6BP Refinery in Texas City, 2005 A massive explosion kills 15 and injures 180 at the BP Texas City refinery. The explosion occurred in an isomerization unit at the site, resulting in the deaths and injuries. According to a report issued after the accident, actions taken or not taken led to overfilling the raffinate splitter with liquid, overheating of the liquid, and the subsequent overpressurization and pressure relief. Hydrocarbon flow to the blowdown drum and stack overwhelmed it, resulting in liquids carrying over out of the top of the stack, flowing down the stack, accumulating on the ground, and causing a vapor cloud, which was ignited by a contractor's pickup truck as the engine was left running. The report identified numerous failings in equipment, risk management, staff management, working culture at the site, maintenance and inspection, and general health and safety assessments.
17INVESTIGATION STRATEGY FACT GATHERINGISOLATE SCENEBE IMPARTIAL & OBJECTIVEPHOTOS/DIAGRAMSINTERVIEW PEOPLECOMPILE PROCEDURES & RULES FOR THE AREAGATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVEDMAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS TO AVOID RECURRENCE, NOT TO APPORTION BLAME
18CONTRIBUTING FACTORS ENVIRONMENTAL DESIGN SYSTEMS & PROCEDURES Noise, heat, light, vapors, dustDESIGNWorkplace layout, tools, equipmentSYSTEMS & PROCEDURESLack of or inappropriateHUMAN BEHAVIOURCommon to all accidents
19Corrective Actions Determine Them Implement Them Look Deep Find them allKeep asking WHYImplement ThemFix itTrain itImprove it
20Concerns If Not, It Will Happen Again None or incomplete investigation Not finding causesNot addressing corrective actionsNo Employee InvolvementNot communicating lessons learnedIf Not, It Will Happen Again
21WHEN AN ORGANIZATION REACTS SWIFTLY AND POSTIVELY TO INCIDENTS AND INJURIES, IT’S ACTIONS REAFFIRM ITS COMMITMENT TO THE SAFETY AND WELL-BEING OF ITS EMPLOYEES
22COMMUNICATIONS Weekly/monthly newsletters All hands meetings/Tailgate Safety flashes/GuardiansSuggestions boxesOpen & HonestTwo-way, Good or BadEmployee InvolvementPost – Near misses, Investigations, Audit findings & Corrective actions, Completion dates, Targets, etc.Builds Trust
24Safety Whiteboard Expectations Supervisor/Safety Rep to hold meetings1/week at Safety Whiteboard on shop floor/break roomMandatory union attendance and support groups (FSE/QE)Target time of 20 min.Only topic is safetyAgenda:Review updates of items on the whiteboardPoll group for new issuesTriple I Matrix (Distribution List)Outstanding Ergo AssessmentsLast week’s statisticsNear Miss/Incidents – description ofOther Safety StuffGuardiansSafety AlertsLeading/Lagging indicators (discuss 1/month)Safety Initiative (Departmental performance) -LWD/RIR
25Before starting work, make sure you have everything you need to do your job safely. Have the right toolsHave the right safety equipmentKnow how to do the job safelyKnow you’re fit and competent
26Speak up about safety Daily briefings Task specific training Suggesting safer ways of working to othersReporting unsafe acts and conditionsBeing safety proactive
27Never walk byIf you see someone acting unsafely… point out the right wayIf you see an unsafe condition… fix it and report itIf someone shows you a safe way… thank them for it; they may have saved you from injury or worse
28Home safeWe all have family and friendsWe all have interests, hobbies and passions24 hours a day
29Working in the Red ZoneHow do you know when you are in the “Red Zone”? There are certain phrases or thoughts that should throw up a flag to alert you that you may be in danger.“I’ve never done this before.”“I don’t have the right tool.”“This isn’t the same as the others”“I haven’t been trained for this”“This is rework”“This is a new job”“This is a new procedure”“This isn’t how we usually do it”
30Most Accidents Happen in the “Red Zone.” When you hear or think any of those phrases you should immediately:STOPTHINKMAKE SURE YOU ARE PERFORMING THE JOB SAFELYGET THE RIGHT TOOLSASK FOR HELPREPORT YOUR CONCERN
31HAZARD RECOGNITION Risk Assessments Job Task Identify them Implement corrective actionsContinually reduce riskReevaluate occasionallyJob TaskJSA’s or JSP’sWork Instructions
33Near Misses/Close Calls Investigate near-misses since they are potential IncidentsIncidents or injuries are the “tip of the iceberg” of hazardsIncidentsHazardsMore Near Misses = Less Incidents
34Why focus on near misses? Our safest sites are those that report the most near misses1fatalityEmployee trips, falls, hits head. Dies.30major injuriesEmployee trips, falls and fractures arm. Eight weeks out of work.300 RecordablesEmployee trips, falls and lacerates hand. Five stitches.3,000 first aid injuriesEmployee trips, falls. Bruises hip.Employee steps over waste. Walks away.30,000 near misses
38AUDITS/INSPECTIONS Conduct training Knowledgeable with OSHA and other regulationsGo in Teams, (2 or 3 members)Do different areasEngage workersShow positives, not just negativesTake others alongIdentify opportunities & Implement Corrective ActionsSet dates or timelinesResponsible parties for completion
40Management of Change Get the picture up front Changes to the process New machinery/equipmentLocation changesNew processes or productsNew or changes to the facilityCheaper to do it up front instead of afterwards
46TRAINING OSHA Other regulations Company Job/Task specific Skill sets Show competencyFollow-upKnow the Difference between right and wrong
47Training helps to Prevent Incidents! Get the picture?
48Rules for Lifting Get close to the load. Test the load Keep feet apart.Keep back straight.Bend your knees.Tuck your chin.Grip the load with your palms.Get help if needed.
49Employee Involvement Always get employees involved Gains support/buy-inEasier for changePeople like to be active and heardThe workers usually know the answerCreate a team environmentHappier & more productive
50SAFETY TEAMS Employee Involvement & Buy In Mission statement Focused Proper membersSpecial Project TeamsFor all TeamsHave a charterKeep minutes and attendanceStay on trackCelebrate successes
51ACCOUNTABILITY Do What You Say What Happens If You Don’t Hold everyone “accountable”Can be very uncomfortable for most people
52“Wise men learn from other’s men’s mistakes, fools by their own”. (Chinese proverb)
53ALWAYS ASK YOURSELF - What am I about to do? How can I get hurt? How severe will the injury be?What can I do to prevent it?