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MINE SAFETY MANAGEMENT:Making Advances in Managing Known
knowns, known unknowns and unknown unknowns
Raja V. Ramani The Pennsylvania State University
Sukumar Bandopadhyay University of Alaska Fairbanks
OUTLINE
SAFETY PERFORMANCE SAFETY MANAGEMENT SAFE MINE? HAZARDS – KNOWNS & UNKNOWNS STATISTICS ON U.S. MINING INDUSTRY IMPLICATIONS FOR MANAGEMENT CONCLUSIONS
“There are known knowns. These are things we know that we know. There are known unknowns. That is to say,
there are things that we know we don't know. But there are also unknown
unknowns. There are things we don't know we don't know.”
Donald Rumsfeld
KNOWN KNOWNS – THINGS WE KNOW
KNOWN UNKNOWN – THINGS WE KNOW WE DO NOT KNOW
KNOWN UNKNOWN – THINGS WE DO NOT KNOW WE DO NOT KNOW
THIS STATEMENT HAS EVOKED CONSIDERABLE DISCUSSION
WHY SAFETY PERFORMANCE ENHANCEMENT?
TREMENDOUS INCENTIVES TO INCREASE SAFETY PERFORMANCE
DO NO HARM – HUMANITARIAN ASPECTS SAFETY IS GOOD BUSINESS – ECONOMICS CORPORATE IMAGE – DIFFICULT TO REPAIR
NATIONAL SAFETY COUNCIL [NSC]BUREAU OF LABOR STATISTICS [BLS]
BUREAU OF LABOR STATISTICS 2009 DATA12 WORKERS KILLED PER DAY ON THE JOB4.1 MILLION WORK RELATED INJURIES 50,000 DEATHS FROM OCCUPATIONAL DISEASES
AFL-CIO 2011 REPORT SUSPECTED UNDER REPORTING OF INJURIESTOTAL COST OF INJURIES - $200 TO 300 BILLION
NATIONAL SAFETY COUNCIL 2009 DATA COST OF A FATALITY - $1.3 BILLIONCOST OF A DISABLING INJURY - $50,000
WHY MANAGEMENT?
MANAGEMENT HAS AUTHORITY TO ESTABLISH POLICIES AND PRIORITIES COMMIT RESOURCES SELECT MINING SYSTEMS AND EQUIPMENT CHOOSE PERSONNEL FOR SPECIFIC JOBS REWARD MANAGERS AND WORKERS
MANAGEMENT DOES THIS BY PLANNING, ORGANIZING, IMPLEMENTING AND CONTROLLING
THE ORGANIZATIONAL RESOURCES.
OBJECTIVES OF THE SAFETY FUNCTION
PROVIDE LEADERSHIP IN SAFETY WITH DEFINITION
OF GOAL AND MEANS DEVELOP OUTSTANDING ORGANIZATIONAL
FRAMEWORK IN SUPPORT OF SAFETY EQUIPMENT, PROCESSES AND PROCEDURES ARE
DESIGNED HAZARD FREE OR REDUCE HAZARD DEVELOP KNOWLEDGE AND SKILLS – QUALITY
TRAINING AN ENVIRONMENT WITH COMMITMENT TO SAFETY
WHEN IS A MINE SAFE?
SAFE MINE IS A PRODUCTIVE MINE WHAT ARE THE CHARACTERISTICS OF A SAFE MINE? HOW ARE INJURIES, ILLNESSES AND DISASTERS RELATED TO SAFETY? HOW IS COMPLIANCE RELATED TO SAFETY?NECESSARY CONDITIONS AND SUFFICIENT
CONDITIONS
ACHIEVING A SAFE MINE
The problem to achieving a completely safe mine is rooted in identifying and meeting all the sufficient conditions. The universe of hazards - defined as unsafe conditions that have potential to cause harm - is not easily identified. The objective of safety management is to identify, eliminate and/or control all the hazards.
