ABG SME Executive Summary+Main Report Draft

DuPont Safety Management Assessment
A Benchmark Assessment
Aditya Birla Group: Cement Business

by for
E. I. DuPont India Private Ltd.
December 2009
Report compiled by:

Ranga Shingte – Senior Consultant
Uday Deshpande – Engagement Manager
Dr. G Krishna Prasad – Safety Perception Survey Consultant
Safety Perceptions and Safety Management Assessment Report – Executive Summary -i-
Sites Assessment Team
1. Edward Simpkinson
2. Ranga Shingte
3. Dr R. K. Mishra
4. KHK Rangan
5. Ragu Rajagopalan
6. Mike Yeo
7. T.J. Loong
8. V. Bhat
9. Uday Deshpande
10. Dr G Krishnaprasad
11. Ashwini Pasricha
12. Sarang Mahajan
Note to Readers
The authors, reviewers, editors and DuPont Safety Resources have made extensive efforts to ensure
that the technology, management systems, and other information contained herein are accurate and
conform to best practices known to them at the time of publication. However, new approaches to
managing safety, reasonable differences in opinions among experts, unique aspects of individual
situations, and different laws and cultures, require that the reader exercise independent judgment
when making decisions affecting the safety of any facility, practice or process. The reader should
consider the applicability of the ideas and opinions offered to each situation based on the reader's
knowledge of the employee culture, physical premises, practice or process in question. Suggestions
for improvements will be warmly welcomed and carefully considered.
Confidential
This Report and the information contained in this Report have been provided to and for the benefit of
Aditya Birla Group – Cement Business only. Other persons may not rely upon this Report or this
information or use it in any manner. E. I. DUPONT INDIA PRIVATE LTD. 7th Floor, Tower C, DLF
Cyber Greens, Sector 25A, DLF City Phase III, Gurgaon – 122002 Haryana, India ("DuPont") is
providing this Report in fulfilment of contractual obligations and assumes no responsibility or liability for
damages or claims in connection with the use of the recommendations, representations, or practices
contained herein. Aditya Birla Group – Cement Business shall independently evaluate any
recommendations made by DuPont hereunder and the suitability of such recommendations with
regards to the safety of operations and appropriately shall make all final decisions on the
implementation of the recommendations.
Safety Perceptions and Safety Management Assessment Report – Executive Summary - ii -

TABLE OF CONTENTS
Page
PREFACE iv
EXECUTIVE SUMMARY 1
Summary of Findings ................................................................................... 1
Priority Recommendations .......................................................................... 11
Suggested Implementation Roadmap .......................................................... 15
Conclusions ......................... 17
BENCHMARK ASSESSMENT–
DETAILED FINDINGS, EVALUATIONS AND RECOMMENDATIONS 18
Introduction .................................................................................................. 18
Safety Management Elements

Management Commitment .......................................................................... 20
Policies and Principles ................................................................................ 24
Integrated Organisation Structure ............................................................... 26
Line Management Accountability and Responsibility ................................... 29
Goals, Objectives and Plans ....................................................................... 32
Safety Personnel ......................................................................................... 35
Procedures and Performance Standards .................................................... 37
Training and Development .......................................................................... 41
Effective Communication ............................................................................. 44
Motivation and Awareness .......................................................................... 47
Audits and Observations ............................................................................. 50
Incident Investigation ................................................................................... 55
Contractor Safety Management ……………………………………………….. 59
CONCLUSIONS ........................................................................................... 62
Safety Perceptions and Safety Management Assessment Report – Executive Summary - iii -
APPENDICES
A. Benchmark Assessment Description
B. Safety Perception Survey results
C. Pictorial Field Observations
D. Hazard Pyramid
E. Individual Site reports
Safety Perceptions and Safety Management Assessment Report – Executive Summary - iv -

PREFACE
Aditya Birla Group – Cement Business (ABG-Cement) engaged E. I. DuPont India

Private Limited (DuPont) to improve the “Safety Culture” across its facilities through
a Safety Improvement Journey. The key deliverables expected from the engagement
are:
• A current state assessment and a Long-term road map for safety

improvement.
• Enhanced capability of Leaders, Managers and Safety Professionals to lead a

sustainable improvement in safety performance.
• Functional tools that provide the framework of processes that will set the tone
right at the top for demonstrating the “Principles of Felt Leadership”.
• Defined organizational structure / restructuring, safety management systems

and processes that integrate safety into the business and the creation of a
supportive environment that drives the safety culture.
• Functional tools, processes and actions, adapted to meet Cement Business’s

operations, to facilitate effectiveness of implementation.
• Structured processes for managing “contractor safety”
The first step in development of the long term plan is to assess the current state. The
assessment of current state encompasses:
• Safety Perception Survey
• Data Analysis
• Site visits and assessment
• Assessment report
The SPS was conducted during the during the month of October. It tapped
management and employee opinions, sentiments and performance drivers at every
level of ABG-Cement, and its objectives were to:
• Provide meaningful insights into ABG-Cement’s safety culture,
• Identify how ABG-Cement culture impedes efforts to improve safety

performance,
Safety Perceptions and Safety Management Assessment Report – Executive Summary -v-
• Prompt an examination of roles and responsibilities,
• Redefine safety culture for the future
• Validate overall findings the Assessment.
The Site Assessments were conducted by the ten (12) DuPont Consultants whose
names are shown on the cover of this report in the period of 28 October 2009 to 11
November 2009. It consisted of a baseline evaluation and gap analysis of the current
ABG-Cement Safety Management System, using as benchmark DuPont’s 12
Essential Elements of Cultural (or Behavioural) and Contractor Safety Management.
Its Scope included:
• Review of pertinent documents;
• Fiels observations of operations at all the 23 sites of ABG-Cement.
o 11 Integrated Plants
o 11 Grinding Units
o 1 White Cement Plant
• Interactions with approximately 1200 people, including confidential formal and
informal discussions with all levels of the ABG-Cement organisation, from the
Chief Executive Officer and other senior management down to staff, operators
and mechanics, and a few contractor personnel.
This report compiles and consolidates findings of all the above steps of current state
benchmark assessment. The individual site reports are attached in Appendix E.
All people with whom we worked were cordial, professional, and exhibited interest in
DuPont's approach to manage safety. We would like to thank all of them for their
hospitality and all the courtesies extended to us during our visits, and we have a
special word of thanks for the ABG-Cement Safety teams at sites lead by Mr. L.
Rajsekhar for coordinating and facilitating the entire engagement process as per the
pre-defined time schedule. Thank you again for the unique opportunity to work with
your company. We hope the results of this assessment will be useful in your efforts to
bring Safety Management at ABG-Cement to excellence by international standards.
Safety Perceptions and Safety Management Assessment Report – Executive Summary - vi -

EXECUTIVE SUMMARY
SUMMARY OF FINDINGS
Our interactions with ABG-Cement 10 corporate leaders (Chief Executive Officer and
Direct reports), 23 Site leadership teams revealed following key strengths and
opportunities which will be vital to progress the safety excellence journey for the
corporation.
Strengths
1. Corporate and site leaders have a sincere commitment to Safety and are
desirous of continuous improvement in line with the international standards
and practices.
2. It is evident that the safety is on the agenda both at corporate and site
levels. The message from corporate management, and supported/reinforced
at all levels of site leadership has been consistent on the importance of
safety. This is well established and provides a good foundation. Safety is
unambiguously seen to be important to management.
3. Similarly there was a consistent message and feeling amongst the people
that resources – funds, equipment , time, people – are readily provided in
support of safety concerns and needs.
4. At almost all sites documented Safety management systems (on paper)

appear very good, and the company has received certifications by several
international organisations.
5. People at almost all sites are educated, experienced and highly dedicated
personnel. There is a strong support and co-operation from workers and
unions. They have a very visible pride in the organisation.
6. World Class Manufacturing (WCM) efforts have taken roots and are visible
at all the sites. This will provide a strong foundation for the safety excellence
journey.
7. The sense of line management accountability for safety is reasonably well

understood at all levels of supervision.
DuPont Safety Management Assessment Page 1

8. Safety professionals are in place for all sites and are significantly active.
9. Mines at all integrated plants are at a higher level of involvement and

commitment and therefore safety performance than the main sites. This
might potentially get ‘lost’ in the overall assessment but should be
highlighted.
Opportunities
1. Although safety has been on the agenda for a number of years
fundamentally in manufacturing Operations only and some policies,
procedures and manuals have existed, there has been little application,
attention, emphasis or discipline and safety management has basically been
only a reactive process.
2. Management of contractors is seen by many as the principal area of concern

with insufficient realization (belief) across all leadership that ‘in house’ safety
processes need to be at a much higher level before successful contractor
management might be realistic. Regardless, there are positive indications
that some contractor selection processes are already being enhanced from a
safety perspective.
3. There was little in the descriptions or perspective provided by the leaders to

indicate either a level of understanding or desire to make safety initiative a
significant culture change, fully integrated into work, as opposed to an
aspect of business that just needed better management. There were a
couple of exceptions but overall this level of thinking is not evident.
4. There is essentially no visible safety message to head office employees,

either at induction or by functional line management, further emphasizing
that this is seem as a manufacturing issue. Even top management who are
indicating their support and increased commitment to driving safety
management improvements did not connect this to their own accountability
to personally set the tone to their departments.
5. Apex safety board just established with membership from CMO, CFO, CPO
and the current Chief Marketing officer (CEO designate). The Role of the

board is not yet fully formulated other than as review board for unit head to
personally report if any fatality.
6. System of automatic financial penalty on supervisor and departmental heads

after fatal accident has been withdrawn in last couple of months. This
system did drive the understanding of line accountability for safety across
the organisation. However, the managers felt helpless in absence of a
structure, knowledge and ability to deliver demanding fatality free safety
performance. There is need to structurally build ability into the line
management to demontrate Felt leadership and accountability across the
organisation.
7. It is also clear that among supervisory levels, including functional heads,

visible behaviours are occasionally still not consistent with the ‘talk’, thereby
undermining the message. E.g. lapses in complying with PPE.
8. The failures in demarcation between construction and operations –

symptomatic of the lack of adequate/increased safety focus when the
decision to commission the plant before construction completion – are still
evident and still a negative on the safety environment.
9. Our assessments at sites and corporate indicate that incident reporting,

investigation, calssification and analysis process at ABG-Cement is at the
fundamentals level. Incident investigations and subsequent actions need
upgrade – e.g root cause analysis and follow up of recommendations.
10. Also audit processes tend to focus on unsafe conditions and equipment
inspections and not sufficiently incorporate people aspects and behaviours.
11. Many leaders including few senior one understand safety as equal to
procuring Personal Protective Equipments (PPEs) and ensuring strict
compliance with the same.
12. Risk perception around road exposure is very poor. Except for Kotputali site
we did see almost all the officer not wearing seat belts and not following
posted speed limits.

