1. An investigation
into reducing
operator injury
within the baler
area at Eastman
Chemicals
Workington
ILM LV3
Award in first line managment
By
Stuart Rogerson
Candidate number–BCN7926
2. Candidate numberBCN7926 1
Contents
SECTION 1
BACKGROUND INFORMATION
Company background
My role and duty’s
SECTION 2
THE SITUATION AND REASON FOR CHANGE
The situation andwhychange is needed
Who does it affect
SECTION 3
THE INVESTIGATION
Individual investigations
Findings from investigation
SECTION 4
RESOULTION OF THE PROBLEM
Wants and would likes
Options generated
Ranking matrix
Option selected, costs, timeframe
SECTION 5
IMPLEMENTAION AND COMMUNICATION OF THERESOULTION
Communication ofchange
Effects of change
My role withinthe change
APPENDICES
3. Candidate numberBCN7926 2
SECTION 1
Company Background,
Eastman chemical company was founded in KingsportTennessee in
1920, by GeorgeEastman, it was formally known as Eastman Kodak,
Eastman Chemical Company was spun off in 1994 and became a public
traded company the company now own and operate sites throughout
the world employing approximately 13500 personnelover 43
manufacturing sites and serving over 100 countries
Eastman Chemicals Company’s business is divided into five segments,
Additives and functional products
Adhesives and Plasticizers
Advanced materials
Speciality Fluids and intermediates
Fibres
The Manufacturing Site at Workington falls into the fibres business it
produces Cellulose Acetate Tow which is used as filter tips for cigarettes,
it has been producing Acetate Tow on the Workington site since 1968,
originally as a joint venture between Eastman Chemicals and Filtrona
Chemicals, the operation was known as Ectona Fibres, Eastman became
the sole owner of the operation in 1984
In 2005 Eastman Chemicals invested $100 million to expanded the plant
the expansion came online in 2008, increasing production volumeby
40%, Eastman chemical Workington primary supplies acetate tow to
Cigarettes factories in Western and Eastern Europe, Russia and Turkey
the Workington manufacturing siteemploys, approximately 130 people
of which, 90 are on a shift systemsplitover 6 crews.
4. Candidate numberBCN7926 3
My Role withinthe organisation
I joined the company in 2008 as part of the expansion recruitment and in
2012 I Was appointed manufacturing Shift Team Manager for Crew E
reporting directly to the Site super-intendantI havea crew of 14
operators that are split into five differentjob roles (Department
Organization, appendix 1) whomoperate a continuous manufacturing
process on the production of acetate tow 365 days a year, operating on
a 12 hour shiftsystemover 6 crews,
(See Shift Rotas in Appendix2)
My Duty’s
My main Management duties include safety checks, coaching
individuals, assistwith training, monitor critical process operations,
process audits, crew and site wide health and safety audits and best
practise, man power deployment, co-ordination with engineers and
process operators, and planner overseeing a safe work permitsystem,
and emergency planning and crew development, holiday planning, and
crew administration and time keeping.
The manufacturing process is very fluid with breakdowns, events and
issues often ariseon a shift that require immediate action froma shift
manager such as critical equipment failure to operator injury.
During this assignmentI will be investigating and looking for a resolution
to operator injuries within a specific area of the production process.
5. Candidate numberBCN7926 4
Section2
The Situation and why it needs to change
The Problem
Since the 2008 expansion projectthe company has seen an increase in
accidents or incidents within the baler area of the plant, although the
majority of incidents are minor or near miss this issueneeds to be
resolved before a major incident or accident occurs.
What Has Brought the Problemtothe forefront?
We as a company havealways been good at recording and investigating
injury and lost time accidents in the workplace, butoperators would not
reportsmall injuries such as bumps and scrapes or near miss incidents.
During 2011 and continuing onwards alloperators undertook an IOSH
working safely one day health and safety course, which expressed the
value in recording all incidents, however small. During that year Eastman
launched a safety first initiative, which would record all incidents in an
online event tracker system all data including near miss incidents are
logged and investigated and any areas of concern are raised, and fed
back to site leadership team.
The event tracking log, has a three year retention on any information
imputed, after that time the data is erased to date over the 3years there
are 713 incidents logged, that figuremoves about as data drops off and
new data added of those713 currently logged 217 are baler related.
