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

2. 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

3. 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

4. 11/14/2018
Martin Consulting LLC

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. Ones Going to Die The John Martin Story
11/14/2018
Martin Consulting LLC