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What is Error Management? (Reason, 1997)
Error Management (EM) has two (2) components: error reduction and error containment Error reduction comprises measures designed to limit the occurrence of errors. Since this will never be wholly successful, we also need error containment measures designed to limit the adverse consequences of those errors that still occur. At this general level, EM is indistinguishable from quality management or,...
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Fostering the principles for a strong safety culture is one of the most challenging tasks facing a management team
Fostering the principles for a strong safety culture is one of the most challenging tasks facing a management team. Successful leadership achieving a strong safety culture will most likely move an organization to the next level of human performance. A leader is any individual who takes personal responsibility for his or her performance as well as the facility’s performance and attempts to influence...
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Where is your safety culture?
I have used this tool, with some modern-day modifications, for years.  When I was a safety manager of a facility I would constantly be looking for these indicators as a means to validate what I was “feeling”.  As safety pros, we have a sixth sense of how things are going, but there are so many markers/indicators in measuring safety cultures that having a list like this comes in...
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Accountability, Culpability and a "Just Culture" (Dr. James Reason)
“Name, blame, shame, retrain” is an often-used phrase for older ineffective paradigms of safety management and accident analysis. Dr. Rosabeth Moss Kanter of Harvard Business School phased the situation this way: “Accountability is a favorite word to invoke when the lack of it has become so apparent.” Kanter, 2009 The concepts of accountability, culpability and just culture are inextricably entwined....
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To vent or Not to vent?
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Using Behavior-Based Observation Process to promote MANAGEMENT BEHAVIORS
Earlier, I outlined the six (6) stages of a Behavior Modification Intervention. Now, I want to discuss how the same six-step process used to change the behaviors of hourly workers can be used to promote critical health and safety behaviors amongst management personnel.  Management behavior will heavily influence the success or failure of a Behavior-Based Observation Process, and safety leadership...
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Do Behavioral Observation Safety Processes Change Behaviors?
Several studies have evaluated the effectiveness of behavioral modification programs in improving workplace safety. These studies have focused on establishing the following: their ability to decrease accidents/injuries, their ability to increase safe behavior and which components in a behavioral observation safety processes are most important in changing unsafe behavior and reducing accidents and...
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Rupture Disc between Pressure Vessel and Relief Valve (and after the RV)
In many processes, the use of a rupture disc (RD) between the vessel being protected and the Relief Valve (RV) is a fairly common practice.  This is ALWAYS done for design necessities and not just “because”.  Some processes could be corrosive to the RV internals, at least this is the most common reason for this type of arrangement.  There are some process safety professionals...
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Boiler Explosion in Elementary School in PA (2005)
The boiler was in the basement at the rear of the school. This happen on a Sunday when the school was closed. If this was during the week there would have been 15 children and a teacher and teacher assistant in that classroom. The damage was so bad the rear of the school building had to be demolished.    
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OSHA PSM Citations @ food plant (Fatality, NH3 & $1.1M)
Citation 1 Item 1 Type of Violation: Serious; $4,500 Section 88.4 – Code of Iowa (2007) 88.4: The employer did not furnish employment and a place of employment that was free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed to a serious corrosive chemical hazard, ammonia used as a refrigerant:(a) In the Plant-...
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Pressure Vessel Failure during Hydrotest - Nov. 2007, China
Pressure Vessel Failure during Hydrotest – Nov. 2007, ChinaPlease see the photos below of a pressure vessel that recently failed whilst under hydrotest during post fabrication testing. This vessel was manufactured by a vessel vendor in China and the plate was of Chinese mill origin. Unfortunately this is another example of serious equipment/material failures with equipment being sourced out of...
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Hot Water Heater Explosion (OK)
Star elementary school Oklahoma 1982. Six children & one adult killed, 42 injured. The cause was an 80-gallon hot water heater exploded. The controls had been tampered with, the temperature probe was removed & the relief valve was improperly installed.    
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