000 HSE - CH 3 - PST PDF

Chapter 3: Problem Solving Techniques
Operational Level:
– Global Maintenance Work Order
– Work Permit
– Complete Feed Back
– Root Case Analysis
– Near Miss / STOP Analysis
– Risk Assessment
– Job Safety Analysis (JSA)
– Root Cause Failure Analysis
– Failure Mode Effect Analysis
Managerial Level:
- ISO 9001 - Quality Management System
- ISO 14001 - Environmental Management System
- OHSAS 18001 - Occupational Health & Safety Assessment System
- OSHA - Occupational Safety and Health Administration
- API-580 - Risk Based Inspection
- RCM - Reliability Centered Maintenance
HSEM HSE management View – Part I - Dr. Attia Gomaa - 2007 1/Ch. 3
Main Forms for Maintenance Operations for Critical Systems
1) Work request (CM=Process) or (PM=Maintenance +Process)
2) Work order (Maintenance)
3) Job safety analysis (Maintenance + Safety)
4) Work permit (Risk ass.) (Safety + Maintenance +Process)
W/O for Critical Systems “Must be customize”
• Responsibility: Maintenance Planner & Process & Safety (Owner)
• Policy: Global methodology (total view approach)
W/O Contents:
1. W/O description (#, description, type PM / CM/ Shutdown, discipline, area, location, .. etc.)
2. Work request (#, requester, description, .. etc.)
3. Dates (start date, finish date, complete date, .. etc),
4. W/O criticality (system/ equipment criticality, W/O priority, .. etc.),
5. Safety condition (work permit #, type: cold, hot, main items, JSA,.. etc ),
6. Last maintenance (type, description, date, .. etc.)
7. Job plan (main steps, planned duration, actual duration, .. etc.)
8. Tool list (code, description, quantity, planned duration, actual duration, .. etc.)
9. Spare parts list (SIR #, Stock code, description, planned quantity, actual quality, etc.)
10. Labor list (code, description, planned quantity & hours, actual quantity & hours, . etc.),
11. Duration (planned duration, planned down time, actual down time, non-direct time,etc.),
12. Failure (fault, code and description, cause, .. etc.),
13. Backlog (cause, root cause, .. etc.)
14. Responsibility (Maintenance, Process, Safety)
WORK PERMIT:
The purpose of the W/P is to achieve a safe working

environment by providing management control over
activities which may have hazardous interactions.
The W/P requires the involvement of competent and

responsible persons as well as the application of
particular safety measures in a controlled sequence.
The necessary elements, as follows, contribute to safe working:

• Good communications between all work groups.
• Detailed planning of the work.
• Thorough training of personnel.
• Effective supervision of the work.
• A skilled and dedicated workforce.
• Regular auditing of the permit system.
The W/P basically consists of three main Work permits:
1. Cold Work Permit,
2. Hot Work Permit
3. Naked Flame
Six relevant certificates:

1. Confined Space Entry Certificate.
2. Electrical Isolation Certificate
3. Spade List
4. Excavation Certificate
5. Radiography Certificates
6. Pressure Test Certificate
Do Not Do Any of These Tasks

Without A Permit To Work
Root Cause Analysis (RCA)
Main Steps:
• Track & Investigate
• Measure & Analysis
• Evaluate & Report
• Remedy & Plan
• Action & Improve
ACCIDENT Root Cause Analysis
Root Causes
Poor Management & Bad Awareness
Personal Factors Environmental Factors
Unsafe Act Indirect Causes Unsafe Conditions
Unplanned release of energy

(Direct Cause)
ACCIDENT
Accident / Failure Causes
• Three causation levels:
– Direct Cause
• Energy or hazardous material
– Indirect Cause
• Unsafe acts and conditions
– Basic Causes (“root” causes)

• Poor management
• Bad awareness
• Personal or environmental factors
Domino Theory
1932 First Scientific Approach to
Accident/Prevention - H.W. Heinrich.
“Industrial Accident Prevention”
Social Fault of the Unsafe Act

Environment Person or Accident Injury
(Carelessness) Condition
MISTAKES OF PEOPLE
DOMINO Theory
This theory postulates that the events, which lead to an injury, are like five
dominos, standing on end, ready to knock each other over in turn.
They are:
Social Those conditions which make us

Environment take or accept risks.
Undesirable Anger, carelessness, tiredness,

Human Traits lack of understanding, inattention.
Unsafe Acts or Poor planning, unsafe equipment,

Conditions hazardous environment.
The accident occurs when the

above events conspire to cause
Accident something to go wrong.
Injury occurs when the person

