CONFIDENTIAL. This document contains trade secret information. Disclosure, use or reproduction outside Cargill and inside Cargill, to or by those employees who do not have a need to know is prohibited except as authorized by Cargill In writing. (Copyright Cargill, Incorporated 2007. All rights reserved.)
A Paradigm Shift into a new future…
NEW RESEARCH ON THE PREVENTION OF SERIOUS INJURIES AND FATALITIES (SIF)
© 2011 Cargill Incorporated. All rights reserved
Learning Objectives
• Definition of SIF• Data Trends• Paradigm Shift with Safety Pyramid• Action plan
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SIF = Serious Injury or Fatality
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SIF Research Team
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Industry Data•
FAR
– Fatal A
ccident R
ate
•T
RIF
– Total Re
cordable Injury F
requency
•LT
IF – L
ost Tim
e Injury F
requency
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Common for Leading Companies• Recordable and lost time injury rates are declining steadily, but the
fatality rate is level or increasing
• How can this be? EH&S experts have been telling us for years about the ‘Safety Pyramid’ The idea that minor injuries predict serious ones is embedded in our culture
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Definition of Serious Injury
Any injury or illness that resulted in:
Life-threatening injury or illness: one that if not immediately addressed is likely to lead to the death of the affected individual. Examples include, but are not limited to:
A. Laceration or crushing injuries or significant blood loss
B. Damage to the brain or spinal cord or Severe burns
C. Use of cardiopulmonary resuscitation or defibrillator
D. Chest or abdominal trauma affecting vital organs
Life-altering injury or illness: one that results in permanent or long-term impairment. Examples include, but are not limited to:
E. Significant head injuries
F. Paralysis
G. Amputations
H. Broken or fractured bones
SIF
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SIF Potential?
Strained Back
Case A (Non-SIF) – Worker was walking across the floor, slipped on grease, caught himself on a railing, and wrenched his back (strained back muscle) classified as “first-aid”
Case B (SIF = Yes) – Worker fell from the top of a rail car when his car was struck by another rail car that was being moved into position. The worker fell on top of the tank car, grabbing the guard rail around the dome lid, preventing a fall to the ground. The only injury resulting was some bruising and a strained back muscle. Even though this event was classified as “first-aid”, it clearly has high potential for SIF.
© 2011 Cargill Incorporated. All rights reserved© 2011 Cargill Incorporated. All rights reserved
The traditional safety pyramid is not 100%
predictive of SIF
Not all injuries have SIF potential
A reduction of injuries at the bottom of the pyramid
does not correspond to an proportionatereduction of SIFs
21% Potentially SIF
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Qualitative Analysis
Theme SIF or SIF-Potential
Incident
N=55
NON SIF-Potential
Incident
N=35
(Life Safety/Safety Absolute = Policy or Procedure) % %
1 Performing a routine production or a maintenance, connected with a deviation
from an established Life Safety/Safety Absolute42% 0%
2 Performing a routine production or a maintenance task connected to an
exposure that changed from a “normal state”, was not
anticipated/recognized/controlled and likely could have been prevented by
a proper Pre-Task Hazard Assessment (PJHA).
29% 17%
3 Self-made human errors that are not connected to a Safety Absolute
Involved in either a routine operations/production or a maintenance/repair task
OR performing a special/unique/unplanned/emergency situation.
11% 74%
4 Involved in routine operations/production or a maintenance tasks, and a
connection to an equipment / facility / process / engineering design flaw has
been established
5% 3%
5 Involved in routine production or a maintenance tasks, and a connection to
predictive & preventive maintenance & inspection, and reliability systems
has been established
5% 6%
6 Involved in a special/unique/unplanned/emergency situation, connected to
an exposure that was unknown or unfamiliar.4% 0%
7 Involved in an act or incident or workplace violence, war, or militia attack or
similar.4% 0%
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You will not reduce SIFs by working at the bottom of the pyramid alone
(the causes and correlation are different)
Senior leadership attention and involvement is necessary
(SIF reduction demands a different focus)
Precursors of SIFs can be identified (and measured)
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A high-risk situation in which management controls are either absent, ineffective, or not complied with,
and which will result in a serious or fatal injury if allowed to continue over time
Definition of SIF Precursor
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Precursor: In order to change the doctor roll on a paper re-roller two workers must stand beneath it and guide it. The doctor roll weighs about 6 tons
Precursor: A worker is repairing a valve 20-feet above grade. There is no engineered anchor point to secure the lanyard
Precursor: During an emergency shutdown workers are unable to follow all aspects of the
procedure because it appears impractical
Examples of Precursors
These precursors preceded the incidents they are related to.
© 2011 Cargill Incorporated. All rights reserved
Ever heard this before?• The last 2 years we’ve had a great safety record. Our
recordable rates were lower than ever. We were proud. A few months ago we celebrated our safety success
• This quarter we experienced an amputation, a severe burn, and two frightening near-misses
• Our GM and his boss are upset and confused. Our safety leaders can’t explain it
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15
•Bloomington, Illinois• High audit scores• No injuries in 6 years
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The problem is in the measurement system that creates a blind spot, not giving visibility to the events necessary to see the root cause in order to prevent SIFs
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The Old Paradigm Revisited
A focus on the potential for serious injury
Precursor:
A high-risk situation in which management controls are either
absent, ineffective, or not complied with, and which will result in a
serious or fatal injury if allowed to continue.
