Importance of Learning - II

Most discoveries are made regularly every fifteen years – George Bernard Shaw (1856-1950), in his play, The Doctor’s Dilemma, (1906)

When organizations put all their efforts, over a period of time,the number disabling accidents will come to single digit, but stagnate and not much progress is made beyond this (w.r.t. safety).

Some of the departments working for a long time without accidents may start having accidents again after some time. Like fortunes, safety record also undergoes different cyclical periods.

Man is an animal without education. We are educated animals. We make mistakes again and again, may not be at the same place / operation / plant or by same person; but similar mistakes are made, may be by different persons. Most of the mistakes are made not because of lack of knowledge or skill. Rather, it is because of an overdose of it.

When we join in the department or new to work, we have formal education but not the specific knowledge and skill about the job to be done. At this time, we are likely to get involved in accidents because of lack of knowledge and skill. After some time, we acquire both knowledge as well as skill and will be attentive. Once, we are used it, over a period of time, we try to find short cuts.

SHORT CUTS IN SAFETY CAN SHORT CIRCUIT OUR SAFETY AS WELL AS OF OTHERS

Once this mentality / attitude sets in, we are prone to accidents. Most of the accidents occur to persons who are either new or well experienced.

When an accident occurs, every body becomes emotional, may be, even take oath not to repeat such mistake(s). BUT soon, we forget or we assume that it will not happen to us and go back to our old ways of doing it. This is called NIMBY syndrome i.e Not In My Back Yard Syndrome. (A term used by Trevor A. Kletz - as I understood).

"Those who cannot remember the past are condemned to repeat it," (sometimes called Santayana's Law of Repetitive Consequences) – George Santayana (1863 – 1952), a philosopher

We have to UNLEARN the WRONG LEARNINGS and LEARN the safe ways of doing the job.

ORGANIZATIONS HAVE NO MEMORY. ONLY PEOPLE HAVE MEMORIES AND THEY MOVE ON – Trevor A Kletz, an internationally acclaimed safety professional, in his book, Lessons from Disaster.

Organization fail to learn the lessons from accidents. Even if the lessons are drawn, then remembering and following them subsequently is a question. How long they remember is another question. Lessons are forgotten, when persons attitude changes or persons are shifted / retired without passing the lessons to youngsters.

God gives us enough opportunities (near misses). The issue is that we should be ready to grab it (analyze the near misses for root causes and remedy the system). Else, the opportunity is lost (leading to accident).

Definitely, time will heal the wounds (of accidents and its pain), BUT we should not loose our sight of lessons from it. We should have an eye to observe the near misses that occur before an accident. Nothing will happen all of a sudden without warning.

Near misses and accidents, either in our plant or others, are the best sources of learning and correcting. If we are not bothered, or afraid to discuss these near misses, then some thing bigger awaits us and we have to pay for it. No body will be penalized or punished for noticing and discussing the near misses. Most of the employees have fears to face the queries raised during root cause analysis / discussions and therefore may not report it. By doing this, we are making self goal not bothering about long term benefits.

Seminars / workshops on case studies are a way of learning, particularly, when we hear from the persons who are actually involved in it.

It is well recognized that training helps to create awareness among the employees and thus reduce the accidents. Though, we can not attribute seminars as the only reason, however, safety statistics over a long period (including before and after training) lead to a downward trend in accidents and severity (man-days lost).

The benefit of such programmes can be seen only when the message (lesson) is carried and spread to all those who did not participate in these programmes.

Importance of careful reading

It is important for anybody to read any document that comes to his attention. Glancing the document or reading here and there and then coming to a decision or conclusion is not correct. If a person is intelligent, he can even understand the intention behind the writing also and will understand properly before taking a hasty decision.

However, most of the persons do not bother to read and instead will mark to their subordinates for briefing them. Then, it all depends on these assistants. If these persons are not intelligent / do not have experience / not in stable mind / have grudge against colleagues or superiors or the organization as whole, then it is not difficult to understand which way they guide their superiors.

Acts, Rules, Standards, Codes, Guidelines, etc made for safety, environment, etc are to be understood clearly. If we read only titles and drawn different meanings, then we can't escape from the arms of the law and oneday we may end up in custody, in a worst situation.

However, may persons even do not bother about punishments met by others because of their faults and assume that they are very intelligent and knowledgeable persons and others are fools. Or, they think that they got God Fathers to protect them and therefore do the things totally not acceptable to law.

When we fail to read between lines, we are trapped by those lines. Nothing can be taken for granted in this world. Today's famous persons may become tomorrow's most hated fellows by the society.

