The Bureau of Safety and Environmental Enforcement (BSEE) issues regular Safety Alerts. These Alerts are invaluable because they describe actual events. They are also powerful educational tools.
Generally, the Alerts describe and discuss occupational safety issues. It is therefore useful to also look for any process safety lessons that they may also provide. With that thought in mind, let us take a look at BSEE’s Alert No. 463 ‘Adaptation and Modification of Tool Results in Injury’.
Occupational Safety Recommendations
BSEE developed the following recommendations from this incident,
Review safety alerts with all relevant employees.
Review the corrective actions implemented by the operator.
Ensure proper tools are available.
Review all Hazard Analysis policies and procedures to ensure hazard identification and mitigation card / compass card is utilized and understood and used to circumvent the regulatory requirements of 30 CFR 250.1911.
These are good recommendations, but they do not address the core question,
Why did the worker do what he did?
In order to answer that question, we should think in terms of process safety management.
Management of Change
Process safety programs typically contain somewhere between twelve and twenty management elements. One of those elements is Management of Change (MOC). The four recommendations from BSEE do not refer to MOC, yet the root cause of the incident was, in fact, uncontrolled change.
The fundamental feature of Management of Change is coming up with a definition for the word ‘change’. Conditions on a process facility are changing all the time, and the vast majority of these changes are within the normal operating/safe boundaries. The key question is, ‘When is a change a Change?’, i.e., what are the criteria that trigger the MOC program?
Management of Change programs are normally thought of as being a formalized system, often using specialized software. Yet, like all of the elements of process safety, MOC is basically a way of thinking (which is why the element ‘Employee Participation’ is the most important element). In the case of this incident, the worker could have said to himself, “You know what, by cutting this handle of this wrench I am changing the maintenance system. Maybe I should back up and consider my options”. Had he done so, he might have stopped what he was doing, and asked his colleagues for other ideas for conducting the work.
In other words, Management of Change is not to do with meetings and software and reports — Management of Change is a way of thinking.
