steps to prevent serious workplace injuries and fatalities · steps to prevent serious workplace...
TRANSCRIPT
©2016 DEKRA Insight. All rights reserved.
U.S.A. Safety in 21 Years:
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Fatality Rate TR
IR
TRIR (per 200,000 hours) Fatality Rate (per 100,000 workers)
©2016 DEKRA Insight. All rights reserved.
Traditional Safety Triangle – ReductionIn Bottom of TriangleResults in a ProportionalReduction at the TopOf the Triangle
©2016 DEKRA Insight. All rights reserved.
A subset of reported cases will have SIF Exposure.
A reduction of injuries across the base of the triangle or working outside the SIF triangle will not correspond to a proportionate reduction of SIFs.
21% Potentially
SIF
Traditional Safety Triangle is not Predictive
©2016 DEKRA Insight. All rights reserved.
A New Paradigm
A new way of thinking about the Safety Pyramid:Focus on prevention of SIFs.
Fatal &Serious
Recordable Medical &FA Injuries
LT/RD Injuries SIF Exposures
PrecursorsHigh-risk situations in which management controls are either absent, ineffective, or not complied with, and which will result in a serious or
fatal injury if allowed to continue.
21%
Near-Misses, Property Damage,Spills & Releases, Fires,
Reliability Incidents, etc.
©2016 DEKRA Insight. All rights reserved.
Headline 1
Don’t Expect SIF Prevention by Working Outside of the SIF Triangle
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
Headline 2
Recordable Injuries Log is Misleading When it Comes to SIF Exposure
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
Headline 3
The SIF Blind Spot is Significant
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
Headline 4
There Are Four Things You Must Do
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
Four Things You Must Do
1. Educate Senior Leaders on SIF:• They need to understand this problem before they
can act on it.• The solutions to the SIF problem require their attention.• Enlist their sponsorship.
2. Provide Visibility to SIF Exposure:• Define “SI”F: Life-Threatening vs. Life-Altering.• Determine SIF Exposure Potential: Judgment-based versus
Decision-tree. • Calculate SIF Exposure Rate: SIF Recordable and SIF Total.
©2016 DEKRA Insight. All rights reserved.
No
SIF Exposure Decision Tree – SAMPLEDid the event involve LOTO?
Did the event involve a vehicle collision?
Did the event involve Confined Space Entry?
Did the event involve pinched between or in line of fire with a release of significant mass or energy?
Did the event involve working at elevations
Did the event involve barricades/machine guards?
Was the event related to working under a suspended load?
Did the event involve NFPA 70E Arc Flash?
Was it an actual SIF event?Could a fatality or life altering/threatening injury/illness
reasonably have resulted?
SIF Exposure
No SIF Exposure
No
Yes
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
©2016 DEKRA Insight. All rights reserved.
SIF Exposure Determination
NEAR-MISS• A forklift slowly fell over
as it was parked on the footbridge of a scaffold. The load was too heavy and improperly secured. Two workers on the scaffold had to jump to ground from 10 feet up as the forklift leaned into the scaffold.
RECORDABLE INJURY• Worker strained his wrist
while pulling a 20 pound condenser out of a cardboard box.
©2016 DEKRA Insight. All rights reserved.
SIF Exposure Determination
FIRST AID• A welder was removing
welding parts from a supply bag. A tightly coiled hose suddenly uncoiled striking the welder on his bare forearm, scratching it.
LOST TIME INJURY• A Caterpillar tractor
operator was standing on the engine housing about 8 feet off the ground. He was greasing the zirks when he slipped and fell to the ground fracturing his ankle.
©2016 DEKRA Insight. All rights reserved.
SIF Exposure Determination
PROPERTY DAMAGE• A forklift operator was
backing up his forklift at approximately 5 MPH. He struck a pedestrian walkway guardrail and damaged it. There were no pedestrians in the walkway.
REPORT• An electrical technician
was cutting a cable to the lighting system. Sparks jumped out of the cable. Electrician was wearing protective rubber gloves. He thought the system was de-energized because he left it that way before lunch break.
©2016 DEKRA Insight. All rights reserved.
Four Things You Must Do (continued)
3. Know Your SIF Precursors:• Three places where they hide:
• High Risk/High Exposure Tasks (81% Routine)• Management Systems Missing, Deficient,
or Not Complied With• Allowed to Continue
4. Integrate Interventions into Existing Safety Management Systems (SMS):• Life Saving Safety Rules, Pre-Task Risk Assessments,
Pausing Work, Incident Handling Systems (reporting, reaction, investigation, etc.)
