Loss Prevention Manual

TITLE Pipelines & Distribution Manual Volume 1 - Administration
SECTION 04: Safety

SUBJECT 31: Loss Prevention System
PURPOSE AND SCOPE
 The purpose of this subject is to document the procedures for the Loss Prevention
System for all Canada Fuels Operations (CFO) sites.
REFERENCES
PDM 01-04-15: Safety Communication Boards
PDM 01-04-29: Safety - Small Vehicle Safe Operating Program
PDM 01-09-01: Incident Reporting: Reporting Overview
PDM 01-09-03: Incident Reporting: Categorizing Incidents & Initial Notification

Standards
PDM 03-02-01: Critical Procedures: General
ASSOCIATED DOCUMENTS
 0104F17.Doc: JLA Form
0104f29.Xls: LPO - Driving
0104f32.Xls: LPO - Operations
0104f41: LPS Training Certificate
 0104f44.Xls: LPO – Work Permitting
 0104f52.Doc: Monthly LPS Stewardship Meeting for FLS and work groups
 0104f53.Doc: Monthly LPS Stewardship Meeting for SLS and Managers
0109F07.Doc: Incident Report
0109F08.Doc: Near Loss Report
0109F11.Doc: Hazard Identification (HID) Report
Page 04. 31-1 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
DEFINITIONS
EMP
Engineering, Maintenance, and Projects workgroup
 FLS
First Line Supervisor; could be EMP Project Manager, Pipeline Integrity Field
Construction Supervisor, Operations Terminal/Site Manager or Group Team Lead
 FRCS
Factors, Root Causes, Solutions
HID
Hazard Identification
IMPACT
 ExxonMobil common electronic platform for incident reporting, tracking and
recordkeeping. Used to document LI’s, NLI’s, & LPO’s.
 JLA
Job Loss Analysis
LI
Loss Investigation
LPO
Loss Prevention Observation
LPS
Loss Prevention System is a system to prevent incidents using behavior-based
tools and proven management techniques.
This prevention of incidents is accomplished in a work culture that:

 Emphasizes proactive activities;
 Capitalizes on the job expertise of employees;
 Maximizes use of positive reinforcement;
 Integrates the LPS tools with the daily business; and practices "providing
direction from the top down while solving problems from the bottom up."
June 2016 Page 04. 31-2 of 61

Pdm10431.doc
SECTION 04: Safety
 LPS Stewardship
Conducted on a monthly basis. Every supervisor to lead team in the monthly LPS
Stewardship meeting and document using either 0104F52 (for FLS lead meetings)
or 0104F53 (for SLS/Manager lead meetings).

LPSA
Loss Prevention Self-Assessment
 LT
Canada Fuels Operations Leadership Team; includes Operations Managers (East
and West), SSHE Team Lead, Pipeline Integrity Manager, EMP Manager and
BA&I Manager
MVI
Motor Vehicle Incident
NLI
 Near Loss Incident
Ops Manager
Operations Manager or as delegated to the Senior Area Manager
SSH&E Manager
 Refers to the Safety, Security, Health and Environmental Manager/Team Lead
SWP
Safe Work Permit
PROCEDURE HYPERLINKS
Listed below are hyperlinks that when clicked will take you directly to that
section of this procedure. This list has been provided due to the length of this
subject to make it easier to navigate within it.
 LPS Overview – page 4
 Loss Prevention Self-Assessment (LPSA) – page 8
 Loss Investigation – page 10
 Factors, Root Causes and Solution (FRCS) – page 15
 Loss Prevention Observations (LPO) – page 29
 Job Loss Analysis (JLA) – page 38
Page 04. 31-3 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
 Stewardship – page 45

PROCEDURE
 INTRODUCTION TO THE LOSS PREVENTION SYSTEM (LPS)
Definition of LPS
LPS is a system to prevent or reduce losses using behavior-based tools and proven management
techniques. This prevention or reduction of losses is accomplished in a work culture that:
 Emphasizes proactive activities;

 Capitalizes on the job expertise of employees;
 Maximizes use of positive reinforcement;
 Integrates the LPS tools with the daily business; and
 Practices “providing direction from the top down while solving problems from the
bottom up.”
What is a Loss?
A loss is defined as any unplanned cost that an organization might experience.
Types of Losses Targeted for Prevention
The goal is to prevent or reduce the occurrence of seven types of losses:
 Personal injuries;
 Equipment or property damage (includes MVCs and fires);
 Product quality losses (includes spills and leaks);
 Regulatory assessments;
 Operational or system inefficiencies;
 Financial losses; and
 Near losses.
How Does LPS Address These Types of Losses?
LPS tools work specifically to identify those factors that cause or contribute to the losses and
implement solutions to eliminate or reduce the likelihood that the adverse event will recur.
Before providing an overview of the LPS tools and activities, let’s review the fundamental
concepts on which the entire Loss Prevention System™ is founded.
June 2016 Page 04. 31-4 of 61

Pdm10431.doc
SECTION 04: Safety
LPS Pyramid Strategy
The erroneous loss reduction strategy adopted by most organizations is to focus on the upper
level of the pyramid. In other words, the majority of the organization’s time and efforts to reduce
losses concentrates on investigations of lost-time injuries only. This approach is a mistake for at
least two reasons. First, the organization actually functions in and is perceived as being in a crisis
mode — which is precisely where the organization has positioned itself. As professional as the
investigation efforts might be, the energy to solve these problems only happens “after the fact.”
Seldom, if ever, are investigations conducted of minor loss cases, equipment damage, and
spills/mixes, not to mention near losses. The organization fails to see the common threads of
factors and root causes that run through each of these levels and types of losses.
This reactive approach is a mistake for a second reason. Generally, companies prefer to develop
loss reduction strategies and make decisions based on analyses of loss data, not on hunches and
myths. Therefore, if the organization only investigates the upper level of the pyramid, it loses
hundreds of opportunities to learn from loss and near loss experiences on the lower levels. The
obvious implication is that the factors that cause or contribute to those losses on the lower levels
are very similar to the causal factors of those losses on the upper level of the pyramid.
The fundamental strategy for loss reduction and prevention is quite basic. As the organization
identifies and eliminates factors and root causes of losses and near losses on the lower levels, it
eventually will prevent occurrences of those more serious losses on the upper levels. Then, the
organization operates proactively rather than reactively.
Traditional Safety Contrasted with LPS

First, traditional safety focuses on the top of the pyramid. LPS has tools that address all levels of
the pyramid, with the primary focus being on the lower levels. Second, traditional safety tends to
limit its efforts to personal injuries and, n some occasions, regulatory violations. LPS addresses
all types of losses, including injuries and government violations to include product spills/mixes,
reliability losses, equipment/property damage, and near losses. Third, traditional safety programs
are understandably perceived as being reactive while LPS is seen as a proactive approach to
preventing losses, anticipating and resolving risks and hazards before losses result. Fourth,
traditional safety programs lose the wealth of information that can be gathered from lower-level
events of the pyramid, while LPS makes decisions based on a tremendous amount of information
from the lower levels of the pyramid.
LPS Principles
LPS has four principles that are essential to its success. Adherence to these principles is an
absolute prerequisite for improving loss prevention performance.
Principle 1: Everyone must participate. The approach to LPS implementation should be that
the overall direction will be provided from the “top down,” while determination of such specifics
as how to best use the LPS tools will be from the “bottom up.” All levels of the company must
Page 04. 31-5 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
be actively involved, with each person having the opportunity to develop ownership and an
identity that includes the daily use of LPS tools and activities.
Principle 2: Integrate LPS tools and activities with the daily business. All LPS tools and
activities should be designed and developed so that they are integrated into the normal, recurring
business affairs of the organization. Some of the LPS activities occur daily, while others take
place weekly or monthly. Nonetheless, communication of losses, and near losses, Loss
Prevention Self Assessment (LPSA), Job Loss Analysis (JLA), Loss Investigations (LI), Near
Loss Investigations (NLI) and Loss Prevention Observations (LPO) must be performed as part of
the job, just like any task is part of the normal business.
Principle 3: Develop and communicate the LPS plan. This principle means that the
organization’s overall business plan must include LPS. Each employee should know the
generalities of the overall LPS plan and, at the same time, be familiar with the specifics of
his/her role to help achieve LPS goals and objectives.
Principle 4: Address risks before a loss occurs. Although LPS includes investigations of losses
that already have occurred, the majority of time spent on LPS tools and activities should be
proactive. In other words, most of LPS’s efforts should focus on identification and elimination of
risks before an injury or other type of loss takes place, not after the fact.
LPS Guidelines
LPS has a systematic approach to minimize all types of losses. LPS follows a consistent and
standard set of operating guidelines as described below.
Guideline 1: LPS requires investigations of all personal injuries, regardless of the level of
severity. The purpose of investigations is to examine information from each injury as it occurs
and then implement recommended solutions that should eliminate or reduce the likelihood that
the injury will recur. All degrees of injury severity are examined because research has proven
that the causes of minor injuries are nearly identical to those causes of more serious injuries.
Therefore, if the organization can determine the cause of a first-aid case, it probably will
eliminate a more serious injury that eventually would have occurred.
Guideline 2: LPS requires that Loss Prevention Self Assessments (LPSAs) be performed at
least daily by all persons before, during, and after work.
Guideline 3: LPS requires conducting Loss Prevention Observations (LPOs) on a planned

and regular basis. An LPO is a systematic tool for observing a work process and determining if
the job or task is being performed according to certain safety/loss prevention standards. The
general objective of the LPO is to help maximize the effectiveness of each work process.
June 2016 Page 04. 31-6 of 61

Pdm10431.doc
SECTION 04: Safety
Guideline 4: LPS requires that a Job Loss Analysis (JLA) be developed for all major work
tasks or processes. The JLA is a tool and a technique to reduce losses in the workplace by
studying a task or job in order to develop the most loss-free way to accomplish it.
The JLA involves defining the major steps in a job, identifying the loss potential associated with
each step, and developing critical actions to eliminate or minimize the loss potential. Similar to
an LPO, the JLA proactively foresees and eliminates the potential for losses.
Guideline 5: LPS requires full communication of loss cases, as well as results from the
application and use of LPS tools. These communications include dissemination and discussion
of (1) root cause of recent losses, (2) solutions to prevent loss recurrence, and (3) results of
previously implemented investigation and observation solutions. The communications occur in
several different forums to include safety discussions at the beginning of each shift, discussions
of LPS Alert and Bulletin information following losses, and written materials in company
publications, and bulletin board notices.
Communications also include feedback to all levels of the organization regarding quality and
process measures for LPS tools. These measures might include LPS tool usage, the percentage
of observations actually conducted in areas targeted for risk reduction, the percentage of
observations with questionable items, the percentage of time observation feedback discussion
sessions were conducted on the same shift as the observation and facilitated by the employee’s
supervisor, the percentage of investigations and observations in which the factors and root
causes were identified rather than symptoms, the percentage of solutions implemented on time,
and the most frequently occurring questionable items by observation type.
Guideline 6: LPS requires that internal loss prevention assessments or evaluations be

conducted periodically. These assessments or evaluations are necessary to ensure that the LPS
plan is being followed and that quality standards are being maintained for each of the LPS tools
and activities. With regularly planned assessments, deviations from LPS can be resolved rather
quickly. Feedback regarding results of these assessments should be provided to all employees on
a regular basis.
Guideline 7: LPS requires that persons at all levels of the organization be accountable for
loss prevention performance. Accountability should not be interpreted as a “negative” event.
Under LPS, accountability refers to recognition for excellent loss prevention performance, as
well as coaching and counseling for unsatisfactory performance. The intent is to change behavior
in a positive fashion, not punish people.
LPS Is Custom Made
LPS is custom made to match an organization’s unique needs. This tailoring must be done to
ensure that LPS reflects the specific circumstances, characteristics, resources, and risks
associated with our business, while at the same time adhering to the LPS guidelines and
principles
Page 04. 31-7 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
TOOL: Loss Prevention SELF ASSESSMENT (LPSA)
DEFINITION: A brief, general risk assessment conducted prior to the start of a work activity or
task.
EXPECTATION: All employees and contractors will perform LPSAs at the beginning of their
work, before doing new activities for the first time, for non-routine activities, and immediately
following a loss or near loss.
OVERVIEW: Many processes, operations, and tasks have risks with loss potential. Before these
risks can be eliminated or controlled, they must be identified. Loss Prevention Self Assessment
or LPSA is a tool that enables everyone to identify and eliminate potential workplace practices
and at-risk conditions that could lead to any type of loss. This tool is based on the principle that
each individual takes responsibility for his or her own loss prevention in all daily activities and
commits to:
EXPECTED BENEFITS
This tool requires that everyone performing the LPSA view each step of his/her work activity as
part of a system. In doing so, he/she assesses the potential risks of each step in the process, while
keeping in mind the relationship between steps and the interaction among workers, equipment,
materials, and the work environment. Other benefits of the LPSA include:
 Identifying at-risk conditions and potential losses;

 Providing information to enable effective controls or procedures to be established;
 Determining whether employees and contractors have the appropriate training,
knowledge, and skill level to perform the job properly; and
 Discovering and eliminating at-risk work procedures, practices, and conditions
June 2016 Page 04. 31-8 of 61

Pdm10431.doc
SECTION 04: Safety
LOSS PREVENTION SELF-ASSESSMENT PROCESS
The LPSA is a three-step mental risk-assessment process.
Step 1: The first step of the LPSA is to “ASSESS the risk!” Everyone must assess the risks
associated with each job. Everyone should assess risks and ask what could go wrong? What is
the worst thing that could happen if something does go wrong? Below are some sample
questions that should be asked:
 Are there materials on the floor that could trip a worker?

