Injury and Illness Analysis. Fiscal Year (FY) 2008 (October 1, 2007 September 30, 2008) Report No. 1

Injury and Illness Analysis Fiscal Year (FY) 2008 (October 1, 2007 September 30, 2008) Report No. 1 Ernest Orlando Lawrence Berkeley National Laboratory

Table of Contents 1 Executive summary...1 2 Introduction...1 3 Analysis Methods...2 4 Analysis...3 4.1 TRC and DART Rates...3 4.2 First Aid Cases...11 4.3 Categories and Causes of Injuries...12 4.4 Work Load Factor...13 4.5 Corrective Action / Injury Causal Factor...14 Table of Figures Figure 1 - FY TRC and Dart with DOE Goal...3 Figure 2 - LBNL TRC and DART Rates vs DOE Contractors...4 Figure 3 Retrospective and Current TRC Rates Moving Average with Control Limits...4 Figure 4 - Retrospective and Current DART Rates Moving Average with Control Limits.5 Figure 5 - TRC Rates Jul 97 to Sept 08...6 Figure 6 - DART Rates Jul 97 to Sept 08...7 Figure 7 - Cumulative TRC Cases FY08...8 Figure 8 - Cumulative DART Cases FY08...8 Figure 9-3 Year TRC Cases: Monthly...9 Figure 10-3 Year DART Cases: Monthly...9 Figure 11 - FY06-08 TRC Cases by Division...10 Figure 12 - FY06-08 DART Cases by Division...10 Figure 13 Percent of All Reported Cases that are Recordable...11 Figure 14 - FY08 Monthly First Aid and Recordable Case Comparison...11 Figure 15 - First Aid - Recordable Case Visual Comparison FY02 to FY08...12 Figure 16 - Categories and Causes of Injuries...12 Figure 17 - Work Load Factor in Injury...13 Figure 18 - Quality of Accident Reports...14 Figure 19 - Injury Causal Factor by ISM Category for FY08...14 Figure 20 Injury Corrective Action by ISM Category for FY08...15

1 Executive summary This trending and analysis report for the LBNL Injury and Illness Recordkeeping and Reporting program is based on the analyses performed during FY 2008 but includes retrospective data and some analyses for years ranging back to 1997 and earlier. Primary drivers for monitoring injury and illness data are (1) to understand what institutional and divisional efforts can be enhanced to improve safety culture and performance and (2) to meet DOE reporting requirements and contract performance goals. The data is presented to allow the diverse Laboratory population access and understanding of our injury and illness performance status and be able to use selected information towards safety enhancements in their work processes. For FY08, the LBNL OSHA recordable injury case rate increased by 6% over FY07 with two thirds of the cases classified as musculoskeletal disorders associated with repetitive motion or other ergonomic factors. The DART case rate improved marginally by 2%. Neither the DOE TRC goal of 0.65 nor DART goal of 0.25 were achieved for FY08. The LBNL longer term improvement from FY 2000 through FY 2008 is nominally 50% for the TRC rate and 40% for the DART rate. Division loss leaders for FY 08 were Genomics (15 TRC and 8 DART cases), Engineering (6 TRC and 4 DART cases), and Facilities (6 TRC and 5 DART cases). A trend continues to show reduction in the number of overall cases that are OSHA recordable which may substantiate effectiveness in the emphasis our ergonomic program is placing on early discomfort and pain reporting as well as intensive intervention. The downward trend in this ratio may also support claims that other EH&S programs and divisional ISM implementation efforts are beginning to pay off. Approximately three quarters of the FY08 OSHA recordable cases were musculoskeletal injuries of which one third were not related to repetitive motion but associated with material handling or other trauma related events. Of the remaining musculoskeletal disorder cases, all repetitive motion based in nature, one half were computer work station related and one half work process related (e.g., pipetting, machine manipulation, etc.). General industrial safety and safe workplace conditions contribute negligibly to the LBNL injury rates. An end of fiscal year study found that at least 4% of the computer related repetitive motion injuries over the last 5 years have some basis in work load management. An analysis of all FY08 first aid and OSHA recordable cases determined that 20% of all injury reports are inadequately completed and don t fulfill the purpose of providing performance monitoring and improvement under ISM. Additionally, the analysis determined that the divisions and institution overall must better align the corrective actions associated with the injury causal factors developed during injury reviews. 2 Introduction Injury and Illness Recordkeeping and Reporting (IIRR) are important contributions to the feedback and improvement component of the LBNL Institutional Integrated Safety Management (ISM) System. LBNL performs IIRR in accordance with PUB 3851, LBNL Worker Safety and Health Plan and the Plan s subordinate requirements set forth in PUB 3000, 10 CFR 851, 29 CFR 1904, and DOE M 231.1A. Page 1 of 17

