Summary Bullets
Failure to know the hazard yields fatalities
Good intentions lead to casualties
Failure to learn from lessons learned
Background
Unfortunately, this case history involves a lot more than one fatal incident, and may number in the hundreds, thousands, or more. It proceeds like this. First, there is a release of some toxic or asphyxiant, either noticed or unnoticed. A worker becomes exposed, and collapses. Another worker, all too often a close friend or relative, sees the person down and rushes to help, only to be overcome and collapse also. Then, sometimes, comes a third, a fourth…
What Happened
Clearly it is possible that a worker could collapse from heart attack, stroke, illness, or dehydration. But we who work in hazardous material industries know deep down that if we are in a hazardous material facility, toxic or asphyxiant exposure was more likely to cause a person down. We know we should pull the alarm and notify the emergency responders. We know that the situation must be assessed wearing respiratory protection. But the person down is our friend or our family member, and they need help. How can we make sure we do the right thing? How can culture help us overcome this problem?
Is there a gap of trust that the proper emergency response can be done on time? How can we ensure this trust? Is there a gap in vulnerability? Do we dismiss the possibility that toxics or asphyxiants could be released, and therefore ignore that possibility when we react? Do such incidents occur without warning? Do we see warning signs before they ever occur, but do not feel a sufficient imperative for safety to prevent them in the first place?
This type of incident happens often enough to suggest that we are not learning from it and advancing our ability to prevent it. How can we learn and implement learnings more effectively?
Is there a gap of trust that the proper emergency response can be done on time? How can we ensure this trust? Is there a gap in vulnerability? Do we dismiss the possibility that toxics or asphyxiants could be released, and therefore ignore that possibility when we react? Do such incidents occur without warning? Do we see warning signs before they ever occur, but do not feel a sufficient imperative for safety to prevent them in the first place?
This type of incident happens often enough to suggest that we are not learning from it and advancing our ability to prevent it. How can we learn and implement learnings more effectively?
Safety Culture Focus
Strong leaders promote hazard awareness among the workforce.
A questioning environment is critical to identifying and changing risky protocols.
Open and effective communication can promote mutual trust among organizations.
Safety Culture Focus Note
**Only 33% of those surveyed indicated emergency response was a strength in their organization.**
Source File
E.43.pptx
(324.8 KB)