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Take Control of Problems in Your Process! Part I – Industrial and Product Accidents

Posted: July 15, 2016 at 7:09 pm   /   by   /   comments (0)

Take Control of Problems in Your Process!
Part I – Industrial and Product Accidents

Disclaimer:
The views and opinions expressed in this article are those of the author(s) and do not necessarily represent the thoughts, plans, policy, strategy or position of any agency or department. Analysis performed within this article are only examples and based only on very limited and dated open source information. Assumptions made within the analysis are not reflective of the position of any company or organization. The author cannot be held responsible for any use which may be made of the information contained therein. Links provided in this article points to the external, third party websites and not guaranteed to remain active at all times.

Metal Recycling Plant in London, UK

Sadly, there was nothing that could be done at the metal recycling plant in London, where 5 men lost their lives and one suffered serious injuries. Investigation to work out what caused the accident may surface issues in company’s procedures and process. There could be some improvement under the union pressure or due to regulatory penalties, but the human loss is irreversible. Serious problems of this nature continue to exist if risk mitigation strategy is ineffective and risk is not reduced to the maximum extent possible.

Most of the time, unusual adverse events happen only once but these have lasting impact on the lives of affected individuals and their families. An unusual adverse event although considered undesired and unsafe if continues to exist takes the form of a systemic issue. Systemic issues progressively lead to several small issues compounded together and remain unnoticed. If ignored and not monitored or addressed properly, these issues grow in severity and damages are evident. Earlier in 2012, the same scrape recycling company was fined after an accident in which a worker’s arm was trapped in machinery. It is understanding that actions were taken. Were they sufficient and effective? Three years later, another accident happened that was much more severe, 5 were pronounced dead. News Link (July 7, 2016).

The Major Problem in the use of Penicillin – an example

Potentially dangerous situations affect every individual involved if the first signal and outcome of a procedure or process is ignored.

The event described in the opening passage reminds me of an allergic reaction to an allergen in sensitive individuals. If a subsequent exposure is not avoided, the allergic reaction grows in its severity. Body’s watch-dog-system reacts with maximum intensity at a later time.

Reaction to penicillin may be mild on its first exposure in sensitive individuals, however, if ignored and not documented in the medical history, subsequent reaction is always intense. If immediate medical assistance is unavailable, the individual suffers life-threatening anaphylactic reaction, which can be deadly. This is how potentially dangerous situations affect every individual involved if the first signal and outcome of a procedure or process is ignored.

Repair Shop in Columbus, USA

A 17 year old pinned in a machine at a Columbus repair shop last week died of his injuries. The matter is under investigation. News Link (July 4, 2016). Police said its preliminary investigation revealed Babcock was cleaning out scrap metal pieces from under a laser cutter when the machine engaged and came down on him.

The Most Important Thing 1

In industrial practice, the first most important thing is to look for opportunities to improve the procedures and process. In busy industries, sometimes when a production process is run for a long time, there is potential to mess with it, in particular, if there is a lack of management support.

In industrial practice, the first most important thing is to look for opportunities to improve the procedures and process.

This is common in an environment with busy production schedules, work pressure, forced reduction in production cycle times, poor maintenance of machinery, lack of safety checks and/or first aid equipment, insufficient operator’s instructions, inadequate assessment of the training needs and human ability to perform a specific activity. Sometimes if everyone is happy and there is no complaint in the production or supply chain (from producer to the customer), the process leading from input to output evolves with time and the standard procedures and safe practices are violated. If the management is negligent and communication is poor within organization, there is also clear violation of the respective laws and regulations.

Sometimes, workers adapt an action or procedure that appears comfortable to an individual but has inherent dangers. Unfortunate events are not rare, but most of the time happen once in a company. In developed countries, the response is instant and actions are appropriate and there is usually no compromise in adapting the best in safety measures. However, in developing countries, several events of this nature remain unreported and risks continue to exist forever.

Garments Factory in Dhaka, Bangladesh

A factory building collapsed outside Dhaka, in 2013. The disaster killed 1,135 workers, while 2,515 other injured were pulled from the rubble. It was one of the world’s worst industrial disaster in history. Large power generators placed on illegally constructed upper floors to house garment factories caused cracks in the building structure – a disaster was waiting to happen. News Link (May 22, 2103).

Industrial accidents are most common when there is a lack of support from the management.

The Most Important Thing 2

In my experience, industrial accidents are most common when there is a lack of support from the management. People need to learn about their rights; share their views on issues that matter and voice concerns over the potential dangers.

Workers are usually hesitant and do not question or ask for clarification if any of the operating procedure is unclear, equipment is malfunctioning or the machine is difficult to operate in the existing (poor) conditions.

In reality, workers at the lowest level in organization are the first to notice discrepancies in results and dangers in running a procedure or process.