Safety Culture Assessment
To be considered as World Class, a manufacturing operation must meet the
following safety performance criteria:
❑ No employee or contractor fatalities in the last 5 years
❑ 5 year employee LWIFR ≤ 0.25 with no single year employee LWIFR

> 0.50. LWIFR is based on 200,000 hours.
❑ 5 year employee TRIFR ≤ 1.00. TRIFR is based on 200,000 hours.
Additionally, On-site assessments by DuPont are required to verify that their Safety
Leadership, Structure, and Processes and Actions are World Class.
In our judgement, ABG-Cement still lags many other international companies in the
Cement industry in its safety and risk management performance. The process of
capturing of Safety performance internally used by ABG-Cement does not conform
to internationally accepted norms. Our assessments at sites and corporate indicate
that incident reporting, investigation, calssification and analysis process at ABG-
Cement is at the fundamentals level. For example, international performance
indicator -Total Recordable Injury Frequency Rate (TRIFR) is neither available nor
understood at sites. Thus, it is difficult for us to make a meaningful comparison with
international industry safety performance.
Nevertheless, the data published in the ABG-Cement’s Sustainability Report 2007-
2008 is reproduced and discussed below:
Lost Time Injury Frequency Rate (LTIFR) shows significant improvement over the
last 3 years both for own and contractor employees. The absolute LTIFR
numbers are surprisingly equal to or better than “Word Class” safety performance

both for own and contractor employees. While safety has been on the agenda for
last few years, we were not able to link this performance improvement to
systemic and cultural changes in terms of Leadership, Structure, Processess and
Actions at the sites.
This LTIFR performance is too good to believe for the sites we have seen,
experienced and felt, though for a short while.
There have been no reported fatalities in directly employed employees between the
period of 2005 and 2008. In addition to the data given, there were 14 fatalities at
different project sites, which are not included in the report scope, concerning
subcontracted jobs during FY 2007-08. We believe that any work related injuries
whether contracted or subcontracted should be included in the performace data.
Of particular concern is ABG-Cement’s upward trend in the total number of fatalities

over the last few years. This trend is opposite that experienced by Lost Time Injury
Frequencies for the same period and underpins the need to strengthen incident
reporting, investigation, classification and analysis process at ABG-Cement.
Another major concern is the perception both at corporate and site levels that
everything is fine with own employees and whatever is wrong is with contractors.
The organisation at every level need to own contractors and contractor injuries and
need to believe that they influence and control contractor activities.

The summary of Safety Perception Survey (SPS) results is reporduced below:
Leadership
Q9a Involvement in safety activities
Q7a Presence of safety values
Q1 Priority individuals give to safety
Q6 Extent that safety is built in
Q7b Influence of safety values
Q2 Priority respondents think others give to safety
Q14 Extent safety rules are enforced
Q19 Recognition for safety achievements
Q3 Belief that injuries can be prevented
Structure
Q8 Extent line management is held accountable for safety
Q22 Rating of the safety organization
Q13b Extent that safety rules are obeyed
Q23 Rating of the safety department
Q21 Knowledge of safety performance
Q13a Quality of safety rules
Q24 Satisfaction with the safety performance of the organization
Q4 Effect of a drive for safety on business performance
Q5 Level of safety where the cost-benefit break-point occurs
Processes and Actions
Q16a Extent of involvement in safety audits
Q17 Rating of modified duty and return-to-work systems
Q12c Quality and effectiveness of safety meetings
Q12b Safety meeting attendance
Q16b Quality of safety audits
Q15 Thoroughness in investigation of injuries and incidents
Q20 Rating of the safety of facilities and equipment
Q12a Frequency of safety meetings
Q10 Extent individuals feel empowered to take action in safety
Q11 Extent of safety training
Q18 The presence of off-the-job safety programs
Benchmark Best
Survey Result
x < 15
15 - 25
x > 25
x
The results show that attitudes and beliefs of ABG-Cement personnel about safety
differ from the attitudes and beliefs of employees in companies with the best safety
performance. This suggests that management can significantly improve Safety
performance by:
• Better communicating and demonstrating to the employees their strong
commitment to improved safety performance,
• Supporting implementation to achieve for fuller achievement of the intentions

and desires of the documented Safety management systems, and
• Emphasising that, while production is a ‘priority’, safety is a ‘value’ and

hence cannot be comprised in any case.
The detailed SPS report is attached in Appendix B

As part of our assessment, using DuPont proprietary methodology we rated the
performance of the organization in 13 elements listed below:
1. Strong, demonstrated management commitment

2. Working safety policy and practices
3. Challenging goals, objectives and plans
4. High standards of performance
5. Supportive safety personnel
6. Safety as a line management responsibility
7. Integrated organisation for safety
8. Progressive motivation
9. Effective two-way communication
10. Continuous safety training and development
11. Comprehensive injury and incident investigation reports
12. Effective Safety Observations
13. Contractor Safety Management
Each element was assigned a performance level of “Fundamentals”, “Awareness”,

“Skill”, “Excellence” or “World-Class”. The safety management system level
definitions for these levels are as below:
1. World Class
The organisation leads its industry in safety performance as a direct result of
its safety focus, leadership, deliberate organisational design and the portfolio
of activities it carries out to maintain a safe workplace
2. Excellence
The organisation has strong capabilities to identify, learn from and correct at-
risk behaviors and workplace hazards Safety is a top priority. There is a free
flow and exchange of information without fear of retribution and the
organisation is focused on learning and improving Hazard reporting, auditing
and corrective implementation are well designed and executed on a regular
basis.
3. Skill
The organisation shows numerous signs of continuous improvement and
has a track record of modest and consistent improvement in safety

performance. Personnel are skilled in the application of basic safety
management tools and techniques
4. Awareness
The organisation is aware of its performance and has established basic
policies and processes to measure and improve safety performance. There
is relatively high value for safety efforts and an auditing system is in place to
eliminate workplace hazards.
5. Fundamentals
The organisation has process in place to avoid known workplace hazards
and uses trailing injury statistics for performance measurement. Injuries and
incidents are the main driving force behind discussion of safety management
practices. There is a written safety policy that may not be familiar to
employees or be perceived as of high value. Safety performance is known to
some in the organisation but is not widely known or thought about.
The best performing companies and organisations would be rated “Excellent” or

“World-Class”. Our Benchmark Assessment for ABG-Cement is summarised on the
following chart:
Benchmark Assessment Results
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The bases for our Benchmark Assessment can be found in our Detailed Report, in
which our element-by-element findings and analyses are covered in the same order
as shown on the above summary matrix.
Based on our experience, excellent safety performance can only be reached and
sustained by organisations in which management creates and fosters a culture of
interdependency on the part of every member of the organisation. Thus, a key part
of our Benchmark Assessment included an assessment of the ABG-Cement safety
culture. Our overall assessment, based on our observations and information
collected during our interactions and tours of operations, is depicted in the following
figure:
37
Current safety culture is transitioning from “Reactive” to “Dependent”
Reactive (Lagging) Proactive (Leading)

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Reactive Dependent Independent Interdependent

⚫ Safety by natural instinct ⚫ Management commitment ⚫ Personal knowledge, ⚫ Help others conform
⚫ Compliance is the goal ⚫ Training commitment, and standards ⚫ Others’ keeper
⚫ Delegated to Safety ⚫ Rules/procedures ⚫ Internalization ⚫ Networking contributor
Manager ⚫ Supervisor control, emphasis, ⚫ Personal value ⚫ Care for others
⚫ Lack of management and goals ⚫ Care for self ⚫ Organizational pride
involvement ⚫ Condition of employment ⚫ Practice, habits ⚫ Open communications
⚫ Fear/discipline ⚫ Increased communication
⚫ Expectations ⚫ Individual recognition
⚫ Value all people
Safety Assessment Aditya Birla – Ceme nt Business , 2009

Copyright © 2009 DuPont. All rights reserved. The DuPont Oval Logo, DuPont™, The m iracles of science ™ and STOP™ are registered tradem arks or tradem arks of DuPont or its affiliates.
In our judgement, there is significant potential for improvement to move the

organisation from its current Reactive/Dependent stage to an Independent stage, in
which individuals behave on the basis of their personal and well-formed judgement,
and then on to interdependency – the stage in which all members of the team are
interdependent among themselves.

ABG-Cement top leadership can and should drive the organisation to higher levels of
performance with a greater sense of urgency and start to address the priority
recommendations provided below.

PRIORITY RECOMMENDATIONS
In our judgement, to drive cultural change in the organisation, ABG-Cement

management must make fundamental changes in its approach to the management
of Safety, specifically in the following key aspects:
1. Strengthen capability of Management to demonstrate Commitment & Felt
Leadership and direct the overall safety effort.
• Safety has to become a ‘value’ (not a ‘priority”) at ABG-Cement. Safety

must be “built in” as an integral part of building ABG-Cement into a world
class organisation.
• Visibility of top management’s commitment to safety needs to increase
significantly in the field. People need to see all levels of management as
role models of safety, taking actions (i.e. doing, not just talking) on safety
matters.
• Safety Policy and Principles should be developed by Leadership based on
internal beliefs and periodically updated. Only one set of Policy and
Principles should be applicable to all employees, contractors and partners.
• Coaching on ways to demonstrate leadership commitment for safety is
required, including the development and execution of individual Personal
Safety Action Plans.
2. Establish an Integrated Organisation for Management of Safety with an
object of involving people from all functions and promoting Safety as line
management responsibility.
• A governance model should be put in place at the corporate level such that it
integrates all functions, and promotes the concept of line responsibility and
supporting safety professionals.
• This governance model should consider safety management committees
both at corporate and site levels supported by subcommittees as part of its
modus operandi.
• Safety management committee should be formed with the objective of
promoting integrated and participative safety management at all organization
levels.This committee should be led by the highest management level and
should include participation of his/her immediate staff.
• The management committee should support structured subcommittees
throughout the organization. The subcommittees must be made responsible
for developing and improving the safety management system’s elements
and tools, thus supporting the management committee and the line

organization. Subcommittees should be structured to allow employees
participation, with multifunctional and multi-skills representation. These
subcommittees are to be led by one of the management committee
members.
• Through the management committee, the leadership should periodically
conduct a critical analysis of the Safety Management System to identify,
measure, and evaluate best practices and improvement opportunities
3. Establish an incident investigation process that ensures ALL Incidents
(Including those with serious potential) are reported, investigated fully
with focus on prevention by identifying eliminating root causes.
• The organization should develop a standard or procedure for accident and

incident reporting, classification, investigation, cause analysis, and
communication. This procedure should include the logical sequence of
events from occurrence to determination of root cause and contributing
factors. An important part of this is the identification of the management
system failures.
• Establish an effort to broadly communicate the lessons learned from all
investigations to all people with similar potential and insist that
recommendations from the investigations are tracked through
implementation.
4. Initiate Routine Safety Observations process that focuses on behaviours
of people in the field.
• Institutionalise a process of Safety Observations to focus on line

management responsibility and involvement for improving behavioural
safety.
o Line management at all levels need to take note of all safety issues in
the workplace and increase their focus on the underlying acts of
people that create and/or the unsafe situations; otherwise those
situations will be taken as being condoned.
o When unsafe situations are observed, management need take time to
create value for safety in people's minds by having them focus on the
potential consequences to themselves of the unsafe situations
instead of ignoring them or just giving directions/instructions to
people.
• Training and coaching to managers, supervisors and employees in a
structured and proven way to accomplish the above should be provided.

