Page 180 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company
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Reinforcement and Corrective Action 149
12. Managerial methods
Equipment Factors:
13. Design configuration and analysis
14. Equipment condition
15. Environmental conditions
16. Equipment specification, manufacture, and construction
17. Maintenance/testing
18. Plant/system operation
External Factors:
19. Human or nonhuman influence outside the usual control of the com-
pany
Responding to Red Flags
Near misses and red-flag observations should also serve as triggers for
corrective actions. The 1996 crash of a 763-foot freighter into a New
Orleans riverfront shopping center made national headlines as an apparent
“freak” accident. However, investigation revealed that of the 500,000 vessel
movements per year through the Port of New Orleans, about 200 vessels per
year lose steering capability, with about 30 vessels making contact each
5
year with bridges, docks, or other vessels. Rather than a “freak” incident,
this was a serious incident waiting to happen.
A performance measure that indicates unsatisfactory results is another
type of red flag that must be addressed. Teams must review measures fre-
quently to ensure early detection of unsatisfactory performance, to deter-
mine actions for correcting performance, and to ensure timely
implementation of corrective actions. For example, if audit scores for per-
formance of lock-out/tag-out procedures indicate deficiencies, the organi-
zation must act firmly and with a sense of urgency to understand and
correct the problem. To do otherwise places the organization and its em-
ployees in extreme jeopardy.
Minor accidents, near misses, performance deficiencies, and other red
flags serve as precursors to serious incidents. An effective system must be
in place to capture and evaluate these precursor events. When an early warn-
ing signal indicating the potential for a serious incident is identified, proac-
tive and timely implementation of corrective action is clearly a challenge
that must not be ignored.
