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Support for Workplace Injury and Illness Prevention Programs

Policy Date: 11/5/2013
Policy Number: 20138

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Currently, the federal Occupational Safety and Health Administration (OSHA) does not require employers to implement comprehensive injury and illness prevention programs. Such programs, also known as occupational health and safety management systems, have been required by individual states and a number of countries and have been demonstrated to reduce work-related injury and illness. Critical components include management leadership, worker participation, hazard identification and remediation, training, and program evaluation. Such programs require accurate information about hazards and adverse outcomes. Many practices, policies, and programs present in workplaces today discourage workers from reporting injuries, illnesses, incidents, and accidents, obscuring the hazards that cause and contribute to injuries and illnesses. The promulgation of a standard to mandate specific requirements that employers have a comprehensive injury and illness prevention program has been delayed. OSHA should move forward by issuing a draft proposal and should address behavior-based safety programs that, through incentives, disincentives, and other schemes, undermine the principles of injury prevention. The science of hazard reduction to reduce or eliminate public health risks is the primary focus of effective workplace health and safety programs and OSHA enforcement. Action items include recommendations for OSHA, the Mine Safety and Health Administration, and the National Institute for Occupational Safety and Health, the federal agencies charged with workplace health and safety responsibilities.

Problem Statement

Injury and illness prevention programs are the core strategy of occupational health and safety professionals. Also known as occupational health and safety management systems, integrated programs that include management commitment, worker participation, hazard identification and remediation, training, and program evaluation have been supported by professional and standard-setting organizations internationally. Thirty-four states have instituted worker safety, health protection, and injury/illness prevention initiatives, including 15 states with required illness and injury prevention programs. The Occupational Safety and Health Administration (OSHA) describes reductions in reported illnesses and injuries following the implementation of such programs, citing Smitha and others who have found that state requirements for safety and health programs and for labor-management safety committees lead to significantly reduced injury rates in the manufacturing sector.[1–3] Canada, Australia, Norway, and the European Union all require comprehensive safety and health programs. In Norway, which has had an occupational safety and health management requirement in place since 1992, a cross-sectional study of garage workers conducted in 1996 demonstrated that workers in garages that had implemented safety and health programs had fewer musculoskeletal injuries.[4]

Comprehensive illness and injury programs are based on core public health principles of assessment, policy development, and assurance and incorporate an ecological framework that addresses interventions at all levels. Such programs attempt to integrate safety into the core values of an organization with the understanding that individual worker errors are inevitable; they rely on systems approaches that account for potential errors and engineered solutions that are tested for effectiveness. Systems approaches depend on trust among frontline workers that information about errors or potential errors is valued by management and will not be met with retribution and disciplinary measures.[5–9] The accepted occupational health and safety practice of elimination of hazards is the most effective method to improve workplace health and safety.[10,11]

Currently, OSHA does not require employers to implement these comprehensive programs, which identify and control hazards to reduce the incidence of workplace injuries and illnesses.

Comprehensive injury/illness prevention programs require accurate data collection to correctly identify hazards and determine whether remediation efforts have been successful. They also require management leadership, worker participation, and training to fully implement hazard identification and remediation. Behavior-based safety (BBS) policies, programs, and practices focus on worker behavior rather than on workplace hazards as the cause of occupational injuries and illnesses, punish workers when injuries or illnesses occur, and promote underreporting of adverse outcomes, leading to lost opportunities for prevention, meaningful worker engagement, and root cause analyses. Organizations in which all workplace injuries are reviewed with an eye toward specific infractions committed by the individual prior to the injury (rather than searching for root causes) and any infractions are punished by point systems that lead to suspension or firing reduce workers’ willingness to report injuries as work related, thereby obscuring valuable information about safety. Similarly, safety reward programs in which groups of workers are awarded incentives as small as a pizza party or as large as pick-up trucks and expense-paid vacations create peer pressure that again mitigates against reporting injuries.[12–21]

Extent of the problem: Fatal traumatic injuries claim more than 12 lives each day in the United States, with an estimated 60,000 more deaths occurring annually as a result of occupational diseases.[1] In addition, 4.1 million workers suffer serious occupational injuries and illnesses each year.[1] The overall annual burden of occupational injuries and illnesses was an estimated $140 billion in 1997.[1] Underreporting of occupational injuries and illnesses has been the focus of congressional hearings, a US Government Accountability Office report, and OSHA investigations.[22,23] Recent estimates suggest that the Bureau of Labor Statistics may miss between one-third and two-thirds of all reportable injuries and illnesses.[24,25] In November 2011, OSHA deputy assistant secretary Jordan Barab reported that half of the workplaces inspected as part of OSHA’s Recordkeeping National Emphasis Program were found to have underreported work-related injuries and illnesses.[26] According to the aforementioned Government Accountability Office report, more than two-thirds of injured workers fear employer discipline or loss of their job if they report a job injury.[23]