 Is lighting adequate?
 Are there any electrical hazards at the job site?
 Are there any explosive hazards associated with the job? Can any develop?
 Are tools, including hand tools, machines and equipment in need of repair?
 Is there excessive noise in the work area, hindering worker communication?
 Is fire protection equipment readily accessible? Have I been trained to use it?
 Are trucks or motorized vehicles properly equipped with brakes, overhead guards,
backup signals, horns, steering gear, and identification?
 Am I wearing the correct personal protective equipment?
 Is ventilation adequate, especially in confined spaces?
 Have tests been made for oxygen deficiency and toxic gases?
 Is the equipment properly locked and tagged out?
 Is any critical safety device altered in this process?
 Is my workstation adjusted per ergonomic standards?
 Are the reports that I am reviewing accurate and complete?
 Have I received proper approval for this purchase or transaction?
Step 2: The second step of the LPSA process is to “ANALYZE how to reduce the risk!” The
individual should evaluate each risk identified during the “assessment process” to ensure
appropriate safeguards are in place to control the risk. During this step, the individual should
ensure that he/she has the appropriate training, knowledge, tools (including reports, databases,
information systems, etc.), equipment, and personal protective equipment to perform the job
properly.
Step 3: The third step is to “ACT to ensure loss-free operations!” The employee should take the
necessary “steps” to ensure the job is done properly. This step includes taking appropriate action
such as locking out equipment, placing warning cones, positioning trucks, standing out of the
line-of- fire, following operating procedures, reviewing data tables, verifying accuracy of data
entry, etc. If an employee is unsure how to perform the job properly then he/she must stop and
ask for assistance.
Page 04. 31-9 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
LOSS PREVENTIOM SELF-ASSESSMENT CARD
The LPSA card is intended to be used as a personal reminder to think about the loss prevention
aspects of a job. This card also reminds us that we as individuals are responsible for, and
empowered with, the appropriate authority to “ensure that no work is performed or continued if it
cannot be done properly.”
WHEN TO CONDUCT LOSS PREVENTION SELF ASSESSMENTS?
Pre-shift: Everyone should take five minutes before starting work to review the work activities
to be performed during the workday. This time period would be used for checking tools and
equipment, conducting pre-trip inspections, reviewing route cards and unusual condition reports,
conducting work site inspections, reviewing on-going work activities and scheduled product
receipts, reviewing prior shift reports, reviewing active work permits, checking compliance with
lock- outs/tag outs, reviewing nightly IT data downloads, reviewing new employee payroll
processing requests, etc.
New Activities or Equipment: An LPSA should be conducted before performing any new
activity or any activity for the first time. This check would include stopping to ensure that an
operating procedure is available and understood. This LPSA may identify that a more thorough
and comprehensive Job Loss Analysis be used to develop proper procedures.
Unusual Circumstances: An LPSA should be conducted for unusual circumstances or during

non-routine activities such as: (1) major construction or demolition activities, (2) changes or
alterations to critical safety devices, (3) system software upgrades or changes, or (4) other
changes in the normal operating procedures, present the potential for hazards to exist.
Additionally, if any activity causes an individual to feel uneasy or unsure that the work can be
performed in a loss-free manner, an LPSA should be conducted.
Losses or Near Losses: An LPSA must be conducted following any loss or near loss to analyze
the potential for recurrence. After a loss or near loss, the individual must STOP all activities until
it is determined that the job can be performed properly.
TOOL: LOSS INVESTIGATION (LI)
DEFINITION: A systematic examination of equipment/property damage, releases, leaks,

reliability issues, regulatory violations, product quality incidents, motor vehicle crashes, fires,
business interruptions, personal injuries, environmental incidents and near losses for the purpose
of eliminating risks and future losses.
EXPECTATION: All types of loss and near losses will be reported and investigated to identify
why the incident occurred and to develop solution(s) to eliminate or minimize the potential risk.
Success in these expectations will reduce loss, creating a more competitive operation.
June 2016 Page 04. 31-10 of 61

Pdm10431.doc
SECTION 04: Safety
OVERVIEW: All injuries will be investigated, including reportable-only and first aid cases.
The reason is that the causes of these relatively minor kinds of incidents are similar to those
associated with more serious losses. When the cause of a less severe loss is identified and
eliminated, the organization can prevent the major loss from occurring. All regulatory citations,
reliability losses, spills, cases of equipment or property damage, and all product quality are
candidates for investigation.
However, common sense dictates that there are an optimum number of investigations that can
and should be conducted during the daily operation. Based on the definition of damage or loss,
there could be an inordinate number of opportunities for investigations. In these cases, the
organization must select higher priority losses or near-losses to investigate.
EXPECTED BENEFITS
If employees and contractors at all levels of the organization work within the “spirit” of LPS, the
majority of investigations will be for near losses rather than losses. Nonetheless, both near losses
and loss investigations should yield several benefits:
 For near loss events, proactive identification and resolution of the risk before a loss occurs;
 For actual losses, consider all factors that potentially caused or contributed to the loss, determination of root
cause(s) and development of solution(s) to eliminate or minimize the risk;
 For all investigations, employee (job expert) input regarding the effectiveness of solutions and whether or
not the loss circumstances have been resolved satisfactorily; and
 A tool to track loss trends and tendencies with the vast majority of data directing the organization’s efforts
toward levels of the pyramid below major incidents.
Near Losses
Near loss investigations are an integral part of the LPS investigation tool. No employee should
feel threatened regarding honest reporting of near losses. It would not be appropriate to
investigate near losses differently than actual losses because the factors and root causes are
nearly always the same. A near loss is simply a loss that was avoided because circumstances
were slightly different. By managing near losses, the more severe loss can be prevented. To
properly determine the factor, identify the root cause(s), and develop solutions for a near loss, we
will use the same report form and analysis technique as for a loss investigation.
Employees are encouraged to report all near losses without fear of reprimand or peer pressure. It
is important to provide as much information about the near loss as possible.
Third Party Loss
The same loss reporting, investigation, and analysis procedures will be followed for any of the
above listed losses that occur to contractors providing services. Use of LPS tools also extends to
contractors. Our goal of “a loss-free workplace” cannot be reached without the loss-free
Page 04. 31-11 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
performance of contractors. It is important that we identify any near losses and investigate all
losses to determine the root cause(s) and develop solutions to prevent the loss or near loss from
recurring.
Reporting
All loss reports, including near losses, should use the Loss Investigation / Near Loss
Investigation form and/or enter the information directly into the Loss Prevention Information
System. The general purpose of this report is fourfold.
 State clearly and describe what happened (describing the problem, not the symptom or consequence);
 Identify the basic issues (factors);
 Identify and describe the root cause(s) and contributing factor(s); and
 Develop solution(s) that match the factor category and address the root cause.
It is important that valuable time not be wasted researching and reporting loss information that
has no bearing on the factors, root cause(s) and corresponding solution(s). Focus on correcting
the circumstances that cause the loss -- behavior focused, not loss focused. For example, the root
cause and solution for a valve left open and corrected before any product was spilled should be
the same as for a valve left open and an entire tank spilled.
Near Loss Reporting
Near loss investigations should be conducted using the same guidelines as are applied for loss
investigations in order to obtain valuable peer input. Once the equivalent of the questionable
item(s) is identified during the fact-gathering step, the FLS and other members of the
investigation team must proceed through the FRCS™ tool.
All near loss reports should be completed by the Investigation Team in the field and entered into
the information database. It is very important to provide enough detailed information so that the
“lessons learned” can be shared throughout the organization.
LOSS (LI) / NEAR-LOSS (NLI) INVESTIGATION PROCESS
1. Loss Occurrence and Initial Notification to Supervisor

Upon identification of an incident or near loss, the involved employee(s) should inform his/her
supervisor and initiate steps to contain the situation within the scope of their training (i.e., take
steps to prevent an escalation of the event impact).
2. Risk Assessment of Incident

Under no circumstances should operations resume until it has been determined to be safe to
continue work. This risk assessment may be as simple as an employee performing a loss
prevention self-assessment (LPSA) of the incident or near loss. Alternatively, the supervisor and
June 2016 Page 04. 31-12 of 61

Pdm10431.doc
SECTION 04: Safety
employee might conduct the risk assessment together and determine if it is safe to resume.
Nevertheless, work should not continue until it is clearly known why the incident occurred.
3. Starting the Investigation

Once the situation has been contained and the scene secured (if appropriate), evidence and data
collection should be initiated to start the investigation.
When Should the Investigation Be Done?

It is important to prevent a loss from recurring under the same circumstances. Therefore, all Loss
Investigations should be initiated within 24 hours and completed according to the Loss
Investigation and Reporting guidelines independent of their severity.
4. Fact Gathering
It is essential that proper information and fact gathering take place at all times during the
investigation. The accuracy and thoroughness with which the investigators obtain and record
information and data will largely determine the quality of the final report and the effectiveness of
corrective actions.
Directing the Fact Gathering Process

The supervisor is responsible to assign personnel to gather the facts and supporting information
surrounding the incident. For minor or non-complex losses, the supervisor or other personnel can
quickly gather the information immediately following an incident. Based on the complexity of
the situation, this information may be all the investigation team needs to analyze the incident,
write a description, and use the FRCS™ to identify the factor(s), determine the root cause(s), and
develop solution(s).
Situations that are more complex may require additional resources and experts to be named to
the fact gathering team, and the time needed to obtain the facts may increase. Regardless, the
investigation should not proceed until all the facts have been gathered.
During the fact-gathering step of the investigation process, it is critical to get to the “equivalent
of the questionable item(s) for an LPO” to understand what led to the loss/near-loss scenario.
Fact gathering team can take photos or videotapes of the incident. The teams should record and
obtain any relevant information such as equipment size, location, manufacturer, quantity, and
pressures. Ideally, the fact gatherers should walk through the process and re-create the incident
scenario.
Interview Process
During the entire investigation process, it is essential that all involved parties focus on fact-
finding, not fault finding. The slightest hint of fault finding will negate the purpose of the loss
investigation.
Page 04. 31-13 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
The fact-gathering team should interview and speak only with people directly involved in the
loss. It is critical that the team deals in facts and not speculation on what might have happened.
The team should create a comfortable setting for the discussion. The team should ask open
ended, non-leading questions. Before leaving, the team should close out the interview and thank
the interviewee.
Supporting Information
Based on the incident there maybe circumstances where the fact- gatherers might require the
assistance of persons with special expertise (for exampled, structural engineer, chemist,
computer programmer, accountant, or manufacturer representative). These experts should be
consulted prior to continuing to the next step of the investigation process.
Additionally, the team should secure and review all documentation associated with the incident.
Documentation such as operating procedures, JLAs, maintenance records, equipment
manufacturer’s guidelines, inspection, maintenance and training records, and/or engineering
design and regulatory standards.
During the fact gathering step of investigation process, it is critical to get to the “equivalent of
the questionable item for an LPO.”
5. Investigation Team
The primary role of the investigation team is to review the facts of the incident and prepare the
investigation report (description and use the FRCS™ to consider all 7 factors, identify the root
cause(s) and develop solution(s). The supervisor is responsible for selecting the remainder of the
investigation team members based on the information provided by the fact-gathering team. Once
the facts have been gathered it is usually easy to decide who should be part of the investigation
team.
Naming the investigation team prior to gathering the facts often times results with the team
dealing with symptoms versus the real root causes of the incident. It is important to remember
that: “All fact gatherers are part of the investigation team, but all investigation team members
may not be fact gatherers.”
Employees’ knowledge and experience are the keys to the success of the LI/NLI tool. The
personnel who perform the jobs or tasks where a loss occurs have the knowledge to identify the
real root cause(s) and develop the solution(s) that will likely keep the loss from recurring. This is
why employees who are responsible for the job or task will participate in the initial investigation
of all losses. The team composition will vary depending on the type, location, and severity of the
loss. Management may designate other personnel in addition to the members listed, as is
appropriate.
June 2016 Page 04. 31-14 of 61

Pdm10431.doc
SECTION 04: Safety
6. Description
The investigation team is required to complete the Description section of the NLI/LI form. This
section provides an understanding of what happened, how it happened, and when and where in
the process the loss occurred. The description should be brief and concise, however enough
detail should be given so that anyone reviewing the report will have a clear overview regarding
the circumstances surrounding the incident and how the event took place.
The description is to share the learning with others in the organization. The description is
valuable so that others in the organization who perform the same job will be able to identify with
the task being performed or the tools or equipment being used. This is why including detailed
information about the actual procedure, process, equipment type, manufacture is important. The
reader of the description should be able to answer from the description: “Do we perform this
same task/activity and do we have the potential for this loss to occur in our organization?”
7. Factors, Root Cause, and Solutions (FRCS™)

The examination of ALL basic issues (factors), identification of the root causes, and
development of solutions are the most critical elements in the investigation and observation
processes. If an investigation or observation only identifies symptoms, rather than the root
causes, the resulting solutions will hold little value because the real issues are never addressed.
Keep in mind that any loss, near-loss, or questionable work activity or condition may have
several basic issues (factors) and root causes. Once the basic factors and root causes are
identified, the development of solutions is fairly easy.
The FRCS™ is used for all investigations and observations. Where you start is important. For
LPOs, use the flowchart for each questionable item. For NLI/LIs, identify the issue, not the
symptom or consequence, before using the flowchart. During the fact-gathering step of
investigation process, get to the “equivalent of the questionable item(s) for an LPO”. Then, use
the flowchart. For example, don’t start with the fire (symptom/consequence). Rather start with
the employee did not close valve (equivalent of LPO questionable item), which is what led to the
fire.
The flowchart leads you through specific factors, in the form of questions that have the potential
to cause or contribute to losses, near-losses, and questionable work activities and conditions.
FRCS™ keeps you focused on basic factors and related root causes and steers you away from
symptoms.
Factors, Root Cause(s), and Solutions Flowchart™ (FRCS™) Explanation
The FRCS™ examines all basic issues (factors), which are in the form of questions. Seven (7)
questions are listed horizontally on page 1 and 2. Each factor question must be considered and
answered with a YES or NO. If the users answer YES to factor questions on page 1, the users
must verify critical information before moving on. If they answer NO to the factor questions on
page 1, users must circle the factor, identify the root cause(s), and develop proper solutions by
following the solution guidance.
Page 04. 31-15 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
Factor Question 1: Is there adequate documentation regarding how to do this task? This
means do we have work documentation (SOPs, JLAs, SWPs, etc.) for the task and are the
developed standards up to snuff? If the answer is YES, the users must physically verify that
adequate documentation (JLA, SWP, or procedure) exists for the task. If the answer is NO, the
users need to identify the root cause(s) of why isn’t there adequate documentation explaining
how to do this task?
Matching solutions should explain who will develop the procedure, JLA, or SWP for this task
(who writes, reviews, and approves, due date, etc.)
Factor Question 2: If tools are needed for task, are they available, operable, safely
maintained and are there proper task and workplace design? In reality this means, “Do I
have the iron to get the work done?” Are the tools and equipment available, designed to do the
job properly, and maintained and operable. In addition, is there proper design of the workplace
and the task. If the answer is YES, the users will specifically explain what tools/equipment are
needed and how they are accessed. If the answer is NO, the users need to identify the root
cause(s) of why tools aren’t available, operable, safely maintained, and why there are not proper
task and workplace design.
Note: If tools are available and operable, but are being improperly used, then we’re dealing with
another factor question.
Matching solutions should explain how tools will be made available, operable, safely maintained
for task (who makes available, due date, etc.) and/or how task and workplace design will be
made proper (who is responsible, due date, etc.).
Factor question #3: Has your supervisor told you to ALWAYS do all tasks according to
procedures or acceptable practices? Supervisors need to communicate face-to-face with every
employee routinely and let them know what the expectations are. If the answer is YES, the users
should give an example of how this face-to-face communication occurred/occurs. If the answer is
NO, the users need to identify root cause(s) of why this face-to-face communication has not
occurred.
Matching solutions should explain how the FLS will communicate face-to-face with the person
to ALWAYS do this task, as well as ALL tasks, according to procedures and acceptable
practices.
Factor question #4: Are you familiar with task documentation and do you know how to do
task according to documentation? The person must have the necessary understanding or
proficiency to perform the task according to documentation. In street terms, do I know how to do
the darn job? I want to do the job right, I’m motivated to do the job according to standard
procedures, I have all the equipment, and the procedure is well-defined. Has someone showed
me or given me a course on how to do this? If the answer is YES, the users must explain how to
do the task according to documentation (JLA, SWP, and procedure). If the answer is NO, the
users must identify the root cause(s) of why the person does not know how to do the job
according to documentation.
June 2016 Page 04. 31-16 of 61

