USW Overview & Resource Handout of Making Non-routine Work Safe

Deaths in confined spaces dropped after OSHAestablished a confined space standard. In fact, the leading cause ofdeath by traumatic injury in the steel industry is in-plant railroads –a hazard for which OSHA has no standards. An equally importantlesson is that a good safety program cannot solely be based onOSHA compliance.ƒnA significant numbers of cases either were not covered by an SJP orJSA, or the SJP or JSA was so general that it gave little usefulguidance. SJPs and JSAs are important. Good ones save lives. Buta good safety program must also address non-routine tasks thatsuddenly arise, for which there is no written procedure.

A significant number of cases involved upset conditions or non-routine operations – usually maintenance procedures. Therefore, a walk-around inspection or observation program would not have uncovered the factors that led to the fatal accident unless the inspection team or observer happened to be present just before the accident occurred. Even then, the inspection team or the observer might not have the expertise to identify the hazards. Therefore, any effective safety program must primarily depend on the workers and managers involved in the job, instead of safety professionals.

A second study is also instructive. In 2000, the USW and National Steel collaborated on a study of workers experiences and attitudes toward safety in three steel plants and one mine. Every worker and supervisor was invited to respond to a lengthy questionnaire. Strict confidentiality was observed. The response rate was 86%. The questions were chosen by the joint safety and health committees, and put into survey format by Drs. Kate Bronfenbrenner of CornellUniversity, and Tom Juravich of the University of Massachusetts at Amherst. Bronfenbrenner and Juravich also analyzed the data.

One of the most interesting questions was: “Have you ever done an unsafe job, knowing it was unsafe?” Fifty-six percent said yes. The follow-up question was “why?” Respondents were given multiple choices – peer pressure; fear of losing incentives; in a hurry to get it done; didn’t want to let down the team; didn’t want to look like a wimp; etc.

Only two answers garnered more than 20% of the vote – “management pressure or threats,” at 60% and “there was no other way to do the job, at 59%. (The totals are more than 100%, because many respondents did unsafe jobs more than once, and were told to check all the answers that applied.) Sadly, the first response is not surprising. Front-line managers are often told by higher management that safety comes first, but their careers depend on productivity. The second answer is more interesting. A majority of the workers who did unsafe jobs did so because they believed there was no other way to do the job. Either the industry has failed to find safe ways to do these jobs, or they have failed to communicate those safe job procedures to the workers at risk.

How Can We Make Non-routine Work Safe?

It’s 3 in the morning when an ancillary electrical feed fails in an upper level of the BOP shop. Management is thin. There is no company safety engineer in the mill, and only one union safety rep. Her normal job is in cold-rolled. There is one experienced electrician. He’s four hours into the second half of a double. Yesterday he worked 16 hours. There are two other workers assigned to electrical maintenance. Between them they have less than two years in the mill. It is not yet known where the problem is or how difficult the repair will be. It may be in a confined space or in a place where a fall could occur. The upper levels of the shop are very hot; sometimes there are pockets of carbon monoxide. The vessel is out of commission, and the production superintendent wants it fixed right away.

What should be done? And what should have been done months ago to prepare the crew to handle this kind of situation?

It will always be harder to plan for unusual conditions, process upsets, and tasks that are out of the ordinary. Nevertheless, it can be done. Four elements are critical: thorough hazard mapping, rigorous job hazard analysis, comprehensive training and careful follow-up of all accidents, near misses, and deviations from safe procedures.

Hazard Mapping:

Hazard mapping was described in the first module of this series.

Actually, there should be two hazard maps for any given work area. The first should be an actual floor plan of the area, showing the equipment, electrical lines, lines carrying steam, gases or liquids, the flow of materials, the pathways for mobile equipment, the walkways and workstations, and any other information important to safety.

The second map should be a process diagram – a schematic flow chart showing the processes in the area. On those maps, the hazards associated with every location on the floor plan and with every step of the process should be clearly identified.

