Page 120 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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98 Serious Incident Prevention

pensing the proper quantity of material; unexpected changes in operating
pressures; a noise that has developed in a pump; instrumentation that has
ceased normal operation; an odor where no odor is typical; changes in op-
erating temperature; and unexpected changes in inventory level. The burden
for recognizing the occurrence of unplanned changes often falls upon indi-
viduals at the point-of-control operating level. Point-of-control personnel
must be timely in communicating evidence of significant changes and in
implementing corrective action. If drum-filling equipment malfunctions,
members of the drumming crew may be the only individuals in position to
suspend operations and initiate corrective action. However, the entire or-
ganization is dependent upon the individuals at the point of control to rec-
ognize the problem and initiate the proper response.
Minimizing the consequences from unplanned changes requires indi-
viduals at the point of control to have expert knowledge of the operations
for which they are responsible. Point-of-control personnel must also have a
clear understanding of organizational objectives. Employees who under-
stand organizational priorities and objectives are much more likely to take
the correct action when responding to the unexpected. Expert knowledge,
together with commitment to safe workplace objectives, is needed to help
ensure workplace “red flags” that often accompany unplanned changes are
observed and properly evaluated.
While traveling to lunch with Eugene Thomas, a first-level supervisor
and fishing enthusiast, I asked for advice on how to fish one of the area
lakes. My past attempts to fish this lake had always ended in frustration due
to the heavy underwater hydrilla fouling my lure on almost every cast. His
response was an enthusiastic dissertation on the best techniques for suc-
cessfully fishing the lake. Eugene detailed the procedure for rigging a “Bass
Assassin” to make the lure weedless while retaining the capability to hook
a high percentage of fish that strike. I was particularly impressed that his re-
search on the rigging technique included observing a professional bass fish-
erman who fished with the “Assassin.” Eugene encouraged me to be more
aware of the details—in particular, the locations of any openings in the un-
derwater hydrilla. The “Assassin” should be allowed to free-fall through
open pockets in the hydrilla to the lake bottom—where big bass lie in wait.
Even though Eugene has developed expert-level fishing knowledge, he
has remained eager to improve his knowledge and skills. He quickly detects
and accurately evaluates the significance of any changes in the fishing en-
vironment—a change in wind direction, water conditions, ambient temper-
ature, or the condition of his fishing gear. In fact, he recently shared with
me that he no longer uses the “Assassin” as his main lure. “Flukes” now
seem to be more successful for him.