Focus on Safety ’08: Incident Notification and …...5 Incidents Since Oct. 2007 LTA = Less than...
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Creating a Safe and Sustainable Environment for Science 1 Focus on Safety ’08: Incident Notification and Prevention Aug 2008
Transcript of Focus on Safety ’08: Incident Notification and …...5 Incidents Since Oct. 2007 LTA = Less than...
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Focus on Safety ’08: Incident Notification and Prevention
Aug 2008
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Objectives
• Learn from incidents, investigations, causal analysis, and corrective actions
• Describe recent SLAC incident trends• Review the new Incident Reporting and
Notification Protocol• Participate in Injury Prevention
Brainstorming Process
Presenter
Presentation Notes
SLAC has recently undergone a review of it’s incident notification and investigation process and we’ve identified several opportunities for improvement. These improvements are intended to enhance our ability to rapidly and effectively respond to emergencies and implement a thorough and useful investigation process to prevent recurrence. This year’s Focus on Safety meetings will cover the new notification process and expectations for incident investigations and identifying effective corrective actions. Then, just as importantly, we’ll do a brainstorming exercise to identify some injury prevention ideas in our department. From October 1, 2007 through July 15, 2008 there have been 17 people injured at SLAC, 12 of these injuries have been so severe that the time away from full duty was required. Our goal is to prevent incidents that produce these injuries from ever happening.
Creating a Safe and Sustainable Environment for Science
• Use ISEMS• Healthful & safe workplace• Sustainable operations• ALARA• Integration of ES&H concepts
into all phases of operation• Compliance and Best
Management Practices• Line Management of ES&H• Identify & stop unsafe activities• Learn from successes and
deviations from expected outcomes, and encourages workers to both report these instances and provide feedback
SLAC ES&H Policy
Presenter
Presentation Notes
You should have all seen the newly revised SLAC ES&H Policy. The policy covers ISEMS, healthy and safe workplace, sustainability, the ALARA concept for radiation operations, and integration of ES&H concepts into all phases of operations (from initial design all the way to decommissioning). The policy also reinforces the concept of Line Management responsibility for ES&H and that anyone has the authority and responsibility to stop work activities that are unsafe. The last paragraph of the policy is directly applicable to today’s topic. We have to learn from our experiences otherwise we run the risk of having repeat instances of accidents and incidents. There is no excuse for not learning from our experience and using the lessons learned to reduce the risk of incidents.
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Review of Recent Events
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Incidents Since Oct. 2007
LTA = Less than adequate; ORPS = DOE Occurrence Reporting and Processing System
Presenter
Presentation Notes
During the first 9 months of this fiscal year, SLAC experienced 29 incidents that were serious enough that either individuals received injuries beyond first aid or were significant enough to be reported to the DOE. As you can see from this table and the next, there are many causes, and all of our cases have an element of management problems that were identified as a contributing causal factor and many of them had what the DOE refers to as “human performance issues,” or what we used to call “mind off task.” Clearly we need to do a better job of focusing on the work we do, communicating our concerns to our managers, and following-up. Management is taking additional actions to increase awareness, provide training, and improve reporting, investigations and actions to prevent recurrence. This session is part of these improvement actions.
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Incidents Since Oct. 2007
FY 08 Data - TRC = 17, DART = 12, First Aid = 30 as of July 1, 2008
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Incident Type
Incidents by Type (since Oct '07)
02468
1012141618
InjuryElectr
ical F
ireConstru
ction
SpillVeh
icle
Pressur
e
Misc.
Presenter
Presentation Notes
The results of these incidents show that the majority have resulted in injuries (17 cases). We’ve also had 4 electrical fire/smoke incidents, and a couple each of construction, spills, and vehicle incidents. When we analyze the incidents, you can you look at the 5 core functions of ISMS and see where failures in the core functions contributed to the event. At the moment, it appears that our analysis of the hazards we face is less than adequate. However, we’ve been discovering that the thoroughness with which we do our investigations needs improvement.
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Concerns with Existing Reporting• Too many pathways of notification• Confusion over what should be
notified• Delays in reporting• Confusion over to whom notification
should be made– Reluctance to call 911
• Confusion over when notification should be made
• Ineffective use of emergency resources
• Delays in investigation process• Management being surprised by
incidents after the fact• Quality of ORPS notification reports
Presenter
Presentation Notes
During the Spring of this year, we experienced an unusually high number of incidents and during that period it became apparent that we were not doing a good job of efficiently reporting incidents. This chart shows all of the various pathways that notifications were taking. As you can see, it was pretty confusing. With all these pathways, there was confusion and delays. As you can imagine, delays in reporting an emergency can have significant consequences. We all know that if there’s a fire and visible flames showing we should call 911. However, it was apparently unclear what the best way of communicating a lesser level emergency. So after, analyzing this communication process, we’ve decided it’s time for a simplified and improved notification process.
