ES&H for Supervisors

1. ES&H for Supervisors FN000413

2. Agenda • Fermilab’s ES&H Policy • Definitions • Occupational Injury History • Supervisor ES&H Responsibilities • Resources • Medical Department

3. Fermilab’s ES&H Policy Fermilab employees, subcontractors, and users will only conduct work and operations in a safe and environmentally sound manner.

4. Integrated ES&H Management Principles & Core Functions

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

6. 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

7. Total Recordable Case Rate • Total Recordable Case (TRC) • Requiring more than first aid • Sutures • Prescription Medication • Fractures • Lost or Restricted Time • Total Recordable Case Rate (TRCR) • (# TRC/hours worked) X 200,000

8. 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

9. 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) FY02 3.86 (90 cases) FY03 1.53 (33 cases) FY04 1.56 (32 cases) FY05 1.25 (25 cases) FY06 1.40 (27 cases) TRC Rate (employees + subs) History

10. FY97 2.90 (67 cases) FY98 2.21 (49 cases) FY99 1.31 (29 cases) FY00 1.84 (42 cases) FY01 1.63 (38 cases) FY02 2.32 (54 cases) FY03 0.56 (12 cases) FY04 0.54 (11 cases) FY05 0.50 (10 cases) FY06 0.30 (6 cases) DART Rate (employees + subs) History

11. Supervisory Responsibilities

12. Supervisory Responsibilities • Accept that ES&H must compete with production for resources.

13. Prevention facility event Production Competing System Resources tn Bankruptcy new facility state Incident t0

14. Supervisory Responsibilities • 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.

15. FlawedDefenses Mission Goals Policies Processes Programs Incident InitiatingAction LatentOrganizationalWeaknesses ErrorPrecursors Anatomy of an Event Vision, Beliefs, & Values Vision, Beliefs, & Values

16. Task Demands Individual Capabilities • Time pressure (in a hurry) • Unfamiliarity w/ task / First time • High Workload (memory requirements) • Lack of knowledge (mental model) • Simultaneous, multiple tasks • New technique not used before • Repetitive actions, monotonous • Imprecise communication habits • Irrecoverable acts • Lack of proficiency / Inexperience • Interpretation requirements • Indistinct problem-solving skills • Unclear goals, roles, & responsibilities • “Unsafe” attitude for critical task • Lack of or unclear standards • Illness / Fatigue Work Environment Human Nature • Distractions / Interruptions • Stress (limits attention) • Changes / Departures from routine • Habit patterns • Confusing displays or controls • Assumptions (inaccurate mental picture) • Workarounds / OOS instruments • Complacency / Overconfidence • Hidden system response • Mindset (“tuned” to see) • Unexpected equipment conditions • Inaccurate risk perception (Pollyanna) • Lack of alternative indication • Mental shortcuts (biases) • Personality conflicts • Limited short-term memory Error Precursorsshort list

17. 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.

18. Performance Modes High KB Patterns RB If - Then Attention (to task) SB Auto Low Low High Familiarity (w/ task) Inaccurate Mental Picture Misinterpretation Source: James Reason. Managing the Risks of Organizational Accidents, 1998. Inattention

19. Fermilab Event Causes

20. Supervisory Responsibilities 3. Keep Communication Chains Open • Go out and watch people work • Discuss why worker’s actions aresafe orunsafe - prompt feedback is important • Ask questions to help identify opportunities • Compliment those who are reducing hazards • Review opportunities to minimize waste and prevent pollution

21. Supervisory Responsibilities • 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?

22. “…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.

23. “Rhino Horn” Lifting Fixture Failure

24. 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

25. 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

26. 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

27. 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

28. 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!!

29. Hazard Analysis Steps • Job Site Walk Down • Analysis of the Hazards • Pre-job Briefing • Performance of the Work • Post Job Review • HA Record Retention

30. TaskDemands TaskPreview WorkEnvironment CriticalSteps IndividualCapabilities HumanNature Error-likelySituations SAFER Dialogue S – Summarize critical steps A – Anticipateerror traps F – Foresee consequences E – Evaluate defenses R – Review operating experience PotentialConsequences FlawedDefenses Pre-Job Briefing

31. Conservative 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 Error-Reduction Techniques

32. 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

33. Supervisory Responsibilities • 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

34. Incident Investigation • Questions 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?

35. Culpability Evaluation Flowchart Discipline may be required Action may be necessary Fix process Issue No No No Yes Yes No Yes No Yes Yes Yes Yes No No Yes Possible reckless violation Organization induced violation Possible negligent error System induced error Were actions as intended? Knowingly violate expectations? Pass substitution test? History of human performance problems? No Selfreported? Were consequences as intended? Were expectations reasonable, available, workable, intelligible, and correct? Deficiencies in training, selection, assignment, or experience? Corrective training or other intervention may be warranted Intentional Act (not an error) Blameless error Evaluate OrganizationalProcesses & Management / Supervisory Methods Diminishing culpability

36. Resources • Senior Safety Officer • Environmental Protection Officer • ESH Section • Fermilab ES&H Manual (FESHM) • ESH Web Page • http://www-esh.fnal.gov/home/esh_home_page.html

37. Medical Department

38. Functions of Fermilab Medical Office • Health Risk Analysis (“check ups”) • Surveillance (ODH, CDL, lead worker, ….) • Work Connected Injuries Management • Sick Leave Administration • Other • Consultations • Workplace Substance Abuse Issues

39. 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

40. 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

41. Common Clues • Absenteeism • Behavioral Changes/Mood Swings • Recurring Injuries • Other?

42. If You Remember Nothing Else…. • Report Work Injuries Promptly • Allow Medical Office to Help in Managing Sick Leave Issues • Ask for Medical Office Help Freely • Consultative Process

43. 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