Which accidents are acceptable?

Now a days, people are opposing setting up of every factory.  The reasons cited are accidents, pollution, etc. Projects are delayed and costs run high. Opposition is expressed going to the extent of damaging public property. At the same time, governments are blamed for unemployment, inability to provided public amenities, and so on. Where from funds will come for governments to spend. Only when overall development happens, taxes are paid honestly and participate in  programmes, governments can do something to its people.

Everybody is concerned about accidents. But, concerns are very high about industrial accidents particularly those related to chemical industry, which are rare. Everyday, many persons die/get injured in road accidents. Many die due to  alcohol/tobacco/drug use, adventure sports, cancer, pollution, different lifestyles, etc. The number of persons affected with these are very high compared to those due to industrial activities.  

This makes us wonder which accidents are acceptable/normal and which are not? Are we accepting regular/routine deaths and illness due to our own making in the course of having our own lifestyle and taking them in our stride as a part of life. And, fear about others.

We enjoy our lifestyle every moment and therefore its ill effects are acceptable? Whereas direct benefits from industries are less visible though indirect benefits are huge and can become apparent only when they are closed.

Every activity will have both positive and negative aspects and we draw a line. But, we magnify the events in industries and ignore those outside. 

We should have realistic approach so that industries can be setup incorporating all measures for safety of people and environment. While issuing clearances, authorities have to ensure that clearances are not issued in violation of rules or by finding loop holes in the law.

Flirting With Disaster - some notes

http://www.flirtingwithdisaster.net/

http://flirtingwdisaster.wordpress.com/

FLIRTING WITH DISASTER

Why accidents are rarely accidental?

Marc Gerstein with Michael Ellsberg

www.flirtingwithdisaster.net

The book is about case studies, root causes and lessons to be drawn. Following is an extract of the book useful in implementing safety at workplace.

