SMA SAFETY SUMMIT 2020BETHUNE MINE

WORKING ON LIVE EQUIPMENT - HPNM

Feb.27, 2020Cody Guskjolen/Lou Maisonneuve

SUMMARY:

1. BACKGROUND

2. INCIDENT OVERVIEW

3. ROOT CAUSES

4. CORRECTIVE ACTIONS

5. PERSONAL MINDSET

BACKGROUND

BACKGROUND

• 2014 – 2017 – Construction phase LOTO/Permit Process

• 2017 – KSPC LOTO/Permit process adapted from construction

• 2018 – Revision of LOTO/Permit process

• Multiple Production areas with different standards applied

• People using their past experience when interpreting the procedure

LOTO and Safe Work Permit Procedures

Procedure

Wet Process

Wellfield

Utilities

Dry Process

BACKGROUND

• Industrial dryer system offline for 4 days of maintenance• Incident occurred on the last day of the scheduled

outage

• Routine pump maintenance

• Short on operations resources on the day of incident

Leading up to the High Potential Near Miss

INCIDENT OVERVIEW

TIMELINE

• Millwright returns to permit desk at end of shift to inform operations that the job would extend a day

• During permit close out the shift supervisor identifies the pumps were not locked out

• Locks were applied to the Industrial Centrate tank LOTO that had been ongoing for 4 days

• The pump maintenance was on the Industrial LeachCentrate tank which was still live and had not been part of the outage up to date

• Millwrights worked on the live pumps for ~8 hours

December 5, 2019

ROOT CAUSES

ROOT CAUSES

• The procedure was interpreted differently by the areas

• Multiple procedural steps were missed by the permit issuer and permit receiver

LOTO/SWP procedures not followed

Permit issuer must field walkdown all jobs requiring a LOTOPermit issuer shall ensure zero energyPermit issuer and receiver shall discuss the scope of workPermit receiver shall confirm zero energy before signing SWPFLHA completed in field – Zero energy check

ROOT CAUSES

• Maintenance schedule – break in work

• Inadequate permit notice

• Daily operations personnel lack of visibility to the maintenance schedule

• Poor quality discussion around the scope of work

Lack of communication

ROOT CAUSES

• Permit issuers putting pressure on themselves to get permits issued quickly to get work going• “Morning permit RUSH”

• Permit receivers putting pressure on themselves to get in the field and start their work• Perceived negative is people are waiting at the desk

Perceived pressure

ROOT CAUSES

• Permit issuer was working on a laptop at the permit desk, which was a common practice

• In between issuing permits they were working on a procedure that was needed for a task that had to be performed that day • Impacts of operations resource shortage

Multi-tasking

ROOT CAUSESNegative Impacts of Multi-tasking

• 50% longer to complete a task

• 50% increase in errors

• Increases stress

• Increases anxiety

• Increases distractions

• 40% decrease in productivity

• 15 point IQ drop

• Reduces focus

• Reduces short and long term memory

CORRECTIVE ACTIONS

CORRECTIVE ACTIONS

• Re-training on the newest version of the LOTO and safe work permit procedures

• Implement a job aid to help permit issuers ask the right questions while reviewing the safe work permit

• Audit the process

• Cross-area alignment

• Simplify existing procedures and job aids

Procedures

CORRECTIVE ACTIONS

• Daily maintenance scheduling

• Follow the weekly schedule

• Limit unnecessary break in work

• Make the schedule visible to all permit issuers and receivers

• Submit permits in advance

• Daily operation/maintenance communication

Better Communication

CORRECTIVE ACTIONS

• Continuous reminders about taking adequate time

• Signage

• Extra support at peak times

• Improve permit information quality, refuse inadequate permits

• Target 5% (instead of the current 1%) of time being spent on planning and discussing the job

• Proper organization at the desk

Remove the pressure

CORRECTIVE ACTIONS

• Remove laptops from the permit desk

• Remove cell phones from the permit desk

• Focus on the current task at hand

Eliminate multi-tasking

PERSONAL MINDSET

PERSONAL MINDSET• Do you see the trends here? We have luck, assumption, non-conformity (not following procedures)

and taking short cuts. I’m going to round off the top 5 deadly sins of work place incidents, Multi tasking.

• I was working the permit desk the day of the incident and writing up a work procedure at the desk on my laptop between permits. I was looking for an operator in each of my areas as we were short that morning. I had also been on my personal phone with my wife as my son had been home sick all week and she had to miss the previous three days of work. I was trying to juggle all these and still trying to do permits when all this happened. Now I’m not up here to make excuses, I’m simply stating that life does happen, and when it does, we should take a step back.

• Once I realized what happen and it all set in, I realized just how serious this was and how bad it could have been. I was up almost all-night that night and most of Friday night trying to wrap my head around this and how it happened. I really took this home and wrongfully took out my stress on my family. The severity of this miss could have caused two workers and their family’s serious consequences.

PERSONAL MINDSET• Having said that, Monday Dec 9th, we had a safety stand down with every employee on site that

day minus our senior leaders and I stepped up to share the reality of this serious event. I tried to take ownership of this whole incident as I was the one who issued the permit to go do the job. I wanted to show that I am accountable for my actions to my team and leaders.

• This was a major near miss on multiple fronts and highlights how serious assumptions are without having a detailed conversation on the scope of work can be. As a group we were all not following the full lockout procedure and got lucky again… but luck runs out eventually. Hopefully this will bring to light just how important it is to follow proper procedures and eliminating multitasking. I wasn’t fully committed to my task that day and because of trying to do too much I was in auto pilot mode.

• My ask from you is to take this back to your teams and share just how important it truly is to recognise these red flags, avoid multi tasking and always follow the proper procedures.

ks-potashcanada.com

THANK YOU