SEA/HK Fuels Operations

VOL . 2

2014 Let's tour in our excellent activi-ties!

News Visiting, safety talks, incident and more

Avoiding Spill How can spill be prevented?

SEA/HK Fuels Operations

VOL . 2

2014 Let's tour in our excellent activi-ties!

News Visiting, safety talks, incident and more

Avoiding Spill How can spill be prevented?

HAPPY NEW YEAR 2014 “We are committed to operation-al excellence.Continuously improve our perfor-mance, safety, security, health and the environment. Focus on our controls program of protecting and enhancing our corporate reputation through brand and product integ-rity and on ensuring disciplinemanagement of chain accross mul-tiple internal and external factors. As an organization, how we achieve our result is as important as result themselves. We must maintain our results to continue to improve across all aspects of op-erational excellence year after year. Quite simply, it represents our license to operate. Operational excellence, the first of our five commitments. ”

Alan Kelly President of ExxonMobil’s Fuels, Lu-bricants and Specialties Marketing

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Contents 2/2014

15 Keys to Zero Cross-overYou Can Do It. Keep it at ZERO.

2Avoiding SpillHow can spill be prevented?

4Multi-tasking – A FALLACYMulti-tasking in motion is dangerous.

7Safety awareness during raining season in Thailand.

8Adverse Weather Nobody gets hurt.Nobody gets hurt.

10Have a Safe FESTI-VAL!

15Safety tip sharing10 tips for managing driver distraction. During Sport Games. Basic Food Safety Guide

17Safety in a Flash Consequences of inappro-priate emergency response

20Excellent ActivitiesOperational Excellence Logo Launch.

22NEWSVisiting, safety talks, inci-dent and more

27Safety AlertManual Internal Valve Top Operators.

29Ergo Tips Repetitive Motion Injuries

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5KeysZeroXover - 5 Keys to Zero CrossoverOur Crossover is One too Many. You Can Do It. Keep it at ZERO

Maintaining World Class OperationsNobody Gets HurtLoading - APPLY 5 Keys - SDC Fill Up & Check Before Loading- Multiple Point, Tell & Touch with SDC- Connect Loading Arm and Do PTT again- Check Loading Arm Product Tag, Comp Tag, SFL & Sight Glass Empty- Do Not Rush; Do Not Hurry

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Avoiding Spill

Case for actions in 2011

An worrying trend having 9 spills in 2011 ( vs.1 in 2010)There are 3 main causes of 2011 spills 1.Truck Rollover 2.Lack of driver attention / concentra tion 3.Not following procedure (no ullage check)All of them are preventable. Examples for each case are followings.Spills due to lack of attention Driver placed a pail on side bumper to drain dry mogas. He then connected un-loading hose to ADO outlet/inlet while the common discharge outlet still open. When driver open the bottom valve to unload ADO, the product flow out into the pail and approx 20 liters of ADO were spilt onto the ground.

Driver removing a sampling buck-et, the grounding cable get caught on one of the sampling adapter ear lock causing it to get loose resulting in ap-proximately 30 liters of product spill to the ground.

Spills due to not following procedure (failure to perform ullage check)

On a routine delivery to an I&W site (property development), the single 20KL tank on site was filled until the overfill protection system was actioned. Acting alone and con-trary to procedure, Driver attempted to transfer product left on board his TT into a small tank fitted on a site’s maintenance truck parked nearby, causing a spill of ADO of up to 150 litres.

Spills due to truck rollover

“You must do the things you think cannot do.” – Eleanor Roosevelt

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Thailand, Truck roll-over resulting into driver MTI and 100L spill. A loaded hauler truck with 8,000 liters of UGR91 and 8,000 liters of ADO on board was on way to customer. On Mitraphap road KM72, hauler driv-er had micro-sleep and therefore truck moved off the road, driver was awaken and tried to head back the truck onto the road but did not success. TT rollover and spill about 100 liters of prod-ucts (UGR91 & ADO) on the road.

HOW CAN SPILL BE PREVENTED?