This trending and analysis report specifically addresses the injury and illness performance for LBNL during the fiscal year 2008 with reference to institutional and DOE goals. Retrospective use of injury and illness data is necessary in the analyses for a true representation of the long term and current short term performance trends. This analysis is based on the DOE prescribed metrics associated with OSHA recordable injuries (TRC total recordable cases) and OSHA recordable injuries with restricted or lost work days (DART days away, restricted, or transferred cases). Important information is also gained by examining trends associated with indicators such as the number of first aid cases, the alignment of corrective actions with injury causal factors, the types of injuries, and the correlation of injuries with work load. Current and archived monthly performance analysis is made available to all LBNL personnel on the Lab website home page (see OUR SAFETY) and on the EH&S Division web pages. 3 Analysis Methods TRC and DART Injuries Monthly and long term TRC and DART injuries are tracked for the institution overall and by division. TRC and DART rates are calculated using industry wide normalization methods that allow comparison across institutional boundaries whereby the calculated rate is that which is equivalent to the injury rate for 100 workers over the course of a year. LBNL bases the calculation on the fiscal year (October 1 through September 30) and these rates are updated on a monthly basis as the fiscal year progresses. These results are reported in conjunction with retrospective data that in some cases ranges back to 1990. Comparison with overall DOE contractor performance and with DOE Office of Science goals is made. Rates are presented both in bar chart and continuous data format. Control chart methods are applied to the current and retrospective data for OSHA recordable and DART case analysis as standard and moving averages. The standard control graph shows the mean, and 1, 2, and 3 standard deviation control lines for application of re-base lining technique where trends exist. The 12 month moving average basis contributes a hysteresis effect to the individual monthly data point. Application of the control rules against data points that lie outside of the 95% boundary validates statistical significance. First Aid All first aid cases (those not classified as OSHA recordable or DART cases) are logged in the IIRR system. The percentage of OSHA recordable to first aid cases is calculated and plotted. Corrective Action Alignment with Injury Causal Factor A new analysis was initiated at the conclusion of FY08 to determine the effectiveness of Lab injury analysis efforts and to provide feedback on where each Lab division can improve their ISM implementation. All first aid and OSHA recordable injury reports were reviewed, the identified causal factors extracted from the reports, and the corresponding corrective actions in response to the causal factors identified. Each causal factor and corrective action was classified as to which ISM Guiding Principle and Core Function it represented. Visual and raw number comparisons were used to assess the alignment of corrective action development with the identified injury causal factors. Page 2 of 17

This analysis also allowed calculation of the percentage of injury reports that did not provide satisfactory information (i.e., deficient reports) to complete the ISM analysis. Type of Injury OSHA recordable and cases are classified and tracked by generic nature and generic cause and graphically presented in each monthly injury and illness summary illustrating the ratio to the total number of cases to date. Work Load Factor Another new analysis was initiated at the conclusion of FY08 that examines the correlation of possible Work Load inducement of injury which has safety management elements in all ISM work cycle elements (Roles and Responsibilities, Work Planning and Prioritization, Hazard Analysis, Control and Mitigation of Hazards, Work Authorization and Performance, and Performance Monitoring and Feedback). All first aid and OSHA recordable cases were reviewed for the period FY03 through FY08. Where specific statement of work load factors was mentioned in the report, the case was counted as a Work Load factor case. The summation of work load factor cases was applied to the Type of Injury analysis described immediately above and the results graphically presented illustrating the impact of work load factor on the population of cases evaluated. 4 Analysis 4.1 TRC and DART Rates Berkeley Lab Site-Wide TRC & DART Rates (Includes all Construction and Service Contractors) Through September 30, 2008 (Revised 12/17/08) TRC & DART cases per 100 employees per year 4.00 3.50 3.00 2.50 2.00 1.50 1.00 0.50 0.00 3.63 2.05 2.44 1.16 2.17 2.51 1.07 1.11 1.17 0.45 Total Recordable Case Rate DART Rate (Days Away, Restricted or Transferred) TRC Goal DART Goal FY '00 FY '01 FY '02 FY '03 FY '04 FY '05 FY '06 FY '07 FY '08 1.81 0.68 1.17 0.5 1.28 0.31 1.65 0.83 0.65 0.25 1.75 0.81 Figure 1 - FY TRC and Dart with DOE Goal Figure 1 demonstrates that the LBNL exceeds the TRC and DART rate performance goals, set by DOE, by over a factor of 2. The chart provides visual comparison with the previous 8 years of experience. The chart only provides an assessment of performance Page 3 of 17