Make a wrong step, all your past good deeds are forgotten and you will be displayed everywhere. Particularly so, in this world of so many news channels, which employ all available means to find and discuss threadbare about the issues.

When we issue safety work permits with suggestions, procedures to be followed, registers to be maintained, etc, I doubt very much how many of the executing agencies really go through these lines. They file it as soon as it is received and does the work in the manner which they are doing for so many years, even if the nature of work is different. They think, they invented standard procedure that meets all situations.

Similarly, conduct any training programmes, the contents will be same, irrespective of the target group. Variations in delivery may come only when the audience are interested in asking questions and then our instructor got sufficient knowledge and experience in that field. Else, the standard replies like, "I will come back to you later, or, you find and tell me, or an intelligence question - any of you can answer - think it over and tell me tomorrow, etc" will come. This kills the interest of the audience and they may become rigid to training programmes.

So, it requires a careful reading for any person to succeed in his field. There is a old proverb, TALK LESS - LISTEN MORE.

On similar lines, we can say, READ THOROUGHLY - TAKE DECISION.

Deaths in confined spaces

Offlate, I started reading persons overcome by the atmosphere while working inside the septic tanks, underground water storage reservoirs / tanks, chemical storage tanks, etc. In some cases, persons while working in trenches, were buried alive by the soil heaps next to the trench. In one case a person was working only about at a meter depth, but he was buried when the soil was disturbed.

Some of the deaths were like this;

1. A Person want to see what is inside a tank from the top, to plan for the work. While looking down, he lost consciousness, fell down and died. Sometimes, to rescue the unconscious persons, others who tried for him also became victims.
2. A person went inside a rice brawn mill discharge storage tank. After some time, he became unconscious and was found dead.
3. A person went inside a water storage tank in the underground for cleaning and was found dead.
4. A person went inside a concrete mixing plant for cleaning. Not knowing this, soon after, the operator operated and the person inside died. Though in this case, it is not the hazardous atmosphere, but it is a confined space and a different type of hazard (Maintenance person's presence inside is not known to the operator).
5. Two persons were working in a trench and were buried alive by the loose soil heap that slid due to some disturbance.

There are many more such cases, mostly involving cleaning jobs inside waste storage tanks of rice brawn mills or septic tanks.

Earlier, while reading such news items, I used to think that my work place is safe and that I need not bother about confined space works. However, as I learn more and more deaths of people like above, whenever I get a work permit for work in a basement or tank, though it is fairly open to atmosphere, I get wild thoughts and sometimes I think whether I am thinking too much in visualizing the hazards. However, I stick to my wild thoughts and accordingly prepare precautions to be taken for the work.

Normally, the oxygen level in the work place will be checked before entry into such places. People say that it is fine if oxygen levels are between 19.5 % and 23.0%.

But in an article, the author advised to verify and find out the reasons for change in oxygen level from the normal levels. Though the general guideline says above 19.5% O2 levels are acceptable, but what are the other pollutant that brought down the O2 level from 21% to 19.5%? For example, if the pollutant is say CO, then we all know that CO is fatal at 0.5% (5,000 ppm) and it is not acceptable. Similarly, it may by H2S which is also a toxic gas.

Sometimes, our instrument may be wrong. In that case we can't depend on the values measured by it, because we do not know the error %. Sometimes, persons check O2 level at the entrance and then give clearance for the work. But, we should check O2 levels at the actual place of work and the measurement time should be reasonable. Instantaneous values may give us wrong picture. Again for checking O2 levels at work place, we should not enter and endanger our lives. Portable hand held instruments with suction pumps and connected hoses (even upto 100 ft) are availalbe at about Rs 30,000/- in the market.

We have to flush the work area continuously till we get O2 levels are as good as open atmposhere and should continue air supply till the work is over and all persons come out. If the work is to be carried for a long time with tea / lunch breaks, then the flushing and air supply should be continued during the breaks and before every entry, the O2 levels should be checked and ascertained that the work atmosphere is safe for work.

Sometimes, there may not be much head room available for free movement of the persons inside. In case of work inside chimneys or furnaces, the lining material may be loose and it may fall on the persons. There may be toxic gases (generated by the process) that are trapped in these lining material and if persons are working on these, they will be exposed to these toxic gases and may be overcome.