5. Build organisational capability in order to develop and implemement
uniform systems and procedures across all sites through training,
coaching and handholding in the field.
• The organization should define a matrix of competence with all requirements

in terms of specific qualification, knowledge and skills for every function.
• An initial Safety orientation program should be made applicable to new hires
and transferred employees. Training must include theory sessions and field
practical exercises and consider technical and legal aspects of Safety.
• Based on the competency matrix, the organization must establish a safety-
training program including qualification, knowledge, and skills required for
every function and activity.
• The training must be defined according to the risks associated with the
activities. The training program is to be revised whenever a hazardous
procedure, activity or material is introduced into or removed from the
process.
• Training must be followed up with on the job coaching and handholding.
6. Develop common corporate standards of performance to be applied

uniformly across all sites.
• Develop an implement Safety Standards for Cement Business which will

communicate the requirements / expectations of the business in consistent
manner. Include standards for management systems e.g. Incident reporting,
investigation, classification and learning process and high-risk activities e.g.
Working at heights, confined space, Driving etc.
• Develop Audit protocol to help monitor the compliance / progress of
implementation of above standards at sites.
• Ensure that local procedures fully encompass corporate standards. Rules
and Procedures must be clear, commonly understood, and enforced all the
time, i.e. made a condition of employment for everyone – employees and
contractors alike.
• All operating and maintenance procedures should explain the reason why
they are required.
7. Structurally integrate Safety into all aspects of Contractor Management,
starting at the bidding/tender stage of every contract.
There must be a standard or procedure for contractor hiring and managing. This
should include: pre-selection of bidders; contract preparation; winner selection;

orientation and training; managing, auditing and monitoring; and post-contract
evaluation.
• Bidders pre-selection
Only contractors with a demonstrated commitment to safety should be used.

When selecting a contractor, use of safety-related information and metrics to
evaluate satisfactory safety performance must be made mandatory.
• Contract preparation
The contract bid package must include safety performance expectations and
conditions for execution of the work. Safety resource should be involved in
preparing the bid package to identify Safety hazards and include appropriate
potential safety conditions.
• Winner selection
The contract manager should confirm that the contractor’s proposal meets
the bid package’s mandatory requirements. Confirmation includes collection
and review of the contractor’s Safety documents, including documentation of
qualifications, training, and certifications.
• Orientation and training
Before contracted work begins, the organization should provide a Safety

orientation to familiarize the contractor’s employees with essential Safety
information and communicate hazards posed by operations.
• Managing, auditing and monitoring
The Organization should put in place a system to manage, audit, and

monitor the contractor’s adherence to the contract’s Safety requirements.
The organization’s contract manager should hold the prime contractor
accountable for subcontractors’ compliance with all Safety expectations.
Contractor safety performance reports should be generated and
communicated.
• Post-contract evaluation
A post-contract evaluation system must be in place to analyze the Safety

performance records during execution of the work. This safety work history
should be considered for future selections.

SUGGESTED IMPLEMENTATION ROADMAP
This assessment contains many recommendations:
• The seven (7) “Priority Recommendations” described above, and
• Many other recommendations that are provided in the detailed, element-by-
element “Benchmark Assessment”.
It is recognised that implementation of all recommendations at once is not possible.
In fact, it is not advisable. We recommend that ABG-Cement management carefully
digest and analyse the entire contents of this report and that a Process Owner
(perhaps someone from the corporate Safety organisation) be designated to
structure an Implementation Project to start implementation in a phased manner,
ensuring that:
• A clear end-point vision and a comprehensive set of implementation
strategies are defined up front,
• All activities are appropriately prioritised,
• A top leadership team steers the entire effort, and leads it with their own
personal engagement and example
• The effort engages all the appropriate parts of the ABG-Cement organisation
at all levels, and
• Appropriate resources are dedicated to ensure success.
DuPont has had experience in helping many other clients who embarked on similar
efforts. In those cases we have recommend the preparation by the client of a “Road
Map” to guide the effort, which at a high conceptual level looks as follows:
Suggested Implementation Roadmap
Program Management & Communications
Organization Performance
⚫ Establish Project Steering Team Process Performance

⚫ Set overall goals, objectives,
timeline ⚫ Charter and mobilize Sub - People Performance
⚫ Set structure & teams Committees
◼ APEX & Sub -Committees ◼ Safety Observations ⚫ Revise and codify training
◼ Set specific goals & ◼ Incident Investigation requirements
objectives (APEX and ◼ Training ⚫ Re -skill staff to new
subcommittees) ◼ Contactor Safety Management business processes
◼ Set standards & expectations ◼ Rules & Procedures ⚫ Manage people
⚫ Set priorities performance
⚫ Revise Processes
Executive Safety Committee Subcommittees Local Safety Committees

Struc tur es
Set Policy and Direction Design and manage processes Get results through Line
Business Leaders Inter-disciplinary Process Teams Sites

Members
Additionally, we recommend that the client develop a more detailed Road Map for
each of the recommendations it chooses to pursue, starting with the Priority

Recommendations, with specific actions planned in detail for each part of each
recommendation.

CONCLUSIONS
We believe the management of ABG-Cement understands the need to make a step
change in safety, starting with a change in the culture of the organisation. This
assessment has identified several areas of strength and significant opportunities for
improvement to help ABG-Cement move toward excellence in safety according to
international standards with the ultimate goals of achieving world class safety
performance.
recommendations.
As progress starts to be made on the priority recommendations, ABG-Cement
management is urged to consider also the additional recommendations that are
contained in detailed element by element analysis.
We believe implementation of our recommendations will allow ABG-Cement to make
significant strides toward Safety Excellence in a way that is sustainable. We wish
everyone at ABG-Cement success in their endeavours.

BENCHMARK ASSESSMENT
DETAILED FINDINGS, EVALUATIONS AND

RECOMMENDATIONS
INTRODUCTION
Aditya Birla Group – Cement Business (ABG-Cement) engaged E. I. DuPont India

Private Limited (DuPont) to improve the “Safety Culture” across its facilities through
a Safety Improvement Journey.
The first step in development of the long term plan is to assess the current state.
The assessment of current state encompasses:
• Safety Perception Survey

• Data Analysis
• Site visits and assessment
• Assessment report
The SPS was conducted during the during the month of October. It tapped
management and employee opinions, sentiments and performance drivers at every
level of ABG-Cement.
The Site Assessments were conducted by the ten (12) DuPont Consultants whose
names are shown on the cover of this report in the period of 28 October 2009 to 11
November 2009. It consisted of a baseline evaluation and gap analysis of the
current ABG-Cement Safety Management System, using as benchmark DuPont’s 12
Essential Elements of Cultural (or Behavioural) and Contractor Safety Management.
Its Scope included:
• Review of pertinent documents;
• Fiels observations of operations at all the 23 sites of ABG-Cement.
o 11 Integrated Plants
o 11 Grinding Units
o 1 White Cement Plant
• Interactions with approximately 1200 people, including confidential formal
and informal discussions with all levels of the ABG-Cement organisation,
from the Chief Executive Officer and other senior management down to staff,
operators and mechanics, and a few contractor personnel.

This report compiles and consolidates findings of all the above steps of current state
benchmark assessment the individual site findings. We evaluated safety leadership
activities and management systems and compared the current state in 13 elements
which DuPont considers essential for effective development of Safety Culture. In
this section of the report the key concepts of each element are described, along with
our detailed findings, evaluations and recommendations.
The individual site reports are attached in Appendix E

E01: MANAGEMENT COMMITMENT
CONCEPT
Management commitment is the basic component of a successful safety
management system. This commitment must exist at the top and be cascaded to all
levels of the organisation, including partners and contractors.
Safety is an organisational value and must be considered as important as any other
business parameter such as quality, productivity and cost when making a decision.
Management must demonstrate through “example, attitudes, behaviour, and follow
up” their commitment level with respect to safety. Management must be consistent in
all they say/speak/write and what they do.
This “Felt Leadership” will create an environment of trust that will be the foundation
of safety improvement.
FINDINGS
Our interactions with ABG-Cement top leadership (CEO and his direct reports)
revealed that they have a sincere commitment to Safety and are desirous of
improvement. However, we found little evidence that this commitment gets
translated into actions or taken into account on a routine basis at the operational
level.
Whilst corporate leadership has dedicated resources to document a well-structured
safety management system on paper at the sites level and to certifications by
several international organisations, systems at lower levels lack specificity on ways
to implement the systems.
Although safety has been on the agenda for a number of years (in manufacturing
Operations only) and some policies, procedures and manuals have existed, there
has been little commitment, application, attention, emphasis or discipline. Safety
management has basically been only a reactive process.
Management of contractors is seen by many as the principal area of concern with

insufficient realization (belief) across all leadership that ‘in house’ safety processes
need to be at a much higher level before successful contractor management might

be realistic. Regardless there are positive indications that some contractor selection
processes are already being enhanced from a safety perspective.
There is good alignment at the top about the need to improve versus current state,
and some evident commitment to provide the resources, time and priority to this
effort. However there was little in the descriptions or perspectives to indicate either a
level of understanding or desire to make this a significant culture change, fully
integrated into work, as opposed to an aspect of business that just needed better
management. There were a couple of exceptions but overall this level of thinking is
not evident.
There is essentially no visible safety message to head office employees, either at

induction or by functional line management, further emphasizing that this is seem as
a manufacturing issue. Even top management who are indicating their support and
increased commitment to driving safety management improvements did not connect
this to their own accountability to personally set the tone to their departments.
While safety is said to be priority#1 consistently everywhere across the organisation,
in our interactions with operating management it became evident that production is
the real priority.
In organisations with strong commitment to safety we find that management

demonstrates and demands high standards of performance. As will be covered in
later sections of this report, we found numerous examples of acceptance of very
poor standards by ABG-Cement management.
EVALUATION
Safety is not an ABG-Cement’s core value.

ABG-Cement management have a long way to go to demonstrate their personal
commitment to safety visibly through on-going actions that are visible to everyone in
the organisation.

RECOMMENDATIONS
01.1 Strengthen Management Commitment and Felt Leadership – Culture

needs to change starting with stronger, visible and felt leadership of
each manager/supervisor.
a. Safety has to become a ‘value’ (not a ‘priority”) at ABG-Cement.