A number of concerns have been raised about programs that discourage reporting. For example:

• Hazards involved in injuries and illnesses that are not reported go unrecognized and uncorrected.
• The ability of workers and employers to fully address the health and safety issues present in their workplace is restricted.
• Workers continue to experience injuries and illnesses when reporting is suppressed because the hazards causing or contributing to these injuries and illnesses are not remediated.
• There is a chilling effect on the participation of employees in workplace efforts to improve health and safety conditions.
• Such programs lead to underestimates of the national impact of workplace injuries and illnesses.[12–23]

Proposed Recommendations Statement

Current strategies to address this public health problem include the following:

• Educate workers, unions, and management about the science of injury and illness prevention and hazard control and the use of tools such as audits; accident, incident, and near-miss processes; root cause analyses; and surveys to identify hazards and hazardous conditions so that they can be eliminated or reduced
• Develop OSHA regulations that would mandate injury and illness programs and prohibit employer policies, programs, and practices that discourage workers from reporting injuries and illnesses
• Develop an OSHA injury and illness prevention program standard that requires employers to implement workplace health and safety programs that identify and address workplace hazards and hazardous conditions

Opposing Arguments

Organizations opposing the institution of injury/illness prevention standards maintain that the requirements would be too burdensome to businesses. Employers have argued that such rules could discourage workers from engaging in voluntary health and safety activities. Many BBS consultants and others have claimed that implementation of BBS programs leads to significant reductions in the incidence of occupational injuries and illnesses. Proponents often claim that these programs are not intended to discipline workers or discourage reporting of injuries and illnesses. Also, they claim that coaching and behavior modification can help employees develop safe work habits. Proponents of safety incentive programs argue that these programs are generally effective and have a proven track record of reducing numbers of reported injuries.[27,28]

In response to proponents of BBS policies and their arguments in favor of such practices, many in the public health community counter that behavior-based safety practices and programs are rooted in the false belief that workplace accidents are caused by workers’ unsafe acts rather than hazardous workplace conditions. A recent study by Lipscomb et al. described the use of incentive and disincentive programs among union carpenters and characterized behavior-based safety as being grounded in two flawed theories. One is H.W. Heinrich’s theory from the 1930s according to which 88% of job injuries are caused by workers’ unsafe acts. Heinrich’s research involved a review of accident reports written by supervisors, and 88% of them blamed the worker for the accident. Heinrich’s theory has been widely discredited.[6] The second flawed theory is that of B.F. Skinner, a psychologist who developed principles of operant conditioning (reward and punishment theory). Lipscomb et al. revealed that operant conditioning has failed to create lasting behavior change when the “carrots and sticks” are removed. Behavior-based safety practices and programs have purported to bring about a decline in job-related injuries and illnesses, but research shows that these practices lead to decreases in the reporting of occupational injuries and illnesses, not to decreases in the actual prevalence of such injuries and illnesses.[13,29]

Action Steps

• OSHA must promulgate an injury/illness prevention standard that requires employers to implement comprehensive workplace health and safety programs focused on identifying and addressing workplace hazards.
• The National Institute for Occupational Safety and Health (NIOSH) must continue research identifying and characterizing employer programs, policies, and practices that discourage workers from reporting injuries and illnesses.
• NIOSH must implement pilot programs involving a scientific approach to identification and control of workplace hazards.
• OSHA, NIOSH, the Mine Safety and Health Administration (MSHA), and other government health and safety agencies must support the development of materials, curricula, and education aimed at promoting workplace efforts to identify and address hazardous conditions. They must also support the development of effective, comprehensive workplace injury and illness prevention programs.
• OSHA and MSHA must strengthen legal requirements prohibiting employers from implementing or maintaining policies, programs, or practices that discourage employees from reporting work-related injuries and illnesses. These policies, programs, and practices include, but are not limited to, safety incentive programs that provide rewards to individual workers as well as groups of workers when there are few or no reports of injuries or illnesses; injury discipline policies wherein employees receive threats of or actual discipline when they report work-related injuries or illnesses; mandated post-injury drug testing for employees who report work-related injuries or illnesses; and programs that focus on worker behaviors as the primary cause of occupational injuries and illnesses.
• OSHA and MSHA must have meaningful penalties for employers found to have policies, programs, or practices that discourage workers from reporting work-related injuries and illnesses.
• State and local jurisdictions must continue to promulgate and enforce meaningful workplace injury and illness prevention programs in the absence of a comprehensive federal standard.