Pdm10431.doc
SECTION 04: Safety
Matching solutions should explain how the person will be shown how to do the task according to
documentation (who will show the person, due date, etc.).
Page 2 of the FRCS™
Why didn’t you do the task the way you know it should be done…? When this category is
considered, we have already established that the employee or contractor has been properly
trained and knows how to do the job, but for some psychological reason, is not motivated to
perform the task as required. We need to consider all of the following factors in the form of
questions (Factors 5-7). If the users answer NO to factor questions on page 2, the users can move
to the next factor. If they answer YES to the factor questions on page 1, users must circle the
factor, circle the root cause, identify what part of the procedure or acceptable practice was not
followed, and develop proper solutions by following the solution guidance.
Factor Question 5a: Have you ever done this task before and not followed procedures or
acceptable practices? Yes to this question and No to “Did anything go wrong?”
If we answer NO to the factor question, then the team will move on to box #6. If users answer
Yes to the factor question and nothing went wrong, then the root cause is: Person did not follow
procedures for this task on other occasions and there were no negative consequences. In other
words, the person thinks that there is no personal benefit to always doing the job according to
standards — this perception is statistically reinforced when procedures are not followed and
there is no consequence. The explanation for this goes back to our loss-ratio triangle— if we
look at the numbers 1-10-30-600, the triangle tells us that 630 out of the 641 times that I take a
short cut, nothing is going to happen to me. If nothing bad has ever happened when I don’t chock
the wheels before I crawl under a machine or if I don’t use the right tools, I quickly begin to
think that “Hey, I’ve done this job a couple hundred times and nothing has ever happened to me,
so it doesn’t really matter if I go by the standards.”
The perception is also reinforced when supervisors do not make compliance with standards
important. If the supervisor walks by and sees me using the wrong tools and doesn’t say
anything, I consciously or subconsciously interpret that it must not really be important— because
if it were important, then the supervisor would have stopped and said something. He must not
think there is any personal benefit for me either.
We should also identify and write out what part of the procedure or acceptable practice was not
followed to help beef up and make our solutions more meaningful.
For the matching solutions, the FLS will have the person verbalize the consequences if he/she
continues to perform the task this way just because he/she did it in the past and no incident
occurred.
Factor Question 5b: Have you ever done this task before and not followed procedures or
acceptable practices? Yes to this question and Yes to “Did anything go wrong?”
If the users answer Yes to this question and indicate that something did go wrong when they
didn’t follow procedures or acceptable practices for the task, then the root cause is: The person
did not follow procedures or acceptable practices on other occasions. The person thinks that
there is no personal benefit to always doing the job according to standards even when they have
Page 04. 31-17 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
experienced minor consequences. In other words, the minor consequences are so inconsequential
to the person.
The perception is also reinforced when supervisors do not make compliance with standards
important. If the supervisor walks by and sees me using the wrong tools and doesn’t say
anything, I consciously or subconsciously interpret that it must not really be important— because
if it were important, then the supervisor would have stopped and said something. He must not
think there is any personal benefit for me either.
For the matching solutions, the FLS will have the person verbalize the consequences if he/she
continues to perform the task this way.
Factor Question 6: Did you not follow procedures or acceptable practices because you have
an easier, faster, or “better” way of doing this task?
If we answer NO to the factor question, then the team will move on to box #7. If we answer Yes
to this question, then the root cause is: Person did not follow procedures for this task because
he/she has an easier, faster, or “better” way of doing task. In other words, it’s a lot easier or
faster for me to do the job contrary to standard procedures or the person feels like their way is
better, even though it’s contrary to standards, regardless of the way I’ve been trained (i.e., It is
physically easier or it gets done quicker). For example, if I’m trying to take a pump apart, and I
know I need a power wrench to break that nut, but it’s three hundred yards away, cold and
raining outside, I may say, “I’ll just take that crescent wrench and get a five foot cheater bar and
break it. It’s faster. And it’s easier than me going outside.” The person knowingly deviates from
standard procedures. He/she has been trained properly, knows how to do it, but consciously takes
a calculated risk.
For the matching solutions to Factor question 6, the FLS will have the person verbalize
consequences if he/she continues to perform the task this way just because he/she has an easier,
faster, or “better” way to do this task.
Factor Question 7: Has your FLS, Manager, or peer observed you not following procedures
for this task and not said anything to you?
If we answer NO to the factor question, then we have considered all basic issues (factors). If we
answer YES to the factor question, then the root cause is: FLS, Manager, or peer observed
person not following procedures for this task and tolerated it. In other words, it means that the
supervisor, manager, or peer either accepts, or positively reinforces me to not do the job exactly
the way it should be done. Let’s say I’m a driver and I have the quickest unloading time of all
drivers who operate delivery trucks. What if we come in at the end of the month for a meeting
with the supervisor, and he/she says, “If everybody ran their truck the way you do, we’d make a
lot more money and we wouldn’t have this overtime. You’ve got the best unloading time of
anybody.” He/she and I both know, as everybody else does, that I am taking all kinds of
shortcuts out there. So since he/she is not coming out and saying I’m not doing the job correctly
June 2016 Page 04. 31-18 of 61

Pdm10431.doc
SECTION 04: Safety
or safely, he/she is really reinforcing my short-cutting because he/she is recognizing me for

having the fastest unloading time.
For the matching solutions, the SLM will show the FLS how to build the right workplace culture
and send the right message via effective— (LPSA stewardship, V&V of tool solutions, LPO
feedback discussion sessions, and monthly LPS stewardship meetings.
External factor is not listed on the flowchart as less than 1% of all root causes of questionable
items, near losses, and losses are beyond the control of the person, his/her FLS, and the
organization. In the rare case when a root cause is beyond the control of the person, his/her FLS,
and the organization, solutions should focus on minimizing loss potential when the situation
occurs again. We should take extreme caution when considering this factor as we are saying,
“We’ve done everything we can possibly to do prevent this issue from happening.” That’s the
good news. The bad news is it’s going to happen again. These events would be factors relating to
weather catastrophes, criminals etc. The event may not be preventable, but often time
organizations can implement policies, procedures, and design parameters that can minimize the
severity of the loss when it does occur.
Page 04. 31-19 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
June 2016 Page 04. 31-20 of 61

Pdm10431.doc
SECTION 04: Safety
Page 04. 31-21 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
Tips on Development of Solutions

The solutions must meet the “Smart definition:
 Specific…must describe in detail exactly what must happen to change to eliminate or control
the risk of the incident.
 Measurable…how will you know the solution has been implemented?
 Action-oriented…assigns equipment, personnel and resources to implement.
 Realistic…the solution is cost effective and maintainable by the organization long-term.
 Time Phased…realistic due dates are assigned
There are a few guidelines to follow when deciding what solution(s) to make to prevent a loss
from recurring. While there are exceptions, the investigation team generally should adhere to
these guidelines.
Solutions should be practical. The most effective solutions are those that focus on personal or job
factors over which the worker or supervisor has control.
Solutions need not be expensive. Again, the majority of effective solutions are relatively
inexpensive and implemented with resources within one’s own organization.
Solutions are not short-term focused. They must be sustainable. If solutions are made that are
unreasonable, and/or impractical the solutions must be re-evaluated. Otherwise, the road is being
paved for “a loss in credibility.”
Lastly, the person responsible for overseeing that the solution is implemented should be
contacted and reach agreement that the person is in agreement with the solution and provides and
agreed due-date. The vast majority of cases the person responsible for the solution should be a
part of the investigation team.
8. Quality Check (FLS) / Quality Review (Manager) and Approval

Supervisor
The supervisor is the first person in the chain of command with responsibility for a quality check
before entry into the database. The supervisor quality checks the investigation report for the
following:
 Complete and accurate administrative information?
 Writes thorough description of near loss or loss?
 Selects factor(s) that matches root cause?
 Identifies root cause(s) by explaining why near loss or loss occurred?
 Develops solution(s) that matches the factor & addresses root cause?
Person responsible for overseeing implementation is a identified with appropriate due dates.
90+% of the time the person responsible is the FLS.
June 2016 Page 04. 31-22 of 61

Pdm10431.doc
SECTION 04: Safety
Then, the supervisor either approves the report or recycles it back to the investigation team with
specific advice. Once approved, the supervisor is responsible for ensuring that the form is routed
and forwarded to the next level to approve the solution if required.
The supervisor is in the key position to ensure quality for the entire investigation process because
he/she is most familiar with the details of the incident and has a working knowledge of the tasks
affected by the solutions.
Other required reviewers and approvers

The investigation team may assign an additional reviewer and approver to the investigation if
they so choose for
additional insight and feedback. This process is used as a separate set of eyes on the quality of
the investigation. The person listed as a reviewer and approver should follow the same process as
the supervisor listed above. Note: This
process is different from the LPS tool quality review as outlined in the LPS Stewardship process.
Safety Issues and Personal Injuries – SHE Subject Matter Expert (SME)/LPS Core Team
Driving Issues – Driver Training Specialist, Driver Instructor
Engineering Issues – Facility engineer
Spills – Environmental specialist
Mechanical integrity issues – Mechanical integrity specialist
Ergonomics – Ergonomics Subject Matter Expert
9. Communication
LPS Alert
Initial communication of a major loss or near loss with a severe consequences
are required in order to communicate the work circumstances leading up to the
loss and an explanation of what happened and how the loss occurred. The
purpose of this immediate communication is to make sure everyone is aware of
the loss so that it does not recur on the same job or at another location. It is not
necessary for the investigation to be completed before reporting and
communicating the circumstances surrounding the loss.
The LPS Alert communication occurs in a four-step process:
1. Initial report of loss received by supervisor or designate.

2. Date, time, location, description of work circumstances and what and how the loss
happened is entered into the LPS Database and
3. LPS core team and key managers disseminate the information to locations that have a
potential for a similar loss to occur.
4. First-line supervisor discusses the Alert information with all employees and contractors
as soon as the Alert is received.
Page 04. 31-23 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
This critical information must not stop at the supervisory level. It is important that this
information be reviewed, in person, with the people who need to know — the employees doing
the work. Again, supervisors are required to communicate LPS Alert information immediately to
their employees and to contractor staff before starting the next shift.
LPS Bulletin
This communication is used for follow-ups to Incident Alerts from major losses and near losses
with the potential for a severe loss, as well as for communication of minor losses/near losses.
The LPS Bulletin is the primary means for complete reporting of other losses. As a result, the
investigation must be completed before root causes and solutions can be shared. The LPS
Bulletin is also used for discussion of important loss prevention information such as trends.
Following a loss or near loss, the supervisor or designee will enter the loss/near loss into LPS
Database and check the LPS Alert/Bulletin box.
The LPS core team and key managers disseminate the loss information throughout the
organization, as needed.
Upon receipt of the LPS Bulletin, each supervisor is required to personally discuss the case with
his or her respective work groups. This discussion with employees should take place as soon as
practical, normally within 24 hours after receiving the bulletin. This communication must
involve a thorough discussion of the loss and a review of the facts to determine if this loss could
occur in their particular work area. The LPS Bulletin discussion should include a question and
answer format to obtain employee input regarding solutions to prevent loss recurrence, if
different solutions are needed.
10. Implementation of solution(s)

The supervisor of the area in which the loss occurred is responsible for seeing that solutions are
implemented, whether directly or by overseeing implementation by others in departments such as
maintenance, accounting, payroll, HR, purchasing or engineering. When other supervisors are
affected by the solutions, they are responsible for coordinating the implementation as appropriate
in their area of responsibility.
11. Verification and Validation

First is the need to verify that the solutions have been implemented as described in the
investigation report. Often, companies develop outstanding solutions to address a risk; however
after completing most of the investigation process, the solutions are never implemented and
remain in written form only. It is the responsibility of supervisors to follow up on 100% of their
solutions to verify implementation as intended and agreed upon.
Second is the need to validate that the solutions are effective in addressing the risk(s) of the
incident. This should be determined with input from several people. First, the supervisor should
talk with a couple of the employees who perform the tasks affected by the solution to find out if
June 2016 Page 04. 31-24 of 61

Pdm10431.doc
SECTION 04: Safety
the solutions have been effective in resolving the risk(s). The verification and validation
activities MUST be performed in the workplace.
If the solutions are not very effective in eliminating the risk or do not reduce the likelihood that
the incident will recur, the investigation must be recycled.
Loss Investigation (LI) / Near Loss Investigation (NLI)

Process Flowchart
Loss Occurs Injuries, equipment damage, product quality losses, reliability, MVAs, fires, business
interruptions, spills/leaks, financial, and near losses.
 Involved employee notifies supervisor of loss & stops operation until it is determined safe
to resume (LPSA).
 Supervisor notifies appropriate agencies & conduct up-line reporting.
Initial Notification
 Alert is issued, if required.
 Supervisors communicate information to employees within 24 hours.
 Involved employee & supervisor conduct initial risk assessment of loss & determine if it is
Risk Assessment of
safe to resume operations.
Loss
 Supervisor initiates fact-gathering process.

