presented by eric glass ehs ul health safety
TRANSCRIPT
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2012 USER SUMMIT
Journey to a Healthier and Safer Workplace
2012 USER SUMMIT
Presented By
Eric GlassEHS Advisor
UL Workplace Health & Safety
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2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
2012 USER SUMMIT
U.S.S. FORRESTAL FIREWorst Aircraft Carrier Disaster Post WWII
134 KILLED 161 INJURED
4 MIA $72M IN DAMAGES
21 AIRCRAFT LOST
40 AIRCRAFT UNSERVICABLE
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Anatomy of the Event
Rocket Fired From #110
Strikes #405 fuel tank; spills/flashes
1st bomb explodes in 1:34 seconds
9 Explosions within 5 minutes
Primary Fire Party Wiped Out
Secondary Fire Party Ineffective
Unexploded Ordnance Below
Fire Raged for 2.0 days
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“Cause” of the Peril
• 5.0 Zuni Rocket
• “Electrical issues with the plane”
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2012 USER SUMMITTrial By Fire “Lessons”
“No one will ever know the full story. Even with written
testimony , the passage of time has a way of veiling or
obscuring material facts.”.”
Lack of SafetyStrong BackingCasual AttitudesOut of uniformProtective GearNot belonging
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Aftermath……“A crate of fireworks with a bonfire on top”
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Formal Inquiry Review
SOPs Altered For CombatApproved By Navy’s ORI
BUTFlight Deck SOPs Written for Peace Time
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Formal Inquiry Review
WESTPAC & ATLANTIC SOPS DIFFERShip was in Atlantic fleet
BUTOperating Under WestPac Jurisdiction
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Formal Inquiry Review
Request DeniedCaptain Requested Fire Training
ANDRequest Denied
(even after the ship returned to port after the incident)
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Formal Inquiry Review
Oriskany Report Not AvailableCould not access Oriskany Investigation
SOTraining Created from Readers Digest Article
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Formal Inquiry Review
Zuni Rockets System FragileSince they were fragile and hazardous
THENWeren’t recommended for carrier ops
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Post-Forrestal
Information Flow/CommunicationTraining, Techniques, EquipmentShip DesignPersonal Protective EquipmentCrew TurnoverEmergency Breathing Apparatuses“Everyone is a Firefighter!”Fire TrucksLiquid O2 Plant On RailsAFFF Hi/Lo Caps
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AWARENESS TRAINING IN ACTION
2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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2012 USER SUMMIT
Will a “Forrestal” Happen At Your Organization?
• Are You Prepared?
• Have you taken measures to avoid it?
• Are you making the same mistakes?
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Complacency
Carelessness
Sloppiness Inaccuracy
Imprecision
NegligenceInattention
Stupid
Dumb
Poor Attitude
Doesn’t Care
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Employers:
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Employers:
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Employers:
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Employers:
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Organizations Are Responsible for:
LEARNING ENVIRONMENTOBSERVATIONS
NEAR MISSES
INCIDENTS/INJURIES/MISHAPS
2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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Danger Conditioning
Psychological
FACT:
More injuries and deaths
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Danger Conditioning
• Psychological• FACT: more injuries/deaths
happen to experienced employees taking shortcuts
• Less experienced employees tend to be more timid
• Without reinforcement, dangers become less and less in the mind of the worker
• Learning Based Organization• An environment of “never ending
discovery” to identify systems, policy and operational breakdowns that foster learning moments to improve the overall effectiveness and success of their organization
• Can you cite examples in your workplace of “danger conditioning”?
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FIGHTING “DANGER CONDITIONING”
• New employee training • Repetitive Subjects, different delivery
methods• Lessons Learned
• Observations• Near Misses• Incidents with Loss• Industry news
2012 USER SUMMIT
LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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Columbia Disaster
MAJOR CAUSE: FOAMRigid HierarchyLack of Ability to Report ConcernsCouldn’t Recommend “Broken Safety Culture”
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Continuous Improvement
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LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
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Continuous Improvement
Employee Involvement
Management Involvement
Communication
Action to Completion
World Class Safety Organization
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LEARNING OBJECTIVES
• The Wake-Up: USS Forrestal
• 3 Factors– Complacency
– Danger Conditioning
– Flaws in Continuous Improvement Programs
• Continuous Improvement
• Empowering Your Workforce– Involvement = Creativity
– Learning from Lessons to Improve Performance
2012 USER SUMMIT
U.S.S. FORRESTAL FIREWorst Aircraft Carrier Disaster Post WWII
134 KILLED 161 INJURED
4 MIA $72M IN DAMAGES
21 AIRCRAFT LOST
40 AIRCRAFT UNSERVICABLE
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“Changes” Made In Reaction Mode
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Total Quality Leadership (TQL)
• TQL implemented • Not universally
accepted• Effective where
accepted• Abandoned, but not
entirely• Foundation for
LEAN/SIX SIGMA
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“People want to do a good job, they need to be trained properly to fit into a process, and the
employee closest to the process probably knows the most about it and can tell you
what’s wrong with it.”
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Involvement = Creativity =Involvement
• Involvement– Early and often
– Avoid “reactive” involvement
– Feedback is key
– Oversight should not be “constrictive”
– Avoid “mandatory” involvement
• Creativity– Encourage “outside
the box” thinking
– No idea is absurd
– Train employees to be thinkers
– Encourage & Reward Thinkers
– Expose to outside operations
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Learning from Lessons
• Learning moments– Observations
– Near misses
– Injuries/illnesses
– “War Stories”
– Industry trends
– Inefficiencies
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Journey to a Healthier and Safer Workplace
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Questions?