SERIOUS INJURY AND FATALITY PREVENTION · - Increased focus on Process Safety / ‘Conduct of...

transcript

Tactics & Metrics

SERIOUS INJURY AND FATALITY PREVENTION

PETE BATROWNY &RICHARD CERENZIOModerators

RON RIFEExxon Mobil Corporation

- Eliminating Higher Potential Events

- Risk Tolerance / Approaching Others - Actively Caring

- Serious Injury & Fatality (SIF) Study / focus on Potential

Consequences / ‘Mining the Diamond’

- Personnel Safety Study / OIMS Leadership Academy / Messaging

Workshops

- SSH&E Leadership / CARE

- Hurt Free Approach

- Increased focus on Process Safety / ‘Conduct of Operations’ / ‘Life Saving Actions’ /

Tier 1 Best Practices / Incident Risk Analysis Tool (IRAT)

- Protect Tomorrow. Today. / Environmental Expectations

- Security is Everybody’s Business / Security Expectations

- Major Incident Team Study

- Nobody Gets Hurt / Critical Success Factors

- Behavior-Based Safety / Loss Prevention System / Human Factors

- Operations Integrity Management System (OIMS)

ExxonMobil SSH&E Journey

‘90s

We are a learning organization . . .

Metrics: Scope / Boundaries

• Corporate, Business Line and Site; ‘right’ metrics at ‘right’ level

• OIMS Leadership, Safety (Personnel / Process), Security, Health, Environment

• Leading and lagging

• Quantitative and qualitative

Boundaries

• Unconstrained by current approaches / metrics

• Fit-for-purpose

• Considered retirement of metrics deemed to have limited value; acknowledged some metrics

required externally (e.g., shareholders, Corporate Citizenship Report, IPIECA, etc.)

Hurt Free Approach to Personnel Safety

Historical Perspective

Drilling’s Safety Journey – 2005 Realizations

• Year-on-year progress … but focus still on “Recordability”

• Focus needs to be aligned with Vision of Nobody Gets Hurt!

LTIR TRIR

Fostering A Culture of Caring

Parental Care Management

• Injury Assessment & Action

• Followed by “The Talk”

Hurt Free Approach to Safety

• Protect the “Family”

Focus on Hurt Free

• Alternative to Treatment-based Approach

• Natural language of Safety; Protect the “Family”

• Aligns well with our Vision of “Nobody Gets Hurt!”

and the NSC’s “Racing to Zero”

• Provides consistent actual severity description, and

• Includes integral potential severity assessment

‘Nobody Gets Hurt’

reat ent- ase

lassifi ations’

urt- ase e els’

Minor Hurt

Fatality

Severe Hurt

Moderate Hurt

Multiple Fatalities

No physical body damage, but actionable learnings

Fatality

First Aid

No Treatment

Near Miss,

Unsafe Act / Condition

Hurt-based Levels

Severity Levels Duration Examples

Fatality(ies)

• 5 – Multiple fatalities

• 4 – Single fatality

Severe Hurt

Long-term,

Life-altering

• Amputation / severe disfigurement

• Total loss of organ / vision / hearing

Moderate HurtWeek to Months

• Bone fractures, significant lacerations

• Moderate hearing / vision loss

Minor Hurt

Minutes / Hours /

• Minor cuts / bruises / sprains / strains

• Mild hearing loss / corneal abrasions

No HurtNo Body Damage

• Object in eye removed by flushing

• Slip / Trip / Fall with no bruising or swelling

• General soreness

Severity Level Determination

• Assign Actual Hurt Level (AHL)

– Determine the actual injury or illness severity (AHL 0-5)

• Determine Potential Hurt Level (PHL)

– Identify ‘worst case’ considering ‘feasible-but-reasonable’

scenarios (PHLWorst Case 0-5)

– Evaluate ‘Barriers’ in place pre-event (effective vs. LTA)

– Determine extent ‘Effective Barriers’ reduced ‘worst case’

– Assess ‘final’ Potential Hurt Level from top down

(PHLFinal 0-5)

• Identify Corrective Actions to prevent future hurt

– Consider any ineffective barriers from PHL assessment,

in combination with causal factors

Mining the Diamond

Serious Injuries and Fatalities

2010 Industry Study

• TRIR typically decreasing

• Rate of Serious Injuries & Fatalities (SIF) were not

improving

• ~20% of all incidents have the potential to be a SIF

EM SIF rate 6% -10%

Potential SIFs are often those events buried deep in

the traditional safety triangle; the actual outcome

falls short of the potential that could have occurred.