When persons work in open trenches, we know that the adjacent heaps of soil can be disturbed by heavy winds or from vibrations due to vehicular movement nearby. It is normally suggested to dispose the soil immediately to an earmarked place. Atleast, the soil should be kept atleast 1.5 m away from the trench and angle of repose should be considered for the soil. Again, as we go deep in the trenches, they should be supported on the sides to avoid collapse due to loads on the adjectent area by proper shoring. If long trenches are made, then for every 30 m, emergency escape ladders should be provided. Care should be taken that these trenches are not flooded by water / sewage lines and workers in it are taken by surprise. Earth moving equipment should be properly supported by outer rigs with proper base supports so that they do not topple due to loose soil and in the process endanger persons nearby.

With the availability of radio sets, workers inside should be in constant touch by the supervisor outside and buddy system should be followed on one-to-one basis i.e for every one person inside, there should be another person outside to monitor the condition and to provide immediate help. People may think it is waste of money, but in the event of some eventuality, the compensation claims and payments will put a big hole in the finances of the executors of the work and then they will regret for not taking protective measures.

However, the story repeats in the next job. BECAUSE, OUR MEMORY IS SHORT AND WE THINK THAT THOSE INCIDENTS ARE OF ONCE IN LIFE TIME AND THEY WILL BE CAREFUL THIS TIME.

Such persons should be put behind bars, with all their propery seized and utilized for helping the families of the victims.

Road Rage - Control

For the last three months, I am commuting between office and residence on my vehicle. Before that I utilized department transport facility. Though the route is same, I am finding it difficult to control my anger at the way others on the road ride their vehicles. I may be getting every month Rs 4,000/- for coming on my own but I think this road rage of others is creating mental tension and is leading to health problems for me.

Most of the persons do not give directions, which way they will be turning. Some intelligent pillion riders keeping waving their hands in the air and we do not know whether to take it as a signal or he is talking. Other fellows, do not bother about the blinking indicators of their vehicles. They do not even bother to see that the indicator lamp is blinking. Then vehicle parking at the T joint roads. People park their vehicles right at the corners of T joints and those coming from side road to main road have to take a long turn with the possibility of collision with other vehicles plying on the main road.

Then, the cell world. With benk necks, keeping the mobile between the shoulder and the ear, it has become a fashion statement for the so called youth to start the vehicle after putting the mobile in above manner. It is unnerving to see such people on the road, particularly when they cross the road at 90 degrees from other roads. Then there are some people who slow down after joining the road from side roads and are undecided to go which way.

One day, when I was driving my bike, suddenly an elderly person (about 60 years, appears retired from service) started crossing the road, by waving the fingers in threatening manner. Not waiting for traffic to ease, he even wants to hold moving motorists responsible his safe road crossing.

Two days ago, I was going down the rail-over-bridge. I was driving the bike parallel to a bus, on its right side. I am not able to see what is on the other side of the bus. As I reached the end of the bridge and about to speed up the bike on the level road, suddenly a old man in his car appeared in front of me crossing the road at 90 degrees. I could not see the car as the bus on my left blocked my view on that side. Car driver could have seen the bus coming down the bridge. But he did not bother. My heart stopped a moment. But, as I observed, the old man was cool. I think he does not have any desire to live also, the way he appeared, the way he crossed the road though a bus was coming down at speed.

Then, there are other cool guys who drive their vehicle almost at the middle of the road at a slow speed. It is good that they are going at slow speed. But, by their action they are occupying the entire road. Common sense that we should drive at LEFT does not occur to them.

Then, the urgent masters. They seem to be in hurry always. Even when ambulances are coming behind with the siren, they do not want to give side. A life is at stake. But, if other motorists in their front are giving way for the ambulance behind to sped past, these hurry masters will use this and keep going forward.

Next come the cut masters. The road will be plain without obstructions or pits. Still, these fellows sometimes with more than one person in pillion, rush their vehicles with sharp cuts increasing B.P. of the other drivers on the road.

I find one of the solutions for these types of problems, is not to allow roads to intersect directly at 90 degrees. Side roads can join the road and then U turns should be provided 1/2 KM away from the point of joining of side road to main road, so that with some discipline, motorists can go along the road and take turn to the other road. This will avoid direct crossing of the road.

Similarly, there should not be any side roads at both ends of flyovers or road over bridges so that speeding vehicles do not hit those trying to cross to side roads at these places.

Then shops / business establishments / eateries at the corners of T joint should not be permitted if they do not have fenced parking place. If any vehicles is parked at the T joints where side roads join main roads, all these vehicles should be towed away and seized. Heavy penalties like Rs 5,000/- for first offence should be imposed so that they remember it for their life and may even spread the message among their friends and known persons. This will create awareness on road safety. It will start slowly, but I am sure, in a short time it will spread every where.

