by Paul English
When the Chicago Assembly Plant opened its doors in 1924, Model T's were rolling off the assembly line. The plant produced 4,211 Model T's with a base price of $490. Soon, the Model T's were joined by Model A's, Model B's and, over the years, such iconic models as Ford Fairlanes, Galaxies and Thunderbirds.
Currently, 2,360 employees manufacture three models of vehicles at the facility: the Ford Five Hundred, Mercury Montigo and Ford Freestyle. Local 551 of the United Auto Workers (UAW) represents the majority of the employees at the facility.
Chicago Assembly is the oldest production facility within the Ford Motor Co. Since 1924, the facility has incurred 13 major expansions, arriving at its current size of 2.8 million square feet.
Times have changed, cars have changed and the safety culture has changed.
The facility has been honored with numerous production and quality awards, such as the Harbour & Associates Top 10 Most Productive Plant in North America for 2002 and 2003; 2002 Shingo Prize for Excellence in Lean Manufacturing; and J.D. Power Silver Award in 1998. In 2004, during the new product launch of the Ford Five Hundred, Ford Freestyle and Mercury Montego, the facility earned the Ford Motor Co. President's Health and Safety Award for Innovation representing the Americas for incident and injury reduction.
Things weren't always so bright at the facility, however. Several years ago, some aspects of the safety process needed some polishing. At that point in time, efforts to reduce injuries at the Chicago Assembly Plant created as many questions as they did answers to safety challenges.
One aspect of the safety process that came under scrutiny was the quality of incident investigations.
As part of the plan to reduce injuries, the safety department undertook a review of incident investigations for a work zone in the Trim Department. A systematic approach was formalized to review past incident and injury data. During the review, it was determined that injury data was skewed due to incomplete information entered into the investigation database.
Safety professionals at the facility attempted to fully utilize the investigation database to identify workplace injuries and illnesses by identifying workstations and job tasks with a high frequency of incidents. Current data regarding job process codes - alphanumeric codes that are assigned to each workstation on the assembly line - within the investigation database was reviewed for any type of injury trends, including first aid injury data.
When incomplete job process codes were found, the safety department determined that a quality control process needed to be established regarding investigations by line supervisors. Six issues impacting the quality of incident investigations were identified and addressed.
The Six Criteria
If the six criteria were not met during the review phase of the incident investigation process, the incident investigation was rejected and sent back for additional information before proper corrective action would be taken. The six criteria examined:
Overall Quality - Investigations would be rejected if the investigation was poorly written. This included, but was not limited to, misspelled words, vague investigator statements and personal opinion written into the investigation statement.
Job Process Codes - The job process code (if available) had to be included, because it ensures that every workplace injury and illness recorded can be linked to a workstation and/or task. Service departments such as Quality, Maintenance and Human Resources are not limited to a job process code and move freely throughout the facility.
Job Safety Analysis (JSA) - If the corrective action involved a process change, the change must be noted and changed on the JSA at the workstation. If the investigation noted a change to the process, including personal protective equipment (PPE), changes to the JSA must be noted and documented into corrective action.
Coaching and/or Counseling Abuse - If the safety department identifies a physical adjustment to the work environment, the investigation would be rejected with a recommendation for the adjustment. If the investigation identified a violation of a safety policy, process or procedure, the investigation is rejected with a recommendation for enforcement of controlling safety programs. This eliminates the "I told the employee to be safe" routine.
Type of Contact - If the investigator identifies the wrong type of contact for the incident, the investigation would be rejected with recommendations on what the type of contact should be changed to.
No Action on Recommendations - This means that the investigation previously had been rejected for one of the six criteria. These investigations are rejected because the supervisor did not follow or implement the recommendations of the supervisor's superintendent and/or the safety department.
Improving Incident Investigations
Safety professionals at the Chicago Assembly Facility found that the overall quality of the investigation was improved when attention was paid to the details of the investigation. The overuse of coaching and counseling as a corrective action to an incident identified investigations in which the corrective action did not address the root cause. In many of these cases, engineering, enforcement of current safety policies or procedures and maintenance of equipment would be a more suitable corrective action.
