Root Cause Analysis in Construction

Transcription

1 Root Cause Analysis in Construction

2 Dave Murphy Safety Director Pepper Construction Company of Indiana

3 What We Build

4 What we Build Health Care Community Hospital East Campus Redevelopment IU Health Various Projects

5 What we Build Higher Education Butler University Science Addition & Renovations // Purdue University Flex Lab Facility

6 What we Build Retail Meijer Stores New and Renovations Apple Stores

7 What we Build Industrial & Manufacturing Ambrose // CAT - Carrier Corp. - Jones // Fedex Hanzo Logistics - JLL // Raytheon - Premier Packaging DTZ // Sunbeam - Vantrust

8 Our Goal >>> SAFETY, QUALITY, PRODUCTIVITY

9 Goals GOAL #1 To SAFELY build high QUALITY projects PRODUCTIVELY. SAFETY QUALITY PRODUCTIVITY

10 Goals Keep in mind what sets safety apart from everything else is Safety is about PEOPLE!

11 Our Path to RCA

12 Our Path to RCA Focus over time has progressed Accident Reports - Field Accident Investigations - Field Accident Investigations - Safety Professionals RCA - Safety Professionals w/ Field Review Meeting w/ President

13 Our Path to RCA Focus over time has progressed Accident Reports Field Accident Investigations Field Accident Investigations - Safety Professionals RCA - Safety Professionals w/ Field Review Meeting w/ President Description Easy Answers Fact Finding Identify - Causal Factors, Root Cause, Corrective Actions Safety Leadership

14 Our Path to RCA

15 Our Path to RCA Late 90 s introduced to RCA

16 Our Path to RCA Software Training Courses

17 Our Path to RCA Why? Why? Why? Why? Why? Answer

18 Our Path to RCA

19 Our Path to RCA

20 RCA Process

21 Definitions Root Cause Analysis (RCA) is a method of problem solving used for identifying the root causes of undesirable events. Causal Factor is one that affects an event's outcome but it does not prevent its recurrence with certainty. However, removing a causal factor can benefit an outcome. Root Cause is a factor whose removal from the problemfault-sequence prevents the final undesirable event from recurring.

22 RCA Process Process or Activity Undesired Result Application of Lessons Learned Investigation Root Cause Analysis

23 RCA Process Process or Activity Undesired Result Near Certain Desired Outcomes Application of Lessons Learned Investigation Root Cause Analysis

24 RCA Process Root Cause Analysis will drive change Can be perceived as a threat Can be met with resistance Management support required to achieve maximum benefit

25 RCA Process Our process: Not about blame

26 RCA Process Our process: Not about easy answers

27 RCA Process Our process: Thoughtful Respectful Reflective Collaborative

28 RCA Process Our process: Cannot be in a hurry!

29 RCA Process Report of Event Initial Investigation Project Team Safety Team Investigation Root Cause Analysis Incident Review Corrective Action Responsibility Follow-up

30 RCA Process Key Concept: The most basic cause (or causes) that can reasonably identified that management has control to fix and, when fixed, will prevent (or significantly reduce the likelihood of) the problem s recurrence. Mark Paradies A Root Cause is the absence of a best practice or the failure to apply knowledge that would have prevented the problem. Mark Paradies

31 RCA Process There maybe more than one Root Cause!

32 RCA Process Step 1 Complete the event timeline

33 ROOT CAUSE ANALYSIS WORKSHEET DATE: PROJECT: ANALYSIS BY: INCIDENT DESCRIPTION: EVENT: EVENT: EVENT: EVENT: EVENT: EVENT: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: EVENT: EVENT: EVENT: EVENT: INCIDENT: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: CONDITION OR CAUSAL FACTOR: Working backwards from the incident circle, describe each event leading up to the incident. Below each event identify conditions and causal factors. Circle each causal factor and copy them to 2 nd page for root cause analysis.

