Accident Summary: A worker drilled into the top of a five-gallon liquid propane tank with a ¾ inch drill, causing a nearly fatal near-miss of an explosion in a gas storage area.
Management’s Action: Discipline the worker; send all shop personnel to additional training; rewrite shop procedures to include a section prohibiting drilling into five-gallon propane tanks with hand tools.
Did management’s actions make sense? It is what many organizations do when faced with an accident.
Let’s get a little background information. This company has and uses a lot of five-gallon Freon tanks at their facility. They have established a gas storage area outdoors for storage of the used tanks for the purpose of recycling the tanks. To do so, they have to make sure the tanks are properly depressurized. The system for depressurizing the tanks was to – you guessed it – drill into the top of the tanks with a ¾ inch drill.
For some of their production processes, this company also had some propane tanks. And someone had started putting the used propane tanks in the same gas storage area. And it was easy to confuse these two types of tanks. They were about the same size and color. You see the problem now, right? The company created what is called an error trap. They made it easy to make a mistake.
The above is a summation of the opening story in a short book called “Pre-Accident Investigations” by a giant in the safety world, Todd Conklin. As Todd says in his book, “Humans make mistakes. People are fallible, and even the best of us make mistakes.” This makes the seemingly common organizational goal of zero accidents almost impossible to accomplish.
So what can we do? Are we destined to work in an unsafe place? OSHA’s General Duty Clause requires all employers to provide a safe place to work. How can we accomplish that?
Todd Conklin also offers these sage statements:
“Safety is not the absence of events; safety is the presence of defenses.”
“Safety is the ability to work to perform work in varying and unpredictable workplace environment.”
A favorite phrase of Paul Gantt, SCM President is this, “Make it easy for your employees to do the right thing and hard for them to do the wrong thing.”
Pre-Accident Investigation is more than looking at an accident event or incident and deciding what the employee did wrong, which is casting blame. It’s creating a safe working environment.
Look around the workplace to determine what might cause someone to work unsafely. Talk to employees, ask them what could make their jobs safer. A good question that can be asked is this, “If your boss gave you $10,000 to spend on making your job easier and safer, what would you spend it on.” The responses might be the defenses that Todd is referring to.