Download - ES&H for Supervisors
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ES&H for Supervisors
FN000413
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Agenda
Fermilab’s ES&H PolicyDefinitionsOccupational Injury HistorySupervisor ES&H ResponsibilitiesResourcesMedical Department
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Fermilab’s ES&H Policy
Fermilab employees, subcontractors, and users will only conduct work and
operations in a safe and environmentally sound
manner.
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Integrated ES&H Management Principles & Core Functions
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Near Miss
An undesired event that, under slightly different circumstances, could have resulted in physical harm to personnel, equipment, material or product loss.
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First Aid Injury
A minor injury that does not require significant medical treatment non-prescription strength medication tetanus immunizations cleaning, and covering wounds hot or cold therapy elastic bandages
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Total Recordable Case Rate
Total Recordable Case (TRC) Requiring more than first aid
SuturesPrescription MedicationFracturesLost or Restricted Time
Total Recordable Case Rate (TRCR) (# TRC/hours worked) X 200,000
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Days Away, Restricted, or Transferred Cases
Days Away, Restricted, or Transferred (DART) Case TRC that results in work restrictions
that affect employees ability to do job “light duty” or lost time
DART Rate (#DART Cases/Hours
Worked)X200,000
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TRC Rate (employees + subs) History
FY97 5.45 (121 cases)
FY98 5.18 (115 cases)
FY98 4.31 (95 cases)
FY00 3.68 (84 cases)
FY01 4.13 (96 cases)
FY023.86 (90 cases)
FY031.53 (33 cases)
FY041.56 (32 cases)
FY051.25 (25 cases)
FY061.40 (27 cases)
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DART Rate (employees + subs) History
FY97 2.90 (67 cases)
FY982.21 (49 cases)
FY991.31 (29 cases)
FY001.84 (42 cases)
FY011.63 (38 cases)
FY022.32 (54 cases)
FY030.56 (12 cases)
FY040.54 (11 cases)
FY050.50 (10 cases)
FY060.30 (6 cases)
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Supervisory Responsibilities
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Supervisory Responsibilities
1. Accept that ES&H must compete with production for resources.
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Pre
ven
tion
Productiont0
tn
new facility state facility event
Incide
nt
Bank
rupt
cy
Competing System Resources
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Supervisory Responsibilities
2. Recognize that humans make errors, and that “human errors” are the cause of most incidents. Human errors represent unintended actions
or inactions that can result in an incident Try to understand the source of the errors,
so that they can be prevented.
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Anatomy of an Event
Incident
ErrorPrecursors
Vision, Beliefs, &
Values
LatentOrganizationalWeaknesses
Mission
Goals
Policies
Processes
Programs
FlawedDefenses
InitiatingAction
Vision, Beliefs, &
Values
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Limited short-term memory Personality conflicts
Mental shortcuts (biases) Lack of alternative indication
Inaccurate risk perception (Pollyanna) Unexpected equipment conditions
Mindset (“tuned” to see) Hidden system response
Complacency / Overconfidence Workarounds / OOS instruments
Assumptions (inaccurate mental picture) Confusing displays or controls
Habit patterns Changes / Departures from routine
Stress (limits attention) Distractions / Interruptions
Human NatureWork Environment
Illness / Fatigue Lack of or unclear standards
“Unsafe” attitude for critical task Unclear goals, roles, & responsibilities
Indistinct problem-solving skills Interpretation requirements
Lack of proficiency / Inexperience Irrecoverable acts
Imprecise communication habits Repetitive actions, monotonous
New technique not used before Simultaneous, multiple tasks
Lack of knowledge (mental model) High Workload (memory requirements)
Unfamiliarity w/ task / First time Time pressure (in a hurry)
Individual CapabilitiesTask Demands
Error Precursors short list
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Example
A waste technician picked up a bag of beryllium contaminated materials scheduled for pickup. He felt a puncture on his left little finger.