34 RCA Process Step 2 Run each Causal Factor thru the Root Cause Analysis

35 HUMAN FACTORS ANALYSIS 1) INDIVIDUAL PERFORMANCE Fatigue, impairment, personal issues, inattentiveness? Procedure not used or used incorrectly? Displays/indicators to recognize/analyze task unavailable or unclear? Human Engineering Immediate Supervision Human Engineering Procedures Training Procedures Human Engineering Workplace Layout Controls NI Labels NI Displays NI Excessive lifting Tools NI Intolerant system Errors not detectable Errors not recoverable BASIC CAUSE CATAGORIES Root Causes HUMAN ENGINEERING Work Environment Housekeeping NI PPE NI Lighting NI Noise levels NI Ambient Conditions NI Work positioning NI Excessive environmental stresses IMMEDIATE SUPERVISION Workload Excessive control action req. Unrealistic monitoring req. Knowledge based decision req. Excessive calculation or data manipulation required CAUSAL FACTOR = ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS ROOT CAUSE ACTION ITEMS = Knowledge of task or equipment missing? Adverse conditions or environment? Repetitive motion, poor body positioning, Vibration, lifting? 2) TEAM PERFORMANCE Coordination between team members? Lack of agreement on who/ what/ where/ when of task? Communication between contractors or owner required? 3) MANAGEMENT SYSTEMS Task performed in a hurry or short cut used? Recurring error or potential for failure known before occurrence? Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? Independent check should have caught the problem? Training Immediate Supervision Human Engineering Training Human Engineering Immediate Supervision Communications Training Communications Immediate Supervision Communications Management Systems Immediate Supervision Management Systems Management Systems Immediate Supervision Procedures Audits 1. Review each causal factor one at a time, by answering the Human Factors Analysis questions. 2. For yes answers, use the basic cause categories adjacent to each question to determine the root cause. 3. Document the specific root cause and associated corrective actions. Preparation No preparation Job plan NI Pre-job walk NI Instructions to tradesmen NI Scheduling NI Not Used/ Not Followed No procedure Procedure unavailable Procedure inconvenient to use Procedure difficult to use Procedure use not required Existing procedure not used No Training No THA No Certification Not required No Comm. or Not Timely Method unavailable or NI Late communication Comm. between contractors NI Comm. between tradesmen NI Comm. w/ owner NI Comm. btwn tradesmen and foremen/ superintendents NI SPAC NI No SPAC Not strict enough Confusing or Incomplete No Safety Plan Drawings/plans NI Technical error Responsibility for activity/item definition NI Planning, scheduling or tracking NI No Audit Audit Not required Audit not completed Worker Selection Not qualified Not trained Fatigued Attitude/ attention NI Mental state Team selection NI PROCEDURES Wrong/Incomplete Typo or sequence wrong Facts Wrong Wrong revision Inconsistent requirements Situation not Covered TRAINING Training Records NI Records incorrect Records not available Records not current COMMUNICATIONS Misunderstood Comm. Standard terminology not used Verification/ repeat back not used Long message MANAGEMENT SYSTEMS SPAC Not Used Comm. of SPAC NI Recently changed Enforcement NI Accountability NI Oversight/Employee Relations Infrequent audit/evaluations Audit/evaluations NI Employee comm. NI No employee feedback AUDITS Audit NI Audit training NI Audit documentation NI Audit techniques NI Audit frequency NI Supervision during Work No supervision Not enough supervision Supervision NI Crew teamwork NI Improper performance not corrected Misleading/ Confusing Details NI > 1 action per step No Checklist or inadequate Confusing instructions Training NI THA NI Content NI Instruction NI Practice NI No Testing or NI Wrong Instructions Job Turnover NI Comm. Between Contractors and Superintendent NI Problem Identification/Control Problem reporting NI Problem Analysis NI Audits NI Corrective Actions NI Corrective actions not yet implemented

36 RCA Process Step 3 Identify Corrective Actions Assign responsibilities and follow up date

37 Root Cause Analysis Example

38 Root Cause Example

39 Incident Description (Embellished for Training Purposes) An earth retention contractor was engaged as a third tier sub to install an earth retention system on a portion of the project where sloping was not a viable protective solution option. The earth retention system is installed by vibrating h-piles into the soil then wood lagging is fastened as the soil is removed. During the installation of the sixth earth retention pile, the steel pile damaged an underground water main line, causing the water main to rupture. The owner was immediately notified and within one hour the damaged water line was shut off.

