Optimization of Safety Optimization of Safety Efforts Using Accident Efforts Using Accident

Avoidance & Other Analysis Avoidance & Other Analysis TechniquesTechniques

International HEP Technical Safety ForumInternational HEP Technical Safety Forum

Jack J. Hahn SLACJack J. Hahn SLAC

Today’s TalkToday’s Talk Provide overview of some SLAC “Safety Excellence” analysis methodsProvide overview of some SLAC “Safety Excellence” analysis methods

Describe three Safety Analysis approaches Describe three Safety Analysis approaches

Accident Avoidance Analysis techniqueAccident Avoidance Analysis technique

Work associated with most common accidentsWork associated with most common accidents

Work associated with most serious accidents (Department of Energy Work associated with most serious accidents (Department of Energy Laboratories)Laboratories)

Show some analysis information shared with all laboratory staffShow some analysis information shared with all laboratory staff

Challenges/Issues for safety progress through Safety AnalysisChallenges/Issues for safety progress through Safety Analysis

““Safety Excellence” vs “Compliance”Safety Excellence” vs “Compliance”

Analysis for “Safety Excellence” (topic today)Analysis for “Safety Excellence” (topic today) Goal to Reduce:Goal to Reduce:

Most common injuries and illnessesMost common injuries and illnesses Goal to Prevent Goal to Prevent

Most serious injuries and illnessesMost serious injuries and illnesses Methods not necessarily required by Safety regulations (U.S. OSHA Methods not necessarily required by Safety regulations (U.S. OSHA

1910, OSHA 1926), may exceed them1910, OSHA 1926), may exceed them Optimization of safety effort Optimization of safety effort

Compliance (important also, not today’s topic)Compliance (important also, not today’s topic) Goal to comply with regulatory requirementsGoal to comply with regulatory requirements Thousands of pages of regulations Thousands of pages of regulations Must do it allMust do it all Use supervision, audits and self-inspection techniques for “analysis”Use supervision, audits and self-inspection techniques for “analysis”

How is Safety Analysis Used?How is Safety Analysis Used? One part of a multi-part safety programOne part of a multi-part safety program

You have opportunity to talk to entire staff about safetyYou have opportunity to talk to entire staff about safety You have 10 minutesYou have 10 minutes You want to provide the potential to make a differenceYou want to provide the potential to make a difference Something that everyone can relate to?Something that everyone can relate to? Results right away?Results right away?

Tool for improvement teams at the labTool for improvement teams at the lab

Tool for defense of safety capital investment decisionsTool for defense of safety capital investment decisions Building/Accelerator/Walkway design?Building/Accelerator/Walkway design?

What is “Accident Avoidance Analysis”?What is “Accident Avoidance Analysis”?

Based on consideration of a number of historical Based on consideration of a number of historical near-miss incidents or accident eventsnear-miss incidents or accident events

Thought experiment by safety professional (s). Thought experiment by safety professional (s). (credits to John Turek, Ishwar Garg) (credits to John Turek, Ishwar Garg)

Semi-quantitative evaluation of relative merits of Semi-quantitative evaluation of relative merits of techniques in preventing the incident or injury.techniques in preventing the incident or injury.

Benefit of Benefit of additionaladditional steps steps

Accident Avoidance Points Accident Avoidance Points (AAP’s)(AAP’s)

Would have prevented accident/incident/injury - 1 Would have prevented accident/incident/injury - 1 pointpoint

May have prevented accident/incident - .5 pointMay have prevented accident/incident - .5 point

Would not have prevented accident/incident - 0 Would not have prevented accident/incident - 0 pointspoints

Accident Avoidance ExamplesAccident Avoidance Examples

Employee moving equipment, splinter Employee moving equipment, splinter embedded under nail- Use of Gloves = 1 embedded under nail- Use of Gloves = 1 Point- would have prevented injury/accident.Point- would have prevented injury/accident.