1. Organizations do not learn routinely and systematically from past errors and disasters – in fact, they rarely ever do.
2. Deliberate decision of not to try to learn from accidents is an anti-learning mechanism. This is because of blame and punishment/penalty one gets after identification of mistakes outweigh the benefits of understanding what should be done within the organization to avoid such mistakes.
3. There is strong and successful resistance within many organizations to studying or recording past actions leading to catastrophe-because doing so would reveal errors, lies, or even crimes.
4. Many accidents are not accidents at all. They were imagined and accurately predicted. But, the alarms were ignored by those who had the power to disregard them. It is hard to grasp the scale of suffering such mistakes can create.
5. Some saw the warning signals, but they were not voiced in such a way, or to the relevant people to galvanize them into action. Such phenomenon is called ‘bystander behavior’.
6. Organizational bystanders are individuals who fail to take action even when important threats or opportunities arise. They often have crucial information or a valuable point of view that would improve an organization’s decision-making, but for a variety of psychological and institutional reasons, they do not intervene.
7. Observers are not likely to act if “better-qualified” authorities or experts are present nearby.
8. Bystander behavior is more likely to occur in organizations with strong hierarchies and rigid group boundaries that are populated with leaders lacking the ability to value, foster, and manage dissent. Such organizations are also more likely to be staffed by midlevel managers who lack the motivation or skill to elicit views that differ from those of their bosses. When those in the middle suspect that things are amiss, they tend to ignore their own concerns. Instead, they defer to others in authority, justifying their inaction by attributing greater knowledge and wisdom to their superiors.
9. Short term thinking about money is a factor in many accidents.
10. Dangers arise when regulators and watchdog agencies develop financial and political ties to the entities they are supposed to be regulating and watching.
11. Regulators are morally culpable when they do not take action.
12. Collapse of firms were result of the corrosive effects of envy, greed and divided loyalties, combined with the deeper issue of organizational culture and its role in the fostering of disaster. The consequences are severe when watchdogs become consultants to the firms.
13. Many solutions to risk reduction involve going against the beliefs and biases. When ignored, most risks do not somehow take care of themselves, or simply cease to be an issue.
14. Each uncorrected risk is one more accident waiting to happen.
15. Truth will not come out in organizations which punish the offenders. Accident investigation is a fact finding mission not a fault finding mission.
16. Many of the disasters including natural disasters are preventable. In all cases, the severity can be reduced by better planning; hard work and a mind open to the nature of risk. The question is whether we have the wisdom and the will to change.
17. Risk versus uncertainty: Risk is associated with something going badly wrong, whereas uncertainty involves outcomes of any kind.
18. Unknown probabilities are riskier.
19. People see greater risk when making decisions about which they feel comparatively ignorant (sometimes, it is the other way).  The more we know the less respect we give.
20. In the modern world, many of the unfortunate outcomes occur to other people, not to the decision-maker and his kin.
21. Being RISK BLIND underlies most tragedies. Knowledge should be available and to be understood by the decision makers.
22. Most of the times, technology is not always well behaved. Innovators do not fully understand the behavior of the systems they create.
23. Emerging technology has not had the time to accumulate a substantial body of experience through use under varied conditions (i.e. not fully tested before put into practice).
24. Engineering personnel might have a hunch about a particular risk but lack culturally acceptable proof that the risk is real. In such a situation, the organization can behave as if conditions are safe until the hunch can be verified as a real risk through further testing or a real-life accident. Conversely, the organization can assume that conditions are risky until it can be proved safe.
25. Wishful thinking: Thinking the way it pleases us.
26. We see what we expected to see, not what was actually there.
27. Under pressure, people often see what they want to see, especially if their push the company and subordinates in a particular direction.
28. Causes for an accident: i) cold causes: unintentional mistakes, although not unimportant; ii) warm causes: include ignoring weak signals of danger and other bureaucratic inefficiencies in response to indications of risk – these choices appear less innocent than many design errors because they involve decision-makers’ priorities and judgment in the face of explicit, identified risks; iii) hot causes: deliberately subordinating safety to financial and political pressure – unethical and immoral decisions – often consist of conscious decisions that may well expose people to harm without their knowledge, and certainly without their consent.
29. Design errors are central to many accidents – not visible till tragedy strikes.
30. Design weaknesses often fall into two categories: the obvious and the subtle.
31. Faulty design creates latent unsafe conditions that can result in an accident under particular circumstances.
32. Design issues are the responsibility of the management, not of the workers.
33. People are tempted by short-term gains or coerced by social pressure, and then their risky behavior is strongly reinforced when they repeatedly get away without incident. People develop comfort with deviations that did not cause any accident/wrong behavior and forget to be afraid.
34. Inability to eliminate recurring warning signals shows system failure.
35. Eleventh hour meetings are generally ineffective environments in which unpopular theories with little evidence are not considered/given due weightage.
36. Ignoring weak signals is the norm in many organizations; it occurs in business and public policy as well as in science.
37. It is easy to find causes for an accident after it occurs, but one should find before accident occurs.
38. Progress inevitably engenders risk.
39. Improving safety also encourages risk taking.
40. People rely on instrumented systems assuming they function as per design intention but the actual behavior of these instruments can vary depending upon their installation, they do not behave as expected leading to difficulties which are severe during emergencies.
41. If responses take decades but hazards take far longer to develop, all is well. If the relationship is reversed - as was the cause during floods, then things may end in disaster.
42. In many organizations, decisions have to be approved by higher-ups, a process that inevitably slows things down.
43. Redundancy is often the key to risk protection.
44. Complex systems introduce unknown failure scenarios (KISS – keep it stupid simple?).
45. Many accidents can be traced to various faults with monitoring and control systems, information overload to the operator, inadequate training.
46. The shift to software-intensive systems has made man-machine partnerships far more complex than we fully understand. Highly reliable technology makes people less vigilant, since human beings are not effective monitors of situations that rarely fail. Employing more comprehensive and reliable systems only exacerbates the problem. Although such systems are more reliable, they are more boring to monitor as well as more difficult to diagnose.
47. Layers of protection include safety procedures; training programs; specialized hardware interlocks; monitors, alarms, and warnings; and various forms of containment systems.
48. Catastrophes occur when defensive systems fail or deliberately disabled.
49. Butterfly effect: The idea that small differences can lead to major consequences down the road and at a distance is often called the butterfly effect (small is big, monsters looking innocent).
50. Energy conservation, would not only reduce dependence on imported oil, but it would also save consumers money and cut urban air pollution, acid rain, greenhouse gases, the production of radioactive wastes, trade deficits, and long-term defense costs of protecting oil installations.
51. Many important dynamics take a long time to have a visible effect.
52. Facing the choice between the short-term requirements versus the long-term needs is not an easy decision.
53. Understanding how an organization recognizes the hazards it faces, as well as how it changes in response to those hazards, is essential to avoiding disaster.
54. Culture consists of emergent organizational properties that cannot be separated from history, especially the actions taken by company leaders.
55. Basic cultural assumptions are deep-level tenets that employees and members of organizations hold to be true, often without realizing it. Over time, decisions that may start out as opinions, personal preferences, or practical necessities evolve into internalized truths that become second nature throughout the organization. Organizational members who “think the unthinkable” find themselves fighting a war on two fronts: the need to prove their case, and the need to establish the legitimacy of the arguments on which their case is based.
56. Easter Island: Easter Island, the most remote inhabited place on the earth, located in the South Pacific Ocean, not ideal for new inhabitants because of the conditions, but contains giant stone statutes. Read the story of how cultural change brought self destruction in the book (http://flirtingwithdisaster.net/easter-island_321.html).
57. Organizational tunnel vision: People within organizations obsessed with maximizing a single metric are especially prone to being blind to other considerations. In order to keep a schedule, engineers with safety concern have to prove that their concern is valid and the scheduled activity is unsafe rather than to prove that it was safe (Program engineers may ask the safety person, ‘show me how it is unsafe’ instead of program engineers analyzing the concern and proving to the safety engineer that it is safe).
58. Tsunami December 2004: A school girl Tilly Smith on vacation on Maikhao Beach, Thailand noticing frothing and rapid receding of ocean waters alerted her mother, as her teacher told such phenomena as signs of an impending tsunami. Her action led to saving lives of all persons in the beach. (Tsunami waves can travel at 500 miles per hour across the deep ocean).

