Over the past several years, I have focused on my SMS/HF postings rather than the traditional technical postings. Being a safety pro means we wear many hats. I break these down into just two (2) main categories: 1) Technical and 2) Management Systems, including the soft skills we need to possess. Those who have followed […]
The Institute of Nuclear Power Operations (INPO) manages the Significant Event and Information Network for its member utilities both within and outside the United States. In 1985 they issued an analysis of 180 significant event reports received in 1983- 84 (INPO 1985). A total of 387 root causes were identified. These were assigned to five
Human error can be divided into either intentional or unintentional actions. INTENTIONAL actions—those actions that involve conscious choices. These actions are primarily due to judgment or motivational processes. UNINTENTIONAL actions—those in which the right intention or plan is incorrectly carried out or where there is a failure to carry out an action. These actions typically
Before disciplining a worker for an “error” or “mistake” that led to undesired consequences, we need to ask ourselves one simple question… How often have we written 2022 when signing checks and documents this year? It is February 15th, 46 days into the new year, yet I just had to correct a document that I
As more facts are coming to light regarding the runway incursion incident at JFK on January 13, 2023, it appears that a “safety system” used by ground controllers may have saved the day. In the NTSB’s preliminary report on the incident, it is stated: The ASDE-X alerted the JFK ATC tower to the conflict, and
For most senior safety professionals, we have arrived at a place in our careers where we can understand the significance of what Dr. Reason said in 1997. Although most would agree, we started our careers in a very different place when it comes to how we derived the root causes of accidents throughout our careers.
The significance (or severity) of an event depends upon the consequences suffered and not on the error that initiates it. The error that triggers a serious accident … and the error that is one of hundreds with no consequences… can be the same error. Human Error, James Reason, Department of Psychology University of Manchester,
Your OSH or PSM/RMP audit report declares a human factor issue was found. You honestly wonder how much of a risk this really is, but you’re told it has to be fixed so we can close out the finding. So I present to you HF Engineering 2023
I thought I had shared this image before, but I could not find it. I did NOT create this image but have had it since 1994. It came from my first HF Engineering Course in preparation for Process Safety, specifically the HFA part of a PHA.
This was a nice attempt to correct the obstructed clock on the wall. Why they did not just move the clock 6″ to the right or run the conduit differently is beyond me..
I am a big believer in Root Cause Analyzes, and Corrective Action Plans to address our findings from an incident investigation – It just does not get more fundamental than this in industrial safety. Early in my career, I worked for a great man who was ALL ABOUT his employees. He was undoubtedly the most
Northwest Airlines Flight 255, a McDonnell Douglas MD-82, crashed in Romulus, Michigan, shortly after takeoff from Detroit Metropolitan Wayne County Airport on August 16, 1987, at about 8:46 p.m. It killed all six crew members and 148 passengers, and two people on the ground. There was only one survivor, it was a 4-year-old girl who sustained
