2. Serious Incident/Fatality Information Exercise Jim Howe, CSP, Safety Solutions Dave Demko, GM Safety Manager

3. Myth or Reality? Health and Safety Performance Incident Rate =

4. British Petroleum, Deep Water Horizon Gulf of Mexico

5. April 20, 2010 The entire oil drilling rig burned and sank. 11 workers died.

6. Executives were on the rig the morning of the incident to celebrate seven years without a lost time injury.

7. “Talking ourselves over the cliff!” Laurie Shelby, EHS Director, Alcoa US Primary Products

8. 64fatalities GM Global Injury/Illness Report Recordable Incident Rates 1993 – 2013 YTD GM Global Injury/Illness Report Recordable Incident Rates 1993 – 2013 YTD

9. GM and Contractor Fatality Comparison 2000 – Q1 2014 April 2014 GM CONFIDENTIAL

10. Examples of serious incidents identified during UAW-GM Conference Black Lake October 2013  Millwright fell into pit – broken neck  Die fell off die cart  Fell into rail dock well  Rail car door almost fell off hanging by 3 bolts  Reach truck struck pedestrian  Fork truck tugger incident, employee thrown from tugger  Die fell, toe amputation  Arc flash, electrician using screw driver  Employee walked behind fork truck, struck, foot amputated  Millwright fell 20 feet off conveyor  Employee stuck arm in machine to clear block, machine cycled trapping arm  Molten aluminum spill  Hoist failure  Contractor struck by 18 wheeler  Employee struck by SUV

11. Is it recordable or lost time? ActualConsequences  PotentialConsequences

12. Minor injury/illness potential Fatal/Serious injury/illness potential More of the organization’s resources should be focused here.

13. UAW-GM Fatalities 1973-Present

14. Fatal and Serious Incident Potential Skilled trades Production Examples of relative dynamic risk Risk Time

15. Focusing Efforts on Fatal and Serious Incident (FSI) Prevention  Audits  Safety Observation Tours  Task based risk assessment G-Risk  High risk activity – stop job if plans change and risk unacceptable  High risk non routine tasks, Pre-Task Planning (Stop the job if plans change)  Supervision  Contractor focus  Training (Lockout, Confined Space, etc.) Focus on FSI’s will require some modification of activities and programs. Accelerate efforts on FSI activities, tasks and precursors

16. Risk-Important Actions and Critical Steps All Procedure Steps All Risk-Important Actions All Critical Steps Risk-Important Steps: procedure steps or actions that expose products, services, or assets to the potential for or actual harm.

17. It is leadership that can make the difference.

18. 3 x 5 Card Exercise

19. DOE STANDARD, HUMAN PERFORMANCE IMPROVEMENT HANDBOOK VOLUME 1: CONCEPTS AND PRINCIPLES, page 131

20. “We Knew About That Problem”

21. All Fatal and Serious Incident Potential Fatal and Serious Injuries and Illnesses Minor Injuries and Illnesses Near misses, precursors- latent conditions and active triggers, activities, tasks Opportunity Focus more on potential consequences of FSI’s

22. Are jobs that get done without an injury or illness safe?

23. Unsafe jobs are often cleverly disguised as safe jobs.

24. Steps to improvement 1)Identify past FSI cases - utilize existing information, past incident/near miss records Page 24

25. Steps to improvement 2)Identify current FSI situations, incidents, activities, tasks and precursors  Sentinel event program  Pre-task plans  Job Safety Analysis  G-Risk (Risk Assessment)  Employee engagement open discussions  Safety Observations  Audits  Employee safety concern process  Supervision  Global call to actions  G-Comply – design in safety  Contractor focus  Others Looking for latent conditions, organizational weaknesses, active triggers Looking for latent conditions, organizational weaknesses, active triggers.

26. Steps to improvement 3)Categorize and prioritize FSI situations, incidents, activities, tasks and precursors by facility  Examples of categories  Methods to prioritize  Critical tasks – especially critical tasks of the day

27. Steps to improvement 4)Utilize learning teams to make improvements

28. Steps to improvement 5)Track improvements and assess results including intended and unintended consequences  Utilize all established UAW-GM policies, practices and procedures  UAW-GM Common Audit Action Plans Spreadsheet  UAW-GM Repeat Needs Improvement follow-up audit within 45 days of the corrective action plan due date  Global call to actions  Global 2014 Safety Actions Tracking Web Site  GMNA Safety Tracking Tool

29. All Fatal and Serious Incident Potential Page 29 Fatal and Serious Injuries and Illnesses Minor Injuries and Illnesses Near misses, precursors- latent conditions and active triggers, activities, tasks Opportunity Support needed

30. All Fatal and Serious Incident Potential Page 30 Fatal and Serious Injuries and Illnesses Minor Injuries and Illnesses Near misses, precursors- latent conditions and active triggers, activities, tasks Opportunity Barriers

31. Fatality and Serious Incident Prevention Planning

32. Thank you!