Engineering disasters are always the result of bad mgmt.... 5

[funnelguy]

JOM,
"Funnel" is the derisive nickname I have given to some products I manufacture. They comprise the majority of my sales, hence the name.

How is it that anybody could activate machinery with personnel in harm's way? Was there no guarding? Had the contractor and electrician defeated interlocks and failed to reset them? I must be missing something here. Why were the controls in an area where the operator couldn't see the bucket and reels?

Some of the risks taken in the process of setting up or maintaining equipment are mind boggling. Anyone who works around machinery for any length of time has their own collection of horror stories. The object of the game is to retire with all your own appendages. My PC always asks "Are you sure" every time I want to delete a batch of emails, but the drives and controls on production equipment just try to do the wrong thing the very first time we ask them to...

 

[IFRs]

JOM - standard lock-out tag-out proceedures would ahve prevented this accident.

Safety starts from the top and works its way down.

The best managers are unafraid to surround themselves with people smarter than themselves, directing traffic and depending on quality subordinates to do the job right. Giving their subordinates the right tools and time to do the job right has to be ingrained into the corporate culture. Managers MUST learn that they to not make the company any money - it is the people down the line who are their most important resources. Treat them well, searchout better talent, train, encourage and reward. That defines a good manager. Under these circumstances, when mistakes are made they are caught by others up and down the line who are unafraid to bring the mistakes to the attention of a responsible party.

In the best companies, each does his/her job the best way he/she knows how. Since that is the culture, slackers are weeded out, innovation is encouraged and building political power is discouraged.

 

[GregLocock]

I must admit, when I read JDM's story, my first reaction was that proper lockout procedures are well known and cheap to implement.

But there again we've only had a proper procedure in place for 4 years.

If you have any influence on the operating procedures of your company, please get them in place. Nobody loses, everybody wins.

Cheers

Greg Locock

 

[JOM]

I don't know any more about this accident. The story has been published by the state safety authority - I guess as an urgent warning to all. There may be a prosecution and certainly a coronial inquest, so more will out.

The common ground with funnelguy's mishap is that someone is working on a machine and someone else has the power to operate the controls at the same time. Isn't it a management issue to prevent that?

Cheers,
John.

 

[funnelguy]

JOM,
I was of the impression that it was quite common for manufacturers of equipment and maintenance workers to bypass safety interlocks and work on equipment in teams to troubleshoot. Quite often there is additional risk involved. Sometimes there really isn't a compelling reason. The work I was performing that particular day could have waited until the machine was powered down. That's what made my decision a poor one. On other occasions I think the added risk of working on live equipment was necessary for troubleshooting, IMO.

Why do utility workers work on hot circuits? Fire stick or no, why not just inconvenience some customers for the safety of the linemen? (Just stirring the pot )

 

[IFRs]

funnelguy -
Manufacturers and maintenance workers should be the LAST ones to bypass safety protocols - they work with dangerous equipment everyday and KNOW what complacency can do to fingers, limbs and life!! If working on live equipment is necessary, perform a JSA (Job Safety Analysis) to identify the risks and determine ways to minimize the dangers. Utility workers work on hot circuts with proper PPE (Personal Protective Equipment) and proper non-conductive tools. The dangers are minimal if proper procedures are followed.

Equipoment powered down is not safe. It needs to be locked out from any and all potential energy sources. The off switch is not enough.

 

[funnelguy]

IFRs,
I have NEVER worked for an organization that stopped to perform a safety audit when equipment went down.

A site foreman for the construction company responsible for a GM truck assembly plant flatly refused to allow me to lock out bus runs I was to inspect for adequate insulation in expansion joints. I was pretty young back then and so I called the home office rather than ruffle the customer's feathers. I suppose my supervisor did the ruffling. Both companies were fortune 500. The compromise was that THEY would lock out the runs I was to work on, but would NOT allow me to add my lock to the tagout.

The ability to observe indicator lights on I/O boards or PLC's would require bypassing interlocks, wouldn't it? What about checking a component with a DVM while it's hot? Many diagnostics are best performed on live equipment. Certainly there are risks involved, but ideally we minimize the risks whenever possible and utilize personnel who are adequately trained/skilled to asses these risks.

Back to the utility worker example. Aren't workers killed doing this type of work? Why not just shut down the substation? Why risk anything at all? Why should tagout procedures be used for industrial equipment and not utility workers dealing with thousands of volts instead of a couple of hundred? (Still stirring... )

 

[IFRs]

funnelguy -
I work in the petrochemical industry where safety is paramount. Our customers are amoung the largest companies in the world. Our company can not work for some customers unless our OSHA injury rate is below certain threshold numbers (which it is). We have our own dedicated safety staff, our corporate goal statement starts with "Safety", we conduct shop and field safety checks, meetings and job assesments on every job. I'd be amazed if other companies in hazardous lines of work do not respect the cost of unsafe acts. One death can ruin a company.

Check with GM today - I'll bet you find that Safety is closer to "job one".

If you could not put your lock on the equipment, you should have walked away and if you though others were in danger from this procedure, contacted OSHA.

I'm sure that you can check a component with a DVM safely - without risking life or limb.

If line technicians are killed, it is probably from bypassing protocols. An accident analysis probably changed safety protocols for future work.

