Safety by default
Safety is culture. Safety is a mindset. Safety is a way of life. Safety is walking the talk. Safety cannot be achieved through empty talk but it has to be adopted as a signature of an organisation.
Every organisation is structured in three basic levels.
The entrepreneurial (top management), that is, policy and strategy makers.
Managerial and Supervisory level, those who convert and implement goals as tasks.
Working-level, the final implementors.
It is the responsibility of every individual within the organisation and also a collective responsibility of personnel at each level of the organisation to ensure safety.
By default, everyone wants to be caring and to work in a safe manner leading to the safety of the organisation, the safety of all personnel in the organisation, the safety of the public in general and the environment. If such default conditions and attitudes strictly prevail, the result should be a harmonious and caring environment free of accidents, for all, the society in general and our planet. But in spite of general agreement in principle, disconnects are formed at all levels and safety gives a slip. Accidents occur. Damage to machinery, personnel, money wastage, environmental damage.
Safety and caring
It is a general assumption that Safe working conditions prevail under caring management. Caring management appoints a qualified safety officer and gives him reasonable authority so that systematic efforts for following safe practices would be undertaken. But, does the concept of Safety go beyond the boundaries of responsibility of the safety officer, beyond the banners, safety apparel, safety equipment and safety training! Does the term “institutionalising safety culture” go deeper than perceived! To what extent it is right to say that safety and caring are two parts of the same coin!
As an effort to find the right answers, we will see here, with appropriate examples,
how the cases of accidents do occur and how incidences arising out of non-caring attitudes and non-caring work conditions do take place.
Whether accidents and non-caring attitudes are supplementary complementary to each other.
Whether accidents occur due to a non-caring environment and conversely, whether a feeling of “not being taken care of” arises in case of accidents occur.
These are negative vibes and detrimental to the well being of the individuals, the organisation and the public in general and these can have far-reaching effects.
Conditions conducive to unsafe working conditions
In an organisation or specifically in an industry, any work right from the conceptual stage, design, erection, commissioning, maintenance, refurbishment and modernisation cannot be treated as a stand-alone procedure or isolated work. It is always a part of the process and needs to be treated as such. We will now look at the factors which bring in negativity, cause the deviation from the default condition and cause disharmony. Some of the factors are,
Total lack of knowledge for working personnel regarding work at hand,
Partial knowledge of work at hand, resulting in risk-taking by working personnel,
Calculated risk-taking by working personnel on account for various reasons,
Callousness at any stage, due to Greed, selfishness, non-caring attitude
We are aware that great disasters such as the Bhopal Gas tragedy, Chornobyl atomic plant tragedy were caused by one or multiple among the above factors and which finally resulted in tremendous damage.
We are also aware of several incidences at reputed organisations where, undue risk-taking through not using proper work apparel, not using proper tools and equipment, knowingly or unknowingly, by haste or through callousness and also, operating the plant at threshold levels, working under unsafe conditions have caused accidents and severe damage.
If the postulate that the default tendency of every being is “to be safe”, is correct, then how do the accidents occur at all.
Role of communication
It is to be noted that the major factor that links all the above events at the organisations is “inadequate communication”.
The most important factor responsible for Negativity creeping inside a positive ambience of the organisation is disconnects caused within the organisation due to inadequate communication. Thereby, the disconnected activity looks like a stand-alone activity, kinks are formed in the armour and disaster is invited. Communication within an organisation is, therefore, required to be top-down, needs to be precise, comprehensive, without any presumptions and open to a continuous stream of bottom-up feedback.
Communication needs to be in writing and well documented. Some of the important forms of communication are,
the manufacturer’s instructions,
detailed descriptions of plant and equipment,
step by step work instructions, checklists,
standard operating procedures
These and many others need to be accompanied by Supplementary oral instructions as and where required, if, high standards of performance are to be achieved safely.
A few examples of accidents through deficit communication are given below and the analysis follows.
Example 1 (standard operating procedures and step by step instructions.)
At a sea shore-based thermal power plant, the equipment called a self-cleaning strainer was being commissioned. The strainer arm makes a wiper like reciprocating movement for which a reversible 415 volt AC motor was provided. At the end of the forwarding stroke of the arm, a limit switch operates which initiates reverse travel of the arm. The commissioning group consisted of young inexperienced engineers and technicians, with no prior field experience. After installation, a cursory check on the control wiring of the equipment was made and a trial operation was initiated. The cleaner arm went into a forwarding stroke but did not stop at the end of the stroke and the equipment was damaged. On investigation, packing paper was found in the limit switch which was not removed after erection. The commissioning instruction of the supplier had clearly mentioned that packing papers in the limit switch should be removed and the switches on both sides should be set by making an inching operation of the arm. Not reading the instructions properly, not understanding them, not getting them explained fully, incorrect presumptions about the ability of new staff etc led to non-compliance with the manufacturer’s instruction and resulted in the accident, damage and subsequent delay in project commissioning.
