“When defeat comes, accept it as a signal that your plans are not sound, rebuild those plans, and set sail once more toward your coveted goal.” —Napoleon Hill
Ever found a fire door propped open? It won’t do much good that way, but studies have found that the probability of finding a fire door propped open is about 1 in 4.
Our safety depends on what we do and on what others do. It also depends on the safety devices that pervade the spaces in which we work and live. Many times, experts have deemed those spaces safe enough because of those safety devices. When safety devices are defeated, the spaces they protect aren’t as safe as we thought they were. Sometimes, those spaces are no longer even safe enough to occupy.
Three Reasons for Defeating Safety Devices
Fire doors are not the only safety devices that we encounter, especially in the process industries. Yet we frequently find these devices defeated. Why? It is not because people do not care about safety. Typically, people defeat safety for one of three reasons:
- They don’t know better
- They only intended to defeat the safety device temporarily
- The safety device makes normal operations too difficult (or impossible)
Don’t Know Better
One reason that people defeat safety devices is because they don’t understand the purpose of the device, or they don’t understand how it is supposed to work.
This is something I encountered in the home of a friend: The relief valve on a water heater was leaking. My friend had just finished the basement, and the new carpet under the water heater was getting wet. His fix was simple—a cork from a wine bottle was just the right size to plug up that pesky leak. Problem solved! Except, of course, for the whole loss of protection against water heater overpressure. But heck, how often does that happen?
An example of a defeated safety device in the workplace that is far too common is the fire door that is propped open. There are devices that will hold a fire door open, usually with an electromagnet, that then release the door to close when the fire alarm is sounded or on loss of power. In many workplaces, however, it is far easier to put a wedge in the door, to block it open with a chair, or to hold it open with a bit of wire. (Bent coat hangers seem especially popular.)
The problem is that one of the key purposes of a fire door is to prevent the spread of smoke or fire through a building, a purpose that is defeated when the door is open. Worse, if the fire door is to a stair well, the open door not only fails to prevent the spread of fire, but by creating a chimney effect, the open door can actually contribute to the spread of the fire.
It Was Supposed to Be Temporary
Another reason that people defeat safety devices is that they pose an obstacle to a temporary task that needs to be done. So that they can complete their task, they defeat the safety device temporarily with the sincere intention of returning it to service as soon as they are done. Then they don’t.
For those of us that work with safety instrumented systems, a horror story that we have all heard is of the maintenance technician that opens a wiring cabinet and discovers that a critical safety interlock has been jumpered out of service with alligator clips, rendering the interlock inoperable. The alligator clips are green with corrosion and a check of the records shows that the service work was done years ago, meaning that for years, the plant has been without that protection, unbeknownst to everyone in the plant.
There are perfectly good reasons to defeat a safety device temporarily. Maintenance is one. A temporary operation is another. When a safety device fails so that it trips spuriously, acting even though there is no hazard, the solution often is to defeat the device temporarily, so operations can continue while awaiting the repair to the safety device. But then, the repair slides, the temporary solution becomes the permanent solution, and safety is defeated.
Safety Devices Are a Pain in the Neck
The reason for defeating a safety device that is hardest to address is that the safety device interferes with operations. It creates problems or doesn’t work the way it should. So, people defeat those devices with no intention of returning them to service.
As a child, you may have noticed that some fire alarm pull-stations at your school had cages around them that were locked closed. Why? Because the school administration was weary of false alarms as bored children casually pulled the alarm on their way to lunch or recess. The locked cages solved one problem but rendered the alarm useless. The school couldn’t remove the pull-stations, though, because the pull-stations were required by code. On the other hand, they couldn’t use the pull-stations because, well, they were locked closed and the key was in the back of a drawer in the principal’s desk. At an early age, we are taught that one way to deal with inconvenient safety devices is to defeat them.
As we get older, we defeat other devices. Ever get into a car where the seatbelts are already buckled in order to defeat the unbuckled seat belt alarm? Ever walk through a plant and see a keyed switch where the key is left in the lock? Ever see a piece of bailing wire hanging on a pipe next to a spring-loaded fail-safe valve, so the valve handle can be held open? Or brick sitting next to a deadman foot switch?
I was in a plant once where one of the units was in an enclosed 4-story structure. There were fire doors at every level, and every one was held open with a piece of flange pipe dropped into the grate. I commented on the doors and personnel immediately closed all of them. Within an hour, the temperature inside the building had climbed to 140 F.
The doors were propped open because it was the only way to the building tolerably cool. Did the operators have a disregard for safety? No. It was just that the threat of heat exhaustion was real and immediate, versus the less likely threat of a unit fire. My superficial solution—reminding the operators of the purpose of fire doors—didn’t fix the real problem.
What to Do?
The best response to a defeated safety device depends enormously on the reason for defeating the device. When people defeat a safety device out of ignorance, then training is the best response. On the other hand, when people intend to defeat a safety device temporarily, but then fail to restore the device afterwards, training is no help.
The failure to put a safety device back into service after a temporary disabling is not because personnel didn’t mean to or didn’t want to. It is not because they didn’t know they were supposed to. Instead, it is because they forgot or got distracted, and all the training in the world is not going to make them remember better. Because safety devices are rarely called upon to act, they are unlikely to call attention to their own defeated state. Instead, restoring a safety device after a temporary disabling needs to be part of a critical procedure. Too often, the focus is on making the fix, and restoring operations is given short shrift. This is why job safety analyses and pre-startup safety reviews are so important.
What about when personnel deliberately defeat safety devices, with the intention that it be a permanent disabling? Assuming that the personnel are not sociopaths or cursed with a death wish, you have to assume that they have disabled the safety devices for a reason. These are the hard cases, because these are the cases that first require you to dig into the reasons for defeating the safety devices and then, almost inevitably, to redesign to provide the necessary protection without creating the problem that is prompting the defeat of the safety device. So, instead of a fire door that stays closed, it may need to be equipped with devices that automatically release them to close when a fire alarm is activated.
Go Beyond Restoration
When you encounter a defeated safety device, think of it as a signal, a call to action. If you’re qualified, restore it. If not, get it restored. That is not enough, though. If all that happens upon the discovery of a defeated safety device is that the device is restored, you can expect to find it defeated again. And again. And again.
When you encounter a defeated safety device, it is also important to take the next step. Find out why it is being defeated and then see to it that those reasons are addressed, be it with training, procedures, or engineering. Otherwise, the probabilities will eventually catch up to you and the safety device won’t be there when you really need it.