The quality of the initial incident investigations indicated that training was needed for employees responsible for conducting the investigations. Employees in each department participated in a training session to learn about the reasons why incident investigations were being rejected. Issues were identified by each department based on the same rejection criterion as used for the entire facility.
In developing the training program to improve the quality of the incident investigations, quality had to be defined as well as the customer.
This problem is not unique to Ford. Safety expert Fred Manuele, at a session at the American Society of Safety Engineers' conference in June 2005, warned that safety managers may find the quality of the incident investigation reports they review "inadequate for in-depth causal factor determination."
In assessing the more than 1,000 incident reports he reviewed from large companies, Manuele rated some a 2 on a scale of 1 to 10, with 10 being the best. "Causal factor determination was dismal," he noted. "Opportunities to re-adjust the focus of preventive efforts to the benefit of workers and employers were lost." Manuele added that after reviewing the incident investigation reports, he now believes the "quality of incident investigation is one of the primary markers in the evaluation of an organization's safety culture."
At Ford's Chicago Assembly Plant, a process check 8 months after the start of the program found double-digit improvements in the acceptance rates for each department's incident investigations, ranging from 13 percent to 84 percent. Implementation of the incident investigation quality control process determined that the use of coaching and counseling decreased by 47 percent, while maintenance fixes as a corrective action increased 123 percent.
Cultural Changes
In an October 2004 article in Occupational Hazards titled "Why Won't They Listen?", Larry Hansen wrote, "Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to "foolproof" the condition or activity. ... The primary purpose of accident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise the inventory of hazards, and/or the program for hazard prevention and control."
This has happened at the Chicago Assembly Plant. A Lean Behavior Survey was conducted at the same time the process improvements to the incident investigation process were being rolled out to determine cultural changes within the facility.
Four questions concerning employee safety were asked to all employees regarding health and safety. In all four questions, double-digit improvements also were discovered in the same 8-month period. This represents a 25 percent improvement in the Ford Production System Lean Behavior Survey for hourly employees from December 2005 to May 2006.
Overall, a 22 percent improvement was seen from hourly employees when asked if their supervisors consistently enforce safe work practices. When analyzed, the corrective action data showed a 47 percent increase in enforcement as a corrective action and a 42 percent decrease in coaching and counseling. The Lean Behavior Survey verifies and confirms that consistent application of good corrective action on incident investigations will change behavior.
Concurrently, a review of standard safety metrics demonstrated a 28 percent decrease in OSHA recordable injuries and a decrease in days away and restricted time (DART) cases.
I feel the quality of the workplace injury investigation is a key component in the loss prevention program and model. Poor investigations will lead to the wrong conclusions regarding hazards in the workplace.
In addition, recent research from the Liberty Mutual Research Institute has determined that if a line supervisor's approach to workplace injuries improves, it has a direct effect on reducing the severity of the injury.
An article in the March 2006 issue of the Liberty Mutual newsletter - titled "A Key to Reducing Future Disability Claims" - noted, "Companies that improve the way supervisors respond to employees' work-related health and safety concerns can produce significant and sustainable reductions in future injury claims and disability costs. Supervisors trained to properly respond, communicate and problem-solve with employees reduced new disability claims by 47 percent and active lost-time claims by 18 percent."
There is no substitute for conducting a quality incident investigation for workplace injuries and illnesses. When incident investigations are conducted properly, root cause is determined with permanent corrective action implemented to prevent further injuries.
The process adopted by Ford Motor Co.'s Chicago Assembly Plant prove that incident investigations can identify safety trends and issues that a workstation, work zone, department or area may be incurring. Proper incident investigation has a positive impact on the classic safety metrics of lost time, days away and restricted time and severity. These metrics logically decline as hazards are identified and eliminated through the incident investigation process.
Paul English is a senior safety engineer at Ford Motor Co.'s Chicago Assembly Plant. He holds a B.S. in fire and safety engineering technology from Eastern Kentucky University. The Chicago Assembly Plant was the winner of the Ford Motor Co. President's Health and Safety Award for Innovation representing the Americas for incident and injury reduction during the new product launch of the Ford Five Hundred, Ford Freestyle and Mercury Montego in 2004. Any questions regarding this article, please contact Paul at [email protected].