59. Rules for preventing and coping with accidents:
1. Rule # 1: Understand the risks you face. Evaluate the hazards every time you face. Probabilities don’t matter once any event with serious consequence like tsunami occurs. Whatever be the probability, in the words of Trevor Kletz, “we have done this way 100 times is not acceptable unless an accident on 101^st time is acceptable”. Take action assuming the probability is 100% all the time.
2. Rule # 2: Avoid being denial. Do not neglect warning signs or ignore assuming they are silly.
3. Rule # 3: Pay attention to weak signals and early warnings. These are a telegraph warning of possible danger. Accidents don’t just happen and are often not accidental at all. Do not take it as one time affair. Because there is a problem, something is lacking, the incident occurred. Ignorance will only lead to a serious incident next time. Ignoring weak signals is a pervasive temptation you must learn to overcome.
4. Rule # 4: It is essential not to subordinate the chance to avoid catastrophe to other considerations. Catching plane does not mean you should drive fast on the road. Missing the plane is worthy than injuring yourself or the person on the road and miss the plane anyway.
5. Rule # 5: Do not delay by waiting for absolute proof or permission to act. The signal may not be true and you may become laughing stock if the signal doesn’t turn out to be true. But don’t get disheartened. It is better than allowing damage / loss of lives if the warning sign turns out to be true.

(Intelligence wings issue alerts many times to the government and citizens about terrorist attacks or of similar nature and many times we do not see attacks. This does not mean that we should not believe in those alerts. It is not possible to understand complex minds of people when even we do not know what we want. Then it is much more difficult to understand the nature. It is easy to blame safety and security officials for being overcautious but you are the first person to blame them when incidents occur without realizing that you are responsible for your safety. If you do not know what to do in your house or does not know what is happening in your backyard, who are you to question others?)

60. Don’t squander your early warnings with delays or half measures. If you do, don’t be surprised if the clock runs out.
61. Treat near misses as genuine accidents: It is a safety sine qua non that near misses and other forms of weak signals be treated as if they were genuine accidents. They are considered “free tuition” – valuable lessons without much cost. Always pay attention as if the worst had actually occurred, but develop efficient ways of confirming or disconfirming the actual danger to minimize your time and effort.
62. In many accidents, the bulk of the damage occurs in the aftermath, not during the event. A tremendous amount of harm can be reduced by early warning systems, defense construction, contingency planning, and rapid response. Even when the incident can’t be prevented, as is often the case in natural disasters like the tsunami, anticipation can often mitigate a lot of harm.
63. Politics trumps safety. Here politics means one-upmanship and resultant timelines, pressures, communication or lack of it, and so on.
64. Routine and non-routine accidents: We do not see a hazard until we experience the consequence. Many accidents occur routinely because people are irrational about danger. People are scared about non-routine accidents like anthrax poisoning, nuclear accident, flu epidemics, etc but not about routine accidents like slips, falls, road accidents, deaths from smoking/alcohol consumption which more than non-routine accidents. People overact to rare risks than common accidents.
65. In some cases like living near ocean/volcanic or seismic zone/mountains, etc we may feel that we have no choice but to accept risk, but flirting with disaster out of ignorance or denial rather than rational choice is simply foolish.
66. Residential fires related cooking: Home cooking is responsible for starting over a quarter of the 400,000 residential fires that cause 13,000 injuries and 3,000 deaths in the United States each year. Smoke alarms, fire blankets, and fire extinguishers as well as safe practices for deep-fat frying and other high-risk activities are sensible precautions even if they are not perfect solutions. (Last few years, we are seeing a number of fires and explosions due to rupture of gas piping in residential areas. The common reasons are, digging without authority, not closing the valve properly, corrosion, poor maintenance and monitoring, etc. Still, thousands of miles of gas lines are being laid every year and we are living with them.)
67. The enemies of effectively dealing with low-probability risks are denial, ignorance, and lack of preparation. Denial prevents our dealing with the risks in the first place (not recognizing the hazard); ignorance constrains our choices and distorts our priorities; and lack of preparation forces us to deal with complex problems under emotional pressure and time constraints, vastly increasing the chances of bad judgment and the possibility that we well be overtaken by events. Examine the cumulative risk of all low-probability threats and make your plans according to the rule of avoiding the greater mistake. You may not always make the same choice for each risk, or the same choices as other people, but they will be your choices, made with knowledge and forethought.
68. The consequence of minor risks will be high. A simple event will grow into a monster when we are not prepared.
69. Moving from BYSTANDER to WITNESS to WHISTLE-BLOWER: You may not be able to question the defaulters at all times. Sometimes just “active watching”, visibly taking notes, or writing a concerned e-mail is enough to change the course of a situation. Being visible and questioning clearly inappropriate actions rather than fading into the background often makes a difference, even if it is not a decisive action. Equally important, when someone else takes stand-up action, lending visible support matters a great deal. Individual effort may not be effective, but team effort will make the wrongdoers to change their ways. Silent watching or cooperating with wrongdoers will lead to destruction of the society and the individual also, while taking action / making right noises will make the person confident, satisfied and help the society.
70. Suggestions for Professionals and Managers:
1. We should not be bystanders and should not encourage bystander behavior in those around us.
2. We should all do what we can to ensure that dissent is encouraged, not repressed, and that the channels of complaint are open.
3. We should do what we can to build viable information and reporting systems that widely disseminate risk-related performance information. According to research, when people’s actions go unrecorded, and are therefore undetectable, the chances of shortcuts under pressure rise by a factor of TEN.
4. We should not collude in cover-ups, even minor ones. Such cover-ups may lead to increased difficulty when it becomes necessary to reveal embarrassing facts later on. Every incident should not be covered as acceptable risk.
5. When there is a likely and recordable unacknowledged risk, each of us should assemble our allies and pursue a complaint with the appropriate institutional body. If all else fails, we should consider blowing the whistle (with documents). Most of us are prisoners of institutional realities that tolerate unacceptable risk in the name of practicality. The fallacy in most organizations is that lowering risks is unacceptably expensive. In fact, not only is it probably much less expensive than people think, over the long term it will probably save money as well as lives.
71. Suggestions for Leaders:
1. Realize that practicalities and shortcuts have costs that inevitably even out in time and that one’s choice is to either pay now or pay later. May be your policies will not immediately lead to accidents in your tenure and you get all appreciation for the gains that are short-term, but the organization suffers later when those of your policies lead to catastrophes in the long run.
2. We can’t put a price tag to injuries and deaths and compensation alone is not sufficient to judge the cost.
3. Leadership is often the originator of the financial, scheduling, or political pressures, and thus is the ultimate source of a significant increase in risk. Imposing nonnegotiable performance objectives combined with severe sanctions for failure encourages the violation of safety rules, reporting distortions, and dangerous shortcuts. Putting people in no-win performance situations encourages recklessness and fraud, inevitably increasing the chances of a major catastrophe. Leaders must therefore hold themselves accountable for the inadvertent consequences of their management philosophy and tactics.
4. Pay scrupulous attention to design. When design is faulty, accidents happen. In organizational settings, accidents are never accidental: They are inevitably the result of faulty management, particularly the management of safety.
5. Systemize paying attention to near misses, weak signals, and assessments of engineers and safety officials. Leaders have to create monitoring systems, systematic review procedures, and independent information channels that do not report through the operational chain of command. While safety and risk management is perfectly compatible with efficient operations over the long term, if often runs contrary to it in the short term, especially if there have been long periods of neglect.
6. Recognize that while every organization tolerates some dissent, on certain subjects it does not. Only leaders can eliminate these “undiscussables”. Encourage whistle blowers to get timely information about risks, else bystander behavior is inevitable and affect the organization in the long run.
7. Create effective contingency plans for serious but low-probability risks.
8. Every organization requires robust, independent watchdogs. There is no substitute for regulatory independence and should not be measured in terms of cost of maintaining it.
9. Leadership must subject itself to relentless review and self-criticism.
72. Relabeling problems as opportunities can have true shift in mental framework and reap benefits to the organization.
73. The first big mental shift is accepting the inevitability of accidents and catastrophes without giving in to them. Do not wait until after a disaster strikes.
74. The second big mental shift is appreciating the difference between new ideas and unpracticed old ones. 