Safety must be “built in” as an integral part of building ABG-Cement into
a world class organisation. Safety excellence requires that safety be
addressed proactively rather than reactively. Management should drive a
change of the culture at ABG-Cement to increase people's personal
value for safety and awareness of all unsafe situations.
b. Visibility of top management’s commitment to safety needs to

increase significantly in the field. People need to see all levels of
management as role models of safety, taking actions (i.e. doing, not just
talking) on safety matters. Some specific ways that this can be done are
included on Recommendation No. 2 below.
c. Coaching on ways to demonstrate leadership commitment for

safety is required, including the development and execution of
individual Personal Safety Action Plans.
01.2 Demonstrate and increase visibility of Management Commitment to

safety.
ALL members of management, starting at the very top, need to convey

their personal commitment and visible involvement in safety through the
example of their own actions. In other words, they must demonstrate that
safety is in their hearts.
“The best you can get is the minimum standard that you are willing to
demonstrate and enforce.”
Some specific suggestions on how this could be started easily are:

a. Set a personal example: Each member of management should analyse
their own behaviour for opportunities to reduce their own personal risk by
changing their own behaviour. Begin by following less risky personal

habits, use seat belts all the time while in vehicles, use hand rails to go
up/down stairs every time. Lead by example, not just by lecturing.
b. Emphasise “Safety is equal in importance to Production” at all

times: Make safety the first item of business in each meeting. Share
practical safety lessons and encourage others to do the same.
c. Undertake safety observations and get involved in incident

investigations: Increased visibility of all line management in the field to
demonstrate their commitment to safety. All management should involve
themselves actively in safety observations (observation and feedback
of safe and unsafe behaviour), not just focus on unsafe conditions or
poor housekeeping. It is essential that line management get actively
involved in incident investigations.
d. Recognise and reinforce positive behaviour. Safety needs to be

viewed positively to gain acceptance and to create an environment that
encourages people to act safely. Catch people doing things safely and
thank them.
e. Talk to people more about safety: Stop and discuss unsafe behaviours
on the part of others any time they are observed. If you don’t do that,
you have lowered your standard and are indirectly telling the employee
that such behaviour is acceptable. It is essential that you approach the
employee in a positive way to make him feel that your correction of his
unsafe behaviour is for his own well-being and that of his co-workers.
Never show a “policeman” attitude, but do enforce adherence to
standards and when necessary apply the disciplinary codes.
d. Develop personal safety action plans: Start with personal safety action
plans by the top management. Cascade these through the line
organisation. These plans should indicate what each individual would
personally do to enhance their own safe behaviour.
f. Participate in the investigation of serious incidents. Insist on

identification of all the underlying and contributing causes, and ensure
that corrective and preventive actions effectively address all causes.

E02: POLICIES AND PRINCIPLES
CONCEPT
The organisation shall establish and implement Safety policy and principles that are
based on the corporate values, mission, and vision.
The Safety policy and principles are effectively communicated through the line
organisation, and their understanding and adherence by members of the
organisation are continuously evaluated.
The actions of all members of the organisation shall be guided by the policy and
principles.
FINDINGS
ABG-Cement has written Safety policies and they are visible at each site. We found
that vision, mission and policies different at different sites.
Through our observations and discussions during our visit we found that the majority
of the personnel have not internalised the above policy statements as over-riding
guidance for their behaviour. We observed numerous examples (documented in
later sections of this report) which indicate that the reality is quite different in most
ABG-Cement work places.
EVALUATION
There are several opportunities for improvement as we compare the reality at ABG-
Cement with our DuPont criteria for this essential element. World-class companies
and companies that are striving for Safety Excellence” reflect a much stronger, more
explicit commitment to safety with a clear statement of intent or action with a sharp
focus on obtaining results and getting everyone to see the value of zero incidents,
injuries (no matter how slight) for themselves, and illnesses.
In addition, for a safety policy to be effective, it needs to be made alive by actions,
instead of being just a set of posted, nicely sounding words, i.e. everyone needs to
“walk the talk”. Those actions need to be guided by a set priniciples estabiished at
the corporate level and communicated to every level.
RECOMMENDATIONS
02.1 Review, Build uniformity and Strengthen the ABG-Cement Safety
policy.

a. Explicitly make line management accountable for results.
b. The policy should reflect the intent of the management to achieve Safety
Excellence, and not just meeting the legal requirements, and it should
give a clear statement of how this is to be accomplished.
02.2 Engage the entire organisation in discussions that will foster

internalisation of the policy.
Management and employees need to identify ways they need to change what
they do to live by the policy.
02.3 Undertake periodic review of the policy.
Introduce a process for a periodic review and adjustment of the policies based
on the organisation’s performance and employee input. This creates the
opportunity for a discussion of the policy’s meaning at the Executive level as
well as with line managers, supervisors, employees and contractors.
02.4 Make the current “beliefs” a set of principles and ensure that all
decisions are guided by those principles on a day-to-day basis.
Develop and provide a clear basis for decision making and influencing
employee behaviour.
02.5 Apply the Policies and Principles.
Use the policies and principles as working documents in meetings of senior

management, in safety committee meetings and in project review meetings
regularly. Line management should audit for communication, understanding
(including the "why" behind the "what"), and compliance with policies.

E03: INTEGRATED ORGANISATION STRUCTURE
CONCEPT
An integrated organisation structure facilitates efficient management of safety
through involvement of all levels, and is applied to whole organisation from the head
offices and administrative areas to the operational sites.
A management committee headed by the highest level of the organisation shall lead
the overall safety effort by developing and improving safety management systems.
Line management has accountability for planning, developing, implementing,
controlling, evaluating, and validating the safety management system, and for
involving all people in their area of responsibility.
The management committee will sponsor a network of subcommittees throughout
the organisation. Subcommittees are responsible for guiding and supporting the
implementation and continuous improvement of safety programmes and procedures.
Subcommittees are multifunction teams led by line managers and comprise safety
specialists, experts, and operational representatives.
FINDINGS
Apex safety board just established comprising Chief Manufacturing Officer, Chief
Finance Officer (CFO), Chief People Officer (CPO) and the current Chief Marketing
Officer (CMO, CEO designate). The role of the board is not yet fully formulated other
than as review board for unit head to personally report if any fatality.
There is no line management body charged with setting Safety policies and providing
direction and guidance to the Safety efforts on an on-going basis.
There are no sub-committees charged with responsibilities in specific areas of
interest.
EVALUATION
Each operating unit needs an organisation to effectively manage safety. The safety
organisation should start at the top level with senior managers and follow a cascade
structure down to the lowest work unit. The safety organisation should involve
everyone. A committee structure works best at the upper levels of the organisation.

The top-level safety committee provides strategic direction, sets goals and
objectives, monitors performance and provides a mechanism for dealing with safety
behavioural issues.
The top-level safety committee is chaired by the upper-most leader in the Line
Organisation (CEO) and includes his direct reports as members. Each of his direct
reports is the chair of a safety subcommittee. These safety sub-committees are in
charge of developing the major safety programmes and procedures as well as
ensuring that the line organisation accepts responsibility for implementing these
safety programmes. Typical sub-committees would include Safety Audit &
Inspection, Safety Rules & Procedures, Incident and Injury Investigation, Training,
Contractor Safety Management and others as necessary.
Major departments and work units (e.g. each Asset), should follow the same safety
committee and sub-committee structure, to the extent necessary. Lower level safety
committees in departments and work units focus on tactical issues and
implementation.
Each major work unit, including office units, should have regular safety meetings,
attended by all employees. Typically these are held monthly in process units and
quarterly in office areas. To develop a world-class safety culture where every
employee feels responsible for safety, everyone must be involved in making
decisions that relate to safety. With full involvement in decision-making, employees
at all levels feel a sense of proprietorship and everyone is much more eager to
implement these safety decisions.
We believe there is significant room for improving Safety management at ABG-
Cement by establishing safety organisations by adopting and adapting the features
of DuPont's Central Safety Committees.
In particular, we believe there is a need to establish several standing sub-
committees to focus attention on the areas where most improvement opportunities
exist.
RECOMMENDATIONS
03.1 Establish a corporate Apex Council chartered with setting Safety
policies and providing direction and guidance to the Safety efforts on
an on-going basis.

a. The Chief Executive Officer of ABG-Cement should assume
chairmanship of this Apex Council.
b. Adopt and adapt the features of DuPont Central Safety Committees. In

particular, the purpose of the Council should be to establish operating
policy consistent with corporate policy and to monitor compliance with
that policy.
03.2 Establish standing sub-committees in the following areas:
• Standards (Safety Rules and Procedures).
• Auditing and observations.
• Incident investigation.
• Training.
• Contractor Safety Management
Membership of the sub-committees should comprise representative individuals from

throughout the organisation (down through all organisational levels and across units,
functions, etc.).
03.3 Establish similar structures at lower levels of the ABG-Cement
organisation.
In our judgement each Site should be required to have its own structure on sililar lines.

E04: LINE MANAGEMENT ACCOUNTABILITY AND
RESPONSIBILITY
CONCEPT
An effective Safety organisation is obtained when roles and responsibilities are
clearly defined and implemented.
The Safety Management System is based on line responsibility and states that the
leadership should be actively engaged and committed to Safety, taking responsibility
for their own performance and the performance of those reporting to them.
This commitment should be reflected in the people management processes (HR)
and must consider both individual and organisational Safety performance in job
career and development plans.
FINDINGS
System of automatic financial penalty on supervisor (and one level up) after accident
has been withdrawn in last couple of months.
In essence all our interactions with ABG-Cement personnel we found that there is
broad acknowledgement of line management’s responsibility for safety. However,
whenever we challenged anyone in line management with probing questions such as
“Why is this (one of the many the many deficiencies that we observed in compliance
with standards) not resolved?” the majority of people responded with answers such
as:
• “Oh, that is not under my control; it is the responsibility of “...” (The “...”
usually was the name of another organisation, a favourite choice of many
was the “contractors” or “Safety Department”.)
• “That’s not possible because it’s India”.
• “As far as our employees are concerned we are OK, but contractors are the
problem.”
We also found little evidence of proactive action plans which use inputs from
incidents near misses, audits and other sources to direct the safety efforts. Instead
the tendency is to react to problems, take some corrective actions and move on
without asking “What do I need to do to ensure this does not happen again?”

Involvement of line managers in Incident Investigations, Audits and Observations is
very limited. Line managers have not undergone any specific training on safety
management.
EVALUATION
The sense of safety accountability among all levels of site management is evident –
from an operations line Management standpoint. This may be the result of the above
mentioned penalty system for the supervisor and supervisor’s supervisor. However
the overwhelming challenges of incorporating the contractor, construction safety into
this accountability had tended to confuse this. Also, and critically, this sense of
accountability does not necessarily translate into consistent, sustainable application
or implementation of safety process.
There is a lack of training of line managers specifically on safety and also lack of
structure to involve line and promote safety as a line management responsibility.
RECOMMENDATIONS
04.1 All employees must have documented safety goals, objectives and
plans that are specific to their job/responsibilities as part of the
existing Performance Contract process, and they must be held
accountable to attaining them.
04.2 Build accountability for delivering targets into the key results areas by
establishing specific key performance indicators and milestones as the basis
of the performance appraisal process and pay systems, including bonuses.
04.3 Top leadership should reinforce line management accountability for

safety by requiring each member of management to establish specific,
individual action plans and ensuring that there is alignment and consistency
of goals and objectives of all parts of the ABG-Cement organisation –
operations and support functions.
04.4 Line management should accept total responsibility for incident

investigations, issuing reports and ensuring implementation of
recommendations – Set criteria for the depth of investigation of incidents
based on maximum potential, and ensure that every incident investigation is
headed by the line management responsible for the area where the incident
took place.

