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. "
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.
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
Copyright notice.
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R. Corcoran. All rights reserved.
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Reminder
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need to take the next step in event investigation, organizational learning,
corrective action, self-assessment, or internal oversight-or when those
processes are not giving you the results you need.
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