All site incidents mustbe reported to the on duty shiftmanager who will
fill out the tracker and appoint a steward to look after the event until a
resolution (if any) is found, this data is then feedback via a monthly
health and safety meeting with the site leadership team.
During a regular health and safety meeting we reviewed the trends from
each area of operations on plant, and spotted a clear trend within the
baler area, as a former operator with experience in that area I was
nominated as a steward for the problem.
6. Candidate numberBCN7926 5
How big is the issue and who does it affect
The issue is far reaching throughoutthe Workington plant and beyond to
the local community and to our customers, if we continue to havea high
rate of near miss incidents and or unsafeacts the like hood of a major
accident gets higher (see fig 1.1)
Fig 1.1 H.W Henirich’s incident pyramid 1931
Source HSE.gov.uk
If a work place injury does occur it accounts for a large number of
working days lost(see fig 1.2) with that in mind it’s important to focus
on safepractice during the plant operations process
Source HSE.gov.uk
Based on our site at Workington, below is a brief summary of the affects
and potential affects an avoidable accident has on the site.
7. Candidate numberBCN7926 6
Cost
The company has been tasked with a £1.5millon saving, a percentage of
that saving can be made up with a reduction of lost time accidents which
could in turn reduce insurancepremiums and overtime bill covering lost
time incidents
Reputation
The company prides its self as a safe company to work for the reputation
of Eastman goes along way with the customers wesupply, if a
potentially serious accident whereto occur it could potently lead to loss
of orders.
Duty of care
The baler area has a 5 man crew on shiftwith 6 shifts 30 operators are
exposed to injury risk every operator has a family if something whereto
happen in a small community like Workington the effects could be
devastating for the individuals and for the company.
Legal obligation
The company has to work to HSElaws, breaking these laws can lead to
fines or imprisonment.
Lack of Operator engagement
Operators now appear to feel the company doesn’tcare for their
wellbeing working in an around machinery that is awkward and has
potential to cause them injury, there is a distinct lack of motivation from
the baler operators as there seems no follow up on accidents
8. Candidate numberBCN7926 7
SECTION 3
Investigation
During the courseof my investigation I havegathered information from
various Sources, to determine whatwas the mostlikely cause of injury’s
to operators within the baler are, I gathered this information via the
following sources.
Questionnaire tooperators (SeeAppendix 3 &3a)
This shortquestionnairewas issued to each operator that worked within
the baler area, it was targeted to identify at risk behaviours and tasks
that each operator in had experienced or though could causepotential
injury, it also went into some detail of potential ideas for change
Eastman Site Leadershipteam
I broughtthe issueof operator safety in the baler area with the SLT; I
asked how they perceived the problem, and how they thought it could
be tackled along with any constraints they would like to build into the
project.
Eastman Health and Safety officers/crewsafety reps
I asked for some time during our monthly H&S meetings to discuss the
issues with the baler area, accident and near miss incidents, and also to
sourceany information and concerns that whereraised by site H&S and
Crew Safety Representatives.
Baler CrewMeeting/RCA session
Fromall the information gathered we formed a team with operators
fromeach crew able to attend fromthis we had a brainstorming session
which was then used to move forward using Ishkawa RCA fishbone
system, welooked for a way forward and improvesafety within the
balers and overall for the company
(See Appendix4 ishikawa diagram)
9. Candidate numberBCN7926 8
Liaise WithAmericanshift manager
I also spoketo shiftmanagers who run the much larger American plant
in Kingsport; they use the same equipment as the Workington site and
as a bench mark talked about their experiences and what if anything
they do different to us,
Other factors
I also researched other factors fromexternal sources, such as the
governments HSEwebsite/ACAS, although we are unique in whatwe
make we do usesimilar equipment such as hydraulics presses and rams
which account for a large number of serious accidents in the UK.
