Some times, strange clues help in investigation

Please see the attached link on the topic.

https://www.google.co.in/amp/s/m.timesofindia.com/city/hyderabad/mutton-soup-burns-lovers-acid-plot-unravels-swap-of-identity/amp_articleshow/62046096.cms#ampshare=https://timesofindia.indiatimes.com/city/hyderabad/mutton-soup-burns-lovers-acid-plot-unravels-swap-of-identity/articleshow/62046096.cms

Accident investigation by birds too

WTF Facts : funny, interesting

LINK

Safety department in the plant – boon or bane?

Governments made it mandatory to have a dedicated safety department in every plant/facility conforming to certain minimum conditions considered as hazardous. Generally, the role of the safety officer specified in the applicable legislations is to advice and assist the plant officials to carryout –

hazard identification, job hazard studies, accident investigation, procurement of safety devices, conduct of safety promotional campaigns, safety competitions, etc.

Further, it should also conduct monitoring inspections to evaluate safety performance, investigate select accidents/near misses, maintain records, etc.

However, when we hear/read from media about occurrence of accidents everyday at some plant or the other, it appears that the safety departments in these facilities are not effective by themselves or concerned plant managements are not heeding to their advice.

Having a separate safety department in every facility along with other departments like production, maintenance, quality, HR, administration, security, etc may be giving the impression to the other departments that safety in the work area is not their job(work/headache). And these departments may also be of the view that it is the safety department which should identify the hazardous conditions and ALSO to rectify them WITHOUT bothering them (i.e production, etc).

Such views are against the role specified by the legislations and clearly the importance of safety department is lost when such views are also supported by the top management. Clearly, safety department cannot go hand in glove situation with other departments, they confrontation is not the solution. Safety department should act tough with erring departments. If the role of safety department is limited by not listening to their advice, then the safety in the concerned facility is doomed and accidents will be just waiting to happen.

One should realize that safety is a line function i.e everybody in the organization should make it happen and not that of staff function i.e it is not the duty of safety department staff alone. If any plant management thinks it is staff function, then safety will not improve in that plant and the expenditure on safety department staff (salaries) is waste. May be they can only show to visitors that they are complying with legislations, they are spending so much, etc and make them scapegoats in case of any accident. This is true, as of late, filing cases on safety department officials along with other department officials is on the rise. It is easy to tell that the safety officer did not caution them about the hazards though clearly, it is the responsibility of the work area in-charge. 

The occurrence of accidents at work places that come to our notice through media, and the possible reasons as above sometimes lead to the conclusion that it is better to abolish the safety department by legislation and to make concerned plant management responsible for ensuring safety. Nobody should be designated as safety officer or person responsible for safety, even within each department as the results will be same.

The responsibilities of every department in-charge should include safety also, apart from other responsibilities. The issues to be discussed   in every review meeting should include all issues like, production, quality, safety, maintenance, developmental activities, projects, etc (need not be in that order, but all issues should be reviewed without fail).

Such procedure will make the in-charges to give equal time to all issues and ensure a safe work place for all.

New year resolutions - Incident reporting culture

Wish you all a healthy, happy and safe new year.

Everybody will be cheerful and resolve to do so many to have a good year. At the end of the year, when we review, there may be some misses and some are forgotten. Everybody wishes for zero accident status in every sphere of work. But, this is possible only when there is a good system of reporting each and every incident whether it involves or not, of injury, property damage and environment damage.
It is reported widely and is also observed that many incidents do not come to the notice of  colleagues, supervisors and managers. This can be due to the fear of rebuke, chiding and becoming a fool in the eyes of others. Sometimes, an enthusiastic employee is dissuaded from reporting. If the employee reporting the incident is issued notice for occurrence of incidents, then he will try to cover from next time. Or, if warned, to ensure that there are no incidents, then also he will not report, though he may try to take some measures to prevent recurrence of such incidents, or he will take care that it will not go to the notice of superiors.
I feel that unless the problem of not reporting all incidents, however minor in nature they are, is not addressed, there will not be any improvement in shop floor safety. And, this is possible and can be done only with the whole hearted commitment and support from the top man of the organization. Though, critics question getting results from the action of one person (i.e top man), being in-charge of all affairs and with his powers, he is the only person who can influence the thought process of all persons down below for a safe production.
One can ask why incidents should be reported? When an incident is reported, it will be investigated by a team comprising production, maintenance, safety and other experts and analyzed for root cause and suggest measures to be taken. If it is not reported, then it may not be investigated, and even if investigated, it will be the individual or his friends which may not lead to effective investigation. Then, each work place should have a mechanism for periodical review on action taken on  recommendations. There should not be any delay in implementing the recommendations. Otherwise, improvement can't be achieved and we will see repetition of incidents again and again.
Sometimes, it appears so simple to take action but will find inordinate delay in implementation. This reflects lack of concern for safety of persons and generally reflects organization's poor safety culture.
When performance of individuals is reviewed, inputs on number of incidents occurred, number of incidents reported, measures taken to prevent incidents at the work place, extra work done to ensure safe place in areas not of his concern also should be obtained along with production figures by the assessor, which will send strong signals to all employees about the intention of the management for a safe work place.
Else, employees will be bothered about reaching production targets without caring for preventive measures to ensure safety of persons and environment.
Jobs done routinely i.e accident investigation after occurrence will yield only limited results whereas a paradigm shift in thinking of the decision makers will help in achieving good results in improving safety culture and ensuring a safe work place.