Injury sustains damage.
Near miss: (discover the hidden hazard)
Unsafe condition (Awareness & No blame)
“‫”إماطة األذي عن الطريق صدقة‬
“‫”النظافة من االيمان‬
Bad Event has the potential to become an incident or accident.
STOP card (detect the early hazard):

Safety Training Observation Program
Unsafe act (Awareness & No blame)
“‫“من رأي منكم منكرا فليغيره‬
“‫”الساكت عن الحق شيطان أخرص‬
“‫”المسلم من سلم الناس من لسانه ويده‬
Bad Event that degrade the efficiency of an operation.
Near-Miss:
Unsafe Conditions (Environmental Factors)

 Poor housekeeping.
 Defective equipment.
 Unsafe dress or apparel.
 Improper PPE.
 Improper tools.
 Improper guarding.
 Improper ventilation.
 Improper lighting.
 Hazardous arrangement.
STOP
Unsafe Acts (Personal Factors)
 Unsafe loading, placing, mixing, combining.
 Taking an unsafe position or posture.
 Working on moving equipment.
 Defecting safety devices.
 Failure to use personal protective equipment.
 Failure to secure or warn.
 Operating without authority.
 Operating or working at an unsafe speed.
 Horseplay.
Unsafe Personal Factors
 Fatigue.
 Unclassified
 Improper attitude.
 Defective hearing.
 Defective eyesight.
 Muscular weakness.
 Lack of required skill.
 Intoxication (alcohol, drugs).
 Lack of required knowledge.
Initial Stable
Accident 1 1
Incident 10 10
Unsafe Conditions (Near-Miss) 300 600
Unsafe Acts (Stop Card) 12,000 24,000
Accident
Incident
Unsafe Conditions
Unsafe Acts
You only see the tip of the iceberg
You See What You Want to See !!!
When You See a Problem, You Welcome !!!
No Blame !!!
Observation Categories:
- Reactions of people
- Positions of people
- Personnel Protective Equipment (PPE)
- Tools & Equipment
- Procedures
- Orderliness
HSEM
Reactions of People
• Stopping / leaving job
• Attaching earth / lockout
• Rearranging job
• Changing position suddenly
• Adjusting / adding personal
protective equipment
Personal Protective Equipment
• Provides a barrier
• Reflects state of mind
• Match the activity with the

protection worn
Tools
Observe People Using Tools
• Right for the job?
• Used correctly?
• Safe condition?
Equipment
Observe People Using or Operating
Equipment
• Right for the Job?

• Used correctly?
• Safe condition?
Procedures (Standards)
Evaluate Standards by Observation
• Adequate for the job?

• Established?
• Maintained?
Orderliness
Evaluate Standards by Observation
• Standards established?
• Standards understood?
• Orderliness maintained?
Follow Up
• Keep talking to your employees
• Audit - follow up on findings
• Review safety procedures
periodically
• Act as necessary on safety-related
reports
• Follow up on orientation and training
Use of Information
• Record of observations
• System for follow-up
• Analysis of data
• Review of management of safety
• Communication of information
• Training
Near-Miss Analysis:
1 Major 1 Major
29 Medium 29 Medium
300 Minor 600 Minor
(New case) (Stable case)
INITIAL STUDIES RECENT STUDIES
Near Miss Analysis D C B A
1500
Number
1000
500
0
2001 2002 2003 2004 2005 Year
2001 2002 2003 2004 2005
D 850 740 660 590 560
C 500 460 400 360 170
B 32 18 10 2 2
A 7 4 2 1 1
Case Study: Near Miss Analysis
Degree of Near Target Weight 2004 2005 Recommendation