04.5 Line management must ensure a high level of compliance with work
permit system and other critical procedures (e.g. lock, tag & try; hot
work, elevated work of all types - production and maintenance; entry into
confined spaces, etc.).
04.6 Line management should accept accountability for all aspects of safety
in their areas and should use the HSE personnel as supporting resources.
(See more about this on the later Safety Personnel section of this report.)
04.7 Observation programmes focused on people's behaviour must be an

integral part of the HSE plans of action of every area/sector. (See more
about this on the later Audits and Observations section of this report.)
04.8 Extensive safety management and leadership training is needed for

senior leaders, managers, line supervisors and employees.
Members of management and supervision should be trained in safety management and

leadership skills.

E05: GOALS, OBJECTIVES AND PLANS
CONCEPT
Like any other important management system, Safety Management Systems
achieve excellence by using continuous improvement concepts, establishing
challenging goals and objectives, and developing action plans accordingly.
The goals set the overall direction of the Management System, and the objectives
define the targets necessary to be met. In establishing challenging goals and
objectives, the Organisation develops Safety programmes and Management System
improvements, and drives Safety performance.
FINDINGS
ABG-Cement’s stated goal is “Zero Lost Tine Accidents” is integrated into Key Result
Areas of line managers.
But, this Zero is not equal to Zero as it is not supported by any planning neigther at
the corporate level nor at the site levels. Only plans that we could see at the site
were Safety Department’s plan on safety.
Both corporate and site management has not had any specific proactive Safety
performance goals in their “Performance Contracts”. Now those who acknowledged
having them stated the only goal they have is “zero lost time accidents”.
EVALUATION
To be the best and to strive for an injury-free workplace it is essential that each
component of an organisation know what its performance has been, including most
importantly, the best level of performance that the group has ever attained. Only
having a clear view of those will it be possible to set goals for each group in such a
way that requires continuous improvement, i.e. the future goal needs to represent an
improvement over the best frequency on record for the group.
Safety achievements are not clearly/objectively accounted for in the overall KPIs in
individuals’ Performance Contracts.
RECOMMENDATIONS
05.1 Establish Aggressive Safety Goals and Objectives – Safety
performance measures need to change and the setting of safety

performance targets that require continuous improvement needs to be
institutionalised.
a. Start tracking safety performance at all levels in the ABG-Cement

organisation using the internationally accepted recordable injury
performance measures. This will require the establishment of systems
and practices for reporting ALL incidents, collecting data, monitoring and
analysing the data routinely.
b. Safety needs to be an integral part of the performance appraisals

and career progression:
i. Everyone needs to have documented, specific safety goals and

objectives in their personal performance contracts (beyond just
“zero” injuries or incidents), including Key Performance Indicators
(KPIs) and action plans to achieve the goals so that continuous
improvement is sought all the time.
ii. Must incorporate at least one or two bottom-line KPIs (e.g.
recordable injury frequency rate) in the individual performance
contract of each Asset Manager or above in the organisation, and
must give it substantial weight.
05.2 Senior leadership to set injury and illness improvement targets for
coming one and three-to-five year timeframes that require continuous
improvement in the frequency of all recordable injuries and serious process
incidents for the company as a whole as well as for each division/section.
Establish short-term objectives that are challenging on year-to-year basis.
a. Cascade Safety goals and objectives: This must be done in a way that
avoids the concept of “one size fits all” to set goals and objectives equally
for all operations. Each department and each asset needs to set its
safety performance objectives for the year among its own group. These
objectives should represent an improvement over the best historical
frequency. Ensure that there is a link between the company, department,
asset and individual objectives in the annual performance appraisals.
b. Establish action plans: Action plans need to be drawn to achieve short-

term objectives at all levels.
c. Review and revise metrics for measuring safety performance.

i. Monitoring safety performance has to be through a combination of
leading and lagging indicators.
ii. Establish specific documentation of safety performance indicators
(leading and lagging) and action plans in the objectives for each
unit.
05.3 Involve employees in action plans. As many employees as possible
should be involved in the development and execution of action plans within
their own areas of responsibility as well as through active participation in
safety sub-committees.

E06: SAFETY PERSONNEL
CONCEPT
Safety professionals are responsible for providing support to the line organisation on
regulatory and technical issues and on the Safety Management System
improvement process.
Safety professionals:
• Serve as an advisor to leadership and line management;
• Support and coordinate the Safety management system;
• Influence, advise, and assist the entire line organisation on Safety
management and programme implementation;
• Participate in field audits to be used as reference for trend analysis;
• Audit periodically the Safety performance and management model;
• Interpret Safety regulations and interact with external agencies.
FINDINGS
One of the ABG-Cement Executive Vice President at the corporate level is also
charged with overseeing Safety support in the whole Organisation.
Until recently at the corporate level the company did not have any Safety support
team. Recently, there is one senior level person appointed for to establish corporate
level safety support team. Each site has its own Safety support team. Each Site
Manager has a direct report whose role is defined as that of Head of Safety.
During our visit we interacted to some extent with all of the above levels, particularly
In general the Safety heads are very experienced people with extensive knowledge
of the cement operations.
The various safety support people described their roles to us, and, on the basis of
their descriptions, we believe that most of their responsibilities are consistent with
the roles described in the above-shown DuPont concept statement principle for this
Essential Element. However, as we observed their interactions with the rest
operating teams at the sites it was apparent to us that many of their duties include
activities that in most other organization are the responsibility of the line
management.
EVALUATION

At the corporate level the Safety support team in ABG-Cement is being established
with recent appointment of Head for corporate safety. This needs to be appropriately
engaged in their rightful support roles to the whole organisation.
The distinction in roles between line management and Safety support gets fuzzy at
the lower levels of the ABG-Cement management structure, and we are concerned
that this could negatively impact the proper balance that should exist in
organisations: Line management needs to be clearly responsible and accountable
for all results, including Safety, and the Safety organisation should be primarily a
support team.
RECOMMENDATIONS
06.1 The corporate Safety team should be established and should provide
the support and guidance for the overall safety efforts.
06.3 At lower levels of the ABG-Cement organisation additional emphasis

should be placed on the role of Safety professionals as facilitators,
advisers, and consultants and the dependence on them as additional
members of line management should be reduced.
06.4 The corporate Safety team should be given responsibility to work with
a cross-section of the various ABG-Cement departments to formulate
and put in motion the necessary steps to best accomplish the above
recommendation over a finite period of time (we suggest no more than
1 year).

E07: PROCEDURES AND PERFORMANCE STANDARDS
CONCEPT
High operational standards are achieved by high quality operating procedures, use
of best practices, and best-in-class installations.
Procedures shall be written, disseminated widely, followed, and reinforced.
Operating procedures provide clear understanding of the parameters of operation
and the risks to people, community, and environment. Processes must exist to
continuously improve and check for adherence to those procedures in order to
guarantee Operational Discipline.
Installations are continually checked for improvement opportunities in safety.
FINDINGS
ABG-Cement does not have corporate standards / guidelines for High hazard
activities, Preparation of Standard Operating Procedures. Procedures at sites such
as Permit to Work procedure, Welding procedures, confined space entry
procrrudure, Working at heights requirements, Scaffolding requirements vary from
site to site.
Safety management systems exist on paper at each site. There are no corporate
safety management systems that oversee site safety management. The field level
we find managerial and operating procedures to be lacking sufficient detail. The
company has received certifications of their Safety management systems by several
international organisations.
When we asked different people to explain the meaning of some rules (e.g. one as
basic as the PPE requirements in open areas) we got widely different (and even
contradictory) responses.
A clear statement of working safely being a condition of employment does not exist.
A work permit system established and it is being used regularly, but spot checks of
the records showed that it is not being strictly followed, and, in fact, we found
discrepancies when we compared the conditions in the field after some jobs had
been done to what had been recorded on the work permit forms.
Generally, the written down operating and maintenance procedures that explain what
why of the activities are absent. Upon questioning people about what they had to do
in their jobs, they were able to tell us the what, but not the why, i.e. they lack

sufficient understanding of the possible safety consequences of not following the
procedures.
In the field we observed numerous situations in which people exhibited unsafe
behaviours and of unsafe conditions that had been created and allowed to continue
without any concerted effort to correct them. Housekeeping (orderliness and
cleanliness) ranges from outstanding in some high level managerial offices to non-
existent at the project sites; at the latter we found utter lack of order and discipline
everywhere – far worse than ever seen by us in similar operations.
Pictorial examples of our findings during our tours can be seen on Appendix F.
Only 16% of the respondents in the Safety Perception Survey felt that safety rules
are consistently enforced in ABG-Cement. This compares to 88% of the
respondents in the best performing companies.
EVALUATION
Lack of consistent corporate standards leading to different procedures at each site is
a major issue at ABG-Cement.
The level of uniformity of procedures and commonality of understanding of the safety
rules and procedures by the organisation at large is far from where it needs to be.
The operating procedures are in general absent and wherever they are present, the
lack of explanation of the reasons for what needs to be done can result in this
knowledge being lost over a period of time.
There is significant room to improve the uniformity and rigor of use of the work permit
system.
The general awareness to common, every-day risks and to subtle details of the
integrity of the facilities is very low, and there is a lack of managerial focus on the
underlying acts of people that create and/or condone the unsafe conditions.
Consequently, we believe that, in general, the potential of injuries (including
fatalities) or very serious incidents is quite high specifically at project sites.
Managers need to establish and enforce behavioural safety standards through
interactive observations, including a strong and urgent need to focus attention on the
base of the Hazards Pyramid (Appendix ???).
RECOMMENDATIONS
07.1 Establish High Standards of Performance at corporate and then
uniformly implement them across all sites – Ensure that all standards are

understood and accepted by everyone; adherence to them must be strictly
enforced by management.
a. Rules and Procedures must be clear, commonly understood, and

enforced all the time, i.e. made a condition of employment for
everyone – employees and contractors alike.
b. All operating and maintenance procedures should explain the

reason why they are required.
c. Ensure that local procedures fully encompass corporate standards.
07.2 Establish a ABG-Cement Apex Rules and Procedures Sub-committee

charged with:
a. Developing and implementing uniform safety processes, standards

and procedures at all with sites.
b. Development and communication of a set of "Cardinal Rules" which

would result in dismissal if broken, and eliminate any rules that you are
not prepared to enforce.
c. Defining ways to Disseminate and enforce all general safety rules

and practices, including indication of the "cardinal rules" that are a
condition of employment.
07.4 Develop and implement operating and maintenance procedures that

should explicitly state all key safety points (including consequences of
non-adherence or of exceeding allowable limits).
07.5 Establish a managing process for job cycle checks and periodic
reviews of SOPs, safe work practices and life saving rules.
a. Formal schedules for reviews of all rules and procedures should be

established, and line management should lead the reviews.
b. Workers who actually perform the procedure should be extensively

involved.

c. All standards and procedures should be reviewed at least annually
and they should be either validated or revised. Whenever they are
revised, the revisions need to be disseminated broadly and thoroughly.

