Download - Presented By Eric Glass EHS UL Health Safety
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2012 USER SUMMIT
Journey to a Healthier and Safer Workplace
2012 USER SUMMIT
Presented By
Eric GlassEHS Advisor
UL Workplace Health & Safety
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2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
2012 USER SUMMIT
U.S.S. FORRESTAL FIREWorst Aircraft Carrier Disaster Post WWII
134 KILLED 161 INJURED
4 MIA $72M IN DAMAGES
21 AIRCRAFT LOST
40 AIRCRAFT UNSERVICABLE
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Anatomy of the Event
Rocket Fired From #110
Strikes #405 fuel tank; spills/flashes
1st bomb explodes in 1:34 seconds
9 Explosions within 5 minutes
Primary Fire Party Wiped Out
Secondary Fire Party Ineffective
Unexploded Ordnance Below
Fire Raged for 2.0 days
2012 USER SUMMIT
“Cause” of the Peril
• 5.0 Zuni Rocket
• “Electrical issues with the plane”
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2012 USER SUMMITTrial By Fire “Lessons”
“No one will ever know the full story. Even with written
testimony , the passage of time has a way of veiling or
obscuring material facts.”.”
Lack of SafetyStrong BackingCasual AttitudesOut of uniformProtective GearNot belonging
2012 USER SUMMIT
Aftermath……“A crate of fireworks with a bonfire on top”
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Formal Inquiry Review
SOPs Altered For CombatApproved By Navy’s ORI
BUTFlight Deck SOPs Written for Peace Time
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Formal Inquiry Review
WESTPAC & ATLANTIC SOPS DIFFERShip was in Atlantic fleet
BUTOperating Under WestPac Jurisdiction
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Formal Inquiry Review
Request DeniedCaptain Requested Fire Training
ANDRequest Denied
(even after the ship returned to port after the incident)
2012 USER SUMMIT
Formal Inquiry Review
Oriskany Report Not AvailableCould not access Oriskany Investigation
SOTraining Created from Readers Digest Article
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Formal Inquiry Review
Zuni Rockets System FragileSince they were fragile and hazardous
THENWeren’t recommended for carrier ops
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2012 USER SUMMIT
2012 USER SUMMIT
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2012 USER SUMMIT
Post-Forrestal
Information Flow/CommunicationTraining, Techniques, EquipmentShip DesignPersonal Protective EquipmentCrew TurnoverEmergency Breathing Apparatuses“Everyone is a Firefighter!”Fire TrucksLiquid O2 Plant On RailsAFFF Hi/Lo Caps
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AWARENESS TRAINING IN ACTION
2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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2012 USER SUMMIT
Will a “Forrestal” Happen At Your Organization?
• Are You Prepared?
• Have you taken measures to avoid it?
• Are you making the same mistakes?
2012 USER SUMMIT
Complacency
Carelessness
Sloppiness Inaccuracy
Imprecision
NegligenceInattention
Stupid
Dumb
Poor Attitude
Doesn’t Care
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2012 USER SUMMIT
Employers:
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Employers:
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Employers:
2012 USER SUMMIT
Employers:
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Organizations Are Responsible for:
LEARNING ENVIRONMENTOBSERVATIONS
NEAR MISSES
INCIDENTS/INJURIES/MISHAPS
2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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2012 USER SUMMIT
Danger Conditioning
Psychological
FACT:
More injuries and deaths
2012 USER SUMMIT
Danger Conditioning
• Psychological• FACT: more injuries/deaths
happen to experienced employees taking shortcuts
• Less experienced employees tend to be more timid
• Without reinforcement, dangers become less and less in the mind of the worker
• Learning Based Organization• An environment of “never ending
discovery” to identify systems, policy and operational breakdowns that foster learning moments to improve the overall effectiveness and success of their organization
• Can you cite examples in your workplace of “danger conditioning”?
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2012 USER SUMMIT
FIGHTING “DANGER CONDITIONING”
• New employee training • Repetitive Subjects, different delivery
methods• Lessons Learned
• Observations• Near Misses• Incidents with Loss• Industry news
2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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2012 USER SUMMIT
Columbia Disaster
MAJOR CAUSE: FOAMRigid HierarchyLack of Ability to Report ConcernsCouldn’t Recommend “Broken Safety Culture”
2012 USER SUMMIT
Continuous Improvement
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2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
2012 USER SUMMIT
Continuous Improvement
Employee Involvement
Management Involvement
Communication
Action to Completion
World Class Safety Organization
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2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
2012 USER SUMMIT
U.S.S. FORRESTAL FIREWorst Aircraft Carrier Disaster Post WWII
134 KILLED 161 INJURED
4 MIA $72M IN DAMAGES
21 AIRCRAFT LOST
40 AIRCRAFT UNSERVICABLE
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2012 USER SUMMIT
“Changes” Made In Reaction Mode
2012 USER SUMMIT
Total Quality Leadership (TQL)
• TQL implemented • Not universally
accepted• Effective where
accepted• Abandoned, but not
entirely• Foundation for
LEAN/SIX SIGMA
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“People want to do a good job, they need to be trained properly to fit into a process, and the
employee closest to the process probably knows the most about it and can tell you
what’s wrong with it.”
2012 USER SUMMIT
Involvement = Creativity =Involvement
• Involvement– Early and often
– Avoid “reactive” involvement
– Feedback is key
– Oversight should not be “constrictive”
– Avoid “mandatory” involvement
• Creativity– Encourage “outside
the box” thinking
– No idea is absurd
– Train employees to be thinkers
– Encourage & Reward Thinkers
– Expose to outside operations
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Learning from Lessons
• Learning moments– Observations
– Near misses
– Injuries/illnesses
– “War Stories”
– Industry trends
– Inefficiencies
2012 USER SUMMIT
Journey to a Healthier and Safer Workplace
2012 USER SUMMIT
Questions?