I share this in my training classes as this is an example that most adults can relate to… We have all seen pics and videos of humans forgetting to remove the fuel hose from their vehicle and driving off, often creating serious hazards.  But about 20 years ago, a very simple device was invented that allows this human error to “fail safely.”  This simple device is an “ENGINEERING...

This is one of my favorite principles of Human Factors. But be careful sharing this, as most organizations with an immature SMS do not like it when they realize the truth of this principle and its statements about the organization. Organizations are perfectly tuned to get the results they are getting … HomeRead More »

In Tony Muschara’s 2018 book Risk-Based Thinking, Managing the Uncertainty of Human Error in Operations he so eloquently lays out how “risk-based thinking” has to become a belief and value within senior leadership, such that they are guided by safety in their decisions, responses, and behavior choices.  Muschara has his seven (7) principles of risk-based thinking that are a MUST...

There is a common phrase in Human Factors Engineering… “Error Trap.” This is the image we will put next to this phrase in my new book… (i.e., an actual real-life “error trap” door). Scenario: Your singing your favorite song in the shower. The spouse needs to go down to the basement and start a load of clothes in the washer. They open the door BUT DO NOT CLOSE IT,...

On May 3, 2022, at about 19:45 local time, the inspected passenger vessel Natchez, with one crewmember on board standing a security watch, was moored in the Industrial Canal in New Orleans, Louisiana, undergoing renovations when a fire broke out.1 Local firefighters extinguished the fire at 2139. No pollution or injuries were reported. Damage to the vessel was estimated at $1.5 million. SPECIAL NOTE: ...

Filling or handling plastic or other non-conducting containers can still be hazardous when the flammable liquid is conductive. The splashing (filling) and turbulence of the liquid in the container can cause a static electric charge to build up in the liquid or on conductive parts of the container that are not adequately grounded. A spark above the MIE of the vapor/air mixture in its flammable range...

Three (3) things that a Human Error is NOT: a sin an event, and most importantly a root cause Tony Muschara, Risk-Based Thinking Managing the Uncertainty of Human Error in Operations, 2018

SPECIAL NOTE: This appears to be the first case where OSHA has applied it’s new Instance-by-Instance Penalty for Willful Citations.  This case involved a leg amupation while working inside a sile with the paddle conveyor still running.  OSHA issued three (3) Willfuls using 1910.28(b)(6)(i) for each citation and all three (3) were willfuls. An grain cooperative’s failure to ensure...

There is a common phrase in Human Factors Engineering… “Error Trap.” This is the image we will put next to this phrase in my new book… (i.e., an actual real-life “error trap” door). Scenario: Your singing your favorite song in the shower. The spouse needs to go down to the basement and start a load of clothes in the washer. They open the door BUT DO NOT CLOSE IT,...

When writing SWPs/SOPs be sure how you phrase things. KNOW your audience. An elementary teacher got what she asked for when she simply asked the class to draw a clock showing the time as 10 minutes past 11. This exercise is called the Clock Drawing Test for Cognition. Usually reserved for the elderly or someone who has suffered a brain injury, the test can also indicate some learning disabilities in...

This case is significant as EPA used the International Fire Code as their basis for several General Duty Clause findings.  They also used NFPA standards in their inspection. Respondent owns and operates a facility that manufactures consumer and industrial products in liquid form and for pressurized containers that use aerosol propellants. Respondent’s manufacturing process uses and stores flammable...

A recent FaceBook post by the South Dakota Highway Patrol is getting a lot of attention. The pics are alarming, to say the least. But some of the comments are an indication of where safety stands in the United States culture of safety.  When people decry government intervention as “crossing a line,”… “that truck driver is just trying to make a living, maybe if the government...