Similarly, penalties should be implemented strictly. Those who use mobiles on the roads, ride the vehicles without helmets / safety belts, go in wrong direction, go at excessive speed, do not stop at the signals, etc should be fined. The penalties should be excessive and targets should be given to the road traffic police. This will avoid corruption, else, with excessive penalties, violators will be willing to pay a fraction of the fine as bribe and escape. More people can be recruited in this regard and I am sure the penalties will be suffice to fund the salaries of these inspectors. If any body repeats his mistake, then, the vehicle / equipment (mobile) should be seized and should be sold by auction. This can be another income for the department.

Any body digging the road should be made to pay twice / thrice the cost of repairs to a road safety fund in addition to repairing the road immediately after his work is completed. This will avoid mindless digging of the roads for functions / cable laying one after another / etc.

If any person by his road movements causes injury / death, 10 - 50 % of his property value, with a minimum of Rs 5.0 lakhs should be collected from him towards the road safety fund. Apart from this, his licence should be cancelled forever, all vehicles under his possession should be seized and sold by auction. Such persons are not fit to drive the vehicles on the roads and it is better for them to use other transport methods.

Rules should be made such that, buyers of vehicles should watch road safety video and go through pamphlets and give under taking that they watched the road safety video and read the reading material and give under taking that they will not violate road safety rules (video and study material to be made specially for this purpose by transport department).

Though one may feel these types of penalties are stringent, reading the number of deaths every day because of road rage, I feel it is appropriate. Danda (stick) only will work in this world. Saama, Daana, Bhedha will not work.

I have some thing to say about road dividers also. With every relaying of the road, the height of the road divider comes down and after some time, the road divider is nothing but a small curb which is taken to their advantage by rule breakers by jumping over the roads on other side. The road divider should in fact be like a parapet wall of 1.5 m height so that road crossing becomes difficult illegally and then the high beam lights of opposite side coming vehicles will not cause momentary blindness to the drivers and thus will avoid accidents due to this cause.

Electrocutions - A Story that repeats

Of late, there were many news paper reports almost on every alternate day about the death of the persons and sometimes animals (mostly) and injuries due to contact of the living being with some cable or wire carrying electricity. The job in hand at the time of the incident involving victim were mostly, repair of a domestic water pump in the sump / repair of connections on the street light pole / touching an electric street light pole / moving near loosely hanging cables or wire / drawing electricity by illegal connection by a greedy person / etc.

For genuine repairs, it is the minimum requirement to cut off power supply and also ensure line clearance from respective agenices and display CAUTION BOARD for not switching ON power supply. It is best to use locking arrangement and keep the key with the person carrying out the work. A supervisor is a must and hazards in the job should be assessed and safety measures for identified hazards should be in place before start of work. This is applicable for jobs executed by agencies.

For repair works at home, it is common practice for the resident to do him self and get shock. All this to save few rupees at the cost of risking life and thus endangering the livelihood of his dependents also. It is best to call experts in the field for repairs even if it appears a small and known job.

Reports say most of the time line clearance is not obtained and the person mostly engaged on the job will be a casual worker. He may be skilled in his work but the responsibility of ensuring isolation of power supply lies with the department person and as it appears from so many deaths, this supervisor simply washes off his responsibility by allocating the job and it is doubtful whether the job is supervised even for some time.

When we learn from these costly deaths, not in terms of money, but that of making the dependents of the deceased to struggle for their livelihood apart from mental agony and pain of losing their dear ones.

Enforcing strict penalties by settingup special fast track courts only to handle the cases of violations of industry related legislations like Factores Act, Environment Protection Act, Indian Electricty Act, Explosives Act, etc and Rules framed under these Acts will bring a sense of responsibility when responsible persons become aware of punishments. It is mostly the lack of application of stick that is making persons irresponsible and fail to ensure safety in their areas of control.

Though we say stick is useful only to some extent, the incidents recurring at regular frequency shows that still we have not yet developed out of this DANDOPAYAM.

Summer Fires

This year, it appears summer started in January itself. As the weeks progress, already less crowds are seen on the roads in the afternoon.

Wild vegetation on the roadside, around industrial plants, chemical storages, along the railway tracks, etc is a cause of concern as it becomes dry. In the beginning of this month, there was a news item that a rail compartment parked in a scrap yard caught fire and was totally burnt. The fire was attributed to the waste material stored around the area.