KNOWN KNOWN HAZARDS – HAZARDS WE KNOW WE KNOW
KNOWN UNKNOWN HAZARDS – HAZARDS WE KNOW WE DO NOT KNOW
UNKNOWN UNKNOWN HAZARDS – HAZARDS WE DO NOT KNOW WE DO NOT KNOW
HIGHLY RELEVANT FOR MAKING PROGRESS TOWARDS CREATING A SAFE MINE
UNIVERSE OF HAZARDS
KNOWN KNOWNS
• CAUSES, CONSEQUENCES AND MANNER OF CONTROL ARE KNOWN WITH CERTAINTY
• MANAGEMENT THROUGH ELIMINATION IS MOST EFFECTIVE
• HAZARD REDUCTION, HAZARD CONTROL AND DAMAGE CONTROL ARE ALL APPLICABLE DEPENDING ON THE MANNER OF CONTROL
• ARE ALL KNOWN HAZARDS ELIMINATED???
KNOWN UNKNOWNS
• CAUSES, CONSEQUENCES AND MANNER OF CONTROL ARE NOT KNOWN WITH CERTAINTY
• QUESTIONS OR UNCERTAINTIES EXIST WITH DATA, ANALYSES, DESIGN AND CONTROL PROCEDURES
• ASSUMPTIONS HAVE TO BE MADE• OBJECTIVE IS TO REDUCE THE RISK TO
TOLERABLE LEVELS – RISK MANAGEMENT
KNOWN UNKNOWNS – MINE SAFETYConsider the case of trying to open a mine in an
old mining district.• Known knowns - [1] There are old mines, [2] There
are maps available of old mines from agencies. [3] There can be issues with reserves and health and safety during operation
• Known unknowns - [1] The accuracy of the maps - extent of workings. [2] The conditions of the workings - water-filled or gas-filled, etc. [3] Exact nature of the health and safety issues.
QUECREEK MINE INUNDATION INCIDENT, JULY 24, 2002
UNKNOWN UNKNOWNS
• THESE ARE SERIOUS THREATS AS NO ONE PLANS FOR AN “UNKNOWN UNKNOWN”
• IMPORTANT TO RECOGNIZE INADEQUACY OF KNOWLEDGE
• EXPERIENCE AND RESEARCH HAVE UNEARTHED NEW PARAMETERS, NEW RELATIONSHIPS, AND NEW KNOWLEDGE
“THE ORDER OF NATURE: NOTHING HAPPENS BY ACCIDENT, AND THERE IS NO
SUCH THING AS CHANCE”
“CHANCE AND ACCIDENTS ARE ALIASES OF IGNORANCE”
THOMAS HENRY HUXLEYINTRODUCTORY, MACMILLAN AND CO, 1880
ARE THERE TRUE UNKNOWN UNKNOWNS?
IMPORTANT ROLE OF HUMANS
KNOWLEDGE AND EXPERIENCE – TAKE TIME TO BUILD IGNORANCE IS QUITE COMMON CORRECT DECISION MAKING – NOT EASY MANAGEMENT OF CHANGE
RECENT EXAMPLES OF UNKNOWN UNKNOWNS
9/11 TERRORIST ATTACK TRIPLE WHAMMY IN JAPAN – EARTHQUAKE, TSUNAME AND NUCLEAR DISASTER THE CURRENT GLOBAL FINANCIAL CRISIS
UNKNOWN UNKNOWNS – BUILDING MODELS
• PARAMETERS’ VALUES AND RELATIONSHIPS KNOWN – KNOWN KNOWNS
• PARAMETERS KNOWN – UNCERTAIN OF EXACT VALUES AND RELATIONSHIPS – KNOWN UNKNOWNS
• PARAMETERS NOT KNOWN – UNKNOWN UNKNOWNS, NOT INCLUDED IN THE MODEL
MINE SAFETY – UNKNOWN UNKNOWN EXAMPLE
• Unknown unknowns - Existence of old mines for which there are no maps, no indications. How can one be sure that [1] all mines have been mapped? [2] all maps are available? and [3] all relevant information have been considered?
