“The more things change, the more they remain the same.” — Jean-Baptiste Alphonse Karr When I was a young engineer living in a small town in central Massachusetts, I would walk into the town center to pick up groceries and go to the post office. On the way, there was a body shop. I got [...]
“We must accept human error as inevitable - and design around that fact.” — Donald Berwick The idea of human error and its contribution to industrial incidents has been the center of debate in recent years. If you’ve been part of more than one incident investigation, you’ve probably experienced an incident being attributed to human [...]
“While devastated at this unimaginable loss, we are so very proud that Ryan died while trying to protect his fellow employees and restaurant patrons.” — family of Ryan Baldera On November 7, 2019, a restaurant employee in Burlington, Massachusetts was overcome by fumes from a “strong chemical cleaning agent” and died. Thirteen others were taken [...]
“Fear is often our immediate response to uncertainty.” — Gabrielle Bernstein In 2001, when the CCPS book, Layer of Protection Analysis: Simplified Process Risk Assessment, “the purple book”, stated that human response is “a relatively weak protection layer” and “less reliable than engineering controls”, many people were willing to accept that piece of conventional wisdom. [...]
“Those who cannot remember the past are condemned to repeat it.” — George Santayana Our offices on Cherokee Street exist in the midst of a vibrant Hispanic community. So here in our neighborhood, Dia de los Muertos is in getting in full swing and will be observed through November 2. Dia de los Muertos, the [...]
“For Fools rush in where Angels fear to tread.” — Alexander Pope I once led some process safety training that involved people from several different plants from around the world. After almost a week together, the people in the training became pretty comfortable with one another. One of the last topics of the training was [...]
“When you gamble with safety, you bet your life.” Slogan on an industrial entrance mat The biggest obstacle to getting people to heed safety training is that unsafe behavior does not result in certain death. The problem with a safety slogan like, “When you gamble with safety, you bet your life,” is that most people, [...]
“Experience: that most brutal of teachers. But you learn, my God do you learn.” — C.S.Lewis We all learn from experience. When it comes to brutal lessons, though, it is better to learn from someone else’s experience. In the course of our work, clients have shared some experiences with us that everyone can learn from. [...]
“How can you trust a man who wears both a belt and suspenders? The man can’t even trust his own pants.” — Henry Fonda as Frank, in Once Upon a Time in the West There’s a cliché in the movies that involves a paranoid urban apartment-dweller with a dozen or more locks, deadbolts, chains, and [...]
“I did everything right. I don’t understand why it happened.”— Aleksandr Akimov, Chernobyl engineer You’ve probably heard of the new HBO miniseries, Chernobyl. The show is a fairly accurate retelling of the events preceding and immediately follow the nuclear disaster that occurred in Pripyat, Ukraine on April 26, 1986. Like any dramatized television production, it [...]
