Note: Do not add page numbers.

Do not refer to page numbers when referencing different portions of the

paper




Journey to Incident-Free Workplace



Kief Hess
Chemtura Corporation
Philadelphia Pennsylvania
Kief.Hess@Chemtura.com







Prepared for Presentation at
American Institute of Chemical Engineers
2013 Spring Meeting
9th Global Congress on Process Safety
San Antonio, Texas
April 28 May 1, 2013


UNPUBLISHED



AIChE shall not be responsible for statements or opinions contained
in papers or printed in its publications







Journey to Incident-Free Workplace

Kief Hess
Director, Process Safety
Chemtura Corporation

ABSTRACT
Safety Excellence is an essential element to achieving manufacturing excellence. This paper
describes proven methods of crafting a journey towards achieving safety excellence in the
chemical industry. The elements described in this paper helped Chemtura to steer the direction
and guide the Corporation on a journey towards safety excellence. The leadership vision,
associated techniques for investigating incidents, communication of investigation results, along
with the development of tracking tools are described herein. Critical success factors and pitfalls
are also illustrated. This paper presents a systematic approach to communicate the vision, collect
and assess data, and share risk awareness information across an organization that can lead to an
incident-free workplace.

1.0 Introduction
Employee injuries and process accidents cost the chemical industry millions of dollars each year
in medical, environmental cleanup, business interruption, legal liability, and equipment
replacement costs. Ensuring excellence in safety performance and process safety is essential to
minimizing these costs and maximizing manufacturing excellence. Accidents, injuries, and
incidents divert vital resources and distract organizations from excelling in manufacturing.
In order to accomplish excellence in safety, companies must provide a clear, simple vision that is
understood by all employees so that they know the expectations and the ultimate goal. The vision
must be considered achievable, otherwise, employees will not buy in.

Continuously reinforcing this vision with subsequent learning programs throughout the
organization help to keep employees engaged and focused on incident-free.

There are many elements that contribute to the path of success, but for Chemtura, the journey
was simple:

Thoroughly investigating all incidents and the generation of corrective actions to address the
cause(s),sharing learnings and corrective actions with all employees, expanding investigations
and sharing to include critical near-misses, and identifying a series of leading metrics to
establish that fundamental management systems are in place and fully functional.

Lets take a closer look at our Journey.


Organizations must provide a vision that will ultimately challenge the employees to the end-goal.
The path on the journey will change with time based on signals and signs of actual performance
and incident rates. For Chemtura, the following provided the direction on the Journey.

2.0 Creating the Vision

The vision is the starting point on the journey to safety excellence. It is a statement set by the
corporation to clearly and concisely convey the goal of the company. The vision must be ever-
lasting and a frequently communicated statement across the entire organization.

The statement must do three things: engage, stimulate, and energize the workforce.

The vision must be simple, understandable, and, above all, attainable. The least successful
visions are those that are too complicated. These are visions that the workforce does not believe
can be achieved.

Additionally, the corporation must always uphold the vision to strive towards that end. Focus
must be maintained every single day.

A number of years ago, Chemtura Corporation realized that its safety performance record was
not acceptable. Chemtura wanted a vision and assembled a broad cross-section of leadership.
After using the guidelines stated above, the vision was crafted. It reads, All employees actively
leading the journey of living incident-free.

This vision statement contains several key elements:

First, it is a short and simple statement that can be remembered by all employees.

Secondly, it contains all employees actively leading,which infers that each and every
employee must be engaged and active to help lead the efforts toward achieving the goal.

Thirdly, it establishes a journey that has no end date. Chemtura is not striving to be incident-free
in one or two years, but, instead, is calling upon employees to work together to keep safety top-
of-mind.. It is and can be achievable. Everyone must learn proper safety and must implement
new, safer procedures and practices that build an incident-free workplace where injuries,
accidents, and incidents do not occur.

So, with this vision, employees are engaged in investigations and work task improvement,
stimulated to use their learnings, and energized toward continuous improvement to sustain
progress towards the goal.

3.0 All Significant Incidents Must Be Thoroughly Investigated

This is an important step. All incidents must be reported, documented, and posted to a common
portal that all employees can access. When an injury, accident, or incident occurs, it must be
thoroughly investigated to the minutest detail. Having this drill-down helps to understand not
only the factors that lead up to the event, but also shows how well the organization is adhering to
rules and procedures and recognizing hazards. The investigation must identify all the failures or
causes, not just a single root cause. A review of several major investigation reports from the
chemical industry has shown many incidents may have as many failures that ultimately
contributed or led directly to the event. Identifying all the contributing causes and ensuring there
are corrective actions for each will help mis-take proof the event from occurring again.