Why people do not want to learn from incidents?

Everyday goes in our life without some incident that would have caused rise in heart beat. If it is during the driving on the road, either we shout or get earful hearing from the other side. Here, always the bigger vehicle driver is at the receiving end. If it is at some other place, like at home, work place, bus, train, or market place, both sides will be vocal in airing the views.

Every time after the incident, consciously or unconsciously we try to analyze what happened and who is responsible. Most of the times, we conclude that we are not wrong and that the incident happened because of the other person. After ascertaining this again and again in our thoughts, we feel satisfied that we did nothing wrong. If we were the affected during the incident but were at the receiving end, we think that we can’t do under the circumstances as we are less in numbers. If, someone got injured in which we are also a party, we tell ourselves that we are right and feel sympathy or that they deserve it for not being correct.

Side effects of automation???

An article in Times of India on 31.08.2011 (Wednesday) on airplane accidents analyzed about how accidents are taking place due to too much dependence on auto piloting and how pilots are loosing their reflexes when they need in most critical situations.
It is our experience that even for simpler calculations, we use calculator or mobile phone instead of doing it mentally. If we want to know about something, we will not search books. Instead, we do google search or yahoo it. Even for meanings we fail to open dictionary. With such lifestyle, how wish to learn. Traditional methods of learning becoming extinct and getting addicted to NET. Less and less memory is being used and we do not play any mind games. The net result is loss of memory. After one or two generations, when creativity and intelligence is lost, I think we come back to square one and start reinventing the wheel.
I am not against automation. Automation should be designed, tested and implemented such that it is fool proof. We should use the technology for our advantage and should not blame it if there are accidents. Accidents occur because we fail to foresee, fail to plan, fail to use it the way it is required. It is easy to blame. But as an individual, as on authority, as on organization, what we are doing.
At home, we admonish our children, spouse, servant for some mistake. But, how many times we ourselves made mistakes. If we do mistakes, we call it experience and if others do it, we are ready to fire.
In the news item, it is mentioned that pilots use automated systems to fly airliners for all but about three minutes of flight i.e during take off and landing; that they have few opportunities to maintain their skills by flying manually as regulators do not allow manual flying.
In the same news item, at the end, it mentions about a fatal airline crash in the US, in 2009 caused after the co-pilot of a regional airliner programmed incorrect information into the plane's computers, causing it to slow to an unsafe speed, thereby triggering a stall warning. The panicked pilot bypassed two safety systems to control the plane unsuccessfully. In this case, even if the copilot fed wrong information, it appears, there are no program logic or supervision to verify about the wrong entry.
To address the complaint of pilots loosing reflexes of manual control due to automation, I feel that, after every fixed number of hours of flying, all pilots should be subjected to simulator training and examination for different types of scenarios and only those who passed with 100% should be put on roster.

http://timesofindia.indiatimes.com/home/science/Addicted-to-automation-pilots-forgetting-how-to-fly/articleshow/9804378.cms

Restrictions on entry of old ships on Indian waters

Mint magazine published an article on the proposal of Indian government to impose restrictions on entry of ships that are older than 25 years into Indian waters due to recent accident.
Regulations are lessons learned from incidents. I thought it is useful to post this article so that history can be remembered. Many times, production managers question the feasibility/utility of rules and regulations without knowing the reason for such issues. Though, they are statutory, but this questioning attitude and not implementing the rules lead to hazardous conditions and endanger the persons and environment. These questioning type are arrogant, no regard for safety and blind by their egos. They do not realize that law of the land is supreme and one has to follow it. People make fun of rules saying that it is not practicable. Threaten them to put behind bars for non-compliance, overnight, they show it how to implement.
Ships older than 25 years will be allowed when they meet certain criterion like, membership in international body, insurance for damage due to accident, registration of agent for foreign ships to deal with issues arising out of any incident. I feel that this move is good and protect waters from pollution which is seen due to oil spillages from damaged oil tankers, ships carrying hazardous goods, etc.

