Tag: Incidents (Page 2 of 2)

Learning from Failure

“Failure is only opportunity to begin again. Only this time, more wisely.” –Henry Ford

We often push PSM practitioners to perform Incident Investigations for fairly minor events in the hopes that the lessons learned from those minor incidents will stop the larger incidents from happening. This is, in part, due to CCPS (Center for Chemical Process Safety) guidance that, for every single catastrophic accident, there are typically nearly 9,900 minor issues / process upsets and 99 near misses.

So, if you only investigate the catastrophic incidents, then you are only acting on 0.010% of the opportunities available to you to improve your control over the process.

OSHA has promoted this idea as far back as a decade ago…

OSHA and industry have found that when major incidents have occurred, most of these incidents have included precursor incidents. Additionally, OSHA and industry (See CCPS [Ref. 41], Section 5, “Reporting and Investigating Near Misses” have concluded based on past investigations, that if employers had properly responded to precursor incidents, later major incidents might not have occurred. Consequently, anytime an employer has an “opportunity” to investigate a near-miss/precursor incident (i.e., an incident that could reasonably have resulted in a catastrophic release) it is important that the required investigation is conducted and that the findings and recommendations are resolved, communicated, and integrated into other PSM elements/systems so a later major incident at the facility is prevented. …It is RAGAGEP to investigate incidents involving system upsets or abnormal operations which result in operating parameters which exceed operating limits or when layers of protection have been activated such as relief valves. (An example RAGAGEP for investigating incidents, including near-miss incidents is CCPS [Guidelines for Investigating Chemical Process Incidents, 2nd Ed.], this document presents some common examples of near-miss incidents). (OSHA, Refinery PSM NEP, 2007)

Going a step further, it’s often true that you can learn something about managing complex operations from businesses in entirely different fields. One field that I like to follow – in part because it’s endlessly re-inventing itself – is information technology.

Google recently published an article on their Post-Mortem culture, with a farcical worked-example that includes the movie “Back to the Future” and a newly discovered sonnet by Shakespeare. The practice of learning from their failures is actually part of their Sight Reliability Engineer handbook and you can read the entire chapter if it appeals to you.

“Failures are an inevitable part of innovation and can provide great data to make products, services, and organizations better. Google uses ‘postmortems’ to capture and share the lessons of failure…

… For us, it’s not about pointing fingers at any given person or team, but about using what we’ve learned to build resilience and prepare for future issues that may arise along the way. By discussing our failures in public and working together to investigate their root causes, everyone gets the opportunity to learn from each incident and to be involved with any next steps. Documentation of this process provides our team and future teams with a lasting resource that they can turn to whenever necessary.

And while our team has used postmortems primarily to understand engineering problems, organizations everywhere — tech and non-tech — can benefit from postmortems as a critical analysis tool after any event, crisis, or launch. We believe a postmortem’s influence extends beyond that of any document and singular team, and into the organization’s culture itself.”

Google’s Pre-Mortem Tool – Anticipating what can go wrong.

Google’s Post-Mortem Tool – Dealing with what actually went wrong.

Pencil-Whipping can Kill

What is it? Pencil-whipping is when you complete a form, record, or document without having performed the implied work or without supporting data or evidence.

Here are some common examples in NH3 refrigeration:

  • Completing “word orders” without conducting the work
  • “Signing off” on SOP reviews or PHA revalidations without actually reviewing or revalidating the documents.
  • Certifying training – or signing training attendance forms – without the training actually occurring.

Why take it seriously? There are several reasons, but here are some obvious ones:

  • You can be prosecuted for false statements resulting in fines and/or jail time.
  • There is significant legal liability if the action leads to an incident.
  • You can be fired for false statements
  • There can be significant safety repercussions to documenting work that wasn’t done.

I want to briefly focus on the last one – what can happen when you document that work was done when it actually wasn’t. If you are being assigned a task, we have to assume that the performance of that task is important to the system as a whole.

Imagine your job was to inspect some equipment that was prone to long-term wear – equipment that was relied upon for normal function. Now imagine that you didn’t conduct those inspections leading the users of that equipment to believe it was in proper working order. They are relying for their safety on YOUR lie!

Here’s what that can lead to:

And here’s what can happen when people investigate the incident:

Thursday morning, the General Manager and CEO of the Board Safety Commission released a statement regarding the firings: “…I want the Board, our employees and our customers to know that this review revealed a disturbing level of indifference, lack of accountability, and flagrant misconduct in a portion of Metro’s track department which is completely intolerable. Further, it is reprehensible that any supervisor or mid-level manager would tolerate or encourage this behavior, or seek to retaliate against those who objected. It is also entirely unacceptable to me that any employee went along with this activity, rather than exercise a safety challenge, or any of the multiple avenues available to protect themselves, their coworkers, and the riding public.

Since the derailment occurred, we have either taken action or are in the process of taking disciplinary actions involving 28 individuals. This represents nearly half of the track inspection department and includes BOTH management and frontline track employees.

Six employees have been terminated, including 4 track inspectors and 2 supervisors

Six more track inspectors are pending termination or unpaid suspension; and 10 more are pending possible discipline pending the outcome of the administrative process

Another supervisor termination is underway; and two more supervisors are pending the outcome of the administrative process

One Superintendent was demoted to Supervisor

One Assistant General Superintendent was demoted to Superintendent

One assistant superintendent separated from Metro before the review concluded

In closing: Pencil-Whipping is immoral, illegal and just plain wrong. Don’t do it.

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