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42 ROOT CAUSE ANALYSIS WORKSHEET DATE: 5/16/16 PROJECT: Xxxxxxxxxxxx ANALYSIS BY: Dave Murphy (Embellished for Training Purposes) INCIDENT DESCRIPTION: During the installation of the sixth earth retention pile that was being installed along the North side of the property, the steel pile damaged an underground water main line, causing the water main to rupture. The water department was immediately notified and within one hour the area of the damage water line was shut off. EVENT: 5/5/16 Risk Assessment completed with earth retention contractor EVENT: 5/13/16 Earth retention contractor began staging on site EVENT: Locators marked buried utility lines CONDITION OR CAUSAL FACTOR: Earth retention foreman spoke with locator but did not review drawings together EVENT: 5/16/16 - Crew began work installing H piles EVENT: 5 H piles were installed per drawing CONDITION OR CAUSAL FACTOR: Project team did not identify water line in close proximity (12 ) to buried water line CONDITION OR CAUSAL FACTOR: Pepper Superintendent not on site due to other project commitments CONDITION OR CAUSAL FACTOR: No morning huddle with Pepper and Earth Retention contractor to review locates and procedures CONDITION OR CAUSAL FACTOR: Drawing was difficult to read because of contour lines and amount of information EVENT: Crew did not see water line locate marks in proximity of next pile CONDITION OR CAUSAL FACTOR: Paint marks stopped at the valve and did not continue thru work area EVENT: Excavator with vibratory attachment was positioned to drive next pile EVENT: Steel H beam was vibrated to bury it to required depth EVENT: Steel H beam contacted water line at 6 to 7 depth INCIDENT: Steel H beam damaged 10 water line causing uncontrolled flow of water EVENT: Utility turned water off at valve to isolate CONDITION OR CAUSAL FACTOR: Line was not identified by locator or marks were erased by equipment and activity 42

43 Water Line Location 43

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45 Drawing with utilities, pile locations and contour lines 45

46 Sketch provided by earth retention contractor 46

47 Drawing submitted by earth retention contractor after utility line hit to provide a clearer description of hydro excavating needed for piles and tie backs. 47

48 HUMAN FACTORS ANALYSIS 1) INDIVIDUAL PERFORMANCE Fatigue, impairment, personal issues, inattentiveness? Procedure not used or used incorrectly? Displays/indicators to recognize/analyze task unavailable or unclear? Knowledge of task or equipment missing? Adverse conditions or environment? Repetitive motion, poor body positioning, Vibration, lifting? 2) TEAM PERFORMANCE Coordination between team members? Lack of agreement on who/ what/ where/ when of task? Communication between contractors or owner required? 3) MANAGEMENT SYSTEMS Task performed in a hurry or short cut used? Recurring error or potential for failure known before occurrence? Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? Independent check should have caught the problem? Human Engineering Immediate Supervision Human Engineering Procedures Training Procedures Human Engineering Training Immediate Supervision Human Engineering Training Human Engineering Immediate Supervision Communications Training Communications Immediate Supervision Communications Management Systems Immediate Supervision Management Systems Management Systems Immediate Supervision Procedures Audits 1. Review each causal factor one at a time, by answering the Human Factors Analysis questions. 2. For yes answers, use the basic cause categories adjacent to each question to determine the root cause. 3. Document the specific root cause and Workplace Layout Controls NI Labels NI Displays NI Excessive lifting Tools NI Intolerant system Errors not detectable Errors not recoverable Preparation No preparation Job plan NI Pre-job walk NI Instructions to tradesmen NI Scheduling NI Not Used/ Not Followed No procedure Procedure unavailable Procedure inconvenient to use Procedure difficult to use Procedure use not required Existing procedure not used No Training No THA No Certification Not required No Comm. or Not Timely Method unavailable or NI Late communication Comm. between contractors NI Comm. between tradesmen NI Comm. w/ owner NI Comm. btwn tradesmen and foremen/ superintendents NI SPAC NI No SPAC Not strict enough Confusing or Incomplete No Safety Plan Drawings/plans NI Technical error Responsibility for activity/item definition NI Planning, scheduling or tracking NI BASIC CAUSE CATAGORIES Root Causes HUMAN ENGINEERING Work Environment Housekeeping NI PPE NI Lighting NI Noise levels NI Ambient Conditions NI Work positioning NI Excessive environmental stresses IMMEDIATE SUPERVISION Worker Selection Not qualified Not trained Fatigued Attitude/ attention NI Mental state Team selection NI PROCEDURES Wrong/Incomplete Typo or sequence wrong Facts Wrong Wrong revision Inconsistent requirements Situation not Covered TRAINING Training Records NI Records incorrect Records not available Records not current COMMUNICATIONS Misunderstood Comm. Standard terminology not used Verification/ repeat back not used Long message MANAGEMENT SYSTEMS SPAC Not Used Comm. of SPAC NI Recently changed Enforcement NI Accountability NI Oversight/Employee Relations Infrequent audit/evaluations Audit/evaluations NI Employee comm. NI No employee feedback AUDITS Workload Excessive control action req. Unrealistic monitoring req. Knowledge based decision req. Excessive calculation or data manipulation required Supervision during Work No supervision Not enough supervision Supervision NI Crew teamwork NI Improper performance not corrected Misleading/ Confusing Details NI > 1 action per step No Checklist or inadequate Confusing instructions Training NI THA NI Content NI Instruction NI Practice NI No Testing or NI Wrong Instructions Job Turnover NI Comm. Between Contractors and Superintendent NI Problem Identification/Control Problem reporting NI Problem Analysis NI Audits NI Corrective Actions NI Corrective actions not yet implemented ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS CAUSAL FACTOR = Earth retention foreman spoke with locator but did not review drawings together including the excavation contractor input. ROOT CAUSE ACTION ITEMS = Procedure not used or used incorrectly? Procedures - Existing Procedure not used Reportedly, University locator refreshed markings on the morning of the incident. The earth retention contractor foreman did discuss the locates but they did not review the site drawings as required by the project specific safety plan. Knowledge of task or equipment missing? Preparation - Job plan NI Training NI - Instruction NI Action Items: follow the PSSP Underground Utility Locating Plan - Procedures for private and public locate personnel. The subcontractor shall: Review Master Utility Location Drawing with the utility locating service representative. Observe locating of line(s). Insure that markings are painted and staked, if possible. No Audit Audit NI Audit Not required Audit training NI associated corrective actions. Audit not completed Audit documentation NI 48 Audit techniques NI Audit frequency NI

