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Safety—Programs & Actions
Fatality Elimination
Zero work-related injuries and illnesses has been a long-standing goal for Alcoa. We believe world-class safety performance is attainable through dedicated effort, and one of our guiding principles is that we value human life above all else and manage risk accordingly. One life lost is one too many.
Unfortunately, we experienced 41 fatalities between 2000 and 2008, including the following incidents in 2008:
- On February 10, a 43-year-old senior electrical engineer was found at the bottom floor of an interior stairwell at the Alcoa Technical Center. There were no witnesses. Evidence suggests the engineer was descending a 111-centimeter-wide (44-inch) staircase and fell through the 0.7-meter-wide (2.5-foot) stairwell to the floor 16 meters (52 feet) below. Each staircase and landing was protected by a continuous standard stair railing of substantial design and construction.
- On April 17, a 58-year-old contractor at Alcoa's Belaya Kalitva location in Russia died from injuries sustained on April 12 while operating an electric railcar. The operator sustained injuries when the electric railcar fell 450 millimeters (17.6 inches) into a transfer bridge track opening. This caused the battery to shift forward, pinning the operator between the battery and front of the car.
- On September 16 in Samara, Russia, a 53-year-old employee transporting a 10-ton load on a flatbed truck stopped on a grade to give way to a passing vehicle. As the driver resumed his progress, the flatbed lurched forward on the incline. This caused the load to slide toward the rear of the truck, and the front end lifted off the roadway and then rebounded as the load dropped off the truck bed. During the rebound, the driver sustained a back injury. On September 25, the employee died in recovery following surgery to replace the damaged vertebra.
- On September 26, a 50-year-old maintenance employee at the Samara facility was fatality injured while transferring oil, lubricant, and coolant wastes from an onsite storage tank to an over-the-road tanker. The task required the employee to use a fixed ladder on the vehicle to access the tanker’s hatch to insert the discharge hose and to periodically monitor the level of waste in the tanker. During the task, the employee fell approximately three meters (10 feet), which resulted in fatal head injuries.
- On October 19 in Samara, a 21-year-old employee with two months experience was fatally injured at the slitting line’s trim scrap baller. The individual was working alone when his leg was caught in a loop of trim scrap and pulled into the machine as the unit’s mandrels rotated under power.
We also experienced a non-Alcoa fatality at our La Coruña, Spain, location on July 31. A customer’s contract truck driver, who was situated by the truck, was fatally injured when a bundle of scrap being delivered to the site rolled over the truck’s side rails and onto the driver while the scrap was being unloaded.
In response to our experiences at Samara, we sent an intervention team to that site in November 2008 to gain a deeper understanding of the underlying issues that may have contributed to three fatalities over a six-week period. What we learned from the tragic experiences at Samara will be applied to the broader fatality prevention efforts across Alcoa.
The level of global focus and attention directed at fatality prevention continues with the objective of building a system and culture that is more robust in its ability to:
- Recognize risks and error-likely situations;
- Improve the effectiveness of pre-job briefings for high-risk tasks;
- Assess the risk for fatal or other high-potential consequences by job or task and routine or non-routine activities;
- Provide layers of protection from recognized risks;
- Stop the work when a risk is identified that cannot be eliminated or controlled;
- Apply lessons learned to predict areas of current and future vulnerability, and incorporate error-proofing;
- Pre-design tested and safe methods for performing job tasks;
- Improve the use of field observations on higher risk tasks as a means to monitor for potential deviations from safe and proven methods; and
- Address contractor and contracted services safety.
During 2008, we actively participated in the Organization Resources Counselors’ Fatality Prevention Task Force. The task force seeks to identify:
- Contributing causes and organizational weaknesses that increase the risk of fatalities;
- Solutions and best practices for preventing fatalities; and
- Areas of future safety research that would drive significant improvement in the ability to predict, focus, and intervene to interrupt the cycle of events that lead to a fatality.
