Why didn't BASF take the necessary precautions and implement safeguards to prevent the release of known hazardous chemicals? Is it due to a lack of accountability or poor execution or unsafe material conditions? j_twois
Good point and I agree with your statement in cases where there is a "clear and present danger" or else a sense of heightened awareness. Lack of ownership breeds complacency, however, and this inattention to detail hides many of the dangers. If you don�t know what the hazard or risk is, there is no way to combat it. Know thy enemy!
Hi Rhawrela---sorry about the play on words�all my other toys were taken away :-(
Seriously, your statistics do not fall on deaf ears although I firmly believe "shiny happy people" go a long way in preventing accidents. It's fortunate the 'sabotage' category falls within minor the 4% range because a college professor or an insurer like M&M are probably not equipped to deal with the psychology of dangerously deranged people. Just think how much higher that 'contributing factor' number might be if employers didn�t offer an EAP.
As a further step in the right direction, I�m pleased to see the predictive aspect of future criminal acts more in vogue. Most of us 'ordinary' folks can already detect a powder keg ready to explode.
Hi SCB. I should have gone one step further in my explanation of M&M's Causes of Failure. From the Primary Failure breakdown, as given in my post, M&M break it down further into Root Causes. From the list of Root Causes you get a listing of Contributing Factors. By the time you have taken 100 incidents and broken them down to root causes, you find that Inadequate Engineering Controls show up in 87% of the incidents ... enough learning lessons to last a life time ... and, as Rat points out, too voluminous to teach young engineers.
Root Causes in the Sabotage/Arson class get into things like childhood abuse, cultural factors (terrorism), etc., etc. In one such case a Mech Eng'g Prof at a Montreal Univ. was disgruntled because he claimed other Profs were stealing his research ideas. They claimed he was stealing their ideas. The Univ Admin. sided with the others. So, he took a rifle, shot and killed 3 of his competitors and the Administrator. Root causes were traced to cultural factors. In his native country, life was pretty cheap and they lived by an eye for an eye. Protecting his family and his honour insured him a place in his heaven.
In another Montreal case, a male entered a 3rd year mechanical engineering class and shot and killed 9 female engineering students before he killed himself. He had been turned down in engineering because the university felt it had to admit a higher % of females. Root causes? It wasn't that simple, but it came down to child abuse.
Hi SCB. You are playing with words again. A symptom of a cold is a running nose. It can also be a symptom of a number of other ailments. A contributing factor for the cold can be the person played golf on a cold, rainy day without proper, protective clothing. I learn nothing from the symptoms of a cold and quite a bit from the contributing factors. This is the reason M&M present part of their analysis as contributing factors.
M&M also present the same data with the following analysis as Causes of Failures:
Mechanical Failure - 41%
Operational Error - 19%
Unknown - 17%
Process Upsets - 10%
Natural Hazards - 5%
Design Error - 4%
Sabotage/Arson - 4%
The last item is quite disturbing as here you get into the area of human behavior. No question it plays an important role. If you believe the sabotage theory in Bhopal, it is easy to see how a disgruntled, uninformed employee could have set off the run-away reaction. Many humans are revengeful. The trick is to identify which ones are revengeful and to help them get over this problem. Ref: Harvard Business School, MBA 101: The Administrator: Cases on Human Relations in Business, 1965.
Hi jt. Keep in mind the 87% number covered a time frame from 1960 to 1989. Technology changed quite a bit over that period and the reasons for inadequate engineering controls kept pace. What was a simple level control failure in 1960 is now possibly a failure of software, or possibly a failure of computer hardware, or possibly a failure of the controller, or all three.
Many of us can remember staring at a group of CRTs during a plant upset, 20 lights flashing, 20 horns going off, flows and pressures off the charts, trying to figure out what the hell was going on? Upsets were much simpler in the 60s. As ODH says, there are very few oldtimers around who really know the process. ODH is one of the last of the Mohicans.
Yes I think management is still concerned about the 87%. At least one guy on the Dow Board of Directors is, the only one with a manufacturing background. He might not remember it but I worked on problems in his PO plant many years ago. I think Rat hit the nail on the head with his last comment on bean counters.
