Optimization of Safety
Efforts Using Accident
Avoidance & Other Analysis
Techniques
International HEP Technical Safety Forum
Jack J. Hahn SLAC
Today’s Talk

Provide overview of some SLAC “Safety Excellence” analysis methods

Describe three Safety Analysis approaches

Accident Avoidance Analysis technique

Work associated with most common accidents

Work associated with most serious accidents (Department of Energy
Laboratories)

Show some analysis information shared with all laboratory staff

Challenges/Issues for safety progress through Safety Analysis
“Safety Excellence” vs “Compliance”

Analysis for “Safety Excellence” (topic today)

Goal to Reduce:
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Goal to Prevent



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Most common injuries and illnesses
Most serious injuries and illnesses
Methods not necessarily required by Safety regulations (U.S. OSHA
1910, OSHA 1926), may exceed them
Optimization of safety effort
Compliance (important also, not today’s topic)



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Goal to comply with regulatory requirements
Thousands of pages of regulations
Must do it all
Use supervision, audits and self-inspection techniques for “analysis”
How is Safety Analysis Used?

One part of a multi-part safety program

You have opportunity to talk to entire staff about safety



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You have 10 minutes
You want to provide the potential to make a difference
Something that everyone can relate to?
Results right away?

Tool for improvement teams at the lab
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Tool for defense of safety capital investment decisions
Building/Accelerator/Walkway design?

What is “Accident Avoidance Analysis”?

Based on consideration of a number of historical
near-miss incidents or accident events

Thought experiment by safety professional (s).
(credits to John Turek, Ishwar Garg)

Semi-quantitative evaluation of relative merits of
techniques in preventing the incident or injury.

Benefit of additional steps
Accident Avoidance Points
(AAP’s)

Would have prevented accident/incident/injury - 1
point

May have prevented accident/incident - .5 point

Would not have prevented accident/incident - 0
points
Accident Avoidance Examples

Employee moving equipment, splinter
embedded under nail- Use of Gloves = 1 Pointwould have prevented injury/accident.

Employee was crawling on hands and knees
under beamline, stood up and hit head on
magnet- Use of Hardhat = 1 Point, Sufficient
workspace to perform task .5 points (may have
prevented accident)
Remedy
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Accident Avoidance Points
Accident Avoidance Points vs Remedy- SLAC
Injury/Ilnesses N = 113 (four years)
Most Efficient Remedies to Prevent
Common Accidents Lab-Wide?

# of Accident Avoidance Points/Cost of Remedy

Rough relative value - Precise cost estimates not suggested nor
required. May point out fixes that can be accomplished in
short to medium term.

Information recently developed- Not used
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Limitations
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Order of magnitude of cost effectiveness of solutions, not precise
Decision making should seldom be based only on cost effectiveness
Costs based on prevention of only those events observed- Could be
refined, not done in this example
e
To
$
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$ per Accident Avoidance Point vs Remedy (SLAC accidents N= 113,
Four Years)
1000
900
800
700
600
500
400
300
200
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0
744
378
164
91
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31
Remedy?
Analysis of Work Associated with
Most Common Accidents
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Original Laboratory Approach
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“Analysis of Work” method
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By Type - Stains/strains/slips, trips, falls
By Division & Department
Welding related injuries?
Material handling related injuries?
Similar “Analysis of Work for Common
Accidents” info from today’s talk presented
site-wide in August 2004
What Types of Work are Associated with SLAC’s
Most Common Recordable Injuries/Illnesses?
(2003/2004 partial)
Computer Work
Chemical Use
Construction
Ladder Use
Cut/Saw/Drill
Machining
Lifting
What Types of Work are Associated with
SLAC’s Most Common Recordable
Injuries/Illnesses? (2003/2004 partial) cont.
Moving Body
Material Handling
All Other
Stair Use
Wrench Use
Welding
Walking
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# Cases
# SLAC Recordable Injury/Illness Cases vs Type of
Activity 2003-2004 partial (N=55)
12
10
8
6
4
2
0
WALKING - 11 Accidents - What could be done?
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Watch where we are going- 6
Poor footing- 1
Jobsite housekeeping- 1
Rate- 1
Facility condition- 1
Walking
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Design/Mitigation Ideas
 Minimize sudden change of elevations - curbs
 Pathway clearance from objects
 Don’t exclude walking in Job Hazard Analysis
and Mitigation (JHAM)
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MATERIAL HANDLING - 11 Accidents What could be done?
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Excess manual force- 4?
No gloves- 3
Proper cart / hand trucks- 2
Unstable body position- 1
Avoid falling objects- 1
Material Handling
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Design/Mitigation Ideas
 Long term plan- decrease manual/increase powered
lifting
 Job Planning- Safety meetings discuss options
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STAIR USE - 5 Accidents - What could be done?
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No handrail use- 3
Rate- 2
No handtruck-1
Splinter from handrail- 1
Design/Mitigation
 Establish culture of using handrails
 Avoid carrying items that prevent you from using
handrail/seeing
 Design OSHA compliant handrails
 Safety meetings/Job Hazard Analysis
Stair Use
Preventing Some of the Most
Serious Accidents - Ladder
Safety
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Pick the right ladder
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Don’t use a ladder that is too
short
Inspect the ladder
Climb with both hands free
Include ladder safety in JHAM
Preventing Some of the Most Serious
Accidents- Electrical Safety
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Work de-energized whenever possible
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If not, approach the situation with
redundant controls
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Electrical Gloves
Mats
Hard hat in keeping with the rules
Appropriate Clothing
Of course include electrical work in
safety planning
Analysis of Work Associated with Most
Serious Accidents