©2016 DEKRA Insight. All rights reserved.
Important SIF Precursor Mitigation Considerations
LIFE-SAVING SAFETY RULES• 42%• Breakdowns occur• Design integrity• Behavioral reliability• Quality & effectiveness
PRE-TASK RISK ASSESSMENT• 29%• Collaborative• Triggers for pause work• Field verifications• Post-job debrief
81% of fatal events involve routine operations and maintenance tasks
©2016 DEKRA Insight. All rights reserved.
Headline 5
Accident Reporting & Investigations Are Not As
Good As You Think They Are
Longitudinal analysis will prove it,and will point out leadership
and culture implications.
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
Accident Investigation Processes Must Become Transformational
• Longitudinal analysis• Multiple contributing factors, root causes, and SIF Precursors • Effectiveness of corrective and preventive actions (use HOC triangle
to evaluate)• Tracking of recommendations and verification of problem-solved• Effective communication and implementation of lessons learned• The perspective of the affected workers• Proportionate response• Case narrative descriptions must help us understand what really
happened and the context surrounding the exposure.
Encourages and supports reporting!
©2016 DEKRA Insight. All rights reserved.
Proportionate Response
SIF Exposure
Patterns Non-SIF Exposure
Report – High Level / Across Organization
Deeper Investigation
Share Action Plan –High Level / Across
Organization
Report – Locally
Short Form –Investigation
Report – Affected Groups
Root Cause Investigation
Develop Action Plan to Address – Trend
Share Action Plan –Those That Need to Know
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EliminationComplete redesign of the system to remove the exposure
Exposure eliminated.
Substitution Switch out a process step with a less hazardous step;Use low voltage system versus high voltage; replacea toxic material with a non-toxic material
Exposure significantly reduced.
Engineering Controls/IsolationIsolate hazard; install guards and/or interlocks;build barriers; use light curtain;develop new tool
Exposure controlled during normal ops; still possible during maintenance operations or emergencies.
Administrative ControlsPost signs and warnings;Write procedures and rules;Train employees
Exposure controlled IF employees rigorouslycomply and IF culture supports compliance andIF leadership maintains commitment to verification and oversight.
Personal Protective EquipmentProvide protective equipment for workers (e.g., hard hats, gloves, glasses, respirators)
Last layer of defense; unreliable for full protection; does not mitigate risk or exposure, only extent of possible injury; primarily used when hazard is unpredictable or pervasive; use is dependent on too many variables.
Gimmicks; incentives;hollow threats
Worker seen as the cause of exposure and simply requires motivation; no change in exposure.
Safety depends
LEASTOn
employee Behavior
Safetydepends
MOSTOn
employee behavior
Leverage The Hierarchy of Controls
15%
85%
------
What if N=100 cases?
©2016 DEKRA Insight. All rights reserved.
Headline 6
The Role for BBS is Significant, andUnderutilized
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
SIF Precursor Discovery –Observation/Interview Process
• Study Results: 87% of the time SIF Precursors discoverablevia interview or observation.
• Critical Behaviors Inventory® could be much deeper.• Observer partnering with front-line supervisors, safety
professionals, and lessons learned processes.• SIF education, SIF exposure selection strategy, different
observation and interview skills, SIF data collection and response.
BAPP®/SIF
©2016 DEKRA Insight. All rights reserved.
Headline 7
SIF Events Are Not One-Offs. The Precursors Have Been There All Along.
Our vocabulary and reaction to SIF must change.
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
A New Paradigm
• The causes and correlates of SIFs are different from Non-SIFs. Work inside the SIF triangle is required.
• Leadership interest and engagement is necessary to impact the top of the triangle.
• A SIF exposure metric is essential.• Accident reporting and investigation processes are
key to understanding & mitigating the SIF exposure situation.
©2016 DEKRA Insight. All rights reserved.
A New Paradigm
A new way of thinking about the Safety Pyramid:Focus on prevention of SIFs.
Fatal &Serious
Recordable Medical &FA Injuries
LT/RD Injuries SIF Exposures
PrecursorsHigh-risk situations in which management controls are either absent,
ineffective, or not complied with, and which will result in a serious or fatal injury if allowed to continue.
21%
Near-Misses, Property Damage,Spills & Releases, Fires,
Reliability Incidents, etc.
©2016 DEKRA Insight. All rights reserved.
Final Thoughts
As senior safety leaders, we can’t“not know” about our SIF exposure.
SIF exposure recognition and mitigation:a core operational responsibility.
©2016 DEKRA Insight. All rights reserved.
