Fatality Prevention in the Workplace Forum Effective Hazard

Fatality Prevention in the Workplace Forum Effective Hazard Controls for High Risk Tasks Breakout Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation Facilitator: Jeff Shockey, CSP Corporate Safety Director, Alcoa Inc. Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation

Definition of a High Risk Task A high risk task: • is an identifiable function of a job or activity • has one or more critical steps ( if omitted or performed incorrectly) • has the potential for single point vulnerability …. that can lead to fatal or life-altering consequences. Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 2

Reducing risk by promoting a lesson’s learned culture Jeff Shockey, Alcoa Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 3

Reducing risk by promoting a lesson’s learned culture Capturing and institutionalizing knowledge about high risk exposures and tasks from past incidents is critical to preventing future incidents. Trigger – Fatalities with similar characteristics can signal that lessons-learned are forgotten over time – in part due to loss of key stewards of institutional knowledge. Hazard – Drift in can develop in fatality prevention efforts and our safety system due to a failure to institutionalize or pass on critical institutional knowledge making one vulnerable to repeat the lessons from our past. Best Practice – Hazard mapping identifies location of historical fatalities, major incidents and currently identified fatality prevention risks identified/closed. Plant map drills down to department to specific incident or risk description. It is visual and effective -especially for employees new to the plan or area. Source: Alcoa Inc. /USW Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 5

Reducing risk through control of overtime and fatigue management Raymond S. Higgs, CSP - TRW Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 5

Reducing risk through control of overtime and fatigue management Re-evaluating company policy to better manage employee fatigue from excessive overtime and reduce the potential for incidents during high risk tasks Triggering Event – Many facilities have reported significant increases in injury and severity rates that can be linked to increased employee fatigue from working more daily and weekend overtime. The increase in incidents has lead to a heightened awareness of the severe injury and fatality potential associated with fatigue from excessive overtime. Hazard – Per the American College of Occupational and Environmental Medicine’s (ACOEM) Task Force on Fatigue Risk Management Guidance Statement published in February of 2012, the number of hours worked in the week prior to the shift when the incident occurred seems to be related to the safety risk. In manufacturing workers, researchers found an 88% excess risk in those who worked more than 64 hours the week before compared with those who worked less than 40 hours (after controlling for within-subject variables). Our experience also suggests that the frequency and severity of injuries has increased as a result of employee fatigue from working excessive overtime. Best Practice – Implementation of a Fatigue Risk Management Policy to control the risks associated with employee fatigue from excessive overtime. The ACOEM Task Force on Fatigue Risk Management Guidance Statement outlines the framework for the development of a comprehensive Fatigue Risk Management System. Source: Raymond S. Higgs, CSP - TRW Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 4

Reducing risk through pre-job/task briefings Jeff Shockey, Alcoa Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 7

Reducing risk through pre-job/task briefings Integrating human performance concepts into the path of work for high risk tasks. Trigger – We recognized that people, programs and processes, the work environment, organization and equipment are all part of a system. Flaws in the system impact the performance of the individual and flaws in the individual impact the system. Hazard – It’s not how long somebody has been in the job that’s important. What really matters is how many times this person has done this task prior to this time. Simply put, doing something for the first time or so infreqently it is veiwed asa non-routine task increases the risk. Best Practice – A pre-job/task discussion focused on ensuring each person involved in the task, regardless of their experience is aware of the critical steps and what could go wrong, the potential hazards and errorlikely situations along with the procedures that apply and the layers of protection available to them. Most importantly it t provides a means to agree on clear and binary STOP Work Criteria. Source: Alcoa Inc. Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 6

Reducing risk through pre-job planning A. J. De. Rose, Indianapolis Power & Light Co. Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 9

Reducing risk through pre-job planning Key process steps include job plan, hazard ID, hazard control, communication, and accountability Triggering Event – in 2007, IPL identified a need for a robust, comprehensive job planning process. Hazards– • Electrical exposures from 120 v to 345 kv. • Fall exposures < 200’. • Heavy equipment to install, operate and manage various electrical devices from transformers to switch gear to meters. Best Practice – IPL developed a task specific Job Planning program for each work group. • Developed by staff assessing Risk and Frequency of work activity. • Then identifying hazards and safety controls for the work to be performed. • Work specific Folders were then developed to be used in Pre Job Briefings. Source: A. J. De. Rose Indianapolis Power and Light Company Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 2

Reducing the risk through focused risk assessment of critical tasks and processes Brian Garrett, EH&S Manager, Ternium USA Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 11

Reducing the risk through focused risk assessment of critical tasks and processes The CTP is part of the Zero Serious Injury program. The main objective of this program is to achieve the goal of zero serious injuries in our plants. Triggering Event - The CTP is a known critical tasks or process that can cause a fatality or a permanent disability in the event of an incident. Hazard – High risk activities that can result in a severe outcome to personnel. Best Practice – A program to identify high risk activities and reduce an undesired outcome. High risk tasks are those which can cause amputation, severe bodily burn or fatality. Each task identified is evaluated for safety that will be applied to protect the individual. The task will have a sign posted there to alert operations/contractors of the hazard and what necessary steps you must take to comply with safety. The sign list the risk of the task, PPE used, tooling necessary, critical steps to follow, specific safety measures and any SOP that relates to that task. Source: Brian Garrett, EH&S Manager, Ternium USA Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 4

