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Tactics & Metrics
SERIOUS INJURY AND FATALITY PREVENTION
PETE BATROWNY &RICHARD CERENZIOModerators
RON RIFEExxon Mobil Corporation
4
- Eliminating Higher Potential Events
- Risk Tolerance / Approaching Others - Actively Caring
- Serious Injury & Fatality (SIF) Study / focus on Potential
Consequences / ‘Mining the Diamond’
- Personnel Safety Study / OIMS Leadership Academy / Messaging
Workshops
- SSH&E Leadership / CARE
- Hurt Free Approach
- Increased focus on Process Safety / ‘Conduct of Operations’ / ‘Life Saving Actions’ /
Tier 1 Best Practices / Incident Risk Analysis Tool (IRAT)
- Protect Tomorrow. Today. / Environmental Expectations
- Security is Everybody’s Business / Security Expectations
- Major Incident Team Study
- Nobody Gets Hurt / Critical Success Factors
- Behavior-Based Safety / Loss Prevention System / Human Factors
- Operations Integrity Management System (OIMS)
ExxonMobil SSH&E Journey
Today
‘90s
2005
2000
2010
We are a learning organization . . .
5
Metrics: Scope / Boundaries
Scope
• Corporate, Business Line and Site; ‘right’ metrics at ‘right’ level
• OIMS Leadership, Safety (Personnel / Process), Security, Health, Environment
• Leading and lagging
• Quantitative and qualitative
Boundaries
• Unconstrained by current approaches / metrics
• Fit-for-purpose
• Considered retirement of metrics deemed to have limited value; acknowledged some metrics
required externally (e.g., shareholders, Corporate Citizenship Report, IPIECA, etc.)
6
Hurt Free Approach to Personnel Safety
7
Historical Perspective
Drilling’s Safety Journey – 2005 Realizations
• Year-on-year progress … but focus still on “Recordability”
• Focus needs to be aligned with Vision of Nobody Gets Hurt!
Incr
eas
ing
LTIR TRIR
8
Fostering A Culture of Caring
Parental Care Management
• Injury Assessment & Action
• Followed by “The Talk”
Hurt Free Approach to Safety
• Protect the “Family”
9
Focus on Hurt Free
• Alternative to Treatment-based Approach
• Natural language of Safety; Protect the “Family”
• Aligns well with our Vision of “Nobody Gets Hurt!”
and the NSC’s “Racing to Zero”
• Provides consistent actual severity description, and
• Includes integral potential severity assessment
‘Nobody Gets Hurt’
reat ent- ase
lassifi ations’
urt- ase e els’
5
4
3
2
1
0
Minor Hurt
Fatality
Severe Hurt
Moderate Hurt
Multiple Fatalities
No physical body damage, but actionable learnings
Fatality
LTI
RWI
MTI
First Aid
No Treatment
Near Miss,
Unsafe Act / Condition
10
Hurt-based Levels
Severity Levels Duration Examples
4 & 5
Fatality(ies)
• 5 – Multiple fatalities
• 4 – Single fatality
3
Severe Hurt
Long-term,
Life-altering
• Amputation / severe disfigurement
• Total loss of organ / vision / hearing
2
Moderate HurtWeek to Months
• Bone fractures, significant lacerations
• Moderate hearing / vision loss
1
Minor Hurt
Minutes / Hours /
Days
• Minor cuts / bruises / sprains / strains
• Mild hearing loss / corneal abrasions
0
No HurtNo Body Damage
• Object in eye removed by flushing
• Slip / Trip / Fall with no bruising or swelling
• General soreness
11
Severity Level Determination
• Assign Actual Hurt Level (AHL)
– Determine the actual injury or illness severity (AHL 0-5)
• Determine Potential Hurt Level (PHL)
– Identify ‘worst case’ considering ‘feasible-but-reasonable’
scenarios (PHLWorst Case 0-5)
– Evaluate ‘Barriers’ in place pre-event (effective vs. LTA)
– Determine extent ‘Effective Barriers’ reduced ‘worst case’
– Assess ‘final’ Potential Hurt Level from top down
(PHLFinal 0-5)
• Identify Corrective Actions to prevent future hurt
– Consider any ineffective barriers from PHL assessment,
in combination with causal factors
(LTA)
12
Mining the Diamond
13
Serious Injuries and Fatalities
2010 Industry Study
• TRIR typically decreasing
• Rate of Serious Injuries & Fatalities (SIF) were not
improving
• ~20% of all incidents have the potential to be a SIF
EM SIF rate 6% -10%
Potential SIFs are often those events buried deep in
the traditional safety triangle; the actual outcome
falls short of the potential that could have occurred.