All available data have been considered is no assurance that there are no unmapped mines.
ABSENCE OF PROOF IS NOT
PROOF OF ABSENCE
WILLIAM COWPER
"These occurrences, I confess, are of exceeding gravity, and more over fraught with terror and peril , so that I should consider that the metals should not be dug up at all, if such things were to happen very frequently to the
miners, or if they could not guard against such risks by any means."
GEORGIUS AGRICOLA DE RE METALLICA, 1556
WILLIAM COWPER
PRECAUTIONARY PRINCIPLE
“WHEN AN ACTIVITY RAISES THREATS TO HUMAN HEALTH OR ENVIRONMENT, PRECAUTIONARY MEASURES SHOULD BE TAKEN EVEN IF SOME CAUSE AND EFFECT RELATIONSHIPS ARE NOT FULLY ESTABLISHED.”
“IF AN ACTIVITY MIGHT POSE SEVERE DAMAGE TO HUMAN HEALTH, WE OUGHT TO CONSIDER CONSEQUENCES WITHOUT NECESSARILY WAITING FOR PROOF.”
MINE HEALTH AND SAFETY EXPERIENCE
• FATALITIES AND FATALITIES RATES DECREASING WORLDWIDE
• DISASTERS AND DISASTER RATES DECREASING WORLDWIDE
• INJURIES AND SEVERITY, AND INJURY AND SEVERITY RATES DECREASING
• OCCUPATIONAL DISEASES – PREVALENCES DECREASING
NUMBER OF FATALITIES IN THE U.S. MINING INDUSTRY, 1910-2000
U.S. MINE FATALITY RATE, 1930-2000
STEEP DECREASES IN FATALITY RATES FOLLOWMAJOR CHANGES IN PRACTICES
0
50
100
150
200
250
300
Nu
mb
er o
f F
atal
itie
s
1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010
U.S. Mining Fatalities CY 1978 - 2010
Year Fatalities Fatality Rate
1978 242 0.0515
2010 71 0.0234
2006 2007 2008 2009 2010
Number of Mines Coal Metal/Non-Metal Total
2,11312,77214,885
2,03012,84114,871
2,12912,77814,907
2,07612,55514,631
1,94512,31914,264
Employment Coal Metal/Non-Metal Total
122,975240,522363,497
122,936255,187378,123
133,828258,918392,746
134,089221,831355,720
135,415225,148360,563
Fatalities Coal Metal/Non-Metal Total
472673
343367
302353
181634
482371
Fatality Rate1
Coal Metal/Non-Metal TotalAll U.S. Industry2
0.04000.01220.02200.0042
0.02930.01490.01990.0040
0.02370.01070.01560.0037
0.01480.00920.01150.0035
0.03840.01290.0234
All Injury Rate1
Coal Metal/Non-Metal TotalAll mines NFDL Rates3
All U.S. NFDL Private4
4.463.193.642.434.4
4.213.023.432.314.2
3.892.873.252.173.9
3.692.543.012.023.6
3.422.382.811.87
U.S. MINING INDUSTRY ACCIDENT-INJURY EXPERIENCE, 2006-2010
Mine Injury Experience2006-2010
Average for the 5-year period: 2006 – 2010 MINE EMPLOYMENT 370,000NUMBER OF COAL MINES 2,060NUMBER OF M/NM MINES 12,600NUMBER OF FATALITIES 60FATALITY RATE 0.0185ALL INJURY RATE 3.94ALL U.S. INDUSTRY FATALITY RATE 0.0038
MINING DISASTER INCIDENTS AND FATALITIES, 1900-2010
MINE DISASTERS: 2001-2010YEAR MINE NAME LOCATION TYPE OF
DISASTERMINERAL MINED
NUMBER OF VICTIMS
2001 No. 5 BROOKWOOD, ALABAMA
EXPLOSION COAL 13
2006 SAGO BUCKHANNON, WEST VIRGINIA
EXPLOSION COAL 12
2006 DARBY No. 1
MIDDLESBORO,KENTUCKY
EXPLOSION COAL 5
2007 CRANDALL CANYON
HUNTINGTON, UTAH
GROUND FALL [FACE OR RIB]
COAL 6
2010 UPPER BIG BRANCH
MONTCOAL, WEST VIRGINIA
EXPLOSION COAL 29
http://www.cdc.gov/niosh/mining/pubs/pdfs/tsomf.pdf
Reported fires for the U.S. mining industry from 1990 to 2007
TOTAL NUMBER OF REPORTED FIRES [1990-2007] = 1601
Percentage of miners with CWP by tenure in mining, CWXSP, 1970-2006
MANDATORY DUST STANDARDS WERE INTRODUCED IN 1969 AND REVAMPED IN LATER
YEARS. THE INCREASE IN PREVALENCE IN RECENT YEARS IS OF CONCERN.
