NEW RESEARCH ON THE PREVENTION OF SERIOUS INJURIES AND FATALITIES (SIF)

1. NEW RESEARCH ON THE PREVENTION OF SERIOUS INJURIES AND FATALITIES (SIF) A Paradigm Shift into a new future…

2. Learning Objectives • Definition of SIF • Data Trends • Paradigm Shift with Safety Pyramid • Action plan

3. SIF = Serious Injury or Fatality

4. SIF Research Team

5. Industry Data • FAR – Fatal Accident Rate • TRIF – Total Recordable Injury Frequency • LTIF – Lost Time Injury Frequency

6. 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

7. 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: • Laceration or crushing injuries or significant blood loss • Damage to the brain or spinal cord or Severe burns • Use of cardiopulmonary resuscitation or defibrillator • 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: • Significant head injuries • Paralysis • Amputations • Broken or fractured bones SIF

8. 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.

10. Qualitative Analysis

11. 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)

12. Definition of SIF 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 over time

13. Examples of Precursors 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 These precursors preceded the incidents they are related to.

14. 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

15. Bloomington, Illinois • High audit scores • No injuries in 6 years

16. 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

17. The Old Paradigm Revisited A focus on the potential for serious injury Serious Injuries and Fatalities Some of our First Aids have Precursor’s for far more serious injuries.. 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.

19. New Paradigm • 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

20. Attack the Pyramids! Now we will work the Top! 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..

21. 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!

22. SIF Data Breakdown Near Misses 1421 incidents 321 had SIF potential • 23% SIF potential for Near Misses

23. SIF Data Breakdown First Aid Cases 106 First Aid Cases 20 had SIF potential • 19% SIF potential for First Aid Cases

24. SIF Data Breakdown OSHA Recordables 81 OSHA Recordables 26 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

25. SIF Data Breakdown Property damage 177 Property Damage Incidents 36 had SIF potential 20% SIF potential with Property Damage Incidents

26. 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

27. SIF Data Top Six Falling Equipment – 50 of 67 incidents had SIF potential 73% of Falling Equipment Incidents had SIF potential

28. SIF Data Top Six Lockout/Tagout – 71 of 113 incidents had SIF potential 63% of Lockout/Tagout Incidents had SIF potential

29. SIF Data Top Six Rail – 41 of 82 Rail incidents had SIF potential 50% of Rail Incidents had SIF potential

30. 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

31. SIF Data Top Six Mobile Equipment – 34 of 107 Mobile Equipment incidents had SIF potential 32% of Mobile Equipment Incidents had SIF potential (This includes all Mobile Equipment except Rail)

32. SIF And Contractor Involvement Contractors were involved in 166 incidents that had SIF potential Contractors were involved in 38% of the incidents that had SIF potential

33. Qualitative Analysis - Revisted

34. So now what is the…

35. Intervention Design 1. 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

36. 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

37. 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

38. “W.H.A.T. will keep you safe” W.H.A.T. The presentation is now complete! Any questions?