16

easily accessible to professionals for specific applications. For example, a
case study format could be used to compile a source reference available in
both “hard copy” and through “electronic access.” Selection criteria should
also be specified to ensure appropriate quality and technical validity.

In addition, existing information centers need to be broadened to include
specific trauma-related data from epidemiologic studies, injury investiga-
tions, surveillance and other sources, such as anthropometric, biomechani-
cal, forensic, and physiologic databases.

. Promote the maximum use of machine guarding technology.

Maximum resources should be used to provide worker protection for all new
or rebuilt single-purpose machines and power-transmission devices. All ap-
propriate enforcement agencies are encouraged to use their resources and
authority to ensure that appropriate safeguards are installed and used.
Another approach would call for model purchase agreements including sup-
plier certification of the presence of current state-of-the-art technology and
use restrictions. Special emphasis should be given to mechanical power
presses and point-of-operation guards. Whenever possible, guards should be
an integral, non-removable part of the machine design to avoid confusion
among users about the adequacy of the safeguards. Regulations or recom-
mendations should be made only after clearly demonstrating that specific
machines present a hazard, that state-of-the-art technology is available to
provide adequate worker protection, and that safeguards will be compatible
with the operations and maintenance of the machines and not introduce new
worker hazards. Additional efforts should be directed toward producing
engineering guides for safe use of multi-purpose machines and machine
controls ensuring that warning signs are posted on or near all machines
known to present traumatic injury hazards to workers.

. Integrate the knowledge of traumatic injury control into educational

curricula.

A national program should be developed and implemented to draw the
attention of educational institutions, professional societies, accreditation
bodies, state and local agencies, and others to the need for education and
training to control acute trauma and disabling injuries. This program would
promote course work in acute trauma prevention in the nation’s educational
institutions, including schools, colleges, and universities of vocational tech-
nology, education, business, engineering, architecture, public health, and
medicine. Model program material would be developed for various educa-
tional levels ranging from high school to graduate school. Educational mate-
rials should be directed through accreditation programs, professional so-
cieties, and higher education administrators. Model curricula should include
hazard communication:, product liability, and control technology information.
Other governmental and private programs should be encouraged to partici-
pate in the effort.

. Develop a trauma control training model for specialists, managers,

supervisors, and workers.

A model training program for use by all firms in meeting the minimum
training requirements specified by regulatory agencies (MSHA and OSHA)


10

genetic engineering, robotics, computers, and space commercialization
are prime candidates for study. To address potential emerging problems
will require:

* The widest possible application of existing safety technology

* Development of research programs for safety technology at the centers
of the emerging technologies

* Specialized surveillance programs keyed to anticipated problem areas

. New Hazard Control Techniques

Innovation in techniques for the recognition, analysis, and mitigation of
hazards and the management of risk is slowly emerging from extensions of
econometrics, policy analysis, reliability engineermg, and operations re-
search. However, no formal body of information, discipline, or center of
excellence now exists to nurture these new approaches to the safety
question. Consideration should be given to establishing a center for re-
search into the non-mechanistic arena of safety.

. Economic Issues

In 1982, $22.5 billion were paid for workers’ compensation insurance
coverage or approximately $275 per worker covered. Yet the National
Safety Council estimates that all workers would need to produce addi-
tional goods or services with a value of $330 per worker to offset the cost of
worker injuries. This finding may indicate that compensation insurance
rates are not high enough to provide a positive incentive for reducing
occupational trauma. In addition, the “liability proofing” that compensa-
tion coverage conveys to the employer may provide a further disincentive
to prevention programs. Nonetheless, the present compensation system
for occupational injuries is important to the nation’s working men and
women and, although perhaps not ideal, it should be maintained and
strengthened.

The economic incentives and disincentives associated with workers’ com-
pensation are being carefully analyzed by the insurance industry, private
economics-oriented research organizations, and governmental compo-
nents. Analyses have been undertaken to determine the savings that can
be realized through emphasis on prevention, but much work is needed in
this area. The emergence of the newly created Workers’ Compensation
Research Institute (WCRI) is evidence of the increasing attention being
focused on understanding the complex economic forces that influence
occupational traumatic injury and fatality incidence and the efforts to
control these outcomes.

Insurance rates are increasing, the work force is maturing as fewer and
fewer young people enter the job market, and labor shortages in key
occupations can be anticipated. These influences will require a more
enlightened approach to management commitments to worker safety. It is
encouraging that many employers are beginning to recognize the negative
economic impact that traumatic injuries have in lost workdays, high medi-
cal costs, loss of productivity, and increases in insurance rates and liability


20

Existing national programs could be used to support the promulgation of
occupational regulation, the development of scientific methods for research
associations, and the generation of research tools that the associations could
apply to problems identified in their specific industries or regions.

. Examine the use and abuse of substances in the workplace.

The influence of substances on a worker’s risk of incurring traumatic injury
should be examined carefully through both personal use and workplace
exposures, alone and in combination. Substances, medications, and chemicals
that can increase the risk of traumatic injury should be identified, as should
the workplaces where such substances may be encountered. Methods should
be developed to screen workers for susceptibility to these substances and to
provide warnings to prevent exposures. On-the-job testing of workers for
illicit use of controlled substances has received much recent attention and
may be appropriate in targeted, high-risk occupations. Although societal and
other pressures often influence affected individuals not to seek assistance for
substance abuse, employee assistance programs have proved to be exception-
ally effective. Substance abuse should be considered a potential contributing
factor to occupational trauma, and effective employee assistance programs
should be made available nationwide.


A Proposed National Strategy
for the Prevention of

Severe Occupational Traumatic
Injuries

Severe Occupational Traumatic Injuries: Problems and Goals

Severe occupational traumatic injuries include serious, often disabling injuries such
as amputations, fractures, severe lacerations, eye losses, acute poisonings, and
burns. Worker deaths that are immediate, and without a preceding illness, are often
the result of severe trauma incurred on the job.