Leaders and SIFs
• I’m not out in the field! What am I supposed to do?• Vision• Challenge the Status Quo
©2016 DEKRA Insight. All rights reserved.
Life-Saving Safety Rules
• Quality, Integrity & Reliability• Do we have them?• Are they the right ones?• What is the basis for them?• How consistent are we in…
• Understanding? • Explaining?• Interpreting?• Applying?
©2016 DEKRA Insight. All rights reserved.
Life-Saving Safety Rules
• Quality, Integrity & Reliability• The rule (and all its moving parts) must truly protect
• If we do it the way it’s described in the paper program, would everyonebe protected?
• Every behavioral aspect at every level must be 100% enabled• Is it even possible to do it the way it’s described in the paper program,
and is everyone enabled to do their part?• People must actually conform• Does everyone actually do it?
• Is “normalization of deviation happening here?”• Is it too easy to grant variances?
• Do we make statements around…• Zero-tolerance?• If only my workers would…?
©2016 DEKRA Insight. All rights reserved.
Life-Saving Safety Rules
• Lockout/Tagout• Confined Space Entry• Working at Elevations/Fall Arrest• Machine Guarding – Barricades• Operations of Mobile Equipment• Suspended Loads• Horseplay, working under the influence of
drugs/alcohol• Equipment and pipe opening• Hot work permits• Excavations, trenches• NFPA 70E – Arc Flash Protection
©2016 DEKRA Insight. All rights reserved.
©2016 DEKRA Insight. All rights reserved.
Pre-Task Risk Assessments
• What do we have in place?• How does it work?• Is it collaborative?• How is it led?• Does it encourage and support open & complete
discussion about exposure?• Is it documented?• How do we measure quality and effectiveness?
• A great leading indicator!
©2016 DEKRA Insight. All rights reserved.
Pre-Task Risk Assessments
• Does it accurately predict… • What the real exposures are?• The measures that need to be put in place to protect
the workers?
• What is our climate for enabling, encouraging, and supporting “pause work for safety reasons?”
• Does it happen enough?• Should it happen more?
• How would you know?
©2016 DEKRA Insight. All rights reserved.
Pre-Task Risk Assessments
• Quality, Integrity & Reliability• Prepare the Job Safety Assessment in a collaborative
manner?• Go out to the field and compare?• Go back out mid-job?• Debrief at job completion?
• Did everything match up?• What else did we need to do that was not predicted
and planned?
©2016 DEKRA Insight. All rights reserved.
Healthy Incident Reporting
• Does this truism exist here?• Managers think everything is being reported• Workers know everything is not being reported
• Does fear of reprisal exist here?• Are leader reactions predictable and positive?• Near-misses are a gold mine of information.
How much gold are we mining?• Is accident investigation depth driven by classification,
rather than SIF potential?• Do we pay more attention to classification or prevention?
©2016 DEKRA Insight. All rights reserved.
Healthy Incident Reporting
• Is our reporting healthy? (Key #1)• Do we have high quality accident case
narratives? (Key #2)• Have we ever done a longitudinal analysis to
look for precursors? (Key #3)
As senior executives, we can’t “not know” about our SIF potential
©2016 DEKRA Insight. All rights reserved.
The SIF Exposure Blind Spot
• Do we really know what our SIF Exposure is?• Can we construct a reliable SIF Exposure metric?• How should we react to cases with SIF potential?• Are my people willing to report, approach others,
pause work?• Are my people capable of recognizing exposure and
exposure change?• Is my accident investigation process healthy?• Can we identify SIF precursors?• Do we have processes to mitigate SIF precursors?
©2016 DEKRA Insight. All rights reserved.
Conclusion
• When and where can I apply these questions/interventions?• Reviewing results of accident and near-miss investigations• Reviewing leading indicators such as JSA Quality, JSA Rates,
Accident Investigation Quality• Reviewing safety audit results• At regular corporate staff meetings• When visiting the sites – meeting with site leadership team, touring
and meeting with front-line workers and union reps• Does our BAPP®/BBS effort have a sampling strategy for critical SIF
behaviors?• When you hear reports of near-misses with SIF potential…
Are we doing what we should? Are we giving this our best effort?
©2016 DEKRA Insight. All rights reserved.
Additional Reading
• DEKRA Insight White Papers• Determining Serious Injury and Fatality Exposure Potential• New Findings on Serious Injuries and Fatalities• The Paramount Importance of Potential• Implementation of Life-Saving Safety Rules• Does Zero Tolerance Really Work?• Safety Program Execution: A Key to Achieving Consistently
Good Performance