“Very few unsafe acts will result in damage or injury. In a highly protected system, the probability that the consequences of an isolated action will penetrate the various layers of defense is vanishingly small. Several causal factors are required to create a ‘trajectory of opportunity’ through these multiple defenses. Many of the causal contributions will […]
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
What is an Injury & Illness Prevention Program (I2P2)? It is a very basic, 8-element, safety management system (SMS). It is OSHA’s attempt to fundamentally change from the complaince model to an SMS model to manage workplace safety and health. OSHA has been talking about I2P2 for nearly 20 years and has faced relentless pushback
We hear it all the time… “yes of course we have a safety management system.” Then we ask one simple question, “can we see your OSH auditing plan for the year/3-years/5-years?” The most common response we get is “OSHA does not require us to conduct overall workplace audits.” That is true and it is also
In his 1990 paper, The contribution of latent human failures to the breakdown of complex systems Jame Reason presented us with three classifications of organizations. As usual, his work and results were spot on! The three (3) categories are: Pathological organizations Calculative organizations Generative organizations When we read these descriptions, as well as what Westrum
As the “safety culture” debate rages on, I came across this 2019 research paper that I found to be spot on. Of course, those are my biases shining through as I believe all organizations have a culture; in fact, they will have multiple cultures. So I am not one who subscribes to the idea that
At 3:00 p.m. on August 18, 2022, an employee entered an empty liquid propane gas (LPG) tank for servicing at an industrial equipment wholesaler facility. Earlier in the day, the employee approached a supervisor and stated that he wanted to enter the tank to spray a penetrating oil product on an internal valve to loosen
I posted an article today @ SAFTENG explaining his accident pyramid model and discussing some of his Domino model. This quote is his own words trying to use the lottery to explain his pyramid model. I think it is a very fitting analogy. “The machine is dangerous as man makes it so. It is the
Another article defending the work of H. W. Heinrich, Assistant Superintendent Engineering and Inspection Division, The Travelers Insurance Company. I feel the need to explain how many have misstated Heinrich’s Accident Pyramid in this article. His Accident Pyramid is probably his most famous piece of work and by far what most attribute to his work.
First, let’s DEFINE what we mean when we use the term “remotely operated shutoff valve.” I have come to love the UK’s HSE definition, which is: A valve DESIGNED, INSTALLED, and MAINTAINED for the primary purpose of achieving rapid isolation of plant items containing hazardous materials in the event of a failure of the primary
“Proximate Causes and Subcauses (Personal).— In connection with the unsafe acts of persons (which are the direct causes of the majority of accidents) the immediately preceding subcauses are of great value in determining the most practical remedy. For example, it is not always enough to know merely that a machine operator oiled his machine while
