One Will Die: The John Martin Story Applying Action Based Safety

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One Will Die The John Martin Story Applying
Action Based Safety

• John Martin

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Journey Back in Time

• A Serious Look at all the Contributing Actions
  that set this Accident in Motion
• Attitudes, Short Cuts, Communication, Production,
  Pride, are all at work in this event

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April May 1984

• With the intention of improving production and
  enhancing technical knowledge

• Operations Maintenance Supervision and Chemical
  Engineers are moved to different process areas
• New mechanical engineers are placed in several
  maintenance areas as front line foreman

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Antecedent

• What antecedents are in place?
• No one wants to work overtime
• Saves money
• Improves production
• Saves time
• Known Risk Taker assigned job
• Safety not a value

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Behaviors

• Operator closing valves
• Operator draining pipe lines
• Mechanics tagging breaker
• Mechanics blocking valves
• Operator energizing valve
• Mechanics not wearing PPG
• Operator closing valve
• Mechanics not tagging valve

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Consequences

• 36 hour outage reduced to 8 hours
• Saves money, no overtime
• Increases production
• Man burned over 70 of body
• Operator overwhelmed
• Mechanics crying
• Supervisor blocks event from memory
• EMTs angry
• Families are Devastated

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Accident Analysis

• Antecedent/Prompt The operator is called to
  open valve
• Behavior/Action The operator hits button to
  activate valve
• Consequence Valve opens causes catastrophic
  release of vessel contents

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Five Whys - People

• Why did the operator push the ON button?
• Why was the operator operating equipment he was
  not familiar with?
• Why was the operator unfamiliar with the
  equipment after completing on the job training?
• Why was the equipment not locked out completely?
• Why were both mechanics working behind one lock?
• Why isnt the time it takes to safely lock out
  built in as part of doing the job?

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Five Whys - Equipment/Materials

• Why was the change to the normal process not
  investigated with input toward safety?
• Why was hot product released while maintenance
  employees were working on the system?
• Why was the product still hot when people started
  working on the system?
• Why was the new process thought to be more cost
  effective?
• Why is time saved allowed to be THE factor in
  making a change to the process?

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Five Whys - Equipment/Materials

• Why was the packing leaking?
• Why couldnt the packing be adjusted?
• Why couldnt the gland water pressure be
  increased?

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Five Whys - Environment

• Why did the job begin without first establishing
  a safe escape route?
• Why are maintenance mechanics not provided with
  hazard awareness training before starting jobs in
  unfamiliar areas?
• Why are inspections not conducted at the job
  site?
• Why are Maintenance employees not included during
  inspections performed by Operations?

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1984 AccidentRoot Causes

• People
• Manpower reduced requiring operator training to
  be accelerated and training modified
• Emphasis on production encourages short cuts
• Materials/Equipment
• To save time, the normal isolation procedure was
  modified to a hot shut-down rather than a cold
  shut-down
• Environment
• No time was taken to identify a safe escape route
  due to emphasis on production

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Root Cause Failure Analysis

• Packing sleeve failure
• Low gland water pressure
• Packing installation failure
• Packing gland fit
• Impeller clearance setting
• Machine misalignment

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Safety Way of Life

• Establish a Job Hazard Awareness Briefing prior
  to starting job
• Read the MSDS Sheet and know the hazards
• Wear PPE to protect yourself from potential
  hazards
• Know were the Eyewash/Shower Station are located.
  With someones help, practice locating how to get
  to them if you are blinded
• Locate two of the closest Fire Extinguishers
  prior to starting work
• Improve training for all employees
• Identifying Risky Behaviors is the key to
  reducing accidents

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Safety Way of Life

• Establish Observation cards to identify actions
  to improve safety
• Line of Fire, Eyes on Path, Lifting in Power
  Zone, Asking for Assistance, Discussing task with
  fellow workers, are examples of practices that
  can improve safety

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Safety Way of Life

• Situational awareness is a key element
• Focus on all aspects of the task
• Avoid distractions

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Ones Going to DieThe John Martin Story

• John Martin
• 843 810 0298
• www.martinsafetysolutions.com
• john_at_martinsafetysolutions.com