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We Never Thought It Could Happen To UsPresented by Scott SnyderDeep Water Horizon 4-20-10

Fukushima 3-11-11

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.

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Ill Get it Done

What is Safety?Safety is freedom from danger, risks or accidents that may result in injury, property damage or death.Recipe for SUCCESSManagement Commitment Incident InvestigationCommunicationsHazard RecognitionAudits/InspectionsManagement of ChangeTrainingEmployee InvolvementAccountability MANAGEMENT COMMITMENTLeadership LEADWalk the TalkSet the GOOD exampleEmployee engagementBe fair & consistent Employee InvolvementIts not Do What I say, Not What I DoStarts at the TOPINCIDENT INVESTIGATION THE KEY RESULT SHOULD ALWAYS BE TO PREVENT A RECURRENCE OF THE SAME INCIDENT.OUTCOMES OF INCIDENTS NEGATIVE ASPECTSDEATH & INJURYDISEASEDAMAGE TO EQUIPMENT & PROPERTYLITIGATION COSTSLOST PRODUCTIVITYREPLACEMENT WORKERSADDITIONAL TRAININGCOMMUNITY IMPACTWHO SHOULD INVESTIGATEDEPENDENT ON SEVERITY OF THE ACCIDENT

INVESTIGATION TEAMINDIVIDUALS INVOLVEDSUPERVISORSAFETY DEPARTMENTUPPER MANAGEMENTWITNESSESOUTSIDE CONSULTANTS

INVESTIGATION STRATEGYGATHER INFORMATION & ESTABLISH FACTS

ISOLATE ESSENTIAL CONTRIBUTING FACTORS

DETERMINE CORRECTIVE ACTIONS

IMPLEMENT CORRECTIVE ACTIONS

INVESTIGATION STRATEGYFACT GATHERINGISOLATE SCENEBE IMPARTIAL & OBJECTIVEPHOTOS/DIAGRAMSINTERVIEW PEOPLECOMPILE PROCEDURES & RULES FOR THE AREAGATHER MAINTENANCE RECORDS ON EQUIPMENT INVOLVEDMAKE IT CLEAR THE OBJECT OF THE INVESTIGATION IS TO AVOID RECURRENCE, NOT TO APPORTION BLAME

CONTRIBUTING FACTORSENVIRONMENTALNoise, heat, light, vapors, dustDESIGNWorkplace layout, tools, equipmentSYSTEMS & PROCEDURESLack of or inappropriateHUMAN BEHAVIOURCommon to all accidents

Corrective ActionsDetermine ThemLook DeepFind them allKeep asking WHY

Implement ThemFix itTrain itImprove itConcernsNone or incomplete investigationNot finding causesNot addressing corrective actionsNo Employee InvolvementNot communicating lessons learned

If Not, It Will Happen AgainWHEN AN ORGANIZATION REACTS SWIFTLY

AND POSTIVELY TO INCIDENTS AND INJURIES,

ITS ACTIONS REAFFIRM ITS COMMITMENT TO

THE SAFETY AND WELL-BEING OF ITS

EMPLOYEESCOMMUNICATIONSWeekly/monthly newslettersAll hands meetings/TailgateSafety flashes/GuardiansSuggestions boxesOpen & HonestTwo-way, Good or BadEmployee InvolvementPost Near misses, Investigations, Audit findings & Corrective actions, Completion dates, Targets, etc. Builds Trust

Safety Whiteboard ExpectationsSupervisor/Safety Rep to hold meetings1/week at Safety Whiteboard on shop floor/break roomMandatory union attendance and support groups (FSE/QE)Target time of 20 min.Only topic is safetyAgenda:Review updates of items on the whiteboardPoll group for new issuesTriple I Matrix (Distribution List)Outstanding Ergo AssessmentsLast weeks statisticsNear Miss/Incidents description ofOther Safety StuffGuardiansSafety AlertsLeading/Lagging indicators (discuss 1/month)Safety Initiative (Departmental performance) - LWD/RIRBefore starting work, make sure you have everything you need to do your job safely.

Have the right toolsHave the right safety equipmentKnow how to do the job safelyKnow youre fit and competent

Speak up about safety

Daily briefingsTask specific trainingSuggesting safer ways of working to othersReporting unsafe acts and conditionsBeing safety proactive

Never walk by

If you see someone acting unsafely point out the right wayIf you see an unsafe condition fix it and report itIf someone shows you a safe way thank them for it; they may have saved you from injury or worse

Home safe

We all have family and friendsWe all have interests, hobbies and passions24 hours a day

Working in the Red ZoneHow 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.Ive never done this before.I dont have the right tool. This isnt the same as the othersI havent been trained for thisThis is reworkThis is a new jobThis is a new procedureThis isnt how we usually do it

Most Accidents Happen in the Red Zone.When you hear or think any of those phrases you should immediately:STOPTHINKMAKE SURE YOU ARE PERFORMING THE JOB SAFELYGET THE RIGHT TOOLSASK FOR HELPREPORT YOUR CONCERNHAZARD RECOGNITIONRisk AssessmentsIdentify themImplement corrective actionsContinually reduce riskReevaluate occasionally Job TaskJSAs or JSPsWork Instructions

Near Misses/Close CallsInvestigate near-misses since they are potential Incidents Incidents or injuries are the tip of the iceberg of hazardsIncidentsHazardsMore Near Misses = Less Incidents

Employee trips, falls, hits head. Dies.30,000 near misses3,000 first aid injuries300 Recordables30 major injuries1 fatalityEmployee trips, falls and fractures arm. Eight weeks out of work.Employee trips, falls and lacerates hand. Five stitches.Employee trips, falls. Bruises hip.Employee steps over waste. Walks away.Our safest sites are those that report the most near missesWhy focus on near misses?

AUDITS/INSPECTIONSConduct trainingKnowledgeable with OSHA and other regulations Go in Teams, (2 or 3 members)Do different areasEngage workersShow positives, not just negativesTake others alongIdentify opportunities & Implement Corrective ActionsSet dates or timelinesResponsible parties for completionYOU MUST GET CLOSUREManagement of ChangeGet the picture up front Changes to the processNew machinery/equipmentLocation changesNew processes or productsNew or changes to the facility

Cheaper to do it up front instead of afterwards

TRAININGOSHAOther regulationsCompanyJob/Task specificSkill setsShow competencyFollow-up

Know the Difference between right and wrong

Get the picture?Training helps to Prevent Incidents!Rules for LiftingGet close to the load.Test the loadKeep feet apart.Keep back straight.Bend your knees.Tuck your chin.Grip the load with your palms.

Get help if needed.

Employee Involvement

Always get employees involvedGains support/buy-inEasier for changePeople like to be active and heardThe workers usually know the answerCreate a team environmentHappier & more productive

SAFETY TEAMSEmployee Involvement & Buy InMission statementFocusedProper membersSpecial Project TeamsFor all TeamsHave a charterKeep minutes and attendanceStay on trackCelebrate successes

ACCOUNTABILITYDo What You SayWhat Happens If You DontHold everyone accountable

Can be very uncomfortable for most peopleWise men learn from others mens mistakes, fools by their own.

(Chinese proverb)

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?