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.

Construction safety - lessons to be learnt

NDTV news report link provides details about construction industry hazards.

Read the report here.http://www.ndtv.com/india-news/even-after-fatal-accidents-indias-construction-sites-remain-death-traps-for-workers-1734233

Lessons learnt from process safety accidents - an article from insurancenewsnet.com

A good article is found on the above title, narrating lessons from five less known accidents. The lessons are,

1. containment of water from fire fighting operations to avoid contamination of water sources in the rundown 
2. to consider all auxiliary equipment also as important as main plant equipment for understanding hazards
3. not to ignore hazards and need for monitoring even during shutdown 
4. positive isolation, purging and checking for hazardous atmospheres (using flame is not a correct check for presence of flammable atmosphere)
5. follow written approval system to override interlocks
6. follow safety permit procedures
7. identify the correct equipment before taking up work
8. communicate with clear identification while handing over the equipment for maintenance
9. ensure physical check by another agency before permitting equipment operation/maintenance
10. hazards from dust, propagation of dust explosions
11. preparation of emergency response management, with detailed instructions for every type of emergency
12. good house keeping
13. establish process safety management procedures
14. inculcate good safety culture, starting from the top management

Accident prevention - sharing of information between the Japan factories

A news item on the above subject is interesting to read.

A good effort by Japanese factories to share information to prevent accidents. It is worth emulating by others also. Only that, the participants should not criticize the speakers for sharing the information about the accidents in their facilities. The speakers and their factory management should be appreciated that they came out boldly to tell about accidents  and the lessons learnt to others with a godly view of preventing such accidents in other facilities.

Let us thank those who find our mistakes

We will be hurt and get irritated too when somebody points out our mistakes. This happens in our annual performance assessment report, audits, discussions (arguments?) with colleagues / partners / spouse / children / etc.

However, there is a saying, "It is easy to find mistakes in others, Difficult to find our own mistakes".

When we take it positively, look at it with a peace of mind, we feel we should thank those who find our mistakes because they have done our job.

As per another saying, " a problem found is as good as half of the work is done, we only have to find a solution". The problem is our inability to find the problem.

Recently, I watched a movie titled, "Hot Shots! Part Deux" in TV. A dialogue in the movie is, 'we all have permission to make mistakes. It is called learning".

A long time patient sometimes, is better than a doctor.

Learning from past accidents (mistakes) is what we should do. Like we can't have life long schooling, we can't be continuous learners, making same mistakes again and again. We have to learn from our mistakes and those of others who suffered.

Safety officers/inspectors during inspection / audit find the deficiencies and communicate to plant in-charges. Plant in-charges should thank these lot for finding the deficiencies and for helping them to work for a better workplace.

Ego - obstacle to safe practices

Generally, safety professionals have advisory role. Any advise from company's safety professional(s) may be taken with good heart, reluctantly accepted because of pressure from top management or will be rejected vehemently. Sometimes, safety professionals will be questioned about their knowledge/experience/capability in matters of production activities and production managers try to draw a line saying that they are more capable of taking care of their work and also of safety in their work place and that they do not need any advise from safety professionals.
However, when some incident happens, safety professional of the company will become the first target of these production managers, saying that they were not sufficiently warned about the hazard, that the safety professional slept without doing his job, and so on. This will be the case even if there were some incidents in the work place.
Surprisingly, sometimes, even regulators too question safety professionals of the company instead of engaging the production managers for safety related lapses in the work place.
The ego in the minds of production managers (and down below) is an obstacle to listen to the voice of safety professional and this endangers safety of employees in the work place. They do not accept the fact that there is something (mindset to see the dangers and to learn lessons from events) missing on their part leading to occurrence of nearmisses, incidents and accidents. Any occurrence is taken as onetime affair and is not acknowledged for system deficiencies. Even efforts will be made to cover up the issues or not to bring to the notice of safety professional for investigation and thus do not want to learn lessons.
The case studies, lessons from occurrence that are freely available in the internet are taken as too theoretical or that these are not applicable to their work place. Nobody can help such managers and those working under them will only become easy prey to the hidden dangers.

Lessons from Fukushima incident - A report at HSE.GOV.UK

Y'day (11.10.2011), a report (6.24 MB) from HM Chief Nuclear Inspector on lessons from Fukushima and implications for the UK nuclear industry is made available. One can draw lessons for their own organization from similar incidents. A video (41.4 MB) from the Chief Nuclear Inspector is also available.
Report:
http://www.hse.gov.uk/nuclear/fukushima/final-report.htm

Video:
http://www.hse.gov.uk/nuclear/fukushima/final-report-video.htm

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.

Nuclear emergency in Japan

The earthquake on 11.03.2011 followed with tsunami and nuclear emergency at Fukushima reminded me of Murphy's law. There was power outage. The pumps for cooling the reactors could not be operated by DG sets. The engineers of the nuclear plant are trying hard with available limited resources. Already there are reports of increase in radiation levels.

What lessons we can learn from this incident in a chemical plant?

Learning from others-blogs or accidents whatever it is!

I used to write a lot in my earlier posts. However, it's my feeling that these are lengthy. I also saw posts of some bloggers which are brief. So I decided to write only to the point. If I want to explain, I can do it in different posts. This is what I learned from others. Similar thing we can do in learning mistakes done by others when they had accidents or near misses and avoid the same.