14
Underlying Principles
• Focus on severity & potential consequences
– “Potential” discussions drive actions to prevent
future incidents
–Consequence potential drives prioritization
• Apply ‘Mining the Diamond’ concept across
full suite of SSH&E disciplines
• Define expected leadership behaviors to
drive culture and desired organizational
behaviors
Personnel Safety & Health example
15
Focus on Higher Potential Events
• Maintain vision to prevent all hurts – Hurt Free Approach
• Recognize and foster understanding of higher risk activities
• Prioritize events with highest potential – Mining the Diamond
• Strive to eliminate life-altering or fatal injuries
• Broadly share and apply learnings from these events
16
Personnel and Process Safety Metrics
17
Personnel Safety & Health
• Hurt Free Approach supports a culture of learning
that resonates with the workforce; builds safety
ownership
• Corporate Stewardship
- Actual Hurt Level 2+ incidents and rate
- Potential Hurt Level 3+ events
- Leading incident types and root causes (from above)
- Traditional lagging metrics (e.g., TRIR, LTIR) receive
less discussion
• Complementary Hurt-related metrics
recommended at business line and site levels
18
Personnel Safety & Health (Example)
0.00
0.05
0.10
0.15
0.20
0
5
10
15
20
1Q 2Q 3Q 4Q
AHL2 AHL3 AHL4 AHL2+IR*
Actual Hurt Level 2+ Workforce Incidents
Potential Hurt Level 3+ Events – 12 Months
Level 5
(Multiple Fatalities)
Level 4
(Fatality)
9
73
142
0
0
2
1
2
6
PHL 3 Events
3PHL 4
Events8
PHL 5 Events
0Total
Events235
Level 3
(Life-Altering)
Level 2
(Moderate Hurt)
Level 1
(Minor Hurt)
Level 0
(No Hurt)
Workforc
e
Fatalities
0 0 0 0
LTIR 0.02 0.01 0.02 0.02
TRIR 0.21 0.22 0.24 0.22
Incr
easi
ng
Rat
e(Example Data)
Incr
easi
ng
Co
un
t
(Example Data)
19
Energy Isolation2
Preventive Maintenance
2
Lifting & Rigging
2
Work at Heights2
Manual Handling
1
Pipe/Casing Handling
1
Release1
• ‘Diamond Event’ type analysis includes:
‒ Root Cause / Causal Factors Analysis
‒ Behavioral Analysis
‒ Corrective Actions / Initiatives
‒ Turning learnings into actions
Personnel Safety & Health (Example)
PHL3+ Events(12 Months)
(Example Data)
20
• Identify ‘Diamond’ Process Safety Events
- Use actual and potential incident severity, as well as barriers
that were available / effective in preventing a “Serious Incident”
- ‘Diamond Events’ are investigated with greater intensity
• Corporate Stewardship
- Process Safety Events (PSEs)
+ PSEs with actual higher consequence
+ PSEs with potential higher consequence and
limited barriers; highlights incidents with
zero or 1 human intervention barrier
• Business Line level recommended metrics
- Lower severity PSE metrics
- Risk Discovery, Risk Mitigation, ‘Total Risk’ metrics
Process Safety
Process Safety example
Dia on E ents’
Tier 1-3 PSEs with higher actual and/or
potential consequence
and limited barriers
21
Actual Incidents PSEs – Potential Higher Consequence
Process Safety (Example)
(Example Data)
0
1
2
3
4
5
6
7
1Q 2Q 3Q 4Q
Inci
de
nt
Co
un
t
Actual Higher Consequence Event*
0
4
8
12
16
20
24
1Q 2Q 3Q 4Q14
Inci
de
nt
Co
un
t
Potential Higher Consequence Event **
0 Total or 1 Human Barrier
(Example Data)
22
Process Safety (Example)
• ‘Diamond Event’ type analysis includes:
‒ Root Cause / Causal Factors Analysis
‒ Behavioral Analysis
‒ Corrective Actions / Initiatives
‒ Turning learnings into actions
(Example Data)
QUESTIONANSWER
STEVEN SCHWARTZ, CSPEli Lilly and Company
Questions to Consider
SIF
Prevention
Strategy
Who, how, and what do you educate regarding SIF Prevention?