Employee was crawling on hands and knees Employee was crawling on hands and knees under beamline, stood up and hit head on under beamline, stood up and hit head on magnet- Use of Hardhat = 1 Point, Sufficient magnet- Use of Hardhat = 1 Point, Sufficient workspace to perform task .5 points (may have workspace to perform task .5 points (may have prevented accident)prevented accident)

Accident Avoidance Points vs Remedy- SLAC Injury/Ilnesses N = 113 (four years)

05

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Most Efficient Remedies to Prevent Most Efficient Remedies to Prevent Common Accidents Lab-Wide?Common Accidents Lab-Wide?

# of Accident Avoidance Points/Cost of Remedy# of Accident Avoidance Points/Cost of Remedy

Rough Rough relativerelative value - Precise cost estimates not suggested nor value - Precise cost estimates not suggested nor required. May point out fixes that can be accomplished in required. May point out fixes that can be accomplished in short to medium term. short to medium term.

Information recently developed- Not used Information recently developed- Not used

LimitationsLimitations Order of magnitude of cost effectiveness of solutions, not preciseOrder of magnitude of cost effectiveness of solutions, not precise Decision making should seldom be based only on cost effectivenessDecision making should seldom be based only on cost effectiveness Costs based on prevention of only those events observed- Could be Costs based on prevention of only those events observed- Could be

refined, not done in this examplerefined, not done in this example

$ per Accident Avoidance Point vs Remedy (SLAC accidents N= 113, Four Years)

12 18 19 23 31

91 92

164 167

378

744

0100200300400500600700800900

1000

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Analysis of Work Associated with Analysis of Work Associated with Most Common AccidentsMost Common Accidents

Original Laboratory Approach-Original Laboratory Approach- By Type - Stains/strains/slips, trips, fallsBy Type - Stains/strains/slips, trips, falls By Division & DepartmentBy Division & Department

““Analysis of Work” method-Analysis of Work” method- Welding related injuries?Welding related injuries? Material handling related injuries?Material handling related injuries?

Similar “Analysis of Work for Common Similar “Analysis of Work for Common Accidents” info from today’s talk presented Accidents” info from today’s talk presented site-wide in August 2004 site-wide in August 2004

What Types of Work are Associated with What Types of Work are Associated with SLAC’s Most Common Recordable SLAC’s Most Common Recordable

Injuries/Illnesses? (2003/2004 partial)Injuries/Illnesses? (2003/2004 partial)

Lifting

Ladder Use

Cut/Saw/Drill

Computer WorkChemical Use

Construction

Machining

What Types of Work are Associated with What Types of Work are Associated with SLAC’s Most Common Recordable SLAC’s Most Common Recordable

Injuries/Illnesses? (2003/2004 partial) cont.Injuries/Illnesses? (2003/2004 partial) cont.

Material Handling

All Other

Wrench Use

Moving Body

WalkingStair Use

Welding

# SLAC Recordable Injury/Illness Cases vs Type of Activity 2003-2004 partial (N=55)

0

2

4

6

8

10

12

Walk

ing

Mat

erial

Han

dling

Stair

Use

Mov

ing B

ody

Other

Compu

ter W

ork

Ladd

er u

se

Cut/S

aw/D

rill

Liftin

g

Chem

ical U

se

Mac

hining

Constr

uctio

n

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nch

Use

Weld

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# C

ases

WALKINGWALKING - - 11 Accidents11 Accidents - What could be - What could be done?done? Watch where we are going- 6 Watch where we are going- 6 Poor footing- 1Poor footing- 1 Jobsite housekeeping- 1Jobsite housekeeping- 1 Rate- 1Rate- 1 Facility condition- 1Facility condition- 1

Design/Mitigation IdeasDesign/Mitigation Ideas Minimize sudden change of elevations - curbsMinimize sudden change of elevations - curbs Pathway clearance from objectsPathway clearance from objects Don’t exclude walking in Job Hazard Analysis Don’t exclude walking in Job Hazard Analysis

and Mitigation (JHAM)and Mitigation (JHAM)

Walking

MATERIAL HANDLINGMATERIAL HANDLING -- 11 Accidents 11 Accidents - - What could be done?What could be done?