Starting the  Notifies appropriate team members.
Investigation  Team begins initial fact finding.
 Supervisor selects Investigation team based on findings from fact gathering process &
team prepares loss investigation report.
Investigation Report  Writes description and completes the FRCS™.
 Develops solution to prevent loss recurrence.
 Assigns appropriate reviewers and approvers, if required.
 Supervisor performs quality check on NLI/LI report coordinates responsibilities & due
Quality Review, dates.
Approval &  Reviews for accuracy, clear description, factor, root cause and development of solutions.
Coordination by  Approves or recycles to team with specific advice regarding quality problems.
Supervisor  Contacts persons responsible for overseeing or implementing solution(s) to obtain an
agreed due date.
Page 04. 31-25 of 61 June 2016

Pdm10431.doc
SECTION 04: Safety
Quality Review &

Approval by
 Manager conducts quality review of NLI/LI report & continues review process, as
Managers (Area
appropriate
Manager,
 Reviews according to Quality Review guidelines, approves, or returns to supervisor with
Department
specific feedback.
Manager, Operations
Manager)
 LPS Core Team distributes summary of loss & solutions to field via LPS Safety Alert or
Communication of LPS Alert or Bulletin.
Implementation of  All First-Line Supervisors discuss NLI/LI summary & solutions with employees.
Solutions  First-Line Supervisors coordinate implementation of solutions, as appropriate, & discuss
changes in detail with all employees.
 Managers perform desktop review of NLI/LI reports (according to LPS Responsibility

Quality Review by Summary: Loss Investigations), monitoring for quality & compliance with LI system.
General Manager  Manager provides specific feedback to direct reports regarding findings.
 Supervisor verifies & validates 100% of solutions in respective area of responsibility.

 Managers field verify & validate randomly selected NLI/LI solutions (according to LPS
Verification and
Responsibility Summary: Loss Investigations).
Validation of
Solutions  Managers provide feedback to ranking field manager/supervisor and direct reports
regarding findings.
June 2016 Page 04. 31-26 of 61

Pdm10431.doc
LPS Responsibility Summary: Loss Investigation (LI) /
Near Loss Investigation (NLI)
TITLE
Second Line
First-Line President/
Employee/Contr Supervisor (SLS) SSH&E Advisor
Pdm10431.doc
Supervisor Operations Manager Vice-
actor / Area Manager
(FLS) President
(AM)
SECTION 04:
SUBJECT 31:
Loss Occurs Stops operations evaluates risk of loss

& then notifies recurrence by
Page 04. 31-27 of 61

supervisors until performing LPSA with
it is determined employee/contractor Follows incident notification and reporting protocols.
safe to resume and Follows
operations Guidelines for
Safety
notification
and reporting.
Investigation Participates as - Initiates investigation Follows incident notification and investigation manual.
team member in process following
investigation, OIMS 9.1 guidelines
helps identify - Selects employees
factors, root for
causes & investigation team
develops - Participates on
Loss Prevention System
Investigation Participates on Reviews 100% of Reviews all high- Reviews Reviews all high-risk Reviews
Report
investigation reports for quality, to risk potential LI/NLI information for potential LI/NLI selected
team by ensure description is Reports per month correct root cause Reports per month & LI/NLI forms &
completing the clear, root cause & stewards the analysis and stewards process for stewards
Loss analysis is complete, process for correct solution quality. correct root cause process.
Investigation and appropriate root cause analysis, Follows OIMS 9.1 analysis, solution Follows OIMS
Form with FLS. solutions are identified. solution quality, guidelines quality, timelines, 9.1
Approves and timelines, participation, etc. guidelines.
forwards for review participation, etc. Follows OIMS 9.1
and approval (if Follows OIMS 9 1 guidelines
Communication Receives / Communicates Reviews all Safety Reviews all Safety Reviews all Alerts & Follows
 Alert
reviews information to Alerts & Safety Alerts & Safety Bulletins. Follows OIMS 9.1
 Bulletin
communications employees/contractors Bulletins. Follows Bulletins before OIMS 9.1 guidelines. guidelines
. Follows OIMS 9.1 OIMS 9.1 distribution. Follows Reviews all
guidelines. guidelines. OIMS 9.1 Alerts &
guidelines Bulletins
Solution Implements as Manages Field verify and Issues Monthly Field verify and Follows OIMS
Implementation,
Verification &
directed. implementation; field validate an agreed Summary Report & validate an agreed 9.1 guidelines
Validation of Notifies verifies & validates all number of solutions Ad-hoc Trend number of solutions as .
Pipelines & Distribution Manual Volume 1 - Administration
Effectiveness supervisor of solutions. Follows as well as tool Reports as well as tool protocol Field verifies
effectiveness OIMS 9.1 guidelines. protocol per month, requested. Follows per month, feedback selected
feedback to direct OIMS 9.1 to direct reports on solutions;
reports on findings. guidelines. findings. Follows feedback to
Follows OIMS 9.1 OIMS 9.1 guidelines. direct reports
June 2016
guidelines. . on verification
SECTION 04. 31: Safety
TOOL: LOSS PREVENTION OBSERVATION (LPO)
DEFINITION: A standardized, systematic tool for observing a work process and determining if the
process is being performed according to company standards.
EXPECTATION: Loss Prevention Observations will be conducted on a planned and scheduled basis
on high-risk or high-loss tasks or activities with direct input from employees and contractors.
OVERVIEW: The principles of the observation process are to provide specific positive reinforcement
to employees and contractors regarding significantly important types of behaviors performed correctly.
In addition, the observation also provides employees and contractors with the ability to be their
“brothers and sisters keeper” by identifying potential at-risk behaviors and conditions before a loss
occurs. The longer-range objective is to help maximize the effectiveness of each work process by
preventing losses and the respective costs associated with all types of loss potential. Industrial research
has shown that these principles applied together will change behavior three times faster than either
approach alone, and more likely to produce a positive, permanent change in behavior.
LPOs should focus on the work tasks that have the greatest risk factors. In other words, first target
those events with the greatest potential for loss reduction. At the same time, remember how important
it is to have at least minimal observation time in all operational areas. No major work process can be
ignored. In any case, the end result is a reduction in injuries, reliability, product quality, environment
and business inefficiencies losses.
LOSS PREVENTION OBSERVATION PROCESS
1. Identification of Target Areas

Each work group unit must identify “target” areas or work processes that have the greatest potential
for loss reduction. Selection of target areas should include a review of past injury and loss cases, as
well as consideration of the risk levels associated with the work processes. Supervisors will facilitate
this process with direct input from job experts.
This strategy does not preclude performing observations in other areas, but merely concentrates
attention and effort where we can make the most significant improvement.
2. Selection of Observers
Observers must be trained as approved observers. One or two persons from the team will be selected
as the initial group of observers. Not everyone will do observations right away. Initially, a few persons
typically perform LPOs for a period of 3 months. Then, another group of observers will perform LPOs
for another 3 months and the process continues with observers rotating every 3 months. Observers
need to perform the LPOs for a few months to really develop effective skills in identifying and
resolving activities and conditions proactively. If observers rotate too frequently, the tool quality and
effectiveness would not be achieved. On the other hand, experience has shown that if observers remain
in their role for longer than 3 months they become “burned out” with the process and the tool quality
suffers. The long-range goal is that everyone will serve as an observer.
Page 04. 31-28 of 61 June 2016

Pdm10431.doc
Employees familiar with the task being performed should be the primary persons conducting
observations. In other words, 80-90% of LPOs should be conducted job expert-to-job expert. These
observers should have unquestioned credibility with both peers and management.
3. Scheduling
No stealth observations! LPOs must be scheduled. Supervisors and employees need to schedule the
observation time enough in advance to allow for some flexibility due to unexpected operating events
that may occur. The LPO plan & schedule should be developed at the LPS monthly stewardship
meeting by selecting the observer, observee, and task to be observed. After the LPO schedule is
developed, it should be posted in a public area for employee reference.
LPO frequency should be consistent with loss history and risk potential. LPOs are not a numbers
game so avoid quotas. The general “rule of thumb” is 1 LPO per 10 employees per week. This is only
a rule of thumb and the exact frequency of LPOs depends on many factors such as loss experience,
risk levels for various tasks, complexity of operations, etc. LPOs should be representative of normal
business activities.
4. Preparation
The purpose for preparing for an observation is to develop a clear understanding of the critical
standards, procedures, and activities for the job they are observing. Observers should review any JLAs
other job standards that are references for standard work practices. This review does not require much
time and is an excellent refresher regarding the details of the job standards.
Observers should also review the LPO form to familiarize themselves with the document, history of
losses associated with the process to be observed, other recently conducted LPOs, Alerts or Bulletins,
etc.
During the preparation stage, the observer should also complete the Administrative and Background
Information and Miscellaneous Comments sections of the LPO form before the observation is
performed.
5. Conducting Observation
The observation should last approximately 20-30 minutes and can vary based on circumstances.
During the observation, the observer compares the activities and conditions of the job or task being
performing to the JLAs or other job standards. The observer notes critically important and correct
behaviors as well as ‘questionable items’ that could potentially be deviations from JLAs or other job
standards.
The observee’s role during this process is to conduct the job or task observed.
6. Supervisor Overview
After the observation is conducted, the observer will contact the supervisor and give the supervisor the
observation form. The observer should talk briefly with the supervisor to highlight the significant
portions of the observation process, citing positive performance, and “questionable items” noted. The
June 2016 Page 04. 31-29 of 61

Pdm10431.doc
Supervisor should review the form for clarity and address any potential form quality issues. In
addition, the observer should confirm the time and location of the feedback discussion session with the
supervisor and observee. This overview should not take more than a few minutes.
Don’t make the mistake of skipping this step. The Supervisor Overview process will enhance the
efficiency and quality of the feedback discussion session.
7. Feedback Session
The feedback session should be conducted within one hour of completion of the observation. The
sooner the discussion is held the better. This helps demonstrate our genuine commitment to the system
and will assist employees from making the connection between their behavior and positive and
negative consequences. In any case, the discussion must be held before the shift is over.
The supervisor should lead/facilitate the communication among the supervisor, observer, and
observee. The supervisor must also ensure feedback session is limited to observation items only to
maintain the group focus.
Feedback Discussion Session Agenda

There are six main points that supervisors should follow in order to conduct the observation feedback
discussion session. Adherence to these points will set the stage for a positive, productive discussion.
These points are listed in the order in which they should be covered:
A. Review LPO Purpose

The supervisor emphasizes at the start of each feedback discussion session why loss prevention
observations are conducted. While we may assume everyone understands, it is easy to forget the real
reason for conducting observations. Continued communication of the observation purpose is very
important to getting results at each facility/work group.
B. Discuss Positive Comments and Percentage of Correct Tasks

The supervisor reviews the observation results with the observee to ensure he/she understands the
information on the LPO form. The supervisor emphasizes the positive points noted during the
observation process by providing positive reinforcement for significantly important behaviors that
were performed correctly. Supervisors must make the connection between what the employee did well
and what he/she avoided by performing activity correctly.
The supervisor communicates the percentage of tasks/activities observed done correctly and according
to work standards. Remember, it is important that this feedback be truly genuine and sincere.
C. Discuss Questionable Items

The supervisor, observer, and observee discuss any questionable items that were perhaps contrary to
work standards. This discussion should precisely identify the deviation from work standards and
explain why it is not correct. To create real change, the observee must understand the potential
impact/consequences (injury, equipment damage, product quality, business inefficiency, etc.) if the
undesirable behavior persists. The supervisor must relate the deviation to a potential loss.
Page 04. 31-30 of 61 June 2016

Pdm10431.doc
It is the supervisor’s role to create an open dialogue among the three participants and avoid one-way
communication. The sooner the observee becomes an active participant, the higher the probability that
the discussion will create positive change. It is important that these discussions be conducted in a
constructive, non-accusatory manner.
D. Factors, Root Causes, Solutions™ (FRCS™)

At this point in the discussion it is essential that the supervisor include the observee and observer in
the use of the FRCS to consider all 7 factors, identify root causes, and develop solutions. As discussed
earlier, the FRCS™ examines all basic issues (factors), which are in the form of questions. Seven (7)
questions are listed horizontally on page 1 and 2. Each factor question must be considered and
answered with a YES or NO. If the users answer YES to factor questions on page 1, the users must
verify critical information before moving on. If they answer NO to the factor questions on page 1 users
must circle the factor, identify the root cause(s), and develop proper solutions by following the
solution guidance.
As discussed earlier, if the users answer NO to factor questions on page 2, the users can move to the
next factor. If they answer YES to the factor questions on page 1, users must circle the factor, circle
the root cause, identify what part of the procedure or acceptable practice was not followed, and
develop proper solutions by following the solution guidance.
LPO solutions should follow the same guidelines as those used for loss investigations. Solutions
should be practical, economical, sustainable, and should focus on factors that the person can control.
Solution(s) must “match” the factor category selected and address the root cause in order for change to
occur.
This portion of the feedback discussion session should result in consensus among these three key
personnel. The supervisor’s role is a facilitator, ensuring active input and participation by all involved
parties.
E. Summarize Key Points

The supervisor concludes the feedback session with a concise, one to two-minute summary of the
discussion items: LPO purpose, positive comments, percentage of tasks observed as correct, factors,
root causes of deviations from work standards, and solutions to change behavior or conditions. All
three people should return to the workplace with a clear understanding of LPO solutions and well-
defined responsibilities for change. Lastly, remember to thank both parties for their involvement in
the process.
F. Provide Observer Feedback

The supervisor should take advantage of this convenient opportunity to give the observer feedback
regarding his/her performance in the entire observation process. The supervisor should comment on
the observer’s thoroughness in completing the administrative sections of the form, the quality of the
positive comments noted, the level of curiosity and detail.
June 2016 Page 04. 31-31 of 61

Pdm10431.doc
(Note: Supervisors are responsible for completing the FRCS™ with employees, selecting the factor(s),
identifying the root cause and developing solutions that match the factor and address the root cause.
Additionally, the supervisor should complete the corresponding sections of the LPO form during the
feedback discussion session).
Process steps 8-11 for the Loss Prevention Observation are the same as the Loss / Near Loss
Investigation process. For detailed information please refer to the LI section of this handbook for
details.
8. Review and Approval

9. Communication
10. Implementation of Solutions
Page 04. 31-32 of 61 June 2016

Pdm10431.doc
Supervisor’s 6-Step Feedback Discussion Session Tool
Review this checklist prior to an LPO feedback session

Tips for effective feedback
 Conduct the feedback session immediately after the LPO is completed
 Maintain eye contact
 Use the 4 to 1 reinforcement rule
1. Opening statement: The reason for conducting this LPO

 Focus on the bottom of the pyramid
 Identify and correct questionable item
 Reinforce LPOs as a positive proactive tool to prevent loss
2. Review positive comments from LPO and their benefits to the individual and the
organization
 Mention specific behaviors that are significantly critical to loss-free performance and what potential losses
were avoided
 Emphasize the percentage of tasks observed as performed correctly
3. Mention % task performed correctly.