What SIF Prevention metrics do you collect and how are they discussed?
How does your organization identify and mitigate SIF Precursors?
What SIF Prevention programs have you implemented? What existing programs have been enhanced to include SIF Prevention?
About Eli Lilly and Company
www.Lilly.com
Our mission:We make medicines that help people live longer, healthier, more active lives.
Global Research and Development, Manufacturing, Sales and Marketing, and Elanco Animal Health
Approximately 45,000 employees as of July 2017
SIF Prevention Model
3. Developprocess to IDand mitigate
precursors
2. Measure SIF and potential
SIF
1. Educate the organization
on the SIF model and
terms
4. Integrateinto existing
business processes
Educating our Employees
SERIOUS INJURIES AND
FATALITIES
SIF
PR
ECU
RSO
RS
LOST TIMEINJURIES
RECORDABLEINJURIES
FIRST AIDINJURIES
NEARMISSES
The SIF paradigm
The SIF prevention model
SIF terminology
Educate employees at all levels
It is imperative to educate employees about SIF Prevention so that they understand the approach and provide insight /direction on how we execute the other aspects of our model.
2016 Manufacturing Operations Data
44%
19%
11%
8%
6%
3%3%
3% 3%
Potential SIF Events 2016
Forklift / PIT
Electricity
Gravity
Chemical
Machine
Motor Vehicle
Fall from stairs
Lockout
Confined Space
Identifying and Mitigating SIF Precursors
Electrical Safety
Lockout
Confined Space Entry
Cranes and Hoists
Forklift / Powered Industrial Trucks
Working at Heights
Management safety discussions
Employee observations
Safety recommendations
Behavior based platforms
FMEA = Failure Modes and Effects Analysis
Integrating SIF Prevention
Auditing: Collaborate with the Global HSE audit team to place more rigor on programs / aspects with SIF impact; Use updated audit protocol(s) to determine if SIF prevention standards are implemented sufficiently.
Behavior / Safety Culture:Sites have begun to analyze observation data for trends around SIF Precursors. Integration of SIF with existing safety culture processes is essential for success.
Communication:Existing communication mechanisms are leveraged to integrate SIF prevention messages. Rapid Fire event sharing.
Self Assess: Site self-assessment (SSA) is imperative to determine if work with SIF impact is conducted flawlessly with and intent to eliminate SIF precursors consistently and comprehensively.
Company Standards• Control of Hazardous energy• Cranes / Hoists• Confined Space Entry• Electrical Safety
• Working at Heights• Forklift / PIT / MH equip• PSM
Lockout site assessment project
Global HS Requirements (13) x 32 sites
Plan6 to 8 onsite
lockouts evaluated per
each site
DoLocal plans updated to
mitigate precursors
Check
Site leverages networks,
global SME’s, and local consult
Act
Did the site have a written program? Did the site sufficiently control the key(s) throughout the lockout process?
Did the site have ESI/ECP or it correctly create field developed ESI?Did contractor(s) (or visitors or vendors) on site utilize a sufficient method of group lockout?
Did the site ESI's include at a minimum the basic steps for machine and equipment lockout and hazardous energy control?
Did the site have an adequate permit or energy control process for breaking process lines (chemicals, steam, etc.)?
Did the site correctly document and/or verify (2PV) complex system lockouts?Did the site conduct an internal assessment of ESI's or energy control procedures; and did it communicate assessment results?
Did the site have adequate labeling of isolation points? Did the site limit how many employees were authorized to conduct lockout?
Did the site have sufficient training (hands-on), and/or qualification/certification of authorized employees?
Did the site bring authorized employees together to discuss program effectiveness, including the results of self assessments and audits?
Did the site have a standard lock for safety; was the safety lock used only for lockout?
Lockout site assessment project
The worst scoring precursor was:Did the site ESI's include at a minimum the basic steps for machine and equipment lockout and hazardous energy control?
