LPS Training - 2015 Update FINAL [PDF]

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Loss Prevention System (LPS) .



Training Package



This presentation includes forward-looking statements. Actual future conditions (including economic conditions, energy demand, and energy supply) could differ materially due to changes in technology, the development of new supply sources, political events, demographic changes, and other factors discussed herein (and in Item 1A of ExxonMobil’s latest report on Form 10-K or information set forth under "factors affecting future results" on the "investors" page of our website at www.exxonmobil.com). This material is not to be reproduced without the permission of Exxon Mobil Corporation.



Background to LPS • What is Loss Prevention System? • A systematic way to promote safe behaviors through use of proven safety management tools



• What is a loss? • Any unplanned cost or business interruption • Injury, fire, equipment damage, hydrocarbon release, spill, regulatory violation



• What is the objective? • To provide workers with a safe, healthy and environmentally conducive workplace



• Why was LPS chosen? • Successful use in different industries and cultures • Result of 30 years of research by Dr. James Bennett



Why the need for LPS? People are still getting hurt due to old habits and behaviors … • JSAs is just paperwork to get permit approved • SPSA is talk only but no action • IPO is a numbers game – minimal to zero questionable recorded • UCUX contributions were declining until recently • Near miss reporting is low and investigation not done unless instructed • General reluctance to intervene



LPS Principles Loss Prevention System Our Journey to “I Will Not Get Hurt Today” • We develop and use Job Safety Analysis for all work tasks or procedures



• We perform Safe Performance Self Assessment throughout the task at hand • We conduct Incident Prevention Observations on a planned and regular basis • We report and investigate all near misses, incidents and injuries • We communicate and implement learnings from all investigations • We perform quality assessments of Loss Prevention System tools and activities • We are each accountable for incident prevention



LPS helps us improve behavioral safety



Facilities



Management Systems Incident Rate



LPS Human Performance Time



Basic Concepts of LPS LPS aims to prevent or reduce losses through establishing a work culture that: • Promotes proactive safety activities versus reactive • Positive reinforcement of safe behaviors • Integrates LPS tools part of daily activities



• Provides direction from the top down • Solves problems from bottom up • Engages all workers



The Seven Tools of LPS 



Safe Performance Self-Assessment (SPSA)







Job Safety Analysis (JSA)







Incident Prevention Observation (IPO)







U-See U-Act (UCUX)







Near Miss and Incident Investigation (NMI /II)







Root Cause Analysis Flowchart (RCAF)







Leadership and Measurement (KPI)



Includes Intervention



Concept of Safety Pyramid



Major Injury



1



Minor Injury



10 3



Equipment / Property Damage



30 21



Near Misses



600 180 Average forExxonMobil 21 Industries Typical



How different is a Near Miss from a Major Incident?



LPS Goes Deeper into the Root Causes



Major Injury



Minor Injury Equipment / Property Damage



Near Misses Unsafe Behaviors



Root Causes



• Focus on proactive activities at bottom of triangle



• Change unsafe behaviors and promote safe behaviors • Find out root cause – it is the same whether near miss, injury or fatality!



How LPS tools are connected Major Injury Minor Injury



Root Cause Analysis Flowchart (RCAF)



Equip / Prop. Damage Near Misses



LPS



Tools are all inter-related



Job Safety Analysis (JSA)



Why the Emphasis on JSAs? • Incident Investigations analysis show “Failure to Identify and Mitigate Hazards” as the most common cause of recordable incidents in EMPC • The JSA provides an organized method for identifying hazards and putting in place necessary safeguards



• Even when JSAs are used, they have not consistently addressed the key hazards, or the applicable hazard controls are not verified • For EMPC recordable incident cases, 40% of applicable JSAs did not address the hazard that most directly contributed to the incident



Why the Emphasis on JSAs?



Contd..



• In addition, Walkabouts (JSA Audits) indicate: • Not all team members are involved in reviewing the JSA for their task • Sampled JSAs did not reflect actual site conditions at the time/location of the task • Reference JSA used with no consideration of the conditions at the time of the task • Identified safeguards and controls were not always implemented • PPE not worn; signs/barriers not in place; wrong tools • Confusion among team members regarding who would implement safeguards



Job Safety Analysis (JSA) Description • JSA is a pre-job planning and safety tool used by the work team to: • Identify major steps of a job or task • Identify potential hazards for each step • Determine the best safeguards to prevent or mitigate the identified hazards • Clarify and coordinate responsibilities between team members



• JSA is a “living” safety tool • Initially developed prior to task, but updated during task as needed if situation changes



• Team refers to JSA during task to verify appropriate mitigations are in place



“JSA is not simply paperwork – it is your Safety Plan!!!”



