Why horrible things can happen to good people

Nancy Grossman

Nancy Grossman, head of the ES&H section, wrote this week’s column.

First and foremost, I want to thank all employees who took the time to complete the safety survey last month. We had a fantastic response rate of 73 percent. This high level of participation will help us take a good pulse of the ES&H culture and risks at our laboratory. We are still reviewing the data, and I will report on the results in Fermilab Today in the future.

At Fermilab we pride ourselves on our open ES&H culture. We ask and expect all employees, contractors and users to report unsafe procedures and situations to their managers and safety officers. Once a week, the division, section and center heads report safety incidents to the directorate and discuss ways to improve safety. We all can improve these safety efforts by taking the time to listen, ask questions and take appropriate action.

Recently I read “Failure to Learn” by Andrew Hopkins about the BP Texas City refinery disaster where 15 people were killed. This refinery had gotten an award for its low injury rates and was supposedly moving to become a High Reliability Organization.

The first part of the book focuses on the actions of the people most directly involved in the chain of events. They did many completely inappropriate things – so many that one cannot imagine them ever happening. The author then delves deeper into what led those people and their managers and supervisors to behave so inexplicably.

The book points to a change in risk awareness known as normalization of risk as one of the main contributors to the events that led to this disaster. Over time, people begin to accept levels of risk they wouldn’t have considered safe previously. This change occurs slowly, over decades. Resources tighten, people focus on production and the quality of maintenance; repairs and oversight slowly degrades. Procedures are not updated and reviewed as they should be. Alarms are occasionally ignored since they inhibit production and don’t appear to serve much purpose. Eventually something very bad happens, shutting down operations and seriously hurting people.

Another main contributor to the Texas City disaster was the lack of knowledge that upper management had about safety concerns. Their direct reports avoided communicating bad news, and they did not get out in the field enough to talk to the people who might have shared their concerns.

Please communicate risks to your management and help your colleagues work safely by pointing out any concerns you might have with what they are doing. Offer to help someone trying to do a task that would go better with another hand. This will help us move closer toward our goal of no injuries.