Control of severe occupational traumatic injuries is not possible without a concerted
effort by government, academia, private business, and labor. A control strategy that
is national in scope must reflect a full spectrum of activities, not only emphasizing
information dissemination and implementation of countermeasures but also including
injury surveillance and analytical research. Therefore, the recommendations in this
report represent not only what can be practically done today but also what should be
done in the future. Embodied in these recommendations is a preliminary national
strategy that may evolve as more is learned about the etiology and prevention of
traumatic injuries and as more individuals and organizations make contributions to
the effort.

Scope of the National Problem

Severe occupational traumatic injuries Gncluding injuries associated with work-
related motor vehicle accidents) pose a continuing and perhaps the major threat to
the health and well-being of American workers. The National Institute for Occupa-
tional Safety and Health (NIOSH) estimates that at least 10 million persons suffer
traumatic injuries on the jo» each year. About 30 percent @ million) of these injuries
are severe, and at least 10,000 are fatal. Analysis of potential life lost from various
causes indicates that “accidents and adverse effects” are the leading cause of loss of
potential productive years of life in this country. Occupational trauma is second only
e motor vehicle accidents as a reported cause of unintentional death in the United
tates.


should address the basic elements of the hazard control process—
recognition, evaluation, and control. The model should include the following
elements:

¢ Techniques for hazard identification, evaluation, and control

¢ Methods for ranking hazards according to potential destructive conse-
quences

¢ Guidelines for selecting training methods

° Materials to be included in presentation

¢ Methods for evaluating effectiveness of training

* Guidelines for post-training management actions and retraining

Particular concern should be given to worker motivational and behavioral
changes and to ultimate distribution of completed programs. The training
model should be adapted to the needs of trauma control specialists, man-
agers, supervisors, and workers.

. Expand occupational trauma research.

Efforts are essential to stimulate the traditional research communities in
engineering, universities, and public health to address hazard identification,
accident causation, and effective intervention/hazard control with specific
funding, such as national grant programs for occupational injury prevention
research. The need for interdisciplinary research initiatives in the area of
traumatic injury research should be emphasized.

. Re-evaluate existing occupational consensus standards and codes.

Existing occupational consensus standards and codes must be re-evaluated
with a view toward establishing a technical basis for each and, based thereon,
appropriate revisions should be pursued. Many occupational standards, reg-
ulations, and engineering practices are based on consensus standards or
codes and rarely reflect the technical rationale that supports the recommen-
ded practice. Therefore, the practitioners who must use such standards or
codes have no basis of understanding. In addition, because the technical
rationale does not exist, such standards or codes are extremely difficult to
review as new information emerges.

. Monitor product liability decisions.

Because outcomes of product liability litigation have a strong influence on
product designers and suppliers, “liability proofing” often overshadows the
need to design safe devices for use in the workplace. Occupationally related
decisions on product liability should be monitored to identify potential in-
creased risk to workers of traumatic injury. Findings should be disseminated
to bodies responsible for consensus standards, regulatory agencies, employ-
ers, worker organizations, and related research organizations.

17


2. Promote epidemiologic studies of traumatic injuries and prevention
countermeasures.

Epidemiologic methods should be used to study traumatic injuries and pro-
vide information about their incidence and prevention. Data from the national
traumatic injury surveillance system can be used for case series and cross-
sectional analyses to provide statistics describing the magnitude and charac-
teristics of specific traumatic injuries. These analyses can also be used to
generate hypotheses and set research and resource priorities. Analytic epi-
demiologic designs (cohort and case-control studies) should provide risk
assessment of selected factors associated with injury incidence. Field trials
should be conducted to evaluate the efficacy of specific prevention interven-
tions.

These applications of epidemiologic methods will minimize many current gaps
in knowledge about traumatic injury incidence. For example, 1) traumatic
injury statistics are often cited that are neither valid nor representative;
2) unsubstantiated conclusions are often made about factors (training,
worker behavior, experience, supervision) that influence the risk of trau-
matic injury; 3) the feasibility and success of prevention countermeasures are
either never evaluated or are subjectively supported.

8. Create industrial associations within each major industrial division for
research on traumatic injuries.

The continuing toll of occupational injuries and illnesses suggests that na-
tional programs established to ensure safe and healthful working conditions
are not yielding the desired results. At least two primary reasons can be cited
for existing programs not producing effective control measures:

a. Developing controls and validating effectiveness scientifically require
extensive resources not currently available.

b. Personnel working within national programs lack sufficient familiarity
with each specific industry to identify the specific problems and the
practical solutions that would result in significant reductions of injury and
illness.

To help reduce these problems, a study is recommended to evaluate the
possibility of organizing Industrial Traumatic Injury Research Associations
for each major industrial division, as defined by the Standard Industrial
Classification (SIC) Manual. These associations should be private, nonprofit
entities, responsible for performing quality research approved by a tripartite
research review board, and should not be for regulatory purposes. Manage-
ment, labor, and state and federal governments should be equally repre-
sented in the administration of these associations. The Construction Safety
Association of Ontario is an example of such an association.

Alternative means of addressing research to specific groups might include a
division along geographic lines. Indeed, some variances in occupational in-
jury experience may be attributed to regional differences (e.g., geographic,
climatic, and demographic). For example, the Occupational Health Program
in the State of Washington shows not only an innovative approach to funding
but also the level of cooperation possible among government, academia,
industry, and labor.