1. Occupational Safety and Health Administration. Injury and illness prevention programs. Available at: http://www.osha.gov/dsg/InjuryIllnessPreventionProgramsWhitePaper.html. Accessed November 30, 2013.
2. Occupational Safety and Health Administration. Employer safety incentive and disincentive policies and practices. Available at: https://www.osha.gov/as/opa/whistleblowermemo.html. Accessed November 30, 2013.
3. Smitha MW, Kirk KA, Oestenstad KR, Brown KC, Loo SD. Effect of state workplace safety laws on occupational injury rates. J Occup Environ Med. 2001;43(12):1001–1010.
4. Torp S, Riise T, Moen BE. Systematic health, environment and safety activities: do they influence occupational environment, behaviour and health? Occup Med. 2000;50(5):326–333.
5. DeJoy DM, Schaffer BS, Wilson MG, Vandenberg RJ, Butts MM. Creating safer workplaces: assessing the determinants and role of safety climate. J Safety Res. 2004;35:81–90.
6. Chapanis A. To communicate the human factors message, you have to know what the message is and how to communicate it. Hum Factors Soc Bull. 1991;34(11):1–4.
7. Dekker SWA, Nyce JM, Myers DJ. The little engine that could not: “rehabilitating” the individual in safety research. Cognition Technol Work. 2013;15(3):277–282.
8. Hopkins A. Safety, Culture and Risk: The Organizational Causes of Disasters. Sydney, Australia: CCH Australia Limited; 2005.
9. Reason J. Managing the Risks of Organizational Accidents. Hampshire, England: Ashgate Publishing; 2000.
10. Manuele F. Reviewing Heinrich: dislodging two myths from the practice of safety. Professional Safety. October 2011:52–61.
11. Holden RJ. People or systems? To blame is human. The fix is to engineer. Available at: http://www.asse.org/professionalsafety/pastissues/054/12/F3Holden_1209.pdf. Accessed November 30, 2013.
12. Lessin N, McQuiston TH. An inverse relationship between injuries and fatalities: what is surprising—and what is not Am J Ind Med. 2013;56(5):505–508.
13. Lipscomb HJ, Nolan J, Patterson D, Sticca V, Myers DJ. Safety, incentives, and the reporting of work-related injuries among union carpenters: “you’re pretty much screwed if you get hurt at work.” Am J Ind Med. 2013;56(4):389–399.
14. Azaroff A, Levenstein C, Wegman D. Occupational injury and illness surveillance: conceptual filters explain underreporting. Am J Public Health. 2002;92(9):1421–1429 .
15. California State Auditor. San Francisco-Oakland Bay Bridge worker safety. Available at: http://www.bsa.ca.gov/pdfs/reports/2005-119.pdf. Accessed November 30, 2013.
16. Review of the Literature on Safety Incentives. Washington, DC: Dennison Associates; 1998.
17. Elgin B. Caution: stats may be slippery. Available at: http://www.businessweek.com/magazine/content/10_12/b4171057616634.htm. Accessed November 30, 2013.
18. Gerard LW. Safety awards that endanger workers’ lives. Available at: http://blog.usw.org/2010/05/21/safety-awards-that-endanger-workers%E2%80%99-lives/. Accessed November 30, 2013.
19. Greenhouse S. Work-related injuries underreported. Available at: http://www.nytimes.com/2009/11/17/us/17osha.html?_r=1&pagewanted=print. Accessed November 30, 2013.
20. Grunberg L, Moore S, Greenberg E. The relationship of employee ownership and participation to workplace safety. Econ Ind Democracy. 1996;17(2):221–241.
21. Ruser JW, Smith RS. The effect of OSHA records-check inspections on reporting occupational injuries in manufacturing establishments. J Risk Uncertainty. 1988;1(4):415–435.
22. Hidden Tragedy: Underreporting of Workplace Injuries and Illnesses. Washington, DC: Committee on Education and Labor, US House of Representatives; 2008.
23. US Government Accountability Office. Workplace safety and health: enhancing OSHA records audit process could improve accuracy of worker injury and illness data. Available at: http://www.gao.gov/products/GAO-10-10. Accessed November 30, 2013.
24. Pransky G, Snyder T, Dembe A, Himmelstein J. Under-reporting of work-related disorders in the workplace: a case study and review of the literature. Ergonomics. 1999;42(1):171–182.
25. Leigh JP, Marcin JP, Miller TR. An estimate of the U.S. government’s undercount of nonfatal occupational injuries. J Occup Environ Med. 2004;46(1):10–18.
26. Bureau of National Affairs. Barab says half of workplaces inspected under OSHA emphasis program underreport. Available at: http://www.bna.com/barab-says-half-n12884904254/. Accessed November 30, 2013.
27. Geller SE. Behavioral safety: key to achieving a total safety culture. Professional Safety. July 1995:16–22.
28. Marcombe JT, Krause TR, Finley RM. Behaviour-based safety at Monsanto’s Pensacola plant. Chemical Engineer. April 29, 1993:15–17.
29. Kohn A. Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A’s, Praise and Other Bribes. New York, NY: Houghton Mifflin; 1993.