Two Types of JSAs Reference JSA • Prepared ahead of time for recurring tasks • Includes common hazards and lessons from prior experience



• Kept on file as starting point for Real-Time JSA



Real-Time JSA • Prepared by work team immediately before starting task • Includes specific and unique hazards for the site and date task is performed • May be a “marked up” Reference JSA, or completely new JSA



JSA Review Form



JSA Review Form • JSA Review Form – facilitates JSA initiation and review • Basic “administrative” data (location, date, task description, Work Permit) • Applicable Procedures and Standards (References) • MOC (Management of Change) or Risk Assessment required? • Key PPE for task, location, and conditions • JSA Review – by Supervisor or designated person • Verification of site conditions prior to work by Task Leader • Team sign-on list (use if not part of Work Permit sign-on)



Task Hazard Assessment Form



Task Hazard Assessment Form • Task Hazard Assessment (THA) Form • Common hazard categories and potential solutions to use in task steps • Identify applicable hazard types • Then, identify applicable solutions



• Additional hazards may apply to task (add directly to Hazard Management Form) • THA does not contain all possible hazards



Hazard Management Form



Hazard Management Form • JSA Hazard Management Form is the primary JSA tool once work starts • Task Description – align with JSA Review Form heading • Task Steps – major activities within the task • Preparation, Execution (main steps), Reinstatement, General Safety • List Potential Hazards for each step/activity • Controls/Safeguards for each hazard



• Assigned Person for each safeguard • A team member “champions” use of designated safeguard during task • Safeguard Completion/Implementation • Assigned Person “checks off” item when safeguard in place



Benefits of using a JSA Immediate Benefits • Aids in planning and understanding the major steps of a task • Proactively identifies real-time hazards of a task and the actions needed to mitigate each hazard • Facilitates discussion of the task by work team (toolbox talk) • Focuses attention of the team on the task to be done • Serves as a memory aid during the task for addressing key hazards Additional Benefits • Helps standardize recurring job tasks/processes – captures best practices from prior experience • Can provide basis for developing more detailed Procedure if appropriate • Provides accepted standard for task observations (IPOs)



Basic JSA Expectations • Every team member reviews and understands the JSA prior to start of work • Team members arriving after task has begun must read JSA prior to start of their work – if questions, ask Task Leader before starting



• Only a “Real-Time” JSA is acceptable for doing a task • “Reference” JSA not accepted without date-specific hazards and mitigations noted (making it a Real-Time JSA)



• JSA scope is “one task for one shift” • JSA may be extended into next shift if same work team continuing task



• JSA must be updated for specific day/site conditions



• Review of site conditions completed before work begins • If new hazards/controls identified, JSA is “marked up” and reviewed by team at site • Energy isolation, if applicable, is verified and demonstrated



• Safeguards are implemented during the task as indicated in the JSA • Follow the guidance of the JSA while doing the job!



JSA Process Overview – 1 • Divide overall job scope into significant Tasks (phases) • Job phase – done by same work team; single location



• Create a JSA for each significant Task • Create a new JSA or edit an existing Reference JSA • Task Leader is responsible for developing the initial Real-Time JSA • Include main activities associated with the task: • Preparation • Execution of Task (main steps) • Reinstatement of systems • General Safety (housekeeping, etc.)



• As practical, allow a knowledgeable person (JSA Reviewer) to review the JSA prior to toolbox talk and going onto work site • Reviewer can verify JSA is consistent with the planned task and covers normally expected considerations



JSA Process Overview – 2 • Discuss the JSA with all team members (toolbox talk) • Everyone in team participates in discussion – ask questions, share ideas • Clarify roles/responsibilities for safety actions (Assigned Persons)



• When team arrives at site, confirm site conditions prior to start of work • Examples of items to check:



• • • •



Proper isolations Site accessibility, housekeeping, walking hazards Other operations/activities in area Work conditions – visibility, noise, cramped spaces



“Update JSA and discuss as needed to mitigate new hazards”



JSA Process Overview – 3 • Execute the task consistent with the JSA • Confirm identified safeguards and controls are put in place • Refer to the JSA during the task to confirm status and mitigate any changes • Include site clean-up when task completed



• Upgrade JSA at end of task with lessons learned • Retain copy of updated JSA as Reference JSA



If at any time during the planning or execution of the task you are unsure about being able to perform the task safely – STOP THE JOB!!!