Underlying Principles

• Focus on severity & potential consequences

– “Potential” discussions drive actions to prevent

future incidents

–Consequence potential drives prioritization

• Apply ‘Mining the Diamond’ concept across

full suite of SSH&E disciplines

• Define expected leadership behaviors to

drive culture and desired organizational

behaviors

Personnel Safety & Health example

Focus on Higher Potential Events

• Maintain vision to prevent all hurts – Hurt Free Approach

• Recognize and foster understanding of higher risk activities

• Prioritize events with highest potential – Mining the Diamond

• Strive to eliminate life-altering or fatal injuries

• Broadly share and apply learnings from these events

Personnel and Process Safety Metrics

Personnel Safety & Health

• Hurt Free Approach supports a culture of learning

that resonates with the workforce; builds safety

ownership

• Corporate Stewardship

- Actual Hurt Level 2+ incidents and rate

- Potential Hurt Level 3+ events

- Leading incident types and root causes (from above)

- Traditional lagging metrics (e.g., TRIR, LTIR) receive

less discussion

• Complementary Hurt-related metrics

recommended at business line and site levels

Personnel Safety & Health (Example)

1Q 2Q 3Q 4Q

AHL2 AHL3 AHL4 AHL2+IR*

Actual Hurt Level 2+ Workforce Incidents

Potential Hurt Level 3+ Events – 12 Months

Level 5

(Multiple Fatalities)

Level 4

(Fatality)

PHL 3 Events

3PHL 4

Events8

PHL 5 Events

0Total

Events235

Level 3

(Life-Altering)

Level 2

(Moderate Hurt)

Level 1

(Minor Hurt)

Level 0

(No Hurt)

Workforc

Fatalities

0 0 0 0

LTIR 0.02 0.01 0.02 0.02

TRIR 0.21 0.22 0.24 0.22

e(Example Data)

(Example Data)

Energy Isolation2

Preventive Maintenance

Lifting & Rigging

Work at Heights2

Manual Handling

Pipe/Casing Handling

Release1

• ‘Diamond Event’ type analysis includes:

‒ Root Cause / Causal Factors Analysis

‒ Behavioral Analysis

‒ Corrective Actions / Initiatives

‒ Turning learnings into actions

Personnel Safety & Health (Example)

PHL3+ Events(12 Months)

(Example Data)

• Identify ‘Diamond’ Process Safety Events

- Use actual and potential incident severity, as well as barriers

that were available / effective in preventing a “Serious Incident”

- ‘Diamond Events’ are investigated with greater intensity

• Corporate Stewardship

- Process Safety Events (PSEs)

+ PSEs with actual higher consequence

+ PSEs with potential higher consequence and

limited barriers; highlights incidents with

zero or 1 human intervention barrier

• Business Line level recommended metrics

- Lower severity PSE metrics

- Risk Discovery, Risk Mitigation, ‘Total Risk’ metrics

Process Safety

Process Safety example

Dia on E ents’

Tier 1-3 PSEs with higher actual and/or

potential consequence

and limited barriers

Actual Incidents PSEs – Potential Higher Consequence

Process Safety (Example)

(Example Data)

1Q 2Q 3Q 4Q

Actual Higher Consequence Event*

1Q 2Q 3Q 4Q14

Potential Higher Consequence Event **

0 Total or 1 Human Barrier

(Example Data)

Process Safety (Example)

• ‘Diamond Event’ type analysis includes:

‒ Root Cause / Causal Factors Analysis

‒ Behavioral Analysis

‒ Corrective Actions / Initiatives

‒ Turning learnings into actions

(Example Data)

QUESTIONANSWER

STEVEN SCHWARTZ, CSPEli Lilly and Company

Questions to Consider

Prevention

Strategy

Who, how, and what do you educate regarding SIF Prevention?

