Safety Thought of the Week - dismissal of people and their behavior concerning risk as idiotic
The dismissal of people and their behavior concerning risk as idiotic really doesn’t help much Membership Content
How good is your HAZCOM program management?
I will use one of the last tests when a facility has hit home runs in managing its Hazardous Communications program. They are great with their container labeling, pipe labeling, training, etc. They even could provide an SDS for all their significant chemicals; however, only a tiny percentage of these facilities can do this... NTSB Animation – Overview of the collapse of the Fern Hollow Bridge
On Friday, January 28, 2022, at about 6:37 a.m. eastern standard time, the Fern Hollow Bridge, which carried Forbes Avenue over the north side of Frick Park in Pittsburgh, Allegheny County, Pennsylvania, experienced a structural failure. As a result, the 447-foot-long bridge fell about 100 feet into the park below. The collapse began when the transverse tie plate on the southwest bridge leg failed due to extensive corrosion and section loss. The corrosion and section loss resulted from clogged drains that caused water to run down bridge legs and accumulate along with debris at the bottom of the legs, which prevented the development of a protective rust layer or patina. Although repeated maintenance and repair recommendations were documented in many inspection reports, the City of Pittsburgh failed to act on them, leading to the deterioration of the fracture-critical transverse tie plate and the structural failure of the bridge. At the time of the collapse, a 2013 New Flyer articulated transit bus, operated by the Port Authority of Allegheny County, and four passenger vehicles were on the bridge. A fifth passenger vehicle drove off the east bridge abutment after the collapse began and came to rest on its roof on the ground below. As a result of the collapse, the bus driver sustained minor injuries and two bus occupants were uninjured. Of the six passenger vehicle occupants, two sustained serious injuries, one sustained a minor injury, two were uninjured, and the injury status of one was unknown.
Are we interior decorators or safety professionals?
This one is bound to offend some folks in the safety profession, but it was some very wise advice a dear friend and former boss gave me after I submitted my first Corrective Action Plan (CAP) to him after a corporate audit. Just 12 years into my career, I was taught the hard way how CAPs get written and managed to closure. But his analogy of what he expected of me stuck with me to this day. Our one-on-one discussion went something like this... NOTE: This former boss is one of my best friends today and was a client for 20 years after we parted ways in 2003; he is a former CSP and began his career as a safety engineer inside the company where we met) Bryan, do you want to be a world-class safety engineer, or did you miss your calling as an interior decorator? Management's Safety Dilemma (Reason's "Safety Space")
A mature Safety Management System (SMS) will contain a Hazard Identification Element that identifies hazards that adversely affect safety. These HAZARD ID processes also provide practical and objective mechanisms to assess the risk presented by those identified hazards and implement ways to eliminate or mitigate the associated risks those hazards may pose to the worker, environment, and business. The result of this SMS Element is achieving an acceptable level of safety while balancing the allocation of resources between production and protection. From a resource allocation perspective, the concept of a "safety space" is instrumental in describing how this balance is achieved. What is the "Safety Space?" HAZMAT Response - TX Style (Safety Satire Video)
The source is unknown, but this is hilarious. The supporting actor gets my vote for an Oscar. Latent Organizational Failure vs Active Failure (LOPC Event and suspending Operators)
Yes, I am betting this same drum again. I believe in Reason's SMS model, especially his Human Failure model of Errors, Mistakes, and Violations. This recent incident is a perfect example of management's lack of understanding of SMS fundamentals and how LATENT ORGANIZATIONAL FAILURES result in horrible outcomes. Essentially, this is what happened: An LOPC event occurred, resulting in a Reportable Release, which requires a written follow-up to EPA on the cause(s) and what will be done to address the event. This LOPC event occurred because an operator made a "mistake" due to the IMPROPER LABELING of a valve. But this was a critical mistake that sent the process into immediate upset conditions and the lifting of a PRD. The Emergency Shutdown procedure instructed the operators to close a Manual Shutoff Valve, which had they been able to do would have certainly reduced the release amount well below the RQ of the chemical involved. However, this Manual Shutoff Valve was about 20' in the air, and access to this valve was not "readily available." Since this release would be "public knowledge" because it exceeded the chemical Reportable Quantity (RQ), the legal team felt the business needed to take swift and firm action against those involved in the event. This way, they could show they were serious about process safety to the "regulators" by taking these disciplinary actions. However, during our PSM/RMP audit about a year later, we came across this incident and all the compliance failures that went with it, and we were shocked to learn that two operators were suspended for 3 and 5 days without pay for "failure to follow procedures." Here is the back story of the LATENT ORGANIZATIONAL FAILURES... As a ops or maintenance manager are you tired of all the safety changes?