In 2008, we asked three independent consultants to review our historical fatalities from 2004 to 2008, along with a sampling of other high-consequence events, in an attempt to identify potential opportunities related to our catastrophic incident experience. Feedback from our independent review concluded that:
- Contractor fatalities represent a disproportionate percentage of the fatalities;
- Transportation and delivery activities represent a significant and emerging risk;
- Russia represented 7% of Alcoa total hours yet contributed 36% of the fatalities in the study period;
- Almost 50% of the fatalities have occurred during the September/October timeframe;
- Many of these events involved people performing potentially high-risk tasks that could have been done by automated systems; and
- High-risk tasks commonly rely on single, low-level hazard controls requiring manual application, which can increase the safety system’s vulnerability to deviation (e.g., conscious violation or unintentional human error) and can contribute to individuals being in the line-of-fire.
According to our panel of independent consultants, we are generally working on a lot of the right issues with the right focus, particularly as it relates to human performance and error precursors. To prevent gaps from developing in our protective systems, however, we must continue to make available the resources needed to support safety through the application of sound engineering practices, inspection, testing, and maintenance programs, along with capital to fund projects that address risks. The capital piece of this will be most difficult in 2009 due to the economic imperatives thrust upon us by the current global economic downturn.
We continue to test how our management systems contribute to fatalities and what predictive or leading indicators might be used to signal when we are moving closer to an at-risk condition and/or a weakness in our protective systems. We are gaining traction in our efforts to create an awareness and understanding of key drivers that increase the potential for human error as it relates to fatalities.
In addition to the 6,000 hours of human performance training reported in 2007 by our Alumar operations in Brazil, we had an additional 18,300 hours of human performance training collectively completed in 2008 by our operations in Davenport, Iowa (USA), and Alcoa, Tennessee (USA), as part of their fatality and injury prevention efforts.
To put our fatality performance in perspective, there were 5,488 manufacturing fatalities in the United States in 2008 (Bureau of Labor Statistics data). In 2005, the World Bank reported the following worldwide work-related fatalities based on a 2001 survey and historical estimates based on the responses received:
- 15,879 in established market economies (includes the United States, Canada, Australia, France, Italy, Spain, etc.);
- 90,295 fatalities in China;
- 6,276 fatalities in the Russia Federation; and
- 39,372 fatalities in Latin America.
The International Labor Organization now estimates (based on 2001 data) that there are more than 350,000 work-related fatalities worldwide associated with acute injury each year. That estimate climbs to more than 2 million work-related fatalities when dangerous substances and disease mortality is included.
During our 2008 review of fatalities and other high consequence incidents, our independent consultants noted that Alcoa’s fatalities may be linked to regional causal factors. For example, Australia remained fatality-free, South America remained unchanged, and a real improvement (45%) showed up in North America. However, increases were noted in Europe (25%), the Caribbean (100%), and Asia/Russia (300%) when compared with a 2000 to 2004 study.
Performance data
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Continuous Improvement Efforts
Since 2005, we have focused on simpler and more binary safety standards, the adoption of the ISO 18001/14001 management system, common information systems, and streamlined audit protocols. Increased stability, reliability, and strength of the safety system were the goals, so long-term improvements in these areas would benefit the customer, the business, and individuals working within the system.
In addition to fatality prevention, the 2009 continuous improvement plan will continue to target hand/finger, employee-new-to-the-job, strain/sprain, and slip/trip/fall injuries. Employees new to the job experienced 39% of our total recordable injuries in 2008. Hand/finger injuries accounted for approximately 35%, and strain/sprain injuries for 57%. Slip/trip/fall incidents were the initiating event for approximately 12% of our total recordable injuries. Overall, the 2008 total recordable injury rate for hand/finger and employees new-to-the-job did not improve significantly over our 2007 results. However, several business units saw significant improvement.