What SIF Prevention metrics do you collect and how are they discussed?

How does your organization identify and mitigate SIF Precursors?

What SIF Prevention programs have you implemented? What existing programs have been enhanced to include SIF Prevention?

About Eli Lilly and Company

www.Lilly.com

Our mission:We make medicines that help people live longer, healthier, more active lives.

Global Research and Development, Manufacturing, Sales and Marketing, and Elanco Animal Health

Approximately 45,000 employees as of July 2017

SIF Prevention Model

3. Developprocess to IDand mitigate

precursors

2. Measure SIF and potential

1. Educate the organization

on the SIF model and

4. Integrateinto existing

business processes

Educating our Employees

SERIOUS INJURIES AND

FATALITIES

LOST TIMEINJURIES

RECORDABLEINJURIES

FIRST AIDINJURIES

NEARMISSES

The SIF paradigm

The SIF prevention model

SIF terminology

Educate employees at all levels

It is imperative to educate employees about SIF Prevention so that they understand the approach and provide insight /direction on how we execute the other aspects of our model.

2016 Manufacturing Operations Data

Potential SIF Events 2016

Forklift / PIT

Electricity

Gravity

Chemical

Machine

Motor Vehicle

Fall from stairs

Lockout

Confined Space

Identifying and Mitigating SIF Precursors

Electrical Safety

Lockout

Confined Space Entry

Cranes and Hoists

Forklift / Powered Industrial Trucks

Working at Heights

Management safety discussions

Employee observations

Safety recommendations

Behavior based platforms

FMEA = Failure Modes and Effects Analysis

Integrating SIF Prevention

Auditing: Collaborate with the Global HSE audit team to place more rigor on programs / aspects with SIF impact; Use updated audit protocol(s) to determine if SIF prevention standards are implemented sufficiently.

Behavior / Safety Culture:Sites have begun to analyze observation data for trends around SIF Precursors. Integration of SIF with existing safety culture processes is essential for success.

Communication:Existing communication mechanisms are leveraged to integrate SIF prevention messages. Rapid Fire event sharing.

Self Assess: Site self-assessment (SSA) is imperative to determine if work with SIF impact is conducted flawlessly with and intent to eliminate SIF precursors consistently and comprehensively.

Company Standards• Control of Hazardous energy• Cranes / Hoists• Confined Space Entry• Electrical Safety

• Working at Heights• Forklift / PIT / MH equip• PSM

Lockout site assessment project

Global HS Requirements (13) x 32 sites

Plan6 to 8 onsite

lockouts evaluated per

each site

DoLocal plans updated to

mitigate precursors

Site leverages networks,

global SME’s, and local consult

Did the site have a written program? Did the site sufficiently control the key(s) throughout the lockout process?

Did the site have ESI/ECP or it correctly create field developed ESI?Did contractor(s) (or visitors or vendors) on site utilize a sufficient method of group lockout?

Did the site ESI's include at a minimum the basic steps for machine and equipment lockout and hazardous energy control?

Did the site have an adequate permit or energy control process for breaking process lines (chemicals, steam, etc.)?

Did the site correctly document and/or verify (2PV) complex system lockouts?Did the site conduct an internal assessment of ESI's or energy control procedures; and did it communicate assessment results?

Did the site have adequate labeling of isolation points? Did the site limit how many employees were authorized to conduct lockout?

Did the site have sufficient training (hands-on), and/or qualification/certification of authorized employees?

Did the site bring authorized employees together to discuss program effectiveness, including the results of self assessments and audits?

Did the site have a standard lock for safety; was the safety lock used only for lockout?