 This is not a score, but represents another opportunity to provide observee with positive reinforcement.
4. Discussion of Questionable Item(s) and use of the FRCS™

 All parties agree with QI(s) listed (deviation from standards)
 Relate questionable activities to potential loss
 All basic issues (factors) are considered
 By proceeding through FRCS™, root causes are identified for each factor.
 Solutions are developed per FRCS™ solution guidance.
 Solutions must match factor and address root causes and have a person responsible identified for
overseeing the implementation with an agreed due date
 Solutions should be practical and sustainable
5. Summarize (1-2 minutes)

 Review reason for conducting LPO
 Review positive aspects of LPO
 Review potential loss consequences of questionable items
 Restate factors, root causes and solutions
 Thank all participants
Give the observer feedback on the quality of the LPO
6. Feedback to Observer
 Supervisor should comment on the observer’s thoroughness in completing LPO form, quality of the positive
comments noted, preparation conducted prior to LPO, and the level of curiosity and detail.
June 2016 Page 04. 31-33 of 61

Pdm10431.doc
Loss Prevention Observation (LPO)

Process Flowchart
First-Line Supervisor and employees select work processes or tasks having greatest potential
Identification of for loss reduction at LPS meeting
Target Area  Base targets on history: losses, near losses, recent LPOs & potential risks
 Post target areas in public area
 Review & adjust targets as appropriate
Selection of First-Line Supervisor facilitates selection of observers, task to be observed & schedules
observation during LPS stewardship meeting
Observers &  Observers must be trained in observation techniques
Scheduling  Observers are designated for each work area & should rotate according to LPO plan
 Scheduling should allow for some flexibility
Observations
Observer completes the following activities in preparation for observation:

Preparation for  Reviews target areas
Observation  Reviews recent loss & near loss investigations related to target areas
 Reviews pertinent job procedures & job loss analyses
 Reviews recently completed LPOs for same target areas
 Schedules feedback discussion session with supervisor
Observer compares how work process is done with organization's work standards
Conduct  Observes work process for approximately 20 to 30 minutes
Observation  Identifies and notes critically important & correct activities
 Notes questionable activities & conditions
 Completes appropriate sections of observation form
Observer gives overview of observation to supervisor

Overview with  Done immediately following observation
Supervisor  Explanation of positive performance noted
 Explanation of questionable activities & conditions noted
 Confirm time & location of feedback discussion session
 Generally does not require more than five minutes
 Quick quality check done by supervisor according to guidelines
Supervisor is responsible for facilitating feedback discussion session

Feedback  Conducted within one hour of observation
Discussion  Active participation by supervisor, observee, & observer
Session  Discussion should follow these main points in the order given:
(1) Restate LPO purpose;
(2) Discuss positive behaviors;
(3) Mention % of tasks observed as done correctly;
(4) Discuss questionable items, use FRCS™ to identify factors, root
cause, & develop solutions;
(5) Summarize entire process by repeating points 1-4.
(6) Supervisor to provide quality feedback to observer
Quality Review & FLS conducts quality check on LPOs prior to entry into database.
Manager reviews LPO form for quality & continues review process, as appropriate
Approval by  Reviews according to Quality Review Guidelines and returns to First-Line Supervisor with
advice.
Page 04. 31-34 of 61 June 2016

Pdm10431.doc
Area/Department/  Forms reviewed per LPS Responsibility Summary: LPOs.
Operations
Manager
Communication Manager is responsible for communication of LPO solutions

 First-Line Supervisor discusses LPO summary analyses & solutions with employees
of  First-Line Supervisor posts information for future reference
Implementation  First-Line Supervisor coordinates implementation of solutions & discusses changes in detail
with employees
of Solutions
Verification and  First-Line Supervisor verifies & validates 100% of solutions in respective area of
responsibility
Validation of  Managers field verifies & validates randomly selected LPO solutions as well as LPO
protocol steps according to LPS Responsibility Summary: Loss Prevention Observations
Solutions  Executive Manager provides feedback to ranking field manager & direct reports
June 2016 Page 04. 31-35 of 61

Pdm10431.doc
LPS Responsibility Summary
Loss Prevention Observation (LPO)
Pdm10431.doc
Employee / First-Line Supervisor Second Line LPS Core Operations President/Vice-
Contractor (FLS) Supervisor (SLS) / Team and Manager President
Area Manager SSH&E
SECTION 04. 31:
Page 04. 31-36 of 61

Conducts LPOs Performs LPO Selects & ensures Monitors overall Monitors Monitors overall Monitors overall
(Observations observer training. LPO process overall LPO LPO process LPO process
conducted by all Schedules time for process
level of observation. Ensure
Management compliance with
Safety
target areas
Target Area Participates in Facilitates selection Monitors process to Analyzes Monitors process to Monitors process to
selection of of target areas at ensure LPOs LPO ensure LPOs ensure LPOs
target areas LPS meeting with conducted in target information conducted in target conducted in target
employees areas to establish areas areas
potential
target areas
Positive Comments, Identifies Conducts feedback Reviews an agreed Reviews an Reviews an agreed Reviews an agreed
Questionable Items, deviation from session with upon number of agreed upon number of upon number of
and Factors, standards and observee & observer LPOs for quality upon LPOs for quality LPOs for quality and
Root Causes, & assists in and completes and provides number of and provides provides feedback
Solutions™ developing FRCS™ with feedback LPOs for feedback
(FRCS™) solutions observer and quality and
b id
LPS Alert and Receives/ Communicates Reviews alerts, Develops Reviews all LPS Reviews & stewards
Bulletin reviews approved solutions & bulletins, then LPS Bulletins LPS Bulletins
communication posts communicates to Bulletins &
of approved direct reports distributes
l ti
Solution Implements as Manages Field verifies & Issues Field verify and Field verify and
Implemented, directed. implementation; field validates an agreed Summary validate an agreed validate an agreed
Verification & Notifies verifies and validates number of solutions Report & number of solutions number of solutions
Validation of supervisor of all solutions as well as LPO Ad-hoc as well as LPO tool as well as LPO tool
Solution effectiveness protocol; per Report as protocol per protocol per quarter,
month; feedback to Needed quarter, feedback to feedback to direct
direct reports on direct reports on reports on findings.
findings findings.
June 2016
TOOL: JOB LOSS ANALYSIS (JLA)
DEFINITION: A tool used to carefully study and record each step of a job or task, identifying
existing or potential risks (operational inefficiencies, business losses, safety, health, environmental,
product quality), and determining the critical actions to follow in order to perform the job loss free.
EXPECTATION: A Job Loss Analysis should be conducted for all major work processes or tasks
with initial JLAs developed for those major work processes that have the potential or have historically
accounted for losses to the organization.
OVERVIEW: Many processes, operations, and tasks have the potential to result in injuries and other
types of losses. Before risks can be controlled, they must be identified. The JLA is a tool to reduce
risks in the workplace. It involves defining jobs and tasks, identifying the risks associated with those
jobs and tasks, and creating critical actions that either eliminate or minimize the risks.
EXPECTED BENEFITS
Often, incidents occur because employees are not aware of the risk or do not fully understand the
consequences of a particular task or the critical step of a process. The development of the JLA for
high risk or tasks will benefit the organization in the following areas:
 Proactively identify risks and prescribes actions to take for each risk
 Provides a bases/standard for Loss Prevention Observations
 Helps standardize common job tasks/processes
 Serves as an excellent “task training” tool
 Great tool for hazard analysis regarding new tasks, equipment or procedures that are non-
routine.
JOB LOSS ANALYSIS PROCESS
1. Selection of Job or Task

A Job Loss Analysis can be performed for all jobs in the workplace, whether the job is “special” (non-
routine) or routine. Obviously, a Job Loss Analysis should be conducted first for high-risk or high-loss
tasks or processes. Also, jobs where significant “near losses” have occurred should also be given
priority. JLAs should be developed before performing either a new job or a job where changes have
been made in processes and procedures. Eventually, a Job Loss Analysis should be conducted for all
major work processes and made available to all employees.
Supervisor facilitates JLA target areas

Normally at the LPS monthly meeting the supervisor will seek input from employees on jobs/tasks
where they feel the greatest potential risk for a loss in his/her groups area of responsibility. It is
critical that all employees are involved in the selection process. The team can then prioritize the list of
JLAs that need developed based on the potential risk.
Additionally, the following situations may identify other JLA target areas:
June 2016 Page 04. 31-37 of 61

Pdm10431.doc
Loss Prevention Self Assessment

Loss Prevention Self Assessment (LPSA, step 3) states that employees should “act to ensure loss-free
operations!” This step requires that you follow written procedures! The JLA technique will be used if
the LPSA identifies a hazard or risk that is not addressed in other procedures or documentation.
Loss Investigations/Near Loss Investigations and Loss Prevention Observations

Organizations can also use the observation and investigation tools to help identify tasks that require
JLAs to be conducted. If during the observation or investigation, the root cause is that there are no
standards or the current standards are not adequate, then a JLA can be completed on that task.
New Equipment, Procedures, or Processes

A JLA should be performed before operating any newly installed equipment or new processes. We
must ensure that the risks are clearly identified and critical actions developed to ensure employees can
perform their jobs in a loss-free manner.
2. Choose Development Team Members

Persons conducting the JLA need to be familiar with the process and understand basic risk analysis
techniques. It is most important that the people who actually perform the operation participate in the
JLA development process. The JLA development team will generally be comprised of 2-3 people (i.e.,
2 job experts and 1 person with risk analysis skills). The key is that the development team directly
involves the right employees in the entire process. It is important that team members be trained and
understand how and why JLAs are conducted. Management is responsible to select and ensure that
employees are trained and understand how to conduct JLAs.
Participating in the development of JLAs provides hands-on training on risk assessment. The
fundamental mistake most companies make is that they have the safety personnel conduct all the JLAs
by-passing the actual employees who are facing the risks on a day-to-day basis. The skills and
abilities to assess the risk, analyze and develop actions is a learned process. This is why it is critical
that rotate developers to ensure all personnel actively and routinely participate in the development
process and consensus is developed among job experts:
 Helps develop individual risk assessment skills
 Results in ownership and better understanding of risks and critical actions
3. Developing Job Loss Analysis
Completing the JLA is a three-step process:
Step 1. List the steps of job or task

Once a job has been selected for analysis, the development team needs to review the procedures for
this task. The procedures would include company standards, safety procedures, and manufacturer or
equipment procedures.
Page 04. 31-38 of 61 June 2016

Pdm10431.doc
In the first part of the Job Loss Analysis, list each major step of the job in order of occurrence as you
watch the employee performing the job. Be sure to record enough information to describe each key
step, but do not make the breakdown too detailed. Later, go over the job steps with the employee.
The team should list the major steps of the task in order trying to keep the document to one to two
pages maximum. The steps on the JLA are not the step-by-step procedures. The steps of the JLA are
general activity categories for the task. For example:
 Preparing task
 Isolating valves
 Reviewing data tables
The team should also discuss the JLA with the employee performing the job and explain its purpose.
Point out that the job itself is being studied, not the employee’s job performance. Involve the
employee in all phases of the analysis — from reviewing the job steps to discussing potential risks and
recommended solutions. The team should also talk with other employees who perform or have
performed the job in the past to understand the key steps of the task.
Step 2. Identify Potential Risks

The second part of the JLA involves listing all potential risks surrounding the job steps. Potential risks
should be pinpointed and avoid generalities. The LPS JLA process is not just focused on traditional
injury/illness issues but classifies and uses the JLA to control any type of risk that could lead to any
type of business losses.
While observing and reviewing that task and the procedures, determine:
 What are the potential risks?
 What could go wrong?
 How could someone get hurt?
 How could a contamination occur?
 How could a spill or business interruption occur?
 How could an invoice be processed incorrectly?
The team should review actual past loss experience to see what activities in the job or task account are
resulting in losses. This review can be internal and across industry experience.
Additionally, it is important to talk with employees who perform the task and seek input known risks
and to share losses, and near losses they have personally experienced, witnessed, or learned about via
other communications. This discussion is where we can gain valuable input from experienced
employees who have altered or developed their own way of doing things to control these risks that
may never be written or documented for newer employees.
Describe the exact potential risk for each step.

It is critical that the team clearly describes how a loss could occur or has occurred and the potential
impact. The common mistake is to list only the type of risk involved such as fire, explosion, slip, trip,
June 2016 Page 04. 31-39 of 61

Pdm10431.doc
fall, spill, invoice error, leaving the user of the document to figure out how this could happen and the
impact. Listed below is an example of how the risks/potential risks should be described:
 Sending accounts payable to wrong account because database sometimes does not update the
correct address.
 Exceeding line pressure of 1000 psi has caused the pressure relief valve to vent to atmosphere
resulting in a regulatory fine.
After each risk or potential risk has been listed and reviewed with the employee performing the job,
determine whether the job could be performed in another way to eliminate the hazards. Consider
possibilities such as combining steps or changing the sequence, or whether safety equipment and
precautions are needed to reduce the risk.
If safer and more efficient job steps can be used, list each new step. If the risk cannot be eliminated,
try to reduce the necessity for performing the job or the frequency of performing it. If no new
procedures can be developed, determine whether any physical changes, such as redesigning
equipment, changing tools, ventilation, adding machine guards, or personal protective equipment, will
eliminate or reduce the danger.
Step 3. Development of Critical Actions to Prevent / Manage Risk

In the third column of the JLA form, list exactly what the employee must do or what specific
procedure to follow to eliminate or minimize the risk. Do not make such general statements about the
recommended critical actions as be careful, but be as specific as possible.
The initial development process will generate numerous pages of information. It is the responsibility
of the JLA team to organize the information into a one to two page procedure format. This conciseness
will facilitate employee training and allow the JLA to be a useful tool for employees to reference in
the future.
4. Review and Approval

After completion (before implementation), the development team is required to “trial-test” the new JLA to ensure employees are
able to understand and follow the JLA and that the major risks and potential losses are identified and addressed.
will route the final one to two page procedure to the

Once the team is satisfied with the quality of the JLA, they
supervisor. The role of the supervisor is to review the procedure for accuracy to ensure that it
addresses the potential risks.
The supervisor with responsibility for the area where the job/task or equipment is located or performed reviews the JLA with
the JLA development team to ensure the job is broken down into key steps, all potential risks have been specifically
identified, and critical actions explain how to address identified risks.
Managers are responsible for reviewing all JLAs developed in their respective areas of responsibility. The manager is then
responsible to approve the JLA. If the JLA has to be recycled, managers are responsible for providing a detailed explanation
regarding why the initial JLA was not acceptable. The JLA should then be returned to the development team through the
normal chain of command.
The review and approval process is outlined on “JLA Process Flowchart.”
Page 04. 31-40 of 61 June 2016