Can we have better surveillance cameras to monitor secured areas?

It is common to see CCTV cameras at important places to monitor the movements of suspicious persons. These are located in super markets, restricted areas, traffic zones, bus stations, railway stations, airports, etc. On many occasions, after the occurrence of an incident, the footage from these helped to nab the culprits. But, the videos that we see in TVs are of poor resolution and less speed. It is beyond my knowledge why it is so and why high resolution cameras can't be installed for surveillance. Normally, the domestic cameras which we use provide good pictures of objects that are at distance, when we zoom. No doubt, the memory occupied by these high resolution pictures will be more and thus require large storage space, but it is affordable and cost should not be an issue when it is with regards to security and safety.
During accidents / incidents, cameras installed at important and critical operation areas also show how they occurred, even if the employees lie about them fearing punishment. This will help in accident investigation and help the organization to take preventive measures.

Accident Investigation 101: What to Do and What Not to Do » SafetySmart

Do's and Dont's for accident investigation, appeared in Safety Smart, 18.07.2012 Wednesday.
Accident Investigation 101: What to Do and What Not to Do » SafetySmart

LINK

Who is responsible for accidents or incidents in an organization?

When some accident or incident occurs, immediately some committee will be constituted to fix the accoutability and normally a worker or immediate supervisor or officer at junior level will be held responsible. But what about the managers or occupier of the company.
People are in limelight and showered accolades for achieving best production. At that time none of the shopfloor level employees will be recognized for the production levels.
Only when some failure or breakdown takesplace, then shopfloor persons will be questioned and punished. From this, we can see that punishments are for shopfloor employees and rewards and recognition are for managers. During delibration of investigation committees, the committee chairman will also be biased because somewhere else he is a manager or senior executive and will be of the opinion that he need not know what is happening at shopfloor and thus is not responsible.
But, Yes. He is responsible for achieving peak production levels. Or, for reducing the costs by process modifications.
But, No for accidents or reducing costs by stopping safety systems or bringing down the level of functioning of safety gear. Such is the appraisal system. Factories Act 1948 clearly holds the occupier of the company responsible for all activites though it exempts him provided he proves sufficiently that accident took place inspite of taking all efforts.

No accidents implies everything safe or something is wrong?

No accidents – Whether everything is in control or something is not identified?


It is reported that the BP’s Deepwater Horizon rig explosion (11 deaths, 115 survivors) caused by escape of gas and oil from the well dug was preceded by seven years of work without any injury. The drilling was done and the well is to be closed. Another rig will takeover for production from the well. While BP managers assembled to congratulate the team for working without any injury, the pressurized gas gushed from the 5 km deep well and exploded.

The incident is not without early warning signs. The rubber gasket (seal to close the drill pipe tightly and shut the well) of the blowout preventer (BOP) located near the seabed, for the well got ruptured in an incident and rubber pieces were found in the mud used for holding the gas and oil within the well. A crewman accidentally forced the drill pipe by 15 ft through the BOP. But, engineers failed to analyse the cause for the presence of these rubber pieces. This shows that every major accident is preceded by a number of near misses and minor accidents. We should be able to identify, report and analyze all near misses and minor incidents however negligible they are. It appears there is pressure on the crew to complete the drilling work fast as they are already behind the schedule. This might have caused the crew to do away with the repair of critical safety systems too.

