not inherent in systems. The systems themselves are contradictions between multiple goals that people must pursue simultaneously. People have to create safety’’. This is consistent with the core category ‘safety as a process’. 5. Conclusions The results indicate that deficiencies in the technical/physical environment and work organisation, poor learning and communication, high responsibility but low control and conflicting goals were factors that compromised safety. Several of these preconditions were indirect and concealed, forming the ‘normal’ in which accidents occurred. The results showed problems in addressing factors that conflict with safety, resulting in a normalisation and acceptance of risks. The participating companies, which showed a serious will to combat accidents, generally managed safety by means of control and passive prevention. However many technical/physical problems remained unsolved. A different perspective that addresses the underlying preconditions, is necessary for effective safety management. A prerequisite for this is insight into the norms and beliefs that influence safety as well as participation and motivation of all parties involved. Seen from a positive perspective the deficiencies and limitations described will, if properly dealt with, offer a possibility to further enhance safety. Acknowledgements Financial support was provided by the Swedish Labour Market No-fault Liability Insurance (AFA) and by the Swedish Agency for Innovation Systems (Vinnova) and are hereby gratefully acknowledged. The authors also wish to express their gratitude to Petra Willquist and Lotta Dellve for valuable feedback and discussion on context and method, as well as to the participating companies and workers for sharing their experiences. Appendix A See Tables 1–6.

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Table 1 Definitions and descriptions of the perception of the accident process (AP) AP 1–3. Accident process

Description

AP 1. Before the accident everything was as usual AP 2. The accident appeared without warning

The operators did not observe the potential risk at the time of the accident, or they perceived the risk but felt in control of the situation

AP 3. The operator’s reasoning

The injury occurred suddenly and caught the injured by surprise. It was not possible to recall any deviation from normal or decision-making process. ’’It happened so quickly. I was more surprised by the fact that something happened. I thought I had it all under control, so there was no time to even think of the emergency stop’’. When reconstructing the accident, the operator could say that he/she must have lost control to explain what happened but this was not a feeling or thought at the time of the accident Operators that were new on the job or had little experience could not foresee the risks related to either technical problems or to lack of knowledge. Some technical faults or malfunctions were not possible to foresee even for an experienced operator. ‘‘It was nasty, because it had never happened before, I haven’t heard of anyone else than me whom this has happened to’’. Those who were aware of the risk usually declared that they should not have acted the way they did. The accident did not occur because of surrounding factors, but because of their actions. They should have managed to handle the problem. ‘‘I’ve been there for such a long time, I should have known that it was slippery’’. The operators felt that they should have foreseen the risk but made a mistake due to either loss of attention, wrong judgement or wrong choice of practice, or a combination of these factors. The operators did not question the need to be completely focused for long periods of time or having to perform several parallel tasks. The supervisor argued that the operator knew how to act, since he/ she had been previously informed, was experienced, or that it was common sense

Table 2 Definitions and descriptions of the open organisational preconditions of a technical/physical character OOP1. Technical/ physical deficiencies

Description

Uncontrollable and inflexible technology

Changes occurred in the physical environment that could not be foreseen, e.g. sharp edges on conveyor belts or uncontrolled compressed air, implying insufficient control. In some cases there was a false safety when the machine was temporarily stopped but still be active. Some machines lacked flexibility in accommodating alterations in packaging or in raw materials. The operators therefore compensated for this deficiency into delivering the goods on time and with the required quality Many workers were exposed to a high risk working with sharp tools or near high energy. Many also had to work under constant hygiene demands and in heat, cold and draught as well as manually handling heavy material. Waste from products containing fat resulted in slippery surfaces and floors Premises that were cramped and had an unpractical design exposed the operator to the risk of getting hit, squeezed or falling. ‘‘It is cramped and one can trip on the uneven floor. In some sections we cannot walk upright but have to bend in order to avoid hitting our head. We are supposed to run around,but there is no time because the boxes keep coming, so we walk across the conveyer belt, otherwise we will run out of boxes and have nothing to pack in’’ Machines, including safety devices and workplaces were designed for actual production. Safety access during cleaning, maintenance, transportation and packing was neglected Poor maintenance or lack of investment in machines, equipment and facilities led to repeated repairs or that the defects remained until an accident occurred ‘‘A stop in production leads to stress. It is a daily problem. We have a lot of machine disturbances, and the repairmen are there every day for urgent operations’’. Worn-out components or equipment caused interruptions in production that had to be handled under time pressure due to the necessity to keep production running continuously

Effects of material and machines

Dysfunctional premises

Poor technical design Poor maintenance Constant repairs

Direct citations are presented in italics.

