Fatality Elimination at Kimberly-Clark - ppwsafety.org · Enhancing the Health, Hygiene and Well-Being of People Every Day, Everywhere Fatality Elimination at Kimberly-Clark

Enhancing the Health, Hygiene and Well-Being of People Every Day, Everywhere

Fatality Elimination at

Kimberly-Clark


Incidence rates are trending down

K-C Global Injury & Illness Rates

An Incident Rate of 1.0 represents 1 in 100 workers injured per year.


Fatalities were reduced in the ‘70’s but have been stable since the 80’s

Kimberly-Clark Fatal Event Experience


Fatalities are not unique events to any one geography

Kimberly-Clark Fatal Event Experience

0

1

2

3

4

5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

N. Asia U.S.A.

S. Asia Mexico

Europe MEA

LAO


Why Are We Doing This?

1. Global safety trends at KC reflect focus on the reduction of incident rate.

• Incidence and severity trend downwards

• Fatality trend is flat

2. Addressing Fatalities is a different “problem set” and requires a different approach.

• Work on reducing incidence and traditional measure of severity does not work on issues causing death.

• Initial work suggests that fatalities at K-C can be classified into priority groups with predictive power.


Key Concepts in Support of a New

Direction


Influential Concept No. 1 Det Norske Veritas - 2002 Study

“Much has been said about the classical loss control pyramid, which indicates the ratio between no loss incidents, minor incidents, and major incidents, and it has often been argued that if you look after the small potential incidents, the major loss incidents will improve also.”

Serious or Major Injury

Minor Injury

Property Damage

Accident

Incidents With

No Visible Injury

or Damage

1

10

30

600

Det Norske Veritas 2002 Study – Published July 2004

http://www.dnv.no/Binaries/LeadingIndicators_rev1_tcm28-99467.pdf

http://www.ohsonline.com/articles/44865/




“The major reality however is somewhat different. If you manage the

small accidents effectively, the small accident rate improves, but the

major accident rate stays the same, or even slightly increases.”


Influential Concept No. 2: Major Catastrophic Event Findings British Petroleum - Texas City - March 23, 2005


U.S. Chemical Safety Board Interim Report - September 2006

• The explosion at British Petroleum's Texas City plant killed 15 people and injured 170.

• Report identified warning events that should have alerted management:

– Unsafe equipment design

– Poor operating practices

– Many HIPO near-miss events

• “Management assumed that if (incident) rates were low, safety was good.”


Influential Concept No. 3 IUP Fatality Prevention Forum, November 1-2, 2007

• “Heinrich's premise - that the more valuable clues to accident causes lie in minor injuries--has been translated into the commonly held belief that safety efforts focused on the prevention of incidents that occur frequently will also encompass severity potential. Statistics and analysis have proven this assumption to be unsupportable. But, the premise is widely taught and is a significant part of the thinking of many safety practitioners. It represents a distracting mindset that impedes our addressing the reality of the causal factors for low probability/serious consequence events.”

Fred Manuele, Occupational Health & Safety, June 2005





IUP Fatality Prevention Forum, November 1-2, 2007

Key Messages:

• An organization cannot address the basic causes of fatal events until it measures and tracks those minor or major loss incidents which, while not resulting in a fatality, could have…..

• If we want to control fatalities, we should try to predict where they will happen.


Sentinel Events

A New Approach to Fatality Elimination


HIPO

Near Miss Events

HIPO

Loss Events

A Different Approach to the Loss Pyramid

Near Miss Events With

Fatality Potential

Loss Events With Fatality

Potential

Permanently Disabling Events

Non-Disabling

Injuries/Illnesses

Property

Damage

Accidents

Incidents with No

Visible Injury or

Damage

Substandard

Acts or

Conditions

Fatal Events

Sentinel Events


What is a “Sentinel”?

• “A soldier standing guard at a point of passage (as a gate)”

• “One that keeps guard; a sentry.”


What is a Sentinel Event?

A Loss Event, Near Miss (Near Hit), or Substandard Act/Condition with the potential for a fatal or catastrophic loss.


What are K-C’s Sentinel Events?


1. Falling Objects

• April 2007

• Family Care, Europe

• Hard roll core shaft failure


2. Lift Truck Events

June 2003 Technical Paper, U.S.

August 2007 Personal Care, LAO

November 2006 KCP, Europe

September 2007 NACP, Europe

Enhancing the Health, Hygiene and Well-Being of People Every Day, Everywhere 3. Falls

• January 2007

• Family Care, LAO

• Contract employee fell ~7 meters through roof during new building construction

• February 2005

• Family Care, U.S.

