Transcript General Industry

General Industry
Breakout Session Summary
November 2, 2007
Process
 1 Hour to validate & prioritize findings
 Select the top 2 causes for each gap by
circling them on the paper
 If you find a significant gap or cause is
missing – write it in
 Select the top 5 best practices
 Select the top 5 areas of research
Overall General Industry Trends
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34% Contact with Equipment/Objects
29% Transportation (Highways 51%)
11% Falls (84% to lower level)
9% Harmful Environments (47% electrical ,
39% substances)
 8% Fire & Explosion
Organizational Consistency With Trends
 Overall consistency with trends
 Additional areas of fatalities
 Railroad
Fatality Fishbone
Methods
Organizational
People
& Procedures
Error traps
Factors
Leadership
Risk Perception
Outsourcing
Mentally Difficult
Deviation
Fatalities
Work
Environment
Confusing
controls
Flammable
Delayed maint.
Process &
Equipment
Products &
Materials
Global
competition
External
Influences
Ice & Snow
Methods & Procedures
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Gaps in safe work procedures
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No procedures exists
• Perception that the procedure adds
no value
• Procedure isn’t necessary for
routine/repetitive tasks
• Procedure can’t be developed for
non-routine task
• Take too long to write procedure vs.
time to do the job
• Staffing constraints limits number of
procedures that can be developed &
maintained current & effective
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Procedure exists but is ineffective
• Not current
• Not comprehensive e & specific enough given
risk of task
• Not readily accessible
• Not in a format that’s easy to understand or
follow
• Does not match culture, language, &
terminology of the user
• Has built in error traps (vague or ambiguous)
• Has no input from the person doing the task
Procedure exists but is not followed
• Lack of enforcement
• Perception is the procedure adds no value
• Perception is that following procedure takes
longer
• People don’t know it exists
• Conflicting procedures (can’t follow both)
Methods & Procedures (cont)
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Gaps in pre-job planning & risk assessment
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No pre-job planning & risk assessment completed before the task begins
• Time constraints
• Familiarity & overconfidence with the task
• Lack of knowledge
• No process tool to formalize /document the pre-job plan or risk assessment
• No expectation for which tasks require a pre-job plan/risk assessment
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Pre-job planning & risk assessment ineffective
• When the job conditions change
• The right people are not involved
• Lack of hazard identification skills
• If it doesn’t cover all phases or covers too many phases
• Fail to identify stop work criteria
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Pre-job planning & risk assessment not followed
• Has no input from the people doing the task
• When the procedure doesn’t work as planned
• Perception of inconvenience physical/mental difficulty
• Individual perception of risk
• Low probability of deviation being observed or corrected
Organizational Factors
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Gaps in safety culture/climate
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Unclear /conflicting/too many expectations
Leadership doesn’t always recognize the impact they have on the safety culture
• Asking for more with less (money, resources, etc.)
• Impact of excessive overtime on risk
• Impact of outsourcing & temporary manpower on risk
• Impact of increasing employee/supervisor ratio – span of control
The rate of leadership turnover drives short term focus versus long term accountability
The impact of leadership turnover on relationships & agreements
Lack of development of effective safety Leadership style (transformation & transactional style)
Focus on production versus safety
Competing priorities
Focus on lagging versus leading indicators (numbers versus fatality risks)
Improving injury rates , good ISO /OSHA compliance correlates to processes in control with a low
fatality risk profile
Lack of near hit/near miss reporting
• Fear of consequences/discipline (trust issue)
• Fail to recognize the value in measuring potential versus actual outcome
Lack of ownership of contractors, outsourced & temporary manpower
Impact of failure to build bench strength & retain safety critical talent (engineers, supervisors, technical,
crafts, safety staff, etc.)
Work Environment
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Gaps in consistent application of safety across all shifts
 Cultural norms can vary by shift
 Variability in the method & timing of safety communication
 Variability in the visibility of Senior Leadership
 Variability in skills/staffing by shift increases deviation potential
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Gaps in working conditions
 Varying risk exposure
 Emerging economies
• Poor roads, traffic hazards, traffic controls, security risks
• Different tolerance for fatalities
• Different perception of risk, don’t understand culture
External influences
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Governments
 Predominately focus on prevention of injuries versus fatalities
 Fail to provide economic incentives for capital investments that support
safety as compared to environmental
 Failure to provide adequate data for analysis
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Stakeholder focus influencing organizational decisions
 Short term
 Predominately profit
 Cost reduction
 Emphasis on environmental risk is competing with fatality prevention
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Global competition
 Lowest cost providers (outsourcing)
 Leanest staff
 Elimination of redundancies in layers of protection
Products & Materials
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Gaps in understanding/recognizing hazards associated with end
products and raw materials
 No/weak new materials review process
 No/weak raw material control/sourcing
 No/weak critical design review of the product
 No/weak emergency response procedures for higher risk products or raw
materials
 Low risk perception
• Receiving, unloading, storage, and movement of raw materials
throughout the manufacturing process
• Packaging, storage, loading, unloading, & transportation of end
product to customer
Process & Equipment
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Gaps in managing the risks associated with processes & equipment
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Aging technology with limited capital to repair/replace
• Short term focus on financial performance
• Reward system aimed at immediate versus sustainable results
• Pressure associated with remaining globally competitive
No realistic view of planned equipment obsolescence
• Retrofit versus state of the art design
• Pushing equipment to design limits such that safety factors are compromised
Gaps in the uncontrolled release of energy (safety versus production)
• Bigger, faster, more powerful translates to increased safety risks
• Bigger, faster, more powerful translates to increased productivity
Gaps in maintenance, service, and repair
• Wrong part
• Right part, but defective
• Failed to replace the part on reassembly
Gaps in layers of protection
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Heavy reliance on administrative controls & PPE versus capital solutions
Process & Equipment (cont.)