Pdm10431.doc
5. Communication
Once approved, the JLA shall be entered into the database. Managers should be engaged in discussion
to determine what locations should be contacted regarding the new JLA.
The LPS Alert and Bulletin process can be used to share new JLAs or changes in procedures.
Any time a Job Loss Analysis is developed or revised, training in the new job methods or protective
measures should be provided to all employees. A Job Loss Analysis also should be used to train new
employees on job steps and job hazards. Go over the suggested recommendations with all employees
performing the job. Their ideas about the risks and proposed critical actions may be valuable. Be sure
that all employees understand what they are required to do and the reasons for the changes in the job
procedure.
Additionally, these one to two page JLA procedures can be very useful for training employees on job
tasks and activities. Before performing a job for the first time, the supervisor should review the JLA
with the employee. Remember that employees are responsible during the Loss Prevention Self
Assessment for not proceeding unless they have the appropriate knowledge and procedures to perform
the job properly. If an employee has never performed a job before, he/she is expected to stop and
notify their immediate supervisor.
First, the supervisor will verify that the JLA is implemented into the work force and integrated into the
daily business. It is the responsibility of supervisors to follow up on 100% of their JLAs to verify
implementation as intended and agreed upon.
Second, the supervisor will validate that the JLAs are effective in properly managing risks. This
should be determined with input from several people. First, the supervisor should talk with a couple
of the employees who perform the tasks affected by the JLA to find out if the JLA is effective in
resolving the risk. Again, verification and validation process MUST be performed in the workplace
with face-to-face discussion with employees and contractors.
If the JLA is not effective in eliminating the risk or does not reduce the likelihood that the incident
will recur, then the JLA must be recycled.
June 2016 Page 04. 31-41 of 61

Pdm10431.doc
Job Loss Analysis (JLA)

Process Flowchart
Selection of Job or Task JLAs will be developed or reviewed when:
 Root cause of an NLI/LI or LPO identifies procedures unavailable or inadequate
 Employee/contractor performing job/task “Loss Prevention Self Assessment”
identifies procedure as inadequate or unavailable
 Introduction of new equipment or processes with high-risk potential
 Review of losses reveals high-loss rate/potential
Supervisor facilitates target list of JLAs to development at monthly LPS meeting
JLA Development Team Supervisor coordinates selection of JLA development Team

 Ensures team includes persons familiar with the job or task and may include the
supervisor
 Team members are trained in JLA development
Developing JLA JLA Team review current job or task and observes process in action if possible
 Team breaks down job into key steps
 Lists potential risk or loss potential
 Develops or modifies critical actions to manage risks
 Sumarizes JLA então 1-2 page format
JLA Review and Supervisor establishes target dates for the completion of JLA
Approval  Development team trial tests in work environment and gives to supervisor
 Supervisor routes for up-line management and LPS core team review of JLA per
LPS guidelines
 Management reviews and approves or recycles to JLA Development Team with
advice
Communications & JLA is input into Loss Prevention Information System database and distributed
Implementation locally. Supervisor communicates new JLA procedures to employees/contractors
 Supervisor conducts training with employees and contractors
 Supervisor uses JLA for “task training” new employees or retraining as required
 Supervisor coordinates implementation and communicates changes with
employees
Field Verification & Field verification and validation process

Validation  First-line supervisor field verifies and validates JLA
 Support Staff will randomly select for Quality Review and Field Verification and
Validation
 Management positions will randomly select for Quality Review and Field
Verification and Validation
Page 04. 31-42 of 61 June 2016

Pdm10431.doc
LPS Responsibility Summary
Job Loss Analysis (JLA)
June 2016
Pdm10431.doc
First-Line Second Line
Employee / President/
Supervisor Supervisor / Area LPS Core Team Operations
Contractors Vice-President
(FLS) Manager Manager
JLA Target Area Performed by Coordinates & Monitors overall Acts as gatekeeper for Monitors overall Monitors
Selection & JLA employees / selects JLA process new JLAs to ensure JLA process overall JLA
Development contractors employees / quality process is process
(development contractors to adhered to
normally 2-3 develop JLAs Supports with JLA
people). per JLA database sustainment
development
plan
Completion of Submits JLA to Reviews,. Reviews JLAs and Reviews JLAs for Quality reviews Quality reviews
JLA supervisor checks & contacts supervisor quality and provides an agreed an agreed
resolves any with feedback feedback to supervisor number of JLAs number of JLAs
deficiencies
Approves all
JLAs once
JLA Receives/reviews Reviews all Develop JLA Overseess Oversees
Communication communication Communicates communication and stewardship stewardship
& Training from supervisor approved JLAs. sharing of JLAs process process
Spot checks
field-level JLA
Verification & Implements JLAs Field verifies Field verifies and Supports Field verifies Field verifies
Validation & provides input to and validates all validates an agreed implementation & selected JLAs, selected JLAs,
supervisor on JLAs to ensure number of JLAs as development of JLAs validates validates
SECTION 04. 31:
effectiveness they are well as JLA implementation implementation

implemented & protocol and & JLA protocol & JLA protocol
effective provide feedback.
Safety
Page 04. 31-43 of 61

TOOL: STEWARDSHIP
DEFINITION: Stewardship is overseeing and monitoring the proper use and quality of LPS tools and
creating an environment within the workgroup where the principles of LPS are as important as any
other business activity.
EXPECTATION: The Loss Prevention System™ and its tools will be stewarded according to the
system’s guidelines and like other aspects of the business. The focus of the stewardship activities will
be on tool use, tool quality and other factors over which employees, supervisors, and managers have
control.
OVERVIEW: Success of the LPS requires that the business follow the key guidelines as outlined for
each LPS tool. Companies that manage the quality of loss prevention activities instead of the
“numbers” are the same companies that have directly reduced all types of loss measures. Supervisors
and managers within these companies steward and manage activities (e.g., LIs, NLIs, LPOs, JLAs,
LPSAs) just like they steward or manage other aspects of their business. They ask questions daily,
weekly, and monthly regarding quality issues for each of the LPS tools. Lastly, they hold their line
chain of command accountable for performance in these areas.
Good business practices state that “what gets measured gets done.” LPS stewardship ensures that we
measure the quality aspects of LPS activities that are proven to achieve loss-free operations.
Supervisors and managers have designated roles and responsibilities to monitor and steward all
aspects of LPS.
Just as personnel are held accountable for items such as sales objectives, productivity and costs,
employees will also be stewarded on loss prevention responsibilities. However, unlike traditional
safety programs that hold people accountable for safety statistics, LPS stewards loss prevention
activities over which employees have full control. The bottom line is that losses must be controlled
and managed just like other key business activities.
By managing LPS in the same way that we manage other aspects of our business, the organization will
improve its key loss measures. Additionally, by rewarding and holding people accountable for
performance in areas where they have direct control, those persons who are truly managing loss
prevention will be encouraged and rewarded.
To properly steward and monitor LPS, the following stewardship activities in the 2-Level
Stewardship Model will be performed.
Two (2)-Level Stewardship Model
First-Line Supervisor Stewardship Responsibilities
There are four stewardship activities that First Line Supervisors (FLS) perform to ensure LPS tools are
being used properly –– (1) stewardship of LPSA use; (2) Quality Checks of tools; (3) Verification and
Page 04. 31-44 of 61 June 2016

Pdm10431.doc
Validation of tool solutions; and (4) leading the monthly LPS meeting. These four activities should be
a planned, fundamental part of how the First Line Supervisor runs the business on a daily, weekly and
monthly basis. Effective performance of these activities will guarantee successful use of LPS tools at
the grass roots level of the organization.
1. Stewardship of LPSA use by employees

The supervisor is responsible for spot checking LPSA use by engaging employees in conversation
about concrete use of LPSA for the task being performed. The conversation should include
identification & mitigation of potential risks before beginning task, during performance of the task, at
conclusion of the task & when circumstances change. Each employee must be stewarded individually
at least once a week.
First Line Supervisors should ask employees every day to give a concrete example of LPSA use for
the task being performed. Effective stewardship of this risk assessment tool requires no more than a
few minutes.
• The FLS simply eases into the LPSA conversation and then directs the discussion following the
basic questions associated with the traffic light image for “red light, yellow light and green light.”
• Red light: what kinds of things could go wrong while performing this task and what’s the worst
thing that could happen?
• Yellow light: what are you going to do to make sure these things don’t happen? In other words,
explain why you are sure that you know how to do this task properly. Tell me about your training to
do this task; what does the JLA for this task say regarding how you can eliminate or reduce the
various risks?
• Green light: if we took a video of you doing this task and sent it to the highest-level Manager of
this operation, would that be okay with you? Would you be confident that the Manager would
approve of your task performance?
• The FLS should guide the discussion with the employee doing most of the talking in response to
the questions.
• No employee should work more than a week without being stewarded by the First Line Supervisor
or a higher-level Manager in LPSA use.
• The number of employees stewarded daily depends on the number of employees assigned to the
FLS. For example, two employees would be questioned daily by the FLS if there are 10 employees
and if the operations uses a five-day work week. If there are 15 employees, the FLS would steward
three employees per day.
• Although most of the LPSA stewardship is done by the FLS, every higher-level Manager should
also steward LPSA use in the workplace. Refer to the section on Manager Stewardship
Responsibilities for more information about frequency of LPSA stewardship.
2. Quality Check of all tools

The First-Line Supervisor is responsible for performing quality checks on 100% of the LPOs, NLIs,
LIs, and JLAs. The supervisor should review and approve tools before entry into the database. Below
are the list of quality check question FLSs should be checking prior to entry into the database.
June 2016 Page 04. 31-45 of 61

Pdm10431.doc

 Pinpointed positive comments for significantly important & specific behaviors?
 Clarifying written comments for each questionable item?
 Identifies root cause(s) by explaining why questionable item(s) occurred?
 Solution is feasible and maintainable?
 Appropriate reviewers assigned?
Near Loss/Loss Investigation

Job Loss Analysis

 Development Team members appropriate for work type/work activity?
 Job steps broken down into sufficient but not too much detail?
 Potential risks addressed for each job step?
 Critical actions are specific & address each potential risk?
3. Verification and Validation of Tool Solutions

As is the case with quality reviews, the First-Line Supervisor is responsible for verifying and
validating 100% of LPO, NLI, and LI tool solutions. As a reminder, the verification process is to
ensure the solution was implemented as agreed upon per the LPO, NLI, and LI and the validation
process is to ensure that employees agree that the solution was effective in mitigating or reducing the
risk exposure.
The First-Line Supervisor’s verification and validation responsibilities are not complete until the
solution has been implemented as intended per the LPO, NLI, or LI form and job experts agree that the
solution was effective is mitigating or reducing the risk exposure.
Only First Line Supervisors are responsible for verification and validation of all tool (LPO, NLI, LI)
solutions for their area of responsibility. This stewardship responsibility cannot be delegated to anyone
else in the organization.
Verification and Validation (V&V) can only be done in the workplace by talking with the person or
persons who were involved with the tool. The FLS cannot perform the V&V via phone calls, emails or
texting. It is critical that this stewardship activity come across genuinely in the spirit of the First Line
Supervisor’s concern for helping to ensure that all employees work as risk-free as is feasible.
Page 04. 31-46 of 61 June 2016

Pdm10431.doc
Verification and validation of solutions on page 1 of the FRCS™ are relatively easy since these types
of solutions are more concrete.
On the other hand, how should behavioral solutions be verified and validated? In essence, the FLS
needs to “witness” a change in behavior on the part of the person involved. Verification and
Validation of behavioral solutions also depend on the circumstances. If the at-risk behavior has a
relatively low severity potential and is not repetitious, V & V can be done by informal observations in
the workplace by the First Line Supervisor. This V & V can and should be done during normal work
activities within the shift. In fact, this feedback to the employee without having the LPO form in hand
is much more powerful than feedback given during the discussion session after the observation. It
sends the message that the First Line Supervisor is interested in the employee’s loss-free behavior all
the time, not just during the LPO process.
On the other hand, if the at-risk behavior is repetitious and/or has a high severity potential, then a
formal, follow-up observation should be conducted. This follow-up observation communicates the
seriousness of the at-risk behavior. Remember, verification means –– was the solution implemented as
described on the observation or investigation form? Validation means –– was the solution effective in
elimination of the risk or in reducing the risk to a manageable level? In addition, it is important that
the determination of effectiveness is based on the opinions of employees, as well as the First Line
Supervisor.
4. Monthly LPS Stewardship Meeting

The First-Line Supervisor is required to conduct a monthly LPS Stewardship meeting with all direct
reports to discuss four topics related to tool activity, tool quality, lessons learned, and strategies for
quality improvement and risk reduction.
A. Steward LPS activity for past month

The first topic of the LPS monthly meeting is to discuss the LPS tool activity for the past month, tool
status, and share lessons learned associated with the tools. Listed below are some examples of
questions that should be asked by the First-Line Supervisor and discussed amongst the group:
JLAs: What is the status of the JLA developed last month? What was the JLA target task/activity?
Who was involved in it? Has it been field-tested? Has the development team agreed that this is the
way the job should be performed?
NLI/LIs: Were any near loss circumstances or incidents scheduled for investigation? Did we get them
done? What were the root causes and solutions? Any other lessons learned that we should have shared
with the people on other shifts? Have we completed the solutions and, if so, can I verify and validate
the solution?
LPOs: What about the three observations that was supposed to be conducted? Were these done?
What were the target areas? What were the factors, root causes and solutions? What are some of the
key takeaways for the observations? Have we completed the solutions and, if so, can I verify and
validate the solution?
June 2016 Page 04. 31-47 of 61

Pdm10431.doc
B. Plan LPS activities for next month:

The First-Line Supervisor should take the next five to ten minutes to discuss what LPS activities will
be performed next month. This should be a collaborate effort between the First-Line Supervisor and
his/her direct reports. Listed below are some examples of how this process should be managed for
each of the tools:
JLAs: Any need to develop additional JLAs? Do we have an additional piece of equipment coming in?
Do we have a new business process or systems that are being rolled out? Do we have any non-routine
activities coming up that have a high degree of loss potential that would require a JLA? Do we have
contractors coming on site next week?
LPOs: Based on the activities we are performing in the upcoming week(s) and where we have
experienced loss/near loss where do you think we should conduct our LPOs next month? Are there any
high-risk activities that we should look at conducting an LPO? Who are the observers? What is the
Date and time for the observation?
C. Review Standard LPS Stewardship Reports

