“We Need To Balance Safety With Progress”: The Hazards Of Giving Safety A Back Seat In Daily Operations

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Many organizations are busy and have limited resources and funding. This is very true of startups and smaller organizations but may be just as true for smaller groups in larger organizations. In my 48 years of experience, I have never met a research group (academic, industrial, or government) that does not feel overworked and underfunded and, to some degree, they all have been right. All research groups have a limited time to research, design, and develop, or improve their product and get it successfully to market or solve their problem and get production back on schedule. If they fail to complete the research in a timely enough manner they may go out of business or at least lose future funding and staffing. Neither is desirable. It is not surprising that these organizations try hard to stay safe but also work to keep safety from slowing their progress. Balancing these two needs is difficult and, in my experience, often poorly done, resulting in a much higher risk to the organization than they realize.

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These organizations recognize that they are probably not fully compliant with every code and safety requirement but believe they are focusing on the most hazardous ones; their safety efforts, although perhaps limited, incomplete, or even less enthusiastic, will prevent any “significant” incident. In some cases, I can understand their logic. If they train all their personnel appropriately but fail to keep good records one can accept that they are focusing on the key safety feature – the training – even if they may be at risk of a citation or even litigation if the records are ever required. They may require thorough risk assessments of any new work but fail to conduct the assessment by any recognized methodology nor adequately document the results. If the assessment is well done, perhaps the weaker documentation is an acceptable risk. They may accept less desirable housekeeping but try to ensure appropriate personal protective equipment (PPE) is always worn, arguing that the PPE’s protection is a more critical need.

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There are many problems with this approach, most of which often go unrecognized. This results in these organizations incurring much higher risks in many areas than they realize. Often higher risks then they should feel comfortable tolerating. Often higher risks are not apparent until someone is hurt.

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Common problems include the following.

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Their focus almost always overlooks all the relevant aspects of the potential hazards. If one does not keep good records who knows if everyone has, indeed, been adequately trained. One organization relied on asking their personnel if they had been trained. Some questioning revealed that many believed they were trained who had never received the required training. Others, who purportedly took the training, were unable to explain any of the key elements, showing that the training, which was informally conducted using inhouse “expertise”,? was inadequate in accomplishing its goals. As a result, another round of training was required, consuming more time and effort than if it had been conducted properly the first time. Worse, an extended period existed where personnel were not working safely as they were not trained enough in what was required to stay safe. If the hazard analysis and risk assessment is informal and poorly documented, how does one know it was adequate? A client told me that the upstream part of their process under review had been previously reviewed and assessed and so was outside the scope of the current review. The documentation was minimal due to budget constraints, but they felt the review was thorough and well done. As part of a later downstream review, numerous questions arose about the upstream process and equipment that identified significant unrecognized hazards. Most had not been identified as part of the previous review. All had been inadequately assessed and poorly mitigated (if at all). Significant rework was required to address the concerns. Another client’s housekeeping was so poor it blocked escape routes out of the area, made accessing many work areas difficult for emergency responders, and created other hazards none of which were addressed by their PPE. Hence, ensuring that the aspects not receiving any real attention are a trivial or at least tolerable risk is always difficult and, quite often, an incorrect assumption.

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The basic assumption that some things are more important than others in safety has a significantly dangerous corollary. It suggests that some things in safety are not really important. Readers of these articles know that I always try to highlight the major issues versus the less critical ones. A hazard that might cause a minor burn is, to me, less critical than one that could result in a permanent disability. However, if you do not address all the safety issues all the time then there will always be a tendency to ignore some areas, at least sometimes. And, as noted above, many times these areas may be a significant hazard. One client felt that any fire from a leak on an operation in a hood would be rare and minor incident (if it ever actually occurred); ?while a risk, they felt it was unlikely to result in anything but a trivial incident – a localized fire easily extinguished and unlikely to hurt anyone. The actual event, when it inevitably occurred, was much more significant and, but for a healthy dose of luck, could have resulted in a fatality or at least a serious hospitalization. Another client felt that an almost non-existent management of change procedure was acceptable because of the high caliber of their research personnel? barely escaped a fatality when a small change failed catastrophically resulting in a serious fire. When a potential hazard is downplayed or ignored, then there is always a strong tendency to underestimate or ignore any attendant risk. This manifests itself in a tendency to assign an unreasonably low probability to a potential hazard or too casually dismiss a potential higher consequence.

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When the organization chooses to deliberately ignore some issues it suggests to its personnel that they may also choose which safety issues they feel are most important. This is a very slippery slope which leads to numerous interpretations of rules, procedures, and policies to “speed” research. Unfortunately, that inevitably leads to incidents and often resultant injuries. Many well intentioned and intelligent operating personnel have weaker hazard identification skills, failing to see even sometimes obvious hazards. Others lack the technical expertise and training to assess the hazards adequately and accurately in sufficient detail. People’s perceptions also enter the assessment. Some personnel simply refuse to admit there is a potential hazard unless they themselves see it. (Of course, by this time it is often too late.) Many other personnel unconsciously (or perhaps consciously) will dismiss a hazard if it is a significant impediment to their progress. Desirability, in this case, out weights, safety.

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So how do you deal with trying to balance safety with progress? Here are some basic suggestions that may help you address this balancing act better.