Dan Corbett in a recent article has stated that providing a forum where people feel free to ask questions is the right approach.

People feel honoured when engaged in a blame-free environment, have no fear and share on-the-floor issues in advance of the system failures or accidents.

In reality, workers at the lowest level in organization are the first to notice discrepancies in results and dangers in running a procedure or process. If the line-staff is afraid and have no trust in their immediate supervisor, issues of any scale are hardly get communicated upward and the results are disastrous – financial and/or human loss is evident.

Paraffin Delivery to a North American Company

A company in North American uses a heavy load of White Petrolatum in its products on a regular basis. The product is always delivered in a molten state regardless of the weather conditions. Molten product, heated to 80 oC or more, is pushed with a force feed pump from the delivery truck through meters long (roughly, 200 m – 300 m) clamped rubber pipes and delivered at a distance directly into the storage tank. In an event of emergency, there is no mechanism or device to control the pressure and product flow at the receiving end. Two-Way Walkie-Talkie is used to communicate the start and stop functions between the truck driver and factory worker.

On the receiving end, a worker stands about 15 feet above the ground on a tiny platform surrounding the large capacity stainless steel receiving tank and holds at the same time a Walkie-Talkie and the end of the rubber pipe that delivers 100’s gallons of molten paraffin in wide opened stainless steel container. It’s unknown if there was any adverse event or fatal injury reported in this company.

People feel honoured when engaged in a blame-free environment, have no fear and share on-the-floor issues in advance of the system failures or accidents.

The company workers hesitate to communicate on-the-floor issues or are unaware of the potential dangers inherent to the procedure or process. There is obviously no support from the management to spend resources and adopt safe practices. As I stated earlier, unfortunate events are not rare but most of the time happens once in a company. The matter is of grave concern, safety in the company is questionable and workers are always in danger. White petrolatum, hard or molten, is oily and if accidentally spilled the glossy mirror finished surface of the 15’ high standing platform, floor and foot ladder (actually used in this company, the tank is approached through the same floor) presents a lot more danger – slip, fall, trap in the tank or surrounding machines are just few to name and could lead to several inter-related potentially dangerous accidents.

Product Design Considerations

Product design issue is another area, where not much work is being done to overcome fatal accidents.

IKEA’s Chest and Dressers

Recently, IKEA announced recall of some 29 million children’s chest and dressers that resulted in 17 injuries to children, including a 22-month-old Minnesota boy who died after the IKEA announced a repair program to prevent tip-overs in 2015. News Link (June 28, 2016). An additional three deaths – in 1989, 2002, 2007 – were blamed on other IKEA dressers and chests that tipped over and pinned children.

IKEA’s recall includes 4 type drawer products sold between 2002 and June 2016. It includes adult versions in addition to the children models. To avoid potential danger in the future, should sufficient measures have been taken in response to the deaths reported in the past, lives in 2015 could have been saved. IKEA has announced that customers can receive a full or partial refund or request a free wall-anchoring repair kit. The human loss is irreversible.

Tesla’s Autopilot

Tesla’s Model S autopilot is under investigation as a result of a recent death. Company believes the system is designed well and reliable. Market watch has this story and YouTube videos: Joshua Brown owned the car since July 2015 and logged about 39,000 miles before he posted a video showing how he was saved from a collision on April 5, 2016. Another video shows a 70-year-old grandmother sitting behind the wheel and basically wringing her hands, saying, “Oh my,” and anxiously exclaiming: “Oh, there’s cars coming. … Oh, where’s it going?”

The sensor camera on Joshua Brown’s Tesla Model S failed to identify a tractor-trailer turning in front of him on Florida highway in early May 2016. Autopilot-engaged Model S collided with the trailer in a fatal accident. The agency and automaker said that Brown’s Model S sedan did not automatically brake when it failed to distinguish between the sky and a partially white tractor-trailer turning in front of him. News Link (July 12, 2016).

Communicate well with your people in determining and renewing their responsibilities, priorities, objectives and authority.

Impact of Organizational Accidents

Controlling risk in the workplace to prevent accidents is a team effort that is supposed to function at its best only with management support. This association could potentially save lives as well as negative impact on company’s reputation and financial position.

Attempts to Prevent Accidents

Second part of this series will focus on risk mitigation strategy in an attempt to control and prevent accidents. Until then stay safe, communicate well with your people in determining and renewing their responsibilities, priorities, objectives and authority. Look further into your company’s policies and procedures and update through regular open meetings. Encourage participation and feedback at all levels, investigate along the vertical and horizontal lines, involve the process owners and line workers, and work objectively to establish a safe workplace.

Impact of Organizational Accidents! – Infograph originally published by the author on December 12, 2015

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Author: Anjum Shafi
Quality Auditor, Exemplar Global