Deaths due to non-communicable diseases

A report in today's Times of India states that non-communicable diseases (NCD) cause more deaths than communicable diseases. As per latest data, in India, 80% of the deaths in urban areas are due to NCDs like cancer, heart ailment, respiratory disease and diabetes and 60% of deaths in rural areas. Globally, 36 million deaths are due to NCDs contributing 63% of all deaths. In India, in 2004, 7.3 lakh deaths are due to cancer, 27 lakh due to cardiovascular. i.e 34 lakh deaths are only due to these two diseases.  And India lost US$ 9 billion from heart disease, stroke and diabetes in 2005 which is a considerable amount.
It is not known about the causes for these NCDs, whether arising out of occupation or not. Heart diseases can be due to  life style, struggle for existence and to have minimum requirements of food, cloth and shelter, good education for children and so on.
The number of deaths appear to be much more than industrial accidents and road accidents put together. This requires initiative by government to provide better facilities for health, transport, education. Also managements of industrial establishments can participate in community activities in the form corporate social responsibility by adopting localities and engaging the people in the area for their betterment.

Industrial courts - concept from Australia

A company was fined by an industrial court for safety violations leading to a nearmiss incident that could have caused several fatalities. Exclusive industrial courts will help in speeding up the hearing and awarding judgement. If it goes to civil courts, with so many cases, industrial cases will be heard when their turn comes and justice will be delayed. Penalties also should be revised with emphasis on punishment in the form of imprisonment rather than on cash penalties which can lead to proactive measures rather than half-hearted measures.
After every accident, it is common to hear renewed commitment by the company management for health and safety of the employees and a list of measures taken or proposed for improving the workplace safety and environment.
In some industrial areas, the cost of establishing and establishing and maintaining local emergency response centers is borne by the industries in the area. Likewise, it should be made mandatory for industries in the area to contribute for industrial courts. If any company is found operating without contribution, it should be closed.
Relevant articles for this blog can be read here 1, 2, 3. 

Some statements on safety

Following are some of the statements in "Process Safety Analysis - An Introduction"  by Bob Skelton published by Institution of Chemical Engineers, UK.

1. A good safety culture ensures that both the spirit and the letter of the law are fulfilled.
2. Attitude to safety should be highly visible and shared at all levels within the company.
3. A well managed company is almost invariably not only a profitable company but a safe company.
4. Changes in existing plant are costlier than that introduced in design stage.
5. Design should be such that operator intervention is not needed for at least 30 minutes after an incident. Experience has shown that operators can not always be relied upon to make the correct decisions under immediate post-accident conditions.
6. Safety in design must be both proactive and reactive. Changes, once a plant is built, are very expensive compared with changes at the design stage.  It is not sufficient and cost efficient to make safety review after completing the design and then BOLT ON safety devices. It will not be cost effective. Engineered safety is BOLT ON safety. Engineered protective devices can fail and never place too much reliance on BOLT ON safety.
7. Commissioning is one of the most hazardous parts of any process plant operation. Not only do design errors which escaped previous checks manifest themselves but problems due to construction errors also become obvious. In addition commissioning generates hazards of its own as the plant moves from construction to operating status. It is essential that a formal set of checks be carried out before process fluids are introduced for the the first time.
8. Fire and explosions can be prevented  by not exceeding 25% of LEL. Flammable atmospheres can be avoided by ensuring that fuel lines and tanks are pressurized so the flammable material leaks out rather than air leaking in. good ventilation of vessels and plant areas can maintain safe working conditions.
9. Dust explosions are best prevented by good housekeeping - that is, by keeping the concentrations of dust down and perhaps keeping the dust damp. Inerting by dilution with non-combustible dust is another effective technique, frequently used in coal mines.
10. The risk is serious in case of static electricity, if the relative humidity is below about 60%.
11. Explosives manufacturing facilities are usually designed so that the buildings are separated by safe distance, surrounded by earth mounds so that any explosion will go upwards rather than affect other plants in the area. In addition there is usually a limit on the number of people allowed in a building.
12. Fire fighting water causes more damage than the fire itself, when polluted water is let into rivers. There may be a conflict between accepting the atmospheric pollution caused by letting the fire burn out and the water-borne pollution caused by fighting it.
13. Non-process hazards account more than 70% of all accidents in process plant.
14. Many of the worst accidents in the process industries are the result of bad maintenance practice. Ex: Piper Alpha and Flixborough
15. As many people die by asphyxiation as from toxic gases.
16. A good health and safety policy is always cost effective; most organisations grossly under estimate the cost of accidents, often by an order of magnitude. The organisation should be such that the attitude to safety is highly visible and shared at all levels within the company. Active participation is encouraged to promote the objectives of not just preventing accidents and industrial illness but motivating and empowering everyone to work safely.
17. A safety culture, once established, must be maintained, any any tendency to careless practices stamped out at once. Experience shows that 80% of accidents tend to happen to 20% of the workforce - the young and the old being particularly vulnerable.  Many accidents are caused by operators not fully appreciating the significance of small, but nevertheless important changes.
18. A good system of accident reporting is proactive and reactive, whereas most tend to be purely reactive.
19. Effective safety at all stages of a project - from inception to demolition - can only be achieved if there is a commitment at all levels. The senior management must see health and safety as being just as important as profitability and they must make certain that all their workers are aware of this fact.
20. A well managed company is almost invariably not only a profitable company but a safe company.
21. In hazard analysis, a distinction must be made between routine operator action and operator intervention in an emergency.  For routine operator action, the operator can usually take time and is under no great stress. Safety assessments involve the prediction of the likelihood of errors when the operator is taking corrective action against alarms. The time for corrective action may short, the operator is liable to be under some stress and so the probability of errors is greater.
22. Total elimination of human error will never be possible. Use must be made of the science of ergonomics to ensure that everything possible is done to enhance the strengths of human operators whilst at the same time allowing for the weaknesses.
23. The most important rule is, 'inherent safety is better than engineered safety', ' what you have not got can not leak'. Even elaborate safety devices can't reduce risk to zero due to the escape of a noxious substance, but replacing a noxious substance by a more benign one could well eliminate that risk altogether.