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Gaps in equipment and process change management
 No or outdated drawings/schematics
 Unapproved modifications or procedures
 Very few industries are staffed to sustain a rigorous change management
process
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Gaps in the operator equipment interface
 Complex feedback & control programs
 Limited recognition of human factors
People
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Gap in people following procedures
 Time pressure (real or perceived)
 Overconfidence
 Individual low risk perception
 Short cuts are easier
 Unaware procedure exists
 Deviation unobserved
 Co-worker tolerance for deviation
 Procedures is too complex or
difficult (too many steps, etc.)
Gaps in supervision to enforce
procedures
 No organizational support
 Conflict avoidance
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Gaps in availability of technically
competent and experienced personnel
 Outsourced engineering
 Turnover in engineering, craft,
process,, and supervisory personnel
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Gaps in knowing what exposure groups to
focus fatality prevention activities
 No method for capturing & transferring
institutional knowledge relative to low
probability high consequence events
 Inadequate data mining system
 Lack of proactive analyzing of data
mining system to focus fatality
prevention efforts
 Not capturing the right data
Best Practices – Start Doing
Procedures
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More employee involvement in the process of
defining procedures – engagement
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Dealing with language & cultural differences –
procedures more visual based
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Procedures – right, practical, enforceable - teach &
coach our frontline folks to have discussion in a nonthreatening manner
Leader Development
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Leadership safety training – every leader should
have hazard recognition training
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Coaching programs for performance improvement –
we assume folks can do it
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Zero tolerance safety climate
Audits
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Review audit criteria to ensure fatality prevention
focus
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Leadership audits – visible on the floor
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Unannounced audits – focused on historical fatality
causes
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Audits with corrective action plans – detailed
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Self-assessment on fatality prevention
Risk assessment
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Formal risk assessment process for routine & nonroutine
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Observation programs with greater employee
involvement
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Pre-job risk assessments – internal & contractor
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Focused observations on root causes
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Major risk programs – good risk assessments
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Pedestrian/vehicular segregation
Lessons Learned
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Robust system for replicating best practices –
collecting, tracking, & replicating
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Incident management – more robust investigations
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Analyzing cases for serious/catastrophic injuries
Fatality focused programs
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Focus on higher risk activities for safety, compliance,
observation, etc.
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Life threatening/critical programs – focus on 4/5 high
risk areas
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Hazard identification – focus on top 3 priorities for
fatality prevention
Reporting
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Well integrated Electronic reporting tools
(audit/injury/detection)
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Using data up front – collect, pinpoint, focus on risk –
look for fatalities…
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Lead, track severe incidents with high potential for
recordables
Layers of Protection
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Double redundant interlocking systems
Future Areas of Research
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There’s a deficiency in the National database
for fatalities – what are the 5+ things you want
to know about fatalities
Need for simplistic fault risk assessment tool
that can be standardized…not a simple
straightforward model
Specific risk assessment tools for specific
fatality risks – mobile equipment pedestrian
safety – specific factors…tools that give you
good triggers
Research that demonstrates the impact that
these programs have on fatality prevention –
correlation/causal relationship – need to
understand the most important levers to
push/pull
 The economic influence on fatalities
 What influence do safety enabling
systems have?
 What about the organizational enabling
systems?
More coordination of efforts across
organizations conducting research – lessons
learned across…
Being in compliance doesn’t = no fatalities –
Does being in compliance make a difference
when it comes to fatality prevention?
Correlation of different tools to the outcomes
(1801)
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Those that have switched from a focus on
tracking indicators to leading indicators –
looking at organizations who have done it and
the impact
Analysis of the impact of key elements of the
Mgmt System to outcomes
Mgmt. System to impact on fatalities
Breakdown of language impact on fatalities
Get the event sequence data from BLS –
mining the data
Contractors within mfctr – how are we
managing them?
Take data & look at work activities to make it
more actionable – are we collecting the right
data?
Research dealing with the span of control &
impact on fatalities (CII – Construction)
Impact of the turnover rate for Leadership on
fatalities (risk of mobile workforce)
Low total case rates had an on-site Safety Svr.
– correlation Amount of time of a safety
resource/professional on site…correlation to
incidence rates…focused resource
Do organizations with Observation programs
have a lower incidence? Correlation?
Link areas of research with root causes