1. We Never Thought It Could Happen To Us
Presented by
Scott Snyder

2. Deep Water Horizon

4. Fukushima

6. BP 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.

8. I’ll Get it Done

10. What is Safety?
Safety is freedom from danger, risks or accidents that may result in injury, property damage or death.

11. Recipe for SUCCESS Management Commitment Incident Investigation
Communications
Hazard Recognition
Audits/Inspections
Management of Change
Training
Employee Involvement
Accountability

12. MANAGEMENT COMMITMENT
Leadership – “LEAD”
Walk the Talk
Set the “GOOD” example
Employee engagement
Be fair & consistent
Employee Involvement
It’s not “Do What I say, Not What I Do”
Starts at the TOP

13. INCIDENT INVESTIGATION
THE KEY RESULT SHOULD ALWAYS BE TO PREVENT A RECURRENCE OF THE SAME INCIDENT.

14. OUTCOMES OF INCIDENTS NEGATIVE ASPECTS DEATH & INJURY DISEASE
DAMAGE TO EQUIPMENT & PROPERTY
LITIGATION COSTS
LOST PRODUCTIVITY
REPLACEMENT WORKERS
ADDITIONAL TRAINING
COMMUNITY IMPACT

15. WHO SHOULD INVESTIGATE
DEPENDENT ON SEVERITY OF THE ACCIDENT
INVESTIGATION TEAM
INDIVIDUALS INVOLVED
SUPERVISOR
SAFETY DEPARTMENT
UPPER MANAGEMENT
WITNESSES
OUTSIDE CONSULTANTS

16. INVESTIGATION STRATEGY
GATHER INFORMATION & ESTABLISH FACTS
ISOLATE ESSENTIAL CONTRIBUTING FACTORS
DETERMINE CORRECTIVE ACTIONS
IMPLEMENT CORRECTIVE ACTIONS

17. INVESTIGATION STRATEGY
FACT GATHERING
ISOLATE SCENE
BE IMPARTIAL & OBJECTIVE
PHOTOS/DIAGRAMS
INTERVIEW PEOPLE
COMPILE PROCEDURES & RULES FOR THE AREA
GATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVED
MAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS TO AVOID RECURRENCE, NOT TO APPORTION BLAME

18. CONTRIBUTING FACTORS ENVIRONMENTAL DESIGN SYSTEMS & PROCEDURES
Noise, heat, light, vapors, dust
DESIGN
Workplace layout, tools, equipment
SYSTEMS & PROCEDURES
Lack of or inappropriate
HUMAN BEHAVIOUR
Common to all accidents

19. Corrective Actions Determine Them Implement Them Look Deep
Find them all
Keep asking WHY
Implement Them
Fix it
Train it
Improve it

20. Concerns If Not, It Will Happen Again None or incomplete investigation
Not finding causes
Not addressing corrective actions
No Employee Involvement
Not communicating lessons learned
If Not, It Will Happen Again

21. WHEN 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

22. COMMUNICATIONS Weekly/monthly newsletters All hands meetings/Tailgate
Safety flashes/Guardians
Suggestions boxes
Open & Honest
Two-way, Good or Bad
Employee Involvement
Post – Near misses, Investigations, Audit findings & Corrective actions, Completion dates, Targets, etc.
Builds Trust

24. Safety Whiteboard Expectations
Supervisor/Safety Rep to hold meetings
1/week at Safety Whiteboard on shop floor/break room
Mandatory union attendance and support groups (FSE/QE)
Target time of 20 min.
Only topic is safety
Agenda:
Review updates of items on the whiteboard
Poll group for new issues
Triple I Matrix (Distribution List)
Outstanding Ergo Assessments
Last week’s statistics
Near Miss/Incidents – description of
Other Safety Stuff
Guardians
Safety Alerts
Leading/Lagging indicators (discuss 1/month)
Safety Initiative (Departmental performance) -
LWD/RIR

25. Before starting work, make sure you have everything you need to do your job safely.
Have the right tools
Have the right safety equipment
Know how to do the job safely
Know you’re fit and competent

26. Speak up about safety Daily briefings Task specific training
Suggesting safer ways of working to others
Reporting unsafe acts and conditions
Being safety proactive

27. Never walk by
If you see someone acting unsafely… point out the right way
If you see an unsafe condition… fix it and report it
If someone shows you a safe way… thank them for it; they may have saved you from injury or worse

28. Home safe
We all have family and friends
We all have interests, hobbies and passions
24 hours a day

29. Working in the Red Zone
How 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”

30. Most Accidents Happen in the “Red Zone.”
When you hear or think any of those phrases you should immediately:
STOP
THINK
MAKE SURE YOU ARE PERFORMING THE JOB SAFELY
GET THE RIGHT TOOLS
ASK FOR HELP
REPORT YOUR CONCERN

31. HAZARD RECOGNITION Risk Assessments Job Task Identify them
Implement corrective actions
Continually reduce risk
Reevaluate occasionally
Job Task
JSA’s or JSP’s
Work Instructions

33. Near Misses/Close Calls
Investigate near-misses since they are potential Incidents
Incidents or injuries are the “tip of the iceberg” of hazards
Incidents
Hazards
More Near Misses = Less Incidents

34. Why focus on near misses?
Our safest sites are those that report the most near misses 1
fatality
Employee trips, falls, hits head. Dies. 30
major injuries
Employee trips, falls and fractures arm. Eight weeks out of work.
300 Recordables
Employee trips, falls and lacerates hand. Five stitches.
3,000 first aid injuries
Employee trips, falls. Bruises hip.
Employee steps over waste. Walks away.
30,000 near misses

38. AUDITS/INSPECTIONS Conduct training
Knowledgeable with OSHA and other regulations
Go in Teams, (2 or 3 members)
Do different areas
Engage workers
Show positives, not just negatives
Take others along
Identify opportunities & Implement Corrective Actions
Set dates or timelines
Responsible parties for completion

39. YOU MUST GET CLOSURE

40. Management of Change Get the picture up front Changes to the process
New machinery/equipment
Location changes
New processes or products
New or changes to the facility
Cheaper to do it up front instead of afterwards

46. TRAINING OSHA Other regulations Company Job/Task specific Skill sets
Show competency
Follow-up
Know the Difference between right and wrong

47. Training helps to Prevent Incidents!
Get the picture?

48. Rules 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.

49. Employee Involvement Always get employees involved
Gains support/buy-in
Easier for change
People like to be active and heard
The workers usually know the answer
Create a team environment
Happier & more productive

50. SAFETY TEAMS Employee Involvement & Buy In Mission statement Focused
Proper members
Special Project Teams
For all Teams
Have a charter
Keep minutes and attendance
Stay on track
Celebrate successes

51. ACCOUNTABILITY 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)

53. ALWAYS 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?