Repetition of similar incidents - need for continuous reminder

When we read or hear about accidents or incidents, immediately, we remember or feel that a similar one happened earlier somewhere, either in our premises or outside. 

Generally, there's nothing new that caused the incident. We only do not follow what is already known. This calls for continuous reminder and thus retraining of persons.

And, HR department faces the problem of not getting the participants inspite of training calendar and listing of employees for training. This is because of not relieving these listed persons by respective incharges for various reasons like production or other jobs, or participants themselves not having interest

I feel that pay rise and promotions should be linked to attendance in training programmes as well as passing the exams conducted at the end of training. 

Also, action should be taken on persons found  responsible for incidents in the form of pay cut, collecting or recovering the loss suffered and initiating legal proceedings. 

This may look absurd, but without accountability and responsibility, we will continue to see occurrence of incidents for which root cause are already known. They happen only because someone ignored and failed to take precautions.

End of financial year - some to do listing

As the end of March month is approaching, industrial establishments will be working at frantic pace to meet their annual financial year production targets. It is likely that here and there safety requirements are skipped thereby increasing the risk.

It is better to plan testing of equipment like cranes, hoists, other material handling equipment, pressure vessels, safety relief valves, calibration of instruments,  inspection and repairs of structures and buildings, painting of equipment/piping/structures, preventive maintenance of equipment, load centres, transformers, PDBs, DG sets; cleaning of drains, etc in the beginning of the financial year at which time stress levels are supposed to be low compared to the last quarter of a financial year. Even refresher courses can be planned and conducted wherein managers will relieve their staff to attend the programmes. 

This will facilitate ensuring readiness of men and machinery and other infrastructure for safe work without accidents, incidents.

Safety monitoring should be done more stringently during peak production periods which will indicate the safety culture of the organization in times of pressures all around.

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.

Safety work permit - violation of conditions

 Safety work permits are issued after ensuring that the site conditions are suitable for safe work. Check points are verified and are certified for start of work. However, still sometimes accidents take place indicating that either job hazard analysis is not done properly, conditions are altered during the course of work, workmen are not briefed about hazards and measures to be taken, many times they are not aware of what is written in the permit and simply do the work as they were told or as they can do, lack of supervision, etc.
In a huge manufacturing facility, a number of works will be going on and generally, the supervisor will be monitoring more than one work at any given time. In such a condition, at least, emphasis should be given to training to the persons engaged. All are not of superman category.
But, when earnings are motive, all other aspects take back seat. Many times, procedure for selection of the contractor or agency to do the outsourced work is the culprit. If selection is made without assessing the competency of the person/agency for safe execution of work, without checking the credentials, without giving proper description of the work, then we will get a wrong person in most of the cases.
In some cases, trainees are placed directly on to the job without proper class room training and supervision. This also leads to accidents as they are in the organization to learn, initially in the class room and then to have on the job training under supervision. Sometimes, these trainees even will be manning the shifts, particularly at night times when availability of regular work force is less and may be when nobody watches. Though, this is disastrous, shop floor managers take such decisions without taking the concurrence of higher ups. If seniors also give consent, then it is silly and such persons should be terminated or they should be asked to supervise instead of posting trainees for manning the shifts / works.

ATTENTION ONLY TO PRODUCTION CAN LEAD TO DETENTION.
ATTENTION TO SAFE PRODUCTION WILL SURELY LEAD TO CONGRATULATIONS.

Domestic LPG cylinder leak - lights ON - explosion - deaths and injuries

In an incident of LPG leak from domestic gas cylinder five days ago, 8 persons died and 3 more are undergoing treatment.
In a housing complex, sensing gas leak in the opposite house, neighbors opened the house by getting the keys from the house owner and when switched ON the lights, the sparks caused gas explosion.

Gas detectors are the need of the hour and any gas leak detection should lead to display of warning sign of "DO NOT USE ELECTRIC SWITCHES-DO NOT USE MOBILES-SPARKS CAN CAUSE EXPLOSION" prominently so that even in panic condition one will not try to use electric switches.
Gas cylinder / piped gas distribution agencies can distribute do's and don'ts along with the cylinders by printing behind the bill or if somebody is paying online, these instructions should be displayed on the billing page and only after checking the boxes on each of the instructions, should lead to payment page. Further, distribution agencies and community centers may take up periodical training of residents and those who fail to attend the training programmes should be penalized by way of higher billing or in the worst case, cutting off of gas supply.

http://timesofindia.indiatimes.com/city/hyderabad/Entire-family-wiped-out-in-Vikarabad-gas-leak-blast/articleshow/19233935.cms

Hi-Tec - by how much?

Some product advertisements mention about manufacturing through computer based technology. Some bill boards for spectacle shops mention about computerized checkups and tests.Some new plants are known as hi-tech facilities.
In all these, what we understand is that they use some software or some techniques that run on computers. However, unless rigorous checks are not made to the software before its use, hi-tec can lead to complex problems, which we can't understand. For this, the programmer should understand fully the requirement, which should be specified by the engaging agency in clear terms. If there is no clarity in specifications and the understanding of the same by programmer is not checked, glitches may come later, which may develop in to unimaginable proportions.
What we start with hi-tec, also can become low-tec after sometime, when changes are made but not tested fully.
Management of change, i.e checking the modifications in an existing procedure for achieving the desired output, if not done properly can manage us later.
Some plant facilities started on PLC based operations initially will be suspended and reverted to manual mode because of the glitches. This is because of lack of clarity in what we want, what we conveyed to the developers/suppliers, and what we got. Hardware problems also can lead to similar situation. Sometimes, because of the complex operations involved in operating PLC based plants and poor training, managers revert to manual operations.
If we are overconfident that nothing will happen because a plant is hi-tec and leave the caution to the air, then also we may find surprises.
Hi-tec will be safe only when we address above issues.

