Properly Managing Change – May 2018
During the week of May 14, Management of Change training sessions were presented to all Business Team Maintenance groups in the Plant, to discuss and address some examples when MOC should and should maybe not be applied. MOC is one aspect of GM’s new Workplace Safety System, and when followed correctly can be used to identify changes that may in turn introduce new hazards compromising safety. A serious incident occurred on February 25 in HFV6 Crank that was deemed a sentinel event, and the resulting investigation uncovered gaps in how the purpose of MOC was understood, how it was being applied, and how we could use this system to drive better accountability and decision making.
On Mod 2 Op 40 during a Sunday afternoon start-up shift, a manually operated overhead gantry door above the machine was found broken and separated from the rails, with the eukner blade engaged in the switch. This door is used to protect team members from the overhead gantry during a tool change and must be closed to allow access to the machine. It is not required for normal operation, when it would remain open while a separate machine door below opens and closes to control chips and aerosols generated during the process. The machine didn’t know this door was open, and with limited trades available to conduct an effective repair the Electrician on the job concluded that to get the machine running, the machine could be fooled into thinking the door was open by taping a coin to the door position prox switch until trades were available to properly repair the door and the machine could be shut down. He attached a danger tag to the door’s handle describing the condition, and reported the condition to his Group Leader who passed the information to the next shift. The Electrician and the G/L were out-of-towners, not regular Crank line employees.
The machine ran in this condition for two more shifts until the following afternoon shift. Concerned when told of the machines condition, this shift decided to do some further investigation and test the front door of the machine to see if it would fault out the machine when opened. When it did not fault as it should have, they shut the machine down and did a safety stand down until the overhead gantry door was repaired.
The company declared this a sentinel event since it was theoretically possible, though unlikely that the gantry could enter the machining envelope while the front door of the machine was open and someone was inside. This prompted a thorough investigation by the Plant’s Lead Technical Engineer with the Assistant Plant Manager conducting the final review. We were told the initial reaction of the company was to fire everyone involved in this incident, and we had the right to support and demand this. When the facts began to emerge, it became clear that those involved believed they were doing the right thing, that they acted in good faith to get the machine running, they took steps to tag out the door and they passed on the information believing that the door would be repaired when trades became available. Had they been regular Crank line department employee’s different decisions may have been made, like simply leaving the machine down until it was repaired or the parts were critically needed. Had they followed the MOC process different decisions would have been made to make the machine equally safe if it needed to run.
We could have been somebody’s hero and gone out on the floor demanding that heads roll for this perception of incompetence. We chose instead to support thoroughly investigating the facts, and communicating the results jointly to all Salary G/Ls, Engineering and all our Maintenance Trades highlighting how the MOC process should be used when changes are made that could affect your safety. This approach has opened the door for a case by case review of safety infractions that may lead to discipline based on the facts of the hazard and not simply blindly enforcing a policy, and has resulted in amending a discipline for a lock-out violation for breaking the plane of an open guard with a flashlight with power on, with no body part exposed to a hazard.
An Employee Safety Concern in HFV6 Assembly Loop 1 on Op 1222 prompted hygiene testing on the residue that accumulates in the machine left from the plasma arc process that burns the oil pan rail prior to the RTV application. T/Ls who clean the residue every three months wanted to know if it was a hazardous material. A swipe of material was collected from here and from Op 202 on HFV6 Head-Sub by Ontario Environmental Safety Network, a local company. The results were typical metallic compounds except for one. Lead, which is a designated substance, was also found in trace amounts of 3ug/m3 on Loop 1, and 1ug/m3 in Head-Sub. We asked that a risk assessment be conducted and possible control plan be developed, as provided by the Ontario Regulations. This prompted a visit by GMCCs Chief Hygienist who conducted the assessment jointly with us on site at the machines. It was noted Loop 1 had local ventilation already in place, which was an adequate control for the operator. The concern was really about coming in contact with the residue while cleaning. For this purpose, vacuums equipped with hepa filters will be purchased for all machine cleaning activities in V6 Assembly, which will address Head-Sub as well. This will replace the current sweeping. Also, a PM will be developed for charcoal filter maintenance on the existing Q-air ventilation on Loop 1, and PPE will be made available to any one who wants it who is assigned to clean the machines. This information was presented jointly during SOS meetings with the Loop 1 teams, who originated the concern. If anyone has any questions, concerns or wants more info, put a call in for us and we can discuss.
In our last Health and Safety report, we introduced a new Safety Concern form (GMS-03A) where an Employee Safety Concern will stay open on your Team’s Level 5 Board as it escalates through the process (if needed), enabling you to take ownership and track the concerns progress until it is closed. We have received a lot of positive feedback on this new process, from both members and managers. If your Level 5 board is not using the new form, please call us.
Shutdown will soon be here, and we’ve been told of many jobs planned to help improve air quality. The next phase of Mod 3 washer ventilation improvements will occur on Head OP 150 over shutdown, with the final phase to occur on Mod 3 Block OP 50 washer during Christmas shutdown. By year end, with all washers in Mod 3 upgraded and venting outside, this area should see a huge improvement in air quality. Many oil mist collectors throughout the plant will have first stage helical tube filters removed and power washed, as were done in Mod 3 last year…some which have never been done. Mod 3 Head hydromation system may be dumped, cleaned and recharged, which will hopefully eliminate the chronic foaming issues experienced in that department. Air Make-up Units that draw fresh air into the plant will also have many issues addressed.
Work refusals crop up from time to time, even though we have a fairly good employee safety concern process. We want to remind our members how important it is to inform your Group Leader that you are refusing because something is unsafe; that you have reason to believe you feel whatever the issue is, that the work or condition is likely to endanger you or your fellow workers. That initiates the work refusal process, and your Union Representatives are to be called immediately to investigate with you in the presence of the Group Leader and Safety Supervisor. You cannot be put on notice for refusing unsafe work, but before issues become work refusals it is our duty as workers under the law to inform our managers of unsafe conditions using the ESCP, giving them the opportunity to address the concern.