Why Unattached Boards On The Charles Dana Bridge Matters

Do you know what the job of a whistleblower is? We are consequence minimizers and occurrence disruptors. We illuminate or bring to light the true behaviors and defects of the organization before the accident happens...before we then all have to spend big bucks on a accident.

We all play the whistleblower role many times in our lives...we are all whistleblowers! 

I will give you an idea of what I am talking about. We drive drunk 100 to 300 times on average before we get caught by the police.

"The Anna Hunt Marsh Bridge connects Brattleboro to Hinsdale Island, which is connected to Hinsdale by the Charles Dana Bridge. JB Mack, the principal planner for the Southwest Region Planning Commission, previously told the Reformer federal highway standards dictate the bridges are too narrow and have insufficient weight limits and vertical clearance. "

 

This is the pdr of the below...easier to read. 

 

The Firebird Forum

THE OCCURRENCE PYRAMID

The Nature of High Hazard Industries

We read about the highly consequential events, but the near misses, compromises, and deviations/infractions seldom get much ink. Thus, the data we encounter can mislead the unwary.

However, we are generally not surprised at the results of detailed government inspections of organizations that have had newsworthy consequential events. These inspections nearly always report that there were near misses, compromises, and deviations/infractions before the consequential event.

The nature of occurrences in high hazard industries, and, perhaps, of life generally, is illustrated by The Occurrence Pyramid in the first column.

Often a regulator, a journalist, or an editorial writer bemoans the failure of the organization to attend to the non- consequentials before the consequential occurred.

Recent consequentials in the news include:

The Occurrence Pyramid

Consequentials and near misses

Compromises

Deviations/ Infractions

Suggestion for root cause instructors

e
The Newsletter of Event Investigation Organizational Learning Developments Volume 16 • Number 10 October 2013

The West Delta 32 Platform Explosions

Links to more information on those consequentials is readily available by internet searching

 

How about "Near Misses"?

A "near miss" is generally thought of as an occurrence that could have resulted in one or more of the d-words given below, but did not because of only one non-robust mitigating factor2.

For every consequential occurrence you should expect to see roughly ten near misses. A "consequential" is an occurrence that resulted in one or more of the d-words: death, damage, dollars of loss, disruption of service, delays in work, disgrace to the organization, defection of customers, or the like.

1 https://en.wikipedia.org/wiki/Lac- M%C3%A9gantic_derailment 2 For a fascinating near miss asphyxiation see https://app.box.com/s/3r4111e5qm9hbsrgi778

Thought of the month

Quotation of the month

Back Issues

The Arkansas Nuclear One Stator Drop

The Crystal River Containment Failure

The San Onofre Steam Generator Failures

The Lac-Megantic Rail Car Explosions

Challenger launch could be regarded as near misses because they had O-rings similar to those of the Challenger, but happened to have been launched at a higher temperature. Sometimes near misses are easy to recognize and sometimes they are not.

Almost everyone would recognize a dropped object event involving penetration of a hard hat3 as a near miss injury.

Most people would recognize a load drop within a few feet of a work area as a near miss. Some people would not. I knew of one organization that did not recognize repeated diesel generator exhaust system fires as near misses.

At another organization an electrician involved in a near miss electrocution did not recognize it, but his foreman did- fortunately. It may well be that near misses are the most difficult level of event to recognize, at least by some people. Thus it is worthwhile to have unfamiliar people review the occurrence database from time to time to see if their calls are the same as yours.

Perhaps like dead men in the old pirate saying4, near misses tell no tales.

How about "Compromises"?

A "compromise" is a situation in which a required safety or quality barrier has been omitted, breached, or degraded. For example, conducting a load lift within a short distance of work would be a compromise.

 

Similarly, driving without a seat belt or driving with air bags disarmed would be a compromise.

The inoperable blowout preventer on the Macondo Rig was a compromise in that important protection was missing5.

The power operated relief valve failures to close that preceded the Three Mile Island Unit 2 fuel damage event were compromises in that they represented a situation in which a required safety or quality barrier was breached, or degraded.

Noticing that one is in the wrong unit of a multi-unit plant is a recognized compromise. But many compromises are unrecognized until after the consequential that they were precursors to.

http://www.marinesafetyforum.org/upload- files/safetyalerts/msf-safety-flash.06-08.pdf#! 4

 

See the last few seconds of the clip at

 

http://youtu.be/aLSJNTr-k9o 5

 

For the whole report see: http://ccrm.berkeley.edu/pdfs_papers/bea_pdfs/dhsgfinalreport -march2011-tag.pdf

More commonly, compromises consist of omissions such as failures to invoke appropriate quality program requirements, failures to reinstall foreign material barriers, failing to close security doors, failures to replace protective covers, failure to recharge fire extinguishers after discharge, and the like. .

We should expect to see about ten compromises for every near miss.

How about "Deviations/ Infractions"?

A "deviation" or an "infraction" is a situation in which a quality or safety requirement that supports required barriers has been inadvertently or deliberately overlooked. For example, if a load lift were conducted without walking down the lift path a deviation or infraction would have occurred.

All non-consequential self-check and peer check errors are deviations or infractions.

These are somewhat harder to detect than consequentials, near misses, or compromises. It takes knowledge of requirements to recognize deviations and infractions and many organizations do not provide effective training in what the requirements are.