49 HUMAN FACTORS ANALYSIS 1) INDIVIDUAL PERFORMANCE Fatigue, impairment, personal issues, inattentiveness? Procedure not used or used incorrectly? Displays/indicators to recognize/analyze task unavailable or unclear? Knowledge of task or equipment missing? Adverse conditions or environment? Repetitive motion, poor body positioning, Vibration, lifting? 2) TEAM PERFORMANCE Coordination between team members? Lack of agreement on who/ what/ where/ when of task? Communication between contractors or owner required? 3) MANAGEMENT SYSTEMS Task performed in a hurry or short cut used? Recurring error or potential for failure known before occurrence? Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? Independent check should have caught the problem? Human Engineering Immediate Supervision Human Engineering Procedures Training Procedures Human Engineering Training Immediate Supervision Human Engineering Training Human Engineering Immediate Supervision Communications Training Communications Immediate Supervision Communications Management Systems Immediate Supervision Management Systems Management Systems Immediate Supervision Procedures Audits 1. Review each causal factor one at a time, by answering the Human Factors Analysis questions. 2. For yes answers, use the basic cause categories adjacent to each question to determine the root cause. 3. Document the specific root cause and associated corrective actions. Workplace Layout Controls NI Labels NI Displays NI Excessive lifting Tools NI Intolerant system Errors not detectable Errors not recoverable Preparation No preparation Job plan NI Pre-job walk NI Instructions to tradesmen NI Scheduling NI Not Used/ Not Followed No procedure Procedure unavailable Procedure inconvenient to use Procedure difficult to use Procedure use not required Existing procedure not used No Training No THA No Certification Not required No Comm. or Not Timely Method unavailable or NI Late communication Comm. between contractors NI Comm. between tradesmen NI Comm. w/ owner NI Comm. btwn tradesmen and foremen/ superintendents NI SPAC NI No SPAC Not strict enough Confusing or Incomplete No Safety Plan Drawings/plans NI Technical error Responsibility for activity/item definition NI Planning, scheduling or tracking NI No Audit Audit Not required Audit not completed BASIC CAUSE CATAGORIES Root Causes HUMAN ENGINEERING Work Environment Housekeeping NI PPE NI Lighting NI Noise levels NI Ambient Conditions NI Work positioning NI Excessive environmental stresses IMMEDIATE SUPERVISION Worker Selection Not qualified Not trained Fatigued Attitude/ attention NI Mental state Team selection NI PROCEDURES Wrong/Incomplete Typo or sequence wrong Facts Wrong Wrong revision Inconsistent requirements Situation not Covered TRAINING Training Records NI Records incorrect Records not available Records not current COMMUNICATIONS Misunderstood Comm. Standard terminology not used Verification/ repeat back not used Long message MANAGEMENT SYSTEMS SPAC Not Used Comm. of SPAC NI Recently changed Enforcement NI Accountability NI Oversight/Employee Relations Infrequent audit/evaluations Audit/evaluations NI Employee comm. NI No employee feedback AUDITS Audit NI Audit training NI Audit documentation NI Audit techniques NI Audit frequency NI Workload Excessive control action req. Unrealistic monitoring req. Knowledge based decision req. Excessive calculation or data manipulation required Supervision during Work No supervision Not enough supervision Supervision NI Crew teamwork NI Improper performance not corrected Misleading/ Confusing Details NI > 1 action per step No Checklist or inadequate Confusing instructions Training NI THA NI Content NI Instruction NI Practice NI No Testing or NI Wrong Instructions Job Turnover NI Comm. Between Contractors and Superintendent NI Problem Identification/Control Problem reporting NI Problem Analysis NI Audits NI Corrective Actions NI Corrective actions not yet implemented ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS CAUSAL FACTOR = Pepper Superintendent not on site due to other project commitments ROOT CAUSE ACTION ITEMS = Recurring error or potential for failure known before occurrence? Management Systems - Planning, scheduling or tracking NI Scheduling of Supervision was compromised by conflicting job assignments and responsibilities. Problem Identification/Control - Corrective Actions NI This is a recurring problem for Pepper where projects are started without sufficient time allotted for Superintendent pre-planning. Projects also begin without adequate supervision on site to manage the risks of the work scope. Action Items: Suggest that management draft and implement a policy for project coverage to ensure that experienced, qualified supervision is in place on all projects for risks associated with the work scope. 49

