ES&H for Supervisors

FN000413

Agenda

Fermilab’s ES&H PolicyDefinitionsOccupational Injury HistorySupervisor ES&H ResponsibilitiesResourcesMedical Department

Fermilab’s ES&H Policy

Fermilab employees, subcontractors, and users will only conduct work and

operations in a safe and environmentally sound

manner.

Integrated ES&H Management Principles & Core Functions

Near Miss

An undesired event that, under slightly different circumstances, could have resulted in physical harm to personnel, equipment, material or product loss.

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

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

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

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)

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)

Supervisory Responsibilities

Supervisory Responsibilities

1. Accept that ES&H must compete with production for resources.

Pre

ven

tion

Productiont0

tn

new facility state facility event

Incide

nt

Bank

rupt

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Competing System Resources

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.

Anatomy of an Event

Incident

ErrorPrecursors

Vision, Beliefs, &

Values

LatentOrganizationalWeaknesses

Mission

Goals

Policies

Processes

Programs

FlawedDefenses

InitiatingAction

Vision, Beliefs, &

Values

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

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.

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

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the

Ris

ks

of O

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.

Fermilab Event Causes

Event Causes

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10

15

20

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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

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?

“…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.

“Rhino Horn” Lifting Fixture Failure

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

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

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

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

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!!

Hazard Analysis Steps

Job Site Walk DownAnalysis of the HazardsPre-job BriefingPerformance of the WorkPost Job ReviewHA Record Retention

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

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

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

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

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?

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?

Resources

Senior Safety OfficerEnvironmental Protection OfficerESH SectionFermilab ES&H Manual (FESHM)ESH Web Page

http://www-esh.fnal.gov/home/esh_home_page.html

Medical Department

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

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

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

Common Clues

AbsenteeismBehavioral Changes/Mood SwingsRecurring InjuriesOther?

If You Remember Nothing Else….

Report Work Injuries PromptlyAllow Medical Office to Help in

Managing Sick Leave IssuesAsk for Medical Office Help FreelyConsultative Process

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