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New Reporting Protocol and Thresholds
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Event Reporting Badge Card for Employees, Users, Subcontractors
Presenter
Presentation Notes
All employees, users, and subcontractors that have badges are receiving the following badge cards to attach to your badge. In addition, Security will now be handing out a one page Safety & Security brochure to all visitors coming through the gate. [NOTE: PASS OUT THE BADGE CARDS AND A COPY OF THE SAFETY & SECURITY BROCHURE]. Let’s take a look at these before you attach it to your badge.
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Incident Notification - Life Threat• For life threatening incidents, always call 911
– Examples include: incidents involving severe injuries, significant amounts of smoke, a fire, an explosion or a large release of hazardous materials, dangerous law enforcement situations
• Calling Sequence1. 911 will roll emergency responders (Fire
& EMS)2. ext. 5555 will activate internal response
and notification• Via mobile phone: 650-926-5555
3. Your supervisor• Call from safe location; provide detailed
information and where you will meet responders
Presenter
Presentation Notes
If you observe a life threatening situation, your first step is to call 911. You can either dial 911 or 9,911…SLAC’s phone system will still recognize it as an emergency call. When you do so from a land-line, your call will go to the Palo Alto emergency dispatch center, but SLAC Security will also know that 911 has been called and will identify the exact phone from which the call was placed. What constitutes a life-threatening situation? Examples include incidents involving severe injuries, significant amounts of smoke, a fire, an explosion or a large release of hazardous materials. Severe injuries include unconsciousness, chest pain, shortness of breath, severe bleeding, altered mental state, symptoms of stroke, burns, and broken bones. Calling 911 will activate emergency responders which include PAFD Engine 7 (on-site) and ambulance paramedics. Although land-line 911 calls notify Security that there is an emergency call, they cannot monitor the details of the call. So, after you are done calling 911, you should then immediately call our new internal emergency number, extension 5555. The Security gate on Sand Hill Road is staffed 24 x 7 and Security will answer the call. You will be asked many of the same questions that the 911 dispatcher asked, but please provide all of the requested information. This will allow us to effectively start the internal emergency notifications so SLAC can manage the situation. If you are calling 911 from a cell phone, where your call routes is dependent upon where you are on the site. In some areas it may go to Palo Alto, in others it may go to San Mateo County, in others it may go the CHP dispatch center. You need to make sure you clearly communicate that you are calling from the Stanford Linear Accelerator Center and the nature of the emergency. Unlike a call from a land-line, SLAC does not receive notification that a 911 call was placed. After you are done with 911, immediately call 650-926-5555 and provide Security with the appropriate information. After you have made the notifications, you should then let your supervisor now. Make sure you are in a safe location when you are making these calls. Also, it is important that you communicate where you will meet the emergency responders when they arrive. Face-to-face communication when they arrive is important.
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Incident Notification – Non-Life Threat• For all Non-Life Threatening incidents:
– Inform your supervisor first• For Injuries/Illnesses:
– During SLAC Clinic hours (8 AM-4:30 PM), report to clinic for treatment
– After SLAC Clinic hours, call ext. 5555 for instructions from Security on what clinic to go to
• For Non-Life Threatening Chemical or Radiation incidents and Facilities or Equipment Damage:– Call ext. 5555; needed to activate
internal response, reporting and investigation processes
• Whenever in doubt call 911 or Security at extension 5555
Presenter
Presentation Notes
Non-life threatening situations also need reporting, but won’t involve a 911 call. I’ll describe examples in the next slides. For non-life threatening situations, the first person you should notify is your supervisor, or for users and subcontractors, your SLAC point-of-contact or university technical representative. However, if you can’t do so in a reasonable amount of time (use your best judgment based on the nature of the incident), proceed to the next step. For medical issues, the next step is to go to the SLAC Medical Clinic during normal clinic hours. This is from 8 AM until 4:30 PM. This applies to ALL people on SLAC premises that have an immediate medical need (SLAC employees, DOE employees, visitors, subcontractors, users, and so on) {EXCEPTION FOR LCLS: TURNER CONSTRUCTION HAS THEIR OWN ON-SITE MEDICAL GROUP AT THE CONSTRUCTION SITE}. To repeat, anyone on SLAC property, if they need immediate medical attention, is to use the SLAC Medical Clinic between the hours of 8:00 AM and 4:40 PM. If the situation occurs at other times, you should contact ext. 5555 and inform them of the nature of the medical problem. SLAC Security will have a detailed procedure that they will use to refer you to the appropriate nearby medical clinic, or Stanford Hospital Emergency Room, if warranted. It’s important that this step be followed to ensure that you receive the appropriate care and to ensure that we are aware that there was an incident. For other types of incidents, notify your supervisor first, then call ext. 5555 to give them the appropriate information. This could include things like small spills or radiation incidents, or reporting facilities or equipment damage. It is important to note: WHENEVER THERE IS DOUBT, JUST MAKE THE CALL. If it isn’t an emergency, we are still better off knowing than having an emergency we didn’t know about.
