Comprehensive Safety Leadership and Incident Analysis Symposium

Incident Analysis Case Study: The McGraw Unit and Cleveland Cliffs Incident

• McGraw Business Unit Overview

  • McGraw is the third-largest business unit within the organization by revenue.

  • Team size fluctuates based on the project, ranging from approximately $120$ to $400$ team members.

  • Sectors of Operation:

    • Industrial Services: Focuses on traditional construction, often paired with industrial coating or subcontracted work for electricians, pipefitters, and boilermakers.

    • Industrial Maintenance: Involves being embedded within client facilities, including steel plants, automotive plants, chemical manufacturing, and breweries (e.g., Molson Coors). Responsibilities include large-scale outages, downturns, and routine maintenance.

    • Off-Site Manufacturing: A facility in Monroe, Ohio, dedicated to pipe, steel, electrical, and form shop fabrication.

• Case Study: The Cleveland Cliffs Pump House Incident

  • Location and Context: Cleveland Cliffs is a long-term client (decades of partnership) at the Middletown steel plant. The incident occurred at an intake pump station that brings cooling water from the river.

  • Facility Condition: The mill and pump house are significantly aged (over $100$ years old).

  • Scope of Work: Demolition of old pumps and installation of new, large-diameter ($36\text{ inch}$) pipes.

  • Sequence of the Event:

    • A team member was removing bolts from pipe flanges. After removing one of the last two bolts, the nut on the final bolt sheared off or failed.

    • The pipe section, weighing approximately $3,000\,lb$, swung toward the wall.

    • The team member was positioned between the pipe and the concrete wall; his arm was pinched in this position.

    • Immediate action was taken to back the pipe off the worker. Despite significant blood loss, there were no broken bones.

    • Medical Outcome: The team member required $12$ stitches but was able to walk away. The speaker notes that if the pipe had struck the worker's head or a major artery, the result could have been fatal.

• Primary Contributing Factors and Causal Analysis

  • Rigging Failure: The pipe spool was rigged at a hefty angle using a $10\text{ ton}$ overhead crane and a $3\text{ ton}$ chain fall with two $2\text{ inch}$ nylon slings. The rigging was not designed to prevent horizontal movement.

  • Inexperience: The foreman on-site had been in the role for only two months and lacked the specific training required for complex rigging loads.

  • Lack of Planning: No formal demolition plan was in place. While an office-level plan was being developed to include a gantry system for sliding the pipe safely, this information had not reached the field.

  • Stand-by Factors: The crew was rushing to finish demolition of a pedestal and decided to remove the pipe section early to facilitate better access for hammers.

The "Four P" Investigation Process: Parts, Position, Paper, and People

• Parts

  • Identify all physical elements involved in the failure.

  • Specifics to Check: Equipment specifications (e.g., $10\text{ ton}$ crane), rigging gear (chain falls, nylon slings, shackles), pipe weights ($2,800\,lb$ to $3,000\,lb$), and the status of system isolation (de-energized/locked out).

  • PPE: Verification of whether the specific PPE worn (gloves, sleeves, etc.) was appropriate or contributed to the injury.

• Position

  • Document exact locations of team members and witnesses during the event.

  • The "Clock" Method: Visualizing a flange as a clock face (e.g., identifying the worker was trying to remove the $12\text{ o'clock}$ bolt while the restraint was in the $9\text{ o'clock}$ position).

  • Environmental Factors: Note weather conditions (e.g., $95\text{ degrees}$ vs. $45\text{ degrees}$) and site access dimensions.

• Paper

  • Review all documentation, including training records, lift plans, and Job Hazard Analysis ($JHA$).

  • Joint Job Hazard Analysis ($JJHA$): A process required by private clients where the crew and client representative walk the site together to identify hazards before work starts.

  • Training Deficiencies: In the Cleveland Cliffs case, the pipefitter had union rigging certifications but lacked the company-specific training required for complex loads.

• People

  • Conduct interviews with witnesses and involved team members to identify behaviors like rushing, complacency, or "mind not on task."

Corporate Safety and Health Information Management System (SHIMS) Transition

• Document Library Management

  • The organization is moving away from SharePoint toward a centralized "Policy Library" (referenced as DAVIDs).

  • Objective: Manage approximately $2,500$ documents ($1,500$ of which belong to the Safety Department).

• SHIMS Topic Leads

  • A new role where assigned individuals "own" a specific technical topic, including the document library, training content, and related communications.

  • Review Cycle: Documents will move to a mandatory $3\text{ year}$ review cycle (consistent with ISO standards). The library is divided into thirds to ensure a continuous update process.

  • System Roles:

    • Owner: Manages the topic and initiates workflows.

    • Writer/Reviewer: Provides edits and suggestions within the policy system.

    • Approver: Final sign-off (currently restricted to leadership like Nick Brannock).

Site-Specific Safety and Health Plans (SSSHP) and Work Packages

• Definition and Purpose

  • The SSSHP is a strategy for success, not just a form to fill out. It establishes risk control expectations for specific job site conditions.

  • The "SQP" Balance: Safety, Quality, and Productivity must work together. Poor quality leads to rework, which increases safety risks. Productivity is owned by operational leaders, but safety is the collective responsibility driven by the and for the operational leaders.

