“The only real mistake is the one from which we learn nothing.” — Henry Ford I know a young woman whose relationships are in a constant state of turmoil. She keeps picking the wrong guys and each relationship ends in heartbreak. “Why do I keep making the same mistake over and over?” Why indeed? I [...]
“All I know is what I read in the papers.” — Will Rogers When there is a catastrophic release of highly hazardous chemicals, I want to know about it. I want to know what happened, why it happened, and what I can learn to keep it from happening again. I go to news accounts. All [...]
“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. [...]
“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. [...]
“By failing to prepare, you are preparing to fail.” — H.K.Williams On July 18, 2019, two people were injured after a chemical fire broke out at Diamond Chemical Company in East Rutherford, New Jersey. At least one of the chemicals involved in the fire was chlorine, which is poisonous, especially as a gas. When it [...]
“If your house were burning down and you could take away one thing, what would it be?”…”I’d take the fire.” — Jean Cocteau, interviewed by André Fraigneau The images of the Notre-Dame de Paris Cathedral burning broke my heart. I am grateful that people and organizations around the world have vowed to contribute to the [...]
“It’s not how we make mistakes, but how we correct them that defines us.” — Rachel Wolchin One of the most common recommendations made as a result of incident safety investigations is “improved training,” especially when the investigation concludes that the incident was the result of an error. It is not because training is so [...]
“The failure of a layer of protection to prevent an incident is not the initiating cause of the incident.” The United States just joined much of the world in grounding the Boeing 737 Max 8 and Max 9. The tipping point was not the crash of Indonesian Lion Air Flight 610 into the Java Sea [...]
