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A Paradigm Shift into a new future…

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Presentation on theme: "A Paradigm Shift into a new future…"— Presentation transcript:

1 A Paradigm Shift into a new future…
NEW RESEARCH ON THE PREVENTION OF SERIOUS INJURIES AND FATALITIES (SIF) A Paradigm Shift into a new future…

2 Learning Objectives Definition of SIF Data Trends
4/15/2017 Learning Objectives Definition of SIF Data Trends Paradigm Shift with Safety Pyramid Action plan

3 SIF = Serious Injury or Fatality

4 SIF Research Team A joint study was conducted by all of the companies, everyone supplied data from their incident databases. For a true zero plant to successed, you must identify where your plan is working and work your plan. And also be prepared to adopt new strategizes when you identify areas' of risk your plan has not effected. 4

5 Industry Data FAR – Fatal Accident Rate
TRIF – Total Recordable Injury Frequency LTIF – Lost Time Injury Frequency Recordable and lost time injury rates are declining steadily, but the fatality rate is level or increasing. How can this be? SH&E experts have been telling us for years about the ‘Safety Pyriamid.’ The idea that minor injuries predict serious ones is embedded in the culture. FAR – Fatal Accident Rate TRIF – Total Recordable Injury Frequency LTIF – Lost Time Injury Frequency

6 Common for Leading Companies
Recordable and lost time injury rates are declining steadily, but the fatality rate is level or increasing How can this be? EH&S experts have been telling us for years about the ‘Safety Pyramid’ The idea that minor injuries predict serious ones is embedded in our culture Question to group, how many of us have lived in the era that believes that if we attack the base of the Safety Pyramid we will eliminated all injuries including fatalities. 6

7 Definition of Serious Injury
Any injury or illness that resulted in: Life-threatening injury or illness: one that if not immediately addressed is likely to lead to the death of the affected individual. Examples include, but are not limited to: Laceration or crushing injuries or significant blood loss Damage to the brain or spinal cord or Severe burns Use of cardiopulmonary resuscitation or defibrillator Chest or abdominal trauma affecting vital organs Life-altering injury or illness: one that results in permanent or long-term impairment. Examples include, but are not limited to: Significant head injuries Paralysis Amputations Broken or fractured bones SIF

8 SIF Potential? Strained Back Case A (Non-SIF) – Worker was walking across the floor, slipped on grease, caught himself on a railing, and wrenched his back (strained back muscle) classified as “first-aid” Case B (SIF = Yes) – Worker fell from the top of a rail car when his car was struck by another rail car that was being moved into position. The worker fell on top of the tank car, grabbing the guard rail around the dome lid, preventing a fall to the ground. The only injury resulting was some bruising and a strained back muscle. Even though this event was classified as “first-aid”, it clearly has high potential for SIF. Give and example of a SIF

9

10 (Life Safety/Safety Absolute = Policy or Procedure)
Qualitative Analysis Theme SIF or SIF-Potential Incident N=55 NON SIF-Potential N=35 (Life Safety/Safety Absolute = Policy or Procedure) % 1 Performing a routine production or a maintenance, connected with a deviation from an established Life Safety/Safety Absolute 42% 0% 2 Performing a routine production or a maintenance task connected to an exposure that changed from a “normal state”, was not anticipated/recognized/controlled and likely could have been prevented by a proper Pre-Task Hazard Assessment (PJHA). 29% 17% 3 Self-made human errors that are not connected to a Safety Absolute Involved in either a routine operations/production or a maintenance/repair task OR performing a special/unique/unplanned/emergency situation. 11% 74% 4 Involved in routine operations/production or a maintenance tasks, and a connection to an equipment / facility / process / engineering design flaw has been established 5% 3% 5 Involved in routine production or a maintenance tasks, and a connection to predictive & preventive maintenance & inspection, and reliability systems has been established 6% 6 Involved in a special/unique/unplanned/emergency situation, connected to an exposure that was unknown or unfamiliar. 4% 7 Involved in an act or incident or workplace violence, war, or militia attack or similar. Key finding from the Research team..

11 You will not reduce SIFs by working at the bottom of the pyramid alone (the causes and correlation are different) Senior leadership attention and involvement is necessary (SIF reduction demands a different focus) Precursors of SIFs can be identified (and measured) 11

12 Definition of SIF Precursor
A high-risk situation 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 over time

13 Examples of Precursors
Precursor: In order to change the doctor roll on a paper re-roller two workers must stand beneath it and guide it. The doctor roll weighs about 6 tons Precursor: A worker is repairing a valve 20-feet above grade. There is no engineered anchor point to secure the lanyard Precursor: During an emergency shutdown workers are unable to follow all aspects of the procedure because it appears impractical These precursors preceded the incidents they are related to. 13

14 Ever heard this before? The last 2 years we’ve had a great safety record. Our recordable rates were lower than ever. We were proud. A few months ago we celebrated our safety success This quarter we experienced an amputation, a severe burn, and two frightening near-misses Our GM and his boss are upset and confused. Our safety leaders can’t explain it 14

15 Bloomington, Illinois High audit scores No injuries in 6 years

16 The problem is in the measurement system that creates a blind spot, not giving visibility to the events necessary to see the root cause in order to prevent SIFs

17 The Old Paradigm Revisited
Serious Injuries and Fatalities Some of our First Aids have Precursor’s for far more serious injuries.. A focus on the potential for serious injury Precursor: A high-risk situation 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. 17

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19 New Paradigm Injuries of differing severity have differing underlying causes The strategy for reducing serious injuries should use precursor data drawn from all available sources of data: accidents, injuries, near misses and exposures 19

20 Continue to work the base..
Attack the Pyramids! Now we will work the Top! Precursor: A high-risk situation 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. Continue to work the base..