Miss ratio
D= Minor 600: 0.001 590 560 Normal
C= Medium 30: 0.01 360 170 Good
B= Major 10: 0.1 2 2 Bad
A= fatality 1 1 1 1 Bad
Total 953 733 Good
Conclusion:
-
-
-
-
Case Study: Near Miss Classification for 2004
Degree of Target Total Responsibility
Near Miss ratio Near Miss Process Utilities Maintenance
D= Minor 600: 590 100 200 290
C= Medium 30: 360 80 120 160
B= Major 10: 2 - 2 -
A= fatality 1 1 - 1 -
Total 953 180 323 450
Evaluation Good Bad Good
Recommendation:
-
-
-
Case Study: Near Miss Classification for 2005
Degree of Target Total Responsibility
Near Miss ratio Near Miss Process Utilities Maintenance
D= Minor 600: 560 60 200 300
C= Medium 30: 170 20 50 100
B= Major 10: 2 - 2 -
A= fatality 1 1 - 1 -
Total 733 80 253 400
Evaluation Good Very Very Good
Good bad
Recommendation:
-
-
-
The Safety Observation Cycle
for STOP for Employees™
DECIDE ACT
Before you Take whatever action
begin any work is necessary to eliminate
activity, DECIDE to and prevent unsafe acts
make safety your and unsafe conditions.
first priority.
STOP THINK
Give your full attention What might happen?
to the work area. Could you get hurt?
What is going on there, and Could someone else get hurt?
what you will be doing. How can you do your job more
safely?
OBSERVE
Look for any unsafe acts
or unsafe conditions that
may cause injury to you
or other employees.
STOP: 1) Awareness program
2) Observe people working
3) Use all senses
4) Enter into conversation
5) Aware & no blame
6) Make agreement
7) Record & analysis
8) Follow up
9) Blame, if it is repeated
10) Corrective action
To reduce risk to all, you will be – ‫من اجل اإلقالل من نسبة وقوع اى اخطار‬
dismissed form the company if you
‫سيتم فصل كل من سيخالف اى من‬
break any of our Fundamental safety
‫المبادئ الرئيسية لالمن والسالمة من‬
rules. These rules are shown below:
:‫ هذه المبادئ بيانها كالتالى‬،‫الشركة‬
1. Physical Fighting.
2. Unauthorized removal of isolation. ‫الشجار والتشابك بااليدى‬ .1
3. Smoking in unauthorized areas. .‫ازالة العوازل او الحواجز بدون تصريح‬ .2
4. Being under the influence of drugs or .‫التدخين فى االماكن المحظورة للتدخين‬ .3
alcohol. .‫الوقوع تحت تأثير مخدرات او كحوليات‬ .4
5. Being in possession of alcohol or ‫وجود كحوليات او مخدرات بحوزة‬ .5
illegal drugs.
.‫العاملين‬
6. Unauthorized entry into a confined
.‫دخول المناطق الغير مصرح بدخولها‬ .6
space.
7. Taking passengers on a fork lift truck. .‫نقل ركاب عن طريق الونش‬ .7
8. Deliberate damage to safety .‫التخريب المتعمد الجهزة االمان‬ .8
equipment.
Weekly Observational Safety Site Inspection Tour
WOSSIT
• ELNG & Contractor Managers Carryout Site Inspections Together

• Mondays at 9 AM – 10 AM
• Meet at ELNG Building; Inspection Areas will be Assigned
• All Contractor Managers are Expected to Participate
Benefits of Safety Audits
• Displaying your interest
• Getting people thinking about safety
• Enhancing employee relations
• Letting you learn what is happening
• Teaching others about benefits of audits
• Clarifying your standards
• Increasing safety efforts
• Evaluating performance of subordinates
Benefits of Safety Audits (continued)
• Teaching others about benefits of audits
• Clarifying your standards
• Increasing safety efforts
• Evaluating performance of subordinates
• Providing a good way to communicate
• Identifying people with promotion potential
• Providing early warning information
• Stimulates others to audit their own actions

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Chapter 3: Problem Solving Techniques

The purpose of the W/P is to achieve a safe working

The W/P requires the involvement of competent and

The necessary elements, as follows, contribute to safe working:

Six relevant certificates:

Do Not Do Any of These Tasks

Personal Factors Environmental Factors

Unsafe Act Indirect Causes Unsafe Conditions

Unplanned release of energy

• Three causation levels:

– Basic Causes (“root” causes)

Social Fault of the Unsafe Act

Social Those conditions which make us

Undesirable Anger, carelessness, tiredness,

Unsafe Acts or Poor planning, unsafe equipment,

The accident occurs when the

Injury occurs when the person

STOP card (detect the early hazard):

Unsafe Conditions (Environmental Factors)

 Taking an unsafe position or posture.

 Working on moving equipment.

 Defecting safety devices.

 Failure to use personal protective equipment.

 Failure to secure or warn.

 Operating without authority.

 Operating or working at an unsafe speed.

When You See a Problem, You Welcome !!!

- Personnel Protective Equipment (PPE)

- Tools & Equipment

• Reflects state of mind

• Match the activity with the

• Right for the Job?

• Adequate for the job?

300 Minor 600 Minor

(New case) (Stable case)

INITIAL STUDIES RECENT STUDIES

Degree of Near Target Weight 2004 2005 Recommendation

• ELNG & Contractor Managers Carryout Site Inspections Together

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