When JSA was not properly used … Contractor Finger Injury… • The work table of the drill press needed to be adjusted • The worker placed a wooden block and a short scaffold tubing under the work table to prevent table free fall. It did fall and pinched his finger



IP’s injured middle finger 



Hazard was identified but mitigations inadequate …



JSA Exercise • Develop a JSA for this task: • Transfer a full chemical drum from main deck to production deck



Safe Performance Self-Assessment (SPSA)



Safe Performance Self-Assessment (SPSA) •



A mental 3-step risk assessment method 1. ASSESS



2. ANALYZE 3. ACT



• • • • •



No paperwork required To be used before, during and after every activity Should also be used during each step of a JSA task It’s also called an “Every Minute Risk Assessment” Goal is to make SPSA a habit – on and off the job



“It’s your last line of defense against injury!!”



SPSA Process Step 1 - ASSESS the risk! • Assess the hazards associated with each job and ask: • What could go wrong? • What is the worst thing that could happen if something does go wrong?



“DO NOT TAKE UNNECESSARY RISK!”



SPSA Process Step 2 - ANALYZE how to reduce the risk! • Evaluate each identified risk to see that appropriate safeguards are in place to control the hazard. • Do I have the appropriate training and knowledge to perform the job safely?



• Do I have all the proper tools and personal protective equipment?



SPSA Process Step 3 - ACT to ensure safe operations! • Take the necessary steps to ensure the job is done safely. • Follow written standards such as JSAs and Operating Procedures.



• Use the correct tools. • If you have a concern or are uncertain, STOP and get assistance



What Happens if I Don’t Use SPSA • Look at the penguin !!!



SPSA Exercise • Ascending the living quarters staircase with a cup of hot coffee



Incident Prevention Observation



What is IPO? •



A systematic tool for observing a part of a work procedure (typically 15 – 20 mins) to: 1. Reinforce good safety behaviors 2. Discuss potentially unsafe behaviors, habits, conditions (called Questionables)



• • •



It is an excellent tool for training in INTERVENTION However, IPOs do not replace on-going interventions Our goal is to help each other achieve “I Will Not Get Hurt Today”



What is a Questionable? • Any unsafe behavior • Any unsafe condition • Anything you observed that you are not sure, and would like to bring up for discussion with the Observee and Supervisor • It is good to have Questionables! It helps your friend become a safe worker over time



The man with insight to admit his limitations comes nearest to perfection. - Von Goethe



IPO Process • Planning / Preparation (~1 IPO per Quarter) • Target activities that have greatest risk for injury • Fingers, Hands, Feet, Arms, Legs • Lifting, pulling, walking, transferring



• Schedule the IPO • Ask someone to observe you, rather than you asking to do an observation on him/her



• Conduct the observation (15 - 20 mins) • Hold IPO Feedback Session • • • •



Reinforce positives Identify questionables Determine root causes Agree on solutions



• Implement Solutions • Field follow-ups for verification and validation.



• Communicate IPO lessons learned in morning meetings



Recap of IPO Feedback Process • Conduct feedback within same day of IPO • First line supervisor leads discussion. • 3-way discussion among participants. • Requires active participation by Observee and Observer.



• Limit discussion to observation issues – 15-20 min. • Reinforce positive actions • Discuss Questionable Items • Root Causes for items to be corrected • Solutions for improvement • Document results on IPO form • Conclude with summary of discussion



IPO Exercise Conduct IPO on a personnel ascending/decending a staircase • What are the good (correct) behaviors?



• What are the Questionable? • In the Feedback, what would you say to the worker?



INTERVENTIONS Some examples : • Stopping a work activity that is questionable to you • Asking someone about their 3A’s of SPSA for the work being done • Warning someone of a hazard nearby • Stopping someone who is not using the proper PPE or right tools • Calling for a stop work when deviations or condition change from JSA • Asking someone who looks overworked or stressed to take a rest



How To Intervene • • • •



Use simple and kind words. Strictly NO cursing Provide advise clearly. Do not use sarcastic words Do not yell



Example of BAD Intervention. “Oi, stop your work! Where’s your brain? On your knee?”



