Summary Bullets
Failure to consider safety in the change process
Urgency takes precedent over safety
Background
Issuing safe work permits were activities used to help ensure the hazardous work was fully prepared before any work began. In a large facility, these permits (e.g. Safe Work, General Work, Hot Work, Confined Space Entry, Line Breaking, and others) had been issued by the on-duty operators.
The very large number of permits being sought at the beginning of day shift would overwhelm the board operator and completely distract him from running the equipment. To address this problem, the company appointed a set of permit approvers especially for this “rush hour.”
The very large number of permits being sought at the beginning of day shift would overwhelm the board operator and completely distract him from running the equipment. To address this problem, the company appointed a set of permit approvers especially for this “rush hour.”
What Happened
These approvers were three other Operations personnel, who sat in a conference room in the control room building. Workers seeking permits lined up to see one of these three approvers. The approvers reviewed the permit presented to them and then signed. This allowed them to work very efficiently, allowing day shift work to begin.
However, the three permit approvers never left the conference room during this process. They cannot from there observe the physical location of the work, and in their rush to issue permits they asked only cursory questions of the permittees.
What cultural gap allowed the Safe Work Permit process to go from bad to worse?
However, the three permit approvers never left the conference room during this process. They cannot from there observe the physical location of the work, and in their rush to issue permits they asked only cursory questions of the permittees.
What cultural gap allowed the Safe Work Permit process to go from bad to worse?
Safety Culture Focus
Strong leadership avoids sacrificing safety for production.
A questioning environment is critical when process or procedure changes are made to identify potential risks.
Failure to consult system experts can undermine process safety.
Safety Culture Focus Note
**Only 51% of those surveyed indicated procedures were a strength in their organization.**
Source File
E.23.pptx
(323.11 KB)