SHIFTING AWAY FROM TRADITIONAL METRIC REACTIVE Measuring incident occurrence (LTI) and developing plan to mitigate recurrence PROACTIVE Identifying significant risk that causes major injuries (SIF), analyzing impact & developing plan to prevent SIF potential
Classic Approach of Heinrich Theory Heinrich Safety Triangle has been the classic concept used for analyzing incident Heinrich theorized that for every major injury or fatality, there were 29 minor injuries and 300 non-injury incidents. Thus, reducing non-injury accident could lead to a reduced minor and major injuries However, today we realize not all non-injury incidents are equal in terms of their potential for resulting in SIF . Only some near misses have the precursors that could lead to recordable injuries, lost time injuries, and even fatalities. Non-Injury = Minor / Major Accident
Revisiting Heinrich Theory Since 1993, total recordable incident rate (TRIR) has shown significant dropped due to the increased workplace safety However, the number of life-altering injuries (LTI) cases are relatively slower in decline. Therefore, it is inaccurate to say reducing non-injury accident would significantly reduce number of LTI Non-Injury = Minor / Major Accident *(Bureau of Labor Statistics US, 2017)
The New SIF Prevention Model Not all near misses have the precursors that could lead to recordable injuries, lost time injuries, and even fatalities. We must isolate that part of the triangle with the potential for SIF and prevent those incidents from occurring. Only 21% has the precursors to cause SIF Treating all minor incidents and near misses as if they have the potential to result in SIF can divert attention away from those incidents that contain the most potential to result in something serious focus must be placed on the specific precursors that have the potential for SIF. 21%
The New SIF Prevention Model Precursors that are PSIF have 3 Key Aspects High Risk Situations - such as working at height, or confined space entry Management controls are absent, ineffective or not complied If continued will result in SIF 21%
Prerequisite prior to SIF Prevention Program .. How is the incident reporting culture from all level of employee? Is there a platform for reporting near misses? Is there a hazard communication to all level of employee so employee understood risk involve at workplace? Is there an audit program in place to look for potential SIF and unsafe finding? Is Safety Triangle developed to determine the correlation between near misses and accident? Note : PSIF Prevention Strategy is an addition to the above tools LTI / Major / Fatal Accident Recordable Injuries Near Miss Incident First Aid Unsafe Act / Unsafe Condition PSIF
IDENTIFYING POTENTIAL SIF EXPOSURE 1. Placing definitions regards to SIF precursors 2. Communicating & identifying SIF on site QUANTIFYING SIF 1. Gathering of data from past (incident / near misses) and present (work activities) 2. Measuring SIF PREVENTION 1. Prevention strategy development 2. Monitor result SIF PREVENTION ROADMAP
SIF PREVENTION ROADMAP Plan Do Check Act Develop roadmap for SIF prevention strategy Develop communication plan for SIF prevention Agree on organizational risk profile & SIF definition Obtain & educate leadership on SIF prevention program Implement education & training on SIF Outline expectation & goals Identify source of data for SIF metric Consider tools & technology for SIF prevention Analyze & track trends in SIF metric Assess how well risk are being controlled Solicit feedback from workers and leaders on SIF communication and education Take action on lessons learned Reevaluate the SIF metrics tracked Identify additional sources of data for SIF metrics Reassess precursors
IDENTIFYING POTENTIAL & SIF PRECURSOR Part 2
STEPS TO IDENTIFYING SIF A lot of activities may have potential to cause SIF. The only real difference between an “actual SIF” and a “potential SIF” is inches, seconds, and luck STEP 1 . Develop SIF definitions and a calibrated decision logic (decision tree) STEP 2. Identify source of data for SIF metric and apply decision logic to source of data STEP 3. Validate SIF precursors and control points
1.1 UNDERSTANDING SIF PRECURSORS SIFs are defined as events where the following 3 factors, or precursors, exist : It involves a high-risk situation or work activity Critical barriers or management controls required to protect workers in these situations are absent / ineffective / not complied with A fatality or serious injury is likely to occur if those conditions are allowed to continue.