Example of GOOD Intervention. “Excuse me, I saw you have not put on nitrile gloves for chemical handling. You might burn your hands if the chemical splash. Can I get it for you?” • If the other person is offended and say “Mind your own business!.”.. do not give up.



Example of GOOD Response.  I’m doing this because I care for you. Your hands are priceless.



Example of BAD Response.  If you don’t care about your safety, I also don’t care



How to Receive Intervention • Receive the advice with open mind. Do not simply brush it off • Even if you are very experienced, you can still make mistakes • Say “Thank you” to those who care enough to stop your work or ask you a question.



THROW AWAY THE OLD MAN(Old habits ) TRANSFORM TO A NEW MAN



A Personal Testimony on Intervention… “ I Could Have Saved A Life That Day… “ I could have saved a life that day, But I chose to look the other way. It wasn’t that I didn’t care; I had the time, and I was there.



Now every time I see his wife, I’ll know I should have saved his life. That guilt is something I must bear, But it isn’t something you need to share.



But I didn’t want to seem the fool, Or argue over a safety rule. I knew he had done the job before. If I called it wrong, he might get sore.



If you see a risk that others take, That puts their health or life at stake, The question asked or things you say Could help them live another day.



The chances didn’t seem that bad. I’ve done the same; he knew I had. So I shook my head and walked on by. He knew the risks as well as I.



If you see a risk and walk away, Then hope you never have to say: I could have saved a life that day, But I chose to look the other way.



He took the chance; I closed an eye. And with that act, I let him die. I could have saved a life that day, But I chose to look the other way.



Summary of IPOs and Intervention • Conduct IPOs frequently! • Target activities that have greatest risk for injury • Use Feedback session to nurture open communication including intervention • Give positive comments • Reward good IPOs for Observer and Observee



• • • • •



It is a intervention training tool Determine root causes Track and close-out questionables promptly Share learnings on behavior improvement trends Keep celebrating success!



Change – “I must change first and then things will change.”



U-See U-Act (UCUX) • UCUX is an empowerment tool for all workers • New form expanded to capture items: • Unsafe condition • Unsafe behavior • Positive intervention • Near Miss • Safety suggestion



• Take immediate corrective actions if you can, and write down other further actions you think that may be required • Sites are empowered to track and close-out items! • Use data for Chairman’s Safety Award nomination



U-See-U-Act Form



Near Miss and Incident Investigation



49



Incident/Near Miss Investigation Cycle PREVENTS Incident or Near Miss Analyze Trends



Corrective Actions Management



Incident Management Cycle



Incident Response



Notification



Investigation & Analysis



Share Learnings Reporting



Near Miss and Incident Investigation • Investigations are important for • Learning • Sharing • Preventing recurrence



• Investigations capture: • WHAT happened (Incident Description) • HOW it happened (Conclusions) • WHY it happened (Root Cause Analysis) • Solutions and Corrective Actions



Investigation Tools 2-Tier Approach to Root Cause Analysis • 5 Why’s / RCAF • Minor Incidents, Near Misses, Questionable Items (IPOs), UCUX



• Simple tool for use by field personnel



• TapRooT® • Major Injuries, hazard loss, recordable incidents, and significant near misses • More structured, needs training



Incident Notification & Investigation Guide Incident



Update ‘Incident Follow-up List’ to track IMPACT entry, investigation report and management review



Field notifies Op Supt verbally , and submit notification via IMPACT PIC



Safety Share incident in morning meeting Op Supt



Asser Manager notifies Op Manager verbally, and initiate investigation based on the investigation guide Op Supt/Mgr



5 Why’s



NO



Formal investigation ? YES



5 Why / RCAF Investigation 1. Minor incidents 2. Near Misses 3. Questionable Items (IPOs) 4. UCUX



TapRoot



TapRoot Investigation: 1. Recordable injuries / illnesses (MTI, RWI, LTI) 2. Significant near misses (includes D&A) 3. Spills > 1 barrel 4. Hydrocarbon release >20kg 5. Process fires/explosion 6. Hazard loss > US50K 7. Vehicle incidents 8. Well control event 9. Significant security



Near Miss Reporting / Investigation • Report all near miss incidents no matter how small • Because near miss is a potential incident, it must be investigated the same as incidents: • They are “free learnings” because nobody got hurt • Use IMPACT to report all near misses at worksites • Investigations must be completed within 10 days



• Why are Near Misses not often reported? • Fear of discipline, bad appraisal, or embarrassment • Administrative burden (paperwork)