MINE SAFETY – PRESENT STATUS• LAWS AND REGULATIONS HAVE BEEN TIGHTEND.• INSPECTIONS AND PENALTIES HAVE INCREASED• MINES ARE DESIGNED BETTER• ACCIDENTS CONTINUE TO HAPPEN – DEATH AND SERIOUS
INJURIES, DISASTERS – EXPLOSIONS, FIRES, INUNDATIONS• QUECREEK MINE INUNDATION [2002] – MIRACULOUS ESCAPE
OF 9 MINERS AND RESCUE OF 9 MINERS• ARACOMA MINE FIRE AT ALMA No. 1 MINE [2006] – 2
FATALITIES, 10 ESCAPED.
ALL ACCIDENTS CAN HAPPEN
ALL ACCIDENTS CAN BE PREVENTED
BAD NEWS
GOOD NEWS
QUESTIONS
• ARE WE DOING WHAT WE KNOW?• ARE WE FINDING AND FIXING THE RIGHT
PROBLEMS?• ARE WE USING THE RIGHT METRICS FOR
ASSESSING SAFETY CONDITION?• ARE WE PROVIDING THE RIGHT KIND OF
TRAINING? MANAGEMENT?• ARE THERE BETTER METHODS?
ARE WE DOING WHAT WE KNOW?• ACCIDENT/DISASTER INVESTIGATIONS• COURTS OF ENQUIRIES• FREQUENT CONCLUSIONS:
1. CAUSES – DETECTABLE2. DISASTER – PREVENTABLE3. HUMAN ERRORS – DOMINANT4. NON-TECHNICALFACTORS EVIDENT –
ORGANIZATIONAL FACTORSNOT DOING WHAT WE KNOW. WHY?
ARE WE USING THE RIGHT METRICS?
WHY MEASURE?[1] TO ASSESS AND EVALUATE EFFECTIVENESS OF
CONTROL
[2] WHAT GETS MEASURED, GETS DONE
[3] IF YOU CAN’T MEASURE IT, YOU CANNOT MANAGE IT
41
ARE WE USING THE RIGHT METRICS? “WHAT GETS MEASURED GETS DONE”
• TRUE ONLY WHEN WE MEASURE THE APPROPRIATE THINGS RIGHTLY AND TAKE ACTION
• SAFETY IN INDUSTRIAL SYSTEMS1. TECHNICAL SAFETY2. OCCUPATIONAL SAFETY3. PROCESS SAFETY
UNDERSTANDING THE RELATIONSHIPS BETWEEN THESE THREE AND MANAGING ALL THREE IS ESSENTIAL FOR GOOD
OVERALL SYSTEM SAFETY
Technical Safety - the focus is on engineering and design of systems, generally mine design, equipment design, process design, etc Process Safety - the focus is on process related events that have high consequences, acute consequences. Occupational Safety - the focus here is on worker health and safety and providing a safe working environment.
Causes and consequences of events affecting these three kinds of safety can be vastly different. The metrics to monitor occupational safety may not indicate the true state of affairs with process or technical safety.