At terminal• Why it is important to check for residual prod-uct in compartment be-fore loading?• Why we are required to have our eyes on our task while loading or unload-ing?• Why we have to ensure loading meter is correctly set prior to start loading product?• What are the steps for preventing spill in top loading? Why?• How the practice of double check can help to prevent spill?On the road

• Why pre-trip inspection is important?• Why applying defensive driving techniques all the time is important?• Why fatigue management and fit for duty is important?• Why distraction management is important?

At customer site• Why we are required to have our eyes on our task while unloading?• Why hose checking is important? What to look for when checking hoses, coupling and drop equip-ment?• During pump delivery, what is the procedure to prevent the camlock from loosening?• How using SDC can prevent spill?• How the practice of double check can help to prevent spill?

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Multi-tasking – A FALLACY

Multi-tasking in motion is dangerous

Multiple cases of city pedestrians walking and talking/texting:• Falling into manholes• Onto train tracks• Into fountains• Crossing streets in front of cars without noticing

Examples of distracted walking• Distraction in our busy lives is more common than you may think!• Talking on cell phone• Typing/reading text or email• Reading a document (off the printer)• Storing receipts• Listening to iPod, mp3 player• Carrying hot/heavy/large item• Eating or drinking• Daydreaming/fatigue• Rushing for appointment• Reading directions• Disembarking plane/train (phone checking)• Preparing for meetings/intense thinking/planning

“Be a first-rate version of yourself, not a second-rate version of somebody else.” – Judy Garland

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Multi-tasking – some stats• Walking and texting/talk-ing• 30-39% of Pedestrians walk distracted • 48% on cell phone stepped into crossing while vehicle approached• Pedestrian injuries in-creased 25% in past 5 years• Estimated 14,000 injuries, and 900 deaths per year (Na-tional Highway Traffic Safety Admin) • Driving and texting/talking• 11% at any point are on cell phones, 81% admit to talking while driving• 18% admit to texting while driving (39% of GenY, 36% teens)• 28% of all crashes are at-tributable to cell phones (4x more likely to crash)• 1.6 million crashes, 645,000 injuries, estimated 11,000-13,000 deaths• Driving and hands-free devices• Still causes cognitive dis-traction, does not decrease the risk

Multitasking: A Brain Drain• Multitasking for the brain is a myth• Human brains do not perform two tasks at the same time• Brain handles tasks sequentially• Brain switches between one complex task and another• Brain filters out info due to overload (2 complex tasks at same time)• Drivers/walkers miss critical infor-mation on potential hazards• Brain juggles tasks, focus and atten-tion, switches between tasks

Driving alone Driving while using device

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One task at a time!• Walking is working, so WORK SAFELY!• Focus on one complex task at a time• Look where you are going• Anticipate and scan for hazards• Maintain a hazard free work area• Be aware and pay attention!

Multi-tasking – Impairs Performance• Listening on cell phone decreased parietal lobe activity 37%• Perception of movement, integrates sensory information, language• Listening and comprehension draws cognitive resources away from driving/walking• Decreased activity of occipital lobe, processes visual information• Cognitively demanding tasks impair ability to walk/drive safely

Driving alone Driving while us-ing device

“Move out of your comfort zone. You can only grow if you are willing to feel awkward and un-comfortable when you try something new.” – Brain Tracy

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Safety awareness during raining season in Thailand

“Considering weather, drive safely”

From Recent Incident The driver stopped TT near side of SS. After confirming the traffic, he started to move TT slowly. When TT was turning to the left and entering the SS, a cyclist, who was running without light on the sidewalk, slipped and toppled over as the sidewalk was covered with snow. The cyclist jumped off from the bicycle, but the bicycle itself slipped into the SS en-trance and TT left tire ran over the front wheel of the bicycle.

What kind of weath-er and road situa-tions do driver have to consider?1. Weather: Snow, Rain, Fog, Sandblast, Thunder and etc.2. Time zone: Drive in night time, early morning3. Traffic jam: Traffic speed4. Road works: Traffic restraint

Drawing of the site:1. Passenger car was parking in front of unloading point. Driver asked staff of cof-fee shop to move the car.2. After confirming following traffic of right lane, the driver ran over to right lane and intended to enter TT left tire ran over the front wheel of the bicycle.