Review/Summarize 28 Selected Department of
Energy (DOE) Type A & B Investigations Apr
1997- Oct 2001

Look Nationally over a number of years, to obtain
reasonable sample size for analysis
What Qualifies as a Department of Energy (DOE) Type A
or B Accident/Incident?


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Type A & B precisely defined in DOE order
Type A’s (Worst) includes
 injury, chemical or biological exposure resulting in
 1 or more fatalities
 3 or more persons with “serious” injuries
 Property Accidents > 2.5M
Type B’s (Bad) includes
 Injury, chemical or biological exposure resulting in
 1 or more persons having “serious” injuries
 Property Accidents > 1 M
Review/Summarize Relevant DOE Type A &
B Incident Investigative Reports
GENERAL WORK TYPE - # OF INVESTIGATIONS
Construction- 9
Maintenance- 8
No Activity- 3
Environmental Work- 2
Transportation- 2
Demolition- 1
Research- 1
Material Handling- 1
Helicopter- 1
Total- 28
Review/Summarize Relevant DOE Type A &
B Incident Investigative Reports (cont.)
Detailed Work Categories- # incidents
Electrical- 8
working in substations- 3
working on power lines- 1
switchgear- 1
motor control center- 1
jackhammer- 1
microwave, student taking measurements- 1
Review/Summarize Relevant DOE Type A &
B Incident Investigative Reports (cont.)
Detailed Work Categories- # incidents
Tree Falling Under Power Lines- 2
Heavy Equipment - Material snagged - 2
DOE Fatalities for Work Relevant to SLAC, as
Reported in Type A Reports
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Tree Falling- Power Line Maintenance-1
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Electrical- De-energized Power Line- Induced
Current - 1
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Grading- Run Over By Equipment - 1
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Heating and Air Conditioning Work- Fall From
Height - 1
List of Detailed Work Type A’s or
B’s
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Electrical- Substation 3
Tree Falling- Power Line 2
Heavy Equipment- Material snagged
2
Leaking Fluid 2
HVAC 2
Painting 1
Electrical- Motor Control Center 1
Asbestos Work 1
Drilling Rig 1
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Electrical- Power Line 1
Grading 1
Helicopter- Bad Weather 1
Hoisting and Rigging 1
Jackhammer 1
Janitorial 1
Hauling 1
Microwave 1
Rooftop Work 1
Switchgear 1
Environmental Sampling 1
Traffic accident on public road
starts fire 1
Waste 1
TOTAL 28
Conclusions Regarding Hazardous from
DOE Data, and Judgment

Hazardous Work- In order of certainty?
 Conventional construction
 Building very large high energy physics facilities
 Conventional maintenance
 Electrical work- Especially high voltage work, substation work.
 Tree falling?
 Maintenance of Power Lines?
 Heavy Equipment Snagging Material?
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Research - Not much type A or B activity seen
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Exotic Experimental Equipment - Not much type A or B activity
Challenges/Issues for Safety
Progress Through Safety Analysis

People don’t always listen or agree
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One-time communication not likely to change ingrained behaviors- need
follow-on communication
 Need to have programs that generate “habit strength”?
 Uniform Hazard Analysis?
 Behavior Based Safety?

Establish requirements in HEP labs for common behaviors such as hand rail
usage, or watching where we are going? Is this going too far? Why?