I'm not saying that all equipment can be made safe from idiots or people intent on hurting themselves but really - if you want to work safely, there always is a way!!!

 

[JOM]

Some really good comments coming out here. I worked on PLCs and DCSs some time ago, and I cannot recall a SINGLE instance of consideration given to personnel safety.

Funnelguy's mishap is a classic - two factors, each in their own of no great concern, but occurring at the same time produces danger. Funnelguy could work under the machine normally without a worry; the LED could fail at any other time without causing harm. But both together? Disaster.

To get back to the original question - "Engg disasters are always the result of management failure". Surely management must ensure the proper procedures are in place so that these two incidents do not occur?

Cheers,
John.

 

[funnelguy]

IFRs,
GM wasn't responsible for that decision. The hardcase jobsite foreman for the construction company was. Memory fails me, might have been Comstock, maybe not.

Still, why should utility company workers work on hot lines? Why should they be exempted from the tagout mandates you favor? (I do too, when possible ) Why not shut down the substation or some such?

I have a drive here in my shop that requires checking a transformer's secondary voltage under load as the means of verifying correct connections on the primary side. I have had to do this three times. The construction of the machine requires me to reach over hot control circuitry to perform the test. Now what?

My point was (and is) that troubleshooting is sometimes necessarily done under power. That involves risk.

Sometimes I think we accept risk if the compensation is acceptable. I know very little about your industry, but I cannot imagine it is without risk. A friend of mine spent some time doing service work on a North Sea rig. He asked for and received hazard pay and a life insurance policy from his employer before he boarded the chopper. That makes my misadventures seem tame... maybe we figure those utility workers are paid enough for their work?

 

[MTE85DRM]

It is interesting to note that no one mentioned the effect of low bid ethos on engineering. In the movie Armageddon there is a great line about being hurled into space by a machine propelled by a million pounds of explosives built by the lowest bidder.

My gradnfather always said "You get what to you pay for"

 

[profengmen]

"In the case of the Challenger, design requirements were clearly violated. Engineering used tools that were never designed for task of simulating impacts by the insulation nor were the tools ever validated. Management allowed themselves to get lulled into complacency based on nothing bad having happened prior to Challenger"


Wrong,
The Challenger had O ring problems.

 

[JOM]

Hi Leanne,

So what do you think yourself? Are all engineering disasters the result of bad management?

Myself, I would go so far as to say that accidents don't just happen, they need to be managed. You don't get a good disaster by chance. And you can't expect employees to produce one. They are so complex they have to be managed into existence.

Cheers,
John.

 

[CanEngJohn]

Here is a question I am have been tossing back and forth in my head ....

If the Engineering Manager makes the mistake would we (as a group) classify that as an Engineering Mistake or a Management Mistake? I would argue that until the error in judgement leaves the Engineering Department it is an Engineering mistake. Even if the Engineering Manager does not happen to be an Engineer.

Also, as a side note, a disaster in Ontario can be classified as either a Management mistake (the Company) or an Engineering mistake (the Engineer). We do it on a daily basis in our disciplinary reviews. So in essence I would have to say that the PEO does not agree that all disasters are a result of bad management. If that were the case we would not have a disciplinary review board and not be discplining Engineers for their mistakes.

Also is it a bad management decision when you relied on faulty engineering decisions from the Engineer who has been working for you for the past 10 years with no other mistakes?

 

[plasgears]

In aviation disasters it has become clear that a string of errors of various kinds compound to make disaster inevitable.

In the Air Florida crash at Washington National, 1985, mismanagement of snow accretion, blind following of FAA noise abatement, not scanning all the instruments in addition to EPR, lack of experience, light banter, etc. added up to disaster. The result was closing down the airline.

Scan the tail numbers of DC-9's for the "AF" indicating a prior Air Florida plane. NWA has a few.

 

[JOM]

CanEngJohn,

You said:

Here is a question I am have been tossing back and forth in my head ....

If the Engineering Manager makes the mistake would we (as a group) classify that as an Engineering Mistake or a Management Mistake? I would argue that until the error in judgement leaves the Engineering Department it is an Engineering mistake.


I think that is sensible. While inside the Engg department, the mistake has no impact. When it leaves the department and enters the outside world, the mistake takes on real significance.

What it interesting is you have raised the notion of engineers making mistakes. Would it raise hackles to suggest that engineers are not too ready to admit they can and do make serious mistakes?

Given that we all make mistakes, it becomes essential to have management processes that detect mistakes and build systems that tolerate errors. So, if the mistake gets through and causes an accident, then management failed.

Is it reasonable to say that for every possible human mistake in industry, there is always a feasible administrive/management process that could prevent or rectify the mistake?


Cheers,
John.

 

[vpl]

JOM

You raised an interesting question -- I think I'm going to start a new thread as this is getting rather long.

Patricia Lougheed

Please see FAQ731-376 for tips on how to make the best use of the Eng-Tips Forums.

 

[PM]

In my experience all man-made catastrophies or incidents are the product of at least two of the following:[ol][li]human error[/li][li]technological (mechanical) failure[/li][li]environmental conditions[/li][/ol]It's rare that incidents occur as the result of human error alone.
Regards,