As part of our 2008 safety plan, each Alcoa business group was challenged to analyze its injury experience and develop and implement a problem-solving and improvement plan that addresses the group’s risk profile as it relates to Alcoa’s injury performance. While individual business unit risks varied, the key corporate drivers included: employees new to the job (less than 18 months); hand/finger injuries; significant ergonomic risk; exposure to slips/trips/falls; and seasonal or non-routine task exposures. Progress was made in 2008, but our risk profile did not change significantly. As such, these focus areas continue to be part of our 2009 safety plan.
Eliminating these drivers of risk often required us to transform the tools we use and how we traditionally view a job. For example, Alcoa’s Cleveland Works Large Aerospace Fatality Prevention team identified an opportunity to reduce employee exposure to large parts suspended by a hoist and manually cut on band saws. Saw operators and helpers work within inches of these suspended parts, some of which can weigh as much as 4,500 kilograms (10,000 pounds).
The location purchased a computer numerical control (CNC) milling machine to eliminate the manual sawing of these large forgings, thus significantly reducing the risk to the operator. Additional benefits from this project included:
- Safety/Productivity—The cleaner surface produced by the CNC machine results in less manual chip and repair time, which is an ergonomic and productivity improvement;
- Quality gains—Approximately US$35,000 of scrapped material was saved through the end of 2008; and
- Cost—Approximately US$984,000 in labor costs will be saved over two years.
An extrusion shop in Alcoa’s Samara, Russia, facility had a single induction heater available to serve two presses. As a result, the pre-heated billet for one press had to be delivered by overhead crane, exposing operators to an increased risk of contact with a hot billet during transfer, as well as the potential for a dropped load. Using internal resources, the location designed and installed an effective billet transfer system, which eliminated the need for crane transfer and greatly increased both operator safety and material handling efficiency.
Performance data
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Training
Two leadership EHS training sessions were conducted in the United States (Cleveland and Pittsburgh) and one in Europe (Brussels) during 2008. The target audience was business unit leaders who were new to Alcoa or new to a senior leadership role. A total of 55 business leaders attended the training.
In addition, we delivered 22 safety and health skill-builders in 2008 to ensure that business unit and location professionals had the knowledge and skills necessary to support the EHS program needs. More than 336 attendees participated in these sessions, and over 440 hours of instructor class time was invested in advancing the capabilities of our in-house safety and health resources.
In addition to traditional classroom instruction, we completed 133 web-based broadcast sessions totaling more than 399 instructor contact hours in 2008. Attendance included 1,285 location-level registrations that varied from one to 20 participants per location.
Alcoa Business System Implementation
The introduction of human performance concepts is just one example where the safety system is moving toward working in concert within the Alcoa Business System (ABS) framework, particularly the people component, to target non-conforming materials, products, equipment, and work practices, as well as accidents and waste. As we shift our safety focus to analyze work activities associated with a particular person, task, and time, we will be making error precursors and triggers more visible. Once visible, errors can be predicted, managed, and prevented through standardized work and built-in tests for validating safe work practices at the activity level.
Creating a clearer connection with ABS also includes the following:
- Applying total productive maintenance principles so that equipment failures with the potential to cause harm are anticipated and eliminated;
- Applying ergonomic principles to improve the flow of work, the demands of the task, and the fit between tools, equipment, materials, and the person;
- Promoting a just and fair culture that supports respect for and encourages employee engagement; and
- Supporting analysis to cause and problem solving.
For example, Alcoa’s Global Hard Alloy Extrusion business used ABS problem solving and a standardized approach to define very specific actions tied directly to where opportunities for improvement existed for focused injury prevention. Results were monitored monthly to validate the actions and progress. As a result, the business unit’s weekend all-injury rate improved by 32%, with a corresponding 62% reduction in total recordable incidents during 2008.
Efficiency and Effectiveness Program
We are continually looking to improve our safety system efficiency by streamlining the many information systems used to accumulate, analyze, and report safety-related information. This enables skilled people to focus on more value-added work, such as risk assessment and root-cause analysis.