10. Candidate numberBCN7926 9
Findings
Fromthe results of questionnaires and meetings this is whatwas
discovered and whatgive us the foundations for options going
forward,
The questionnaires were issued on 12 February 2013 with all
questionnaires being anonymous and returned via a ballet box of
40 operators who were eligible, 36 wherehanded back giving me
a 90% return on completed forms, seePie Chart for details and
appendix 3 for full results details
Likely Area for an injury to occur
1. Incidentoccurred due to production interruptionsand joinups
2. Injury’s due to trips and falls
3. Operator error
4. Charging productionwaste to waste baler
5. other
Whilst the questionnaires were handed out I had several meeting with
the site leadership team who give supportto operators safety on site
26%
21%
6%
35%
12%
1
2
3
4
5
11. Candidate numberBCN7926 10
but had to put a reasonable coston the project, any findings had to be
reported back to them beforea solution(if found) could be agreed,
Fromthe results of the questionnaires and feedback fromsite leadership
it gavefoundations for a brainstorming session,
And fromthat to a group RCA, (see appendix 4) Smaller Focus groups
concentrated on each section fromthere we developed some options
moving forward
Those options that where appropriate
Redistribute manpower – useother operators to help in areas
Change methods or dealing with interruptions – follow a American
system
Change the environmental conditions- deal with the machinery
and not the man, eliminate any risk
Make no changes – leave everything as it was
All these options will be discussed in detail whilst looking for a resolution
for the problem.
12. Candidate numberBCN7926 11
Section 4
Resolution of the problem
From the investigation, it gave us four solid option to move forward
those options are examined in detail before it could be decided all
options where imputed on the ranking matrix, to find the best solution,
but ideal fromthe solution I would like to incorporatethe following
Wants
1. To see better systems in place to protect baler operators
2. Reduce near miss incidents, and minor accidents within the baler
area
3. Feedback systemin place so operators can follow a near miss or
injury until its conclusion
4. To have measures in place to monitor results
Would like
1. to introduce a cost effective safety systemwith a minimum cost to
the company, butwith maximum results
2. to see a reduction in near miss incidents and operator injuries
3. To get the supportof the Site Leader Ship Team and operators to
reduce injuries
13. Candidate numberBCN7926 12
Option 1
Deal with Production interruptions elsewhere, as in our sister plant in
the United States, the baler operators don’t touch the baler systems
during a production interruption, the CDO operator would carry out the
correction from aboveleaving the operator in the balers justto wrap the
finished product, eliminating the potential risks
Pros-
This systemis tried and tested in the American plant, it is cost effective
and also proven to work, thebaler operators would only be exposed to
the bale at the completion, there is only one injury whilstdoing this last
year so it would become low risk task.
Cons-
The Workington site has a lower number of reject product (in
Comparison to the USA Plant) becausebaler operators can remove
defective product this during interruption, (thus saving the bale) this
facility is unavailable to the US plant, so if a defected is in a productthat
then bale becomes reject.
Effectiveness
Itwould be very effective at reducing operator injury’s by a potential
35% based on operator survey
14. Candidate numberBCN7926 13
Option 2
Operators and manpower, each line has its own run times to produce
the producteach bale can run between 3 and 5 hours it’s a unstoppable
process the bale must be out of the press within 9 mins otherwise it will
causea production choke, if an operator has severalbales to wrap and
deal with an interruption at the same time he is likely to be rushing, an
operator fromanother department could drop into the baler area during
these times to relieve pressure,
Pros,
This option is costneutral; there is an operator on a constantpatrol
whomcould be-retrained to fulfil this role during his patrols, becoming
effectively a 6th
man on the baler crew as and when they require it
Cons,
Operator resistance, the patrol operator does havehis own tasks to
complete adding extra to his role might not be well received, the patrol
operator may also be dealing with a spill or other incident and may not
be able to attend leaving it as it was before
Effectiveness-
This option may gave shortteam gains by relieving pressureon a team
that is pressed and is rushing, there is no real evidence that getting the
baler crews to take their time would reduce injury’s, only timewould tell
15. Candidate numberBCN7926 14
Option 3
Equipment modification, the environmentrequires attention new
lighting and changing safety catches allowing hold up bins and slides to
be raised and secured out of the way (see equipmentoverview appendix
5) so the operators don’tneed to duck inside the baler during
interruptions allowing them to stand without stooping, also the
introduction of a tipping buggy to allow operators to safely discharge
wastewithout twisting or stooping
(See Photograph set1&2 in appendix 6)
Pros
Hazards areeffective removed allowing operators an easier access to
the baler would also makeit much better for the operators trying to spot
defects within the product
Cons
Higher costthan every other option operators would also need retrained
in the use of new safety systems potentially adding extra cost
Effectiveness
This option would be highly effective at reducing accidents and injury’s
within that environment
Option 4
Continue as beforeand do nothing but log accident data
Pros
No cost, no extra labour
Cons
The situation would get worse, moralwould drop off, and company
reputation would suffer as a resultof unsafepractise.