Mean (13.4); Median (12.5); Mode (17.5; 10.5)
0
5
10
15
20
25
Equip Specific
Instructions
(Detail)
Second
Person
Verification
Program
Effectiveness
Internal
Assessment
Equip Specific
Instruction
(Provision)
Hands-On
Training
Key Control Standardized
Locks
Written
Program
Contractors Labeling Line Breaking Limited
Authorized
Employees
Lockout AssessmentSIF Precursor Count
SIF Prevention Model - Implementation
3. Developprocess to IDand mitigate
precursors
2. Measure SIF and potential
SIF
1. Educate the organization
on the SIF model and
terms
4. Integrateinto existing
business processes
Lessons Learned
Education should include simple and standard terms:
(SIF, Potential SIF, and SIF Precursor)
Potential SIF Events (injury + near miss) are an excellent leading indicator to drive management discussions
Identification and mitigation of SIF Precursors can take place at many levels (company, business, site)
Integrate SIF Prevention into existing processes to use resources wisely and to shift more intensity on legitimate SIF events
Planning Forward
SIF
Prevention
Strategy
Create standardized, organizational training that focuses on the SIF Prevention model and key terms; Influence employees at all levels.
Select leading indicators (Potential SIF Events) that drive valuable conversations between members of management
Identify and mitigate SIF Precursors locally, and where possible, globally
Blend SIF Prevention into existing (stable) processes that employees already know and follow.
Questions?
TAYLOR ABEL, P.E.The Mosaic Company
Serious Injury and Fatality Prevention NSC CongressExecutive Edge Track Workshop A Meeting
Taylor Abel, P.E.
Sr. Mgr. EHS Process Optimization
September 26, 2017
39
Serious Injury & Fatality (SIF) Prevention
AGENDA
Overview of Mosaic
Mosaic’s SIF Journey
Prevention
Metrics
Closing
40
About The Mosaic Company(NYSE: MOS)
41
Our Work We are the world's leading integrated
producer and marketer of concentrated
phosphate and potash.
Our MissionWe help the world grow
the food it needs.
Who We Are
• Fortune 500 company incorporated March 2004, combination of IMC
Global Inc. & Cargill fertilizer businesses
• 100 years of phosphate mining history in U.S.
• 50 years of potash mining history in Canada
• Approximately 22.2 million tonnes of operational capacity
• $7.2 billion in sales in calendar 2016
• Customers in approximately 40 countries
• Nearly 9,000 employees in operations and joint ventures (JVs) in:
United States
Canada
Brazil
Paraguay
China
India
Australia
Peru (JV)
Saudi Arabia (JV)
Global Offices & Operations
Distribution and Markets
Daily global distribution:
Approx. 50,000 tonnes
Mosai ’s SIF Journey
45
46
Common trend of injuries versus fatalities
0
0.5
1
1.5
2
2.5
Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7
Nu
mb
er o
r R
ate
47
Mosai ’s SIF Journey
2004-2008Formed in 2004Numerous programmatic improvements
2009-2011ISO14001 & OHSAS18001 RegistrationsJoined BST/Dekkra SIF Working Group
2012 – 2015Develop SIF concept within EHSDefine Mosaic specific “SIF” definitionSocialize SIF concept with leadersTargeted Interventions
2016 and beyondBranding SIF as Potentially Serious IncidentsDelineated Environmental potentialStrategic approach to improving controlsDeployed PSI across organization
48
PSI Definitions:
An Safety Potential Serious Incident (PSI) is an event
that could potentially and reasonably result in a fatality
or permanent disabling injury if only one factor changed.
An Environmental Potential Serious Incident (PSI) is
an event, if only one factor was changed, that could
potentially and reasonably result in a:
• Significant environmental impact that takes weeks or
months to remediate.
• Receipt of enforcement AND media coverage.
A Factor could be a control, the weather, time of day,
person’s location, etc.