E08: TRAINING AND DEVELOPMENT
CONCEPT
The Safety Management System ensures that people are prepared for their jobs
physically, mentally, and technically.
People selection and training are basic principles that increase personal capability
and awareness of risk when dealing with operational hazards. In addition proper
selection and training help to improve personal and team performance.
A people development process including initial orientation certification for special
activities, professional progression, and retraining is in place.
FINDINGS
The average level of experience of ABG-Cement employees (both in supervisory
and non-supervisory jobs) is high. Employee turnover is relatively low. Most people
have been doing their jobs for many years. That will help people improve their
proficiency but it can lead to complacency.
Training is provided to newly assigned personnel, but we found no evidence of a
structured plan/methodology for training on safety to ensure that all of the assigned
individuals indeed meet all the requirements of the job.
We did not find any training programme on leadership skills for line management.
Line management also lack skills to investigate accidents with application of root
cause analysis. Also training on observation of behavioural aspect is absent.
EVALUATION
Currently, the overall level of job competency is high. However, we are very
concerned about the quality of training for safety.
There is a need for ongoing, structured and documented safety training for all
employees. Therefore, such training should be aimed at the following:
• A new employee
• An employee who was transferred from another plant
• An employee who transferred to a different area of the plant
• The management / supervision

• Long-time employees (refresher course)
• Contractors
Management needs to use ongoing training programmes to provide new information,

maintain worker qualifications, encourage and reinforce a positive attitude towards
safety and ensure a deep understanding of safety by all employees. The regular
safety meetings are an excellent opportunity for continuous training. Personnel who
are properly trained and who perform all tasks properly will keep all process
equipment in safe operating condition. Employees must also be physically able,
mentally prepared and capable of making the appropriate decisions to follow the
prescribed practices.
We also believe there is a need to provide training on leadership skills to the line
management team as a whole; we consider this to be very important for effective
management of all aspects of a business, not just of safety.
RECOMMENDATIONS
08.1 Formal training programmes need to be established for all personnel.
These should include:
a. A detailed training plan for each job, integrating job-specific and safety
training.
b. Delivery of training by people trained to teach the material.
c. Skill demonstrations used to confirm the effectiveness of training.
d. Documentation of employee qualifications.
e. Plans to ensure all employees are trained on safety aspects of all

tasks, including refresher training at appropriate intervals. An excellent
technique to accomplish this is a “job cycle check” where the worker
demonstrates competency.
f. Mandatory training requirements for contractors and verification that all

contracting companies and have proper safety training and retraining for
their workers.

As already recommended in the Element 04 section of this report, extensive safety
management and leadership training is needed for senior leaders, managers, line
supervisors and employees.
08.2 After all senior leaders, managers and supervisors receive training on
safety management and leadership, ABG-Cement should extend safety
training throughout the work force.
DuPont offers seminars for employees titled “Making the Workplace Safe:
Actions Employees Can Take (AECT)” that may be of interest.
08.3 The training needs and processes should be reviewed periodically,
including:
a. Continuous upgrading of the training plans, processes, and contents

based on re-evaluation of training needs.
b. Auditing of the effectiveness of training efforts and use of the audit

results to develop improvements to training methods and content.
08.4 ABG-Cement management should solicit employee feedback and use it

to improve the training process.

E09: EFFECTIVE COMMUNICATION
CONCEPT
Information related to Safety is clearly, objectively, and promptly communicated in a
way that enables all levels of the organisation and the local external community to
interact effectively to improve safety performance.
Communication processes are based on a two-way approach throughout different
levels of the organisation, ensuring both employee understanding and active
leadership participation. These processes use different communication vehicles for
different objectives.
FINDINGS
Some site heads conduct monthly mass meetings with all employees including
contractor. These meetings start with safety performance sharing and sharing of
learning from incidents.
Each site has a statutory Safety Committee with equal membership from
management and workers. These committees are basically used for communication.
There are Safety “Tool Box” talks held, but our impression (which may be
incomplete) is that generally these are superficial in nature.
The vast majority of operational information that is shared routinely deals with
operating activities, production volumes, etc. Safety information does not appear
very prominently.
We found no evidence of Safety performance metrics (trend charts, etc.) being
generated, shared or displayed along with other business metrics (production, etc.).
EVALUATION
We believe there is significant room to make all ABG-Cement employees aware of
goals and programmes, action plans, current performance, and recent issues so they
are well and understood by all everyone as an important part of their business, and
to engage them in 2-way communications that get people in the habit of thinking
about safety in a way that lets them internalise its importance to them, that is in a
way that builds value for safety in their minds.

In our experience we have found that if management convincingly transmits to all
employees that their ideas are as valued as their work, the contributions that can be
made by employees identifying ways to improve safety and all others aspects of the
business are limitless.
The quality and effectiveness of communication are crucial to ensure the reliability of
any human system. Effective two-way communication is an integral part of operating
discipline. Excellent communication will speed the implementation and
administration of safety management systems. Management achieves world-class
safety communication when they:
• Develop a message with the true content of all that must be expressed
• Convey the message
• Ensure the message was received and understood
Senior management plays an important role in developing the message; the line
organisation conveys the message and makes sure that it is understood. Complete
communication requires a two-way process – from the management to the
employees and from the employees to the management. Effective communication
requires both formal and informal communication paths between the top of the
organisation and lower level workers.
RECOMMENDATIONS
09.1 Encourage frequent, multi-faceted two-way communications. To
accomplish this management needs to commit resources, including
their own time, to develop and use communication packages that will
promote two-way Safety communication. The following are example of
some of the types of communications that should be considered for inclusion
in a well structured safety communications scheme:
a. Safety observations that initiate and sustain two-way communication.
b. Regularly scheduled, routine Safety meetings, with design and

delivery that encourage interaction, two-way communication.
c. Safety suggestion schemes that encourage staff to suggest solutions

on safety issues they observe.

d. Involve staff members to develop action programmes to achieve the
Safety goals contained in their annual objectives.
e. Start every meeting with a safety pause, where the meeting leader
discusses a relevant safety topic with meeting participants in a way that
the lessons are conveyed and learnt effectively.
f. Bulletin board in all areas should show Safety performance versus

the goals, safety meeting minutes, incident reports and other Safety
information. Show examples of good performance also, not just
negatives.
g. Develop and utilise safety themes to focus employees’ attention on

improving work practices (behaviours). The message should be aimed at
connecting unsafe acts with the eventual probability of injury, and it must
emphasise an employee’s obligation to work safely in such situations.

E10: MOTIVATION AND AWARENESS
CONCEPT
Safety motivation and awareness are achieved when the management system
includes programmes and processes that continuously promote Safety and connect
individual contributions to an effective results-oriented system.
Leadership participation and initiatives are designed to ensure that rules and
procedures are followed as well as to motivate people to follow them.
FINDINGS
Based on inputs from interviewees, the primary motivation system traditionally used
by ABG-Cement management has been to give directions/instructions to people.
We found no evidence of any structured or unstructured ways to provide recognition
(positive reinforcement) of safe behaviours.
We found no evidence of any established, progressive disciplinary procedure in
existence or in practise at ABG-Cement aimed at correction of unsafe behaviours.
A penalty system to for concerned supervisor and his supervisor I n case of fatality
was in place and has been withdrawn from this year.
EVALUATION
We believe there is tremendous room for significant improvement to get people to
value safety on an on-going basis and to get to use their own minds and take the
initiative to seek better/safer ways of doing the work all the time.
The most important – and often most difficult – task is to generate motivation. In a
motivated organisation:
• Management is completely involved in the safety effort, and
• Every employee is committed to a good safety performance.
These two safety aspects reflect the motivation on the part of senior management
and its influence on the line organisation. The foundation for worker motivation is the
interest and personal involvement by management. Workers see this in the safety
activities of Managers in the field. Workers hear about safety commitment in daily
dialog with supervisors and managers. Workers value safety to the extent personally

demonstrated by management. Formal safety statements from management rapidly
lose their impact if management does not translate these statements into their own
personal actions. The best motivational method is to involve each employee in the
safety effort of sub-committees, special safety activities and by participation in
regular safety meetings.
Motivation also comes through positive reinforcement, by recognising and rewarding
individuals and groups for their skills, efforts, ideas, suggestions and safety
performance. Motivation also involves managing the consequences of unacceptable
behaviour (negative reinforcement) with a consistent and fair disciplinary policy.
Both positive and negative reinforcement is necessary to ensure compliance with
behaviour standards. Positive reinforcement is much more effective.
In DuPont we believe that it is crucial to have strict operating discipline, and we
make it very clear to everyone that working safely is a condition of employment.
However, we have found that we get the best results by relying primarily on positive
motivation and maximising the involvement of people in such a way that people at all
levels exercise some degree of initiative and decision-making (i.e. not just follow
orders).
In the few cases when people do not conform in response to coaching, involvement
recognition and other ways to motivate them positively, it is important to ensure there
is uniform enforcement of the existing disciplinary process to avoid further violations
of rules and procedures. We have also found that it is crucial that disciplinary action
be regarded by everyone as impartial, consistent (i.e. applied in the same way by all
supervision), and predictable. Also, disciplinary actions need to be administered as
corrective actions and not as a means to punish. Typically our corrective action
systems have four steps – informal or verbal contact, formal written contact,
probation, and termination. People that require discipline should be subjected to it for
not following procedures or rules before incidents or injuries occur. In the first two
steps, the onus is on management to get the employee to work safely. In the third
step (usually three to six months, but at times as long as a year), the onus shifts to
the employee to demonstrate that he or she should remain an employee. We have
found it most effective for supervision to be aggressive in the warning stages and to
rely heavily on coaching and counselling to avoid the need for the later steps.
However, undoubtedly some employees will require the later steps. A similar

progressive approach has worked well with contractors – both for individual
employees as well as for contract companies.
There is a large opportunity to upgrade the audit system, develop personnel to make
them partners in achieving HSE goals, and move forward on development of the
desired behaviour among employees. This will be covered in further detail on the
next section of this report.
RECOMMENDATIONS
10.1 Continue to involve employees in the safety activities that they already
are involved in.
10.2 Encourage employee involvement in HSE sub-committees and

additional safety activities, such as incident investigations, audits,
inspections, procedure reviews, safety programme design, etc. These
activities help develop teamwork within the organisation and promote safety
accomplishment.
10.3 Redesign the compensation system – Link it to personal accomplishment

of safety objectives so that it becomes a genuine motivator of positive
behaviour.
10.4 Develop, establish and use a structured disciplinary process – All levels
of management need to become trained on the proper techniques to use it.

E11: AUDITS AND OBSERVATIONS
CONCEPT
A continuous improvement system is based heavily on Safety audits and inspections
with effective leadership participation at all levels of the organisation.
Processes exist to enter, report, monitor implementation effectiveness, and do
periodic critical analysis for all audit conclusions and recommendations.
Use of the Overall Safety Management Audit and the three audit levels (first, second
and third party) are consistently used as a reference guide.
FINDINGS
We found no evidence of routine, internal safety management system audits. ABG-
Cement has a practice of engaging outside parties (mainly certification
organisations, etc.) to conduct audits of its facilities and its safety management
systems.
Our impression is that physical audits have primarily focused on conditions and that
audits of systems have primarily focused on documents and not on the practise of
the systems in the field on a routine basis, nor on the behaviours of people.
As already mentioned on an earlier section of this report, in our tours of operating
areas we found quite a few situations that could have led to significant injury or
incident, but these had gone unnoticed or unresolved. Examples of those are shown
on Appendix C. As we observed these situations, members of management
accompanying us tended to give some explanation as to the reason why the items
had not been corrected, and often it was some reason like “We’ve asked for..., but
we have not been able to obtain it because...”. This was read by us as saying “that’s
not under my control; others are supposed to take care of that”. When unsafe
situations that were admitted to be under their control were pointed out the tendency
was to give us assurances that the situation would be corrected promptly along with
the tendency to give directions/instructions to people, but do not take time to create
value for safety in people's minds by having them focus on the potential
consequences to themselves of the unsafe situations nor asking themselves or
others “What do we need to do to ensure this type of situation does not occur?”.