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Table 3 Definitions and descriptions of the open organisational preconditions of an organisational character OOP2. Organisational deficiencies

Description

Production disturbances

Organisational deficiencies in production led to frequent disturbances that were considered ‘normal’. These had to be compensated for by a faster work pace or longer working hours. ‘‘The disturbances can come from the top of the production line, so that different sorts of products won’t be ready in time and the drivers will have to wait. There is almost always something that does not work’’ The operator had to act while the raw material was buffered, discarded or in constant movement, which implied working with concentration under time pressure either for long periods of time or at short notice following periods of inactivity Operators could temporarily get help from co-workers or compensate for the lost time themselves during breaks or by increasing workspace There was little individual adjustment of the work. Many jobs were standardised, and it was difficult to take the capacity of the individual operator into consideration In order to increase the efficiency of the production the manpower had been reduced by half in some sections, so that operators had to control a much larger area and tasks were more compressed. ’’The problem is that there is a conflict between production, costs, working environment and manning. It is of great importance for the working environment that the production is slimmed, and most of the time one person short (‘‘Is there a risk in that?’’) ‘‘Yes, because you have no margins. If you have margins you’ve got time to reflect, to talk to each other and the training and instructions for the newcomers can take time and resources’’

High demands on concentration High pace and demand of work Poor individual adjustments Production efficiency

Direct quotations are presented in italics and quotations within brackets indicate interviewer questions.

Table 4 Definitions and description of the concealed organisational precondition ‘Deficient communication and learning’ COP1. Deficient communication and learning

Description

Safety as a technical issue

If the cause of the accident was technical, measures were quickly taken, while factors such as lack of knowledge and information were seldom acknowledged. Supervisors also experienced difficulty in dealing with behavioural factors Some of the injured that were new to the job acted beyond their abilities due to a lack of risk knowledge, since there was little education/training concerning safety aspects. Experienced workers could be relocated to totally different jobs without any further training Effective communication and learning as an ongoing process were deficient. ‘‘They corrected the faulty machinery immediately, but after that I don’t know if I should connect the device myself or how it functions. That safety function easily disappears after repairs, it often causes trouble’’ The operator seldom received feedback and unsafe behaviour could continue without any comments from the supervisor. Both the operator and the supervisor found it difficult or inappropriate to offer advice to a person with long work experience. ‘‘You decide for yourself now. No one should come up to me and tell me what to do. You don’t give someone a telling off if they’re not a newcomer. If they want to cut themselves it’s their own problem’’ (continued on next page)

Deficiencies in learning

Working methods unclear Poor feedback on performance

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Table 4 (continued) COP1. Deficient communication and learning

Description

Poor learning from accidents

Since several of the accidents were considered self-inflicted, the interest in reporting or discussing them was low, resulting in insufficient learning from incidents or accidents. The injured party was seldom informed about any preventive actions taken, nor was his/her experience used for ongoing safety improvements. Sometimes they had to return to the environment or the machine where they had been injured, without any alterations having been made to reduce the risk. The fact that accidents were often considered unpredictable implied that learning from them was not an option. Operators did not normally engage in communication regarding accident causes or technical or organisational solutions. ‘‘If it’s your own fault you don’t talk about it, but if someone else could get injured, you report it’’ Routines regarding information about changes that might result in risks were rare. Supervisors trusted that the news would ‘‘spread rapidly’’. Safety information was also poorly communicated between operators and repairmen or between working shifts. Both the operator and the supervisor expressed a sense of resignation concerning information and communication. (‘‘Do you inform the operators that the safety doors don’t mean 100% safety?’’) ‘‘No we don’t, it’s impossible, and there are so many similar problems. You can never inform about everything at a place like this, there will always be new risky areas’’ When operators attended meetings, some did not actively participate and little dialogue took place. Some of the women thought they would not be taken seriously. ‘‘If I were to inform a repairman about my concerns about technical safety, he would only laugh at me. What am I to know about that’’. There were operators who were doubtful regarding whether those higher up in the organisation knew what to do in order to prevent risks. Minor defects could be dealt with, but larger and more organisational, general and expensive changes were beyond the operators’ influence. (‘‘Can you influence your working environment to reduce the risks?’’) ‘‘It works with the small things, that one can handle oneself, but the big things are not up to us’’ The probability of an accident and its consequence was often not considered, which was reinforced by previous risky but successful actions. Measures were taken by the organisation to reduce risk, resulting in new risks that were not detected due to a lack of consequence analysis. The fact that accidents could be due to organisational aspects was rarely recognised

