The Real Way to Prevent Accidents
The safety philosophy in the United States has focused primarily on identifying and correcting “unsafe conditions,” and only on the most glaring and obvious “unsafe acts.” But consider: how did the unsafe condition come to be? If the condition was the result of normal wear and tear, why didn’t someone notice it and respond appropriately? If the condition was the result of someone’s failure, let’s say, to clean up a spill of liquid on a slippery floor, wouldn’t you say that condition was caused by someone’s unsafe act? Not only would the initial spill be considered an unsafe act, but so would the failure to clean it up or to report it to someone who could: an unsafe act of OMISSION, rather than an unsafe act of COMMISSION.
An architect was hired to design a chemical plant expansion. There was a very limited amount of property on which to make this expansion, so all the process equipment was jammed into a limited space. All the process lines were manually controlled. Three batches were scheduled to be run. Certain steps required the manual opening and closing of certain valves at a very precise time. The operator was required to be in three different, widely spaced and inaccessible parts of the new plant, at the same time.
Two of the three batches were ruined, along with significant damage to the reactors. Who got blamed? If you said “the operator,” go to the head of the class. But, was the operator the real culprit? No mention of the poor design; no mention of a failure to conduct a Hazard and Operability Study that would have anticipated this problem; no mention of a supervisor bringing the difficulty in accessing process controls to the attention of the plant engineer. All of these are unsafe acts whose consequences all lined up one day, to result in significant property damage and the loss of a chemical operator’s job.
But holding the person who performed the unsafe act responsibly is a serious mistake. Most often the unsafe act was due to a more fundamental error:
- Lack of training
- Lack of supervision
- Lack of motivation to recognize that no unsafe act is preferable
- Lack of an effective safety program
- Poor equipment design
- Poor design or lacking machine guards
- No lockout/tag out practices
When conducting plant inspections, do you just note the unsafe conditions you see without asking yourself, “How was this allowed to happen?” If you find yourself continually finding and correcting the same unsafe condition, (putting out brush fires), there is some underlying cause or causes that need to be addressed.