In our visits to offices in the Mumbai area we also found a number of unsafe
situations, including some right in front of the offices. The emergency doors at these
offices were locked.
EVALUATION
Audits at ABG-Cement are not achieving the objective of setting and raising
standards to internationally practised levels.
In our experience we have found that good safety management system has to
include two distinct types of verification or audits: one to evaluate people and their
behaviour – observations or behaviour audits – and another to evaluate the
management systems in terms of suitability and compliance (that is, actual practices
vs. what’s specified in the documented systems on paper) – system audits.
Observations or behaviour audits are crucial because studies have shown that the
majority of all injuries and incidents are the result of unsafe acts. A programme that
concentrates on identifying, eliminating and publicising these acts greatly improves
the safety effort. Workplace observations which focus on people and their behaviour
as they work can prevent injuries. People are alerted about an unsafe habit or act
before it causes an injury. These observations must be carried out by supervision
and upper management members. The management team must be trained in the
techniques of identifying unsafe acts and approaching people.
System audits – They provide an evaluation of the compliance with process safety
management system implementation. This is more than a review of
documentation. To be accurate and effective, the audit must include a verification
of implementation through field observation in process units, workshops,
laboratories, and other operations. Field observations provide data to evaluate the
performance in comparison to established standards. These audits, either on a
single operation, a specific process unit, or across the entire site, must be
conducted by personnel trained in the essential elements of Safety Management.
We believe that ABG-Cement has a lot of opportunity to improve the general level of
awareness to hazards and the skills necessary to significantly improve performance.
Management focuses primarily on equipment and things and much less on people
and behaviour – the mindset needs to change so everyone recognises the injury
potential of many commonplace situations. There is a need to institutionalise audits

of personnel and behavioural observations to set standards and improve
performance.
We also believe that ABG-Cement needs to have and practise regularly its own
internal audit protocols for management systems audits that probe deeply into the
actual practises.
Office safety also needs to be considered seriously. Although the office environment
does not have such hazards as high temperature, high pressures, hazardous
chemicals, etc. as in the field, unsafe behaviour and office conditions can cause
injury and occupational illnesses. There are also a large number of employees
concentrated in office areas, so the total risk is relatively high. Injuries to office
workers come from many unsafe habits or conditions, such as:
• A fall while going up or down stairs without using the handrail.
• A fall and/or serious cuts from bumping objects while walking through
congested office hallways.
• Tripping, falling, or electrocution from unsafe electrical cords or panels.
RECOMMENDATIONS
11.1 Initiate Routine Safety Observations that focus on behaviours of
people.
a. Institutionalise a process of Safety Observations to focus on line

management responsibility and involvement for improving
behavioural safety.
• Line management at all levels need to take note of all safety

issues in the workplace and increase their focus on the
underlying acts of people that create and/or the unsafe
situations; otherwise those situations will be taken as being
condoned.
• When unsafe situations are observed, management need take

time to create value for safety in people's minds by having
them focus on the potential consequences to themselves of

the unsafe situations instead of ignoring them or just giving
directions/instructions to people.
b. Training and coaching to managers, supervisors and employees in

a structured and proven way to accomplish the above should be
provided. This will require training on behavioural safety
behavioural skills for leadership, managers, line supervisors and
employees so that awareness to all hazards increases substantially.
11.2 Establish a permanent Safety Observations sub-committee of the HSE

Committee to:
a. Oversee and monitor the application of the Safety Observations Process,
b. Assist the line organisations in its implementation, and
c. Suggest improvements to the process as experience is gained.
11.3 Establish a system to collect complete information from all safety

observations and develop trend analysis for tracking unsafe acts as a
very important leading indicator of injuries and incidents.
11.4 Establish methodology (protocols, scope, responsibilities, frequency,

etc.) for periodic internal audits of the all the safety efforts and
management systems, and start implementation of:
a. First party audits by line management within their own areas of

responsibility, and
b. Second party audits by line management with assistance from other

units within ABG-Cement.
(Third party auditing can and should be considered much later – in 2-3 years
– after sufficient experience is developed with second party audits.)
11.5 Introduce office safety audits.
a. Consider chartering Office Safety Sub-Committees to promote safe

behaviour in office areas.
b. Use the Office Safety Sub-Committee to organise monthly audits of the

office for unsafe behaviour and conditions, annual audits of the structural

integrity of office chairs, ergonomics audits (including computer user
work station), etc.

E12: INCIDENT INVESTIGATION
CONCEPT
The learning process from undesirable events occurs in a structured way, uses the
line responsibility concept, and is treated as a priority by the whole organisation.
The accidents and incidents investigation processes include activities from
classification to analysis of all possible causes as well as follow up on the
effectiveness of the actions taken.
Support on investigations methodologies exists to guarantee high quality results.
FINDINGS
A system exists on paper for reporting and investigating incidents at sites and varies
from site to site in terms of content, level of understanding and application.
Based on the sampling of 6-8 incident reports that we were given to review, it
appears that incident investigations are performed by mainly safety professionals.
While some of the investigation reports that we reviewed indicated that substantial
efforts were put into the investigation, none of the reports we reviewed adequately
addressed all the underlying factors that contributed to the incident in sufficient depth
to ensure that systemic issues are addressed adequately. Nowhere in the reports did
we find any evidence that the investigations delved deeply enough (asking “why”
successively at least 5 times) into the underlying reasons for the described
situations. Based on our experience we can think of many additional contributing
causes that likely played a significant role, such as inadequate design standards,
inadequate hazards review of the design, inadequate installation practices (which in
themselves can arise due to a myriad of other factors), unauthorized facility changes
and/or failure to properly consider the potential impact of a change, etc. Given the
lack of such in-depth analysis, we believe such factors, unless properly addressed
and resolved, can cause other serious incidents.
We found no evidence of any training being done to impart the necessary skills for
effective Incident Investigations to line management.
EVALUATION

There is enormous room for improvement in the following aspects of the incident
investigation and reporting process at ABG-Cement:
• Investigating teams need to do a much deeper analysis of underlying causes
and corrective actions taken to address each of the underlying causes. A
rule of thumb quality gurus utilise, which we have found quite effective in
identifying all the necessary actions to prevent recurrence, is that you should
ask “why” at least five times, digging deeper each time.
• Management system failures are typically not identified as the root cause in
incident investigation reports.
• The action plan to prevent recurrence needs to be documented in the report,

it needs to address all contributing causes, the name of the person
responsible for each item in the action plan needs to be identified, and the
completion timing needs to be noted.
• Creation of a more open and trusting environment which supports reporting

of all near misses with an opportunity for lessons.
• Use of incident metrics and investigation findings to upgrade programmes,

training, and audit processes.
In DuPont we consider an incident to be any event that did result in or could result in
any injury or illness (no matter how slight), significant property damage, significant
environmental impact, or unfavourable impact on the public. Our experience has
taught us that all injuries and incidents are preventable (that is, there is something
that could have been done to prevent recurrence), and that experience has led us to
set "zero" as a long-term goal. But to reach that goal requires the setting of
objectives and action plans that will result in continuous improvement toward the
goal. An integral part and an expectation of the job of any member of the line
organisation, is the commitment to achieve progressively more challenging
objectives as time goes on.
In our experience in DuPont we have also found that an unsafe situation can lead to
incidents and injuries with different degrees of severity, depending on the particular
circumstances (or, in some cases, just luck), as illustrated by the Hazard Pyramid –
Hierarchy of Consequences on Appendix D. Therefore, it is essential to report and

investigate all incidents, even near misses so that effective measures can be taken
to prevent recurrence. In the setting of objectives, we strive for reduction of what we
call recordable injuries (any injury that required any kind of medical treatment).
Consistency is required in reporting incidents. Consistency is also required in how
deep and broad an investigation is conducted. For ABG-Cement to be able to
reduce what it today calls "accidents", it is essential that all units starts recording,
investigating and preventing all incidents that do result in, or have the potential to
result in, a recordable injury.
RECOMMENDATIONS
12.1 Ensure ALL Incidents (Including those with serious potential) are
investigated fully with focus on prevention. The investigation of all
incidents needs to be institutionalised and the depth of the investigations
needs to be consistent with the real or potential gravity of the incident. Two
key requirements are:
a. Expand the programme to investigate all injuries and serious

incidents by training people at each location in how to conduct
investigations.
b. Establish an effort to broadly communicate the lessons learned

from all investigations to all people with similar potential and insist
that recommendations from the investigations are tracked through
implementation.
12.2 Create an environment of trust to encourage reporting of all incidents.

To that end, have a representative group of employees identify actions that
can be taken to encourage/motivate the reporting of all injuries and incidents
(including near misses), no matter how slight.
12.3 Revise the categories of incidents and reporting requirements, and

require each member of management to establish specific criteria
(based on potential) to be followed by his/or subordinates to conduct special
investigations in his/her area of responsibility.

12.4 Establish a consistent tracking process for all incidents and
recommendations of investigations.
a. The record keeping for all incidents needs to be monitored and

periodically audited.
b. A comprehensive recommendation tracking system should be

implemented so site leaders can properly manage resource allocation
and be assured of timely progress in corrective action.
12.5 Establish a permanent Incident Investigations sub-committee to:
a. Develop a detailed Incident Investigations Procedure for implementation

by line management, and assist line management in “roll-out” of its
implementation.
b. Oversee and monitor the application of the Incident Investigations

Procedure and assist the line organisations in its use.
c. Suggest improvements to the Incident Investigation process as additional

experience is gained.
12.6 Disciplinary action, if any is required, after an incident should be

unrelated to the process of incident investigations.
12.7 Names of people involved in an incident and disciplinary action

assessed should not be mentioned in incident investigation reports.
The main purpose of investigations should be to find and correct root causes
to prevent future harm to people and assets. The purpose should not be to
punish and humiliate workers.