An “Exacto Knife” blade was found sticking out the side of the bag.
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Performance Modes
KBPatterns
RBIf - Then
SBAuto
Familiarity (w/ task)Low High
High
Low
Att
enti
on
(to
task
)
Inattention
Misinterpretation
Inaccurate Mental Picture
Sou
rce:
Jam
es R
easo
n. M
anag
ing
the
Ris
ks
of O
rgan
izat
iona
l Acc
iden
ts,
1998
.
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Fermilab Event Causes
Event Causes
0
5
10
15
20
25
30
Nu
mb
er
of
Cau
ses
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Supervisory Responsibilities
3. Keep Communication Chains Open Go out and watch people work Discuss why worker’s actions are safe or
unsafe - prompt feedback is important Ask questions to help identify opportunities Compliment those who are reducing hazards Review opportunities to minimize waste and
prevent pollution
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Supervisory Responsibilities
4. Look out for System Creep Are processes allowed to change through a
series of incremental shifts without review?
Are non-compliant practices and/or un-reviewed workarounds tolerated?
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“…No debris shall emanate from the critical zone of the External Tank on the launch pad or during ascent…”
Ground System Specification Book –
Shuttle Design Requirements
After 113 shuttle missions, foam shedding, debris impacts, and TPS tile damage came to be regarded as only a routine maintenance concern.
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“Rhino Horn” Lifting Fixture Failure
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Supervisor Responsibilities
5. Set a personal example Clean office Wear Personal Protective
Equipment (PPE) Be up to date on your training
Try to take the training with your employees
Follow all work rules Enforce them in your area
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Supervisor Responsibilities
5. Set A Personal Example Maintain general knowledge of Fermilab
ES&H Manual Encourage reporting of safety concerns –
FOLLOW UP! Encourage dissemination of waste saving
opportunities Make ES&H part of every meeting
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Supervisor Responsibilities
6. Get Employees Established in Medical Surveillance Program
Complete Work Activity Analysis Form (WAAF) http://www-esh.fnal.gov/pls/default/WAAF.html
Review WAAF annually or when job changes
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Supervisory Responsibilities
7. Training is Important Perform Individual Training Needs Assessment
(ITNA) on each employee at start of assignment. https://www-esh.fnal.gov/pls/fnal_user/itna.html
Review ITNA when job changes or at least annually
Make sure employee receives all required training http://www-esh.fnal.gov/pls/default/itp.html
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Supervisory Responsibilities
8. Perform Hazard Analyses Do not allow anyone to
perform a task without assuring yourself that they know how to do the job safely and identify waste reduction and pollution prevention opportunities
FESHM 2060 provide guidance http://www-esh.fnal.gov/FESHM/2000/2060.htm
Include employees!!
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Hazard Analysis Steps
Job Site Walk DownAnalysis of the HazardsPre-job BriefingPerformance of the WorkPost Job ReviewHA Record Retention
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Pre-Job Briefing
SAFER Dialogue
S – Summarize critical stepsA – Anticipate error trapsF – Foresee consequencesE – Evaluate defenses R – Review operating experience
IndividualCapabilities
TaskDemands
HumanNature
WorkEnvironment
Error-likelySituations
PotentialConsequences
FlawedDefenses
CriticalStepsTask
Preview
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Error-Reduction TechniquesConservative decision-making
Three-way communication
Concurrent verification
Independent verification
Meetings
Peer-checking
Placekeeping
Prejob Briefing
Problem-solving
Procedure use & adherence
Questioning attitude
Self-checking
Stop & collaborate
Two minute walkdown
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Supervisory Responsibilities
9. Respond to All Incidents and “Near Miss” Immediately
Dial 3131 or send employee to Medical Department
Notify management and Senior Safety Officer Review Form-5 (
http://www-esh.fnal.gov/FESHM/3000/3020A1_2Form.pdf) with employee
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Supervisory Responsibilities
9. Respond to all incidents and “near miss” immediately
Begin investigation immediately. Complete Supervisory Incident Investigation Report (http://www-esh.fnal.gov/FESHM/3000/3020A1_2Form.pdf)
Get employee input on how to avoid recurrence Implement corrective actions promptly Take Incident Investigation for Supervisors
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Incident InvestigationQuestions to ask:
What do I know? How do I know it? So What? What more do I need to know? What was individuals’ perspective What management system weaknesses drove the
actions? What lesson did I learn?
