One Will Die: The John Martin Story Applying Action Based Safety 11/14/2018 Martin Consulting LLC

Journey Back in Time A Serious Look at all the Contributing Actions that set this Accident in Motion Attitudes, Short Cuts, Communication, Production, Pride, are all at work in this event 11/14/2018 Martin Consulting LLC

April & May 1984 With the intention of improving production and enhancing technical knowledge: Operations & Maintenance Supervision and Chemical Engineers are moved to different process areas New mechanical engineers are placed in several maintenance areas as front line foreman 11/14/2018 Martin Consulting LLC

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Antecedent What antecedents are in place? No one wants to work overtime Saves money Improves production Saves time Known Risk Taker assigned job Safety not a value 11/14/2018 Martin Consulting LLC

Behaviors Operator closing valves Operator draining pipe lines Mechanics tagging breaker Mechanics blocking valves Operator energizing valve Mechanics not wearing PPG Operator closing valve Mechanics not tagging valve 11/14/2018 Martin Consulting LLC

Consequences 36 hour outage reduced to 8 hours Saves money, no overtime Increases production Man burned over 70% of body Operator overwhelmed Mechanics crying Supervisor blocks event from memory EMT’s angry Families are Devastated 11/14/2018 Martin Consulting LLC

Accident Analysis Antecedent/Prompt: The operator is called to open valve Behavior/Action: The operator hits button to activate valve Consequence: Valve opens causes catastrophic release of vessel contents 11/14/2018 Martin Consulting LLC

Five Whys - People Why did the operator push the “ON” button? Why was the operator operating equipment he was not familiar with? Why was the operator unfamiliar with the equipment after completing on the job training? Why was the equipment not locked out completely? Why were both mechanics working behind one lock? Why isn’t the time it takes to safely lock out built in as part of doing the job? 11/14/2018 Martin Consulting LLC

Five Whys - Equipment/Materials Why was the change to the normal process not investigated with input toward safety? Why was hot product released while maintenance employees were working on the system? Why was the product still hot when people started working on the system? Why was the new process thought to be more cost effective? Why is time saved allowed to be THE factor in making a change to the process? 11/14/2018 Martin Consulting LLC

Five Whys - Equipment/Materials Why was the packing leaking? Why couldn’t the packing be adjusted? Why couldn’t the gland water pressure be increased? 11/14/2018 Martin Consulting LLC

Five Whys - Environment Why did the job begin without first establishing a safe escape route? Why are maintenance mechanics not provided with hazard awareness training before starting jobs in unfamiliar areas? Why are inspections not conducted at the job site? Why are Maintenance employees not included during inspections performed by Operations? 11/14/2018 Martin Consulting LLC

1984 Accident Root Causes People Materials/Equipment Environment Manpower reduced requiring operator training to be accelerated and training modified Emphasis on production encourages short cuts Materials/Equipment To save time, the normal isolation procedure was modified to a hot shut-down rather than a cold shut-down Environment No time was taken to identify a safe escape route due to emphasis on production 11/14/2018 Martin Consulting LLC

Root Cause Failure Analysis Packing sleeve failure Low gland water pressure Packing installation failure Packing gland fit Impeller clearance setting Machine misalignment 11/14/2018 Martin Consulting LLC

Safety Way of Life Establish a Job Hazard Awareness Briefing prior to starting job Read the MSDS Sheet and know the hazards Wear PPE to protect yourself from potential hazards Know were the Eyewash/Shower Station are located. With someone’s help, practice locating how to get to them if you are blinded Locate two of the closest Fire Extinguishers prior to starting work Improve training for all employees Identifying Risky Behaviors is the key to reducing accidents 11/14/2018 Martin Consulting LLC

Safety Way of Life Establish Observation cards to identify actions to improve safety Line of Fire, Eyes on Path, Lifting in Power Zone, Asking for Assistance, Discussing task with fellow workers, are examples of practices that can improve safety 11/14/2018 Martin Consulting LLC

Safety Way of Life Situational awareness is a key element Focus on all aspects of the task Avoid distractions 11/14/2018 Martin Consulting LLC

Ones Going to Die The John Martin Story 843 810 0298 www.martinsafetysolutions.com john@martinsafetysolutions.com 11/14/2018 Martin Consulting LLC