At Chemtura, an incident investigation technique called causal-mapping was identified as the
preferred technique to be used throughout the organization. This simple but very powerful
technique allows investigation teams to recreate the details of the incident to identify all the
causes and effects that lead to the incident, which, in turn, enables the team to develop specific
corrective actions for each cause. Having all significant incidents investigated in this manner
helps all employees to better understand how incidents occur and why they occur. This also helps
to identify signals that may have gone un-noticed had the technique not been used.

Causal mapping starts with identifying the incident and working backwards to identify all the
causes necessary to have the effect. For example, in order to have a fire, three elements
oxygen, fuel, and an ignition sourceare necessary. Then, each one of these becomes a root for
further evaluation. For example, what circumstances made fuel present? What had to occur to
have oxygen? By breaking down each component or cause and determining what is needed for
the effect, findings all of the influences and failures that lead to or contributed to the incident
are identified. By knowing all the contributing factors and implementing effective corrective
actions for each and many of those factors, future repeat incident should be eliminated.

The causal map allows the team to drill-down into very small details, such as employee actions,
positions, and practices, which may otherwise be lost if not used. This drill-down data proves
valuable in gaining the string-of-failures, yielding greater understanding of the activities that
led to the event. These are considered learnings.

In the example below, one can see how the causal maps were developed, with the white boxes to
the left indicating the potential effect and the boxes on the right identifying the cause. Each
cause, then, is actually an effect for which additional causes can be determined. The pink box is
the evidence box that contains information that supports or denies the cause-effect
relationship. The causal map should have a number of green boxes to represent solutions or
possible solutions, which would prevent this cause from occurring again and having a follow-on
effect. In this example, there are a number of evidence boxes and solution boxes that help lead to
the causes of the event. The investigation team will follow the causes all the way to the end
until either the evidence will not support further drill-down or it leads to adequate detail about a
given cause.








Figure # 1 Example of Incident Causal Map




Figure 1 Causal Map


4.0 All Corrective Actions are Closed

The results of the investigation are an important step; however, it is also critical that the
organization take specific corrective action. As part of the investigation, corrective actions for
each and every cause are identified (possible solutions or green boxes are discussed above). Of
all those possible corrective actions, the feasible/desired corrective actions are selected for
implementation. Each of the corrective actions selected must then be closely tracked until
closure. Corrective actions are frequently identified during investigations, but following the
commissioning of equipment and processes, employees often get distracted, and corrective
actions are left incomplete. This can derail the organization towards its goal of instilling
appropriate layers of protection to avoid future incidents. If corrective actions are not completed
promptly, the employees will quickly decide that corrective actions are not important, and thus
the time and effort becomes less valued (and hence, faith in the vision wanes). Firm, specific
corrective actions must be identified, resourced, completed, and fully functional following the
incident. The organization must have strong will and robust systems to ensure tracking of all
corrective actions to prompt closure. If the targeted closure date is not met, then an appropriate
escalation to higher management levels in the organization must be communicated to obtain the
necessary resources for closure. Persons responsible to close the corrective action must
understand that they will indeed be held accountable for prompt closure. As corrective actions
are implemented, the organization must continue to implement layers of protection to prevent
future incidents for long-term sustainability. In this way, not only are the causes of the incident
addressed, but the aforementioned vision is given support among the employees.

5.0 Learnings Must be Shared

Sharing the insight of investigations is key to staying on the path to the journey of incident-free.
All employees must be acutely aware of incidents and be able to internalize those learnings in
their own workplace- no matter where they work in the organization. This is particularly
important in a global corporation with multiple locations. Without the sharing of incidents,
causes and corrective actions, employees don't become aware of the potential hazards in their
workplace and cannot take appropriate action to prevent it from occurring. The potential learning
from one incident in one facility, in essence, becomes unused in any of the other plants.

To accomplish this sharing, Chemtura communicates in various ways. First, a corporate and
plant leadership call is held to discuss the early facts of the incident. Secondly, a preliminary
written report is distributed among the organization leaders. Third, a bi-weekly global conference
call is held with any interested member from all sites to share the incident learnings and
recommendations. A representative from each site where a significant incident or near-miss
occurred will present a safety alert during the global conference call, emphasizing the
learnings of the incident. The call is recorded for those that miss it. Fourthly, a standard template
is used for all safety alerts and is posted on an organizational shared drive for all global
employees to access. The safety alerts shared from the global calls can then be used for local
safety meetings, tool-box talks, and during site safety committee meetings to ensure a broad
communication among all employees. The global discussions have shown that many incidents
have occurred previously at other locations, further emphasizing that institutional learnings and
corrective actions have not been fully integrated and utilized as an asset throughout the
organization.