19


research, make recommendations, and train professionals regarding
workplace hazards, NIOSH should continue to help those agencies that
have specific responsibility for personal behavior and substance abuse by
supplying them with technical information and by increasing their sen-
sitivity to worker attitudes and needs.

d. Risk Taking

Risk taking is one of the basic human behavioral factors that made the
United States the type of society is it today. We are accustomed to risk
taking and are born and raised with the belief that it is the heart of the free
enterprise system. Such a philosophy has permeated our society, life-
styles, and workplace. Risk-taking behavior in the workplace is not only
recognized but rewarded, such as through piecework wage rates and time-
to-complete incentives in the construction industry. This fundamental
aspect should receive additional attention and should be modified where
possible when it contributes to occupational trauma.

e. Lifestyle Changes

Major life events (e.g., the death of a spouse) are recognized as important
health sentinels, but their impact on the risk of traumatic injury has not
been systematically studied. Research should be initiated to evaluate
whether major life events can increase the risk of occupational traumatic
injury. A growing trend in industry is the availability of employee coun-
selors, particularly in larger, well-established companies. Employee con-
cerns may range from family to finances, work, or career mobility. These
companies realize that the mental well-being of workers is important and
that employees may need trained counselors to help them through crisis
periods. Such a service may have an impact on reducing both intentional
trauma such as suicide and homicide, and unintentional trauma such as
accidental injury resulting directly from inattention.

4. Rehabilitation

Rehabilitation of severly injured workers, although clearly not a prevention
technique per se (in terms of initial traumatic events), is a method of mitigat-
ing the severity of traumatic injuries by preventing unnecessarily prolonged
/ disability, loss of income, and ultimately reduced quality of life. In addition,
| employers’ rehabilitation programs can serve as evidence of management’s
commitment to employee well-being, and can, therefore, lend credibility to
other, more prevention-oriented aspects of a trauma control program. Cur-
| rent rehabilitation programs are expensive, and the value of such activities
has yet to be fully assessed. Evaluations of rehabilitation programs from
national, state, local, private sector, and personal perspectives should be
conducted with a view toward enhancing the effectiveness of such programs.

One area requiring further research is the development of objective tech-
| niques for diagnosing traumatic injuries to specific body parts, in which
i neurologic and motor dysfunctions are assessed and the worker is given
| appropriate treatment. Essential considerations from a management stand-

point include allowing sufficient time and ensuring mental, psychologic, and
| physical conditioning to-prepare and integrate the worker's return to the
| workplace. Management should be aware that a gradual recuperative work

14



tions by consensus organizations such as the American National Standards
Institute.

2. Manufacturer Safeguards

Manufacturers are continually seeking to build a better “mousetrap.” State-
of-the-art technology can be geared toward producing a safer and a more
functional machine. Employers should take advantage of proven develop-
ments when procuring machines. At a minimum, procurement procedures
should require that newly purchased machinery meet all appropriate cur-
rently recognized regulatory and consensus standards.

D. Human-Oriented Strategies: Managing the Worker

The most complex and the least measurable component of the task/environment/
machine/worker model is the worker. To some safety practitioners, a worker is
characterized by the behaviors exhibited in the workplace that influence systems
output. Many of these practitioners believe that human behavior is totally unpre-
dictable and uncontrollable. To others, a worker is a set of abstracted
attributes: occupation, sex, age, part of body injured, etc. Still others see the
worker as the sum of the effects produced by the working environment: stress,
injury or illness, disability, fatigue, motivation, productivity or nonproductivity,
absenteeism, etc. To some, a worker is a set of psychologic and physiologic
capabilities and limitations. Perhaps the most successful practitioners in the area
of traumatic injury control see the worker as their most valuable resource, to be
carefully nurtured and protected.

Of course, human beings are all of these characteristics and more. Thus, a variety
of people need to be involved in the study of tasks, working environments,
machines, and workers to comprehend the worker as both an entity and a func-
tioning part of larger systems. Individuals with training and experience in behav-
ioral science, ergonomics, biomechanics, biomedical engineering, and related
scientific and engineering fields are needed to study the control of occupational
traumatic injury and to provide critical knowledge regarding the human compo-
nents of industrial systems.

1, Training

Training is an integral component of trauma prevention. From the earliest
days of childhood, we are taught to look both ways before crossing the street
or, more recently, to buckle our seat belts after getting into a car. Asa result,
some of us do these things automatically. However, most of us are not trained
early in life for the vocation we may have as adults. As a consequence, we get a
job and learn firsthand about its inherent dangers.

Strong evidence indicates that knowledgeable, well-trained workers can
avoid injury while performing hazardous work, and that untrained, unin-
formed workers can be injured under almost risk-free conditions. NIOSH
field investigations of fatalities associated with confined spaces have shown
that lack of awareness or recognition of the hazards, by both managers and
workers, and lack of training in hazard awareness may be major factors
contributing to occupational fatalities. Government agencies, notably the
Occupational Safety and Health Administration (OSHA) and the Mine Safety
and Health Administration (MSHA), have addressed the need for training


WV.

One set of scientific methods, known collectively as epidemiology, has received
inereasing attention among trauma control professionals. Epidemiologic techniques
can help those interested in reducing the incidence and severity of occupational
trauma to see more clearly the scope of the problem and the complex relationships
among the causal factors operating in the working environment.

Epidemiology: Charting the Course

Epidemiology is a discipline applied to the practice of preventive medicine and public
health. Use of epidemiology to evaluate the incidence of traumatic occupational
injuries has tremendous potential because these injuries, like chronic and infectious
diseases, seem to result from the interaction of a susceptible host and one or more
etiologic agents within a particular environment. Furthermore, precedents have
been established for the successful application of epidemiologic methods to evaluate
injury etiology. For example, epidemiology has been used to assess the association of
aleohol with automobile fatalities, the occurrence of falls and poisonings in residential
buildings, the incidence of occupational and nonoccupational burn injuries, the factors
associated with recreational injuries, and the success of various strategies for sur-
vival in disasters.

Epidemiology may serve as a common thread associated with the identification,
evaluation, and control activities necessary for the prevention of traumatic injuries.
Initially, descriptive epidemiology (e.g., surveillance and cross-sectional studies) is
needed to identify high-risk exposures and factors. This identification will allow for
the generation of scientific hypotheses about causation. Next, analytic epidemiology
(e.g., cohort and case-comparison studies) can test the validity of these hypotheses.
This analysis will allow for the evaluation of potential risk factors and exposures and
for suggestions of appropriate control strategies. After designating specific control
strategies, epidemiologic field and clinical studies can be used to evaluate the efficacy
of these strategies. Appropriate surveillance activities can then assess progress in
the control of traumatic injuries based on implementation of specific preventive

strategies.

