Fatality Elimination at Kimberly-Clark
K-C Global Injury & Illness Rates An Incident Rate of 1.0 represents 1 in 100 workers injured per year. Incidence rates are trending down
Kimberly-Clark Fatal Event Experience Fatalities were reduced in the 70 s but have been stable since the 80 s
5 Enhancing the Health, Hygiene and Well-Being Kimberly-Clark Fatal Event Experience N. Asia U.S.A. 4 S. Asia Mexico 3 Europe LAO MEA 2 1 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Fatalities are not unique events to any one geography
Why Are We Doing This? Enhancing the Health, Hygiene and Well-Being 1. Global safety trends at KC reflect focus on the reduction of incident rate. Incidence and severity trend downwards Fatality trend is flat 2. Addressing Fatalities is a different problem set and requires a different approach. Work on reducing incidence and traditional measure of severity does not work on issues causing death. Initial work suggests that fatalities at K-C can be classified into priority groups with predictive power.
Key Concepts in Support of a New Direction
Influential Concept No. 1 Enhancing the Health, Hygiene and Well-Being Det Norske Veritas - 2002 Study Much has been said about the classical loss control pyramid, which indicates the ratio between no loss incidents, minor incidents, and major incidents, and it has often been argued that if you look after the small potential incidents, the major loss incidents will improve also. 1 10 30 600 Serious or Major Injury Minor Injury Property Damage Accident Incidents With No Visible Injury or Damage Det Norske Veritas 2002 Study Published July 2004 http://www.dnv.no/binaries/leadingindicators_rev1_tcm28-99467.pdf
The major reality however is somewhat different. If you manage the small accidents effectively, the small accident rate improves, but the major accident rate stays the same, or even slightly increases.
Influential Concept No. 2: Major Catastrophic Event Findings British Petroleum - Texas City - March 23, 2005
U.S. Chemical Safety Board Interim Report - September 2006 Enhancing the Health, Hygiene and Well-Being The explosion at British Petroleum's Texas City plant killed 15 people and injured 170. Report identified warning events that should have alerted management: Unsafe equipment design Poor operating practices Many HIPO near-miss events Management assumed that if (incident) rates were low, safety was good.
Influential Concept No. 3 IUP Fatality Prevention Forum, November 1-2, 2007 Heinrich's premise - that the more valuable clues to accident causes lie in minor injuries--has been translated into the commonly held belief that safety efforts focused on the prevention of incidents that occur frequently will also encompass severity potential. Statistics and analysis have proven this assumption to be unsupportable. But, the premise is widely taught and is a significant part of the thinking of many safety practitioners. It represents a distracting mindset that impedes our addressing the reality of the causal factors for low probability/serious consequence events. Fred Manuele, Occupational Health & Safety, June 2005
IUP Fatality Prevention Forum, November 1-2, 2007 Key Messages: An organization cannot address the basic causes of fatal events until it measures and tracks those minor or major loss incidents which, while not resulting in a fatality, could have.. If we want to control fatalities, we should try to predict where they will happen.
Sentinel Events A New Approach to Fatality Elimination
Sentinel Events Enhancing the Health, Hygiene and Well-Being A Different Approach to the Loss Pyramid Fatal Events Permanently Disabling Events Non-Disabling Injuries/Illnesses Property Damage Accidents Incidents with No Visible Injury or Damage Substandard Acts or Conditions HIPO Loss Events With Fatality Potential Loss Events HIPO Near Miss Events With Fatality Potential Near Miss Events
What is a Sentinel? Enhancing the Health, Hygiene and Well-Being A soldier standing guard at a point of passage (as a gate) One that keeps guard; a sentry.
What is a Sentinel Event? A Loss Event, Near Miss (Near Hit), or Substandard Act/Condition with the potential for a fatal or catastrophic loss.
What are K-C s Sentinel Events?