You should expect to see roughly ten deviations/infractions for every compromise. This is shown in The Occurrence Pyramid. The base of the Occurrence Pyramid suggests a thousand or so deviations/infractions preceding every consequential.

All deviations/infractions are noncompliances with requirements. This creates a link between compliance and safety.

But what good does this do me?

If you buy into this model you can use it in at least two ways.

You can use it to test the integrity of your occurrence database and you can use it to gain support for certain safety improvement measures.

Occurrence Database Integrity

Often the occurrence database is a reflection of what is going on in people’s minds rather than what is going on in the facility.

An occurrence database will reflect what gets into it. It will reflect The Occurrence Pyramid if the database "holds water", i.e., has integrity. Otherwise it will not.

If, for example, you see about the same number of compromises as near misses, you might hypothesize that the compromises are not being reported faithfully.

You might want to explore what it is about your organization that results in its recorded experience not being typical of high hazard industries. Is there something that is suppressing compromises relative to near misses?

Or are the compromises being concealed? Or do people just not bother to report compromises?

Gaining Support for Safety Improvements

Given your belief in The Occurrence Pyramid a strategy for reducing the consequentials and the near misses is to correct the conditions, behaviors, actions, and inactions that result in deviations/infractions and in compromises.

The same conditions, behaviors, actions, and inactions that result in deviations/infractions and in compromises will, under different conditions, result in consequentials or near misses.

By use of The Occurrence Pyramid you may be able to convince some people in your organization that it is in their best interests to understand and correct the b conditions, behaviors, actions, and inactions involved in compromises and in deviations/ infractions.

A reliable way to reduce the size of The Occurrence Pyramid in your organization is to reduce the size of the base. What we are talking about is finding out what conditions, behaviors, actions, and inactions cause the compromises and deviations/ infractions and correcting them.

Unfortunately, many organizations ignore the compromises and deviations/ infractions or simply record them without finding the behaviors and conditions that cause them. Even some regulatory agencies downplay non-consequential pathogenic occurrences by giving them dismissive names.

We are not suggesting that a Root Cause Analysis be done on all such minor occurrences, but we are suggesting that an intelligent sampling scheme might surface the dominant behaviors and conditions that need to be corrected for safety and business reasons.

But what about precursors?

A “precursor” is a situation that has some, but usually not all, of the ingredients of a certain type of consequential occurrence, e.g., there are precursors to plant scrams, precursors to large environmental releases, electrocution precursors, etc.

Seen in this way, all occurrences in the pyramid are precursors, even the consequentials. For example, an electrocution of one worker is a precursor of an electrocution of multiple workers if there is a possibility of doing the same job with a larger work team. Most electrocutions are also precursors of serious fires.

Thus it is generally not useful to single out certain events as precursors and exclude others. Any harmful event, condition, behavior, action, or inaction worth discussing is a precursor to something consequential, otherwise it is not very significant.

Precursors come in exactly three types by their potential involvement in the consequential that has not yet happened. These are facilitators, initiators, and exacerbators. A facilitator precursor is a condition, behavior, action, or inaction that sets the stage for a certain specified type of consequential.

An accumulation of transient combustible material could be a facilitator precursor to a hot work induced fire. An accumulation of combustible gas could be a facilitator precursor to a hot work induced explosion.

An initiator is a condition, behavior, action, or inaction that could have initiated a consequential (but didn't because other ingredients were missing). For example, creating a spark in an area known to occasionally contain combustible gas would be an initiator precursor to a detonation.

An exacerbator precursor is a condition, behavior, action, or inaction that couldn't facilitate a consequential or initiate one, but could make the consequences of an event worse, should it be initiated.

For example, a defective piece of fire fighting equipment could be an exacerbator type of precursor of a consequential fire.

The failures of the reactor shutdown systems at Salem and Browns Ferry were exacerbator precursors.

Before the chemical release at Bhopal the inoperability of some safety systems6 was an exacerbating precursor, even though it was not recognized as such.

Summary Table

The Summary Table below shows the relationship of The Occurrence Pyramid levels to the normal types of precursors. These relationships are not always as shown, but this table is a good rule of thumb. Like all rules of thumb apparent and legitimate exceptions are not unusually difficult to find.

6 https://en.wikipedia.org/wiki/Bhopal_disaster

 

Occurrences

Level

Precursor Type Facilitator Initiator Exacerbator Conseq-

Not uential

Normally

Not Normally Near Miss

Yes

Not Normally

Yes Yes

Compro- mise

Yes

Not Normally

Yes

Deviation Infraction

Yes Yes Yes

Suggestions for root cause instructors

Discuss The Occurrence Pyramid. Indicate how the behaviors that result in pyramid base occurrences can also result in pyramid peak occurrences.

Thought of the Month

The consequential occurrences are the tip of the iceberg. They are supported by the whole pyramid of near misses, compromises, and deviations/ infractions. In order to understand the culture you must understand the whole pyramid and the management behaviors that sustain it.

Quotation of the Month

Geiger's Principle: "If you only investigate consequentials you will soon have consequentials to investigate."

Firebird Forum Staff

William R. Corcoran, Ph.D., P.E. 21 Broadleaf Circle Windsor, CT 06095-1634 Tel: 860-285-8779 e-mail: firebird.one@alum.mit.edu

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