UNDERSTANDING AND PREVENTING SEVERE INJURIES AND …
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COPYRIGHT UNDERSTANDING AND PREVENTING SEVERE INJURIES AND FATALITIES
Transcript of UNDERSTANDING AND PREVENTING SEVERE INJURIES AND …
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UNDERSTANDING AND PREVENTING SEVERE INJURIES AND FATALITIES
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TIM BOYER DEKRA SMS
CHIEF TECHNOLOGY OFFICER
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UNDERSTANDING AND PREVENTING SEVERE INJURIES AND FATALITIES
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SEVERE INJURY DEFINITION • Life-Threatening
• If not immediately addressed is likely to lead to the death of the affected individual
• Life-Altering • Results in permanent or long-term impairment or loss of use of an
internal organ, body function, or body part.
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Total recordable incident rate have been on the decline for decades
5 4.8 4.6 4.4 4.2 3.9
3.6 3.5 3.4 3.4 3.3 3.2 3 2.9 2.8
1.5 1.4 1.4 1.3 1.2 1.1 1.1 1.1 1 1 1 1 0.9 0.9 0.9
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
U.S. Incident Rates (Bureau of Labor Statistics data)
Total recordable cases Cases with days away from work
Workplace Fatalities are not following the trend
5575 5764 5734 5840 5657 5214
4551 4690 4693 4628 4585 4821 4836
5190
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Fatalities
What are SIF’s and why are we hearing so much about them?
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TRADITIONAL SAFETY THINKING • Safety Triangle is predictive • All Injuries have the same causes
and precursors • You can impact the top of the triangle
by working on the bottom of the triangle TRIR is a reliable indicator of SIF Exposure
• Our investigations are good enough
Near Miss
First Aid
Recordable
Loss Time
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THE SAFETY TRIANGLE IS NOT PREDICTIVE • Not all injuries have Serious Injury
and Fatality (SIF) potential. • A reduction of injuries at the
bottom of the triangle does not correspond to a proportionate reduction of SIFs.
• SIFS have different precursors
21% Potential
SIF
Precursors
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SIF POTENTIAL IN GRAIN INDUSTRY Random sampling of 100 recordable Incidents from DEKRA SMS Benchmarking group • 19% of Recordable Incidents were
actual SIF’s or had SIF potential Random Sampling of 100 Near Misses • 32% SIF Potential
Near Miss
First Aid
Recordable
Loss Time
19%
32%
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TAKE AWAY #1 Don’t Expect SIF Prevention by doing the same things you have been doing! Focusing at the bottom of the triangle does not work.
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Traditional safety methods are still important!
• Observation & Interaction
• Employee Communication
• Incident/Injury Reporting & Handling.
• Pre-Task Risk Assessments.
• Exposure Recognition:
• Risk perception and risk tolerance.
• Blood, break, and bruise.
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TAKE AWAY #2 Your OSHA 300 log and Total Incident Rate are misleading when it comes to SIF exposures!
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RECORDABLE INJURY LOG IS MISLEADING Fractured Foot
Case A (SIF Exposure = No) – Employee suffered a fractured foot when they climbed out of a truck cab, missed the bottom rung of the ladder, and fell 30 inches to the ground. Their foot rolled off a small rock, resulting in a fracture.
Case B (SIF Exposure = Yes) – Employee suffered a fractured foot when backed over by a forklift truck (PIT). The PIT operator backed up without looking, and the backup alarm was not functioning. This easily could have been a serious (life-threatening or life-altering) injury, or fatality if the employee’s full body had been struck and run over.
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TAKE AWAY #3 The SIF Blind Spot is Significant! • Common comments after SIF occurs;
• We did not see that coming… • Our incident rate has been dropping for years, what happened? • We have a policy, what were they thinking?
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SIF’S PRECURSORS HAVE CONTROLS IN PLACE…. • Regulations • Policies • Permits • Training • JHA’s • Engineering & Design
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BUT IN MOST SIF’S THEY ARE NOT EFFECTIVE Risk control systems were missing, deficient, or were not being complied with.
Design
Policies, Procedures, Training
PPE, Warning Signs
Human Factors (People)
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Presenter
Presentation Notes
Others; Fires and Explosions Chemical Release Working under suspended loads
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TAKE AWAY #4 Accident investigations are not as good as you think they are!
Employee Focused 80%
Exposure Focused 20%
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ACCIDENT INVESTIGATION PROCESSES MUST IMPROVE • Contributing factors.
• Root causes.
• Precursors.
• Longitudinal analysis (look for trends, not one each)
• Effectiveness of corrective and preventive actions.
• Tracking of recommendations.
• Effective communications of lessons learned.
• Case narratives must provide adequate descriptions to help us understand what really happened and the context surrounding the exposure.
