Page 18 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company

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4 Serious Incident Prevention

Investigators found the cause to be another failure to reinstall wing
screws. 6
In Hamlet, North Carolina, 25 people died in a chicken processing
plant fire because designated emergency exit doors were locked. 7
In Houston, Texas, an inadequately trained night clerk silenced the
switchboard buzzer indicating the need to activate the hotel’s fire
alarm system because “the noise annoyed him.” Ten people were
killed and 30 injured in the blaze. 8
In Dallas, Texas, three construction workers died when a crane col-
lapsed. At the time of collapse, the workers were positioned along the
crane boom approximately 12 stories above the ground. After re-
moving an 80-foot section from the front of the boom, the workers
apparently failed to remove the proper number of concrete counter-
weights to keep the structure in balance prior to swinging the boom. 9
In a Florida hospital, doctors mistakenly amputated the left leg of a
diabetic instead of the right leg as scheduled. With corrective sur-
gery, the patient became a double amputee. Eleven days later in the
same hospital, a patient died when a respiratory technician unhooked
the wrong patient. 10
At a major university, 12 students died and dozens of others were in-
jured when a massive bonfire of traditional but suspect design col-
lapsed during construction. 11

Since the mid-1980s, industry and many service organizations have
made great strides in improving performance in key areas including prod-
uct quality, customer service, productivity and cost control. Progress has
often been driven out of necessity to recapture market share and improve
profitability in the face of fierce competition. Performance management
principles including teamwork, empowerment, employee participation,
measurement, feedback, and positive reinforcement of individuals and
teams have been a cornerstone of the improvement process.
Is the progress in preventing serious safety-related incidents consistent
with the breakthrough levels of improvement achieved in other key per-
formance areas? Evidence indicates that progress has been less than stellar.
For example, a 30-year analysis of 100 large property damage losses oc-
curring in the hydrocarbon-chemical industry (Figures 1-1 and 1-2) indi-
cates that the frequency of incidents has remained high compared to
long-term historical levels. It is clear that breakthrough levels of improve-
ment have not been achieved. Serious incidents have continued to occur and
impact key company performance areas: safety, financial performance, em-
ployee relations, customer service, and company image.