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Adverse Weather (Nobody gets hurt)

Emphasis to drivers that deliver under adverse weather conditions is not an accuse for them to ignore safety aspect. The expectation is drivers to delivery safely under all kind of weather condi-tions

Stress to drivers on the importance of paying at-tention to other road users who may not be trained to drive safely under adverse weather con-ditions- Not switch on head light under poor visibility- Drive too fast on wet or slippery road surface- Not maintain or increase safe following dis-tance• Wet, hot, cold, slippery and poor visibility are conditions that may affect drivers on the road• Driving under adverse weather conditions need to be more cautious & careful• Applying your safety knowledge & defensive driving skills to avoid errors by other road us-ers………………………How?

“The best way to make your dream come true is to wake up.” – Anna Wintour

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“Adjust Your Speed To Road Condition When Driving In Abnormal Weather”

How adverse weathers can affect ourdriv-ing perfor-mance

What should we do when driving under adverse weather –condi-tions

How adverse weathers could af-fect our perfor-mance during un-loading.

- Wet and slip-pery road surface cause skidding- Poor visibility may cause drivers to make mistakes

- Increase the safe following distance. Bigger and heavier vehicle needs longer distance to stop- Adjust the speed accordingly- Poor visibility - Switch on your light / use proper signal to ensure other road us-ers are aware of your presence or what you are going to do

- Wet condition - post a slippery hazard while get-ting in and out of truck. - Extreme hot or cold weather - avoid rushing, take time to ensure all nec-essary checks are correctly done- Poor visibility - may af-fect tank dipping reading, wrong ATG reading, take time to ensure all are cor-rect- Heavy rain - take time to wear rain coat or wait for rain to stop - Drivers have a higher tendency to short-cut / make mistake in these conditions. Therefore it is very important to follow on the agreed procedures

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Have a Safe feSTIvaL! Whether you're staying in and celebrating with friends and family, or you're traveling to a party or city bash, following a few safety tips will ensure that you're safe and sound

Be alertBe aware of your surroundings and how others are acting. Stay away from those who are out of control and might cause harm. Taking preventive measures is key. If someone is really intoxicated, prevent them from trying to drive or leaving with someone they do not know. It's important to keep an eye out for each other.

DON’T DRIVEIf you don't have to go behind the wheel, avoid it. More people will be driving under the influence on this particular night, so avoid a potentially dangerous accident by staying off the road. Otherwise, be alert and drive defensively. Most importantly, wear your seatbelt! Also, using public transportation is a wise option.

STICK TOGETHERThis way we can look out for our friends and family. Going out to parties and nightclubs means a fast-paced, crazy night; so be sure to travel in groups. Having a safety net around you in this environ-ment is imperative.

“Nothing is too small to know. Nothing is too big to attempt.” –William Van Horne

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Have a Safe feSTIvaL!

MONITOR YOUR ALCOHOL INTAKEA majority of people will be drinking on New Year's Eve, and there is nothing wrong with that. Just be sure to pay attention to how much you and others are consuming. Drinking too much alcohol can have lethal affects. Be responsible.

DON'T FOGET ABOUT YOUR PETS!They are just as much a part of the family as everyone else. If you are using fireworks, anything with loud noises, or fire, be sure that pets are kept at a distance as well as children. None of these are a good mix.

BE CAREFUL WITH OPEN FLAMESIf you're burning candles, incense or oil burners, remember to extin-guish them before you turn in or before you leave the room they are burning in. Pay extra attention to pets and children around open flames.

BE EXTRA CAREFUL WITH FIREWORKSIf you are letting off fireworks in a residential area, be sure to practice proper safety precautions when using them. Let off fireworks in a field or other open area where homes and power lines are out of site. Have a fire extinguisher nearby and never try to re-light a firework that did not go off when first lit. Also, be sure pets and children are at a safe distance from where fireworks are being ignited. Finally, always have an adult present when using any type of firework.

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Safety Tips 10 tips for managing driver distraction.

Distracted drivers pose a deadly risk to everyone on the road. The Na-tional Highway Traffic Safety Administration (NHTSA) estimates that in 2011, the most recent year for which data is available, 3,331 people lost their lives and another 387,000 were injured in distraction-affected crashes.1 Drivers engage in a range of distracting activities from talk-ing and texting on their phones, to eating, grooming and reading. Even the use of hands-free technologies isn’t without risk as dangerous mental distractions exist even when drivers keep their hands on the wheel and eyes on the road.