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Get a cold eyes review of your current situation and current practices. A cold eyes review is a knowledgeable person from outside your organization who does not share the same prejudices and blind spots. See Groupthink That Can Lead To Inadequate Hazard Analysis And Risk Assessment, https://www.dhirubhai.net/pulse/groupthink-can-lead-inadequate-hazard-analysis-risk-richard-palluzi , Are We Safe or Complacent? https://www.dhirubhai.net/pulse/we-safe-complacent-richard-palluzi, and “My Laboratory is Very Safe.”: The Dangers of Myopic Looks at Laboratory Safety, https://www.dhirubhai.net/pulse/my-laboratory-very-safe-dangers-myopic-looks-safety-richard-palluzi for additional discussion on these blind spots inherent in every organization. Another good reference for the importance of these type reviews is Research Projects: The Importance of ‘Cold Eyes’ Project Reviews, R P Palluzi, Chemical Engineering, Feb 2017.

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Always question whether something is not a risk, a trivial risk, or too unlikely to be a credible issue. All too often the results of risk assessments are based on the desirability or being able to ignore the actual risk and plunge ahead with the research rather than the hazard associated with the risk. Subjecting these assessments to an outside review or at least a more detailed analysis often highlights major concerns not adequately addressed. See The Often Overlooked Problems With Relocating Laboratory, Pilot Plant, and Research Facilities, https://www.dhirubhai.net/pulse/often-overlooked-problems-relocating-laboratory-pilot-richard-palluzi , “We Are Comfortable with Our Current Safety Procedures”: How Do You Prevent Something You Don’t Recognize?, https://www.dhirubhai.net/pulse/we-comfortable-our-current-safety-procedures-how-do-you-palluzi , and “How Could This Have Happened?”: The Often Overlooked Hazards of Moving Chemicals Within A Research Facility, https://www.dhirubhai.net/pulse/how-could-have-happened-often-overlooked-hazards-moving-palluzi/ for a discussion of some aspects of this too casual dismissal of risks.

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Ensure you are conducting a detailed and thorough hazard analysis and risk assessment of the proposed operation, new installation, or modification. Many are done too quickly and too cursorily. Consider cold eyes participation in some assessments, particularly those with more potential hazards, or at least on some frequent intermittent basis to help identify that these reviews are – or are not – being comprehensive enough. See? Laboratory Hazard Analysis And Risk Assessment, https://www.dhirubhai.net/pulse/laboratory-hazard-analysis-risk-assessment-richard-palluzi-tvewe? and Inherently Unsafe: The Hidden Issues Often Overlooked in Research Hazard Analysis, https://www.dhirubhai.net/pulse/inherently-unsafe-hidden-issues-often-overlooked-research-palluzi for a further discussion.)

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Many reviews ?fail to identify if something is, or is not, a credible risk without any real analysis. Too often a hazard is evaluated as a broad potential and the person or group simply decides if it is or is not a tolerable risk. “The operator gets burned due to a fire from a leak” cannot be adequately evaluated as you have not identified the path that leads to them getting burned. Without the path, the steps of things that must happen, then there is no realistic way to evaluate the likelihood and determine if it is high enough to warrant any action. What caused the leak? What caused it to ignite? Why was the operator burned? How badly was the operator burned? What was the operator doing that caused the problem? All these questions require a hypothetical path be developed and analyzed for safety. You need a specific scenario which can lead to an undesirable outcome for evaluation. Otherwise, people can be evaluating subtly different scenarios and/or making different, unspoken, assumptions. See “Do You Think We Should Consider This Risk”: The Need for Making Credible Scenarios in Risk Assessment “, https://www.dhirubhai.net/pulse/do-you-think-we-should-consider-risk-need-making-credible-palluzi/ for a further discussion of how to do this.

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Recognize the full potential for human error. Everyone makes mistakes. No amount of knowledge, skill, or training can eliminate that potential. Reduce yes; eliminate no, Too many assessments fail to assess the full range of potential human errors. People tacitly assume no one would be that foolish to open the valve before checking the line is connected, start up the reactor with the control thermocouple sitting on the base of the hood rather than inside the reactor, or open the toxic gas cylinder without doing any leak testing first. Yet these, and numerous other incredibly ill-advised actions, happen with unremitting frequency due to human error. See Scared Safe: The Importance of Human Error when Evaluating Research Operations for Safety, https://www.dhirubhai.net/pulse/scared-safe-importance-human-error-when-evaluating-research-palluzi . Try to evaluate what mistakes could hurt someone versus just ruin research or equipment. Avoiding the latter is desirable but perhaps accepting that risk is possible. Preventing the former is mandatory. And remember to factor in stress and distractions particularly when one is in a rushed, crash, or accelerated research program. These create significant safety as well as cost and schedule issues. See “We Need It Faster”: Issues with Accelerated Pilot Plant Schedules, https://www.dhirubhai.net/pulse/we-need-faster-issues-accelerated-pilot-plant-richard-palluzi/ for some more discussion of these factors.

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Recognize that procedures, once learned, are followed from memory. The more comfortable one is with a procedure the more likely one is to just modify it “slightly” to make it simpler, easier, faster, or just more comfortable. The total of these “trivial” modifications, over time, can result in serious, unrecognized hazards. As mentioned above, a cold eyes review or audit will often identify areas that have drifted into very unsafe practices over time due to normalization of deviation, poor management of change, or simple complacency. Recognize? that something that was safe in Lab A at time X may no longer be safe in Lab B or at time Y. See Safe Where It Is; Safe Where It Is Going: The Often Unrecognized Hazards of Moving Research Equipment, https://www.dhirubhai.net/pulse/safe-where-going-often-unrecognized-hazards-moving-research-palluzi/ for further discussion.

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So how do we achieve the best balance between safety and research productivity?

?Carefully, very carefully, understanding it is a continuing balancing act, all the time, every time. Recognizing that research is like a minefield that we are forced to navigate with our eyes only partially open and a compelling desire to move a lot faster to get to the end.