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Incident Notification: Additional Details
• Non-life threatening situations (notify supervisor, then ext. 5555):– Unusual odors
• Note: suspected natural gas leak call 911.– Any unplanned environmental release of ANY liquid,
solid or gas. (Viz., OUTDOORS or to INDOOR AIR OR DRAINS)
– Small chemical releases • Guideline: spills of hazardous materials less than 1 pint/1 pound
& ability to clean up safely can be done so locally; otherwise, should be reported as an emergency
– If in doubt, call ext. 5555 or 911
– Alarm notifications (audible and/or visual)
Presenter
Presentation Notes
What are some examples of other non-life threatening emergencies? Unusual odors, for example an “electrical” smell or some other odor. If you think it’s a natural gas leak, don’t wait…call 911. Any unplanned release of any hazardous material to the environment needs to be reported. Anything other than rainwater observed going into a storm drain must be reported. Large chemical releases are a 911-reportable event. What about smaller ones? A very small scale chemical spill may be cleaned up by local personnel if they have the equipment, training and procedures to do so. For example a few drops of a spilled solvent in a laboratory hood in a chemical lab would not be an emergency. As a rough guide, if you have a spill less than 1 pint or 1 pound and you have the equipment and training to do so safely, it can be cleaned up by local lab personnel. If it’s greater than that amount, if you don’t have the necessary equipment or training, or if it’s escaped to the environment, it should be reported. Again, if in doubt, report it! If you hear an audible, or see a visible alarm notification, call ext. 5555 and report it. Most of our alarm systems are automatically monitored, but it will be beneficial to get additional information from someone in the area. If you need to evacuate, do so and call from a safe location.
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Incident Notification: Additional Details
• Non-life threatening situations, cont.:– Suspicious activities– Suspect/counterfeit and defective items or materials– Loss of radioactive material or discovery of
unaccounted for radioactive material– Unexpected short term radiation exposures or
contamination– Damage to facilities or equipment that affect safe
operations (e.g., utility strikes, significant electrical events, etc.)
• Disaster information update:– SLAC Information Hotline: 1-877-447-SLAC (7522)
Presenter
Presentation Notes
Suspicious activities such as someone seen climbing a perimeter fence or a suspected theft should be reported to Security through ext. 5555. Certain situations require investigations for both our own purposes and under DOE orders and regulations. Reporting these to ext. 5555 will initiate that process. These situations include: If you become aware of any suspect, counterfeit or mission critical defective items or materials Loss of radioactive materials or the discovery of an unaccounted for radioactive material Unexpected short term radiation exposures If there is an event that results in damage to facilities or operational equipment that affects safe operations, ext. 5555 should be called. Examples might include striking a utility line during an excavation activity or a piece of electrical equipment experiencing an unexpected problem like shorting out. On the back of everyone’s picture ID badge, there is also a disaster hotline number. In the event of a major disaster that might temporarily shut down lab operations, a recorded message will be placed by HR on the hotline. All staff will be directed to check that message for specific instructions.
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Normal Operations Security Contact
• Examples of issues to contact Security at ext. 2551:– Badging issues– Traffic control– Escorts to and from offices and/or vehicles – Vehicle accidents (without injuries) / vehicle
damage– Building or office unlock requests – Theft reports– Stores access after hours
• Lost & Found: call ext. 3806
Presenter
Presentation Notes
The regular Security phone number, ext. 2551 should still be used for non-emergency situations. These include: Badging issues Traffic control Escorts to and from offices and/or vehicles at night Vehicle accidents (without injuries) or reports of vehicle damage Building or office unlock requests Theft reports Access to Stores after hours If you are reporting or enquiring about a lost and found issue, the phone number is ext. 3806.
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In short, for PPA
• For an ambulance or a cleanup team:– Call 911, then 5555 from a land line, then
Frank O’Neill at 5300• For an injury:
– Go to supervisor, then Medical (daytime) or call 5555 (off hours)
– Call Frank O’Neill, 5300
Presenter
Presentation Notes
The regular Security phone number, ext. 2551 should still be used for non-emergency situations. These include: Badging issues Traffic control Escorts to and from offices and/or vehicles at night Vehicle accidents (without injuries) or reports of vehicle damage Building or office unlock requests Theft reports Access to Stores after hours If you are reporting or enquiring about a lost and found issue, the phone number is ext. 3806.