In this case, it would be incorrect to put the blame squarely on the inexperienced commissioning group. This example can be cited as an organisational failure. The training for newly recruited raw-from-college engineers and technicians was inadequate, the instructions from supervisory staff were inadequate and a checklist oriented commissioning procedure was not established by the management. Overall neglect of vital communication links created the disconnects and invited disaster.
Example 2 (Knowledge regarding assigned work, no risk to be taken)
In an Extra high voltage switchyard, hotline washing was being carried out. The agency which was carrying out the job had provided an experienced engineer. The station manager, under a caution order taken from the control room, was responsible for overall supervision. Suddenly a lightning arrester which was being washed under hotline (live) condition, shattered and failed. Investigations revealed that lightning arresters differ from other EHV switchyard equipment and they cannot be subjected to hotline washing. Failure due to unequal voltage distribution across the spark gaps was likely.
The lightning arresters were old equipment and hotline washing was a new technic. In their enthusiasm to introduce new technic and new technologies the management of the company had forgotten to check whether their old generation equipment was compatible with new-age technology. A disconnect in information due to inadequate communication.
Example 3 (need for standard operating procedures, good engineering practices)
Subsequent to the failure of a Current Transformer (CT) in an EHV switchyard, a replacement spare CT was brought from the store and after an insulation check, ratio check and high potential test it was installed and taken into service. This CT was part of the original supply and was stored for 6 years in dead condition. No one thought of conducting a tan delta test. The CT failed after 6 months. The supplier commented that although it was a hermetically sealed CT, such prolonged storage may cause degeneration due to traces of moisture finding their way inside. Hence tan delta test should have been conducted to assess the condition of the insulation media.
Here the communication inadequacy is seen in not contacting the manufacturer {obviously the most knowledgable expert in the subject matter) for advice under this specific condition. Adoption of good engineering practices such as appropriate diagnostic testing should be part of the safety culture of the organisation.
Example 4 ( good engineering practices)
Cable laying and cable connection are supposed to be mundane jobs and many times not adequately supervised. It has been noted that mistakes such as earthing the HV cable armour at both ends thereby inviting the possibility of damage due to circulating current, pulling unarmored cables through provisionally laid conduits, thereby damaging the jacket of cables, giving acute bends to cables thereby damaging single strand conductors of cables, have often been done due to inadequate supervision. Such errors come to light only after some disastrous results due to the errors.
It should be noted that no task should be overlooked as an unimportant task. Safety has neither physical boundaries nor time tags. Disconnects due to such neglect are like time bombs ticking slowly and eventually exploding with widespread damage. It is the job of caring management to remove such disconnects.
Example 5 (cross-functional knowledge, third party clearance of sensitive work)
At a coal-fired thermal power plant, a maintenance team undertook to carry out the work of poking and loosening ash lumps through a manhole of the ash hopper. The supervisor took just a caution order. The plant was in service, the ash hopper stream was not isolated. Unfortunately, rat-holing had taken place in the dry ash accumulated in the hopper and as the hopper manhole was opened and poking was done and ash was loosened, the negative pressure of the furnace was exposed to the atmosphere through the manhole. The hopper imploded due to negative pressure inside. This caused unit tripping, damage to the boiler, and loss of life.
Here an important point to note is that the maintenance supervisor and the operation engineer were substantially knowledgeable regarding their own job but lacking in cross-functional knowledge. Hence neither of them could perceive the possibility of an accident of the kind that occurred, howsoever remote the chance of such a thing happening could be.
The maintenance work as above may have to be undertaken rarely but that does not make it a stand-alone job. It is still part of a process and the operating procedure for the same should be standardised. Further, when critical equipment, working at critical levels of operating parameters is involved, a system of third party clearance should be introduced.
Caring governance
The definition of Caring Governance does not stop at Benevolent Governance.
Good Engineering Practices shall be at the core of Caring Governance. It includes inculcating the habit and attitude of safe working at all levels of the own organisation and partnering the same with all the contractors, vendors, sub-vendors, and stakeholders of the organisation. Caring Governance begins at the conceptual stage of the organisation and checks and balances need to be installed at all important nodes to ensure no deviation from the adopted principles.