with respect to a set of arbitrary DOE goals. FY08 TRC and DART performance changes over FY07 are +6% and -2% respectively. There is no specific information that lends itself to systemic improvement. TRC and DART rates are termed lagging indicators. Berkeley Lab Site Accident Rates 6.00 5.70 Site Total Recordable Case Rate Site DART (Days Away, Restricted, Transferred) Case Rate 5.00 4.95 DOE Contractor (Calendar Year) TRC Rate DOE Contractor (Calendar Year) DART Rate Cases per 200,000 hours worked 4.00 3.00 2.00 1.00 3.90 3.41 3.79 2.65 2.92 2.93 2.05 1.70 3.27 2.43 3.63 2.05 2.44 1.16 2.51 2.17 1.07 1.11 1.17 0.45 1.81 0.68 1.28 0.31 1.75 1.65 0.83 0.81 0.00 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Fiscal Year Revised December 17, 2008 Figure 2 - LBNL TRC and DART Rates vs. DOE Contractors Figure 2 shows that LBNL has exceeded the DOE contractor experience in the past two years for both TRC and DART rates. Again, there is no inherent specific performance improvement information gained from this analysis. Berkeley Lab Total Recordable Case Rates With Control Limits At 95% Confidence Level Cases per 200,000 hours worked 12.00 10.00 8.00 6.00 4.00 2.00 Interpretation Rules: 95% of monthly rates are expected to be within the control limits. The following situations warrant inquiry to determine if changes are statistically significant: 1. A monthly rate outside of the control limits 2. Seven consecutive values above or below the central line 3. Seven successive values trend up or down 4. 10 of 11 successive values all above or all below the central line Site TRC Rate Monthly Site TRC Rate 12 Months Moving Average Upper Control Limit Lower Control Limit 0.00 Jan-91 Jan-92 Jan-93 Jan-94 Jan-95 Jan-96 Jan-97 Jan-98 Jan-99 Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Revised December 17, 2008 Figure 3 Retrospective and Current TRC Rates Moving Average with Control Limits Page 4 of 17

Berkeley Lab DART Rates With Control Limits At 95% Confidence Level (Cases with Days Away, Restricted or Transferred) Cases per 200,000 hours worked 10.00 9.00 8.00 7.00 6.00 5.00 4.00 3.00 2.00 1.00 Site DART Rate Monthly Site DART Rate 12 Months Moving Average Upper Control Limit Lower Control Limit Interpretation Rules: 95% of monthly rates are expected to be within the control limits. The following situations warrant inquiry to determine if changes are statistically significant: 1. A monthly rate outside of the control limits 2. Seven consecutive values above or below the central line 3. Seven successive values trend up or down 4. 10 of 11 successive values all above or all below the central line 0.00 Jan-92 Jan-93 Jan-94 Jan-95 Jan-96 Jan-97 Jan-98 Jan-99 Jan-00 Jan-01 Jan-02 Jan-03 Jan-04 Jan-05 Jan-06 Jan-07 Jan-08 Revised December 17, 2008 Figure 4 - Retrospective and Current DART Rates Moving Average with Control Limits Figure 3 and Figure 4 present the twelve month basis moving average of the TRC and DART rates respectively for the 17 year period through FY 2008. The primary value of this analysis and presentation is support for the argument that although the TRC rate of 1.75 and DART rate of 0.81 exceed the DOE performance goals, LBNL rates fall statistically in a range equivalent to stochastic noise when considering a 95% bandwidth above and below the mean. The control charts in Figure 5 and Figure 6 (below) display 4 basic trend periods in the retrospective and current TRC and DART case rate data for the period July 1997 through September 2008. Four distinct baseline regions are shown. During the first 3 baseline steps TRC rates decreased by 25% (starting around October of 2000) and 42% (starting around October 2003) but then increased by 20% starting around July 2006. Likewise, the DART rates decreased by 46% and 44% and increased by 28% over the same time intervals. Explanation for these significant trend changes is quite subjective without testing different hypotheses. Page 5 of 17