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Incident Notification and Investigation Badge Card for Supervisors
Presenter
Presentation Notes
In addition to notification changes, we are improving the investigation process. All supervisory personnel will be receiving this card as well. {Note: each Department can figure our which people should receive this card and how to distribute}
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Incident Investigation – Day 1 Actions• First and always - ensure you and
others are safe, i.e., GET OUT OF AREA
• Make notifications per the Notification Protocol, then call Frank O’Neill at 5300.
• Ensure that medical treatment is provided to those in need
• Secure the scene and help preserve evidence
• Security will notify the on-call Facility Manager Designee (FMD) and others are notified as needed.
• The supervisor starts completing the SU-17, SLAC Occupational Accident Report form.
Presenter
Presentation Notes
This card covers all the major steps from Day 1 to Day 3 after an incident. The highlighted items correspond to issues that supervisors and managers will be responsible for. Prompt initiation of investigation serves several purposes. First of all, any evidence at the scene is less likely to be disturbed and the memories of witnesses will be fresh. Furthermore, it results in improved communications of the facts within SLAC and between SLAC and the DOE. First and always, ensure that everyone is safe. If the scene is not safe and secure, not one should be there. The next step is to make sure that the notification steps we just discussed are completed. Next, ensure that any needed medical treatment is initiated. Keep people out of the area and make sure evidence is preserved. For example, moving the equipment around may make it difficult to recreate the setup that may have caused or contributed to the incident. After ext. 5555 is notified, Security will contact the on-call Facility Manager Designee (rotates between Brian Sherin, Ralph Kerwin, and Liam Robinson). Other key individuals within SLAC and the DOE will also be notified depending on the type and level of the emergency. Supervisors will need to start the SU-17 SLAC Occupational Accident Report form to document initial information.
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Investigations – Days 2 and 3 Actions• Day 2
– The Incident Investigation Program Manager works with the Facility Manager to determine DOE occurrence reporting requirements and submits preliminary notification report if needed.
– Management is briefed and an ORPS Investigation may be formed
– Supervisors performing their investigation should request assistance from Frank O’Neill, x5300.
• Day 3– SU-17 finalized and submitted and
management is briefed– The Site Office is briefed and SLAC and
DOE ORPS are updated as needed.• Approximately 1 week: Incident Assistance
Review Team will contact supervisor
Presenter
Presentation Notes
During the second day, further details will be gathered and a decision is made as to whether the incident is reportable to the DOE under it’s “ORPS” system. For the supervisor, further investigation should be conducted in order to finish the first draft of the SU-17 report on the third working day. When the report is complete, it should be reviewed with the ALD. It should then be submitted to the Incident Investigation Program Manager in ES&H. Appropriate corrective actions will be entered into CATS to be tracked to completion. Within a week of the incident, the responsible line manager will receive an invitation from the Incident Assistance Review Team to go through the findings of the investigation and the report.
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Brainstorming: Injury Prevention in Our Department
Presenter
Presentation Notes
This section of Focus on Safety ’08 is intended to get everyone in the Department thinking about injury prevention. The following slides are a series of questions that should be opened up for brainstorming. Some rules of brainstorming to consider: There are no dumb ideas. Period. Ideas can be evaluated later for practicality and solutions. This can be one of the more fun tools, so keep everyone involved. Don't criticize other people's ideas. Build on other people's ideas. Often an idea suggested by one person can trigger a bigger and/or better idea by another person. Building on ideas leads to out of the box thinking. Reverse the thought of 'quality over quantity.' Here we want quantity; the more creative ideas the better. Note to Facilitator: The following four questions should be pretty self explanatory. 5 min. a question should have you done with your list in 20 min. or less. Capture the ideas on the worksheet that is provided and when done, upload it to the Focus on Safety ’08 SLACspace page.
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Focus on Safety ’08• “What safe work behaviors have you
observed in the last week?”
Presenter
Presentation Notes
While observing people wear safety glasses and using seatbelts are safe behaviors we all expect to see, the supervisor should engage the work group to have a more comprehensive discussion. Examples should be surround the work group’s experience.
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Focus on Safety ‘08• “What will likely be our work group’s
next injury or incident?”
Presenter
Presentation Notes
This discussion should lead folks to critically think about their activities, include close calls they are aware of that can result in an injury, etc.
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Focus on Safety ‘08• “What are we doing, or can we do to
prevent this incident?”
Presenter
Presentation Notes
This discussion should be lead to focus on a) safe behaviors within the work group, b) conditions the work group can address (engineered and administrative controls) themselves, and then c) conditions the workgroup needs help with addressing outside of their ability (e.g. items requiring work order, etc.)
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Focus on Safety ‘08• “What unsafe conditions or behaviors
can we correct now, in the next week, next month?”
Presenter
Presentation Notes
The intent here is to focus on immediate and near term actions the work group can execute.
