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Quote of the Day: Accidents
There’s an old saying: “If you think safety is expensive, try an accident.”
The first choice after an accident is to say “How can we improve the design so this can’t happen? How can we remove the opportunity for errors?”
In a well-designed plant, a simple error like closing the wrong valve shouldn’t result in an accident.
For a long time, most people were saying that most accidents were due to human error. This is true in a sense, but it is not very helpful. It’s like saying falls are due to gravity.
— Trevor Kletz (1922-2013)
Trevor Kletz was the founder of process safety management/engineering. Process Safety deals with major accidents and defects in the process, as opposed to accidents on a personal scale. The ideal process is designed to be resilient and capable of dealing with human error.
When you change a process, you need to carefully consider how the change affects the other processes at the plant. If you don’t, a seemingly minor change could have terrible results. Replace that damaged reactor with stretch of pipe with expansion bellows, it will let you keep the system running; the result was Flixborough. Deactivate the flare stack and scrubber while the plant is shut down – it should not be a problem. Don’t tell workers about the potential for catastrophic events if the chemicals react with water. The result was Bhopal.
I highly recommend his book What Went Wrong? Case Studies of Process Plant Disasters to anyone who works in manufacturing, processing, etc. Rent it from your local library, as the Amazon price is insane. It’s written for the operator and foreman, with clear descriptions of how things can go off the rails. At the end of the book, he discusses is how analysis of change is applicable outside of the chemical industry. ICI corporation engaged in massive acquisitions without considering the effects on their viability. The result was bankruptcy and the company getting carved up.
You could say that the field of process safety is inherently conservative, in the broad sense. The famous Chestertonian Fence is basically a management of change review. Conservatism is the reminder that new does necessarily mean improved. That new program might just make things worse or waste money to no effect. Why, yes, despite our health care system having problems, we could get worse. Much worse. It is no accident that liberal plans tend to fail – they do not stop to consider the unintended consequences. That also could describe a good portion of the disasters in What Went Wrong?
The Constitution is designed deliberately to be resilient against minor errors, and remain enduring. Conservative policy should be designed similarly — carefully crafted to be resistant to mistakes, corruption, and leftists.
Published in Group Writing
Why can’t Communists, Socialists, Leftists, and wacko “Liberals” understand the same effect with government? If people were “perfect,” then a simple but resilient government would be all that is needed.
If you are curious about process safety, I recommend the US Chemical Safety Board videos. They are excellent documentaries with decent CGI animations of what happens. https://www.youtube.com/user/USCSB
Here is an example that features Illinois corruption:
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I’ve always thought there should be a federal agency, the Bureau of Unintended Consequences. It would publish an annual report titled, “We Told You So”.
Process and change management. You’re singing my songs.
Change control and configuration management are crucial elements in project management. CM involves what we call the three Ps: plant, procedures, and people. Change control is how we make sure any change to a P is well thought out, evaluated, officially approved, and properly implemented.
There has a been a push in public safety for the last few years to no longer refer to motor vehicle crashes as accidents. The acceptance term now is crash, because generally the reason isn’t accidental, but rather some bad choice. I find it kind of interesting, because I don’t know how it started but it’s pretty widespread now.
We all still refer a crash as an “MVA” on the radio.
Terrific post. We spent a lot of time on process safety, change management and improving our accident investigation process to get at underlying system problems and beyond human error. And I like the comparison to public policy making.
One of the things triggering my defection from liberalism was no matter what problems happened with a policy or program the solution was always the same – spend more money, more laws, more regulations, better regulators. There never seemed to be any deeper reflection about why problems were occurring. Liberalism turned out to be remarkably bad at learning from experience. And then it got worse.
Pilots have always joke that the FAA & NTSB has the accident reports pre filled out with “Pilot Error”. The rest of the form is just for the particulars.
It usually is. Isn’t it?
They didn’t coin “Controlled flight into terrain”, for no reason.
I think that it’s been very good at learning from experience, according to its fundamental economic theory, which is called “economic positivism” or “economic empiricism”.
Not so according to the competing theory, which is called “Austrian”, “logical”, or “causal realist” economics, where
Economic positivists like Krugman, the Fed board, and other establishment economists, believe that economic laws can only be discovered by the same process as laws of the physical sciences: creating hypotheses and testing them in an infinite series of experiments on society as a whole, where it is known beforehand that the effects of the test variable will be more or less swamped by variables which one hasn’t controlled for.
One is good at learning, under this doctrine, if one keeps tweaking his one’s collectivist/totalitarian/elitist/utopian policies (one’s hypotheses) after each experiment and performing another poorly controlled and thus not-very-conclusive experiment, ad infinitum.
That is exactly what the opponents of economic liberalism (whom you refer to as “liberals”!) do.
It’s been done in criminal justice for years:
“My client is not a bank robber. He just made some bad choices in life.”
Just remarking “Thank You!” so I can find my way back to this topic later on.
Me too. We have a “safety minute” fad in routine meetings where I work. The Kletz quote will be fine to get me through when it’s my turn.
So, we have to keep commenting to keep it alive so y’all can find it? Wouldn’t it be easier to bookmark it?