Critical Aspects of Safety and Loss Prevention

Trevor A. Kletz

• Publisher: Butterworth-Heinemann
• Year: 2014
• ISBN:
  9781483192352
• Topic: Technologie et ingénierie
• Subtopic: Ressources d'alimentation

Critical Aspects of Safety and Loss Prevention reflects the author's managerial experience and safety operations experience. This book is a collection of almost 400 thoughts and observations on safety and loss prevention, illustrated by accounts of accidents. The items, mostly short, are arranged alphabetically and cross-references are provided. The accident reports in this volume highlight the ignorance, incompetence and folly but also originality and inventiveness in the cause of accident prevention. This book also argues on the importance of loss prevention over the traditional safety approach. This book will be of interest to persons who work in design, operations and maintenance and to safety professionals.

Abbeystead

In 1984 an explosion in a water pumping station at Abbeystead, Lancashire killed 16 people, most of them local residents who were visiting the plant. Water was pumped from one river to another through a tunnel. When pumping was stopped some water was allowed to drain out of the tunnel leaving a void. Methane from the rocks below accumulated in the void and, when pumping was restarted, was pushed through vent valves into a pumphouse where it exploded.

If the presence of methane had been suspected, or even considered possible, it would have been easy to prevent the explosion by keeping the tunnel full of water or by discharging the gas from the vent valves into the open air. In addition, smoking, the probable source of ignition, could have been prohibited in the pumping station (though we should not rely on this alone). None of these things was done because no-one realized that methane might be present. Although there were references to dissolved methane in water supply systems in published papers, they were not known to engineers concerned with water supply schemes.

The official report¹ recommended that the hazards of methane in water supplies should be more widely known, but this will prevent the last accident rather than the next. Many more accidents have occurred because information on the hazards, though well known to some people, was not known to those concerned; the knowledge was in the wrong place. See lost knowledge, need to know and LFA, Chapter 14.

The Courts ruled that the consulting engineers were responsible for damages as they should have foreseen that methane might be present. However, one judge said that an ordinary, competent engineer could not have foreseen the danger ²

Abdication, management by

We have heard of management by delegation, management by participation and management by exception. More common but less often mentioned is management by abdication. This is illustrated by accident reports which say that the accident was due to human failing and that the injured man should take more care; this does nothing to prevent the accident happening again and is merely an abdication of management responsibility.

In some factories over 50%, sometimes over 80%, of the accidents that occur are said to be due to human failing. In other factories it is 10%. There is no difference in the accidents, only in the managers. See EVHE.

Another example of management by abdication is turning a blind-eye.

Aberfan

This village in South Wales was the scene of one of Britain’s worst industrial accidents. In 1966 a colliery waste tip collapsed, a school lay in its path and the 166 people killed were mainly children. The immediate cause was the construction of the tip over a stream but the underlying causes were:

• A failure to learn from the past. Forty years earlier the causes of tip instability were recognized and warned against but the warning went unheeded, as none of the earlier collapses caused any loss of life.

• A failure to inspect adequately. There were no regular inspections of the tip and when it was inspected only the tipping equipment was looked at, not the tip itself.

• A failure to employ competent and well-trained people. Tips were the reponsibility of mechanical, not civil, engineers and they received no training on choice of sites or inspection. The official report¹ said, ‘it was the blind leading the blind in a system inherited from the blind’.

See alertness and LFA, Chapter 13.

Absolute requirements

Under UK safety legislation employers are not required to do everything possible to prevent an accident, only what is ‘reasonably practicable’. However, there are some absolute requirements. For example, dangerous machinery must be securely fenced (guarded) even if the chance of anyone being injured is low and the cost of fencing is high.

The difference between the two approaches is not as great as it seems at first sight. To quote from a Factory Inspector, ‘… inspectors have been reluctant to press for an “absolute” standard of fencing as required by the statute where … the consequences of achieving that standard would mean that the machine became unworkable… This “Nelsonian” approach to the realities of industrial life, relying as it does on the experience and judgement of inspectors, has generally proved satisfactory. Indeed, so successful have been these informal (and in some cases formal) arrangements that there has been little desire to amend the primary legislation to reflect the need for a more pragmatic approach to machinery safety¹.’

Abstractions

For children, abstractions do not exist. Concrete things like chairs and tables and trees and gardens are real, and so are actions like running or shouting, but abstractions are not.

As we get older we learn to use abstract thought, but we often forget that children are right: abstractions do not really exist but are only a convenient shorthand to simplify our thoughts and conversations.

Thus, it is often convenient to talk about attitudes or policies. We say that someone’s attitude to safety is wrong, meaning that he deals with safety matters in what we think is the wrong way. Instead of trying to change his attitude – difficult because it does not exist – let us discuss his problems with him and try to persuade him to deal with them in a different way. If we are successful we may say that his attitude has changed; so it has, but not as the result of a direct, head-on attack.

Attitude and policy are examples of what philosophers call an epiphenomenon, something that does not exist on its own but only as a sort of glow or halo around other things. If you want to get a halo you don’t try to make one or buy one; instead you behave in a saint-like way and hope that a halo will appear and so it goes with attitudes.

Generalizations such as the chemical industry, technology or modern youth do not really exist. Critics blame the chemical industry (or technology) for causing pollution or for making chemical weapons but the industry (or technology) does not have a mind of its own. There are only individual companies, made up of individual people, who have different aims, morals, etc.

The headings in this book include many abstractions (cause, perception of risk, perspective and so on) as they provide convenient headings f...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Inside Front Cover
• Introduction
• Chapter 1: Abbeystead
• Chapter 2: Back flow
• Chapter 3: Cancer
• Chapter 4: Damage control
• Chapter 5: Early involvement in design
• Chapter 6: Factories Acts, Factory Inspectors
• Chapter 7: Gas detection
• Chapter 8: Hazard analysis (Hazan)
• Chapter 9: Iatrogenesis
• Chapter 10: Joints
• Chapter 11: King’s Cross
• Chapter 12: Labels
• Chapter 13: Machinery
• Chapter 14: Near-miss
• Chapter 15: Occupational disease
• Chapter 16: Packaged deals
• Chapter 17: Qualitative
• Chapter 18: Radioactivity
• Chapter 19: Sabotage
• Chapter 20: Take-over
• Chapter 21: Underestimated hazards
• Chapter 22: Vacuum
• Chapter 23: Water
• Chapter 24: Zeebrugge