Excess manual force- 4?Excess manual force- 4? No gloves- 3No gloves- 3 Proper cart / hand trucks- 2Proper cart / hand trucks- 2 Unstable body position- 1Unstable body position- 1 Avoid falling objects- 1Avoid falling objects- 1

Design/Mitigation IdeasDesign/Mitigation Ideas Long term plan- decrease manual/increase powered Long term plan- decrease manual/increase powered

liftinglifting Job Planning- Safety meetings discuss optionsJob Planning- Safety meetings discuss options

Material Handling

STAIR USESTAIR USE - 5 Accidents - 5 Accidents - - What could be done?What could be done? No handrail use- 3No handrail use- 3 Rate- 2Rate- 2 No handtruck-1No handtruck-1 Splinter from handrail- 1Splinter from handrail- 1

Design/MitigationDesign/Mitigation Establish culture of using handrailsEstablish culture of using handrails Avoid carrying items that prevent you from using Avoid carrying items that prevent you from using

handrail/seeinghandrail/seeing Design OSHA compliant handrailsDesign OSHA compliant handrails Safety meetings/Job Hazard AnalysisSafety meetings/Job Hazard Analysis

Stair Use

Preventing Some of the Most Preventing Some of the Most Serious Accidents - Ladder Serious Accidents - Ladder

SafetySafety

Pick the right ladder Pick the right ladder Don’t use a ladder that is too Don’t use a ladder that is too

shortshort Inspect the ladder Inspect the ladder Climb with both hands freeClimb with both hands free Include ladder safety in JHAMInclude ladder safety in JHAM

Preventing Some of the Most Serious Preventing Some of the Most Serious Accidents- Electrical SafetyAccidents- Electrical Safety

Work de-energized whenever possibleWork de-energized whenever possible

If not, approach the situation with If not, approach the situation with redundant controlsredundant controls Electrical GlovesElectrical Gloves MatsMats Hard hat in keeping with the rulesHard hat in keeping with the rules Appropriate ClothingAppropriate Clothing

Of course include electrical work in Of course include electrical work in safety planningsafety planning

Analysis of Work Associated with Most Analysis of Work Associated with Most Serious AccidentsSerious Accidents

Review/Summarize 28 Selected Department of Review/Summarize 28 Selected Department of Energy (DOE) Type A & B Investigations Apr Energy (DOE) Type A & B Investigations Apr 1997- Oct 20011997- Oct 2001

Look Nationally over a number of years, to obtain Look Nationally over a number of years, to obtain reasonable sample size for analysisreasonable sample size for analysis

What Qualifies as a Department of Energy (DOE) Type A What Qualifies as a Department of Energy (DOE) Type A or B Accident/Incident?or B Accident/Incident?

Type A & B precisely defined in DOE orderType A & B precisely defined in DOE order

Type A’s (Worst) includesType A’s (Worst) includes injury, chemical or biological exposure resulting in injury, chemical or biological exposure resulting in

1 or more fatalities1 or more fatalities 3 or more persons with “serious” injuries3 or more persons with “serious” injuries

Property Accidents > 2.5MProperty Accidents > 2.5M

Type B’s (Bad) includesType B’s (Bad) includes Injury, chemical or biological exposure resulting in Injury, chemical or biological exposure resulting in

1 or more persons having “serious” injuries1 or more persons having “serious” injuries Property Accidents > 1 MProperty Accidents > 1 M

Review/Summarize Relevant DOE Type A & Review/Summarize Relevant DOE Type A & B Incident Investigative ReportsB Incident Investigative Reports

GENERAL WORK TYPE - # OF INVESTIGATIONSGENERAL WORK TYPE - # OF INVESTIGATIONSConstruction- 9Construction- 9Maintenance- 8Maintenance- 8No Activity- 3No Activity- 3Environmental Work- 2Environmental Work- 2Transportation- 2Transportation- 2Demolition- 1Demolition- 1Research- 1Research- 1Material Handling- 1Material Handling- 1Helicopter- 1Helicopter- 1

Total- 28Total- 28

Review/Summarize Relevant DOE Type A & Review/Summarize Relevant DOE Type A & B Incident Investigative Reports (cont.)B Incident Investigative Reports (cont.)