The mapping has to be as thorough as possible. No line should be ignored because it “only passes through” the area. Remember that we are planning for unusual events. What would happen if the line was broken? Nor should any line be ignored because it only carries “non-hazardous” materials. Almost every material can be hazardous under the right conditions. Water is the prime example of a “non-hazardous” liquid, but in a steel mill water can combine with hot metal to cause a devastating explosion. In addition, if a line is not included on a hazard map, someone using the map will not know whether was excluded because it does not present a hazard, or because it was simply overlooked. Hazard maps can become very complex in a steel mill or any other complicated operation. The best way to deal with the complexity is by computerizing them. In a relatively simple work area, plastic overlays can be used. Of course, hazard maps will always be a work in progress as new hazards are uncovered, and as processes change. Hazard maps have two primary uses. First, they should lead to a better system for physically identifying all lines and vessels in the work area, and for posting hazard warnings. Second, they are an essential tool in job hazard analysis.

Job Hazard Analysis:

Job hazard analysis is the task of analyzing the safety of a job in advance, to ensure that the hazards are fully understood and dealt with when the job commences.

Sometimes the resulting plan is called a “job safety analysis (JSA),” or a “safe job procedure (SJP),” “energy control procedure (ECP) “standard operating procedure (SOP),” etc. In this module we will call the process “job hazard analysis,” and the resulting document a “safe job procedure (SJP).” But whatever it is called, job hazard analysis is an essential tool in maintaining a safe workplace. Of course, every routine task should be the subject of a thorough job hazard analysis. The analysis should look carefully at the hazards in the area and determine the best ways to reduce or eliminate the risk of injury. This is where hazard maps come in. Special attention should be given to upset conditions. You should ask, “What would happen if this line was broken?” What would happen if a hauler hit this piece of equipment?” What would happen if this sensor failed?” SJP’s should be reviewed frequently to ensure that they actually cover the job in question, and that they are capable of being followed. When the process or technology changes, the SJP must also change. Most important, SJPs exist to be used. Far too many SJPs exist only on paper, locked in a supervisor’s office. Far too many are obsolete, or are generally ignored because following them on a real job is almost impossible. But this module deals with unusual circumstances. What if there is no SJP for the job in question? The process of safe job analysis should still be followed. Using the hazard maps, the work team should review each step of the task, charting how to do it safely, and what might happen if the team runs into unexpected circumstances. No matter how trivial the job seems, it should not be attempted until there is a thorough understanding of how to do it safely. After the job is over, an SJP generally should be prepared for the future, based on the pre-job planning and the way the job actually went.

Training:

Training programs often do not address non-routine jobs and unusual circumstances. OSHA requires training for workers exposed to coke-oven emissions, lead, cadmium, and many other toxic substances under specific standards, as well as more general hazardous substance training under the Hazard Communication standard. OSHA training also extends to safety standards, such as the Confined Space and Lockout/Tag Out standards. This training is effective and essential to the implementation of those standards.

OSHA also certifies voluntary training in OSHA standards, such as the OSHA 10 and 30 hour classes.

But remember that a larger proportion of fatalities in the steel industry were caused by factors that OSHA does not directly address. Clearly, training programs must go beyond OSHA standards and OSHA compliance. Most steel companies have training programs of their own. Usually, the programs concentrate on the routine jobs in the mill and emphasize strict adherence to the SJPs. This training is valuable, but it does not necessarily deal with unusual circumstances or non-routine tasks. A number of outside vendors also sell “safety awareness” training. Too often, this training simply lectures workers on the need to “work safely,” without giving them the tools to analyze the tasks they are asked to do. The message of the training seems to be that, if you are injured in the plant, it’s probably your fault for not paying enough attention to safety.

What kind of training would be effective for non-routine jobs? First, the training should teach people to use hazard mapping and job hazard analysis. Even for jobs with existing SJPs, the goal of the training should not be to simply follow the rules, but to understand the reason for the rules and to question situations where the rules may not be sufficient. One useful concept is simulation. Pilots, nuclear plant operators, and the military make great use of simulations in which the trainees are presented with a sudden, unexpected problem and expected to solve it – sometimes in an expensive mock-up of a cockpit, control room, or battlefield. The goal is not to simulate every possible problem, but to teach participants to analyze situations and think through problems as they are occurring. While it is impractical to build a steel-plant simulator, classroom simulations on paper can certainly be added to any training curriculum. These methods are part of the extensive training offered by the USW through the union’s Tony Mazzocchi Center for Health, Safety and Environmental Education.

Learning the Lessons of Accidents, Near Misses, and Deviations from Safe Procedures

Experience is the best teacher. There are lessons to be learned in every accident and near miss. A complete course in accident investigation is beyond the scope of this module. The USW offers “root-cause” accident investigation training, as do many other organizations.

