I recently viewed the video from the US Chemical Safety Board (CSB) on the fire at Caribbean Petroleum Corporation in Puerto Rico in 2009 (you can see the video here https://www.youtube.com/watch?v=41QMaJqxqIo).
I was surprised to see many similar issues with the fire at the Buncefield facility in the UK (December 2005).
The idea of learning from the mistakes of others is something our parents try to teach us. We are taught to not repeat the mistakes of our parents, our grandparents, our extended family, our neighbours, and key people / organisations in history. We are also taught this in school (a key learning of history classes).
Many things that we learn at a young age now come naturally to us. Why does learning from the mistakes of others not come natural to us? I do not know. But I understand the need to do it better.
Back on the CSB, this video (https://www.youtube.com/watch?v=rjxBtwl8-Tc) shows how a practice in two very different industries (food processing and electric power generation) was common enough to cause similar outcomes (explosions).
So why do we continue to put our heads in the sand and not look at others when it comes to process safety? I do not know.
- Is it because people tend to rely on standards and regulations? If it meets regulations, it must be safe, right? A colleague recently told me about a fire in a reactor that “met regulations”.
- Is it because people tend to not take safety seriously when dealing with “safe stuff”? The Honolulu Molasses spill of 2013 highlights that problem.
- Is it because people and organisations tend to rest on their reputation? I can offer no solid proof, but look at DuPont for an analogy of a company that had a great safety reputation in the past, and has a less great safety reputation now.
By the way … looking back at my career, I can remember situations where I have been guilty of all three of the above (almost all of them when I was young).
I have become convinced that the ability to willingly learn from the mistakes of others is a key part of a good safety culture. And because the ability to willingly learn is difficult to quantify, I expect it is not part of any KPI – therefore it is difficult to implement.
I am also pleased to hear others think constructively about safety and safety culture. One of my former students recently told me that he thinks anytime one looks at a mobile phone while driving – it is a near miss. He says there is 1-2 seconds where the driver does not know what is going on. Since driving requires the driver to be in control at all times, this 1-2 second period is a period when the driver is not in control. I think his idea makes perfect sense, and I have added it to my safety thinking.
In closing, I would like to paraphrase one of my mentors. He said there are three ways for many men to learn (sorry ladies, the story does not work well for you).
<Category 1> He says there are men that learn by reading the instructions (the safe way, especially if the reasons are explained, but this puts a demand on the technical writer).
<Category 2> He says there are men that learn by watching others (another safe way, especially if the results are available).
<Category 3> And … he says there are just some men … the only way they will learn is to urinate on the electric fence.
My training business tries to encourage people to move into categories one and two, but my consulting business is happy for people to remain in category three.