The third agenda item is for the First Line Supervisor to review the standard LPS Stewardship reports.
Next are paragraphs that briefly provide guidance regarding what to do with each LPS stewardship
report.
• Tools submitted: First Line Supervisors should monitor the number of LPOs, NLIs, JLAs, and
LIs done monthly. Based on the size of the work group, there should be certain expectations of
tool activity (e. g., as a minimum, one observation per 10 employees per week). Leaders should
also monitor the ratio of losses to near losses and observations.
• Losses by type of loss & by task: What are the different types of losses (injuries, spills,
product quality incidents, production delays, financial loss, data entry errors, etc.) that occur
for various work tasks (transferring product, tank gauging, working from heights, confined
space entry, administration, data entry, etc.)? This report helps to determine our target areas,
that is to say, where our observation time should be spent.
• Observations by task: Are observations done on the targeted tasks? Target areas are picked
because these tasks are the ones that have a history of near loss and losses and/or represent
high risk potential. Spend observation time wisely on tasks that are at greatest risk.
• Observations with questionable items: What percentage of observations has questionable
items? Remember, people are less than perfect and it is expected that this percentage will be
high during the first few years of implementation. In addition, each questionable item
represents a chance to make the individual/operation safer and more efficient.
• Feedback sessions: Does the First Line Supervisor have the feedback discussion before the
end of the shift? This percentage should be extremely high, initially at least 80%. Otherwise,
the First Line Supervisor is sending the message that observations are not important.
• Factors analysis: What are the percentages of the seven factors from the FRCS™? What are
the percentages for the factor where the employee “. . . did not follow procedures or acceptable
practices because. . .” Remember, globally 90% of the root causes are on the second page of
the FRCS™.
Page 04. 31-48 of 61 June 2016

Pdm10431.doc
• Solutions implementation: At least 90% of solutions should be implemented on time. If not,

what message are we sending? Remember, you’re in charge of whether or not the solution is
implemented.
• Most frequent questionable items: This report tells us what questionable items are most
likely to result in future losses. This report is like looking into a crystal ball! What is being
done proactively with this predictive information?
• Tool status: This reports shows where each tool is, in terms of the tool process –– initial,
recycled, under review, final, closed –– and can be helpful to ensure solutions are implemented
on time and not delayed.
D. Communications (Alerts & Bulletins)

The monthly session is also a timely opportunity to review all LPS communications (while most
employees are present). The First-Line Supervisor should have received guidance and specific
expectations from the Second-Line Supervisor regarding what Alert and Bulletin information to
review and what actions to take for pertinent solution implementation.
Manager Stewardship Responsibilities
There are four stewardship activities that Managers perform to ensure LPS tools are being used
properly –– (1) stewardship of LPSA use; (2) Quality Reviews of tools; (3) Verification and
Validation of tool solutions and tool processes; and (4) monthly LPS stewardship session. These four
activities should be a planned, fundamental part of the Manager’s duties and responsibilities.
Furthermore, there are two objectives of these four stewardship activities that each Manager in the
chain of command performs:
• The first objective is to assess how effectively employees and contractors are using LPS tools.
• The second objective is for the Manager to use the findings from these four stewardship activities
to monitor and steward the effectiveness of each FLS and Manager in the chain of command.
1. Manager’s stewardship of LPSA use by employees.

Spot check use by engaging employees in conversation about concrete use of LPSA for the task at
hand.
Conversation should include identification & mitigation of potential risks before beginning task,
during performance of the task, at conclusion of the task & when circumstances change.
At a minimum, second –line managers should steward LPSA use a couple of times per week; third-
line managers & higher should stewardship LPSA use at least weekly.
While the FLS stewards LPSA use daily, all second-line managers and above make random spot
checks throughout the organization. There are two objectives of the Manager’s stewardship of LPSAs:
• The first is to assess how well employees are using the LPSA tool, providing positive feedback, as
well as coaching to ensure that the critical parts of the LPSA process are completed with a high
degree of quality.
• The second objective is for the Manager to use these findings to monitor and steward the
effectiveness of each direct report –– in other words, the Manager must steward the FLS’s
June 2016 Page 04. 31-49 of 61

Pdm10431.doc
frequency & effectiveness of LPSA engagement, as well as the frequency & effectiveness of each
Manager in the chain of command. The bottom-line question for each Manager is: How well does
each direct report coach his/her subordinate FLS or Manager in LPSA use? If the Manager does
not achieve both of these objectives, the FLS or direct report could be going through the motions
without having shaped or molded behaviors for a loss-free workforce.
• The Manager simply eases into the LPSA conversation and then directs the discussion following
the basic questions associated with the traffic light image for “red light, yellow light and green
light.”
• Red light: what kinds of things could go wrong while performing this task and what’s the worst
thing that could happen?
• Yellow light: what are you going to do to make sure these things don’t happen? In other words,
explain why you are sure that you know how to do this task properly. Tell me about your training
to do this task; what does the JLA for this task say regarding how you can eliminate or reduce the
various risks?
• Green light: if we took a video of you doing this task and sent it to the highest-level Manager of
this operation, would that be okay with you? Would you be confident that the Manager would
approve of your task performance?
• The Manager should guide the discussion with the employee doing most of the talking in response
to the questions.
• No employee should work more than a week without being stewarded by the First Line Supervisor
or a higher-level Manager in LPSA use.
2. Manager’s Quality Reviews of tools

Each month the Manager reviews a sample of observations, investigations, and job loss analyses and
completes an electronic template to document the Quality Review (QR). The quality questions asked
are essentially the same as for a FLS. At least one tool should be reviewed from each direct report’s
area of responsibility.
There are two objectives of the Manager’s QR:

• The first is to provide feedback directly to the FLS to ensure that the critical parts of the tool
process are completed with a high degree of quality.
• The second objective is that the Manager will use these findings to monitor and steward the
effectiveness of each direct report –– in other words, the Manager must steward how well each
direct report is coaching and stewarding his/her employees. If the Manager does not achieve both
of the QR objectives, the FLS could be going through the motions without having shaped or
molded behaviors for a loss-free workforce.
What are the differences between the FLS’s Quality Check and the Quality Review that a Manager
conducts? The FLS examines all information on each tool form and ensures it is accurate and complete
before database entry. However, the FLS does not complete an electronic template to document the
Quality Check.
Each month the Manager reviews a sample of observations, investigations, and job loss analyses and
completes an electronic template to document the Quality Review (QR). The quality questions asked
Page 04. 31-50 of 61 June 2016

Pdm10431.doc
are essentially the same as for a FLS. At least one tool should be reviewed from each direct report’s
area of responsibility.

 Pinpointed positive comments for significantly important & specific behaviors?
 Clarifying written comments for each questionable item?
 Identifies root cause(s) by explaining why questionable item(s) occurred?
 Solution is feasible and maintainable?
Near Loss/Loss Investigation

Job Loss Analysis

 Development Team members appropriate for work type/work activity?
 Job steps broken down into sufficient but not too much detail?
 Potential risks addressed for each job step?
 Critical actions are specific & address each potential risk?
3a. Manager’s Verification and Validation of tool Solutions

Managers are responsible for Verification and Validation (V & V) of a sample of tool (LPO, NLI, LI)
solutions for their area of responsibility.
There are three principal objectives of the Manager’s V & V:

• First, the Manager’s V & V helps to ensure that tool solutions are implemented on time rather than
falling through the proverbial crack and remaining undone.
• Second, the Manager’s V & V provides an opportunity for managers to physically show
commitment to LPS by being visible in the workplace, by interacting with employees and
contractors about their use of LPS tools, and by listening to what employees have to say about
their efforts to achieve a loss-free workplace.
• Third is for the Manager to use these findings to monitor and steward the effectiveness of each
direct report –– in other words, the Manager must steward how well each direct report is
stewarding his/her tool solutions to ensure they are implemented and effective. If the Manager
does not achieve all three of the V&V objectives, the FLS could be going through the motions
without having shaped or molded behaviors for a loss-free workforce.
June 2016 Page 04. 31-51 of 61

Pdm10431.doc
Verification and Validation (V&V) can only be done in the workplace by talking with the person or
persons who were involved with the tool. The Manager cannot perform the V&V via phone calls,
emails or texting. It is critical that this stewardship activity come across genuinely in the spirit of the
Manager’s concern for helping to ensure that all employees work as risk-free as is feasible.
Verification and validation of solutions on page 1 of the FRCS™ are relatively easy since these types
of solutions are more concrete.
On the other hand, how should behavioral solutions be verified and validated? In essence, the Manager
needs to “witness” a change in behavior on the part of the person involved. Verification and
Validation of behavioral solutions also depends on the circumstances. If the at-risk behavior has a
relatively low severity potential and is not repetitious, V&V can be done by informal observations in
the workplace by the Manager.
This V&V can and should be done during normal work activities within the shift. In fact, this feedback
to the employee without having the LPO form in hand is much more powerful than feedback given
during the discussion session after the observation. It sends the message that the Manager is interested
in the employee’s loss-free behavior all the time, not just during the LPO process. On occasion,
Managers should take supervisors with them on V&V of tool solutions to demonstrate and role model
this leadership behavior.
On the other hand, if the at-risk behavior is repetitious and/or has a high severity potential, then a
formal, follow-up observation should be conducted. This follow-up observation communicates the
seriousness of the at-risk behavior.
Remember, verification means –– was the solution implemented as described on the observation or
investigation form? Validation means –– was the solution effective in elimination of the risk or in
reducing the risk to a manageable level? In addition, it is important that the determination of
effectiveness is based on the opinions of employees, as well as the Manager.
3b. Manager’s Verification and Validation of tool Protocol

Management is also responsible for providing positive and constructive feedback to their direct reports
regarding compliance with LPSA, LPO, JLA, NLI, and LI tool protocol. This feedback is based on
the verification and validation activities as part of the direct report’s LPS Standards.
Remember, V & V must be done in the field, not over the phone or via e-mail. No special trip to the
workplace should be made since executive managers are supposed to regularly visit the workplace as a
fundamental part of managing the business.
There are three principal objectives of the Manager’s V & V of tool processes:
• First, the Manager’s V&V helps to ensure that tool processes are being followed and that the
process for each tool is not being compromised.
• Second, the Manager’s V & V provides an opportunity for managers to physically show
commitment to LPS by being visible in the workplace, by interacting with employees and
Page 04. 31-52 of 61 June 2016

Pdm10431.doc
contractors about their use of LPS tools, and by listening to what employees have to say about
their efforts to achieve a loss-free workplace.
• Third, is for the Manager to use these findings to monitor and steward the effectiveness of each
direct report –– in other words, the Manager must steward how well each direct report is
monitoring the process for each tool to ensure that the tool process is followed.
If the Manager does not achieve all three of the V&V objectives, the FLS could be going through the
motions without having shaped or molded behaviors for a loss-free workforce.
This stewardship activity occurs immediately following the V & V of the tool solutions. The Manager
is already in the workplace and simply takes a few additional minutes to ask questions about critically
important tool processes. Answers to these questions cannot be determined through a review of the
LPS stewardship reports.
Below is a partial list of key questions or points that should be raised by the Manager to determine if
the process is being followed for each LPS tool.
Loss Prevention Self-Assessments

• When should an LPSA be done?
• Give a specific example of how LPSA was used today.
• How is LPSA process stewarded here?
Loss Prevention Observations

• What are your target areas?
• How are targets selected?
• How is LPO schedule developed?
• What positive comments were given during last feedback?
• What questionable items were identified?
• How did you determine root cause(s) of questionable items and develop solutions?
Near Loss & Loss Investigations

• What could be benefit of near loss investigation?
• Give an example of a near loss situation at your facility.
• How were you involved in investigation?
• Explain how solution matches factor & addresses root cause.
• How do employees & First Line Supervisor know solution worked?
Job Loss Analyses

• What are three major steps in JLA process?
• When is a JLA required?
• How can JLAs be used to improve workplace safety & reduce losses?
• Give an example of last time you used JLA.
June 2016 Page 04. 31-53 of 61

Pdm10431.doc
4. Formal monthly LPS stewardship meeting

Successful use of LPS requires formal monthly stewardship sessions by all Managers at each level in
the chain of command.
At each level of the organization, the Manager meets with his/her direct reports and stewards LPS just
like other aspects of the business –– that is to say, there are certain topics that are always addressed,
whether the organization is in the first year of LPS implementation or the fifth year. Nonetheless, the
amount of time spent on any particular topic or the level of detail of the discussion depends on where
the organization is in terms of tool quality and integration of LPS into the daily business.
Preparing for Meeting

The Manager prepares for the stewardship session by completing four preparation activities: (1) LPSA
stewardship in the workplace; (2) Quality Reviews of tool samples; (3) Verification & Validation of
tool solutions and tool processes; and (4) a review of the standard LPS stewardship reports.
Completion of the first three activities has been described in previous slides 10-15. The fourth
preparation activity pertains to the LPS stewardship reports. See standard stewardship reports above
for guidance regarding what to do with each LPS stewardship report.
Conducting Meeting
Having completed these four preparation activities, the Manager is now ready to lead the monthly LPS
stewardship session and steward each of his/her direct reports. The Manager focuses on four agenda
items, which are identical to the preparation activities.
For each of these first three agenda items, the Senior Manager does not necessarily query each direct
report but rather distributes the questions among all direct reports, making sure there is equitable
opportunity to engage all Direct Reports over the course of the session.
A. Stewardship of LPSA Use

The first agenda item is stewardship of LPSA use. The Manager begins by sharing his/her own
personal experience with LPSA stewardship in the workplace –– location visited; occupations
engaged; specific responses of employees to questions about LPSA use. Then, the Manager asks a few
direct reports to share their experiences.
The objective is that the group of Managers will collectively make an assessment of how well the
organization is using this risk assessment tool. In addition, it affords an opportunity to ensure that each
Manager is leading by example and performing this visible leadership activity. If this is not the case,
the senior Manager provides clear expectations of the direct report for the next session.
B. Stewardship of Quality Review of Tools

Senior Manager should show a chart that indicates the numbers of QRs and V&Vs completed by each
individual manager. Ask direct reports to share what he/she has learned via the QRs with respect to
certain quality issues (e. g., Are positive comments specific and do they point out significantly
important behaviors?). Indirectly, Senior Manager is explicitly forcing their direct reports to give real-
life concrete examples of what they have seen and experienced in the field. The senior manager should
Page 04. 31-54 of 61 June 2016

Pdm10431.doc
be measuring effectiveness of coaching on quality issues by his/her direct reports. Senior Manager
should always provide positive and constructive feedback as appropriate.
C. Verification & Validation activities (tool solutions and tool protocol)

As with the LPSA Stewardship the Senior Manager should ask direct reports to share what he/she has
learned via the V&Vs with respect to solution effectiveness and tool protocol compliance. Senior
Manager should also provide feedback to their direct reports on what they have witnessed and
experienced when they performed their activities.
D. Standard LPS stewardship reports