I did a bit of consulting after I retired in 93. Too frustrating working without the resources I had available at Dow. I prefer teaching at UWO. I'm one of the guys xfofww talks about who is struggling with the research mentality.
I agree with most of your post and I can safely say that I am a product of a school that placed more emphasis on research then manufacturing. But having said that looking at the varity of industries that my fellow chemical engineers ended up in I do not know how it would even be possible to cover all of the hazards and practicalities of manufacturing involved. We had people go to the food industry, oil, chemicals both organic and inorganic, paper, and yes even a few of us into mining. What is a hazard for us in mining like high wall failures and leach pad blow outs are not even on most peoples radar screens. By the same token I have a class mate who works in the oil business and handles gas sweeteners. His worries are different then mine even if we are both dealing with toxic gases (Personally I will take our hydrogen cyanide over his hydrogen sulphide any day but that is a different subject.)
Think that in the end the safety all boils down to the company and how they really feel about things other then what is written in the handbook. Most people in the industry know of places where safety is just a slogan and the hedquarters people are just interested in how much product can be pushed through the facility with out regard to safety or quality.
Now I don't want to sound like I have something about bean counters since I do know some who actually understand manufacturing but cannot help but think that much of the current problems reside in the fact that much of the current industry management has never worked in a process operation and their experience consists soaly of looking at balance sheets.
'Why haven't schools and company management, unions addressed this weakness and eliminated this "trial under fire" for people handling hazardous chemicals?'
In general, manufacturing is considered a less glamorous part of any industry. R&D, engineering, marketing are all viewed as more desirable. Many engineering schools slant their BS programs to preparation for a higher degree (R&D path) and give manufacturing short shrift. In general, schools that have co-op programs do a better job of turning out manufacturing types. Examples of these schools include Georgia Tech, Purdue, WVU-IT, VaTech. Even so, the freshouts have a lot more to learn. In heritage Carbide, engineers in a new production unit (plant, in Dowspeak) had to pass a test before they could independently direct the work of others. Freshouts typically needed three months to be able to qualify.
In the Kanawha Valley of WV, there is a program in the vo-tech school system to train chemical plant operators. However, the training necessarily is generic because the chemistry varies from company to company and within company units. Typically, a new hire operator has to work under the direction of an experienced operator for about three months, following a predefined study plan, to be able to pass the written and hands-on testing to be certified on one job. Most operators become certified on three to five jobs so they undergo a lot of training before they are turned loose, not trial under fire.
1. My ISP got folded into Yahoo somehow. As a result, I can no longer use 'fofww' as an alias. "Yahoo is aware of this problem and is working to solve it." (I am more distressed that Yahoo's fancy new customized browser does not support the scroll wheel on my track ball, a Logitech Marble+, not something exotic. At least Yahoo did not wipe out my old browser.)
2. I have recently been synergized, so I am no longer a Faithful Old Fart With Watch (Carbide term for a longtime employee). I am an eX Faithful Old Fart With Watch.
The contributing factors are symptoms, not causes. Delving deeper into the etiology requires an understanding that humans are essentially self-centered. Keeping this in mind, employees are like renters. In general, renters don�t give their dwelling the same TLC as homeowners do and are not responsible for the upkeep. There is nothing in it for them. Employers, on the other hand, are like landlords. They want to expend the minimum cost and effort while maximizing profit.
Why should we expect the psychology of employees (the "renters") to differ when the CEO�s (the "landowners") often earn over 600 times the rate of the average employee and are always trying to squeeze out even more? Employees may be terminated "with or without cause" in the same way renters may be evicted (though, arguably, renters have more rights). The ability of employees to make improvements are limited, as are renter�s choices to personalize or make changes. People who have no claim will not show the same "pride of ownership" as those who have a personal stake. How can a landlord expect a tenant to "safeguard" a rented unit in the same way he/she might protect a home they had some ownership in? Apply this concept to industry and it's no wonder there are so many incidents, accidents and near misses.
The difficulty is, I�m not sure how to measure this variable as a �contributing factor�. How to correct it appears much more straight forward---it�s pyschology 101.