Here are 10 tips for managing some of the most common distractions.

1. Turn it off and stow it. Turn your phone off or switch it to silent mode before you get in the car. Then stow it away so that it’s out of reach.

2. Spread the word. Record a message on your phone that tells callers you’re driving and will get back to them when you’re off the road, or sign up for a service that of-fers this feature.

3. Pull over. If you need to make a call, pull over to a safe area first.

4. Use your passengers. Ask a passenger to make the call or respond to a text for you.

“Nothing great in the world has been accomplished without passion.” – Hebbel

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5. X the Text. Don’t ever text and drive, surf the web or read your email while driving. It’s danger-ous and against the law in most state. Even voice-to-text isn’t risk-free.3

6. Know the law. Familiarize yourself with state and local laws before you get in the car. Some states and localities prohibit the use of hand-held cell phones in addition to texting.GHSA offers a handy state law chart at www.ghsa/org/html/stateinfo/laws/cellphone_laws.html.

7. Prepare. If using a GPS device, enter your destination before you start to drive. If you prefer a map or written directions, review them in advance. If you need help while driving, ask a passen-ger to assist you or pull over to a safe location to change your GPS or review your map/directions.

8. Secure your pets. Unsecured pets can be a big distraction in the car.

9. Mind the kids. Pull over to a safe place to address situations involving children in the car.

10. Focus on driving. Multi-tasking behind the wheel is dangerous.4 Re-frain from eating, drinking, reading, grooming, smoking, and any other activity that takes your mind and eyes off the road.

Driveway Safety

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Safety Tips During Sport Games

Rest adequately. Avoid stay-ing late for the games. Get enough sleep, at least 7 - 8 hours daily.

Take time to fin-ish your work. Do not rush to finish your work to catch the games.

Concentrate while working. Avoid from be-ing distracted by the games’ result.

Pay extra cations while driving. Other road users may drive differ-ently. Some may be rushing to go home and some may be driving under influence of fatigue.

Put Priority To Your Job, Not The Games! Your Family Is

Depending On YOU!

Basic Food Safety Guide

Many people do not think about food safety until a food-related illness affects them or a family member.

“Until we can manage time, we can manage nothing else.” – Peter F.Drucker

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There are approxi-mately a million cas-es of acute diarrhea reported each year in Thailand, among which more than 120,000 are food-borne. Consump-tion of raw or un-dercooked food and contaminated water used to prepare food are important causes.

ExxonMobil employ-ees are not immune to this risk and have experienced incidents of food borne illness at work locations around the world. Even though reliance on reputable food

providers and strong contractual provisions usually ensures that this food is safe, Exx-onMobil was motivat-ed by a recent history of food borne illnesses to establish Food Safety Guidelines for global implementa-tion.

The use of “Basic Food Safety Guide-lines” below provides acceptable protection against food borne illnesses when arrang-ing food service.

No. 1- Ensure that the food is ordered from a qualified vendor./' The site has had a successful history with this vendor./' The vendor is part of a nationally I re-gionally recognized chain./' It has been verified that this vendor has a valid health certificate, or any other lo-cally established means of qualification

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No. 2 - Select a menu to avoid higher-risk foodsPotentially higher-risk foods are:x Raw or rare meatsx Undercooked poultry x Undercooked porkx Raw oysters and other un-cooked seafood x Raw or under-cooked eggs

No.3- Ensure that food is con-sumed within 2 hours of delivery time unless adequate refrigera-tion and heating control devices are used-This assumes that the food is delivered at the correct holding temperature.-The food is not allowed to go above room temperature during these two hours.

No.5 - Plan and arrange for left-overs disposalArrange for left-over food to be stored in proper containers at the appropriate temperature, or dis-carded properly.

No 4. Ensure that the food tem-perature issues are managed.Acceptable temperatures are 140o F (60 o C) or higher for hot food and below 41o F (5o C) for cold food.

