Wednesday, November 2, 2016

Not a good answer

I read an article this morning about an explosion at a chemical plant in Germany that killed three people and seriously injured seventeen people.  The article said the preliminary investigation showed the cause of the accident to be human error.

That, my dear readers, is not a good answer.

To be perfectly clear, it is probably possible to blame every unintended consequence on human error.  One, we are not a particularly good species, and two, humans orchestrate millions of actions every day.  Even if the only human error was not recognizing the unintended consequence was available, that is still a human error.

As a safety professional, my position on this topic never changed.  If the consequence of error is unacceptable, you must put a safeguard in place so that the human can not make the error.  Safeguards are ranked in order of effectiveness.

The most effective safeguard is elimination.  Elimination is exactly what it sounds like, remove or eliminate the hazard.  One of the types of elimination used is substitution, where you use a less hazardous method or material.

Then there are engineering controls.  There are two types of engineering controls, passive controls and active controls.  Passive controls are controls that are just there, like impact absorbing bumpers on a car.  Active controls have to be deployed, either by human interaction, like putting on a seatbelt, or by a device, like the activator on an airbag.

The least effective hazard controls are administrative controls.  This is where rules, procedures and training are used to reduce the probability of error.  But since we're still talking about humans, very weak.

Finally there is personal protective equipment.  This is where protective clothing, respirators, hard hats, safety shoes, gloves, etc. come into play.  Sometimes, using personal protective equipment in addition to other controls is just the right answer, because personal protective equipment can reduce or remove the probability of life altering injury.

So, all of that is valuable information, no matter what you do for a living or what environment you find yourself in.

Many parents of small children use elimination on a regular basis as hazard control to keep their children safe.  Parents remove sharp objects, and generally control all items allowed in their children's environment.  They also often substitute harmful cleaning solutions with things like vinegar and baking soda.

We're all used to the passive and active engineering controls on our cars.  Most of us have circuit breakers or fuses in the electrical systems in our homes that disrupt the flow of electricity if there is an overcurrent situation.  Many of us have Ground Fault Circuit Interrupters (GFCI) protecting the electrical outlets in our homes.

And most of us also use rules, like "Don't run with scissors", "Look both ways before crossing the street", "Put your seatbelt on" to mitigate hazards that we recognize.

As I said earlier, though, none of us can see or imagine all the hazards that exist.  And when a hazard acts on anyone of us, that gives us all the opportunity to learn to guard against it.

Human error is not a cause of accidents.  It is a universal truth.  Humans will always make mistakes.  Hazards will always exist.  When terrible accidents occur, we should try to learn all that we can about what went wrong, what safeguard or system failed so that we can make the safeguards and systems better so that no future suffering has to occur.

We can take the easy way out and blame accidents on human error.  Or we can try harder to make the world safer for all of us by figuring out ways to protect humans from the inevitable errors that we make.


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