 

Process Safety Management - for whom?

Everybody says process safety management (PSM) without knowing or having commitment. Many may be thinking it as day-to-day plant operation. In this regard, to identify, evaluate and control hazards in chemical plants, OSHA has given guidelines and can be read here.
It must be understood that by doing PSM, we are doing favour to ourselves and not to others. Even, production cost can be brought down, if we do PSM sincerely and follow it. If we do not care to spillages/leakages of chemicals, air, steam; do not care to study in detail before going for a new process / chemical / modification; do not make checklists for operations, then it means that enough attention is not paid for plant operations and it adds to cost of production by way of wastage, inefficient operation, accidents, and so on.
We should not feel like Alice in the wonder land when the unidentified hazards manifest into incidents/ accidents. One may feel stressed to follow the safety principles all the while. But, the stress will be more and can also lead to penalties and punishments when there is loss of life/damage to environment/property.
Many times when we land into simple accidents outside factory, we vow not to repeat such mistakes. But, when we commit such mistakes in a factory, the consequences will be very high and at that time we can move the time back to correct our mistakes. There is no time machine yet available to correct ourselves otherthan following safety principles in toto.

Leniency to violators by authorities

Every day, we see reports of many accidents, incidents, violations by factories. There will be hue and cry for lenient attitude / laxity on the part of the regulating authorities. There will be injuries/fatalities/release of fumes, gases from plant to public domain/dumping of chemicals in the night in public areas/failure of containment from tankers, etc. Immediately, regulators are found fault for not keeping eye on violators. Regulators also visit the affected areas, factories and say that there is no licence for operation or matter is under investigation or notices are slapped, etc. The issue will be left. Media also will leave it as the importance is lost after the item is aired in all channels.
This is not happening in our country alone. When we see reports appearing in several websites of different countries, we come to know that this is worldwide phenomenon. Even, in countries where regulators are tough nuts, stiff penalties are imposed, still accidents/incidents/violations continue to occur and reasons seem to be silly. Though, many do not agree now-a-days that 'safety is nothing but common sense', still that common sense alone can prevent many accidents.
We are all greed and want to save few bucks by following short cuts. Finally, after sometime, everybody would have experienced a huge loss because of one accident and the loss far exceeds all savings accrued so far from short cut methods. Still, the lessons are confined to the affected individual alone and again the same individual will bypass safety after sometime, because our memory is short.
In such a situation, what a regulator can do is the big question, when we do not have self discipline. Then, we have to face the consequences and suffer.

A study on PPE use (not using) by workers - reasons - recommendations

There is good article on why workers do not use PPE and risk themselves to accidents. The article also elaborates on view of the safety professionals about reasons and recommendations for making the workers to use PPE.

Use of robots in automated processes - What are the safety implications?

Automation of processes is preferred by most of the organizations as it reduces human interface and improves productivity. In manufacturing / engineering industry, auto sector, etc most of the material handling jobs are automated and robots are engaged for complex jobs. This reduces lifting of weights of human beings, avoids stress / strain caused due to repetitive jobs and thus reduces health care costs.

However, it is important to understand the programming that went into sequencing of operations to be done in automated jobs and its implications particularly when the jobs are partly automated, partly manual. The job may look simple when routine sequence of operations are carried out. However, if any interruptions / change of sequence is there or breakdown occurs or power failure takes place, we need to know its impact on operations. May be we did not thought of restricting the functioning of robots or like it happens in computers when power failure occurs, there may be hanging of the computer programme. Whether such a situation creates any hazard to shopfloor operators in the vicinity is to be assessed.

Or, what are the hazards when maintenance is to be done when these automated systems are in energized condition. Whether safe positioning is incorporated when emergency stop switch is operated is to be known. Else, when someone looks into the problem during a breakdown, any of his repair job may cause the robot arm to move and hit the maintenance engineer.

Before programming the logics, a detailed WHAT IF analysis is to be done by involving concerned including design engineer, operation engineer, instrument engineer, maintenance engineer, safety engineer, etc to assess all possible hazards for all regular operations / breakdown jobs / maintenance, etc.