Detailed Work Categories- # incidentsDetailed Work Categories- # incidents

Electrical- 8Electrical- 8

working in substations- 3working in substations- 3

working on power lines- 1working on power lines- 1

switchgear- 1switchgear- 1

motor control center- 1motor control center- 1

jackhammer- 1jackhammer- 1

microwave, student taking measurements- 1microwave, student taking measurements- 1

Review/Summarize Relevant DOE Type A & Review/Summarize Relevant DOE Type A & B Incident Investigative Reports (cont.)B Incident Investigative Reports (cont.)

Detailed Work Categories- # incidentsDetailed Work Categories- # incidents

Tree Falling Under Power Lines- 2Tree Falling Under Power Lines- 2

Heavy Equipment - Material snagged - 2Heavy Equipment - Material snagged - 2

DOE Fatalities for Work Relevant to SLAC, as DOE Fatalities for Work Relevant to SLAC, as

Reported in Type A ReportsReported in Type A Reports Tree Falling- Power Line Maintenance-1Tree Falling- Power Line Maintenance-1

Electrical- De-energized Power Line- Induced Electrical- De-energized Power Line- Induced Current - 1Current - 1

Grading- Run Over By Equipment - 1Grading- Run Over By Equipment - 1

Heating and Air Conditioning Work- Fall From Heating and Air Conditioning Work- Fall From Height - 1Height - 1

List of Detailed Work Type A’s List of Detailed Work Type A’s or B’sor B’s

Electrical- Substation 3Electrical- Substation 3 Tree Falling- Power Line 2Tree Falling- Power Line 2 Heavy Equipment- Material snagged Heavy Equipment- Material snagged

22 Leaking Fluid 2Leaking Fluid 2 HVAC 2HVAC 2 Painting 1Painting 1 Electrical- Motor Control Center 1Electrical- Motor Control Center 1 Asbestos Work 1Asbestos Work 1 Drilling Rig 1Drilling Rig 1

Electrical- Power Line 1Electrical- Power Line 1 Grading 1Grading 1 Helicopter- Bad Weather 1Helicopter- Bad Weather 1 Hoisting and Rigging 1Hoisting and Rigging 1 Jackhammer 1Jackhammer 1 Janitorial 1Janitorial 1 Hauling 1Hauling 1 Microwave 1Microwave 1 Rooftop Work 1Rooftop Work 1 Switchgear 1Switchgear 1 Environmental Sampling 1Environmental Sampling 1 Traffic accident on public road Traffic accident on public road

starts fire 1starts fire 1 Waste 1Waste 1 TOTAL 28TOTAL 28

Conclusions Regarding Hazardous from Conclusions Regarding Hazardous from DOE Data, and JudgmentDOE Data, and Judgment

Hazardous Work- In order of certainty?Hazardous Work- In order of certainty? Conventional constructionConventional construction Building very large high energy physics facilitiesBuilding very large high energy physics facilities Conventional maintenanceConventional maintenance Electrical work- Especially high voltage work, substation work. Electrical work- Especially high voltage work, substation work. Tree falling? Tree falling? Maintenance of Power Lines? Maintenance of Power Lines? Heavy Equipment Snagging Material? Heavy Equipment Snagging Material?

Research - Not much type A or B activity seenResearch - Not much type A or B activity seen

Exotic Experimental Equipment - Not much type A or B activityExotic Experimental Equipment - Not much type A or B activity

Challenges/Issues for Safety Challenges/Issues for Safety Progress Through Safety AnalysisProgress Through Safety Analysis

People don’t always listen or agreePeople don’t always listen or agree

One-time communication not likely to change ingrained behaviors- need One-time communication not likely to change ingrained behaviors- need follow-on communicationfollow-on communication Need to have programs that generate “habit strength”?Need to have programs that generate “habit strength”?

Uniform Hazard Analysis?Uniform Hazard Analysis? Behavior Based Safety? Behavior Based Safety?

Establish requirements in HEP labs for common behaviors such as hand Establish requirements in HEP labs for common behaviors such as hand rail usage, or watching where we are going? Is this going too far? Why?rail usage, or watching where we are going? Is this going too far? Why?