All options would have a training element by allowing operators to be
trained in there event log system, allowing operators to follow their own
injury and near miss incident and be involved in the resolution of an
issue,
16. Candidate numberBCN7926 15
Ranking Matrix to help decide which option is most appropriate for
reducing accident/injury within the baler area at Eastman Workington
Scoring System
1. Does not meet any expectations
2. Meets 25% of expectations
3. Meets 50% of expectations
4. Meets 75% of expectations
5. Meets all expectations
Option
Has
Minimum
cost to the
company
Effective at
reducing
injury’s or
potential
injury’s
Ability to
deliver
effective
training on
job role
Buy-in
from site
leadership
and
operators
Not a task
heavy
production
project
TOTAL
SCORE
1
Deal with
issue
elsewhere
5 2 5 1 1 14
2
Use
effective
manpower
5 2 2 3 1 13
3
Equipment 1 5 3 4 5 18
4
Do Nothing
5 1 1 1 5 13
OBJECTIVES SCORE 1 to 5
17. Candidate numberBCN7926 16
Having reviewed all the option on the ranking matrix, I have discussed
the outcome with the Baler operators, department heads and shift
managers and havedecided that option 3 is the best solution to
implement,
Cost
Unfortunately there is high cost involvement, but there is a budget for
safety, the site leadership agreed and allowed the budget to complete
the works, providing itwas in the new finical year, 2013/2014 and was
under £29000
Below is a table detailing the cost involved?
AREA OF COST Individualcost Total Required total
Razing safety
catches
Each system
adjustmentis
£400
28 £11200
new tipping
buggies
1 tipping
buggies £700
6 £4200
Retraining and
overtime
Overtime 18
p/h
12hours/training
40 operators 12
hours O/Tto
cover
£8640
Time Frame
The work will be carried out over a ten week timeframe, there are
always two sparepairs of balers at any one time used for waste product,
these could be modified on a rota basis as each baler is cycled over time
normally on a monthly basis allowing work to be carried out without
production interruptions, this chartis adapted to allow a switch each
day allowing work to be carried out on each baler as required (bale
switch plan appendix7),
Projecttotal
£24040
18. Candidate numberBCN7926 17
Section 5
Implementation and communication of the solution
We have a time scale of up to 10 weeks to complete the work, the
changes will be gradualas each baler will be upgraded on a day by day
basis, see (Gantt chartAppendix8)
How the change will be communicated
I will set up a meeting with the site leadership team, and team managers
to discuss the proposed baler changes and agree on a final method
when all systems and paperwork arein place each team manager will
communicate all relevant information to their respective teams prior to
the firstworks been completed
Training
Each baler operator would requirea one day 12 hour training session to
be carried out as overtime on the operators restdays (see shiftrota
appendix2) the baler technologist would formulate a training plan and
use the baler trainers to deliver a quality training session on the new
procedures and safety catches this would also allow a written record of
the fact the training has been received and understood, thetrainer
would also go through how to use the event tacking system.
Moral and Benefits
Itis perceived that with a proactive management of the safety of the
baler crews, the operators will feel morevalued in the job an as they
were involved in the democratic way the options wherediscussed and
decided upon it was in effect there idea they will feel some sortof
motivation and supportof the plan,
ReviewandMonitor
We have the data fromthe last three years of accidents/near miss at
Eastman weshould be able to review that Month on month and
statistically monitor the situation, with senior baler operators
monitoring that the new procedures are physically followed.