E13: CONTRACTOR SAFETY MANAGEMENT
CONCEPT
The organisation’s contracting party shall manage contractor Safety issues in the
same way their own personnel are managed. Conceptually, all contractors must be
part of the local Safety Management System and also be an active member of the
team.
Effective methodology for contractor Safety management involves Safety in all
contracting stages, from bidder pre-selection to after-contract evaluation. Internal
capable contract managers/inspectors shall exist to guarantee compliance with
requirements.
FINDINGS
In almost all our conversations we heard that we are okay in safety as far as our own
employees are concerned, we have a problem with contractors. That is not our
problem. It is their (contractor’s) problem. We need somebody to fix this for us.
It is noted that some personnel felt powerless with respect to contractors saying that
“this can not work in India….”, “It is tough to manage contractors in remote
locations…” etc.
There is little done at almost all sites in terms of contractor qualification, selection,
structured contractors training, contractor management and contractor evaluation.
EVALUATION
Management of contractors is seen by many in ABG-Cement as the principal area of
concern with insufficient realization (belief) across all leadership that ‘in house’ safety
processes need to be at a much higher level before successful contractor
management might be realistic. Regardless there are positive indications that some
contractor selection processes are already being enhanced from a safety
perspective.
RECOMMENDATIONS

14.1 Formally integrate Safety into all aspects of Contractor Management,
starting at the bidding/tender stage of every contract.
There must be a standard or procedure for contractor hiring and managing. This should
include: pre-selection of bidders; contract preparation; winner selection; orientation and
training; managing, auditing and monitoring; and post-contract evaluation.
• Bidders pre-selection
Only contractors with a demonstrated commitment to safety should be used.

When selecting a contractor, use of safety-related information and metrics to
evaluate satisfactory safety performance must be made mandatory.
• Contract preparation
The contract bid package must include safety performance expectations and
conditions for execution of the work. Safety resource should be involved in
preparing the bid package to identify Safety hazards and include appropriate
potential safety conditions.
• Winner selection
The contract manager should confirm that the contractor’s proposal meets the
bid package’s mandatory requirements. Confirmation includes collection and
review of the contractor’s Safety documents, including documentation of
qualifications, training, and certifications.
• Orientation and training
Before contracted work begins, the organization should provide a Safety

orientation to familiarize the contractor’s employees with essential Safety
information and communicate hazards posed by operations.
• Managing, auditing and monitoring
The Organization should put in place a system to manage, audit, and monitor the
contractor’s adherence to the contract’s Safety requirements. The organization’s
contract manager should hold the prime contractor accountable for
subcontractors’ compliance with all Safety expectations. Contractor safety
performance reports should be generated and communicated.
• Post-contract evaluation

A post-contract evaluation system must be in place to analyze the Safety
performance records during execution of the work. This safety work history
should be considered for future selections.

CONCLUSIONS
We believe the management of ABG-Cement understands the need to make a step
change in safety, starting with a change in the culture of the organisation. This
assessment has identified several areas of strength and significant opportunities for
improvement to help ABG-Cement move toward excellence in safety according to
international standards with the ultimate goals of achieving world class safety
performance.
recommendations.
As progress starts to be made on the priority recommendations, ABG-Cement
management is urged to consider also the additional recommendations that are
contained in detailed element by element analysis.
We believe implementation of our recommendations will allow ABG-Cement to make
significant strides toward Safety Excellence in a way that is sustainable. We wish
everyone at ABG-Cement success in their endeavours.

APPENDIX A
BENCHMARK ASSESSMENT DESCRIPTION
SCOPE
• Data / Document Review, including but not limited to:

o Safety management structure and system (at corporate, off-shore
regional and asset levels)
o Performance reports, analysis, goals & plans
o Injury and incident reports, including review of files in offshore platform’s
infirmary
o Safety Rules and Procedures
o Safety audit, inspection and observation programmes, processes and
reports
o Operating and Maintenance procedures
• Field Assessments
o Interactions with CEO and 9 corporate leaders in Mumbai offices
o Review of pertinent documents;
o Fiels observations of operations at all the 23 sites of ABG-Cement.
▪ 11 Integrated Plants
▪ 11 Grinding Units
▪ 1 White Cement Plant
o Interactions with approximately 1200 people, including confidential
formal and informal discussions with all levels of the ABG-Cement
organisation, from the Chief Executive Officer and other senior
management down to staff, operators and mechanics, and a few
contractor personnel.
• Focus of field tours:
o People working
o Interactions of people and things
o Safe and unsafe behaviours and situations
DuPont Safety Management Assessment – Detailed Report Appendix A – Page 1

METHODOLOGY
Five (5) DuPont consultants spent a combined total of approximately 30 man-days of

effort assessing ABG-CEMENT’s implementation using as benchmarks DuPont’s
proprietary criteria for the elements shown on the following two models:
DuPont's Essential Elements for General/Behavioural Safety Management:
Policy Responsibility &

Organisation Accountability* Goals &
Objectives
Visible
Incident
Investigations
Management
Commitment Standards
Supportive Motivation
Safety
Personnel Safety
Observation Training
s Communication
DuPont's Essential Elements for Process Safety and Risk Management:
The focus of the Cultural Elements is on the implementation of management systems,

in particular the involvement of management, their influence on the actions of people,
and the actual behaviour and mindset of everyone in the organisation as determined
through sampling, observation, and discussion.
In our experience the Safety Culture of organisations evolves through four stages
(reactive, dependent, independent and interdependent), and we also assessed the
current stage of the ABG-Cement Safety Culture relative to these four stages.
DuPont Safety Management Assessment – Detailed Report Appendix A – Page 2

APPENDIX B
SAFETY PERCEPTION SURVEY (SPS) RESULTS
The Safety Perception Survey (SPS) was designed to capture Aditya Birla Group’s
opinion of its safety management through the perception of its employees. It
consisted of 24 core questions tapping the opinions, sentiments and performance
drivers in three broad areas: Safety Leadership, Safety Structure, and Safety
Processes / Actions. Responses were obtained from 17,425 members of
Management, Staff, Workmen & Contract personnel across 23 manufacturing units &
Ahura Centre.
Safety perception survey results indicate that personnel are not satisfied with the
current safety performance and are desirous of further improvements. Attitudes and
beliefs of personnel also differ from that of employees in companies with the best
safety performance. This suggests that the management can significantly improve
Safety performance by:
• Better communicating and demonstrating to the employees a strong

commitment to improved safety performance,
• supporting implementation to achieve intentions and desires enshrined in the

documented Safety management systems, and
• Emphasizing regularly that, while production is a ‘priority’, safety is a ‘value’

and hence cannot be compromised in any case.
We believe that our benchmark assessment of the cultural elements is consistent

with the responses of the personnel in the survey, with particular significance to the
following responses:
% Responses
Question Support
Leaders Managers Workers
Staff
I rank Safety First 72 78 81 65
Others rank Safety First 55 63 67 53
All injuries can be prevented 54 38 44 33
Safety achievements are recognized 42 34 50 35
Satisfied with Safety Performance 38 38 57 39
DuPont Safety Management Assessment – Detailed Report Appendix B – Page 1

1. While 79% of the respondents (72% of leaders) say that they rank Safety first,
only 65% of the respondents (55% of leaders) perceive that others too rank
safety first. These values for benchmark best companies are 96% & 91%
respectively.
2. Only 42% of total respondents (54% leaders & 38% Managers) believe that all
injuries can be prevented and this compares to 94% for the best performing
companies.
3. 46% overall (42% leaders & 34% Managers) said that Safety achievements are
recognized and this compares to 92% for the best performing companies.
4. And, finally only 38% of Leaders & Managers both, believe that they are satisfied
with the current level of safety performance compared to 82% in the best
performing companies. We believe that this is an honest opinion provided by the
respondents and therefore should be leveraged to bring about desired
improvements.
The full, detailed results and analysis of the SPS are contained on a report titled
Safety Perception Survey Report which is too voluminous to include here. That report
is being submitted as a separate file named SPS.PDF, and it should be considered as
an integral part of this Detailed Report.
DuPont Safety Management Assessment – Detailed Report Appendix B – Page 2

APPENDIX C
PICTORIAL FIELD OBSERVATIONS
DuPont Safety Management Assessment – Detailed Report Appendix C – Page 1

APPENDIX D
THE HAZARD PYRAMID
HIERARCHY OF CONSEQUENCES
Incidents / Losses Are a Matter of Probabilities, …

Really!
Shift emphasis
from here
To
here
DuPont Safety Management Assessment – Detailed Report Appendix D – Page 1

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DuPont Safety Management Assessment

Aditya Birla Group: Cement Business

Report compiled by:

Safety Perceptions and Safety Management Assessment Report – Executive Summary - ii -

Priority Recommendations .......................................................................... 11

Suggested Implementation Roadmap .......................................................... 15

Safety Management Elements

A. Benchmark Assessment Description

B. Safety Perception Survey results

C. Pictorial Field Observations

E. Individual Site reports

Safety Perceptions and Safety Management Assessment Report – Executive Summary - iv -

Aditya Birla Group – Cement Business (ABG-Cement) engaged E. I. DuPont India

• A current state assessment and a Long-term road map for safety

• Enhanced capability of Leaders, Managers and Safety Professionals to lead a

• Defined organizational structure / restructuring, safety management systems

• Functional tools, processes and actions, adapted to meet Cement Business’s

• Structured processes for managing “contractor safety”

• Identify how ABG-Cement culture impedes efforts to improve safety

• Redefine safety culture for the future

• Validate overall findings the Assessment.

Safety Perceptions and Safety Management Assessment Report – Executive Summary - vi -

4. At almost all sites documented Safety management systems (on paper)

7. The sense of line management accountability for safety is reasonably well

DuPont Safety Management Assessment Page 1

9. Mines at all integrated plants are at a higher level of involvement and

2. Management of contractors is seen by many as the principal area of concern

3. There was little in the descriptions or perspective provided by the leaders to

4. There is essentially no visible safety message to head office employees,

DuPont Safety Management Assessment Page 2

6. System of automatic financial penalty on supervisor and departmental heads

7. It is also clear that among supervisory levels, including functional heads,

8. The failures in demarcation between construction and operations –

9. Our assessments at sites and corporate indicate that incident reporting,

DuPont Safety Management Assessment Page 3

❑ 5 year employee LWIFR ≤ 0.25 with no single year employee LWIFR

❑ 5 year employee TRIFR ≤ 1.00. TRIFR is based on 200,000 hours.

DuPont Safety Management Assessment Page 4

Of particular concern is ABG-Cement’s upward trend in the total number of fatalities

DuPont Safety Management Assessment Page 5

• Supporting implementation to achieve for fuller achievement of the intentions

• Emphasising that, while production is a ‘priority’, safety is a ‘value’ and

DuPont Safety Management Assessment Page 6

1. Strong, demonstrated management commitment

Each element was assigned a performance level of “Fundamentals”, “Awareness”,

DuPont Safety Management Assessment Page 7

The best performing companies and organisations would be rated “Excellent” or

Benchmark Assessment Results

DuPont Safety Management Assessment Page 8

Current safety culture is transitioning from “Reactive” to “Dependent”

Reactive (Lagging) Proactive (Leading)

Reactive Dependent Independent Interdependent

Safety Assessment Aditya Birla – Ceme nt Business , 2009

In our judgement, there is significant potential for improvement to move the

DuPont Safety Management Assessment Page 9

DuPont Safety Management Assessment Page 10

In our judgement, to drive cultural change in the organisation, ABG-Cement

• Safety has to become a ‘value’ (not a ‘priority”) at ABG-Cement. Safety

DuPont Safety Management Assessment Page 11

• The organization should develop a standard or procedure for accident and

• Institutionalise a process of Safety Observations to focus on line

DuPont Safety Management Assessment Page 12

• The organization should define a matrix of competence with all requirements

6. Develop common corporate standards of performance to be applied