1.2 Serious Injury & Fatality Definition Fatality One that, if not immediately addressed, is likely to lead to the death of the affected individual and will usually require intervention of internal and/or external emergency response personnel to provide life-sustaining support. Laceration or crushing injury that results in significant blood loss An event that requires the application of cardiopulmonary resuscitation or an external defibrillator Chest, Head or abdominal trauma affecting vital organs Serious Burns Poisoning caused by exposure to hazardous chemicals Life-Threatening injury One that results in permanent or long-term impairment or loss of use of internal organs, body function or body part. Significant head injuries Spinal cord injuries Paralysis Amputations Broken or fractured bones Serious Burns Life-Altering injury
Energy source such as electrical, mechanical, thermal, pneumatic, gravity, hydraulic that was uncontrolled A falling or dropped object Slip, trip, fall, or fall from height greater than 4 feet from a platform or ladder PIT striking a pedestrian, object, or operator injury Contact with a rotating shaft, sprocket, chain, or drive of a conveyor, motor, or machine Uncontrolled release of hot water, steam, chemical, or hot product Ascending or descending stairs, ramp, or ladder Donning proper PPE as required for the task being performed Incorrect or poorly maintained tools appropriate for the task Dock Safety Systems (Salvo, Door, Leveler) Confined space activities Step 1.3 DEFINE HIGH RISK ACTIVITIES
Step 2.1 IDENTIFYING SOURCES OF SIF Use of data from near misses and incident reports help to understand where SIF is present and to predict in the future Incorporating existing audit program with SIF identification Training & providing communication medium to shopfloor employee is crucial to gain data from employee engagement Review activity on existing risk assessment and SOP would help to provide accurate picture of SIF exposure SOURCE OF SIF Reportable incident trends Near miss event Observation / Walkabout / Audit / Inspection Employee insight / engagement Existing Risk Assessment (JHA / HIRARC) Analysis of SOP
STEP 2.2 APPLY DECISION LOGIC Using decision tree checklist to determine if the source of data has SIF exposure Define existing control measure that was used to control SIF exposure
STEP 3. VALIDATE SIF PRECURSORS Ask these question: Is the control barriers able to control SIF exposure? Is there a point where control is lost / absent?
STEP 3. VALIDATE SIF PRECURSORS Ask these question: Is the control barriers able to control SIF exposure? Is there a point where control is lost / absent? If the answer is yes, there is a definite SIF exposure that requires to further control
CASE STUDY. Is this SIF? CASE 1. Employee working at Forming area. The formax operates automatically and continuously throughout the production and does not require any manual intervention. However, during running of chicken breaded product, the product tends to easily sticks onto the conveyor. Therefore, cleaning of conveyor is required. Tool is provided to be used by employee for the cleaning work so that employee does not need to put body parts into conveyor. The SOP states that conveyor must be stopped when cleaning activities is ongoing. Question Y/N Why? Is there SIF exposure? Is there control in place? Is the control point sufficient? Are there point where control is lost?
CASE STUDY. Is this SIF? CASE 2. Employee is working at a raw material receiving area. After forklift has unloaded the raw material into the area, he is required to cut open the raw material plastic wrap using the provided cutting tools. Employee is required and provided with cut resistance glove. Question Y/N Why? Is there SIF exposure? Is there control in place? Is the control point sufficient? Are there point where control is lost?
CASE STUDY. Is this SIF? CASE 3. Maintenance technician conducting repair work on auto packing machine. The machine requires changing of parts and therefore, safety machine covers are required to be opened. LOTO switches are available, and all technicians are provided with and trained on LOTO. Question Y/N Why? Is there SIF exposure? Is there control in place? Is the control point sufficient? Are there point where control is lost?
ASSESSING SIF EXPOSURE RISK Part 3
HOW DO WE MEASURE SIF EXPOSURE? SIF Exposure is measured by the possibility of a barrier being breached
DEFINITION OF RISK Source of harm that could lead to SIF exposure Getting cut by knife is not the hazard. The sharp point at the knife is the hazard. Hazard Risk Harm / SIF Relative exposure of a person to a certain hazard Commonly, it is quantified by likelihood and severity of the exposure An SIF event that is caused by the exposure towards hazard
DEFINITION OF RISK RISK = LIKELIHOOD of SIF occurring SEVERITY of SIF exposure x Considering > the likelihood of barrier being breached The effectiveness of existing control Are there risk amplifier? Considering > The worst severity if control is either available / absent / inadequate
Risk matrix are based on qualitative measure due to insufficient data to conduct quantitative measures Likelihood Explanation 1 Impossible / not known to have happened 2 Possible to occur 3 Certain / Highly possible to occur Severity Explanation 1 Life Altering Injury 2 Life Threatening Injury 3 Fatality SIF EXPOSURE MATRIX
SIF EXPOSURE MATRIX Result of Risk calculation will provide the level of SIF risk exposure. Low – 1-2 Medium - 3-4 High – 6-9 3 Certain 3 6 9 2 Possible 2 4 6 1 Not known 1 2 3 x 1 Life Altering 2 Life Threatening 3 Fatality All medium & high risk should be prioritized on monthly KPI tracking review
CASE STUDY. Calculate SIF exposure Hazard Existing Control Likelihood Severity Risk CASE 1. Employee working at Forming area. The formax operates automatically and continuously throughout the production and does not require any manual intervention. However, during running of chicken breaded product, the product tends to easily sticks onto the conveyor. Therefore, cleaning of conveyor is required. Tool is provided to be used by employee for the cleaning work so that employee does not need to put body parts into conveyor. The SOP states that conveyor must be stopped when cleaning activities is ongoing.