Jul-08 Case Rate Baseline Avg UCL 2 σ 1 σ -1 σ Linear (Case Rate) 42% Improvement 20% Decline 1.38 1.65 Apr-08 Jan-08 Oct-07 Jul-07 Apr-07 Jan-07 Oct-06 Jul-06 Apr-06 Jan-06 Oct-05 Jul-05 Apr-05 FY08 Injury and Illness Recordkeeping and Reporting Trending and Analysis Report TRC Jul 97 to Sept 08 Re-baselined 8.00 25% Improvement 3.16 7.00 2.38 6.00 5.00 4.00 TRC 3.00 2.00 1.00 0.00 Jan-05 Oct-04 Jul-04 Apr-04 Jan-04 Oct-03 Jul-03 Apr-03 Jan-03 Oct-02 Jul-02 Apr-02 Jan-02 Oct-01 Jul-01 Apr-01 Jan-01 Oct-00 Jul-00 Apr-00 Jan-00 Oct-99 Jul-99 Apr-99 Jan-99 Oct-98 Jul-98 Apr-98 Jan-98 Oct-97 Jul-97 Figure 5 - TRC Rates Jul 97 to Sept 08 Page 6 of 17

Jul-08 Case Rate Baseline Avg UCL 2 σ 1 σ -1 σ Linear (Case Rate) 44% Improvement 28% Decline.78.61 Apr-08 Jan-08 Oct-07 Jul-07 Apr-07 Jan-07 Oct-06 Jul-06 Apr-06 Jan-06 Oct-05 Jul-05 Apr-05 Jan-05 Oct-04 Jul-04 FY08 Injury and Illness Recordkeeping and Reporting Trending and Analysis Report DART Rates Jul 97 to Sept 08 5.00 46% Improvement 4.50 4.00 2.00 3.50 1.09 3.00 2.50 2.00 DART Rate 1.50 1.00 0.50 0.00 Apr-04 Jan-04 Oct-03 Jul-03 Apr-03 Jan-03 Oct-02 Jul-02 Apr-02 Jan-02 Oct-01 Jul-01 Apr-01 Jan-01 Oct-00 Jul-00 Apr-00 Jan-00 Oct-99 Jul-99 Apr-99 Jan-99 Oct-98 Jul-98 Apr-98 Jan-98 Oct-97 Jul-97 Figure 6 - DART Rates Jul 97 to Sept 08 Page 7 of 17

Berkeley Lab and Contractors Cumulative Total Recordable Cases By Fiscal Year 60 50 40 Cumulative Cases FY 2006 Cumulative Cases FY 2007 Cumulative Cases FY 2008 Approximate Cases for Contract Goal = B+, TRC=0.65 Linear (Cumulative Cases FY 2008) Linear (Cumulative Cases FY 2007) Linear (Cumulative Cases FY 2006) 34 39 44 46 52 Cases 30 20 15 17 20 24 27 B+ 10 7 11 Note: Cumulative Case Goals are based on the assumption that the same number of hours will be worked in the current year as previous year 0 October November December January February March April May June July August Through May 16, 2008 September Figure 7 - Cumulative TRC Cases FY08 30 Berkeley Lab and Contractors Cumulative DART (Days Away, Restricted, Transferred) Cases By Fiscal Year 25 20 Cumulative Cases FY 2006 Cumulative Cases FY 2007 Cumulative Cases FY 2008 Approximate Cases for Contract Goal = B+, DART=0.25 Note: Cumulative Case Goals are based on the assumption that the same number of hours will be worked in the current year as previous years 18 19 22 21 24 Cases 15 13 14 10 6 8 9 10 B+ 5 3 0 October November December January February March April May June July August September Figure 8 - Cumulative DART Cases FY08 Figure 7 and Figure 8 visually display the raw numbers of cases against the projected number of cases that would result in performance meeting the B+ level DOE goal for the year. The projected goal number of cases is based on project hours for the year based on Lab historical data. Closely similar case history in FY07 and FY08 Page 8 of 17