Still, there may be surprises depending upon the extent of questioning, imagination, thinking is put during hazard evaluation.

Why accidents continue to occur?

We read regularly in news papers that accidents continue to occur though here and there the concerned are charge sheeted. Most of the time, the families of the victims are compensated by the managements and the issue is resolved to the satisfaction of both parties. Many times, accidents are reported. It is likely that there are many accidents which are not reported and settled without notice. Though this may satisfy the aggrieved, it will not stop recurrence of accidents, if not in the same organization, as no lessons are drawn. The only lesson drawn is that it is economical to pay rather than ensure safety at workplace. This is a common sense. Why one will spend more when there are ways to reduce costs.

There will be reports for sometime in newspapers and then everybody will forget. This is true everywhere in the world. In some countries, as experts say, regulators are task masters and award huge penalties. However, the fact that accidents continue to occur in these countries shows that there is something wrong in implementation of accident prevention programme.

When there is some financial scam, more are affected and there are many stake holders in voicing there concern and try to punish the responsible. However, this is not visible in case of industrial accidents. I do not know, in how many cases, regulators stopped operations permanently after an accident. There may be suspension of operations for a while, but not as a whole. Managements can absorb losses due to suspension of operations for a while. Some can even clevery carryout maintenance works during this period which may be due after sometime and thus save time from annual shutdown.

A serious message is to be sent to managements with severe actions that can make them to realize about the importance of safety given by governments and that they may lose even their personal wealth if any accident occurs.

Otherwise, it is better for the regulators to stop issuing press notes about poor conditions in factores and be contended with the existing conditions.

Workplace accidents - where we are?

I read three articles 1) Why Safety Training is a Good Investment, 2)  Safety Training Pays Off Every Minute and 3) Training Adult Learners on importance of safety training for accident reduction. According to these, in US every year there are 4.0 million non-fatal injuries, 1.0 million man-days lost, every day 15 workers die because of workplace injuries / illness. Training the persons makes them to realize, recognize, evaluate and take effective measures for control of workplace accidents and avoid its ill effects / consequences. As pointed out in the 3rd article, to succeed careerwise, people will be learning relevant new issues. However, we have to make them realize that they have to learn safety aspects also. Otherwise, there will be bloodbath at the workplace as no attention is paid for ensuring the workplace safety. Any decision for increase production without safety means somebody will be hurt in the field. The decision maker may not realize that his decision is the reason for the deaths / injuries. Like, some people say 'to give human touch', decision makers have to give 'safety touch' and assess all consequnces arising out of their consequences.

Now-a-days, in western countries, when buying or placing order on a company, organizations conduct audit including quality, environment and safety audit. Similarly, while recruiting executives, these organizations should verify the safety credentials in the previous employment. For first timers, they can assess knowledge on safety systems, applicable legislations, etc or after recruitment, they can impart safety training. It is not sufficient only to see capabilities / past experience in achieving / reaching production targets alone. Assessment is to be done for SAFE PRODUCTION. Otherwise, accidents like at Bhopal, Deep Water Horizon, etc can happen and lead to closure of the unit or selling of the assets to meet obligations.

CHOICE IS YOURS. WHICH WAY YOU WANT TO SEE YOUR ORGANIZATION.

Safety nets - test before use!!!

It is a good practice to have safety nets for works at height to prevent injuries during fall of persons. Small time contractors usually avoid provision of safety nets and even if they were forced, they will provide nets only below the place of work and shift the net as the work proceeds. Because of the cost, the quality of these safety nets also is questionable. In case of doubt, it is better to test the capacity of the nets by dropping sand bags of sufficient weight from height and see whether the net is intact or strands are broken or the net sags. This will also give confidence to the workers and will be an eye opener for the contractor if the net fails. Normally, safety nets should withstand 2200 kgf. They should be provided such that the fall of person is restricted to 2 m and the width of the nets is atleast 6 m from the place of work. There should not be any gap between the wall and the net. Any construction material / debris that falls should be removed immediately to avoid injuries to persons falling on to the net. At many construction sites, I saw construction debris accumulated on the nets with nobody to remove them.

If the floor is good, then one can provide mobile nets which I saw at a construction site. A scaffold structure is made with the net tied all around. This will be located below the place of work at height and is moved as per requirement.

A few construction engineers question about the need for providing the safety net or its practicality to provide. At many places, I saw even for a small work, scaffold is erected (11 storyes height at one software company building, 5 storey height at one super speciality hospital). Therefore, what is required is commitment to ensure safety. Else, we get 1000s of excuses for not providing the scaffold / safety net.

A simple incident during the construction

Recently, I heard an accident from my friend who experienced during the floor tile work in his apartment. Tiles were purchased and brought to the apartment. The marble tiles (about 10' x 6') were kept in an inclined position in the corridor outside the apartment. The corridor is about 4' width. Next day, when he went to construction site, one of the worker commented that the tiles are having vertical straightline cracks and appear to be joined with white cement.
To check the condition, the person in-charge for laying the tiles was called. Both my friend and the worker pulled one tile to vertical position and checked for cracks. To the dismay of my friend, there were such vertical lines as if joined by white cement. Then, 2nd tile also was brought to vertical position and then the third. While checking the third, by holding the tiles in vertical position with my friend on one side and the worker on the other side, slowly the tiles started moving towards the worker's side as the center of gravity (C.G) shifted. This could not be seen initially, but shortly both understood something is wrong and tried to push the tiles to the wall without success. The tiles were now heavy and beyond the capacity of the both persons. Both shouted for help.
Immediately, workers in the ground floor rushed and with great difficulty, the tiles could be put back into position. By that time, the worker had chest congestion because of the weight of marble tiles on him. Immediately, he was rushed to the hospital and the person was alright in a day.
The above accident is unimaginable for ordinary folks like us. The fact that the experienced construction worker also did not caution before examination shows that we have to learn a lot.