In 2009, we will continue to work with a leading vendor of EHS software to implement an advanced standardized reporting and data information system that also integrates centralized task management, data analysis, compliance, and other management tools. The long-term benefits of a standardized system are the simplification and integration of EHS processes and data to meet growing global reporting, EHS compliance, and performance management requirements.
We also seek to reduce our safety costs while maintaining or enhancing our safety performance. In partnership with our procurement group, for example, we focused on strategic sourcing for safety supplies and services based on total-cost-of-ownership strategies and global leveraging. Much of our focus during 2008 centered on sustaining the savings associated with flame-retardant clothing and other personal protective equipment.
We continued to benefit from improved delivery of EHS training through the use of regional skill-builders and web-based broadcasts, which contribute, on average, US$1 million in annual cost avoidance.
Additional options to promote sustainable resources and reduce costs are ongoing. Some examples include recycling ear plugs and eyewear, eliminating unnecessary packaging, and evaluating bulk containers for reuse. Two of our locations—Torrance and Fullerton in California (USA)—have achieved 100% elimination of inside forklift use. In addition to improving pedestrian safety in the plants, this initiative reduced capital investment and maintenance costs and improved the plants’ manufacturing flow.
Key Performance Indicators
In addition to fatality elimination, our safety strategy, targets, and objectives continue to be focused on improving our performance in the following key metrics.
- Incident Frequency Rates
- Lost Workday (LWD) Incident Rates: These rates most often represent temporary or permanently disabling incidents that impact the long-term health and welfare of our employees and contractors.
- Total Recordable Incident (TRI) Rates: These are the more frequent and visual reminders of gaps that remain in critical areas, such as ergonomics, noise, and hand/finger injuries, that most frequently stand in the way of Alcoa locations achieving an injury- and illness-free workplace. These incidents include those resulting in lost time or restricted work activity, as well as those that require medical treatment.
- Employee New-to-the-Job Incident Rates: Work conducted by Alcoa’s Yale Partnership has documented an association between time in a job and injury rates. The study revealed that injury rates for employees new to a job, irrespective of actual company tenure, was approximately 12 times higher for employees with one year or less in their current position compared to all other employees. Since this type of incident has traditionally accounted for approximately 30% of all occupational injuries annually, it has become a critical focus area for targeted intervention and improvement in our protective systems.
- Major Incident Profile: While major incidents may not lead to an injury or illness, they have the potential to result in a fatality, a permanent or temporarily disabling injury, severe property damage, or a risk to the surrounding community. Tracking and profiling our major incidents provide us with valuable information to solve non-catastrophic incidents to cause and apply the lessons learned to prevent similar or repeat events with perhaps more significant consequences in the future.
- Injury-Free Event Profile: Similar to major incidents, these are incidents that do not lead to an injury or illness but have the potential to do so. Encouraging injury-free event reporting raises the level of employee engagement in safety and health and promotes proactive risk recognition and response. Often the lessons learned while investigating these minor incidents highlight a potential that otherwise would remain undetected as a latent condition or error-likely situation.
- Safety Engagement Profile: Safety research suggests that one of most important leading indicators of sustaining organizational change in safety is the level of employee involvement and engagement. Some of our proactive means for promoting employee engagement include: safety suggestions; single-point accountable roles for a specific focus area of the safety system; and participation on safety problem-solving teams, pre-job briefings, toolbox meetings, incident investigations, safety committees, and incident investigations.
- Overtime Profile: The Yale Partnership study also documented an association between injuries and extended work hours. The risk of injury increases significantly after 16 consecutive work hours. An increase in injury risk was also observed when more that 64 hours were worked in seven consecutive days. As a result, we have implemented overtime caps of 16 hours per day and 64 hours per week (66 hours for employees working 12-hour shifts) and require waivers with location manager approval. Trends in overtime and waivers are reviewed by the Alcoa Executive Council quarterly to track and evaluate system stability and potential for at-risk situations.