“The key is in not spending time, but in investing it.” – Stephen R. Covey

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Safety in a flashConsequences of inappropriate emergency response

What happened?May 20, 2013 - A contractor driv-er, with 1yr experience, entered by mistaken wrong receiving tank ul-lage of 15000L instead of 13500L in SDC. Driver failed to identify his error and proceeded to un-load. After a while, driver noticed that product flow had stopped but product was still left on board of his truck and in the hose. He closed truck API valve and start-ed to evaluate the situation. He found a slight leak occurred at the ADO pump’s degasser. In order to quickly stop that leak, driver de-cided to disconnect the hose. As a result, some of the product (>1L) in the hose was spilled to the driveway. Driver connected the hose to the second tank to empty product in the truck compartment (some 400 to 500L was delivered).

Why?- Driver was not focus on job or dis-tracted when doing his SDC- Driver failed to follow correct emergency response procedure. After stopping product flow by shut-ting off the API valve, driver should report to supervisor immediately. Driver should not attempt to fix the issue by himself - disconnecting an unloading hose which is full of product- Identified hazards were not fully addressed in RA – Gallon is used (instead of liter) in this station and there is no overfill protection in this service station

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What should you do as profes-sional driver?World Class Operations - Keep mind on task and avoid being distracted - Ensure you are familiar with emergency response procedure (e.g. handling tank full situa-tion)- Actively use SPSA / Take 5 to identify hazardsActively Caring- Actively report UDCR and near-miss on potential spill

Consequences of dis-traction & not follow-ing procedure

What happened? April 5, 2013 - A contractor driver, with 2 months experi-ence, had dropped ~2.8KL of diesel into G91 tank in service station. The crossover was dis-covered when the station high level alarm was triggered. Driver responded by stopping all flows and report to station and super-visor. Luckily there was no spill and no customer was affected.

Why?- Driver used 2 hoses in this unload-ing. When he completed unloading G91, he changed hose at truck side but failed to change hose at fill point- Driver did not refer to SDC when changing hose and allowed cross-hos-es- Driver failed to perform multiple point touch and tell- Driver was possibly rushing and distracted due to 8 month pregnancy of his wife

What should you do as professional driver?World Class Operations - Follow agreed procedures all the time. Dur-ing unloading, always refer to SDC when connecting hoses and conduct “MPTT” before dischargeActively Caring – Discuss any issue which have the potential to cause dis-traction / not fit for duty with your supervisor

“Ordinary people think merely of spending time. Great people think of using it.” – Anonymous

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Consequences of failing to say “No”

What happened?June 12, 2013 - A contractor driver completed his delivery. The unloading area was sur-rounded by parked customer vehicles. Driver was unable to drive forward to exit unload-ing area as per site card. Driv-er attempted to ask assistance from station staff to remove parked customer vehicle but unsuccessful. Driver decided to leave unloading area by reversing with the assistance of station staff as spotter. Dur-ing the backing maneuver, the tank truck made contact with stations vapor recovery pipe. The contact caused damage to both the vapor recovery pipe and the turn signal light on the hauler truck.

Why?- Driver did not stop work when facing un-safe condition- Driver did not call back to depot per proce-dure- Inadequate LSM (Low speed maneuvering) techniques- Did not place cones (to indicate position of hazards)- Did not communicate with spotter regard-ing positioning and hazards- Station allowed customers to park and block truck egress but no driver had reported UDCR

Backing is not required as per site card. Station fails to keep unloading area clear.

What should you do as professional driver?- World Class Operations - Follow instructions in site card, stop work and call back depot if unsafe (e.g. need exces-sive backing maneuver due to parked custom-er vehicle etc)- Follow LSM procedures if reversing is re-quired per site card or agreed by supervisor- Actively Caring- Actively report UDCR and near miss on po-tential DVA

20 “As you simplify your life, the laws of the universe will be simpler.” – Henry David Thoreau

What happened?•TT driver erroneously swapped the mogas consign-ments during his final trip which was a 2-drop delivery at service stations ‘A’ and ‘B’.•All of the mogas products were correctly unloaded into the right tanks at both sta-tions.• Potential product mix / spill / run-out concerns.

Why?• Driver was referring to the Safe Discharge Certificate (SDC) of which he had filled out part A incorrectly at the Terminal load rack.• By not clearly reading the loading advice issued by Terminal, driver inadvertently swapped a Syn8000 order as-signed for station ‘B’ with Syn5000, when drafting part A of the SDC for station ‘A’. [Volume was identical (5.4kl) for Syn5000 & Syn8000].• Some distraction due to dark clouds / impending rain.