19. Candidate numberBCN7926 18
My role within the change
As the person responsiblefor the implementation of the new systems
will coordinate the initial schedules meetings and relevant paperwork’s
required so the transition goes smoothly, I willundertake the initial
communication of the new systems to site leadership and to the
management teams and shift managers, the shiftmanagers will then be
responsibleto managing their team and ensure all operators on their
respective crews carry outthe work
20. Candidate numberBCN7926 19
APPENDICES
APPENDIX 1
Eastman chemical organization chart
APPENDIX 2
Eastman ShiftRotas (6 month Snapshot)
APPENDIX 3 & APPENDIX 3a
Example of operator Questionnaire & results
APPENDIX 4
RCA Diagram
APPENDIX 5
Standard baler layout/pre and post ram
APPENDIX 6
Interruption photos
APPENDIX 7
Amended baler rotation chart
APPENDIX 8
Gantt chart (progress planning)
22. Candidate numberBCN7926 21
Eastman chemicals shift rota 2013
M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu
APR 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
A 8 8 8 8 8 D D N N D D N N D D N N
B D D N N D D N N D D N N D D N N
C D D N N D D N N D D N N D D N
D N D D N N D D N N
E D N N 8 8 8 8 8 8 8
F 8 8 8 8 8 8 8 8 8 8 D D N N D
W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F
MAY 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
A D D N N D D N N D D N N D D N N
B D D N N D D N N
C N 8 8 8 8 8 8 8 8 8 8
D 8 8 8 8 8 8 8 8 8 8 D D N N D D N N
E 8 8 8 D D N N D D N N D D N N D D
F D N N D D N N D D N N D D N N
Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su
JUN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
A 8 8 8 8 8 8 8 8 8 8
B 8 8 8 8 8 8 8 8 8 8 D D N N D D N N
C D D N N D D N N D D N N D D N N
D D D N N D D N N D D N N D D
E N N D D N N D D N N D D N N
F D D N N D D N N
M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W
JUL 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
A D D N N D D N N D D N N D D N N
B D D N N D D N N D D N N D D N N
C D D N N D D N N D D N N
D N N D D N N 8 8 8
E 8 8 8 8 8 8 8 8 8 8 D D N
F 8 8 8 8 8 8 8 8 8 8 D D N N D D N N D
Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa
AUG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
A D D N N D D N N D D N N
B D D N N 8 8 8 8 8
C 8 8 8 8 8 8 8 8 8 8 D D N N
D 8 8 8 8 8 8 8 D D N N D D N N D D N N
E N D D N N D D N N D D N N D D
F D N N D D N N D D N N D D N N
Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M Tu W Th F Sa Su M
SEP 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
A 8 8 8 8 8 8 8 8 8 8 D D N N
B 8 8 8 8 8 D D N N D D N N D D N N
C D D N N D D N N D D N N D D N N
D D D N N D D N N D D N N D D
E N N D D N N D D N N
F D D N N 8 8 8 8 8 8
Appendix 2
23. Candidate numberBCN7926 22
OperatorQuestionnaires
overseveral monthsourplanthasseenan increase inoperatorinjury’sinandaroundthe
balerarea,as part of the Eastman “all infor safety”campaignwe have issuedthe following
short questionnaire togauge youfeedbackof potential safetyissuesandchangesthatcan
be made in the balerarea.
1. On a Scale of 1-10 Please indicate how safe frompotential injury’syoufeel the
workingenvironmentis,Please Circle,1beingunsafe 10safe,( Noinjury’snear
missetc.)
Unsafe - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 - 9 - 10 - Safe
2. What workswell (withregardstosafety) withinthe balerare
3. What doesn’tworkwell asregardsto Safety?
4. What injuriesare youlikelytosee withinthe balerarea?
5. What wouldyoulike toimplementtomake yourworkingenvironmentsafer?
6. Do youthinkYou Have adequate PPEprovidedbythe company?
7. Whendo youthinkyourmost at riskof injury?
Appendix 3
24. Candidate numberBCN7926 23
On a Scale of 1-10 Please indicate how safe from potential injury’s you feel the working
environmentis,Please Circle,1 beingunsafe 10 safe,( No injury’snear missetc.)
What works well (withregards to safety) withinthe baler area?
What doesn’twork well as regards to Safety?
Appendix 3a
25. Candidate numberBCN7926 24
What injuriesare you likelyto see within the baler area
What wouldyou like to implementtomake your working environmentsafer?
Do you think You Have adequate PPE providedby the company?
YES – 87% NO – 13%
Whendo you think you are most at risk of injury?
REVIEW
WRONGFOR
TASK
TRAINING
Appendix 3a