Poor information routines and motivation

Powerless without information

Low system awareness

Direct citations are presented in italics.

Table 5 Definitions and description of the concealed organisational precondition ‘High responsibility and low control’ COP2. High responsibility and low control

Description

Operators have to assume final responsibility

The supervisor was formally responsible, but the operator often had the actual responsibility for managing the existing risks, in order to fulfill production goals. The risks that had not been dealt with by others had to be solved ‘on the floor’. Sometimes the supervisor did not know how to carry out some of the jobs and was not familiar with existing practice. (‘‘How do the operators normally do it?’’) ‘‘I don’t know, when they are cleaning I normally do my paper work, so I do not know how they really do. The experienced are the driving force’’ Communication was often one-sided, top–down. However, the responsibility of producing the goods that were ordered fell on the individual/team regardless of whether or not they had control over the factors that affected these matters. The operators did not try to alter this situation

Dialogue is top–down

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Table 5 (continued) COP2. High responsibility and low control

Description

Tensions within groups

Different levels of ambition within groups led to tension and stress. Many operators were dedicated to their work, trying to help or ‘save’ a situation. Some supervisors also mentioned the tendency to work too quickly at times when it was unnecessary. This was viewed as risky behaviour and a personality trait that the supervisor could not influence or take responsibility for Some operators claimed that they should have foreseen the risk but technical and organisational aspects were often beyond their control. Others planned, implemented and had control over safety measures, while the operator was handling the risk ‘‘The supervisor is aware of the safety problems, but we can’t do anything about these things’’. Some of the operators expressed doubts about management’s concerns regarding operator safety Stress was often mentioned by operators as the most common underlying cause of accidents, but less so by supervisors. ‘‘The main problem is stress, you don’t have time to reflect over practice, you act on instinct not knowledge’’. ‘‘You have to be quick otherwise the problem will increase’’. The supervisor usually perceived stress as a problem only due to a lack of time, while from the operator’s point of view stress was most often caused by the demand for a constantly running production. ‘‘Stress is always at the back of my mind. If production must be running, it is in the marrow that we must produce all the time’’

Little control over work

Stress is build in

Direct citations are presented in italics.

Table 6 Definitions and descriptions of the concealed organisational precondition ‘Conflicting goals and a gap between procedure and practice’ COP3. Incompatible conditions

Description

Conflicting goals

Since production had to be kept running, the criteria for stopping it for safety reasons were vague. Sometimes safety was disregarded in favour of production goals, which was informally accepted. This created a concealed gap between reality and what was stated as desirable. ‘‘The problem was that the operator didn’t want to press the safety button, because so much happened inside the machine that resulted in extra work, so they put their hands inside the machine’’. The operators emphasised that they had to be profitable. Some also mentioned that safety was not given proper priority by the organisation According to the rules, the machines should be shut down for cleaning or repairs, but it was informally accepted that this rule could be broken, since it was difficult to perform the work otherwise. However, when an accident actually occurred, this working practice was considered wrong. Some of the supervisors emphasised that the operator had the choice of a safe working practice, but sometimes this was an unrealistic or impossible option. If everyone were to give priority to safety, the production goal could not be accomplished. In some cases there were no safe alternatives, or the operator was not aware of them

Gap between procedure/practice

Direct citations are presented in italics.

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