deteriorated by over 50% from the TRC rate improvements of FY06 and by over 325% from the FY06 DART rates which more than met the B+ performance goals. LBNL Recordable Cases FY06 through September 30 FY08 9 8 7 FY '06 Total = 37 Cases FY '07 Total = 48 Cases FY '08 Total = 52 Cases Number of Cases 6 5 4 3 2 1 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Figure 9-3 Year TRC Cases: Monthly LBNL DART Cases FY06 through September 30 FY08 5 FY '06 Total = 8 Cases FY '07 Total = 24 Cases FY '08 Total = 24 Cases 4 Number of Cases 3 2 1 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Figure 10-3 Year DART Cases: Monthly Figure 9 and Figure 10 profile by month the number of TRC and DART cases experienced by the institution. Primarily this frequency distribution can be used to qualitatively corroborate other efforts results that identify temporal (with respect to season or calendar driven) impacts on worker safety (such as higher rates of students on site in the summer, heavier construction activity in the spring and summer, etc.). Page 9 of 17

LBNL Recordable Cases by Division FY06 through September 30 FY08 0 2 4 6 8 10 12 14 16 Division AFRD ALS Chemical Sciences Computational Research Earth Sciences Engineering Environmental Energy Tech. Genomics Life Sciences Materials Sciences NERSC Center Nuclear Science Physical Biosciences Physics CFO Directorate, OPS Environment, Health & Safety Facilities Human Resources Information Technology Public Affairs Number of Cases FY '06 FY '07 FY '08 LBNL Construction LBNL Service Subcontractors Figure 11 - FY06-08 TRC Cases by Division LBNL DART Cases by Division FY06 through September 30 FY08 0 2 4 6 8 10 12 AFRD ALS Chemical Sciences Computational Research Earth Sciences Engineering Environmental Energy Tech. Genomics Life Sciences Materials Sciences NERSC Center Nuclear Science Division Physical Biosciences Physics CFO Directorate, OPS Environment, Health & Safety Facilities Human Resources Information Technology Public Affairs Number of Cases FY '06 FY '07 FY '08 LBNL Construction LBNL Service Subcontractors Figure 12 - FY06-08 DART Cases by Division Figure 11 and Figure 12 graphically present the frequency of TRC and DART cases respectively by division for the last 3 fiscal years. These provide qualitative trending capability to Lab management as to which divisions are loss leaders and where improvement is needed. The 3 year history provides some perspective on improvement or deterioration of safety management in the respective divisions. Page 10 of 17

4.2 First Aid Cases Percentage of All Injuries Reported That Are Recordable Monthly, 12 Month Moving Average, Trend since 1/1/2000 90.0% 80.0% 70.0% Percentage of Cases Recordable 12 Months Moving Average Linear (Percentage of Cases Recordable) Revised December 17, 2008 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Jan-00 May-00 Sep-00 Jan-01 May-01 Sep-01 Jan-02 May-02 Sep-02 Jan-03 May-03 Sep-03 Jan-04 May-04 Sep-04 Jan-05 May-05 Sep-05 Jan-06 May-06 Sep-06 Jan-07 May-07 Sep-07 Jan-08 May-08 Percentage Sep-08 Figure 13 Percent of All Reported Cases that are Recordable Figure 13 demonstrates a decreasing trend in the percentage of recordable cases over the past 2 decades. The probable basis for this is continued improvement in reporting practices and reduced severity of injuries stemming earlier and more frequent care at the first aid level. FY08 First Aid to Recordable Comparison through September 30, 2008 16 14 Number of Cases 12 10 8 6 4 2 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep REC 7 4 4 2 3 3 3 6 5 4 5 6 FA 14 10 5 13 8 10 13 8 12 16 8 8 Figure 14 - FY08 Monthly First Aid and Recordable Case Comparison Page 11 of 17