1. Falling Objects Enhancing the Health, Hygiene and Well-Being April 2007 Family Care, Europe Hard roll core shaft failure
2. Lift Truck Events Enhancing the Health, Hygiene and Well-Being June 2003 Technical Paper, U.S. August 2007 Personal Care, LAO November 2006 KCP, Europe September 2007 NACP, Europe
3. Falls Enhancing the Health, Hygiene and Well-Being February 2005 Family Care, U.S. Maintenance operator fell ~20 feet (6 m) when he stepped on the improperly seated hatch cover. January 2007 Family Care, LAO Contract employee fell ~7 meters through roof during new building construction
January 2008 Personal Care, U.S. An employee was exposed to an arc flash resulting in first degree burns to his right hand and right side of his face & neck. Enhancing the Health, Hygiene and Well-Being 4. Electrical Contact
5. Contact with Energized Equipment Enhancing the Health, Hygiene and Well-Being February 2007 Family Care, LAO Operator s foot was caught in cardboard shredder (lower leg amputation)
6. Confined Space Operation Family Care, South Asia April 2006 During a work break in a maintenance operation for tank which supplies the plant sprinkler system, a contractor left a gasoline-powered pump running inside the tank. Using a gas meter, the entry supervisor and utility operator found the carbon monoxide reading inside the tank to be 51 ppm, which triggered the alarm. The OEL is 25 ppm. The entry supervisor and utility operator averted an imminent hazard by stopping the activity. Enhancing the Health, Hygiene and Well-Being
7. Fires and Explosions August 2005 Family Care, LAO Propane leak cafeteria flash fire April 2005 Family Care, South Asia Boiler explosion low water level
8. Transportation October 2006 April 2007 February 2008 Transportation Subsidiary, Mexico Note: These examples are the ultimate results of failure to identify Sentinel Events and take corrective action.
Sentinel Events Hazard Detail 1. Falling objects Dropped loads during lifts - mechanical failure or incorrect equipment use Improper or unstable stacking of raw material or product; rack storage failure Failure of overhead structure 2. Lift-truck events Pedestrian contact Tip-over Dock drive-off 3. Falls Ladder use (fixed or portable) Unexpected or unprotected elevation change Roof activities (repair or construction) 4. Electrical contact (arc potential) Servicing, troubleshooting or repairing New installation 5. Contact with energized equipment (whole body) Movement past established equipment barrier or guard Improper application of energy control procedure Uncontrolled ejection of equipment or parts 6. Confined space operation Unexpected formation of hazardous atmosphere or condition Improper application of confined space operations procedure 7. Fires and explosions Fire or potential fire resulting in evacuation Failure of pressurized vessel (e.g. boiler, Yankee dryer) Explosion or potential for explosion 8. Transportation (road & highway) Product transport Sales (fleet) vehicles operation Facility-sponsored employee transportation General business travel 26
Sentinel Event Reporting Capture incidents from the 8 Sentinel Event groups that could have resulted in fatality. Include any other loss event or Near Miss or that could have resulted in fatality in Other category. Sentinel Events resulting in loss (injuries, property damage) and Near Miss incidents will be investigated and captured in facility CAPA system. Corrective actions receive high priority. Incident report should be broadly communicated within business unit, at a minimum. Include significant substandard acts and conditions in reporting; full investigation may occur after trending analysis is completed.
First Data Collection... Enhancing the Health, Hygiene and Well-Being 132 Sentinel Events reported. Represents 58 facilities and ~28,000 permanent & temporary K-C employees Top 2 categories = 52%
Currently Available Data... Enhancing the Health, Hygiene and Well-Being 768 Sentinel Events reported 109 mfg. and dist. Facilities 48K perm. & temp. K-C employees Top 2 categories = 52%
Currently Available Data... Enhancing the Health, Hygiene and Well-Being 1027 Sentinel Events reported 129 Mfg. and Dist. Facilities 60K perm. & temp. K-C employees Top 2 categories = 48%
Currently Available Data... Enhancing the Health, Hygiene and Well-Being 631 Sentinel Events reported 127 Mfg. and Dist. Facilities 63.5 K perm. & temp. K-C employees Top 2 categories = 49%
So Why Are We Doing This?
Answer... As a company, K-C has met or nearly met our injury objectives (TIR, LWIR, Severity), and made significant progress on disabling injuries. Yet, we have consistently failed to meet our objective for ZERO fatalities. Efforts focused on driving down our reportable incident and severity rates will NOT produce sustainable results for fatality elimination. Work to eliminate fatalities must occur simultaneously and in parallel with efforts to eliminate injuries.
So What? (What do we do with this information?)
Recognize Sentinel Events as Loss Lessons Quality of investigation Classification of criticality, especially severity Corrective action hierarchy of control for risk reduction Level of leadership attention Level of communication to business unit
What Do We Gain From This? A Sentinel Event which is reported, investigated and has a corrective action applied is a Potential Life Saved!
Thank you! Questions?