Surveillance appears to be a key epidemiologic component in the prevention of
occupational traumatic injury. This component must be viewed as both an initial
activity designed to establish baseline information, and as a continuing activity
designed to generate dynamic profiles characterizing how the national occupational
safety experience is changing, and in some instances, why the change has occurred.

Most workplace accidents occur as a result of the coincidence of separate cause-effect
sequences, each influenced by multiple factors or stressors. In formulating actions
aimed at controlling severe occupational trauma, consideration must be given to the
risk factors associated with the following workplace components: the task, the work-
ing environment, the machine, and the worker. Each set of risk factors represents an
area in need of scientific study in the multidisciplinary effort to mitigate occupational
trauma through research.

All too often, however, researchers focus on only one of these aspects without
considering the total workplace. Modifications in any component of this complex
system must be carefully evaluated with a view toward effects on the total system.
Traumatic injury research must be specific and painstaking, yet must reflect a
balanced, systems-oriented perspective so that the findings will be adaptable to
employers’ needs; employers, after all, must manage these complex industrial sys-


Occupational injuries, of which severe traumatic injuries constitute one of the impor-
tant components, resulted in 80 million lost workdays in 1983. That same year,
occupational injuries cost the United States an estimated $33.4 billion in direct costs
(e.g., wage losses, insurance administrative costs, and medical costs) and indirect
costs (e.g., time lost by other than injured workers, and administrative costs asso-
ciated with accident investigation and reporting). This figure may grossly underesti-
mate the extent of total costs to industry and to society at large resulting from
occupational injuries and cannot begin to describe the immeasurable toll in human

suffering.

National Safety Council estimates show declining rates of occupational fatalities and
disabling injuries since the early 1970s, partly as a consequence of a growing
workforce. However, the actual number of fatalities has declined slowly and the
number of disabling injuries has remained essentially unchanged since 1945.

Amenability to Intervention

Several techniques and methods are available to prevent and reduce the severity of
traumatic injuries. Traditional approaches include removing the hazard, placing
barriers between the hazard and the worker (including the use of personal protective
equipment), pre-employment screening to prevent assignment of particularly sus-
ceptible individuals (e.g., those incapable of performing the tasks or sustaining the
stresses imposed by the tasks), job hazard analysis, improved job and tool design,
compliance with regulatory and consensus standards, and training the worker to
avoid the hazard. Evidence shows that application of traditional trauma prevention
methods by knowledgeable professionals in a positive management environment
reduces occupational injuries.

A dual approach is proposed to reduce the burden of such job injuries on the
workforce, the economy, and the population of the country.

A. Immediate actions can be taken by interested groups and individuals based on
prudent, carefully considered options for trauma prevention programs. These
actions involve implementation of already developed aud accepted policies and
practices to reduce injuries within the context of positive, safety-minded man-
agement. Actions that can improve awareness and control of hazards include
training; compliance with existing regulatory and consensus standards; better
ergonomic design of equipment and jobs; early identification and recognition of
emerging hazards; upgraded education of safety and health professionals, engi-
neers, managers, and workers; and targeted, short-term injury control research.

B. For the long term, a major effort must be made to more thoroughly describe and
study occupational injury incidents and to use the most rigorous methods of
science available. Although present interventions are valuable in reducing work-
place injury, scientific study is necessary because occupational “safety” is a set of
control technologies (e.g., engineering, personal protective equipment, and
monitoring) and administrative techniques (e.g., training, written policies, safe
work practices) that have not been rigorously tested and validated. As an under-
developed science, occupational trauma control needs research using the scien-
tific methods that have contributed greater knowledge and prevention efforts in
related health and injury fields.


period is needed before a worker can return to his potential. Research is
needed on the system approach of industry, worker, health care, rehabilita-
tion, return to work, and work adjustment.

Vil. Recommendations

Two types of actions are recommended, immediate and long-term. The first set of
recommendations can be implemented immediately based on the current state of
knowledge and societal organization. The second set reflects the need to 1) scientifi-
cally investigate further the causal mechanisms underlying occupational trauma and
the available potential control technologies, 2) reevaluate the structure of our exist-
ing national programs for addressing the problem of occupational trauma, and
3) assess economic benefits resulting from effective trauma intervention; i.e., a
realistic focus on the savings.

A. What Can Be Done Now

1. Develop models of programs for successful occupational trauma prevention
and encourage their implementation through a workplace-specific, self-
evaluation approach.

Generic components of successful programs for trauma prevention across a
variety of industries have included strong management commitment, stable
work force, high level of housekeeping and effective environmental quality,
and effective training practices. Most employers who voluntarily seek ways
to improve programs, such as adaptation of successful program components,
are already committed to employee protection. An effort must be made to
influence less committed employers to use available prevention tools.

The self-evaluation approach has proven successful in specific industries
where self-evaluation tools were keyed to industry-specific characteristics.
Several important concepts are embodied in the recommendation: 1) the
need to promote the anticipation of hazards through an analytical process,
2) the need to involve the work force in identifying hazards and developing or
discriminating among existing controls to address hazards, and 8) the need to
tailor self-evaluation tools to specific industrial settings, as demonstrated in
the utilities and communications industries.

Two important areas of consideration need to be emphasized: 1) making such
self-evaluation procedures voluntary and exempt from punitive repercus-
sions (when such models have been field-tested and validated, promulgation
of standards may be feasible), and 2) focusing on two important groups:

° High-risk industries identified through existing data systems and ad-
dressed in a priority-setting basis.

* Specific worker populations that may be neglected in coverage by regula-
tory or statistical databases and may, on scrutiny, be high hazard groups;

e.g., agricultural workers, truck drivers, small business employees, the
self-employed.

2, Develop information centers for injury prevention technology.

