Applying Action Based Safety Applying Action Based Safety

One Will Die:One Will Die: The John Martin Story The John Martin Story

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Journey Back in TimeJourney Back in Time

A Serious Look at all the Contributing A Serious Look at all the Contributing Actions that set this Accident in Actions that set this Accident in MotionMotion

Attitudes, Short Cuts, Attitudes, Short Cuts, Communication, Production, Pride, Communication, Production, Pride, are all at work in this eventare all at work in this event

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April & May 1984April & May 1984

Operations & Maintenance Supervision andOperations & Maintenance Supervision and

Chemical Engineers are moved to different Chemical Engineers are moved to different

Process AreasProcess Areas

New mechanical engineers are placed inNew mechanical engineers are placed in

several maintenance areas as front line foremanseveral maintenance areas as front line foreman

With the intention of improving With the intention of improving production and enhancing technical production and enhancing technical knowledgeknowledge

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MAC ModelWhy People Do What They Do

MOTIVATION ACTION CONSEQUENCES

Is what happens after an ACTION.

There are positive and negative consequences in everything we do.

Is anything that gets a ACTION started.

MOTIVATION is a prompt...

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MotivationMotivationWhat motivations are in place? What motivations are in place?

Saves moneySaves moneyNo one wants to work overtimeNo one wants to work overtimeImproves productionImproves productionSaves timeSaves timeKnown Risk Taker assigned jobKnown Risk Taker assigned jobSafety not a valueSafety not a value

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ActionsActionsOperator closing valvesOperator closing valvesOperator draining pipe linesOperator draining pipe linesMechanics tagging breakerMechanics tagging breakerMechanics blocking valvesMechanics blocking valvesOperator energizing valveOperator energizing valveMechanics not wearing PPGMechanics not wearing PPGOperator closing valveOperator closing valveMechanics not tagging valveMechanics not tagging valve

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ConsequencesConsequences36 hour outage reduced to 8 hours36 hour outage reduced to 8 hoursSaves money, no overtimeSaves money, no overtimeIncreases productionIncreases productionMan burned over 70% of bodyMan burned over 70% of bodyOperator overwhelmedOperator overwhelmedMechanics cryingMechanics cryingSupervisor blocks event from memory Supervisor blocks event from memory EMT’s angryEMT’s angryFamilies are Devastated Families are Devastated

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Accident AnalysisAccident Analysis

MotivationMotivation: The operator is called : The operator is called to open valveto open valve

Action:Action: The operator hits button to The operator hits button to activate valveactivate valve

Consequence:Consequence: Valve opens causes Valve opens causes catastrophic release of vessel catastrophic release of vessel contentscontents

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Five Whys - PeopleFive Whys - PeopleWhy did the operator push the “ON” button?Why did the operator push the “ON” button?Why was the operator operating equipment he Why was the operator operating equipment he

was not familiar with?was not familiar with?Why was the operator unfamiliar with the Why was the operator unfamiliar with the

equipment after completing on the job training?equipment after completing on the job training?Why was the equipment not locked out Why was the equipment not locked out

completely?completely?Why were both mechanics working behind one Why were both mechanics working behind one

lock?lock?Why isn’t the time it takes to safely lock out built Why isn’t the time it takes to safely lock out built

in as part of doing the job?in as part of doing the job?

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Five Whys - Equipment/MaterialsFive Whys - Equipment/Materials

Why was the change to the normal process not Why was the change to the normal process not investigated with input toward safety?investigated with input toward safety?

Why was hot product released while maintenance Why was hot product released while maintenance employees were working on the system?employees were working on the system?

Why was the product still hot when people started Why was the product still hot when people started working on the system?working on the system?

Why was the new process thought to be more Why was the new process thought to be more cost effective?cost effective?

Why is time saved allowed to be THE factor in Why is time saved allowed to be THE factor in making a change to the process?making a change to the process?

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Five Whys - EnvironmentFive Whys - EnvironmentWhy did the job begin without first Why did the job begin without first

establishing a safe escape route?establishing a safe escape route?Why are maintenance mechanics not Why are maintenance mechanics not

provided with hazard awareness training provided with hazard awareness training before starting jobs in unfamiliar areas?before starting jobs in unfamiliar areas?

Why are inspections not conducted at the Why are inspections not conducted at the job site?job site?

Why are Maintenance employees not Why are Maintenance employees not included during inspections performed by included during inspections performed by Operations?Operations?

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1984 Accident1984 AccidentRoot CausesRoot Causes

PeoplePeopleManpower reduced requiring operator training to be Manpower reduced requiring operator training to be

accelerated and training modifiedaccelerated and training modifiedEmphasis on production encourages short cutsEmphasis on production encourages short cuts

Materials/EquipmentMaterials/EquipmentTo save time, the normal isolation procedure was To save time, the normal isolation procedure was

modified to a hot shut-down rather than a cold shut-modified to a hot shut-down rather than a cold shut-downdown

EnvironmentEnvironmentNo time was taken to identify a safe escape route due to No time was taken to identify a safe escape route due to

emphasis on productionemphasis on production

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Safety Way of LifeSafety Way of Life Establish a Job Hazard Awareness Briefing prior to Establish a Job Hazard Awareness Briefing prior to

starting jobstarting job Read the MSDS Sheet and know the hazards Read the MSDS Sheet and know the hazards Wear PPE to protect yourself from potential hazards Wear PPE to protect yourself from potential hazards Know were the Eyewash/Shower Station are located. Know were the Eyewash/Shower Station are located.

With someone’s help, practice locating how to get to With someone’s help, practice locating how to get to them if you are blinded them if you are blinded

Locate two of the closest Fire Extinguishers prior to Locate two of the closest Fire Extinguishers prior to starting workstarting work

Improve training for all employeesImprove training for all employees Identifying Risky Behaviors is the key to reducing Identifying Risky Behaviors is the key to reducing

accidentsaccidents

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Safety Way of LifeSafety Way of Life

Establish Observation cards to Establish Observation cards to identify actions to improve safetyidentify actions to improve safety

Line of Fire, Eyes on Path, Lifting in Line of Fire, Eyes on Path, Lifting in Power Zone, Asking for Assistance, Power Zone, Asking for Assistance, Discussing task with fellow workers, Discussing task with fellow workers, are examples of practices that can are examples of practices that can improve safetyimprove safety

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Safety Way of LifeSafety Way of Life

Situational awareness is a key Situational awareness is a key elementelement

Focus on all aspects of the task Focus on all aspects of the task

Avoid distractionsAvoid distractions

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STOPSTOP AT ALL STOP SIGNS AT ALL STOP SIGNS

Next Seven Days Next Seven Days Come to a complete Come to a complete stopstop at all at all stopstop

signssignsSpell Spell S T O PS T O PLOOK BOTH WAYSLOOK BOTH WAYSProceed when clearProceed when clearE-Mail your FEEDBACK E-Mail your FEEDBACK

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Ones Going to DieOnes Going to DieThe John Martin StoryThe John Martin Story

John MartinJohn Martin

843 810 0298843 810 0298

www.martinsafetysolutions.comwww.martinsafetysolutions.comjohn@martinsafetysolutions.com