How do to stop this from happening again?• Check loading advice properly prior to filling out the SDC part A and signing it.• Check the station ‘Fax order’ in the DCD box with Delivery Ticket for further confirmation that truck is at the right station with the correct product and quantity.• STOP & perform SPSA when dis-tracted or not focused before continuing with work.

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Slip and Fall

Driver Pre-Trip Inspection, API ValvesAPI Valve Visual Inspection Areas

LeaksA visual leak on any part of the API valve e.g. (Nose adapter, handle, mounting flange, poppet or integral sight glass).

ClearanceIf insufficient clearance exists between the API valve handle and the handle stop-pin.

Proper clear-ance 3/16 inch 4.8mm

No clear-ance.

WearIf the API adapter does not fit tightly on the API valve e.g. (Adapter or dust cover has to be rotated to fit tightly)

“Call super-visor for in-struction.”

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Excellent Activities

AP Observation day, 15th Nov.

2014 SEA/HK Fleet Hauler Forum SG 6-7 Feb, 2014s

“This time, like all times, is a very good one, if we but know what to do with it.” – Ralph Waldo Emerson

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Driver of the year Linfox HongKong.

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HOSES AWARENESS TRAIN-ING - SUMMARYSTOP ALL Equipment Related Incidents

Hose Inspection at LLK hauler yard .

Hose Inspection at Closer Examination

-What is defective and What is good for service ?

Inspection at Hose-Coupling fit-tings

Elbow Coupling Inspection

“Simplicity is the ultimate sophistication.” – Leonardo da Vinci

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Operational Excellence Logo Launch

Operational Excellence require us to effectively apply our Management Systems based on a platform of Actively Caring To support achieving Operational Excellence we must effectively apply our management systems across all areas of the business, namely LPS (Safety behavior, Am I Safe), OIMS for our safe operations, CIMS in our controls and GPQMS to ensure our product quality to customers

•Everywhere!- Presentations- Documenta-tion- Posters- Brochures- Promotions

•Where do I get an copy?- The image files are in the AP SSHE Team Site- Links have been circulated

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NEWSlaptop/House fireA little after midnight on May 28, 2013, my family and I were awak-ened by our home fire/smoke detection system. Immediately after being awakened, I heard a shout from my oldest son so I ran to his room. Upon entering his room (both my teenagers sleep with their doors shut), I was confronted with heavy smoke and his Apple MacBook laptop on fire on top of his desk. I in-structed my wife and 3 boys to take the dogs and evacuate the house (our bedroom are upstairs). I smothered the fire with a

battery remnants had melted/fallen onto the floor. Fire department responded and checked to ensure no hot spots remained and gave the all clear around 0100. Pictures below show the bedroom, comput-ers (my middle son’s laptop was sitting on desk, shut down and not plugged in) and bucket contains what’s left of battery and towel Although I had some temporary symptoms from inhaling smoke and dry chemicals, there were no injuries and everyone reacted calmly and did exactly as we have discussed in case of this type of event.

heavy towel from his bathroom but the towel quickly began to burn. I then grabbed two ad-ditional heavy towels, wrapped the laptop and removed it from the house. I then went back upstairs with one of our home fire extinguisher (my wife had already pulled the pin and my middle son had called 911 as I had instructed during these first min-utes) and discharged it to extinguish his desk and area of carpet in his room and in the play-room that were burning where the laptop

“Have nothing in your house that you do not know to be useful, or believe to be beautiful.” – William Morris

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PROBABLE CAUSAL FACTORS:

Laptop battery failure- Laptop had been shut down and was being charged. Son had be-ing using laptop most of afternoon working on a school project so battery was low. Laptop has been shipped to a lab to try and identify root cause of battery failure.