Information about hazard control problems and effective solutions must be

15


to detect previously unknown or undetected hazards. Appropriate preventive
countermeasures can then be applied to eliminate or reduce risk to the worker
from those hazards, including modifications to the task. Job hazard analysis is an
important approach because hazards can often be anticipated. This is clearly
better than reacting to a hazard after a traumatic event.

Although the effectiveness of known countermeasures has not been determined,
inereased implementation of appropriate safe work practices and procedures is
anticipated to have a major impact on reducing national injury and death rates.

. Environment-Oriented Strategies: Changing the Work Environment

The working environment includes the physical environment, the psychosocial
environment, and the political/economic environment. Of these, the physical
environment is the most amenable to immediate action. The impact of broader
environmental issues on the incidence of traumatic injuries must be carefully
studied.

The influence of factors in the physical environment (e.g., layout and condition of
the facility, illumination, temperature, relative humidity, noise, vibration) on the
productivity and safe performance of occupational tasks has been studied for more
than 50 years. Based on consensus and standard industry practice, guidelines
have been developed for the control of these potential physical stressors to
minimize direct bodily insult or trauma. Compliance with these guidelines can help
to reduce the risk of occupational injury. The principal obstacles to wider applica-
tion of known controls are inadequate information dissemination and inadequate
safety program management. Cost constraints can also inhibit adoption of neces-
sary environmental controls.

Many private sector organizations have developed safety and health prevention
programs that have demonstrated trauma reductions and worker health enhance-
ment. Means should be sought through trade associations, the National Safety
Council, labor organizations, insurance organizations, and others to influence
other companies to incorporate the essential aspects of such effective programs
into programs of their own.

. Machine-Oriented Strategies: The Safe Machine

Machines are assemblages of parts designed to transmit or modify the application
of power, force, or motion to perform predetermined functions. Workers use a
wide variety of machines to be more productive. The various forms of energy
associated with machines, if not adequately controlled, can result in traumatic
injuries to workers. Numerous measures known to control this release of energy
should be applied in the workplace.

1. Standards

Regulatory and consensus standards now exist to protect workers in various
ways from interaction with specific industrial machines. Many of these protec-
tive measures propose the placement of barriers between the worker and
recognized hazardous energy sources associated with the machinery. These
barriers range from guards placed on moving pieces of machinery to protec-
tive equipment worn by workers. References to recognized controls can be
found in the occupational safety and health standards and appropriate publica-


Contributors

NIOSH WORKING GROUP MEMBERS

John B. Moran, Chair
Alfred A. Amendola
Donald L. Campbell, Ph.D.
Murray L. Cohen, Ph.D.
Joyce A. Johnson

Herbert I. Linn

Robert D. Mahon

James D. McGlothlin

Michael B. Moll, Ph.D.

Stanley J. Reno, P.E., C.S.P.
Richard M. Ronk

Lee M. Sandeson, Ph.D.
Alexander B. Smith, M.D.
Ronald L. Stanevich, M.S.
James B. Walters, M.P.H., P.E.

SYMPOSIUM PANELISTS

John B. Moran, Chair
National Institute for Occupational
Safety and Health

Mohammed M. Ayoub, Ph.D.
Texas Tech University

Susan H. Baker, M.P.H.
Johns Hopkins School of Public Health

Ralph L. Barnett, Ph.D.
Triodyne, Inc.

Richard F. Boggs, Ph.D.

Organization Resources Counselors, Ine.

Darrel D. Douglas
Workers Compensation, State of Oregon

Richard M. Duffy, M.S.
International Association of Fire
Fighters, AFL-CIO

James L. Frost, M.D.
West Virginia University School of
Medicine

Thomas H. Seymour
Occupztional Safety and Health
Administration

Ralph J. Vernon, Ph.D.

Texas A&M University

21




Vi. Prevention Components: What Knowledge Do We Need

Because the basic elements of effective safety programs are known, management can
operate such programs efficiently and profitably to reduce occupational injuries.
However, to progress in this endeavor, management must have access to cost-
effective, scientifically proven methods that reduce injuries, and it must have more
information to help allocate limited resources for occupational safety programs.
Information valuable to management would include:

° Risks presented in measurable terms

Methods developed to assess workplace hazards and controls

Criteria to select workers for specific task, environment, machine, and worker
interrelationships

¢ Components of effective safety training programs

* Means of assessing worker stress indicators in relation to safe job performance

Access to proven safe work practices and procedures

A. Task-Oriented Strategies: Modifying the Job

Scientific validation is needed for the established countermeasures relating to
task procedures. In general, established countermeasures represent the best
judgment of the trauma control community, but they have not been demonstrated
through rigorous scientific studies to be effective. Recommended procedures for
specific tasks would certainly be more readily accepted and used if they were
demonstrably effective in reducing worker injury and death. In addition, mea-
surement of the effectiveness of a particular countermeasure would be invaluable
in demonstrating the cost-effectiveness to employers, managers, and the publicin
general.

B. Environment-Oriented Strategies: Changing the Work Environment

1. Physical Environment

Although guidelines are available for controlling harmful environmental
agents, the influence of these agents on the incidence of occupational trau-
matic injuries has not been defined. For example, some initial investigations
of the potential detrimental effect of such agents on optimal safety perfor-
mance have been conducted, but much research lies ahead.

. Psychosocial Environment

A major impediment to traumatic injury control is the notion, prevalent in the
general population, that “accidental” injuries are not preventable. In addi-
tion, two fundamental components of the national psychology —risk taking
behavior and the perception of personal immunity from injury—extend quite
naturally into the working environment. The psychosocial environment, as it
influences the perception of hazard and risk taking, is amenahle to modifica-
tion through the techniques of advertising, information dissemination, and
social interaction. For example, the decline in cigarette smoking in the United


through standards and educational resources. Although these various regula-
tory agencies require training, the degree and level of training are seldom
specified, resulting in extreme differences in the application of training
among similar industries or within the same industry. Also, existing regula-
tions may not cover certain high-risk groups at all, and therefore even
minimal training in hazard awareness and control is not provided.