Lockout site assessment project

The worst scoring precursor was:Did the site ESI's include at a minimum the basic steps for machine and equipment lockout and hazardous energy control?

Mean (13.4); Median (12.5); Mode (17.5; 10.5)

Equip Specific

Instructions

(Detail)

Second

Person

Verification

Program

Effectiveness

Internal

Assessment

Equip Specific

Instruction

(Provision)

Hands-On

Training

Key Control Standardized

Written

Program

Contractors Labeling Line Breaking Limited

Authorized

Employees

Lockout AssessmentSIF Precursor Count

SIF Prevention Model - Implementation

3. Developprocess to IDand mitigate

precursors

2. Measure SIF and potential

1. Educate the organization

on the SIF model and

4. Integrateinto existing

business processes

Lessons Learned

Education should include simple and standard terms:

(SIF, Potential SIF, and SIF Precursor)

Potential SIF Events (injury + near miss) are an excellent leading indicator to drive management discussions

Identification and mitigation of SIF Precursors can take place at many levels (company, business, site)

Integrate SIF Prevention into existing processes to use resources wisely and to shift more intensity on legitimate SIF events

Planning Forward

Prevention

Strategy

Create standardized, organizational training that focuses on the SIF Prevention model and key terms; Influence employees at all levels.

Select leading indicators (Potential SIF Events) that drive valuable conversations between members of management

Identify and mitigate SIF Precursors locally, and where possible, globally

Blend SIF Prevention into existing (stable) processes that employees already know and follow.

Questions?

TAYLOR ABEL, P.E.The Mosaic Company

Serious Injury and Fatality Prevention NSC CongressExecutive Edge Track Workshop A Meeting

Taylor Abel, P.E.

Sr. Mgr. EHS Process Optimization

taylor.abel@mosaicco.com

September 26, 2017

Serious Injury & Fatality (SIF) Prevention

AGENDA

Overview of Mosaic

Mosaic’s SIF Journey

Prevention

Metrics

Closing

About The Mosaic Company(NYSE: MOS)

Our Work We are the world's leading integrated

producer and marketer of concentrated

phosphate and potash.

Our MissionWe help the world grow

the food it needs.

Who We Are

• Fortune 500 company incorporated March 2004, combination of IMC

Global Inc. & Cargill fertilizer businesses

• 100 years of phosphate mining history in U.S.

• 50 years of potash mining history in Canada

• Approximately 22.2 million tonnes of operational capacity

• $7.2 billion in sales in calendar 2016

• Customers in approximately 40 countries

• Nearly 9,000 employees in operations and joint ventures (JVs) in:

United States

Canada

Brazil

Paraguay

Australia

Peru (JV)

Saudi Arabia (JV)

Global Offices & Operations

Distribution and Markets

Daily global distribution:

Approx. 50,000 tonnes

Mosai ’s SIF Journey

Common trend of injuries versus fatalities

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7

Mosai ’s SIF Journey

2004-2008Formed in 2004Numerous programmatic improvements

2009-2011ISO14001 & OHSAS18001 RegistrationsJoined BST/Dekkra SIF Working Group

2012 – 2015Develop SIF concept within EHSDefine Mosaic specific “SIF” definitionSocialize SIF concept with leadersTargeted Interventions

2016 and beyondBranding SIF as Potentially Serious IncidentsDelineated Environmental potentialStrategic approach to improving controlsDeployed PSI across organization

PSI Definitions:

An Safety Potential Serious Incident (PSI) is an event

that could potentially and reasonably result in a fatality

or permanent disabling injury if only one factor changed.

An Environmental Potential Serious Incident (PSI) is

an event, if only one factor was changed, that could

potentially and reasonably result in a:

• Significant environmental impact that takes weeks or

months to remediate.

• Receipt of enforcement AND media coverage.

A Factor could be a control, the weather, time of day,

person’s location, etc.

