Some thoughts on fall of safety standards - forgetfulness, over-confidence, complacency, arrogance

Anybody or any organization, immediately after an event not to like to happen will have several commitments to itself. I/we will do this or that, now on wards.
Even a student also makes such resolutions in or after an examination, which he did not do better.
But, in most of the cases, nothing will be done.
Some will start, but, the steam is lost.
Very few will sustain to a great extent. Even in such persons/organization will make exemptions, here and there.

This week, I attended a meet organized by a regulator. It was told in the opening remarks that regulators have to do the act of listening, observe the things and make informed decisions. This is applicable even to all those who are in the job of monitoring / advising and they need not be necessarily the designated regulators.

In case of individuals also, we are our own regulators and doers. As a proverb goes, we have one mouth, two ears and two eyes, indicating see and hear more, but talk less.

Coming back to the title, I observed that even in those entities who have developed highest standards, became role models and even are in the business of training, events have taken place for simple reasons which can be avoided / addressed totally before the occurrence of the event. Events in these places make me to think that whether they are wrong in the lessons learnt i.e. whether the lessons learnt for implementation are impracticable.

In many post accident recommendations, training and supervision aspects are listed routinely. Even if the training is good, absorption of the knowledge and its use in the day-to-day affairs is highly doubtful factor. Even those who understood the information too do not implement inspite of knowing that this may lead to incidents.

Like in financial sector, as I read somewhere, risk and returns are proportional. Low risk investments yield less returns and so high risk investments generate huge returns. I had my own experience in share market investment at two different periods and on both occasions, I had the opportunity (!) to learn the lessons to come out with some loss.

I think, it is in human behavior to take risk when it comes our activities, let it be on the roads or work place. And, it is the other way when it comes to our home.

I commute to my work place which is at 13 km from my house, by bike and these thoughts do occur generally, but I am yet to get any reason.

In nuclear field, ALARA (as low as reasonably achievable) concept is preached and is genrally followed to limit radiation dose to occupational workers and public. Whereas in industrial safety, it is ALARP (as low as reasonably practicable) implying that we have to be practicable in taking measures to ensure safety and health of the persons. This also implies (to me) that certain value is attached to human lives for dispensation. If an accident takes place leading to injuries / fatalities, generally we read declaration of compensation. Though enquiry takes place, hardly there are cases where the wrong doers i.e. those responsible for the occurrence of accidents are punished. Every year, lakhs of persons are dying in accidents (on the roads / work place), equal or similar number of persons responsible for these are not punished and it shows that human life got only some number and things will proceed as usual as if nothing happened. Reasons for recurrence are generally as in title of this post. This makes the job of the safety advisers / regulators, a difficult task.

If some disturbance takes place in an inhabited place, police will be blamed for not doing the job. If some emissions take place in a factory, pollution control authorities will be blamed that they are sleeping or accepted something. If some accident takes place, safety adviser will be blamed internally and factory inspectors externally. And so on.
But, little or no action is taken to identify the wrong doers and punish them.

Authorities for control of activities have a difficult task of facing pressures from all around and at the same time, not to succumb to these pressures. They have to be like stones not having any emotions to keep their health and family not to get affected by workplace pressures. Some will resign the post to look for different type of jobs or bade good bye forever (if they are financially resourceful to lead the rest of the life).

Any management would like to have highest productivity at minimal cost. Availability of qualified human resources is an issue face by many. Most of the educational institutions have become factories to churn out the students with good grades / marks but many of them fail miserably in getting suitable employment commensurate with the certificate as they can't answer the questions of the interviewers. Hence, they settle for jobs whatever they can get. They may get satisfied or may not. This can lead to dissatisfaction and doing the job for the sake of earning money only. It requires lot of efforts from the side of managements too train such people and I am not sure how many organizations have the policy of training their manpower before engaging them and then even doubtful case of retraining at regular intervals or change of job / modifications in workplace.

With these things, may be there is some optimal safe production i.e. under present set of conditions, it can deliver X numbers of their products. If we try to stretch production on higher side without commensurate additions / improvements, accidents / failures do take place, if not immediately, but definitely at a later date. This is because, it requires some time, even for the established systems to degrade. Now, if there is a change of management, persons at top can claim for success even at higher production in the beginning (higher production is initially possible because degradation also needs some time), but the person coming later can't deliver the same, because degradation process starts accelerating.

Hence, those with safety in mind have to conclude / decide what is their optimum safe production capacity and stick to it. Else, what we are seeing or reading in papers will continue to happen.

Poor safety management - cause for blasts in chemical factory leading to 23 deaths

The chemical factory stores vinyl chloride (chloroethene, chloroethylene) in three tanks. Two tanks were full with the chemical at the time of the incident. Due to leak, pressure in the tank dropped. Instead of finding the cause for pressure drop, operators pumped more chemical into the tank. This lead to bursting of tank and release of chemical. Ignition source from outside the plant caused explosion of the leaked chemical, burning the trucks and cars outside the plant. 23 persons died and 22 were injured in the incident.

http://www.ecns.cn/news/2018-11-30/detail-ifzahqkf0371003.shtml
http://www.ecns.cn/news/2018-11-29/detail-ifzahqkf0369490.shtml) 
http://www.ecns.cn/news/society/2018-12-10/detail-ifzanuxq9377375.shtml

Boy dies in oven, after entering in it to escape cold weather

A 15 year old boy dies inside the oven, after he enters into it to escape cold weather. The oven door closes leading to the death of the boy.
https://www.indiatoday.in/india/story/up-gonda-teenager-boy-dies-trap-oven-biscuit-factory-1405407-2018-12-08

Similar incident occurred elsewhere. Here, four persons get trapped inside and cooked to death. From the news report, it is understood that they entered again into furnace after their cleaning work is over, did not inform anybody, did not put caution board, did not remove furnace fuse.

https://www.dailymail.co.uk/news/article-2113800/Metalworkers-cooked-death-inside-giant-Austrian-oven-door-closed-800C-furnace-accidentally-switched-on.html

Death from hydrogen gas cylinder blast in IISc Bengaluru

A person was thrown about 20 feet away, hit the wall and died due to suspected hydrogen cylinder blast.  3 others sustained injuries during the incident. 

The window panes and 20 m high roof sheet got damaged.

Small scale hydrogen explosions are made to create shock waves for conducting experiments.

https://www.thehindu.com/news/cities/bangalore/laboratory-accident-at-iisc-kills-one-injures-three/article25671763.ece

https://www.deccanherald.com/city/research-scholar-killed-3-706586.html