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Yes
No Yes
Yes
Yes
NoNoNo
Yes No
Culpability Evaluation Flowchart
Intentional Act Intentional Act (not an error)(not an error)
Intentional Act Intentional Act (not an error)(not an error)
Were expectations reasonable, available,
workable, intelligible, and correct?
Were expectations reasonable, available,
workable, intelligible, and correct?
Deficiencies intraining, selection,
assignment, or experience?
Deficiencies intraining, selection,
assignment, or experience?
Blameless Blameless errorerror
Blameless Blameless errorerror
CorrectiveCorrectivetraining ortraining or
otherotherinterventionintervention
may be may be warrantedwarranted
CorrectiveCorrectivetraining ortraining or
otherotherinterventionintervention
may be may be warrantedwarranted
PossiblePossiblenegligentnegligent
errorerror
PossiblePossiblenegligentnegligent
errorerror
System System inducedinduced
errorerror
System System inducedinduced
errorerror
PossiblePossiblerecklessrecklessviolationviolation
PossiblePossiblerecklessrecklessviolationviolation
Organization Organization induced induced violationviolation
Organization Organization induced induced violationviolation
Discipline may be requiredAction may be necessaryFix process Issue
YesNoYes
Yes
Diminishingculpability
NoWere actions as intended?
Were actions as intended?
Knowingly violate expectations?
Knowingly violate expectations?
Passsubstitution
test?
Passsubstitution
test?
History ofhuman
performance problems?
History ofhuman
performance problems?
Were consequences as intended?
Were consequences as intended?
Evaluate OrganizationalProcesses & Management /
Supervisory Methods
Evaluate OrganizationalProcesses & Management /
Supervisory Methods
NoSelf
reported?
Selfreported?
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Resources
Senior Safety OfficerEnvironmental Protection OfficerESH SectionFermilab ES&H Manual (FESHM)ESH Web Page
http://www-esh.fnal.gov/home/esh_home_page.html
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Medical Department
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Functions of Fermilab Medical Office
Health Risk Analysis (“check ups”)Surveillance (ODH, CDL, lead worker, ….)Work Connected Injuries ManagementSick Leave AdministrationOther
Consultations Workplace Substance Abuse Issues
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How Can the Fermilab Medical Office Help You? (as Supervisor)
Interpret/Translate Notes from Outside Doctors
Define Worker’s Limitations due to Medical Conditions
Help Create a Plan of Action in Challenging Cases
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Coping With Substance Abuse
5–10% of Adult Population in U.S. Meets Criteria for Alcohol Abuse/Dependence
20-50% of Hospitalized Patients and 15-20% of Outpatients Suffer from Substance Abuse Disorder
¾ of Drinkers Experience No Serious Consequences from Alcohol Use
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Common Clues
AbsenteeismBehavioral Changes/Mood SwingsRecurring InjuriesOther?
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If You Remember Nothing Else….
Report Work Injuries PromptlyAllow Medical Office to Help in
Managing Sick Leave IssuesAsk for Medical Office Help FreelyConsultative Process
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Conclusion
Questions? Ask your SSO: AD – John Anderson – 4973 BS/FI – Greg Mitchell – 8002 CD – Amy Pavnica - 8493 DI/ES – John Cassidy – 8223 FE/WR – Mike Bonkalski – 8448 PD – Martha Heflin – 3511 TD – Rich Ruthe - 5424