Applying Action Based Safety One Will Die: The John Martin Story

9/3/2015 Martin Safety Solutions Journey Back in Time A Serious Look at all the Contributing Actions that set this Accident in Motion A Serious Look at all the Contributing Actions that set this Accident in Motion Attitudes, Short Cuts, Communication, Production, Pride, are all at work in this event Attitudes, Short Cuts, Communication, Production, Pride, are all at work in this event

9/3/2015 Martin Safety Solutions April & May 1984 Operations & Maintenance Supervision and Chemical Engineers are moved to different Process Areas New mechanical engineers are placed in several maintenance areas as front line foreman With the intention of improving production and enhancing technical knowledge

9/3/2015 Martin Safety Solutions MAC Model Why People Do What They Do MOTIVATION ACTION CONSEQUENCES Is what happens after an ACTION. There are positive and negative consequences in everything we do. Is anything that gets a ACTION started. MOTIVATION is a prompt...

9/3/2015 Martin Safety Solutions Motivation What motivations are in place? Saves money Saves money No one wants to work overtime No one wants to work overtime Improves production Improves production Saves time Saves time Known Risk Taker assigned job Known Risk Taker assigned job Safety not a value Safety not a value

9/3/2015 Martin Safety Solutions Actions Operator closing valves Operator closing valves Operator draining pipe lines Operator draining pipe lines Mechanics tagging breaker Mechanics tagging breaker Mechanics blocking valves Mechanics blocking valves Operator energizing valve Operator energizing valve Mechanics not wearing PPG Mechanics not wearing PPG Operator closing valve Operator closing valve Mechanics not tagging valve Mechanics not tagging valve

9/3/2015 Martin Safety Solutions Consequences 36 hour outage reduced to 8 hours 36 hour outage reduced to 8 hours Saves money, no overtime Saves money, no overtime Increases production Increases production Man burned over 70% of body Man burned over 70% of body Operator overwhelmed Operator overwhelmed Mechanics crying Mechanics crying Supervisor blocks event from memory Supervisor blocks event from memory EMT’s angry EMT’s angry Families are Devastated Families are Devastated

9/3/2015 Martin Safety Solutions Accident Analysis Motivation: The operator is called to open valve Motivation: The operator is called to open valve Action: The operator hits button to activate valve Action: The operator hits button to activate valve Consequence: Valve opens causes catastrophic release of vessel contents Consequence: Valve opens causes catastrophic release of vessel contents

9/3/2015 Martin Safety Solutions Five Whys - People Why did the operator push the “ON” button? Why did the operator push the “ON” button? Why was the operator operating equipment he was not familiar with? Why was the operator operating equipment he was not familiar with? Why was the operator unfamiliar with the equipment after completing on the job training? Why was the operator unfamiliar with the equipment after completing on the job training? Why was the equipment not locked out completely? Why was the equipment not locked out completely? Why were both mechanics working behind one lock? Why were both mechanics working behind one lock? Why isn’t the time it takes to safely lock out built in as part of doing the job? Why isn’t the time it takes to safely lock out built in as part of doing the job?

9/3/2015 Martin Safety Solutions Five Whys - Equipment/Materials Why was the change to the normal process not investigated with input toward safety? Why was the change to the normal process not investigated with input toward safety? Why was hot product released while maintenance employees were working on the system? Why was hot product released while maintenance employees were working on the system? Why was the product still hot when people started working on the system? Why was the product still hot when people started working on the system? Why was the new process thought to be more cost effective? Why was the new process thought to be more cost effective? Why is time saved allowed to be THE factor in making a change to the process? Why is time saved allowed to be THE factor in making a change to the process?

9/3/2015 Martin Safety Solutions Five Whys - Environment Why did the job begin without first establishing a safe escape route? Why did the job begin without first establishing a safe escape route? Why are maintenance mechanics not provided with hazard awareness training before starting jobs in unfamiliar areas? Why are maintenance mechanics not provided with hazard awareness training before starting jobs in unfamiliar areas? Why are inspections not conducted at the job site? Why are inspections not conducted at the job site? Why are Maintenance employees not included during inspections performed by Operations? Why are Maintenance employees not included during inspections performed by Operations?

9/3/2015 Martin Safety Solutions 1984 Accident Root Causes People People Manpower reduced requiring operator training to be accelerated and training modified Manpower reduced requiring operator training to be accelerated and training modified Emphasis on production encourages short cuts Emphasis on production encourages short cuts Materials/Equipment Materials/Equipment To save time, the normal isolation procedure was modified to a hot shut-down rather than a cold shut- down To save time, the normal isolation procedure was modified to a hot shut-down rather than a cold shut- down Environment Environment No time was taken to identify a safe escape route due to emphasis on production No time was taken to identify a safe escape route due to emphasis on production

9/3/2015 Martin Safety Solutions Safety Way of Life Establish a Job Hazard Awareness Briefing prior to starting job Establish a Job Hazard Awareness Briefing prior to starting job Read the MSDS Sheet and know the hazards Read the MSDS Sheet and know the hazards Wear PPE to protect yourself from potential hazards Wear PPE to protect yourself from potential hazards Know were the Eyewash/Shower Station are located. With someone’s help, practice locating how to get to them if you are blinded Know were the Eyewash/Shower Station are located. With someone’s help, practice locating how to get to them if you are blinded Locate two of the closest Fire Extinguishers prior to starting work Locate two of the closest Fire Extinguishers prior to starting work Improve training for all employees Improve training for all employees Identifying Risky Behaviors is the key to reducing accidents Identifying Risky Behaviors is the key to reducing accidents

9/3/2015 Martin Safety Solutions Safety Way of Life Establish Observation cards to identify actions to improve safety Establish Observation cards to identify actions to improve safety Line of Fire, Eyes on Path, Lifting in Power Zone, Asking for Assistance, Discussing task with fellow workers, are examples of practices that can improve safety Line of Fire, Eyes on Path, Lifting in Power Zone, Asking for Assistance, Discussing task with fellow workers, are examples of practices that can improve safety

9/3/2015 Martin Safety Solutions Safety Way of Life Situational awareness is a key element Situational awareness is a key element Focus on all aspects of the task Focus on all aspects of the task Avoid distractions Avoid distractions

9/3/2015 Martin Safety Solutions STOP AT ALL STOP SIGNS Next Seven Days Next Seven Days Come to a complete stop at all stop signs Come to a complete stop at all stop signs Spell S T O P Spell S T O P LOOK BOTH WAYS LOOK BOTH WAYS Proceed when clear Proceed when clear your FEEDBACK your FEEDBACK

9/3/2015 Martin Safety Solutions Ones Going to Die The John Martin Story John Martin