PSI Quality Assurance Process - Overview
Site
• Reviews and determines if incidents are PSI in real time
• Maintains PSI category in Incident information system
• Reports and investigates incidents per Investigation & CAPA procedure
Business Unit
• Conducts monthly review to determine:
• Incorrectly determined or categorized PSI (false positives)
• Review of non-PSIs (false negatives)
Corporate
• Conducts periodic review to determine:
• Incorrectly determined or categorized PSI (false positives)
• Missed PSI (false negatives)
• Generates reports / metrics
49
SIF Prevention Approach
50
Prevention
51
SIF Prevention Approach
SIF Prevention
Analysis or
Accident
Determine Improved Controls
Ensure effective-
ness
Update
52
SIF/PSI by Category
0
10
20
30
40
50
60
70
80
Falling Object High Energy:Elec >110
High Energy:Non-Electrical
FallProtection
MobileEquipment
Haz Materials Ground Fall Blasting:Explosives
Co
un
t
Defining further
53
Falling Objects
Lifting and Rigging
Structural
Dropped/Unsecured Objects
Intervention: Prevention of Dropped Objects
• Developed Corporate Standard
• Created communication strategy• Stop the Drop
• Trained employees on requirements
• Procured tools to enable employee success
• Conducted field checks for coaching & feedback
• Integrated into Management System self assessment & audit programs
54
55
Dropped/Unsecured Objects
0
5
10
15
20
25
30
35
40
2012 2013 2014 2015 2016 2017*
Nu
mb
er o
f ev
ents
YEAR
*2017 prorated for full year
Co
un
t o
f ev
ents
56
SIF by Category
0
10
20
30
40
50
60
70
80
Falling Object High Energy:Elec >110
High Energy:Non-Electrical
FallProtection
MobileEquipment
Haz Materials Ground Fall Blasting:Explosives
Co
un
t
Life Critical Standards
57
Pictogram Life Critical Standard
Lockout/Tagout & Linebreak
Confined Space Entry
Work at Height
Falling Objects
Lifting Operations
Electrical Safety
Mobile Equipment Safety
Underground Ground Control
Machinery Safety
Working Around Water
58
Utilizing Hierarchy of Controls
59
Metrics and Measures
Leading Metrics
60
Hierarchy of Controls
• Focus on Elimination,
Substitution, & Engineering
• % of corrective actions
Pre-Job Hazard Assessments
• PJHA Quality - leading indicator
• Safe Work Permit use
Administrative
PPE
Procedural
Engineering Substitution
Elimination
NA/Other9%
0
2
4
6
8
10
12
14
16
Effectiveness of Pre Job Hazard Assessments
Total Number of Assessments
Tota
l Nu
mb
er o
f A
sses
smen
ts (
Ba
r Ch
art)
Leading Metrics
61
A)Abrasive/Water Blasting
E1)Electrical Contact
F1)Falling Object - lifting
F2)Falling Object -unsecured
F3)Falling Object -structural
H)Hazardous Materials
I1)Energy Isolation
I2)Stored Energy
M)Mobile Equipment
O)Operating Equipment
P1)Fall Protection
P2)Unprotected Opening
V)Vehicle TravelW)Water
Q)Hot Work
Health & Safety PSI Types
0
2
4
6
8
10
12
14
16
18
0.00
0.25
0.50
0.75
1.00
1.25
1.50
Nu
mb
er o
f P
SI In
cid
en
ts
PSI
Rat
e (
Ye
ar t
o D
ate
)
Safety & Health PSI Rate
Time
62
Environmental PSI rate
0
0.5
1
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.40
0.45
0.50
Time
PSI
En
viro
nm
enta
l R
ate
63
Closing
64
Our Next Steps:
Implementation of Life Critical
Standards
Advance Environmental PSI
Using data to provide more insight
Expand knowledge sharing
65
Benefits
Spend time and energy commensurate
to the risk
Increased awareness and visibility of
environmental and safety risk
Improved identification of PSI
exposures in the workplace
Improved controls
66
Summary
- Develop your definitions/program
- Analyze the data
- Take Action
- Measure and communicate
- Refine
- Importance of SIF concept
- Be an SIF prevention leader
67
QUESTIONANSWER
DISCUSSIONTABLE
Discussion Questions
1. What is your organization’s overall approach to SIF prevention? Have you not
started, just on the way, more mature? What have been your biggest successes
and barriers?
2. What metrics does your organization track related to SIF exposure or potential?
Have you identified a set of common precursors or causal factors for SIF? If so,
what are they?
3. What technological advances do you believe are going to make an impact on SIF
in your organization in the future? Are there are any new solutions you’re already
leveraging?
2018 SYMPOSIUMCreate Change for the Future of EHS
FEBRUARY 20-21, 2018
thecampbellinstitute.org/symposiumCharlotte, North Carolina
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