21 SIF BU Analysis Information
1800 incidents evaluated from December through December 2011 437 incidents had SIF potential This is 24% of our incidents had SIF potential!

22 23% SIF potential for Near Misses
SIF Data Breakdown Near Misses 1421 incidents 321 had SIF potential 23% SIF potential for Near Misses

23 19% SIF potential for First Aid Cases
SIF Data Breakdown First Aid Cases 106 First Aid Cases 20 had SIF potential 19% SIF potential for First Aid Cases

24 SIF Data Breakdown OSHA Recordables 81 OSHA Recordables
26 had SIF potential 26% SIF potential for OSHA Recordables 2 actual SIF injuries One multiple face fractures when struck by channel iron after a come along anchor point failed One steam burn to face, neck and torso when a steam line failed

25 SIF Data Breakdown Property damage
177 Property Damage Incidents 36 had SIF potential 20% SIF potential with Property Damage Incidents

26 SIF Data Breakdown Corn Milling Top 6 SIF categories are:
Elevated Work – 84 of 103 had SIF potential 82% SIF potential with Elevated Work Incidents

27 SIF Data Top Six 73% of Falling Equipment Incidents had SIF potential
Falling Equipment – 50 of 67 incidents had SIF potential 73% of Falling Equipment Incidents had SIF potential

28 SIF Data Top Six 63% of Lockout/Tagout Incidents had SIF potential
Lockout/Tagout – 71 of 113 incidents had SIF potential 63% of Lockout/Tagout Incidents had SIF potential

29 SIF Data Top Six Rail – 41 of 82 Rail incidents had SIF potential

30 SIF Data Top Six Chemical Release – 65 of 140 Chemical Release Incidents had SIF potential 45% of Chemical Release Incidents had SIF potential Chemical Release incidents include Chemical releases/leaks of acids, caustics, steam and other operating materials

31 (This includes all Mobile Equipment except Rail)
SIF Data Top Six Mobile Equipment – 34 of 107 Mobile Equipment incidents had SIF potential 32% of Mobile Equipment Incidents had SIF potential (This includes all Mobile Equipment except Rail)

32 SIF And Contractor Involvement
Contractors were involved in 166 incidents that had SIF potential Contractors were involved in 38% of the incidents that had SIF potential

33 Qualitative Analysis - Revisted
Theme SIF or SIF-Potential Incident N=55 NON SIF-Potential N=35 (Life Safety/Safety Absolute = Policy or Procedure) % 1 Performing a routine production or a maintenance, connected with a deviation from an established Life Safety/Safety Absolute 42% 0% 2 Performing a routine production or a maintenance task connected to an exposure that changed from a “normal state”, was not anticipated/recognized/controlled and likely could have been prevented by a proper Pre-Task Hazard Assessment (PJHA). 29% 17% 3 Self-made human errors that are not connected to a Safety Absolute Involved in either a routine operations/production or a maintenance/repair task OR performing a special/unique/unplanned/emergency situation. 11% 74% 4 Involved in routine operations/production or a maintenance tasks, and a connection to an equipment / facility / process / engineering design flaw has been established 5% 3% 5 Involved in routine production or a maintenance tasks, and a connection to predictive & preventive maintenance & inspection, and reliability systems has been established 6% 6 Involved in a special/unique/unplanned/emergency situation, connected to an exposure that was unknown or unfamiliar. 4% 7 Involved in an act or incident or workplace violence, war, or militia attack or similar. Key finding from the Research team..

34 So now what is the…

35 Intervention Design 1. Educate all constituents on the New Paradigm
Senior Leadership to understand these findings and lead the effort 2. Measure Serious and Fatal Injuries and SIF- Potentials as one category Better safety metrics Evaluate and judge all incidents based on SIF potential Improved tracking of SIF precursor events and progress In order to help us look at SIF better we have added SIF to our incident reporting system and will be a new area.

36 Intervention Design Develop processes to identify precursors and recommend mitigation Study your data Observations, audit findings, focus groups Customize to site Generalize regionally, business unit? Use BST/ORC findings to start?

37 Intervention Design Integrate mitigation efforts with existing safety systems, and audit & observation processes More rigor around cardinal rule situations Pre-task risk assessment capability Leverage behavior-based safety system Verification audits Rules staying current with equipment, process and procedural changes

38 “W.H.A.T. will keep you safe” The presentation is now complete!
Any questions?


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