6.0 Drill Down to Near-Miss Incidents

As thorough investigations are conducted and corrective actions are identified, tracked,
implemented, and communicated, the number of incidents will begin to decrease. With a
lessening of actual incidents, learning opportunities also fade. For continuous improvement, the
organization must recognize this reduction in learning opportunities and support improvement
with new, continuing data. To do so, an organization can shift focus to near-misses (NMs) and
less significant incidents.

Generally, every organization records near-miss data, but they often deal with the more
significant near-misses. At Chemtura, there were several sites that were doing a good job in
collecting near-miss data; however, overall near-miss reporting was generally lacking. Reporting
failed to identify lesser misses or overlooked the smaller details, namely lack of sign-offs, a
diversion from procedure and protocol, failure to complete an MOC formall of which can
represent some form of risk. Near-miss reports can provide a continuous stream of learning
opportunities, even if a NM does not lead to an incident. These additional learnings will foster
increased understanding of the conditions and behaviors that may lead to accidents and incidents.

Emphasizing near-miss reporting may be difficult at first. Employees may view it as additional
work to an already hefty workload. Some may hesitate to report actions of their co-workers.
Others may fail to document their own unsafe practices. Also, early on, employees may not be
able to recognize all of the potential NMs around them. To overcome this issue, the organization
must have strong top-level leadership to reassure the organization of the importance of NM
reporting and the valued learnings they can have on further enhancing safety. Hopefully, with
employee buy-in and engagement and recognition of the benefits of steps 1-4 of this journey,
there will be a bottoms-up support for work on NMs as well.

One approach to control the resource impact on an organization is to select those NM reports
which have the greatest risk potential. The NMs that have a high risk potential should be
investigated as if had it resulted in an actual significant incident, including using the causal map
and sharing those learnings. A good tool to risk-rank NMs is to use a risk-ranking chart. This
chart has severity (A through F) on one axis and likelihood (1 through 6) on the other. The NMs
with a higher potential severity and potential likelihood result in a red risk ranking. Those with
red risk rankings are investigated, corrected, and communicated globally. As the red NMs
potentials begin to drop off, the organization will investigate and share the yellow risk NMs, or
those with a medium potential severity and potential likelihood. See the chart below.

Figure #2 Risk Matrix



Although an incident did not occur, the learning from these NMs helps to continue the sharing of
failures (learning assets) so employees can continue to learn and recognize risks. Understanding
the learnings also enhances employees abilities to see or spot potential hazards before they
occur. As more NMs are reported, more learning and risk awareness is acquired. To date,
Chemtura reports nearly thousand NMs per month, with several hundred reviewed and shared
globally annually.

There is generally a good correlation of increased NM reporting with lower accidents, incidents,
and injuries. However, the organization must be cautious. NMs not only have to be reported, but
there must be follow-up in some form of investigation into the cause and subsequent learnings in
order for the reports to be beneficial.

At Chemtura, it was initially noted that an increase in NM reporting did not result in improved
safety statistics. A standard metric (the number of NM/employee) was established for the sites to
report. In this case, the NMs being reported were only done to meet for the metric and not for the
value in learning opportunities. NMs were not being reviewed or discussed. We caution that
local site leadership must overcome the concern that a large number of NM reporting may reflect
poorly on the plant. Leadership must understand and recognize the real value in reporting and
sharing across the organization and report as NMs are observed and evaluated. It's not
necessarily the number of NMs reported, but the discussions and the understanding of what went
wrong that will drive the sites performance to zero incidents.


7.0 Understand trends with Near-Miss Data

The near-miss reporting will yield a tremendous value of information, particularly when
analyzed from a causal perspective. At Chemtura, a subcommittee of global employees
developed a list of all causes from causal mapping of prior incidents, using a simple Fish-Bone
diagram technique. This familiar diagram was used to identify specific causal codes and enable
sites to select one or more of the 18 highlighted elements as the main cause(s) of the near-miss.
Those causes that appear in the greatest number can then be targeted by the organization or local
site to drive improvement. For example, if a large percentage of NMs occur due to poor
maintenance, then the site will review and make the necessary changes to equipment
preventative maintenance. The focus on a specific cause factor from the fish-bone will help
lead to further reduction in accidents and incidents.
