Slip & Fall Incident on Wet Floor

Incident Description• On Sep 25, 2013, an employ-ee slipped & fell on wet floor in a restaurant during dinner. Employ-ee suffered from pain however could walk• The employee went to meet-ings in hotel, and office for work the next day. Due to increased discomfort the employee went to hospital 24 hours after the inci-dent • Diagnosis from hospital sug-gested fracture of vertebra. Doc-tor in emergency recommended 3 days’ rest• Employee reported incident to supervisor next morning ( +2 days )• Supervisor informed OI, management & arranged for MOH consultancy• MOH/GHC suggested con-tusions at bottom vertebra of but-tock and rest for 2 weeks, no med-ication prescribed

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Investigation• MOH was not contacted at the time of incident or prior to first contact with the doctor• Employee reported the in-cident to supervisor > 24 hours• Employee did not notice wet marble floor in restaurant• No warning sign in restau-rant for slippery floor hazard

Findings / Root Causes• RCAF 1: Lack of skill and knowledge in number of areas • Recognizing potential safe-ty hazards of a routine task• Incident care management • Timely escalation process• RCAF 8 : External factors• No warning sign for wet floor

Lessons Learnt• Being vigilant in seemingly mun-dane and routine tasks as safety haz-ards are ever present in such tasks• Recognition of potential condi-tions requiring medical care is lacking – urgency to seek further clarification / medical escalation needs to be dis-tilled • Recognizing post-incident care management mindset as a critical as-pect of an Actively Caring culture• Reporting process needs to be enhanced with a timely review process to enable management line-of-sight on incidents at bottom of pyramid • Sharing the case widely is a step to improve IP & supervisors’ sense of safety responsibility• Use SPSA mindset when in new environment to identify potential haz-ards

Slip Incident on Wheeling Ramp

“The more things you own, the more things own you.” – Anonymous

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Incident Description• On the night of Oct 8, 2013, employee while on her way home, descended down a pedestrian bridge, slipped and fell while step-ping on the side ramp• The employee fell on her rear and felt pain. She phoned her colleague whom she knew was still close by. Two colleagues immediately took her to the hospital and she was at-tended to by a duty doctor. The employee informed her supervisor in a timely manner• The employee re-turned to the hospital the next day to get resulting diagnosis which indicated a “sacral fracture”. Some traditional Chinese medi-cation was prescribed and the employee was advised to rest

Investigation• The employee did not use the pedestrian staircase but chose to step on the side ramp which served bicycles to take a shortcut• The employee was not holding the hand rail• It was night-time and the area was not well-lit

Findings / Root Causes• RCAF 3: Short-cutting procedures or acceptable practices is positively reinforced or tolerated - Stepping on the ramp to take the short-cut• RCAF 4: Past deviations from pro-cedures or acceptable practices produced no negative results - Previous walk on the ramp did not result in a fall

Lessons Learnt• Always use handrails when walk-ing up and down stairs. If handrails are not available, be extra careful• Need to be extra vigilant when sur-rounding is dim• Always conduct a thorough SPSA to assess all possible risks – what could go wrong and what is the worst thing that could happen, e.g. when taking a short cut. Do not tolerate the risk of any unsafe act

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Slip / Fall in office

A part time contractor was getting milk from the Seaview (terminal office space used by mul-tiple functions) kitchen chiller for a coffee ma-chine that is positioned in the F&L office area. As they were leaving the kitchen area they slipped and fell causing muscle damage to their left hamstring area. Due to the extreme pain the IP was experiencing an Ambulance was called to assist in the treatment. The Paramedics pro-vided intra-venous Mor-phine prior to taking the IP to hospital for further

assessment. Nothing further was found. The IP was released from Hospital after the assessment and advised they could return to work. The Company approved Doctor is now moni-toring the IP after attending the hospital after the incident oc-curred. The incident has been classified MTI as Morphine was administered.

Causal Factors• Heeled Boot tread was not sufficient to maintain a good con-tact with the floorOther Contributing Factors• Previously water has been spilt on the floor and people have neglected to clean it up• Previous incidents have not been com-municated across func-tions well enough to all potentially affected personnel• Not all office staff aware of the reporting procedures

A4 poster that was displayed after incident on 17 June 2013. Message not bold enough. Reads: “When carrying drinks, avoid trips and slips by cleaning up any spills no matter how small”

“The ability to simplify means to eliminate the unnecessary so that necessary may speak.”- Hans Hofmann

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Lessons Learned/Follow up actions: • Conduct Safety Stand-down with all MONZ Personnel scheduled for 10 July 2013• Check your per-sonal shoes are fit for the workplace you are in• Provide basic LPS training to all non-dis-tribution staff in Seaview , Wellington on 10 July 2013, then Auckland by 19 July 2013• Provide cross func-tional lessons learned from all incidents to potentially affected per-sonnel.

