Admiral Rickover is the Father of Nuclear Safety in the U.S. Navy.  He holds the Navy’s record for years of service, having served 60 years (1922 – 1982). He passed away 4 years later at the age of 86.  Admiral Rickover coveted the following “7 Rules” in developing, implementing, and managing his nuclear safety program for the Navy.  A lot of businesses could...

What Happened: Two contractors re-injected the wrong clamp. The flange bolts failed, and the two contractors involved in the work died in the steam released. In the legal case, the judge focused on the possibility of human error. The company should have anticipated the possibility of this human error and concluded that the site did not sufficiently protect the workers from that. Humans do make errors...

In the world of Human Factors, we have a saying, “failing safely,” which translates into… all humans make mistakes – it’s our job to identify those error/mistake traps and design work to lessen those error opportunities.  In Process Safety we used to use the phrase “cascading failures”, which is the opposite of “failing safely.”  In a...

Earlier this year, a member of the SAFTENG FaceBook group posted a question about this type of system being used in a warehouse within the USA.  Many of us were caught off guard as it seemed very risky to drop the Oxygen level to 13% in an occupied space, even with all the alarms and such in place.  Many of us are familiar with Fixed Systems like the old Halon systems in computer rooms in...

This is an excellent presentation by John S. Carroll, MIT Sloan School of Management at the NTSB Public Forum on Transportation Safety: Enhancing Safety Culture.  His presentation does an excellent job of explaining where the term “safety culture” originated and how organizations shape their culture of safety. CLICK HERE for the presentation

PLEASE READ NOW AND TAKE ACTION Dear MSA Customer, MSA is issuing this User Safety Notice to inform you of a PROCEDURAL UPDATE regarding usage of the Altair 5X PID gas detector. MSA has determined that PID sensors manufactured from March 2020 to and including June 2023 may not respond to gas after being turned on due to the lamp of the sensor not lighting upon startup and the Altair 5X PID will not...

We don’t see this often, but the number of facilities that do not know of this fundamental OSHA/IFC/NFPA requirement for their fixed LPG storage tank(s) is sad.  How one defines “high water table or flood conditions” is open for discussion as no one has reallty DEFINED or QUANTIFIED the phrase as of yet.  The video below is most likely just a residential tank caught up in...

I keep using this tragedy as a teaching/learning tool. This officer was convicted and sentenced to 4-years in prison for aiding and abetting manslaughter for holding back the crowd during George Floyd’s murder. TAKE THE POLITICS OUT OF IT and ask…. Why didn’t he step in and do something? This is the difference between “latent organizational failures” and “active failures.” For example, suppose a person...

The conditions that increase the risk of violations can differ from those that produce errors. Violations are often associated with time pressure, poor procedures, poor supervision, and shortages of equipment or spares. The table below shows some reasons people gave for not following procedures in one study. … HomeRead More »

Some error-producing conditions are more powerful than others.  The table below shows estimates of how different conditions create the risk of error. Poor instructions or procedures are said to triple the rate of error.  Lack of experience with the task is estimated to result in a 17-fold increase in the risk of error. … HomeRead More »

If we aim to learn from the error and to lessen the chances of it happening again, we need to consider the organizational context that surrounds the person’s action, including equipment, procedures, people, the environment, and management. There are two aspects to managing error: … HomeRead More »

When an organization has identified hazards and established the risks those hazards pose, it must have a process(es) in place to ELIMINATE hazards, or where this is not possible, to reduce the risks associated with the identified hazard(s), using the hierarchy of controls. At the top of the hierarchy of controls is ELIMINATION. This is the most effective way of managing risks associated with identified...