Best Practice Human Performance Plus Hazard Controls John T Miller, Entergy Services Inc Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 13

Best Practice Human Performance Plus Hazard Controls Applied Human Performance Tools = Effective Hazard Controls! Human Performance Tools Individual: • Self Checking • Place-Keeping • Questioning Attitude • Procedure Usage Team: • Pre-Job Brief • Post-Job Review • Effective Communications • Turnover • Peer Checking • Coaching • Accept That Human Error Exist- Understand (PSF) Performance Shaping Factors • Human Performance Tools Plus Hazard Controls- Use human performance tools to achieve effective application of Hazard Controls • Establish Self Sustaining Human Performance Culture – Culture that understands human performance applies everywhere all the time • Written Accident and Incident Root Cause Procedure – Written process for investigation, defined deliverables, defined team makeup, members trained in root cause, non subjective culpability models (find the real problem) • Promptly Address Latent Organizational Weaknesses (LOW) – Worst enemy of human performance, hazard controls and root cause Source: John T Miller Entergy Services Inc Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 7

Reducing Risk of an Unexpected Release During Line Breaks P. Brandon Mausel, CSP, Du. Pont Global Workplace Safety Competency Leader Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 15

Reducing Risk of an Unexpected Release During Line Breaks Defining a line break and associated considerations and minimum precautions to be taken when breaking into lines and equipment. Background: • Between 1996 and 2001, fifteen (15) line break incidents occurred that resulted in 17 lost Breaking flanges workday cases and one fatality. • Numerous serious injuries have occurred as a result of making incorrect assumptions that lines Removing one or more or equipment were free of hazards when they bolts from flanges actually were not. Many incidents are the result of people not understanding the definition of a line break. Opening valves to the atmosphere Best Practice: Nine Key Elements of making a safe line break: 1. New projects and modifications to existing systems 2. Training 3. Job planning Turning spectacle plates 4. System preparation (i. e. , blanks) 5. Lockout/isolation 6. Job turnover 7. Personal protective equipment: selection and use Disconnecting loading 8. Job execution and unloading 9. Incident investigation process hoses Source: P. Brandon Mausel, CSP, Du. Pont Global Workplace Safety Competency Leader Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 1

Reducing risk through applied technology Jeff Shockey, Alcoa Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 17

Reducing risk through applied technology Applying technology available to eliminate or reduce the likelihood of exposure for personnel during high risk tasks. Trigger – A number of fatalities were reported in other companies where an aerial lift operator becomes trapped between the lift basket and a fixed overhead structure such that the operator’s chest is compressed against the joystick such that they can’t act to free themselves. Hazards – Single administrative layers of protection are often vulnerable to human error, vague or poor communication and guidance, organizational drift and normalized deviation triggered by overconfidence or a lack of knowledge – particular when employees first time in task are involved. Best Practices – Genie® Operator Protection Structure and Nationwide Platform’s Sky. Siren, Antientrapment Solution Source: Alcoa Inc. Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 18

Reducing risk through applied technology Researching the technology available to reduce the risk and improve the reliability of crane runway inspections. Trigger – A number of major incidents where load swing lead to equipment product damage or loss of load that had the potential to cause fatal or serious injury. Hazard –Experience suggests serious head injuries as a result of load swing or loss of load that can often result in fatalities or process safety incidents. Best Practice – Anti - load swing device reduces risk of potential for fatal or serious injury by eliminating the need for personnel to touch and guide suspended loads. Overall cycle time improves by 10% to 40% and one study by a major aerospace manufacturer confirmed a reduction in payload collisions by 94%. Enables every crane operator, regardless of skill level, to perform at a higher level. Source: Alcoa Inc. Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 4

Reducing risk through changes in job design and work methods David I. Jacobi, Kimberly-Clark Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 20

Reducing risk through changes in job design and work methods Rethinking the tools, techniques and work methods to reduce the risk of falls from trucks and trailers. Source: David Jacobi, Kimberly-Clark Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 2

Reducing risk through changes in job design and work methods Ken Joerger, International Paper Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 22

Reducing risk through changes in job design and work methods Reducing the risk of falls from chip trailers Best Option Chosen by Team (2 parts) : Part 1: Counterweight system at the origin (chip mill) pulls the tarp over the top of the trailer as it leaves the chip hopper. Note: Facilities with 100% ground crank utilization will not need a counterweight system installed Source: Ken Joerger, International Paper Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 4

Reducing risk through changes in job design and work methods Reducing the risk of falls from chip trailers Part 2: At the destination (paper mill), tarps are removed using portable ladder/work platforms Source: Ken Joerger, International Paper Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation 4