A key activity in the development of training programs is identification of
training components that combine to produce a successful program. The
establishment of a model training program could ensure that a wider popula-
tion of workers is provided more uniform and basic training in hazard aware-
ness and trauma control. Of course, such models would require tailoring to
meet the specific needs of particular industries, worker populations, and
facilities.

Employees in such high-risk occupations as punch press operators, crane
operators, industrial truck operators, over-the-road truck drivers, agricul-
tural workers, and workers in many occupations who are exposed to the
hazards inherent in confined work spaces, trenches, and chemical handling
tasks should be primary targets for such training.

. Hazard Communication

Effective communication through information dissemination, education, and
training could have an immediate positive impact on the incidence of work-
related injuries and deaths. Certain workplace energy hazards, or intrinsi-
eally dangerous operations such as confined space entry and excavations
work, might be effectively mitigated by implementing a program comparable
to the OSHA hazard communication standard addressing workplace chemi-
cals (29 CFR 1910.1200). Requiring employers to provide workers with
information and training on particularly hazardous aspects of their work could
substantially reduce traumatic injuries associated with those hazards.

. Known Interventions

When surveillance, particularly at the organizational level, identifies the high
incidence of a type of injury associated with a high risk industry, occupation,
or task (e.g., foot injuries in a foundry), known intervention methods (e.g.,
protective footwear) should be applied. Training and reinforcing the worker
to be aware of the high probability of traumatic injuries are important compo-
nents of an intervention program. By providing the worker with the tools and
knowledge to avoid traumatic injuries, intervention strategies serve as effec-
tive models toward prevention efforts.

. Rehabilitation

Rehabilitation services, available through several programs, provide retrain-
ing in different occupations for workers suffering permanent disabling inju-
ries at work. Such programs will increase in importance with the decrease in
the number of younger workers entering the workforce and the national trend
toward an older workforce.


tems. Indeed, the importance of management's role in the prevention of occupational
traumatic injuries cannot be overemphasized, and providing managers with valid,
useful information is a must.

The present discussion follows the order of the workplace components outlined
above. It addresses those risk factors of the workplace components for which we now
have sufficient information to implement effective intervention strategies and then
examines those risk factors for which critical knowledge gaps must still be explored
before meaningful intervention can begin.

. Prevention Components: What We Know and Can Implement Now

Energy release is associated with the interaction of task, environment, machine, and
worker. Traumatic injuries may result from employee exposures to unexpected
releases of energy in amounts that the human body cannot tolerate. The release of
energy that results in harm is usually due to lack of management control or improper
management of the working environment.

Programs established to reduce occupational traumatic injuries must be formulated
and implemented by management. Management policies, procedures, and supervi-
sion dictate how effective injury prevention efforts will be.

Evaluation of effective safety programs has established that the most important
component of such programs is management’s commitment from the top down. Such
programs contain basic elements such as safety policy statements, assignment of
safety responsibilities through all levels of management, establishment of safety
performance accountability, identification of hazards in the workplace, establishment
of control measures (in accordance with regulatory and consensus safety standards),
employee involvement in hazard identification and control, safety training for em-
ployees, accident investigation policies, and planning for emergencies. Management
accepts the responsibility of tying these elements together so that the nucleus of the
industrial system (task, environment, machine, worker) can function with the least
possible unforeseen interruption.

A. Task-Oriented Strategies: Modifying the Job

Failure to follow established standards for work practice is considered responsible
for a large portion of occupational injuries and deaths. Reduced numbers of
injuries and deaths can result from the increased use of effective work practices.

Safe work practices exist for many hazardous operations. Control methods exist
for all energy sources found in United States workplaces. The extent of occupa-
tional injury incidence indicates that employers either are unaware of the hazards
inherent in their operations, or the appropriate control strategies, or are unable or
unwilling to effectively implement those strategies. This indicates weaknesses in
dissemination and employers’ safety programs.

Employers can use job hazard analysis as a technique to identify job hazards and
appropriate preventive countermeasures. All job tasks should be analyzed indi-
vidually from the perspective of identifying obvious, anticipated, or foreseeable
hazards. Of course, not all hazards are immediately obvious or can be reasonably
foreseen. Programs should include timely reassessment or monitoring activities


B. Longer Term Actions
1. Develop a national surveillance system for traumatic injuries.

Based on the current limitations of existing documentation and reporting
systems for traumatic injury and the redundancies in these systems, it would
be highly desirable to establish a single surveillance system that satisfies all
regulatory, compensatory, litigation, and research requirements (including
causative models). Such a system would relieve American employers and
employees who are currently burdened with redundant criteria for reporting
information that is often not efficiently and effectively collected, analyzed,
and disseminated.

This reporting system for mortality and morbidity from injuries should cover
all American workers, regardless of their occupation, the number of employ-
ees they work with, or the extent of associated disability. A model with
optimal data elements in the system should be developed and tested to fulfill
all current and anticipated uses of such data.

Data should include information on products (machines, tools, equipment)
used in the workplace, such as identification of manufacturer and model;
engineering controls used; personal protective equipment used; job title and
tasks; worker characteristics, such as training, experience, and shift factors;
compliance with standards; and location of accident.

Information should also include sufficient etiologic descriptions of the cireum-
stances associated with injury incidence. All possible sources of information
about injury cases should eventually be tapped, including hospital reports,
medical examiner reports, and accident investigation reports. The system
should also include denominator data of sufficient detail to assess worker
risks of injury when combined with numerator data.

Design of the surveillance system should address the issues of confidentiality
(e.g., privacy act requirements) and the consideration of whether the acci-
dent investigation data collected should be used for punitive action (introduc-
tion of information bias). For selected areas of specific interest, the system
should allow further collection of specified information through followup of
individual cases.