FY02 to FY08 First Aid to Recordable Comparison through September 30, 2008 140 120 Number of Cases 100 80 60 40 20 0 FY 02 03 04 05 06 07 08 REC 63 74 32 47 36 47 52 FA 130 134 122 102 107 132 125 Figure 15 - First Aid - Recordable Case Visual Comparison FY02 to FY08 Figure 14 and Figure 15 are two frequency distributions that provide the landscape details on a monthly basis for FY08 and annual basis for FY02 through FY08 for the number of recordable and number of first aid injury cases. As in earlier institutional level frequency distributions, the primary value is corroboration of other analysis results. 4.3 Categories and Causes of Injuries Injury Categories and Causes FY08 through September 30, 2008 Electrical, (1) Windblown Debris, (1) Eye - Foreign Object, (1) Musculoskeletal Disorder, Computer Repetitive Motion, (13) Laceration via slip/trip and razor blade and scissors, (4) Musculoskeletal Disorder, Slip/Trip, (6) Musculoskeletal Disorder, Not Repetitive Motion, (12) Musculoskeletal Disorder, Lab Equipment/Process Repetitive Motion, (10) Figure 16 - Categories and Causes of Injuries The frequency distribution in Figure 16 allows visual comparison with the whole for FY08. The salient information this analysis provides is that nominally one half of our OSHA recordable injuries are due to repetitive motion, roughly equally distributed between computer workstation use and laboratory or other work process activity. This analysis graphically demonstrates that there is only a small contribution to the Lab OSHA recordable injury rate from industrial safety or gross safety issues. Page 12 of 17

4.4 Work Load Factor Work Factor Impact on Musculoskeletal Disorders on LBNL Injuries All Cases FY03-FY08 MSD Computer, 252, 23% MSD Computer w/ Workload Factor, 42, 4% Other, 613, 57% MSD Lab/ Process, 70, 7% MSD Not Rep, 98, 9% Figure 17 - Work Load Factor in Injury Figure 17 presents the results of the study of first aid and OSHA recordable case histories for the last 5 years. Only 4% of the cases had a direct statement in the initial injury report or the injury review report that linked or proposed that work load factors were one of the contributing causes to the injury or discomfort. All work load factor cases identified in this study were associated with computer workstation use. This provides some evidence that work load factor is a contributor to development of ergonomic related musculoskeletal injury, but not as great as earlier spot analyses have indicated. This result has seeded the development of additional standardized information gathering questions for the injury review process. Page 13 of 17

4.5 Corrective Action / Injury Causal Factor 25 Quality of Information Contained in SAARs and Investigator Reports Insufficient Info in SAAR Or Investigator Report To Classify Causes Or Corrective Actions 20 Good Data 15 Cases 10 5 0 PAff NERSC NSD DIRC CRD EETD ChSciDiv PBD HR CFO Division LSD EH&S IT ENG ESD ALS MSD GND FCLT Figure 18 - Quality of Accident Reports Figure 18 shows the frequency of sufficient and inadequate injury review report information (by division) as determined during the internal causal factor and corrective action ISM review. Nominally, 20% of the Supervisors Accident Analysis Reports and Liaisons Investigator reports (combined) were of little to no value in supporting the Performance Monitoring and Improvement process. LBNL Accident Causal Factors By ISM Category For FY08 SAARS Other - Not Attributable To ISM Issues 22% Performance Monitoring and Feedback 0% Roles and Responsibilities 17% Work Planning and Prioritization 16% Work Authorization and Performance 3% Control and Mitigation of Hazards and Environmental Aspects 11% Hazard Analysis 31% Figure 19 - Injury Causal Factor by ISM Category for FY08 Page 14 of 17

LBNL Accident Corrective Action Items Identified By ISM Category For FY08 SAARs Other - Not Attributable To ISM Issues 14% Performance Monitoring and Feedback 0% Work Authorization and Performance 5% Roles and Responsibilities 11% Work Planning and Prioritization 19% Control and Mitigation of Hazards and Environmental Aspects 37% Hazard Analysis 14% Figure 20 Injury Corrective Action by ISM Category for FY08 Figure 19 and Figure 20 visually display a proportionate chart of the distribution of causal factors and corrective actions from each first aid OSHA recordable case from FY08 with respect to the ISM category within which the causal factor or corrective action resides. The significant finding is the misalignment of corrective actions in the Hazard Analysis category (too few) and Control and Mitigation of Hazards (greater than the number of causal factors in this category). Not surprising is the absence of Performance Monitoring and Improvement as a causal factor, but alarming is the absence of any corrective actions in this category. Page 15 of 17