Serious Injuries and Fatalities
Some of our First Aids have Precursor’s for
far more serious injuries..
© 2011 Cargill Incorporated. All rights reserved
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• Injuries of differing severity have differing underlying causes
• The strategy for reducing serious injuries should use precursor data drawn from all available sources of data: accidents, injuries, near misses and exposures
New Paradigm
© 2011 Cargill Incorporated. All rights reserved
Attack the Pyramids!
Precursor: A high-risk situation in which
management controls are either absent, ineffective, or not complied with, and which will result in a serious or fatal
injury if allowed to continue.
Continue to work the base..
Now we will work the Top!
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SIF BU Analysis Information
1800 incidents evaluated from December 2009 through December 2011
437 incidents had SIF potential
This is 24% of our incidents had SIF
potential!
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SIF Data Breakdown
Near Misses1421 incidents321 had SIF potential
23% SIF potential for Near Misses
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SIF Data Breakdown
First Aid Cases106 First Aid Cases20 had SIF potential
19% SIF potential for First Aid Cases
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SIF Data Breakdown
OSHA Recordables81 OSHA Recordables26 had SIF potential
26% SIF potential for OSHA Recordables
• 2 actual SIF injuries One multiple face fractures when struck by channel iron after a
come along anchor point failed One steam burn to face, neck and torso when a steam line
failed
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SIF Data Breakdown
Property damage177 Property Damage Incidents36 had SIF potential
20% SIF potential with Property Damage Incidents
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SIF Data Breakdown
Corn Milling Top 6 SIF categories are:Elevated Work – 84 of 103 had SIF potential
82% SIF potential with Elevated Work Incidents
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SIF Data Top Six
Falling Equipment – 50 of 67 incidents had SIF potential
73% of Falling Equipment Incidents had SIF potential
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SIF Data Top Six
Lockout/Tagout – 71 of 113 incidents had SIF potential
63% of Lockout/Tagout Incidents had SIF potential
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SIF Data Top Six
Rail – 41 of 82 Rail incidents had SIF potential50% of Rail Incidents had SIF potential
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SIF Data Top Six
Chemical Release – 65 of 140 Chemical Release Incidents had SIF potential
45% of Chemical Release Incidents had SIF potential
Chemical Release incidents include Chemical releases/leaks of acids, caustics, steam and
other operating materials
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SIF Data Top Six
Mobile Equipment – 34 of 107 Mobile Equipment incidents had SIF potential32% of Mobile Equipment Incidents had SIF
potential(This includes all Mobile Equipment except Rail)
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SIF And Contractor Involvement
Contractors were involved in 166 incidents that had SIF potentialContractors were involved in 38% of the incidents
that had SIF potential
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Qualitative Analysis - Revisted
Theme SIF or SIF-Potential
Incident
N=55
NON SIF-Potential
Incident
N=35
(Life Safety/Safety Absolute = Policy or Procedure) % %
1 Performing a routine production or a maintenance, connected with a deviation
from an established Life Safety/Safety Absolute42% 0%
2 Performing a routine production or a maintenance task connected to an
exposure that changed from a “normal state”, was not
anticipated/recognized/controlled and likely could have been prevented by
a proper Pre-Task Hazard Assessment (PJHA).
29% 17%
3 Self-made human errors that are not connected to a Safety Absolute
Involved in either a routine operations/production or a maintenance/repair task
OR performing a special/unique/unplanned/emergency situation.
11% 74%
4 Involved in routine operations/production or a maintenance tasks, and a
connection to an equipment / facility / process / engineering design flaw has
been established
5% 3%
5 Involved in routine production or a maintenance tasks, and a connection to
predictive & preventive maintenance & inspection, and reliability systems
has been established
5% 6%
6 Involved in a special/unique/unplanned/emergency situation, connected to
an exposure that was unknown or unfamiliar.4% 0%
7 Involved in an act or incident or workplace violence, war, or militia attack or
similar.4% 0%
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So now what is the…
© 2011 Cargill Incorporated. All rights reserved
Intervention Design1. Educate all constituents on the New Paradigm
– Senior Leadership to understand these findings and lead the effort
2. Measure Serious and Fatal Injuries and SIF- Potentials as one category– Better safety metrics– Evaluate and judge all incidents based on SIF potential– Improved tracking of SIF precursor events and progress
© 2011 Cargill Incorporated. All rights reserved
3. Develop processes to identify precursors and recommend mitigation
– Study your data– Observations, audit findings, focus groups– Customize to site– Generalize regionally, business unit?– Use BST/ORC findings to start?
Intervention Design
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4. Integrate mitigation efforts with existing safety systems, and audit & observation processes
• More rigor around cardinal rule situations• Pre-task risk assessment capability• Leverage behavior-based safety system• Verification audits• Rules staying current with equipment, process and
procedural changes
Intervention Design
CONFIDENTIAL. This document contains trade secret information. Disclosure, use or reproduction outside Cargill and inside Cargill, to or by those employees who do not have a need to know is prohibited except as authorized by Cargill In writing. (Copyright Cargill, Incorporated 2007. All rights reserved.)
W.H.A.T.
“W.H.A.T. will keep you safe”
The presentation is now complete!Any questions?
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