The Entry Supervisor is an ABSOLUTE CRITICAL PATH in safely performing entries into PRCSs. With that said, if entry supervisors simply attend the same training that everyone else attends, we have FAILED them. We were asked to assist with a 2012 PRCS fatality incident where the abject failure of the facility to train its entry supervisors was undoubtedly the root cause of the tragedy. Yet the business wanted to lay the blame for two deaths at the feet of the attendant, rather than the entry supervisor and the management team’s failures. Although the management team could provide us “sign-in sheets” for their entry supervisors showing they had attended “PRCS training”, that training (an online video from a large online trainer) simply read the “roles and responsibilities” of the entry supervisor word for word from 1910.146(j). When we sat down with each entry supervisor (13 in all), we found that not a single entry supervisor was capable of explaining:
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Why Oxygen Concentration must be measured FIRST (then LEL and then Toxicity)
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The Correction Correlation with the LEL readings
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Why OSHA defined the LEL of 10% as a Hazardous Atm
- What it means to verify rescue services are available and the means to summon them are operational BEFORE signing the permit and authorizing entry
- The means and measures to reclassify a PRCS to a non-PRCS status
I do NOT blame the Entry Supervisors for their lack of knowledge – I blame management for doing as little as possible for such a CRITICAL PATH to safety.
The lawyers even found communications from the previous safety team about the need for “adequate training” for those involved in PRCS entries. Then the “great recession” hit and the entire safety team was let go. The business made the maintenance manager the safety leader (dual hats!). When the economy and this business recovered, management decided that rather than hire another degreed/trained/experienced safety professional, they would rotate the role of safety leader through their roles. Now, none of these management personnel could answer any of the five (5) questions, but they all held the role of safety leader for some period of time leading up to this tragedy. A new manager, hired from outside the company, suggested the online training option as a means to save time and money; as his previous employer had used this service “with great success” (i.e. they had not killed anyone inside a PRCS). Oh, and by the way, it was this same online service that the safety team pushed back against in 2009 when management was looking for ways to save time and improve efficiencies.
Are you seeing the Latent Organizational failures at work here? These knowledge gaps were HUGE and allowed people who lacked adequate knowledge to make life and death decisions and they were not even aware that the decisions were indeed live and death decisions.
So use those five (5) questions on your Entry Supervisors and see how well your PRCS program is being implemented during entries.