Most common available data is on occupational safety – mostly lagging indicators [what happened?]
High performance in the metrics of occupational safety may provide a false sense of security on system’s safety and occurrence of catastrophic failures in the process.
KEY PERFORMANCE INDICATORS [KPIs]• PERFORMANCE INDICATORS – CHARACTERISTICS• TECHNICAL, PROCESS AND OCCUPATIONAL SAFETY
INDICATORS• LAGGING INDICATORS• LEADING INDICATORS• COMPOSITE INDICATORS – VERY USEFUL • INTERVENTIONS BASED ON INDICATIONS
Percentage of Job Safety Analyses completed for critical activities Percentage of safe behaviors observed Percentage of actions implemented from observations Percentage of hazards rectified
EXAMPLES OF LEADING INDICATORSBHP BILLITON
Percentage of Incidents investigated Number of near misses reported Ratio of near misses to accidents reported. Number of repeat incidents Percentage of significant incidents reviewed and closed out
EXAMPLES OF LEADING INDICATORSBHP BILLITON
PRO-ACTIVE AND REACTIVE SYSTEMS SAFETY ANALYSIS RISK ANALYSIS NEAR-MISS INCIDENTS ACCIDENTS AND DISASTERS
INVESTIGATION OF NEAR MISS INCIDENTS IS ONE OF THE KEYS TO UNEARTHING UNKNOWN UNKNOWNS
LEARNING CURVES FOR DISASTER CONTROL
2003 2004 2005 2006 2007 Total
Gas & Dust Ignitions
59 49 36 57 63 264
Fires 07 13 07 08 15 50
Inundations 19 14 13 13 23 82
Total 85 76 56 78 101 396
UNDERGROUND COAL EVENTS 2003-2007
SOURCE: MSHA, 2008, PERSONAL COMMUNICATION
CONCEPT OF PRECURSOR EVENTS – FORETELL POSSIBLE FUTURE EVENTS
PARADOX OF ACCIDENT INVESTIGATIONS
“THE MORE YOU INVESTIGATE, THE LESS YOU HAVE TO INVESTIGATE”
ARE WE PROVIDING THE RIGHT KIND OF TRAINING?
• DEVELOPING KNOWLEDGE AND SKILLS• DEVELOPING THE ENTIRE PERSON• TRAINING VERSUS LEARNING• LIFE LONG LEARNING• INDEPENDENT LEARNING• DEVELOPING INTO A LEARNING ORGANIZATION
“One thing a person cannot do, no matter how rigorous his analysis or heroic his imagination, is to draw up
a list of things that would never occur to him”
Thomas Schelling’s Impossibility Theorem
www.therisktoolboxshop.com/Harm_Process.jpg
THINK 6 – LOOK 6 HAZARD-RISK MANAGEMENT
PROCESS TOOL
IDENTIFY RISK, ASSESS RISK AND MINIMIZE RISK
LOOK 6 – LOOK ALL AROUND YOU
UP, DOWN, LEFT, RIGHT, FRONT AND BACK
THINK 6 – EVALUATE
1. WHAT ARE THE HAZARDS AROUND YOU?2. WHAT TRIGGERS WILL RELEASE THE HAZARD?3. WHAT INCIDENT OR ACCIDENT COULD OCCUR?4. WHAT WILL BE THE CONSEQUENCES OF THE ACCIDENT?5. HOW WILL YOU CONTROL THE HAZARDS AND TRIGGERS?6. HOW WILL YOU MINIMIZE THE CONSEQUENCES AND RECOVER THE SITUATION?