Later, on enquiry, the supplier informed my friend that they are not cracks but lines which come during polishing and that he will not spoil his reputation by supplying damaged tiles. He offered to replace the tiles of much superior quality and premium brand, even if one single tile shows cracks.

Similar to the above incident, I remember, few years ago, when my child (about two years old at that time) climbed over the refrigerator racks to take some fruits, the refrigerator started falling towards the floor.
Fortunately, I was next to the refrigerator and immediately could hold and stop the fall of the unit. Otherwise, my child could have got injured under the falling refrigerator.
Same is the case, when we go up the portable ladders and try to access by over reaching. Then also, ladder can fall on the side because of shifting of C.G.

Safety management OR managed safety

It is usual for us to hear and read about the commitment expressed by CEOs, CMDs, ... at various functions. They say, SAFETY FIRST, QUALITY SECOND AND PRODUCTION NEXT. After the function is over, these same people will be enquiring about the production statistics for that day without bothering to enquire about safety status. Managers will be fired, if they report drop in production or come with their problems. Such managers may be threatened to find another job or transferred to less important posts and will be given earful in the presence of others, sometimes in front of juniors also. The CEO / CMD wants to prove that he is the boss. If this is the situation, what the managers have to do. They will pressurize their subordinates without much thought about safety. Because, bypassing safety systems will show immediate results i.e increase in output, though in the long run it can result in more accidents and may even lead to breakdown. But, people do not think such breakdowns are because of failure to follow safety. They think it as an event which they attend to rectify and go on. If any accident occurs, then it may not be reported, not investigated and will be covered as a minor accident. Thus the management actually will be practicing the principle of PRODUCTION FIRST, QUALITY NEXT, SAFETY LAST.
If someone is concerned about the accident, if this someone is a union person or safety officer, then the accident will be investigated and some measures may be implemented. Otherwise, it is lost with no record.

Generally, only those accidents where injured have to be taken to hospital for surgery or saving life, will be reported. All other accidents will be recorded as minor accidents. In such organizations, naturally, safety record will be the BEST and the CEO can boast to the world that he leads by example, that he spends so much money on safety systems, training, etc, etc. And one morning, there will be the news of a major accident, shuts down all operations and investigation begins into its activities by the regulator.

Though the regulators scream about lack of safety procedures and systems, nobody is bothered, even the public. Because, they have stake in the company in the form of investment, jobs, contracts, auxiliary business, etc.

We are living like fools where we do not want to see the facts and when something happens, we are happy to discuss threadbare till the topic is HOT or interesting till something new happens. Even media also does the same.

How to improve safety culture - an example

Be a Roman in Rome, is a proverb i.e we should behave the way others do. Similarly, the attitude of the employees for safety reflects its culture, the thinking and will power of the top management and efforts put into it. If accidents are viewed as part of the work and that the injured can be compensated, then the accidents will continue to occur, because it is cheaper to pay for an accident rather than investing in safety systems. It appears costly to change the designs, incorporate safety features, provide training, provide PPE, etc. This is the reason why in many sites, accidents recur. However, if there is strict enforcement of regulations of the land, then there will be a sea change in the attutude of the management towards safety. Now, they think it is cheaper and rewarding to invest in safety rather than pay penalty and worse, go to jail.

Such a change is possible. Suppose, we go to a new place where the language spoken is different. Then, we try to learn or atleast try to find ways to communicate. The need forces us to find ways to communicate and get what we want. Necessity / need forces a person to chage.

Similarly, if regulations are enforced, then factory mangements though feel like fish out of water for sometime, soon they will understand and follow the safety principles prescribed under rules and regulations.  Can we term this as cultural change. I think this is a cultural change. And it happens because someone somewhere is monitoring with a whip in his hand, ready to punish the erring managements.

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’.

Safety training - for what?

Many times it is said that to avoid accidents, create awareness, training should be imparted to workers, supervisors and managers. Even employees also will ask for training programmes, seminars, etc. But, what is the actual interest from people. In many training programmes and seminars, we find participants enquiring about refreshments, lunch, bag, pen, etc for the programme rather than the technical programme. Once I heard that a programme will be termed successful, if three conditions are satisfied. They are,
1. Kit
2. Transport
3. Food

The next condition is some sight seeing tour. Even, in seminars we see participants constantly moving in and out with actual serious discussions limited to very few persons. In training programmes conducted within the plant premises also, participants get phone calls to attend some work at shopfloor. Why people will be nominated, if they can't spare the person for the programme. Only for records?

For some, nomination to training programme is like a holiday with pay. They will come at the beginning of the programme and then disappear to do their personal works in the town or see friends.

A training programme will be effective only when participants are subjected to some form of test at the end of the programme and are penalized, if they do not secure atleast minimum marks. Participants should be asked to discuss on a given topic and should be evaluated for their active participation and contribution. If they are involved in any accident or incident after the programme, then he should be asked what is wrong with him or the training he received earlier. May be such evaluation will help the organization to make the training programmes effective and worthy.