confidential. this document contains trade secret information. disclosure, use or reproduction...

CONFIDENTIAL. This document contains trade secret information. Disclosure, use or reproduction outside Cargill and inside Cargill, to or by those employees who do not have a need to know is prohibited except as authorized by Cargill In writing. (Copyright Cargill, Incorporated 2007. All rights reserved.)

A Paradigm Shift into a new future…

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

© 2011 Cargill Incorporated. All rights reserved

Learning Objectives

• Definition of SIF• Data Trends• Paradigm Shift with Safety Pyramid• Action plan


SIF = Serious Injury or Fatality


SIF Research Team


Industry Data•

FAR

– Fatal A

ccident R

ate

•T

RIF

– Total Re

cordable Injury F

requency

•LT

IF – L

ost Tim

e Injury F

requency


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


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:

A. Laceration or crushing injuries or significant blood loss

B. Damage to the brain or spinal cord or Severe burns

C. Use of cardiopulmonary resuscitation or defibrillator

D. 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:

E. Significant head injuries

F. Paralysis

G. Amputations

H. Broken or fractured bones

SIF


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.

© 2011 Cargill Incorporated. All rights reserved© 2011 Cargill Incorporated. All rights reserved

The traditional safety pyramid is not 100%

predictive of SIF

Not all injuries have SIF potential

A reduction of injuries at the bottom of the pyramid

does not correspond to an proportionatereduction of SIFs

21% Potentially SIF


Qualitative Analysis

Theme SIF or SIF-Potential

Incident

N=55

NON SIF-Potential

Incident

N=35

(Life Safety/Safety Absolute = Policy or Procedure) % %

1 Performing a routine production or a maintenance, connected with a deviation

from an established Life Safety/Safety Absolute42% 0%

2 Performing a routine production or a maintenance task connected to an

exposure that changed from a “normal state”, was not

anticipated/recognized/controlled and likely could have been prevented by

a proper Pre-Task Hazard Assessment (PJHA).

29% 17%

3 Self-made human errors that are not connected to a Safety Absolute

Involved in either a routine operations/production or a maintenance/repair task

OR performing a special/unique/unplanned/emergency situation.

11% 74%

4 Involved in routine operations/production or a maintenance tasks, and a

connection to an equipment / facility / process / engineering design flaw has

been established

5% 3%

5 Involved in routine production or a maintenance tasks, and a connection to

predictive & preventive maintenance & inspection, and reliability systems

has been established

5% 6%

6 Involved in a special/unique/unplanned/emergency situation, connected to

an exposure that was unknown or unfamiliar.4% 0%

7 Involved in an act or incident or workplace violence, war, or militia attack or

similar.4% 0%


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)


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

Definition of SIF Precursor


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

Examples of Precursors

These precursors preceded the incidents they are related to.


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


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


The Old Paradigm Revisited

A focus on the potential for serious injury

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.

Serious Injuries and Fatalities

Some of our First Aids have Precursor’s for

far more serious injuries..


• 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

New Paradigm


Attack the Pyramids!

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..

Now we will work the Top!


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!


SIF Data Breakdown

Near Misses1421 incidents321 had SIF potential

23% SIF potential for Near Misses


SIF Data Breakdown

First Aid Cases106 First Aid Cases20 had SIF potential

19% SIF potential for First Aid Cases


SIF Data Breakdown

OSHA Recordables81 OSHA Recordables26 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


SIF Data Breakdown

Property damage177 Property Damage Incidents36 had SIF potential

20% SIF potential with Property Damage Incidents


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


SIF Data Top Six

Falling Equipment – 50 of 67 incidents had SIF potential

73% of Falling Equipment Incidents had SIF potential


SIF Data Top Six

Lockout/Tagout – 71 of 113 incidents had SIF potential

63% of Lockout/Tagout Incidents had SIF potential


SIF Data Top Six

Rail – 41 of 82 Rail incidents had SIF potential50% of Rail Incidents had SIF potential


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


SIF Data Top Six

Mobile Equipment – 34 of 107 Mobile Equipment incidents had SIF potential32% of Mobile Equipment Incidents had SIF

potential(This includes all Mobile Equipment except Rail)


SIF And Contractor Involvement

Contractors were involved in 166 incidents that had SIF potentialContractors were involved in 38% of the incidents

that had SIF potential


Qualitative Analysis - Revisted

Theme SIF or SIF-Potential

Incident

N=55

NON SIF-Potential

Incident

N=35

(Life Safety/Safety Absolute = Policy or Procedure) % %

1 Performing a routine production or a maintenance, connected with a deviation

from an established Life Safety/Safety Absolute42% 0%

2 Performing a routine production or a maintenance task connected to an

exposure that changed from a “normal state”, was not

anticipated/recognized/controlled and likely could have been prevented by

a proper Pre-Task Hazard Assessment (PJHA).

29% 17%

3 Self-made human errors that are not connected to a Safety Absolute

Involved in either a routine operations/production or a maintenance/repair task

OR performing a special/unique/unplanned/emergency situation.

11% 74%

4 Involved in routine operations/production or a maintenance tasks, and a

connection to an equipment / facility / process / engineering design flaw has

been established

5% 3%

5 Involved in routine production or a maintenance tasks, and a connection to

predictive & preventive maintenance & inspection, and reliability systems

has been established

5% 6%

6 Involved in a special/unique/unplanned/emergency situation, connected to

an exposure that was unknown or unfamiliar.4% 0%

7 Involved in an act or incident or workplace violence, war, or militia attack or

similar.4% 0%


So now what is the…


Intervention Design1. 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


3. 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


4. 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

CONFIDENTIAL. This document contains trade secret information. Disclosure, use or reproduction outside Cargill and inside Cargill, to or by those employees who do not have a need to know is prohibited except as authorized by Cargill In writing. (Copyright Cargill, Incorporated 2007. All rights reserved.)

W.H.A.T.

“W.H.A.T. will keep you safe”

The presentation is now complete!Any questions?

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