SAFETY MANAGEMENT SYSTEMS
OSHA - Process Safety Management [PSM] EPA - Risk Management Program [RSM] BOEMRE - Safety and Environmental Management Systems [SEMS] OSHA - I2P2 - Injury and Illness Prevention Program MSHA - SHMP - Safety and Health Management Programs for Mines ANSI-AIHA - Z10-2005 - Occupational Health and Safety Management Systems
SAFETY MANAGEMENT SYSTEMS
ISO - ISO 9001:2008(E) - Quality Management Systems Requirements BSI - BS OHSAS 18001:2007 - Occupational Health and Safety Management Systems – Requirements ILO - ILO-OSH 2001 - Guidelines on Occupational Safety and Health Management SystemsAPI RP 75 - Recommended Practice for Development of a Safety and Environmental Management Program for Offshore Operations and Facilities, May 2004
KNOWLEDGE AND SKILLS ARE NECESSARY CONDITIONS BUT ARE NOT SUFFICIENT TO ENSURE HIGHLY EFFECTIVE INDIVIDUALS.
PROCESS IMPROVEMENT REQUIRES/DEMANDS INNOVATION,
CREATIVITY, TEAMWORK, INTERDEPENDENCE AND TRUST
Knowledge, skills and desire shape the habit of an individual
Why and what of things
Want to do thingsHow to do things
Knowledge
Skills Desire
Habit
From Stephen Covey’s ‘The 7 habits of Highly Effective People’
Internalized principles and patterns of behavior
ATTITUDE ATTITUDE IS A WAY OR
METHOD OF DOING THINGS WHICH SHOWS ONE’S NATURE OR TENDENCY
GOOD ATTITUDE RIGHT ATTITUDE POSITIVE ATTITUDE BAD ATTITUDE NEGATIVE ATTITUDE
ATTITUDE IMPACTS OUTCOME
• I CAN’T • I WON’T• I WISH I COULD• I WANT TO• I CAN• I WILL
GREATER THE POSITIVE ATTITUDE,
GREATER THE CHANCES OF SUCCESS
FAILURE
SUCCESS
Knowledge and skills:What?Why?How?Able to
Desire:YearningThirstAspireLoveWant to
Organization:CorporateDivisionPlantsUnits
Policies and proceduresGuidelines and manuals
NormsCulture
Individuals:ExecutivesManagersSupervisorsWorkers
Education and trainingExperience
AttitudeMotivation – intrinsic/extrinsic
ARE THERE BETTER METHODS?
1. KNOWN KNOWNS – WE STILL CAN SEE THEM CAUSING MAJOR HEALTH AND SAFETY PROBLEMS – IMPROVE ENGINEERING, OPERATIONS, AND MANAGEMENT
2. UNKNOWN KNOWNS – DEPENDING ON THE ISSUE, INCREASE ATTENTION TO PROACTIVE RISK ANALYSIS AND RISK REDUCTION THROUGH ELIMINATION AND CONTROL.
3. RECOGNIZE THAT THE SYSTEM HAS RESIDUAL RISKS – RISKS NOT ELIMINATED OR CONTROLLED.
KNOWNS, UNKNOWNS AND UNKNOWN UNKNOWNS
1. RESIDUAL RISKS ARE MADE UP OF IDENTIFIED RISKS THAT ARE REGARDED AS ACCEPTABLE AND RISKS THAT ARE NOT KNOWN OR UNIDENTIFIED.
2. UNKNOWN UNKNOWNS – A. BE WARY – NEVER BE CERTAINB. NEVER ASSIGN A ZERO PROBABILITYC. SEEK CONTINUOUS PROCESS IMPROVEMENT AND
D. SUPPORT RESEARCH AND DEVELOPMENT TO INCREASE RELIABILITY OF DATA, ASSUMPTIONS, MODELS AND ANALYSIS
KNOWNS, UNKNOWNS AND UNKNOWN UNKNOWNS
Six Basic Requirements for Enhancing Safety
Outstanding Engineering Design Knowledgeable Workforce Realizable Laws and Regulations Enlightened Management Research to unearth new hazards, and new
solutions to eliminate, reduce or protect against all hazards
Educated public – realistic expectations and risk aware
CONTINOUS SAFETY IMPROVEMENT
PLAN
CHECK
ACT
DO
Use PDCA processes and procedures as a part of integrated management system for continuous improvement.
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