From great natural disasters to the more human engineered ones people are fascinated by the ill fate that befalls others. In my discipline this becomes something of an essential quality. I would be interested in your thoughts. Here I lay out the why I think a respectful harnessing of morbid fascination in health and safety is a necessity.
Undoubtedly a great deal of our time and expertise has to be devoted to legislation. The paper work to prove that due diligence has been maintained is often regarded as paramount and I sometimes see that as a danger in itself.
An old adage is that if something is not written down it did not happen. However, the reality is that recording our adherence to protocols and legal requirements is nothing more than marks on a screen unless the action described has been carried out. It cuts both ways, sometimes the correct thing has been done without logging it and probably more often safety is ignored but the paper work looks tip top.
Lives ruined, that is what provides ample motivation. Rightly any coverage of an horrific accident concentrates on those who die as a result. Behind the names inscribed on various monuments are the countless others who suffered life changing injuries. Along side them are the families who have to pick up the pieces.
What if you are hard hearted though? A cynical type, a tough business person? There are few I have met that are so cynical that they would not see human cost as enough motivation for safe working. I concede there are some though. The loss of reputation, downtime and compensation might work better for them. I have met several ‘no nonsense’ types who cut not just the corners but rather the middle out of safe working. If the worst happened I wonder how they would feel? Like the wretches who have to sit in the glare of the press at inquires?
In short there are no winners when industrial safety goes badly wrong. In addition, for some key players even survival brings with it a life time of regret.
Elsewhere on this site I looked at the Piper Alpha disaster ( Click Here). The scale of the tragedy was the result of many factors, however, you could reduce the cause down to a filing system gone wrong. 167 people died because work on a piece of equipment was filed in two separate places. If the paper work had been available at a glance it may well have been sufficient to prevent what happened.
If You Don’t Regularly Review History You are Doomed to Repeat it
It is possible to go through life on or offshore paying little or no heed to events of the past and have nothing foul happen. The odds are stacked against your luck holding though and when it breaks you potentially destroy both lives and the businesses you work for. Even the most cynical and ill informed need only look at the failures in the past in order to find urgent need to up their game. The good news is even if you are driven purely by profit, even if you are the busiest HS adviser in the world the lessons are quickly found.
Filing to a Missing Light
Maybe I will do a top ten simple causes of disaster though that starts to sound flippant, on this issue I am anything but. Piper Alpha we have mentioned. Sadly similar incidents are enough to keep me going on tired days.
6th March 1987. The Herald of Free Enterprise left Zeebrugge with the bow doors open. The roll on, roll off ferry took in water as it gathered speed. Those responsible for closing the colossal doors simply didn’t do it. Calls in the past for devices to avoid such a thing happening had been ignored. The reality was the captain could not see the doors, there was no check list before setting off and there was pressure to save time. 193 lives were lost. In addition, the future of their families and 346 survivors changed forever. Again the cause was multilayered though it could be brought down to a simple thing. If a light had been fitted on the bridge to inform the captain of the position of the doors it is likely nothing bad would have occurred. A simple indicator system costing less than a night in the pub.
Kings Cross, again in 1987. Here a quick cigarette likely caused the death of 31 and injury to 100. It is a good example of what happens when smoking rules are not enforced. Smoking on the London Underground had been banned since 1984, however, lighting up on the escalators as people left the station was ignored. On 18th November someone ( probably blissfully unaware to this day) dropped a match which found the grease on the escalator rollers. This grease had been thought of as low risk. The thought was wrong.
It was discovered in the investigation that a fire burning next to an inclined surface can result in a flashover. The heat from the fire causes material further up to release combustible gases, they ignite and so on. The end result in this case was a jet of flame that erupted in the ticket hall. The causes of the tragedy were again complex. The reality is though that a well enforced none smoking policy from 1984 onwards would have almost certainly averted disaster.
Not marking the difference between valves killed 23 employees at a plant in Texas and injured 314 in October 1989. Two valves, looking exactly the same, were reversed on a previous maintenance. This meant that staff in the control room thought that a reactor was sealed when it was actually vulnerable to a leak. Along comes another crew who do everything right. They wanted to carry out further maintenance at the Phillips polyethylene plant. They stripped off everything including the compressor hoses that would actuate the valves but of course the valve they thought was closed was actually set to open. 85, 0000 pounds of flammable gas was released in seconds. A chain reaction followed the initial explosion, there were a total of six, as storage tanks and another reactor blew up. Debris flew a half dozen miles and the shock was recorded as if a small earthquake had taken place. OSHA ( Occupational Safety and Health administration ) in the end came up with a whole host of faults that were found in safety standards but if the valves had been clearly identified then who knows?
How many times have we tapped a gauge in order to see if it is working? In old cars I used to do that on occasion. What about if the gauge is monitoring the capacity of a huge petroleum storage tank? At the Buncefield facility in Hertfordshire the total capacity of all the tanks was 60 million imperial gallons. As one tank was taking in unleaded petrol it was noticed the gauge reading didn’t changed. The fact was it had stuck on several previous occasions. Still the automatic shut off would work right? No, nor did an alarm sound. Still never fear there was a bund wall surrounded the tanks. When petrol overflowed in the early hours of 11th December 2005 there was nothing to stop it, the wall was quickly overwhelmed. It had been the equivalent of putting a fill up hose into your car and going away for several hours while presuming the nozzle would shut off when the tank was full. The difference was the rate was 19,423 cu ft per hour.
Pooling petrol releases gas and a lot of petrol releases a cloud of gas. When it ignited it was a miracle no-one was killed but nevertheless 43 people had to be treated in hospital, 2 for serious injuries. The injuries of course were paramount but the location and nature of the fire also caused pollution, disruption, damage and huge expense. At one point 180 firefighters were on scene and foam to suppress the flames was being transported from all over the country.
Lessons for Everyday
Well, first has to be that hindsight is a beautiful thing. It is a gift in many ways but only if I remember the lessons and apply them. The overwhelming lesson, almost the oldest in human endeavour, is that presumption is the mother of all….mess ups.
Men on the ferry presumed others had or would close the bow doors. The captain presumed he would be told if they were open and the manager at home presumed that the others would be fine despite requests for an indicator system.
At Kings Cross it had been presumed that the grease on the escalator rollers was not flammable.
In Texas it had been presumed that no-one could mix up identical valves.
In Hertfordshire it was presumed that a valve would shut off or an alarm would ring if the tank overflowed.
It is easy to sit here and boil down all the procedural and mechanical failures into one single cause. We design things with failure in mind, but these examples show that people powered or electrical powered it doesn’t matter. I look at these and feel for the victims and the people who on that day did what we all have done, they messed up. I don’t want to be one of them though.
Buncefield teaches us that if there is a fault with one part of a system then the whole system is suspect. The Herald of Free Enterprise gives us the reminder that a man with a specific job will probably do it, several with the same job probably won’t. Piper Alpha says that the paper work can be spot on but if the records are in different places something will go wrong. Kings Cross cries out for enforcement of common sense as does the Phillips fire.
It is less easy to look forward and try and prevent the misery and financial cost of a future incident. That is what we are charged with doing however and by harnessing so called morbid fascination we have a valuable tool to ensure fewer such disasters occur in the future.