• Updating the SSSHP

  • The plan must be updated when:

    • There is a major shift in the scope of work (e.g., moving from bridge construction to drainage repair).

    • A change in the phase of the project (e.g., traffic shifts or demolition starting).

    • New personnel arrive on-site.

  • OHA (Occupational Hazard Analysis): A micro-level plan for specific tasks. Components include: task steps, hazards, controls, training requirements, equipment lists, and required inspections.

Fleet Safety and DOT Regulatory Requirements

• Fleet Initiatives

  • Telematics and Cameras: Implementation of Samsara systems for tracking driver behavior. Cameras are primarily for driver exoneration in the event of an accident and for rewarding high-performing drivers.

  • DOT Competent Person Training: Safety specialists will undergo training in truck/trailer inspections and regulatory compliance.

• Regulatory Thresholds and Definitions

  • Commercial Motor Vehicle ($CMV$): Any vehicle with a Gross Vehicle Weight Rating ($GVWR$) of $10,001\,lb$ and up.

  • Commercial Driver’s License ($CDL$): Required for vehicles over $26,001\,lb$. All $CMV$ drivers must possess a valid medical card.

  • Hours of Service ($HOS$): Standard limits include a $14\text{ hour}$ total on-duty window, $11\text{ hours}$ of driving time, and a mandatory $10\text{ hour}$ off-duty reset.

• Materials of Trade ($MOT$)

  • Refers to small quantities of hazardous materials used to support the job.

  • Weight Limit: Maximum of $440\,lb$ of hazardous materials allowed in the vehicle without a hazmat endorsement.

  • Diesel Fuel: Limited to $119\text{ gallons}$ ($dm^3$) in a transfer tank. Most company tanks are sized at $112\text{ gallons}$.

  • Violation Examples: Using bungee cords to secure cylinders (must use one-inch load-rated straps), failing to remove regulators from bottles during transport, and leaving safety caps off valves.

Industrial Hygiene and Chemical Management: The Lebanon Water Project

• Project Scope: Treatment and disinfection of miles of new $36\text{ inch}$ potable water pipe.

• Chemical Hazards: Usage of DryTek (calcium hypochlorite) granules.

  • Exposure Risks: Respiratory irritation from dust; skin and eye burns; fire risk as an oxidizer.

  • Unexpected Reactive Hazard: Interactions between the calcium hypochlorite and city water (containing ammonium sulfate) can result in the off-gassing of Chloramine vapors.

• Industrial Hygiene (IH) Sampling

  • Bailey (IH Specialist): Coordinates sampling using NIOSH methods:

    • Method $7303$ / $0500$: Measuring DryTek dust levels.

    • Method $7607$: Measuring chlorine and chloramine levels.

  • PAPR (Powered Air-Purifying Respirator): Selected to provide respiratory protection while mitigating heat stress in summer conditions.

• Velocity EHS (MSDS Online)

  • The organization manages an inventory of $6,597$ chemicals.

  • Digital Inventory Management: Moving toward location-specific "eBinders" to reduce the noise of the master list. Safety specialists will use a mobile app to perform site inventories and index high-risk chemicals for hazard reporting.

Career Development and Strategic Plan 2031

• The Weekly Report

  • A tool for short-term development and continuous dialogue with supervisors.

  • 1% Improvement Theory: Improving by $1\%$ daily results in becoming $37$ times better over one year ($1.01^{365} \approx 37.78$).

• Safety Twenty-Four Seven Strategy

  • Goal: Engaging employees in safety behavior both at work and at home.

  • Inspection Targets: Safety specialists are expected to complete $10$ inspections/conversations per month ($120\text{ annually}$); managers are expected to complete $5$ per month.

• Core Values and The Energy Wheel

  • Sticky (High-Exposure) Hazards: Focus on the "Energy Wheel" to identify various forms of hazardous energy: Gravity, Motion, Mechanical, Electrical, and Pressure.

  • BTG (Balance, Traction, Grip): Addressing underfoot conditions that cause nearly $100$ injuries per year. The initiative promotes "Premium Access" (building ramps, clearing debris, maintaining handrails).

Questions & Discussion

• Q: How often are documents updated?

• A: The current goal is a $3\text{ year}$ review cycle. Some items, such as the confined space update, required massive operational input and longer cycles.

• Q: Is the $10,001\,lb$ medical card requirement recent?

• A: No, it has been a regulation for a significant amount of time, but the enforcement focus on smaller $CMVs$ (like three-quarter-ton trucks with hitches) has increased.

• Q: Can we use the barcode scanner in the Velocity app?

• A: Yes, but only if the data has been "indexed" on the back end so the system recognizes the product barcode. This is part of upcoming pilot programs at four locations.

• Q: Why are we doing the weekly report?

• A: To align short-term actions with your Individual Development Plan ($IDP$). It is the bridge between day-to-day tasks and career goals like becoming a Safety Manager.

• Q: When does the co-op role end?

• A: It doesn't have to end with the summer; the organization often retains co-ops for remote work during the school year to assist with document coding and administrative development.