Many organizations have become very good at identifying the ACTIVE failures associated with an accident; however, in almost all of the accident investigations I have been involved with, I find LATENT failures to play a bigger role than active failures. But that is a really hard pill for most organizations to swallow. But there is a tool within our process safety management system that is specifically designed to identify LATENT failures that lie dormant until that day they all align, and coupled with the ACTIVE failures, result in our accident.
However, many organizations’ approach to their 3-year PSM/RMP audit(s) is a LATENT failure in and of itself! When these audits are viewed as a “regulatory-check-the-box” requirement rather than a “verification” of the management system, they fail to serve their intended purpose. And this is how auditing becomes a LATENT FAILURE.
We have several catastrophic accident investigations that we are currently involved in. For each one, we have found the facility approached its 3-year audit with either profound ignorance or arrogance, and both led to catastrophic consequences. Some facilities had untrained, uneducated, and unskilled personnel managing process safety, and because of this, they did not understand the critical role the 3-year audit plays in process safety management. I do NOT blame the individual – I blame facility/company management who put that individual in that role and failed to ensure they had the skills and knowledge to be successful in that role. Couple this failure with a budget crunch, and you have an individual deciding on their auditor(s) based on their lack of understanding and costs. Thus the audit fails to find many of the failures within the management system that could have/should have given management the ability to address BEFORE the accident.
In some cases, arrogance played a role. The facility and its management used improper “indicators” to convince themselves that the management system must function well. Thus, they decided to perform their 3-year audit “internally” and allow the element owner to “self-audit” their work. You can imagine the biases that creep into this level of “self-auditing.” But this practice is even more common when a contractor is involved. Many smaller companies will hire contractors to develop and implement the PSM/RMP program. When it comes time to validate that management system and its implementation, they will use the same contractor to perform the audit. We call this…
hiring the fox to design, build, and provide security to your henhouse
These games with auditing are real and fairly pervasive in most PSM/RMP industries. Hire the cheapest contractor who will find fewer problems, resulting in fewer fixes and less money needed afterward. It worked well until that accident, where all the causes/contributing factors could have been/should have been identified in a well-executed and thorough 3-year audit.