OSHA Top Fatalities/Serious Injury and Fatality (SIF) Activityesafetyline.com/eei/conference s/2017spring/summit/SIF.pdf · Injury Prevention Considerations •Traditional improvement

Gregg Slintak, Consolidated Edison Co.

Lee Boulanger, Par Electrical Contractors, Inc.

OSHA Top Fatalities/Serious

Injury and Fatality (SIF) Activity

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Severe Injury and Fatality Prevention,

Precursor Implementation

Version: 041217

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Injury Prevention Considerations

• Traditional improvement strategies are based on Heinrich’s Law

• Ratios describe event frequency

• Reductions at base of triangle translate to reductions at top

• Current research demonstrates lack of correlation between low and high severity events

• Reducing less serious incidents may not necessarily reduce SIF event frequency

Fatalities

Severe Injuries

Lost Time Injuries

Medical Treatment

Near Misses

Conditions & Behaviors

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ConEd Examples Management Tools

• Gas on the fly • Live electrical work • Trenching • Transmission tower work • Crane operations

Standards and Planning • Specs and Procedures • Job Planning • Job Briefing

• Damaged equipment • Backfeed condition • Changing plan on the fly • Infrequent task • Uncontrolled line of fire

• Arc flash event due to no testing

• Dropped load due to damaged winch line

• Fall from roof edge

Performance Expectations • Positive Recognition • Rules We Live By

Breaking the Event Sequence

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Is this a high- energy job or

task?

Should work

proceed?

What precursors are

present?

CII Precursor Analysis Approach

Identify Precursors

Experiment to Test

Precursors

Validate with Multiple Groups

Simplified Tool

Predicting Severe Events

Note: Material from CII RT-321’s “Using Precursor Analysis to Prevent Low-frequency High-impact Events, Including Fatalities,” August 2016

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Program Alignment and

Interconnection

•Reference JSA

•Identify additional energy/barriers

•Post-job review

•Feedback

•Reference JSA/JB

•Identify energy/barrier gaps, and opportunities

•Data Platform

•Feedback

•Identify energy and barriers

•Challenge and validate controls

•JSSE results

•Post-job reviews

•Event outcomes

•Close Calls

•Research Findings

Corrective Actions

Job Safety Analysis

Job Briefing Job Site Safety

Exchange

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Precursors

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Step 1: Precursor Use in JSSEs

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Poor Work Planning

Unfamiliar with applicable procedure/specification

Unclear that changes require stop for re-briefing

Job briefing not performed, or low quality

Productivity Safety Stressors

Any safety violations visible

Physically fatigued; <9-hrs sleep in previous 48-hrs

Unusual management or customer focus on job

Shift exceeds 12-hrs

Associated with RWLBs and significant events

Vulnerability to High Energy

High energy hazard not recognized or understood

Accessible high energy hazard not controlled

Deviating from work plan / briefing

Outside Safety Influences

Multiple crews performing work in parallel

Eyes/mind on other than task at hand

Safety Rep. not party to planning or briefing; no visit

Supervisor not party to planning or briefing; no visit

Single person operation in high energy environment

CII

RT3

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Pre

curs

ors

Key JSSE Factors

Translates

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Precursors in JSSE System

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Figure 1: Existing JSSE data collection approach (excerpt) Figure 2: New approach (excerpt)

• Free-form text for comments about given job aspects • Descriptors highlight items of concern (e.g., precursors) for observers

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Step 2: Precursor Use in Job Briefings

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Poor Work Planning

Understand applicable procedures/specifications

Will stop for changes to rethink and re-brief

Final questions asked and answered

Productivity Safety Stressors

Any safety violations visible

Rested and physically ready for task demands

No perceptions of unusual emphasis or push

Shift duration <12-hrs; prior shift <16-hrs

--

Vulnerability to High Energy

High energy hazards second-checked

High energy lines of fire understood

Committed to the work plan

Outside Safety Influences

Coordinated with all crews working in parallel

Everyone focused; eyes and mind on task

--

Discussed job and reviewed plan with supervisor

--

CII

RT3

21

Pre

curs

ors

Su

ccess Factors

Translates

Precursors in Job Briefing Forms

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What we will do

during work:

Specific error

prevention

tools are

identified for

job at hand,

and reviewed.

Precursors

restated as

positives for

final check of

crew dynamic

before briefing

conclusion.

Sample Job Briefing Form, Excerpt

Next Steps Toward Zero Harm

• Reposition high severity injuries for more dedicated focus

• Align existing program elements to leverage precursors

• Build awareness for precursors among workforce

• Identify actionable precursors, specific to utility industry work

• Develop metrics that support the severity-based focus shift

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Good Catch Program

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ARE PREVENTABLE.

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• GOOD CATCHES WILL BE SUBMITTED THROUGH THE

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Good Catch Program

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ARE PREVENTABLE.

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• GOOD CATCHES WILL BE SUBMITTED THROUGH THE

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