Fatality
Prevention
in the Workplace
Forum
Enterprise-Level Strategy
Kimberly-Clark Corporation
David I. Jacobi, CIH
Sponsored by
Indiana University of Pennsylvania
Safety Sciences Department
in cooperation with
Alcoa Foundation
Sponsored by Indiana University of Pennsylvania Safety Sciences
Department in cooperation with Alcoa Foundation
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Background
• Since 1970, 125 employees have died on the job across all
business units.
• From 1997 until 2009, KCC experienced an average of 2 fatal
injuries per year.
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
2
Background
IUP/ALCOA Fatality Prevention Forum
November 1-2, 2007 - Key Messages:
Prevention of fatalities requires some process for
predicting their occurrence.
An organization cannot identify the characteristics
and causes of fatal events until it measures
and trends loss incidents which, while not
resulting in a fatality, could have…..
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
3
Background
Key Realization No. 1
Data analysis suggests that fatal and
near-fatal events at KCC can be
classified into priority groups with
predictive power.
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Background
While isolated events for each facility, patterns emerge for the Enterprise...
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Background
Key Realization No. 2
Addressing Fatalities is a different
“problem set” and requires a different
approach.
 Work on reducing incidence and traditional
measure of severity does has not addressed
issues leading to death.
Fred Manuele, 2008
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Background
Dual Path Strategy for Prevention
Low
Severity
Exposure
Risk
Assessment:
F(x): Severity
+ ExperienceBased
Likelihood
Risk
Mitigation:
Low to Middle
Order from
Control
Hierarchy
Likely
Precursor to
Fatality or
Serious
Injury
Risk
Assessment:
F(x): Severity +
Control-based
Likelihood
Risk Mitigation:
High Order
from Control
Hierarchy;
Layers of
Protection
Hazard
Recognition
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Strategy and Approach
Fatality Prevention Structure
0 Injuries
Vision
Global Fatality Elimination Leader
Direction
Foundation
LEARN
PREVENT
BUILD
Apply
learnings from
failures in
safety systems
and processes
Mitigate
recognized
hazards
through
adherence to
robust internal
standards
Build OS&H
capability
through
education and
practical
training
EHS Management System
Global OS&H Policy
Code of Conduct
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Strategy and Approach
Fatal
Permanently Disabling Events
Property
Damage
Accidents
Incidents with No
Visible Injury or
Damage
Substandard
Acts or
Conditions
HIPO
Sentinel Events
Non-Disabling
Injuries/Illnesses
Events
Loss Events With
Fatality Potential
Loss Events
HIPO
Near Miss
Events With
Fatality
Potential
Near Miss
Events
9
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Strategy and Approach
KCC’s Sentinel Event Hazards
Falling objects
Powered vehicle operation (facility)
Falls
Electrical contact (arc flash)
Whole body contact with energized equipment
Confined space operations
Fires and explosions
Transportation (road)
See Appendix Slide for Detail
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Strategy and Approach
Papeles de Cauca
6-9 Apr 2010
Neenah CSF
19-22 Apr 2010
Istanbul
14-17 June 2010
Loudon
7-9 Sep 2010
Enstra
11-14 Oct 2010
4
5
4
12
5
10
12
2. Lift-truck events
4
8
1
2
5
6
7
7
4
44
3. Falls
4
10
3
6
2
4
3
3
38
4. Electrical contact
1
5. Contact w/energized equipment
8
3
2
6
2
8
4
6. Confined space operations
7. Fires and Explosions
1
8. Transportation
1
Leaders & EE's trained
25
34
28
101
15
62
1
1
1
12
59
16
95
23
54
3
5
4
1
38
0
1
2
17
77
60
1
2
9. Other
Total
195
629
Total
Nogales
9-11 Mar 2010
8
Sentinel Event Observations
Nahariyah
1-4 Nov 2010
Millicent
15 -17 Dec 2009
1. Falling objects
Pilot Sessions
Kimcheon
22-25 Mar 2010
LaGrange
17 -19 Nov 2009
KCC 2009-2010 Sentinel Event Training Pilots
1
4
1
7
0
20
35
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
30
72
9
40
195
629
Strategy and Approach
EHS Management System
• Revision of key safety performance standards
that impact control of Sentinel Event hazards
• Refocus scope of global EHS Management
System Assessments on these performance
standards
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Strategy and Approach
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
13
Strategy and Approach
Dedicated
input
interface
as part of
Global
Safety
Reporting
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Strategy and Approach
•
•
•
•
1065 Sentinel Events reported
154 Mfg. and Dist. Facilities
81K perm. & temp. employees
Top 2 categories = 54%
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
15
Strategy and Approach
2011-13 Communications Plan
Global deployment: E-newsletters, mini-posters & hazard
bulletins) for 8 Sentinel Event hazard categories across 3 years
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Barriers and Enablers
Barriers
• Cultural differences in reporting
• Entropy potential for any new strategy or
initiative
Enablers
• Strong operations leadership safety culture
• Committed safety personnel across Enterprise
• Continued visibility of the problem
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Results
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
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Lessons Learned
Fatality Elimination Strategy Summary
• Recognition that fatality elimination is a separate but parallel
effort to injury elimination
• Global rollout of employee and leadership-specific Sentinel
Event recognition training
• Focused implementation of safety performance standards for
activities and tasks with fatality potential
• CEO and executive line-of-sight to measureable objectives
• Dedicated Intranet (SharePoint) Site for Tools (Solutions)
• Web-based reporting interface with database used for trends
• Global communication plan linked to message branding
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation
Questions?
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Appendix
KCC Sentinel Events – Hazard Detail
Sponsored by Indiana University of Pennsylvania Safety Sciences Department in cooperation with Alcoa Foundation