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TAKE AWAY #5 To find SIF precursors you must increase your field of view! • Look for potentials before incidents • Engage employees • Are First Aid incidents and Near Misses being reported? • Investigations • Audits • Behavior Based Safety Observations • Employee interviews • SIF Hunts
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Dominic Cooper Ph.D. ISHN Magazine Published SIF Study; “Corrective actions focused on job planning could eliminate about 30 percent of potential SIFs and focusing on people’s behavior could reduce another 45 percent.” DEKRA Insight Study
• A study of 55 SIF/SIF-Potential cases has confirmed that the SIF precursors, pre-conditions, and exposures that contributed to the occurrence of these incidents would be discoverable through interviews, and/or observations in 87% of the cases.
• In 7 cases (13%), unlikely to detect precursors or variables through an observation or interview process
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Observations Audit Findings
Near Miss First Aid
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TAKE AWAY #6 SIF Events Are Not One-Offs, they are not new, the precursors have been there all along. You have been practicing for SIF’s for a long time!
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WHAT SHOULD YOU DO? 1. Educate Leaders and Employees on SIF:
• They need to understand this problem before they can act on it. • The solutions to the SIF problem requires everyone's attention. • Leaders need to sponsor initiatives.
2. Provide Visibility to SIF Exposure: • Define “SI”F: Life-Threatening vs. Life-Altering. • Adapt Decision-tree mentality for evaluating risk. • Further investigations for incidents that contain SIF potential. • Calculate SIF Exposure Rate: SIF Recordable and SIF Total.
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FOUR THINGS YOU MUST DO (continued)
3. Know Your SIF Precursors: • Three places where they hide:
1. High Risk/High Exposure Tasks (81% Routine).
2. Management Systems Missing, Deficient, or Not Complied With.
3. Allowed to Continue.
4. Integrate SIF discovery into existing activities: • Life Saving Safety Rules, Pre-Task Risk Assessments, Pausing Work,
Incident Handling Systems (reporting, reaction, investigation, etc.)
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TAKE AWAY RECAP 1. You can not prevent SIF’s with traditional tactics. 2. Traditional measurements are misleading (Incident Rates). 3. The SIF blind spot is real. 4. Accident investigations are not as good as you think they are. 5. To find SIF precursors you must increase your field of view. 6. SIF Events Are Not One-Offs, they are not new, the
precursors have been there all along.
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SIF OR NO SIF? Activity:
Employee was reversing polarity on conveyor at the disconnect.
Result: Employee suffered arc flash burn to the right hand.
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SIF OR NO SIF? Activity: Throwing a bag of AMS from spray trailer onto spray rig parked alongside the trailer
Result: Fell off of trailer
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SIF OR NO SIF? Activity: Checking the amount of product in a bulk tank.
Result: Another employee was climbing a ladder to check the level of product in a bulk tank. The ladder slipped and fell over striking the person on the ground. The ladder hit him to the side of the right eye causing a cut.
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SIF OR NO SIF? Activity: Unloading truck
Result: Employee was talking to another employee on a forklift and while they were wrapping up the conversation the employee on the forklift started backing up slowly not realizing the injured employees foot was right next to the tire. This lead to the injured employee getting his toes ran over.
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SIF OR NO SIF? Activity: Loading truck with beans
Result: Climbing ladder and hand slipped off top of truck while checking bean level. Landed on feet and broke his ankle
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SIF OR NO SIF? Activity: Delivering bulk feed
Result: Climbed free standing to open lid to unload feed inside building. while opening lid which is hard to open lost balance and slipped and feel backward about 6 to 10 feet.
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SIF OR NO SIF? Activity: Using skid loader to fill auger on the bunker.
Result: Employee was getting out of the skid loader and foot slipped. He used his hand to break the fall. Resulted in a broken wrist.
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SIF OR NO SIF? Activity: Employee was trying to dislodge a chunk of grain from overhead that was plugged. Employee stepped into the trailer to poke rod into bin. Was using a strap from tarp to hold onto while trying to dislodge grain and it broke and he fell about 2 feet into the bottom of the hopper. It had rained and they did not want to get the forklift and cage as when they dislodged the plug it would fall onto the wet ground. Result: Strap broke and he fell into bottom of hopper striking his back.
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SIF or No SIF? Activity: Employee was lifted on a pallet by a forklift.
Result: Stopped work and pointed out the danger of the situation
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SIF OR NO SIF? Activity: The wheels were not chalked before the employee went under the truck to do maintenance.
Result: Another employee from another location came to get the truck and didn't know he was under the truck and he started to move it and he starting yelling and banging and he stopped.
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SIF OR NO SIF? Activity: employee was walking around on the top of the bean house and walked over one of the man hole covers
Result: when the employee stepped on the man hole cover the cover slipped out of place and them employee fell through the hole . When he fell through the bin was full of beans so he only fell about 2 feet but it could have been far worse if it was an empty bin
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