Now the stage is set for the fourth agenda item, which is to enter into meaningful discussion regarding
the LPS stewardship reports. These first three agenda items will provide insights into why the
stewardship reports metrics are what they are –– positive or negative.
The tendency on the part of some Managers is to want to skip the first three agenda items and jump
immediately into the metrics. The reason is because some Managers feel more comfortable discussing
statistics/numbers, things that are somewhat black and white, and less comfortable discussing issues
that involve use of “soft” skills.
Discussions around LPSA use, Quality Reviews, and Verifications & Validations have much
credibility because the experiences are a result of looking at people eye to eye, listening to answers to
questions, etc. In other words, these discussions will yield learnings that the database will never
produce.
Let’s look at a positive and a negative example of how to steward an LPS stewardship report metric.
For an example, let’s use the percentage of feedback sessions conducted before the end of the shift.
• Negative example: The stewardship report is the percentage of feedback sessions that was held
before the end of the shift. The expectation is a minimum of 80%. The first three agenda items are
omitted. One Direct Report has 40%. The Senior Manager immediately launches into a lecture
regarding how low and unacceptable 40% is and says that there better be significant improvement
by the next month. The Direct Report has no idea how to improve and only knows that significant
change is needed or there will be repercussions.
• Positive example: The stewardship report is the percentage of feedback sessions that was held
before the end of the shift. The expectation is a minimum of 80%. Earlier, during sharing of
experiences surrounding the Verification and Validation activities, another one of the Direct
Reports makes reference to a FLS who held the feedback sessions 100% of the time before the
shift was over. Now, when the discussion begins for the Direct Report with 40%, the Senior
manager asks the other Direct Report what the key to success was for the FLS who always was
able to hold the feedback sessions on time. He responded that the FLS explained it was simply a
matter of planning –– that during the monthly LPS meeting, when the FLS and the employees
were all together, they selected the task for the observation, the observer, the date and approximate
time so that the FLS could block time for the feedback discussion. Listening to that success story,
June 2016 Page 04. 31-55 of 61

Pdm10431.doc
the Direct Report with 40% knew exactly what to do to improve his results and most importantly,
hold the feedback sessions in a timely manner.
ROLES AND RESPONSIBILITIES

Every employee will have a role in stewarding the LPS process. We have seen responsibilities detailed
in the Loss/Near Loss Investigation, Loss Prevention Observation and Job Loss Analysis
Responsibility Summaries. These responsibilities can also be broken out by job type, so that all
employees are aware of exactly what is required of them to steward and ensure its success. The
following three pages are examples of these responsibilities broken out by job type
Page 04. 31-56 of 61 June 2016

Pdm10431.doc
LPS Standards: First-Line Supervisor (FLS)

Daily/As Appropriate
 Communicate with employees regarding LPS activities (e.g., LPOs conducted, target areas, LI and NLIs
conducted status of an investigation if a loss occurred, JLAs completed, etc.).
 Review Loss Prevention System database, electronic mail, LPS Alerts and LPS Bulletins for loss
information, post on bulletin board, and discuss with employees.
 Observe work procedures while going through operational/work areas and give appropriate feedback.
 Review LIs and LPOs for quality as they occur (according to quality guidelines) and provide feedback.
 If there is a loss or near loss, communicate initial notification, participate in LI/NLI and ensure that the
following occurs:
 Appropriate members are assigned to investigation team.
 Investigation is begun within required time frame.
 Clear description of loss/near-loss investigation.
 Factor(s) selected matches root cause .
 Root cause explains why the loss/near loss occurred.
 Solutions match factor and address root cause.
 Solutions are feasible and maintainable.
 Coordinates and selects employees to conduct JLAs (when necessary).
Weekly
 Conduct field follow-ups for verification and validation of all LIs, NLIs, LPOs and JLAs.
 Conduct LPO feedback sessions as LPOs occur.
 Ask direct reports detailed questions on how they used the LPSA process
 Communicates approved JLAs.
 Performs Quality Check on LPS tools before entry into database
Monthly
 Review LI, NLI and LPO stewardship and summary reports for field follow-ups.
 Facilitate selection of JLA and LPO target areas.
 Review JLAs as completed and give appropriate feedback.
 Conducts LPS Stewardship meeting with employees.
June 2016 Page 04. 31-57 of 61

Pdm10431.doc
LPS Standards: HES Specialist/LPS Core Team

Daily
 Communicate with management as requested, regarding LPS activities (e.g., LPOs conducted, target
areas, LI and NLIs conducted, status of an investigation if an incident occurred, JLAs completed, etc.).
 Develop, review and electronically mail LPS Alerts and LPS Bulletins or other pertinent information
for management.
 If there is a loss, participates in LIs and NLIs, at request of the management or and ensure that the
following occurs:
 Investigation is begun within required time frame.
 Clear description of loss/near-loss investigation.
 Factor(s) selected matches root cause.
 Root cause explains why the loss/near loss occurred.
 Solutions match factor and address root cause.
 Solutions are feasible and maintainable.
 Appropriate information about the incident is communicated to others.
Weekly
 Participate, as requested, in JLA development.
 Review JLAs as completed, as requested, and give appropriate feedback to JLA Development Team
“Primary Contact.”
Monthly
 Review LI, NLI and LPO summary reports.
 Participate and advise, as requested, in selection of LPO and/or JLA target areas.
Quarterly
 Observe work procedures while conducting LPS field assessments and give appropriate feedback. Note
if employees are performing LPSA’s.
 Perform activity associated with LPO (conduct an LPO or participate in feedback session) for an
employee or contract employee.
 Field verify and validate an agreed upon number of LI or NLI solutions per quarter, and give
appropriate feedback to management.
 Field verify and validate an agreed upon number of LPO solutions, and give appropriate feedback to
management.
 Field review, verify and validate an agreed upon number of JLAs (if available) and give appropriate
feedback to JLA Primary Contact.
 Communicate in person with job experts regarding LPS activities (e.g., use of LPSAs, LPOs
conducted, target areas, LI and NLIs conducted, status of an investigation if an incident occurred, JLAs
completed, etc.) and provide feedback to job experts and Managers.
 Conduct and advise on LPS activities, as requested by job experts and Managers, and others throughout
the organization.
 Conduct quarterly field assessments and co-sponsor quarterly stewardship workshops with site
managers.
Page 04. 31-58 of 61 June 2016

Pdm10431.doc
LPS Standards: Managers (Second-Line Supervisors & above)

Daily
 Communicate with First-Line Supervisors regarding LPS activities (e.g., LPOs conducted, target
areas, LIs and NLIs conducted, status of an investigation if a loss occurred, JLAs completed, etc.).
 If there was a loss, receive initial notification, participate in LIs per company guidelines, ask the
following questions the same day and/or when the loss investigation report is completed:
 What is the status of the loss investigation?
 Who is involved on the investigation team?
 What is the description of loss/near-loss?
 What is the factor?
 What was the root cause of the loss?
 What solution was developed to prevent recurrence of the loss?
 What is the solution implementation due date, and who is responsible for the implementation?
 Investigation is begun within required time frame?
 Review electronic mail, near loss reports, LPS Alerts and LPS Bulletins and discuss as appropriate.
Weekly
 Perform quality reviews as assigned (according to quality review guidelines) and give appropriate
feedback.
 Perform activity associated with LPO (conduct an LPO from time to time, participate in feedback
session).
 Observe work procedures while going through operational/work areas and make comments as
appropriate.
 Review contractor activities and give appropriate feedback.
 Steward LPSA process with employees in direct reports’ areas at least a couple of times per week. In
addition, ask direct reports detailed questions on how they used the LPSA process.
Monthly
 Conducts LPS stewardship with first-line supervisor and gives appropriate feedback.
 Prepare for LPS stewardship with management.
 Perform Quality Review for an agreed upon number of LI, NLI, LPO and JLA (according to quality
guidelines) and give appropriate feedback on findings.
 Field verify and validate an agreed upon number of LPSA LI, NLI, LPO and JLA (according to field
verification and validation guidelines) per month and give appropriate feedback on findings.
Quarterly
 Conduct LPS field assessment at one field location and give appropriate feedback.
June 2016 Page 04. 31-59 of 61

Pdm10431.doc
ADDITIONAL STEWARDSHIP QUESTIONS
In addition to the field verification and validation activities, there are questions that should be asked as
part of the organization’s normal daily, weekly, and monthly business affairs. These kinds of questions
might be asked in person during daily contacts, in conjunction with other business questions during a
phone conversation, or in formal stewardship meetings where all aspects of the business are reviewed.
The following examples are the kinds of questions that might be asked for LIs, NLIs, LPOs and JLAs
to help determine if we are applying LPS tools appropriately.
Loss Investigations/Near Loss Investigations

 How many losses/near losses has your facility/work group had during the past day, week, month, quarter?
 How many investigations have been completed? Are any incomplete? Explain why any investigation cases have not
been completed.
 Were the investigations completed on time? If any of the investigation cases were late, explain why.
 Did the investigation involve employees in the identification of the factor and root causes of the loss or near loss? Give
some examples of the factor and root causes that they identified.
 Did you involve employees in solutions to avoid the recurrence of the loss circumstances? Give some examples of the
types of solutions that were made by employees.
 Were the solutions implemented? If not, why?
 Were the solutions implemented on time? If any were late, why?
 How did you verify the implementation of the solutions?
 How did you determine that the solutions were effective in the elimination of the root cause? Did you ask employees if
they felt the root cause was eliminated?
 Give a brief summary of those cases where the solutions did not completely address the factor and resolve the root
cause of the loss or near loss or only partially addressed the cause. What is being done to target the part of the root
cause that still exists?
 Give an assessment of the quality of the solutions made for various losses. (Compare this response to what you have
seen in the cases that you reviewed.)
 Have you had repetitive types of losses or near losses? Explain what they are and what’s being done to stop the
repetition.
 Regarding those solutions that were “well done,” describe the kind of positive feedback/reinforcement that you provided
for the deserving persons.
 How have you provided positive feedback for those supervisors or managers who did an excellent job in the entire loss
investigation or near loss investigation process?
 Regarding those cases where solutions were less than satisfactory, describe the kind of feedback that you have
provided and explain what you are doing to help those persons do a higher quality job.
Loss Prevention Observations

 Have the observations been completed for the various targeted areas? If not, why?
 What are your observation target areas? How do you identify these areas?
 Where is your LPO schedule posted?
 As an observer, what kind of preparation do you do before you conduct an LPO?
 Give a few recent examples of observation solutions that have reduced workplace risks.
 How have you provided positive reinforcement for those persons who have done an outstanding job on the
observations?
 What are you doing to resolve those situations where personnel are not doing a satisfactory job on the observations?
 Were the observation solutions implemented on time? If any were late, why?
 How did you verify the implementation of the observation solutions?
 How did you determine that the observation solutions were effective in the elimination of the root cause of the hazard?
Did you ask employees if they felt the root cause was eliminated?
 Do employees feel that the observation process is beneficial? If not, why?
 Is the observation feedback session being conducted after every observation? If not, why?
Page 04. 31-60 of 61 June 2016

Pdm10431.doc
 Describe the steps followed by the supervisor during the observation feedback session.
Job Loss Analyses

 How many JLAs has your group developed in the past month, quarter, year?
 Did any investigations or observations recommend conducting JLAs? Were they conducted in a timely manner? If not,
explain why.
 Did employees participate in the JLA process? Give examples.
 Did you verify the JLAs were effective? Explain how.
 Describe how you provided positive feedback for those employees, supervisors, and work groups who have done an
outstanding job completing and monitoring the JLA process.
June 2016 Page 04. 31-61 of 61

Pdm10431.doc

Loss Prevention Manual

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Loss Prevention Manual

Uploaded by

Copyright:

Available Formats

TITLE Pipelines & Distribution Manual Volume 1 - Administration

SECTION 04: Safety

PURPOSE AND SCOPE

PDM 01-04-15: Safety Communication Boards

PDM 01-04-29: Safety - Small Vehicle Safe Operating Program

PDM 01-09-01: Incident Reporting: Reporting Overview

PDM 01-09-03: Incident Reporting: Categorizing Incidents & Initial Notification

PDM 03-02-01: Critical Procedures: General

 0104F17.Doc: JLA Form

0104f29.Xls: LPO - Driving

0104f32.Xls: LPO - Operations

0104f41: LPS Training Certificate

 0104f44.Xls: LPO – Work Permitting

 0104f53.Doc: Monthly LPS Stewardship Meeting for SLS and Managers

0109F07.Doc: Incident Report

0109F08.Doc: Near Loss Report

0109F11.Doc: Hazard Identification (HID) Report

Page 04. 31-1 of 61 June 2016

This prevention of incidents is accomplished in a work culture that:

June 2016 Page 04. 31-2 of 61

Operations Manager or as delegated to the Senior Area Manager

Page 04. 31-3 of 61 June 2016

 INTRODUCTION TO THE LOSS PREVENTION SYSTEM (LPS)

 Emphasizes proactive activities;

A loss is defined as any unplanned cost that an organization might experience.

Types of Losses Targeted for Prevention

The goal is to prevent or reduce the occurrence of seven types of losses:

How Does LPS Address These Types of Losses?

June 2016 Page 04. 31-4 of 61

LPS Pyramid Strategy

Traditional Safety Contrasted with LPS

Page 04. 31-5 of 61 June 2016

Guideline 3: LPS requires conducting Loss Prevention Observations (LPOs) on a planned

June 2016 Page 04. 31-6 of 61

Guideline 6: LPS requires that internal loss prevention assessments or evaluations be

LPS Is Custom Made

Page 04. 31-7 of 61 June 2016

TOOL: Loss Prevention SELF ASSESSMENT (LPSA)

 Identifying at-risk conditions and potential losses;

June 2016 Page 04. 31-8 of 61

LOSS PREVENTION SELF-ASSESSMENT PROCESS

The LPSA is a three-step mental risk-assessment process.

 Are there materials on the floor that could trip a worker?

Page 04. 31-9 of 61 June 2016

LOSS PREVENTIOM SELF-ASSESSMENT CARD

WHEN TO CONDUCT LOSS PREVENTION SELF ASSESSMENTS?

Unusual Circumstances: An LPSA should be conducted for unusual circumstances or during

TOOL: LOSS INVESTIGATION (LI)

DEFINITION: A systematic examination of equipment/property damage, releases, leaks,

June 2016 Page 04. 31-10 of 61

Third Party Loss

Page 04. 31-11 of 61 June 2016

Near Loss Reporting

LOSS (LI) / NEAR-LOSS (NLI) INVESTIGATION PROCESS

1. Loss Occurrence and Initial Notification to Supervisor

2. Risk Assessment of Incident

June 2016 Page 04. 31-12 of 61

3. Starting the Investigation

When Should the Investigation Be Done?

Directing the Fact Gathering Process

Page 04. 31-13 of 61 June 2016

June 2016 Page 04. 31-14 of 61

7. Factors, Root Cause, and Solutions (FRCS™)

Factors, Root Cause(s), and Solutions Flowchart™ (FRCS™) Explanation