• Maintenance operator fell ~20 feet (6 m) when he stepped on the improperly seated hatch cover.


4. Electrical Contact

• January 2008

• Personal Care, U.S.

• An employee was exposed to an arc flash resulting in first degree burns to his right hand and right side of his face & neck.


5. Contact with Energized Equipment

• February 2007


• Operator’s foot was caught in cardboard shredder (lower leg amputation)


6. Confined Space Operation • Family Care, South Asia

• April 2006

• During a work break in a maintenance operation for tank which supplies the plant sprinkler system, a contractor left a gasoline-powered pump running inside the tank.

• Using a gas meter, the entry supervisor and utility operator found the carbon monoxide reading inside the tank to be 51 ppm, which triggered the alarm.

• The OEL is 25 ppm.

• The entry supervisor and utility operator averted an imminent hazard by stopping the activity.


7. Fires and Explosions

• August 2005


• Propane leak – cafeteria flash fire

• April 2005

• Family Care, South Asia

• Boiler explosion – low water level


8. Transportation

• October 2006

• April 2007

• February 2008

• Transportation Subsidiary, Mexico

Note: These examples are the ultimate results of failure to identify Sentinel Events and take corrective action.


Sentinel Events – Hazard Detail

1. Falling objects

– Dropped loads during lifts - mechanical failure or incorrect equipment use

– Improper or unstable stacking of raw material or product; rack storage failure

– Failure of overhead structure

2. Lift-truck events

– Pedestrian contact

– Tip-over

– Dock drive-off

3. Falls

– Ladder use (fixed or portable)

– Unexpected or unprotected elevation change

– Roof activities (repair or construction)

4. Electrical contact (arc potential)

– Servicing, troubleshooting or repairing

– New installation

5. Contact with energized equipment (whole body)

– Movement past established equipment barrier or guard

– Improper application of energy control procedure

– Uncontrolled ejection of equipment or parts

6. Confined space operation

– Unexpected formation of hazardous atmosphere or condition

– Improper application of confined space operations procedure

7. Fires and explosions

– Fire or potential fire resulting in evacuation

– Failure of pressurized vessel (e.g. boiler, Yankee dryer)

– Explosion or potential for explosion

8. Transportation (road & highway)

– Product transport

– Sales (fleet) vehicles operation

– Facility-sponsored employee transportation

– General business travel

26


Sentinel Event Reporting

• Capture incidents from the 8 Sentinel Event groups that could have resulted in fatality.

– Include any other loss event or Near Miss or that could have resulted in fatality in “Other” category.

• Sentinel Events resulting in loss (injuries, property damage) and Near Miss incidents will be investigated and captured in facility CAPA system.

– Corrective actions receive high priority.

– Incident report should be broadly communicated within business unit, at a minimum.

– Include significant substandard acts and conditions in reporting; full investigation may occur after trending analysis is completed.


• 132 Sentinel Events reported.

• Represents 58 facilities and ~28,000

permanent & temporary K-C employees

• Top 2 categories = 52%

First Data Collection.....


• 768 Sentinel Events reported

• 109 mfg. and dist. Facilities

• 48K perm. & temp. K-C

employees


Currently Available Data.....



• 129 Mfg. and Dist. Facilities

• 60K perm. & temp. K-C

employees





• 127 Mfg. and Dist. Facilities

• 63.5 K perm. & temp. K-C employees




So – Why Are We Doing This?


Answer.... • As a company, K-C has met or nearly met our

injury objectives (TIR, LWIR, Severity), and made significant progress on disabling injuries.

• Yet, we have consistently failed to meet our objective for ZERO fatalities.

• Efforts focused on driving down our reportable incident and severity rates will NOT produce sustainable results for fatality elimination.

• Work to eliminate fatalities must occur simultaneously and in parallel with efforts to eliminate injuries.


So What?

(What do we do with this information?)


Recognize Sentinel Events as Loss Lessons

• Quality of investigation

• Classification of criticality, especially severity

• Corrective action – hierarchy of control – for risk reduction

• Level of leadership attention

• Level of communication to business unit


What Do We Gain From This?

A Sentinel Event which is reported, investigated and has a corrective action applied is a

Potential Life Saved!


Thank you!

Questions?

Documents

Fatality Elimination at Kimberly-Clark - ppwsafety.org · Enhancing the Health, Hygiene and Well-Being of People Every Day, Everywhere Fatality Elimination at Kimberly-Clark