Although development of a single, comprehensive surveillance system that
would satisfy a wide range of data requirements for traumatic injuries might
be an ideal solution to the limitations and burdens inherent in existing
systems, more practical interim efforts are possible. For example, existing
systems might be effectively augmented to expand their value for resear-
chers in traumatic injury control. At present, privacy acts have made some
data sources largely unavailable to those studying traumatic injuries. Such
sources might provide extensive and useful data if the sensitive information
can be properly protected. Surveillance systems specific to industrial sectors
and that support industry-specific research efforts might also be feasible (see
recommendation #3 below). A variation of the comprehensive system out-
lined above might entail the collection of a small core of data on each severely
injured worker, with mechanisms available to access other pertinent files or
accomplish more in-depth sampling of particular types of injuries, agents,
populations, or other factors.


Introduction

This document, A Proposed National Strategy for the Prevention of Severe Occupational Trauma-
tic Injuries, summarizes what actions need to be taken to prevent severe occupational traumatic
injuries. It was developed in 1985 at a conference sponsored by the National Institute for
Occupational Safety and Health (NIOSH) and The Association of Schools of Public Health (ASPH),
which brought together over 50 expert panelists and 450 other occupational safety and health

professionals.

In addition to the strategy for severe occupational traumatic injuries, NIOSH and ASPH have
published strategies for the other nine leading occupational diseases and injuries: occupational
lung diseases, musculoskeletal injuries, occupational cancers, occupational cardiovascular dis-
eases, disorders of reproduction, neurotoxic disorders, noise-induced hearing loss, dermatological
conditions and psychological disorders.

The proposed strategies were originally published in a two volume set, Proposed National Strat-
egies for the Prevention of Leading Work-Related Diseases and Injuries, Part 1 and Part 2. These
proposed strategies are not to be considered as final statements of policy of NIOSH, The Association
of Schools of Public Health, or of any agency or individual who was involved. Hopefully, they will be
used in the quest to prevent disease and injury in the workplace.

To learn of the availability of the complete texts of Part 1 and Part 2, or to obtain additional copies
of this or other Strategies, contact NIOSH Publications, 4676 Columbia Parkway, Cincinnati,
Ohio 45226, Telephone (518) 533-8287.


claims. Programs should be undertaken to identify the true costs of inju-
ries and fatalities and to moré clearly show the economic consequences of
trauma. For greater impact, these findings should be specific for industry
and occupation; and the results should be widely disseminated.

Furthermore, the human element of this issue of occupational trauma
insurance has dimensions beyond just compensation insurance. The cost of
not only compensation insurance but of disability and product-liability
insurance must be considered as well. From the designer’s perspective,
liability especially third party liability appears to be the driving force.
This may operate as a negative force by pushing up disability costs for
trauma and related compensation. The cost relationships between these
competing insurance elements, whether positive or negative, have never
been examined from the perspective of occupational trauma. Studies of
this should be undertaken and recommendations made for changes as
appropriate.

C. Machine-Oriented Strategies: The Safe Machine

Present concepts of safe machines generally involve installation of barriers or
enclosures around hazardous machine parts to prevent accidental worker contact.
Although these concepts seem to be effective, employees working with or around
machines still experience numerous injuries. This finding implies that several
potential problems exist with either the barrier concept or the lack of knowledge
of other factors contributing to injuries. Moreover, the large body of voluntary
consensus standards for machinery should be reevaluated and refined where
appropriate, and wider compliance should be promoted. Establishing and includ-
ing the current technical basis for each standard as part of the guidelines would
enhance user understanding and acceptance and would facilitate necessary revi-
sion.

Scientific studies must be performed to determine the efficacy of barrier methods
and to provide managers with expected rates of injury reduction through applica-
tion of these methods. Motivational and behavioral elements, such as piece wage
rates, should be evaluated with the associated injury problem.

Machines are being designed to operate faster and with greater reliability in
quality control of the product. Production systems are becoming more automated
with management goals of totally automated production lines, and new technolo-
gic uses of energy are being applied within these systems. These design concepts
should take into account safe methods of feeding and removing stock materials
and the stressors on workers to keep the automated system running. This should
lead to development of controls that minimize human (both manager and worker)
error and limit the speed and travel of machines within human reaction toler-
ances.

D. Human-Oriented Strategies: Managing the Worker
1, Age and Traumatic Injuries
America’s population is aging. By the year 2040, an estimated 68.4 million
people—one American in four —will be over the age of 65. The 18- to 24-year-

old work force, which has traditionally evidenced the highest traumatic
injury incidence rates, is declining in size. As the work force gets older, age-

il


the current workplace. Practical techniques of positive reinforcement must
be improved and applied for safe work practices.

a. Motivational Factors

Changes toward more service activities, the maturing of the work force,
and the decline of the 18- to 24-year-old population have already stimula-
ted major corporations to reexamine the factors that motivate workers.
Such studies have focused on economic considerations, with workers hired
and maintained on the basis of their motivation to produce. Some attention
has been devoted to motivational issues, such as studies of different
reinforcing strategies, which may be important to the reduction of trauma
in the workplace. More such studies should be undertaken.

b. Employee Participation

Inthe future, reducing traumatic injuries will involve more group partici-
pation than it has in the past. Recently, quality circles, formed in the
automobile industry to bring workers, unions, and management together
to discuss work issues including safety, have proved to be extremely
productive. However, the impact of such participative processes on
worker safety has not been fully evaluated scientifically.