However, any good accident investigation program will have several common characteristics:

The goal of the program must be prevention, not punishment.
Valid conclusions depend on good information. Workers and managers involved in an accident will be reluctant to share information if they think they will be blamed and disciplined.
Accountability may be important, but it is secondary to learning the truth.

All accidents and near-misses should be investigated. It is equally important to investigate situations where the work team was forced to deviate from the SJP guiding the job.

Investigations should aim at root causes.

For example, the immediate cause of an accident may be equipment failure. But why did the equipment fail? Perhaps it was poorly maintained. If so, why was the maintenance program inadequate? And what led to that? The important thing is to follow the chain of causation back to fundamental causes. Correcting those may prevent not only identical accidents, but many others as well. “Human error” is never a satisfactory explanation. Even if someone made a mistake, the question is why? Improper training? Faulty job hazard analysis? Conflicting demands? Work overload? Fatigue?

What can be done to make such mistakes less likely? At the same time, what can be done to increase the inherent safety of the system, so that a single mistake does not cause a serious accident?

Investigations must be followed up. The problems uncovered must be corrected. The lessons learned should be incorporated into future planning.

For example, many of the USW Triangle of Prevention sites have integrated the union’s lessons learned program into the ongoing efforts to address workplace health & safety at their sites. One resource is the USW website, which contains a large database of lessons learned from a wide variety of industries.

Job Hazards Analysis:

Non-Routine Task

This form should only be used where a written Safe Job Procedure does not exist, or where the SJP is out-of-date or inadequate.

Note: that there are two parts, to be used before the task is undertaken, and after.

Although the supervisor in charge of the task is ultimately responsible for its safety, all members of the crew and the union safety representative should be involved in the job hazard analysis.

This form is a sample and should be modified as needed for particular tasks.

Part A: Pre-Task Review

Department: Location:

Describe the task:

Personnel assigned:

Supervisor in charge:

Supervisor who ordered the task:

When will the task be done?

How long is the task anticipated to take?

What tools and equipment are required?

Describe each step in the task:

Job Hazards Analysis: Non-Routine Task

What are the hazards to which the crew might be exposed? Check all that apply:

___Unguarded machinery

___Electricity

___Flammable Liquids or Gases

___Combustible Solids

___High-pressure Lines or Vessels

___Poisonous or Asphyxiating Gases

___Oxidizers

___Hazardous Chemicals

___Confined Spaces

___Hazardous Stored Energy

___Molten or Heated Metal

___Falls from Height

___Unstable or Dangerous Walking or Working Surfaces

___Being Struck By Material

___Mobile Equipment

___Moving Parts

___Heat

___Noise

___Other (specify)

Is a hot-work permit required?                 ___Yes   ____No

Is a confined space permit required?        ____Yes   ____No

Is lockout/tag out required?                     ____Yes   ____No

What personal protective and other safety equipment is required?

Does the crew have adequate training for this task?          ___Yes ___No

Does the crew have enough personnel?                            ___Yes ___No

Is the crew sufficiently rested to perform the task safely?   ___Yes ___No

Are all lines and vessels clearly identified?                       ___Yes ___No

Job Hazards Analysis: Non-Routine Task

Do MSDS’s exist for all hazardous materials? ___Yes ___No

Have the MSDS’s been reviewed? ___Yes ___No

Is there a usable evacuation route in case of emergency? ___Yes ___No

Does the crew include a designated “competent person” (i.e. one who has the training and authority to recognize the hazards of the job and take appropriate steps to correct them)? ___Yes ___No

What steps must be taken to defend against the hazards identified above, including in upset conditions?

Can this job be done safely with the resources and personnel available? ___Yes ___No (If no, the job should not be done.)

Has this form been thoroughly reviewed with the work crew and the union safety representative? ___Yes ___No

Supervisor in charge:

Date:

Cc: Union Safety Representative

Job Hazards Analysis: Non-Routine Task

Part B: Post-Task Review

Did the job go as planned? If not, why not?
Were there any accidents or near misses? Describe.
Was it necessary to deviate from the procedures specified in the pre-task review? Describe.
Should the pre-task job hazards analysis be revised? If so: how?
Should an SJP be prepared for this job?
Has this form been thoroughly reviewed with the work crew and the union safety representative?
Supervisor in charge:
Date:

Cc: Union Safety Representative

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