“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 [...]
“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. [...]
“Facts are stubborn things, but statistics are more pliable.” — Oscar G. Foellinger, 1927 As an engineering student, I once used empirical data to solve a design problem. The approach gave a reasonable answer, but my professor scolded me. “Mere curve fitting,” he sneered. “Good engineering requires working from first principles.” I didn’t agree then, [...]
“But how they can be charged with negligence because they were not wizards, appellant’s brief does not make clear.” — Osmond K. Fraenkel, successfully arguing before the New York Supreme Court, 1935 In a world where companies tout “Zero Incidents,” not as an aspirational definition of perfect safety, but as a measurable and achievable target, [...]
“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. [...]
“Umpires don’t make the rules. They apply them…They make sure everybody plays by the rules. But it is a limited role. Nobody ever went to a ballgame to see the umpire.” — Supreme Court Chief Justice John Roberts A call about doing a PSM audit usually begins with a question from the caller about whether [...]
“A prudent question is one-half of wisdom.” — Francis Bacon There are about a gazillion “best” ways to do HazOps. What they all have in common, however, is that they use worksheets that are set up as tables that look at deviations in a node. For each deviation, a HazOp team considers “Causes”, “Consequences”, “Safeguards”, [...]
“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 [...]
“If the government wanted people to drive safely, they’d mandate a spike in the middle of each steering wheel.” — Gordon Tullock We call economics “the dismal science.” Economist Gordon Tullock certainly reinforced that idea when he applied the economic phenomena of risk compensation to driving safety and suggested that we would all drive more [...]