CASE STUDY. Calculate SIF exposure Hazard Existing Control Likelihood Severity Risk CASE 2. Employee is working at a raw material receiving area. After forklift has unloaded the raw material into the area, he is required to cut open the raw material plastic wrap using the provided cutting tools. Employee is required and provided with cut resistance glove.
CASE STUDY. Calculate SIF exposure Hazard Existing Control Likelihood Severity Risk CASE 3. Maintenance technician conducting repair work on auto packing machine. The machine requires changing of parts and therefore, safety machine covers are required to be opened. LOTO switches are available, and all technicians are provided with and trained on LOTO.
SIF PREVENTION & MONITORING Part 4
Three Pillar of Safety In general, safety is built on 3 pillars. All the pillar sits on safety culture as its foundation. Each pillar represent a line of defense. Hence, a barrier to prevent PSIF Developing SIF prevention means that we need to Continuously strengthen safety culture foundation Strengthen pillar Look for holes at each pillar & reconstruct
Developing an effective SIF prevention In general, each control that is defined is called as Barriers In common, there are 3 type of barrier Prevention Recovery Mitigation
Developing an effective SIF prevention In general, each control that is defined is called as Barriers Barrier-based safety approach is a specific are of knowledge In common, there are 3 type of barrier Prevention Recovery Mitigation SIF Recovery Barrier Preventive Barrier Mitigation Barrier Working at Height on elevated platform Purpose : To reduce severity of the accident consequences Purpose : to prevent risk from happening Purpose : to recover high risk activity where control has been lost Permit to Work Training Machine / tools assessment 1. PPE Stop Work Authority Compulsory pause & check
Developing an effective SIF prevention STEP 1 . Define an effective Prevention Barrier for each SIF As far as practicable, apply Hierarchy of Control as part of preventive control. Involve relevant parties to discuss and provide input
Developing an effective SIF prevention STEP 2 . Revisit existing & new control measure. Where required, apply ‘Fix measures’
Developing an effective SIF prevention STEP 3 . Safety Lead to define a definite timeline and target completion date for each of PSIF Category Goal Description Meets High Meets Comments WINNING WITH OUR TEAMS MEMBERS 30% Reduction in RIFR against 2021 baseline (Recordable Injuries Frequency Rate) 10% reduction 15% reduction Monthly tracking as per current process PSIF Management – each business unit to conduct 10 reviews per 1,000 TM’s, per month. (Potential Serious Injury or Fatality) Meet target Target plus 10% PSIF review document to be provided by 1 Dec. 2021. For Australia, due to small number TM’s at least 4 reviews per month.
Developing an effective SIF prevention STEP 4 . Ensuring Continuous learning & accountability Process Owner with help of Safety & PSIF Champion identify SIF & submit PSIF Champion validates SIF PSIF Champion assess SIF exposure risk Safety Lead develop into action plan & timeline Discussion with Process Owner to close action All parties should be made accountable to identify SIF and submit. Continuous Learning program should be conducted to gain awareness of SIF at all level PSIF Champion acts as a gate to ensure true SIF are identified and properly recorded Safety Lead should ensure the action is made visible and compelling to the process owner for gap closure. Continuous learning & promotion
TOOLS & REPORTING STRUCTURE Part 4
PSIF findings via inspection or any other programs Reviewed cases Submissions Safety Plant Leads to share reviewed cases quarterly Align understanding All BUs to review similar PSIF events Sharing & Alignment Present learnings to APAC LT on quarterly basis Review past preventive measures Updates Collaborate & Align
Developing an effective SIF prevention TOOLS 1. PSIF Validation Checklist To be used by process owner as a self-checklist To be sent to PSIF champions for validation & quantifying
Developing an effective SIF prevention TOOLS 2. Monthly PSIF Database To be used by PSIF committee to review and track PSIF To track KPI performance on PSIF