- Mobile Equipment Profile: In plants, free-moving mobile equipment represents the most significant fatality risk in Alcoa. In particular, the vehicle-pedestrian interface represents the most frequent type of mobile equipment exposure of concern. Our Engineered Products and Solutions (EPS) group took the most basic safety approach with regard to this potential—eliminate the risk rather than manage it. Since 2006, the six businesses within EPS have eliminated an average of 30% of forklifts used inside their plants, with the two California facilities mentioned above achieving 100% elimination. In 2008, Alcoa’s global entities adopted the same challenge and targeted a 20% reduction in their mobile equipment risk profile globally. Based on feedback from 181 locations, more than 3,350 free-moving mobile equipment units—a 30% reduction from the baseline—were eliminated or replaced with alternative equipment, greatly reducing the risk for vehicle-pedestrian collisions.
As of December 31, 2008, 124 people missed one or more days of work due to a work-related injury or illness. Total recordable injuries stood at 1,786. By comparison, we logged 164 LWD cases and 1,849 TRI cases in 2007—updated numbers from our 2007 reporting to reflect lost time and restricted medical treatment that occurred in 2008 for injuries received in 2007. In 2008, we started reporting rolling LWD and TRI rates to more accurately reflect lost time and restricted or medical treatment that occurs in a subsequent year but is recorded against the initial injury date and year.
The leading major-incident categories reported for the 2008 injuries included free-moving mobile equipment, electric overhead cranes, different-level falls, equipment failures, and falling objects—all of which remain major focus areas in our fatality prevention efforts.
Progress toward our goal of zero lost workday incidents remained relatively flat during 2008, and we ended the year with an LWD incident rate of 0.12 and a TRI rate of 1.34. However, our risk-based focus is having a positive impact on incident severity year over year. As of December 2008, the total days lost due to a work-related injury during the year was 25,115, which compares very favorably with the 50,646 total days lost in 2007.
As of the end of 2008, 76% of our 251 safety reporting units worldwide had worked 12 consecutive months without an LWD incident, and 44% reported working without a TRI. While this performance is certainly noteworthy, it was marred by the disappointment and tragedy associated with four employee fatalities and one contractor death during the year.
Performance data
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Case Studies
Safety League Reduces Injuries, Increases Community Engagement
Suralco Helps Suriname Schools Improve Chemical Lab Safety
Employee-Developed Solution Reduces Safety Risks, Improves Efficiencies
100% Crew-Led Kaizen Event Eliminates Fatality Risks
An Evolving World-Class Safety Culture in Iceland
Instilling a Zero Injury and Illness Culture
New Incident Investigation Technique Results in Safety Improvement
Union, Management Jointly Work to Decrease Injuries
Suggestion Systems Reduce Costs, Improve EHS, Engage Employees
Integrating Alcoa's EHS Standards, Culture into New China Facilities
Focus on Safety, Local Economy Brings Benefits to Jamaican Community
Strengthening the Safety Culture
High-, Low-Technology Segregates Pedestrians, Mobile Equipment
Focus on Key Injury Factors Reaps Double-Digit Improvements
Taking Fatality Prevention Wider, Deeper
Alcoa Helps Deliver EHS Improvement in Romania
Brazil Expansion Project Achieved with Zero Lost Workdays, Low Recordable Rate
Bringing EHS, Sustainability Awareness to the Community
Continuous Safety Improvement Nets Injury Reductions, Recognition
Dross Processing System Provides Safety, Cost, Environmental Benefits
Keeping Schoolchildren Safe and Healthy in Guinea
Primary Focus on Safety Nets Significant Improvements
Serving as an EHS Benchmark
Structured Approach to Attaining EHS Goals
Vegetation Management Plan Reduces Risks, Increases Biodiversity
Safe and Healthy Australian Children
Programs Focus on Safe Behavior
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