Further, the backup control system called ‘pod’ for BOP lost some of its functions. This reminds us of Murphy’s law.

The emergency drill carried out every Sunday to escape after head count was not followed after the accident. People started leaving in the available lifeboats without looking for others on the rig. This shows that whatever drills we do will go haywire and those in possession of escape vehicles will disappear instead of carrying the persons for which vehicles are intended.

It appears that safety is ignored because of the short term profits seen by the management compared to possible losses that may accrue to the organization when run without safety systems in place. The management that is responsible for allowing safety violations may not be there as they may take bonuses and leave. Once a system is violated and is in place for sometime, this wrong practice itself becomes an established system and will be considered normal. This has happened in Bhopal accident. All safety systems for MIC tanks were removed to save running costs. As there were no incidents, the management thought that they have done a wonderful job and reduced operating costs. May be, they are under pressure to show profits so that investors will be happy. Accidents do take place because public memory is short. They may be losers only for a short term and reaping increased valuation of their shares. Those affected because of the accident are limited in number and their voice is lost in the herd (of investors).

Normally when people are happy having achieved certain safety record, it will be followed with a major accident. There is no accident because we are lucky till the accident occurs. We are overconfident of our performance. We ignore the warning signals saying that everything is under control. We venture out to do something adventurous. Those who protest about violations are treated as ‘nuts’ and ‘pessimistic’. They may questioned about their integrity, commitment and chided for accepting bonuses or rise in salaries when systems are wrong as pointed out by the same persons. These persons will be blamed in all respected for pointing the violations forcing them to leave or they will be fired.

When accident occurs, people will conveniently forget everything though cautioned by few and term it as ‘one of those rare accidents which no one expected’.

Accident Investigations - Recommendations - Implementation

In any factory, after any major accident takes place leading to loss of life or huge property damage, a committee is constituted to investigate to find the root cause and secondary causes. The committee investigates and makes some recommendations. It is observed in many investigations, a number of recommendations are of general in nature, like,

i) applicable statutory requirements to be followed
ii) house keeping to be improved
iii)training to be provided
iv) supervision to be ensured
v) safety studies to be carried, etc

The management faces the problem of finding what is to be done with these types of recommendations and they are blank about how to avoid recurrence of such accidents / incidents. It appears as though a separate committee is to be constituted for each of the recommendations to understand what it means and what should be done.

Instead, if the accident investigation committee that comprises persons from production, safety, maintenance, etc is able to make recommendations specific to the factors that are responsible for the cause of accident, then the direction for management will be straight forward. For example, say that earthing and bonding is not done for all piping as per so and so legislation (Petroleum Rules). Then, this should be stated and identify the procedure and persons to be responsible for doing and checking. Similarly, a checklist can be made what should be seen for the supervisor every day for the job so that instead of simply standing to supervise the job, he will be clear of what is expected of him to ensure that the job is carried out safely. Along with these, punishments like suspension of the increment / cut in pay also should be mentioned for each of the jobs so that when a person carries the work without following the written instructions, he will face these consequences. Once every thing is put in writing right from the nature of the job, methodology, checks and punsihment, then the system is established and will become independent of the individuals. There should be no mercy for failures of the persons responsible to do the given job. Only when leniency is shown, then the parasites will grow and favouritism starts.

After the implementation of recommendations, if again a similar accidents occurs, then the committee should introspect itself about its efficiency and what went wrong. Whether all recommendations are implemented to the satisfaction / stated intention of the committee or whether full information was obtained earlier or the investigation was only a face wash and the committee should be fixed for its failure to see all facts and handed out proper punishment. After implementation of recommendations, whether all concerned employees were informed about these and whether these were trained for resumption of work is also to be seen. There can be production pressures, but if work is resumed without corrective and preventive actions, then there is no meaning in investigation. Definitely such establishements should prepare to close their shops soon.

Safety becomes an obstacle or costly affair, when proper thought is not given for it during design stage itself and then not followed. If any person says that he does not care for safety as he pays the persons through salaries, then he is a criminal and whether he will accept such a thing if his own kith and kin work in such environment should be seen. If the answer is negative, then he should not ask for output without correcting the system.