As you know, I always like to go back in time and pass on what I learned from my former bosses and mentors. This one is a classic and is usually in the Top 5 frustrations of non-safety management personnel: The ever-changing safety programs and expectations every time we get a new safety leader I hate to be the one to say it, but usually, I'm one of the few who will say it, but this problem/frustration lies SOLEY AT THE FEET OF MANAGEMENT! As safety pros, we have all experienced this and the backlash we get when trying to improve a "safety program." The lack of MANAGEMENT OWNERSHIP of said compliance program drives this scenario and the frustrations accompanying it. This lack of ownership may also be why there is so much turnover in a facility's safety role(s). But in 1999, I got many a_s handed to me by my new plant manager when I began to identify necessary changes to out-of-date or poorly written safety programs based on MY PERSONAL (and VPP Star) safety standards. He was not against me making improvements; after all, that is precisely what he hired me to do. He got fired up about how I was making those changes as if the "safety program" was all "mine" to do with as I pleased. Granted, most of the other managers on his staff were fine with me doing everything within my little world of safety. However, my PM "politely" clarified that this is a management program for which I am just the SME. They OWN it, not me or my team. And from that day forward, this is how safety got managed... Boeing Safety Assessment nuggets (Part 3)
These two (2) findings could almost be standard for most SMS assessments/audits. Two of the major failures in the implementation and day-to-day management of an immature SMS... (emphasis by me) Finding: Boeing primarily focused its SMS implementation efforts on safety risk management (SRM), which is only one fundamental pillar of the ICAO or Boeing SMS structure. To some extent, Boeing also focused on the pillar of safety policy. ICAO guidance offers SMS is intended to be implemented as an integrated structure. Successful implementation requires all pillars of the ICAO SMS structure, which are safety policy and objectives, safety risk management, safety assurance, and safety promotion. The Expert Panel observed that these pillars have not been fully implemented.
Finding: The Expert Panel found the complexity and amount of SMS documentation, the constant state of document changes, and the lack of clarity in the revision descriptions, creates employee confusion. This contributes to the delay and improper development of SMS at Boeing. Boeing Safety Assessment nuggets (Part 2)
The topic of SMS in aviation has been around for more than 30 years. The FAA provides the following description of SMS and its principles: Technology and system improvements have made great contributions to safety. However, part of being safe is about attitudes and paying attention to what your surroundings are telling you. Whether through data or through the input of employees and others, recognizing that many opportunities exist to stop an accident is the first step in moving from reactive to predictive thinking. SMS is all about decision-making. Thus, it has to be a decision-maker's tool, not a traditional safety program separate and distinct from business and operational decision-making. 8 (FAA) The FAA further describes connections between SMS, organizational behaviors, and safety culture and how SMS addresses the organization’s role in safety. Boeing Safety Assessment nuggets (Part 1)
I was reading through the Boeing Safety Assessment report and was so happy to see they used James Reason's safety culture model, which consists of five components that collectively would cultivate a positive safety culture. The five (5) components include:
SAFTENG members can read more on Reason's Model HERE Boeing adopted these same five components in its Positive Safety Culture structure. The components are also used by numerous government, academic, and industry organizations, including NASA and the FAA. The Expert Panel considered each of the five safety culture components throughout its review. Safety Culture Principles |
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