Figure # 4 Causal Factor Fish-Bone




The data can be analyzed on a total organization perspective as well as geographical/regional
data to determine if specific regions or even specific facilities have differing causal factors. The
organization must use the data and let the data lead and guide future efforts in achieving safety
excellence.

8.0 Leading Metrics Help Create the Road on the Journey

The last important compass used on the journey is to use predictive information to determine
where failures might occur. Incidents can be measured because they are factual events; however,
having the ability to see in advance where potential failure of practices, equipment, and people
may occur can be beneficial.

Chemtura wanted to identify which system(s) is the foundation to sustain safety excellence. Once
known, having a set of metrics to monitor the implementation and effectiveness of this critical
system would help ensure the organization has the proper foundation to build success.

Leading metrics might represent elements of management systems that are in place that help
drive improvement in performance. Examples of leading metrics might be: critical inspections,
on-time process hazards analysis, past due findings/inspections/trainings, Standard Operating
Procedure reviews, number of behavioral observations, audits conducted, actions closure, etc.
Using the Chemtura Layer of Protection, as seen below, the corporation identified PHA and
MI (mechanical integrity) as critical management systems that, if executed efficiently, would
provide an optimum first layer of protection to ensure process safety and personnel safety. Why?
If the plant does not understand the potential hazards and consequences associated with
chemical, equipment, or operational practices, then it is reasonable to believe that incidents will
occur. Ensuring the hazard studies are thoroughly conducted and all recommendations are
completed on time is considered a critical leading metric. Additionally, the mechanical integrity
program is another critical management system. If the organization cannot ensure that all the
equipment is properly fit-for-service and operated as designed and installed, then it is
reasonable to believe that poor mechanical integrity will lead to incidents, accidents, and injuries.



Figure # 5 Chemturas Layer of Protection Chart





Every day, there are many layers of protection that are accurately and correctly implemented that
prevent an incident. An organization must understand the ones they believe are important and
monitor their effectiveness.
`
In the Chemtura organization, leading metrics make up an important element of monthly and
quarterly reports. At the end of each month and quarter, each site will enter leading metric data
for PHA and mechanical integrity and post on a portal. Following each quarter, the leading
metrics are presented to senior management and the Board of Directors. Presenting the data to
these groups stresses the importance to all employees the importance of the management systems
being monitored (PHA and MI) have on safety excellence.

These simple metrics allow the site management teams to understand how well the PHA and
mechanical integrity program is being executed and sustained.

For PHAs, the leading metric are:

% PHA conducted on time Government Required
% PHA conducted on time Non-government required
% Recommendations Completed
% Recommendations Past Due >30 days, > 90 days, or > 180 days.

For Mechanical Integrity Inspections, eight various systems are identified which leading metrics
are required for each:

Pressure Vessels
Atmospheric Tanks
Relief Devices
Safety Instrumented System
Critical Transfer Systems
Critical Sensors, LEL, Toxic, Etc.
Piping
Electrical

These major equipment categories are believed to be critical to the reliable and safe operation of
the facility. Included in each of the equipment categories are:

% inspection complete
% inspections past due in the > 30 days , > 90 days, or > 180 days,
% of deficiencies detected or discovered during the inspection.

The recently added metric for deficiency represents how well the equipment or system is
maintained during normal operation and in between preventative maintenance. Having a leading
metric of a very low number of deficiencies may indicate the mechanical maintenance and
operability of the equipment is good. However, a leading metrics showing a high number of
deficiencies may indicate an incorrect application, a lack of repair, or poor preventative
maintenance procedures.

Table #1 Simplified PHA Leading Metric Data Entry





Table # 2 Simplified Mechanical Integrity Leading Metric Data Entry







9.0 Conclusion

In closing, to achieve manufacturing excellence, an organization must have a robust safety
program that includes proper design, well-trained employees, and the proper layers of protection
to achieve an incident-free workplace. The journey that will lead to safety excellence must first
come from a clear vision that promotes a learning organization. Learning from incidents and
near-misses, along with monitoring vital leading metrics, will lead to safety excellence. The
examples provided in this paper can have an impact on safety practices towards the goal of
having an incident-free workplace.

Engaging employees to actively lead toward the goal, stimulating them with data and its
analysis, and energizing them toward continuous improvement will lead to a sustaining world-
class safety performance..