In automobile plants, workers have been aiding management in a
smoother transition from one technology to another as manual materials
handling and assembly give way to automated systems, such as robot
material handlers and assemblers. Although the change in technology may
reduce some traumatic injuries (e.g., amputations from power presses),
impact or crushing fatalities may occur with robots. Therefore, manage-
ment must initiate ways to enlist the interest and cooperation of workers
so that the hazards inherent in new technologies can be fully understood
more quickly. Appropriate controls can be developed and made available
more rapidly if managers draw on the largest possible pool of expertise
available, including workers. Safety researchers need to determine what
intervention and prevention programs will be most effective in reducing
and eliminating traumatic injuries in computer-mediated work processes.

c. Use and Abuse of Substances

The use and abuse of substances as a factor in highway trauma is well
documented. Although the role of alcohol or drug abuse in the occupational
setting is less well understood, use of these substances has been linked to
such disasters as train derailments. Alcohol, controlled substances, physi-
cian-prescribed and self-prescribed medications are known to be used in
the workplace, but the magnitude of the problem is largely unknown. Use
of a single substance alone (e.g., alcohol) may result in trauma, or per-
sonal-use substances may combine with chemicals in the workplace (e.g.,
inhaled chlorinated hydrocarbons) to produce additive or synergistic ef-
fects that contribute to trauma-producing conditions. For example, the
pharmacologic effect of a prescribed medication may be altered by a
substance present in the working environment. If the effect is increased, it
may manifest in an overdose; if the effect is decreased, it may deprive a
worker of the needed benefits of medication. Either could contribute to a
traumatic injury at or after work. Consistent with its mandate to conduct

13


DHHS (NIOSH) Publication No. 89-131


Proposed
National Strategy
for the

Prevention of
Severe Occupational Traumatic Injuries

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service

Centers for Disease Control

National Institute for Occupational Safety and Health

1986


States can be attributed in large part to two closely related factors: 1) the
shift from media saturation with “pro-smoking” advertising toward a more
balanced media presentation of smoking (with some media legally prohibited
from “pro-smoking” advertisements) and 2) the evolution from an absence of
clear scientific and clinical evidence to a flood of information propelled by the
Surgeon General’s anti-smoking campaign.

The approach of environmental modification, including efforts to influence
coverage by the mass media, should be exploited through a serious concerted
effort. Messages must be specific, supportable, and persuasive. General
themes such as “safety first” or “think safety” have been minimally effective,
if at all. Clearly, modifying public perception to the degree that 1) traumatic
injuries are no longer regarded as resulting from “chance” occurrences be-
yond human control, and 2) the large number of injuries and deaths attributed
to work-related trauma are no longer morally acceptable, will represent a
quantum leap for a national preventive effort.

. Political/Economic Environment
a. Changing Work Force

The composition of the work force in the United States has changed
dramatically over the past 3 decades. Some industrial sectors are growing
much faster than others. For example, from 1950 to 1980 the rates of
increase in employment ranged from 14 percent in mining, 28 percent in
transportation, and 33 percent in manufacturing, to 170 percent in govern-
ment, 173 percent in finance, and 234 percent in the service sector.

Fundamental shifts in national employment patterns have continued into
the 1980s, such as rapidly increasing numbers of women and increasing
participation of certain ethnic minority groups in the work force. Other
changing patterns are likely to continue, with some estimates suggesting
that less than 10 percent of the national work force will be blue-collar
workers by the mid-1990s. The changing economic environment character-
ized by the exportation of blue-collar jobs and polarization of the work
force into professional, technical, managerial, and service occupations has
not been fully accommodated by a corresponding change in the thrust of
safety program application.

Remodernization, associated with increased use of computers and automa-
ted or programmable machines (robots), is rapidly expanding. These fac-
tors create a unique and dynamic environment that challenges proponents
of traumatic injury prevention and control to anticipate change. Develop-
ment of positive prevention-oriented planning must occur in parallel with
industrial change, not follow it.

b. Emerging Technology

We must begin immediately to apply to problems of the future those
organizational and technical lessons learned at such a high cost in the past.
After all, our failure to consider the potential hazards of the “new” techno-
logies of yesteryear (e.g., mass production, basic chemicals, and iron and
steel) allowed an exorbitant toll in unnecessary injuries and deaths
through the years, even to this day. Newly emerging technologies such as


12

related risk factors for traumatic injuries increase. Older workers give up
speed for accuracy, are slower to react in quickly changing situations, and
have reduced range of motion compared with their younger counterparts. In
addition, they may have less tolerance for changing environmental condi-
tions, such as extreme heat or cold. Although older workers are often consid-
ered more cautious and even more productive than their younger counter-
parts, the decreasing influx of young workers may force older workers to
remain in high-risk jobs or activities longer. Therefore, larger numbers of
injuries to older workers seem likely, not so much because of diminished
physical and sensory capabilities, but because of increased exposure.

Given the changing age of the United States work force, employers have
already begun to study ways to attract and keep younger workers. Careful
planning will be necessary to reduce traumatic injuries with consideration of
the risk characteristics of both young and older workers.

. Training

As our economy changes from heavy industry to service, training will become
more important, particularly as new and sophisticated equipment and sys-
tems are introduced into the workplace to increase productivity.

Training the worker is an art as well as a science. To master their jobs, and, as
a result, to reduce their odds of incurring traumatic injuries, workers have
basically been trained in four levels of technology: 1) the worker supplies
power and control, such as using a box wrench to tighten a nut, 2) the tool
supplies power and the worker controls it, such as using a hand-held power
screw gun to drive in a screw, 3) both power and information are supplied, but
the worker is in control, such as in a paper-making plant, and 4) power,
control, and information are supplied in a self-monitoring system, and
workers intervene only if something goes wrong, such as in a nuclear power
plant or when an autopilot is activated in an airplane.

In many industrial processes technology is rapidly leaving levels one and two
and moving toward levels three and four. Gomputer technology has made this
possible at an accelerated rate. Training of workers and retraining of older
workers have become issues that will be of greater importance in the future.
Research is needed on the ability of workers to control entire systems and to
provide quick, controlled, and reliable responses when problems arise.

The mere provision of training does not ensure that a traumatic event will not
occur. The adequacy of training, retraining, and post-training policies and
practices needs evaluation to determine appropriate prevention strategies
for particular groups of workers in selected work settings. The need for
retraining could be evaluated by analyzing surveillance data on the compo-
nents of traumatic events or investigations of near-misses.

. Behavior

Human behavior and its relationship to safe work activity have received little
if any research attention. Why do workers circumvent safety devices? Why
do they attempt to rescue a fallen worker in a confined space only to die
themselves in the rescue attempt? What outside workplace forces stimulate
or mitigate such behavior? Such issues must be addressed in the context of