• Workers don’t understand definition of Near Miss • More work to investigate • No confidence that recommendations will be implemented



Near Miss versus Hazard What is the difference between a Near Miss and a Hazard? • A Near Miss is when an event happened but no one was injured • A Hazard is an unsafe condition or behavior – nothing has happened



Examples of Near Miss are: • Rotating equipment component narrowly misses hand of worker reaching in to make adjustment. • Sour water vapors from a vacuum truck set off an area H2S alarm. • Forklift slides on wet pavement and drops pallet – no damage to equipment nor product spilled. • Wrench slips while opening stuck valve – operator slips and bumps head, no injury because wearing hard hat. • Two employees collide when rounding a corner in the office building. Neither employee is hurt. • Object falls from higher level deck, narrowly missing workers below.



Incident and Near Miss Investigation • • • •



After experiencing an incident or near miss – STOP YOUR WORK! Don’t restart work until it is safe to do so Perform SPSA (or JSA) to determine if it is safe to continue If you can’t eliminate or manage the risk, Do Not Continue



« IF IT’S NOT SAFE – DON’T CONTINUE! »



Learning from an Incident • Investigating an incident is like “peeling the layers of an onion”



Facilities Design & Working Conditions • Improper materials



• Cramped work area



Process Conditions (High T, P, etc.)



Management Systems • Inadequate training • No written procedure



Human Behaviors • Insufficient Operator care • Hurrying to finish



Incident!



Example of 5 Whys • 5 Why’s is a simple question and answer tool • Start with description of incident • Example: Finger pinched at door



• Followed by Why’s … • Why was the finger pinched? • Why did he not notice where he put his hands?



• Why was he not wearing gloves? • Why was there no stopper on the door? • Why was he in a hurry?



• Finally, determine probable root causes



Root Cause Analysis Flowchart Loss, Near Miss, or Questionable Item PERSONAL FACTOR Did Not Follow Accepted Procedures or Practices Because:



1. Lack of Skill or Knowledge



2. Using the Correct Way Takes More Time or Effort 3. Not Following the Correct Practice is Positively Reinforced or Tolerated 4. Deviations from the Correct Practice have Not Resulted in Problems in the Past



JOB FACTOR



8. EXTERNAL FACTOR



5. Lack of, or Inadequate, Procedures or Standards 6. Inadequate Communication of Expectations, Procedures, or Standards 7. Inadequate Tools or Equipment (Availability, Design, Condition)



Development of Solutions Implementation of Solutions



Verification and Validation of Solutions



Develop Solutions to Address Root Cause • Solutions / mitigations must help to eliminate or minimize the hazard. • Solutions must “match” root cause. • Close-out the recommended solutions and incident should not occur again



Close-out all investigations timely or it can happen again – maybe tomorrow!



Incident and Near Miss Investigation It’s about Fact Finding – Not Fault Finding ! Experience is the name everyone gives to their mistakes



Investigation helps us learn not to make the same mistakes



Leadership and Stewardship



Stewardship Activities – PIC / FLS • “What gets measured, gets done.” • Measuring and monitoring the correct aspects of the LPS processes will ensure its effectiveness in preventing losses – so that “Nobody Gets Hurt”. • Spot check use of SPSA, JSA, UCUX (daily)



• Quality reviews of IPO, UCUX, Near Miss, IMPACT Reports • Tracking and timely close-outs of action items • Discuss LPS tool use and KPIs in regular field meetings • Daily morning coordination meetings



• Daily field leadership meetings • Monthly Safety meetings • Weekly tele-con meetings with Asset Manager



• Recognition and Corrective Actions • Care Point System (CPS) recognitions given for LPS tool use (JSA/UCUX/IPO/)



Stewardship – Data Management • IMPACT is used for all near miss and incident reporting, tracking and close-outs • Other LPS data will be tracked in Excel spreadsheets parked in common LAN (I:\shdsrvc\Information\SHE Reference\Safety\Site Safety Leader Corner\Monthly LPS Database) : • For Asset tracking of action items and close-out • For benchmarking and sharing • For recognition such as Chairman’s Safety Award



• For analysis to target areas/activities with greatest opportunity for improvements



Successful LPS Has Following Features • Visible management participation • Tools are used frequently by all at worksites • Focus is in areas of greatest risk or exposure • LPS results and trends are discussed regularly • Root causes are determined for all near miss and incidents • Solutions match root causes • Solutions are implemented timely • Quality reviews are occurring



• Annual stewardship takes place