50 CAUSAL FACTOR = No morning huddle with Pepper and Earth Retention contractor to review locates and procedures. No Excavation Permit form was completed. ROOT CAUSE ACTION ITEMS = ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS Procedure not used or used incorrectly? Procedures Not Used/ Not Followed - Existing procedure not used Communication between contractors or owner required? Communications - Comm. between contractors NI Recurring error or potential for failure known before occurrence? Management Systems SPAC Not Used - Comm. of SPAC NI Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? Immediate Supervision - Supervision during Work - No supervision The Daily Coordination Meeting is required by the PSSP based on past lessons learned from utility hits. Action Items: follow the PSSP Underground Utility Locating Plan - Daily Coordination Meeting The Pepper Superintendent and the subcontractor(s) will meet before work starts at the beginning of each shift. The meeting agenda shall contain the following items: Completion of Excavation Permit form. Subcontractor to return form to Pepper Superintendent at the end of the shift. Prior to issuing permits ensure that: A qualified PCCI employee reviewed the layout of underground installations to identify possible conflicts with existing utilities. Discussion and documentation of previous days (shift) trenching and excavating activities the on the Master Utility Location Drawing. Discussion of the scope and location of work for the days (shift) work. Verification of known underground utility locations and applicable private and public locates using the Master Utility Location Drawing and Project Utility Locate Calendar. Review of the pot-hole/daylight/hand excavation procedures for all located utility crossing points. 50

51 CAUSAL FACTOR = Project team did not identify water line in close proximity (12 ) to buried water line ROOT CAUSE ACTION ITEMS = ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS Displays/indicators to recognize/analyze task unavailable or unclear? Displays NI Drawing of underground utilities and piles was very difficult to read (EX 6). Knowledge of task or equipment missing? Immediate Supervision - Preparation - Job plan NI Pre-job walk NI Earth retention contractor Superintendent was not part of the PSSP/Risk Assessment meeting. Supervision during Work - No supervision - Not enough supervision Pepper Superintendent was not on site to review plans and utility locates with excavation and earth retention contractors. Communication between contractors or owner required? Communications - Comm. between contractors NI Superintendents for excavation and earth retention contractors did not review pile locations and utility location for this pile to determine work should not be completed until the line had been day lighted with the hydro-vac. Recurring error or potential for failure known before occurrence? Management Systems -Comm. between contractors NI This error has happened before and plan was amended to help prevent future recurrence. Will continue to recur without improved communication between contractors. Standards, Procedures Admin Controls, or policies to prevent/ mitigate error not used missing or in need of improvement? SPAC NI - SPAC NI - Drawings/plans NI Procedures - Existing procedure not used Pepper did not have site drawing posted with utility and plie overlays for review before days work began. 51