Manual Internal Valve Top Opera-tors

The manual internal valve top operators are found on top of the tanker and are usually located in between the hatches. There will be one for each compart-ment and are designed so you can manually open the internal valve in the event that the bot-tom air control valves cannot be operated due to a malfunction of the operating system. The top operator is con-nected to the internal valve via a cable inside the compartment. Al-though it can be difficult to determine if a valve is open or closed, the height of the valve han-dle will confirm valve status. If the valve han-dle is a raised position then the internal valve is being held open. When the handle is down and almost flush with the base then the internal valve will be closed.

SAFETY ALERT

OPENED

CLOSED

“DURING NORMAL OPERA-TIONS THE MANUAL TOP OPERA-TOR VALVES MUST RE-MAIN CLOSED.”

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Ergo Tips Repetitive Motion InjuriesRepetitive Motion injuries are injuries to the musculoskeletal and ner-vous systems that may be caused by:Repetitive task like stapling the papers in huge amounts at one time, typ-ing for chatting via smart phone, pushing the button of game deviceMechanical compression like placing the wrists on the sharp edge of desk, sitting lean to one side and placing one elbow on the hard surface to maintain such positionSustained or awkward positions like Turing the neck to one side to read documents for long time, watching the medias or playing with smart phone for an extended period of timeSymptomsTendinitis: The most common symptom associated with tendini-tis is pain at the site involved. Ten-dinitis is made worse by active mo-tion of the inflamed tendon. The skin overlying the inflamed tendon may be red and warm to the touch.Bursitis: Common symptoms in-clude pain, tenderness, and de-creased range of motion over af-fected area. Redness, swelling, and a crunchy felling (crepitus) when the joint is moved may also be found.

Treatment- Reducing or stopping the mo-tions that cause symptoms- Taking breaks to give the af-fected area time to rest- Adopting stretching and relax-ation exercises- Applying ice to the affected area- Medications such as pain re-lievers

“So much of what we know of love we learn at home.” – Anonymous

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Drive safe tip fatigue

Fatigue is often referred to as the hidden killer; because manydrivers are unaware they are experiencing its effects until it is too late.Fatigue is a major cause of road crashes.High-risk times for fatigue-related crashes appear to be midafternoonand between midnight and dawn.Those at risk include; young drivers, shift workers, heavy vehicle drivers and drivers whosuffer from sleep disorders are especially at risk from fatigue-related crashes. Driving on lessthan five hours’ sleep in the previous 24 hours raises the risk of having a crash threefold.

The best way to avoid a fatal fatigue crash while driving is to recognise the early warn-ing signs:• Yawning & poor concen-tration• Tired eyes• Restlessness• Drowsiness• Slow reactions• Boredom• Oversteering

Tips on avoiding fatigue-related accidents:• Get a good night's sleep before commencing a long trip.• Do not drive at times when you would normally be asleep.• Avoid long drives after work.• Take regular breaks from driving (use rest areas).• Share the driving whenever possible.• Pull over and stop when drowsiness, discomfort or loss of concentra-tion occurs.• Find out whether any medicine you are taking may affect your driving.

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Overfill System Inspection & TestingOverfill detection systems shall be set to stop the flow of product at a given level above the calibration mark. Best Practices have probes set to allow 230 liters / 60 gallons of vapor space.

A visual inspection of the controller should be conducted at each load-ing and unloading task• Verify no overfill LED’s are lit – notify a supervisor before proceed-ing• Ensure no retain LED’s are lit in empty compartments – notify a supervisor before proceeding• For units without controllers, check the loading rack permissive signal for proper overfill system operation

Overfill systems require periodic maintenance:• Verify all LED lights are functioning at every PM• Perform a “wet cup” test a minimum of twice a year. Place a cup of liquid over the probe in each compartment and ensure each overfill LED illuminates and the permissive LED turns off• Perform a wet cup test on all probes anytime a repair is completed on the overfill system• Overfill systems without controllers require the manufacturer’s test equipment to perform a wet cup test

Probe inside compartment Controller Ready to Load Controller displaying wet probe