Safety - who cares?

In an article that appeared in The Hindu today (23.12.2012), the author of the article, an Honorary Consultant to Tamilnadu Fire and Rescue Services talked about home safety, school safety, hospital safety, industrial safety, and need for training and engaging trained personnel in various jobs. Though laws, which are knowledge houses, are available, he lamented about the fact that implementation and enforcement is lacking. 

The article ends with the statement that, ' let not accidents teach us safety but at the same time let us learn safety from accidents'.

http://www.thehindu.com/opinion/open-page/why-safety-takes-a-back-seat/article4229877.ece

28 years after Bhopal accident - lessons not learnt by others

It is 28 years now after the occurrence of Bhopal accident on 2/3 Dec 1984. As is widely reported, it happened because of,

1. engaging no so well versed technicians at the time of the incident
2. no proper training to employees, local government agencies including health department, nearby residents
3. storage of excessive quantities of MIC
4. non-availability / switching off of safety systems, like, refrigeration to maintain at 2 deg C temperature, maintenance taken up for scrubber and flare systems
5. starting of cleaning of lines also during the non-availability of emergency systems
6. any safety permit was taken for cleaning of lines (is not known)

Murphy's law was proved in this accident. None of us learnt the lessons from this accident. Though, there was initial euphoria, it did not last long. Though the scale of the accidents is not like Bhopal accident, we read / learnt about occurrence of so many accidents.

We continue to engage cheap labour, without providing them any training. Most of the labour are daily workers. A person coming today may not be coming tomorrow or next week. The safety systems provided are not tested, or, they are only show pieces for regulatory agencies. The large number of accidents that appear in media is a proof of this as in many of the organizations in which accidents occur engage short term workers. The reasons for many of these accidents are also simple and are avoidable. It is not that some complex and unknown thing happened leading to such accidents.

We also continue to discharge effluents / offgases / solid wastes into environment. Large quantities of dangerous materials are transported through public domain, probably, without the knowledge of local government agencies. All these can affect the health of the people if not immediately, but over a long period of time.

The most common finding of CSB during their investigations is lack of training. Training and retraining programmes should be established and examinations should be conducted for the employees to put them in to service. It is not sufficient to cut the incentive which is paid for acquiring and renewing operators' licence after passing out the examinations. Such failed employees should not be engaged for plant operations till they pass out. And while evaluating the performance, it should be ensured that they answer all questions and not that because they answered 50% or so, they can be passed. Because, any mistake can lead to accidents greatly affecting the people and environment.

Plants should have policy of not operating the plant in case of failure of any of the safety systems. And ensure monitoring of the plant even when it is under shutdown.

Plants should realise that safety department alone can't guaranty safety as they are not operating the plant and they do not have the knowledge as good as actual plant operators. Further, how many organisations give serious thought to the advice of safety department. Many times, they are projected as hindrance for production and any production loss is attributed to as obstacles from safety department.

Government and regulators should make start a website with different categories and or key words for publishing all accidents, investigation reports from both the concerned company as well as regulators/government agencies. Governments should encourage all companies to upload about accidents and incidents in government website as per the category and should assure that those who reveal accidents immediately after occurrence in the website and also upload investigation reports say within 3-6 months will not be prosecuted for criminal proceedings. But penalties and compensation as applicable have to be borne by the company.
We can't expect organisations to run for charity, but they should ensure safety of their employees, public and environment and in this process they should not bypass safety procedures. 

Two employees receive chemical burns - firm is fined

It is reported that a cleaning firm was fined after two of its employees received chemical burns in two separate incidents. The firm was fined for lack of enforcing supervision. Though there are no details about the extent of injuries or procedure followed, it appears that the accidents could have been due to (i) lack of procedure or violation of procedure, or (ii) hiring of persons without knowledge about the work, or (iii) lack of training, apart from the lack of supervision.

Training and supervision are generally the two most commonly found recommendations made by the Chemical Safety Board (CSB) of US in their investigation of several accidents. And, these are also statutory requirements. 

We have to ensure proper selection of persons, training, job hazard analysis, safe operating procedure, do's and dont's material safety data sheets and supervision to carryout given task safely.

http://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10845300

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

Difference between danger, warning, caution

I was not clear about what is a danger sign, what is a warning sign and what is a caution sign, till I read this article in Safety Daily Advisor. It also explains about biological hazard sign and instructions.
Danger sign is about a hazard that can lead to death, warning sign is about potential hazard and caution sign is in-between.

Whatever be the display of signs, the articles mentions, that if one can't understand what it means and what should be done, then it serves no purpose.

It's better to provide training and provide booklets containing the information to all employees. Also, display the measures to be taken, near the area where it can be seen by the employees.