PSI Quality Assurance Process - Overview

• Reviews and determines if incidents are PSI in real time

• Maintains PSI category in Incident information system

• Reports and investigates incidents per Investigation & CAPA procedure

Business Unit

• Conducts monthly review to determine:

• Incorrectly determined or categorized PSI (false positives)

• Review of non-PSIs (false negatives)

Corporate

• Conducts periodic review to determine:

• Incorrectly determined or categorized PSI (false positives)

• Missed PSI (false negatives)

• Generates reports / metrics

SIF Prevention Approach

Prevention

SIF Prevention Approach

SIF Prevention

Analysis or

Accident

Determine Improved Controls

Ensure effective-

Update

SIF/PSI by Category

Falling Object High Energy:Elec >110

High Energy:Non-Electrical

FallProtection

MobileEquipment

Haz Materials Ground Fall Blasting:Explosives

Defining further

Falling Objects

Lifting and Rigging

Structural

Dropped/Unsecured Objects

Intervention: Prevention of Dropped Objects

• Developed Corporate Standard

• Created communication strategy• Stop the Drop

• Trained employees on requirements

• Procured tools to enable employee success

• Conducted field checks for coaching & feedback

• Integrated into Management System self assessment & audit programs

Dropped/Unsecured Objects

2012 2013 2014 2015 2016 2017*

*2017 prorated for full year

SIF by Category

Falling Object High Energy:Elec >110

High Energy:Non-Electrical

FallProtection

MobileEquipment

Haz Materials Ground Fall Blasting:Explosives

Life Critical Standards

Pictogram Life Critical Standard

Lockout/Tagout & Linebreak

Confined Space Entry

Work at Height

Falling Objects

Lifting Operations

Electrical Safety

Mobile Equipment Safety

Underground Ground Control

Machinery Safety

Working Around Water

Utilizing Hierarchy of Controls

Metrics and Measures

Leading Metrics

Hierarchy of Controls

• Focus on Elimination,

Substitution, & Engineering

• % of corrective actions

Pre-Job Hazard Assessments

• PJHA Quality - leading indicator

• Safe Work Permit use

Administrative

Procedural

Engineering Substitution

Elimination

NA/Other9%

Effectiveness of Pre Job Hazard Assessments

Total Number of Assessments

Leading Metrics

A)Abrasive/Water Blasting

E1)Electrical Contact

F1)Falling Object - lifting

F2)Falling Object -unsecured

F3)Falling Object -structural

H)Hazardous Materials

I1)Energy Isolation

I2)Stored Energy

M)Mobile Equipment

O)Operating Equipment

P1)Fall Protection

P2)Unprotected Opening

V)Vehicle TravelW)Water

Q)Hot Work

Health & Safety PSI Types

Safety & Health PSI Rate

Environmental PSI rate

Closing

Our Next Steps:

Implementation of Life Critical

Standards

Advance Environmental PSI

Using data to provide more insight

Expand knowledge sharing

Benefits

Spend time and energy commensurate

to the risk

Increased awareness and visibility of

environmental and safety risk

Improved identification of PSI

exposures in the workplace

Improved controls

Summary

- Develop your definitions/program

- Analyze the data

- Take Action

- Measure and communicate

- Refine

- Importance of SIF concept

- Be an SIF prevention leader

QUESTIONANSWER

DISCUSSIONTABLE

Discussion Questions

1. What is your organization’s overall approach to SIF prevention? Have you not

started, just on the way, more mature? What have been your biggest successes

and barriers?

2. What metrics does your organization track related to SIF exposure or potential?

Have you identified a set of common precursors or causal factors for SIF? If so,

what are they?

3. What technological advances do you believe are going to make an impact on SIF

in your organization in the future? Are there are any new solutions you’re already

leveraging?

2018 SYMPOSIUMCreate Change for the Future of EHS

FEBRUARY 20-21, 2018

thecampbellinstitute.org/symposiumCharlotte, North Carolina

PLEASE COMPLETE YOUR

FEEDBACK CARDS

SERIOUS INJURY AND FATALITY PREVENTION · - Increased focus on Process Safety / ‘Conduct of...

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