52 CAUSAL FACTOR = Project team did not identify water line in close proximity (12 ) to buried water line ROOT CAUSE ACTION ITEMS = Action Items: follow the PSSP Underground Utility Locating Plan - Contract private locating service to locate and grid the project for all utilities public and private; and overlay all utility locations on one Master Utility Location Drawing. Private locating service will be contracted to daylight all utilities before work begins. Verify locates against drawings. Daily Coordination Meeting The Pepper Superintendent and the subcontractor(s) will meet before work starts at the beginning of each shift. The meeting agenda shall contain the following items: Completion of Excavation Permit form. Subcontractor to return form to Pepper Superintendent at the end of the shift. Prior to issuing permits ensure that: A qualified PCCI employee reviewed the layout of underground installations to identify possible conflicts with existing utilities. No dig zones are identified with white paint. Discussion and documentation of previous days (shift) trenching and excavating activities the on the Master Utility Location Drawing. Discussion of the scope and location of work for the days (shift) work. Verification of known underground utility locations and applicable private and public locates using the Master Utility Location Drawing and Project Utility Locate Calendar. Discussion of private and public locates needed for upcoming trenching and excavating activities. Review of the excavation protective system i.e. sloping, benching, trench box prior to be utilized during the shift. Review of the pot-hole/daylight/hand excavation procedures for all located utility crossing points. Follow 6.2 and 6.3 of the Subcontractor Safety Handbook Requirements - 6. SAFETY PLANNING & PROGRAMS ROOT CAUSE DESCRIPTION AND CORRECTIVE ACTIONS 6.2. Safety Plan Review Meeting all SUBCONTRACTORS are required to attend a Safety Plan Review Meeting that must take place before any work starts. The PEPPER CONSTRUCTION Superintendent will schedule the meeting. Required attendees include the SUBCONTRACTOR full time Site Superintendent/Foreman and the PEPPER CONSTRUCTION Superintendent. The SUBCONTRACTOR COMPETENT PERSON must be fully aware of this plan and the procedures necessary to eliminate any hazards The SUBCONTRACTOR is required to review the Project Specific Safety Plan with their tradespeople prior to beginning work. 52

53 Procedure from Project Specific Safety Plan for Underground Utilities 53

54 Procedure from Project Specific Safety Plan for Underground Utilities (continued) 54

55 Utility Damage Prevention THA created by Pepper before job start and shared with excavating contractor 55

56 Excavation Risk Assessment completed by Pepper and earth retention contractor before job start 56

57 Utility Damage Prevention THA created by Pepper before job start and shared with earth retention contractor contractor 57

58 Incident Review Meeting

59 Learning Opportunity

60 Lessons Learned Vehicles RISK POTENTIAL: Serious injury, death ROOT CAUSES: Distracted driving, excessive speed, aggressive driving SOLUTIONS: No texting or , hands free phone, defensive driving techniques

61 Lessons Learned Material Handling Glass and Mirrors RISK POTENTIAL: Serious Injury, Lacerations ROOT CAUSES: Not qualified to handle, lack of experience SOLUTIONS: Subcontract glass and mirror scope to professional glaziers

62 Lessons Learned Material Handling Trash removal RISK POTENTIAL: Lacerations to fingers, hands arms; back, shoulder arm, knee strains and sprains; foreign debris in eyes, respiratory hazards ROOT CAUSES: Sharp edges, body positioning, weight of load, flying dust and debris SOLUTIONS: PPE Cut resistant gloves, Dynema sleeves, eye protection, dust masks, get help if needed, use mechanical aids

63 Lessons Learned Utilities Interior MEP Electrical HVAC Plumbing Med Gas Controls RISK POTENTIAL: Electrocution, fire, explosion, service interruption, flood, property damage ROOT CAUSES: No locate or radar, poor or no as-built drawings, wrong equipment, inadequate training, poor lighting SOLUTIONS: Review drawings, locate, training, plan, safe work practices, good lighting

64 SIF Prevention

65 SIF Prevention and RCA

66 SIF Prevention and RCA

67 SIF Prevention and RCA

68 Wrap-up >>> SAFETY, QUALITY, PRODUCTIVITY

69 Teamwork