The source of fire can be anything, starting from cigarette butt. Even oil soaked cotton rags, when left as such, or wet grass under sun can be subjected to bacterial action and this results in slow heating of the matter and gradually with increase in day time temperature, it can catch fire.

Few (9-10) years back, there were a series of reports about fires in ammunition depots during summer. The reason attributed at that time was that many of the material are covered under tarpaulin cloth and the heat trapped inside caused increase in temperature and finally lead to fire.

Legislations also say to keep all plant / storage surroundings to be free from combustibles so that even if fire starts, it will not affect plant / storage areas. It is better, if atleast 6 m around these areas is maintained free of wild vegetation, trees, etc by paving the areas so that recurring work of grass cutting, etc can be avoided and no one needs to be reminded for these jobs.

Similarly, if HT wires are going above, the area below should be free from wild vegetation, as any spark can start fire below and this happened at many places. It is a common sight to see growth of creepers around HT towers. These also can catch fire during summer as they become dry.

Public also behave irresponsibly by dumping all the waste around the HT towers, transformers, street light poles. Even if municipal waste bins are available, people throw the matter near the bin, instead of dumping into the bin.

Thought there is talk of 'Behaviour Based Safety Processes (BBSP)', I am unable to think of what we can do to educate the persons, as everybody says that they know the hazard, when we explain them, but keep repeating it. We can compare this attitude with wearing of helmet. The reaction of the persons is, 'Yes, we know that we can break our head without helmet, but, oh, that nasty thing, it irritates'.

What type of movement is required to drive the persons to follow safe practices, without loosing our patience. If anybody sees this article, may kindly suggest.

Risk = Probability (???) x SEVERITY

Yesterday I read a news item that a US satellite Iridium-33 in use collided with a Russian satellite Cosmos 2251 that is no longer in use on Tuesday (10.02.2009) at 0455 GMT at 790 km height above Siberia. It seems that this type of accident happened for the first time. There are more than 17000 man-made objects at present in the space. I went through internet and found that the probability of such collision is once in tens of years and the debris now generated can reduce this probability to once in a year or so as there are some more satellites in the same altitude and the total debris may hinder space craft movement in the future.

Now, the question is not about space but on the events on the earth.

In any factory, accidents keep occurring. When somebody (normally safety officer / advisor) points out about unsafe acts / unsafe conditions in the shop floor / factory premises and asks for correction, the usual reaction is, a staring look and then the reply comes, "oh, we have been doing this for the last few years / we are doing like this from the beginning / who is expert -you are me - you safety people does not know any thing other than talking / I can't do - you come and do / so on...

How true are the words of the famous safety professional Trevor Kletz -

Corporates do not have memory.

We have done this way 100 times is not acceptable unless an accident on 101st time is acceptable.

We never imagined that satellite collision is possible. But, it happened. Where the chances are remote, still it happened and where the chances are high in our activities in the shop floor, we do not want to correct our selves.

If we see the accident history in any factory, after the accident, the usual sheepish answer from the injured or his colleagues or manager is that it happened for the first time, the person is experience, skilled, safety conscious, near retirement, he doesn't want to take official leave and will take personal leave for the period away from duty due to accident, so on.

In spite of all the above qualities, still accidents occurred, then imagine what can happen to others. It is the attitude that requires correction rather than any thing else.

When somebody narrates their own experience, people listen attentively, appreciate him that he came clean and after coming out from the room the listeners do the same old things. This is why accidents keep occurring again and again, if not to the same person / or same shop floor, they will be occurring somewhere else to some body else.

We love short cuts and feel that we are above all others, accident does not occur when we are working.

One of my colleague, who retired 4 years ago, used to tell in all his training classes, that we should leave the organization with same organs as we had when we joined.

Yes, it is true that no body wants to lose their organs and suffer. But, momentary decision without thought for consequences will lead to accidents.

Rarely, does the type of accident will be new in any factory that is few years old. May be after the accident, corrective actions are taken. But after few years, the corrected systems will be replaced because people forget the reasons for safe guards in place and meddle with the systems. They want to prove to their bosses that they are inventors and soon after their will be accidents and shop floor persons will be suffered. But, the so called inventor would have got his promotion or pay rise and even would have left the organization.

So, every body should work seriously on the hazards at the shop floor, let the probability is however less. Nobody says there is no (zero) probability of occuring for an accident. In fact the word probability it self gives meaning of some uncertainty. Hence, if the severity / consequence from even from remote probable event is not acceptable, without looking for chance of occurrence, we should eliminate all those hazards and make our work place safer.

Risk assessment and actions should concentrate more on consequence rather than on probability and make life safer for persons.