The US Chemical Safety Board (CSB) conducts chemical accident investigations and issues findings and recommendations. Several years ago, it conducted an investigation on a refinery explosion in Texas that killed 15 and injured 180 persons. Here are some of its findings:
- “Cost cutting, failure to invest and production pressures” from senior management impaired process safety performance at the refinery.
- “Reliance on low personal injury rate” as a safety indicator failed to provide a true picture of process safety performance.
- There was a “check the box” mentality at the plant where people simply just checked off on safety procedures even though they had not been completed.
- “Personnel were not encouraged to report safety problems and some feared retaliation for doing so.”
- There were “numerous surveys, studies and audits identifying deep-seated safety problems” but management’s response was often “too little, too late”.
We can all learn from these fatal mistakes.
The issue of reward structure at manufacturing facility is a tricky one. Many companies offer bonuses to middle managers for meeting production deadlines. Fewer companies offer similar rewards for excellence in safety. And when they do offer reward on safety, it often pertains mainly to personal safety and not process safety. That is understandable since it is harder to quantify process safety. There are lots of safety indicators for personal safety.
One of the findings by the CSB was that the refinery relied too much on its low personal injury rate as a false indicator that the process was safe. Just because people are not getting injured working next to a building that is about to collapse does not mean that the building will not collapse.
Measuring the wrong thing is worse than not measuring anything at all.
Another fatal mistake this refinery made was that it failed to act on the findings of its own numerous studies and audits. What is the point of doing all these audits if you are not going to fix the problems?
The “check the box” mentality at this refinery is most likely a result of the lack of ownership and training on the part of the employees. If an employee does not feel that he is part of the safety process and does not understand the rationale behind a long check list that he is given to complete, he is likely to just check them off. That’s just human nature.
We can all learn from these mistakes.