WEAK SIGNALS

Things are going well.? A minor thing occurs, but no serious consequence and things seem to keep working. So, we move on as always.? But we received a wakeup call and “slept” through.

• ?The temperature settings are set once for a Programmable thermostat.? For a number of years, the HVAC system has provided comfort.? But over that time the filters get dirtier (slowing the air flow) or the fans have wear and tear (weaker air flow).? When the fans turn on, they are noisy.? It takes longer to heat/cool the space.? But the HVAC system is still “running” and blows some air. These things we see and feel, but we move on anyway. Then, at an unexpected time when the fans turn on, the power system trips, and the HVAC fails.

?We live in a Set-and-Forget culture.? We plug a device in, install an App, or start a process and then move on. This is done for convenience and simplicity.? But unintentionally this leads to us to a mishap, an error, or in a worst-case scenario, significant harm.

• A survey finds that one in three drivers confess to driving with a check engine or maintenance light on. In fact, the average driver will keep going for nine days with a warning light on before taking their vehicle in for maintenance. OnePoll Survey for Hyundai March 2020

?Generally, things go fine for a period of time, so much so, we get comfortable and relax (complacent).? Afterall, things have been working and nothing has seriously gone wrong for a long while.? But there is indeed a minor problem brewing or a small defect in the system (weak signals), that if not attended will progress over time to the failure.? A failure that will result in a significant impact to our safety, to the environment or to our finances.? We are surprised when that event happens.? But subsequent investigation tells us there was a “weak signal” long before the event.

Researching the hundreds of significant/catastrophic incidents in the chemical/oil/gas industries affirms that every significant incident was preceded by a history of smaller events.? The incident investigations may even attest that if action had been taken when these prior events (weak signals) occurred the significant incident would have been prevented.

• ?A release of flammable vapor led to an August 2012 fire at the Chevron Refinery in Richmond, California.? The investigation reports notes that:
• repeatedly over a ten-year period failed to effectively apply inherently safer design principles ….. such as the critical metallurgy of piping.
• in 2002, 2006, 2007, 2009 and twice in 2011, including during the maintenance turnaround which immediately preceded the 2012 release…..failed to apply inherently safer design and implementing changes
• Had this been done, the investigation team concluded, the accident could have been prevented.

Excerpts from CHEVRON RICHMOND CA August 2012 CSB April 15, 2013 Report

?The overwhelming tendency is to respond to weak signals with a relaxed response.? Yes, something bad happened, but it didn’t result in anything major.?

• ?“It is tragic the number of times people are harmed in accidents where earlier warning signs had been overlooked” CCPS Recognizing Catastrophic Incident Warning Signs in the Process Industries, 2012 [61, p. 120].

?An organization with a high reliability for safe operations sees the significant meaning of these weak signals and gives a strong response to those weak signals.

Mindfulness requires that we are ever alert to our environment.? Having the mindset (a way of operating) that there is a potential problem out there, and we need to find it. Call it chronic unease or constant vigilance.

And when something minor presents, assess if it is a “weak signal” of a defect in the system.? If so, manage it then -- before it “festers” into the major failure.