there’s no glory in fighting a fire that could have … · there’s no glory in fighting a fire...

THERE’S NO GLORY IN FIGHTING A FIRE THAT COULD HAVE BEEN PREVENTED

Using Prevention Through Design Presented by: Paul Gantt, CSP, CET

Sponsored by the Engineering Practice Specialty

There’s No Glory.... Prevention Thru Design

Paul Gantt •  Certified Safety Professional (CSP) •  Certified Environmental, Safety and Health Trainer (CET) •  President and Founder, Safety Compliance Management

•  Fire Chief, Retired •  Expert Witness

•  Student


Session Objectives:

1.  Identify what most people think of when they think of PtD. 2.  Identify the key elements/concepts of PtD. 3.  Describe how the Fire and Building Codes use PtD concepts. 4.  Review the ANSI Z-10 Hierarchy of Controls. 5.  Describe how we set employees up to fail – error traps. 6.  Identify ways to use PtD in your workplace to reduce error

traps. 7.  R&D – Share ideas and stories of how you have used the

PtD concepts.


An ADD Moment How many of us started out wanting to be a Safety Professional when they grew up?


Definitions: Safety:

Not the absence of accidents. It is the presence of defenses or controls.


Definitions: Second Fire: The consequences that come from an initial event. Examples – exposure of personnel to smoke and heat after a fire starts.


Definitions: Error Traps: Situations and environments that increase human error potential.


Definitions: Safety R&D: The practice of ripping off and duplicating another’s work – giving credit to the other is optional.


R&D = Ripoff and Duplicate Fred Manuele Todd Conklin ASSE Webinar University of Alabama


What do you think of when you hear ANSI/ASSE 590.3-2011 Prevention

through Design . . . ?


So what is it that you think of?

Too Complex

Others?


THE REQUIRED CONCEPTS OF PtD

5 key elements

1. Regulations + People

2. Bricolage

3. Right and

Wrong

4. Resilience

5. Plan B

Remember the Hierarchy?

Elimination

Substitution

Engineering Controls

Warnings

Administrative Controls

PPE

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Heinrich Warned Us About This!

Acts of God (2%)

Unsafe Conditions (10%)

Unsafe Acts (88%)

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Origin of Human Error

10%90%

30%

70%

Human Error

Slip, trip or lapse

Equipment Failures

Human Errors

Operational Upsets

System Induced Error


So why use PtD? •  To protect them, from them, in spite of

them. •  To keep failure from being successful. • Because events are not always

predicable but the environment in which they happen is.

•  To provide opportunity for employee involvement.


THE REQUIRED CONCEPTS OF PtD

5 key elements

1. Regulations + People

2. Bricolage

3. Right and

Wrong

4. Resilience

5. Plan B


1.  Regulations Plus People

• Are people naturally (inherently) safe? • Begin with the regulatory minimums and incorporate

the Human Element – people into the process. What will they do when they interface with the system and the hazards?

• Consider what will be the normal behavior of people when they are exposed to hazards.


What’s wrong in this picture?


The picture is from a lawsuit.

Facts: •  Elderly woman fell, suffering serious injury. •  Rails were compliant, but were they adequate to prevent

injury? •  Other influences: Lighting was lowered during

performances; reduced visibility increased likelihood of fall – but it was still compliant with codes.

• Think past what the minimum requirements are – design in risk reduction.

Thinking about human error

People make mistakes • Blaming someone for being human (i.e. making an

honest mistake) isn’t helpful – it’s like blaming gravity for a fall.

• Employees are the most important part of the

system and also the least reliable.

•  “Human error is a symptom of trouble deeper in the system” - Sydney Dekker

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2. Bricolage

• Noun: Something made or put together using whatever materials happen to be available.

• People will attempt to develop workarounds even when they know better!


Count on this: • People will be as safe as they need to be, without being

overly safe in order to get their job done.

• People using their bodies as a tool to work will constantly look for short cuts.

•  The same is true when tasks become repetitious or boring.

• Procedural non-compliance is the norm.


ANSI/ASSE Z590.3-2001, Section 4.1 .... The knowledge, skills, experience, insight and creativity of employees close to the hazards and risks should be used in the design process.... Involve them before they involve themselves when you aren’t looking. Toothpaste box example.

Sharp End

Blunt End

Workers

Managers

Front-line Supervisors

Leaders

Customers

Regulators

Company

Conklin

Highest Influence

Over System

Highest Injury

Potential


3. Right and Wrong

•  Integrate “Doing the Right Thing” into your design.

• Make it easy for people to do the right thing and hard for them to do the wrong thing.

• Look for and eliminate error traps.

What is an Error Trap? • Something that violates operator

expectations – something we would normally rely on – e.g. the shower.

• Anything that requires performance

beyond what an employee can deliver – Texas City BP operator working 28 days.

• Something that induces fatigue.

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What is an Error Trap? • Processes that provide inadequate facilities,

equipment, or information for the operator. • Something that is unnecessarily difficult or

unpleasant. • Everything that is unnecessarily dangerous.

• Anything that increases operational ambiguity.

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Considerations in designing a system to help people do the right thing. Look for error traps and correct them:

•  Elimination of the hazard. •  Substitution of a less hazardous process. •  Ensuring valves or gauges are easier to read. •  Reduction of distractions, including noise. •  Reducing choices – e.g. cartridges. •  Providing adequate equipment – e.g. ladders. •  Other Examples?


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4.  Resilience • The ability of the system or organization to continue

operations or recover a stable state following a mishap. • The ability of systems to prevent or adapt to changing

conditions in order to maintain (control over) a system property.

• Robustness within a system.


Build resilience into the system so that it can adapt as changes occur – preventing failures when minor deviations occur. “Errors without consequences is a good thing. It shows that our systems are error tolerant and that they are working.” – Todd Conklin


Resilience – NO SINGLE POINT FAILURES Examples: Resilience – NO COMMON CAUSE FAILURES Examples:


5. Plan B

Be ready with a plan to provide protection for when things fail because we cannot plan for everything. We must consider the effects of the second fire.

We need a balance

Prevention

Contingency

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• Prevention is focused upstream - Stopping the initial event from happening.

• Contingency is focused downstream, but with a proactive mindset - Stopping the event from having its negative effect – the second second fire.


Fire Safety Codes Worked In Harmony Prevent the Initial fire from starting - If that didn’t work, then . . . Prevent the second fire – the consequences that follow Sound alarms to provide warnings, close fire doors to prevent fire spread, activation of automatic fire sprinklers. Safety Examples?


Automobile Industry Approach to Safety:

• They assume people will make mistakes and that error will occur. They manage the failure.

• They design the system to be tolerant of common

mistakes - e.g. bumps in the road keep the accident . • Airbags and other crash protection reduce the

consequences of the initial incident.


Takeaways: PtD is not always a program – it is just a new way of thinking about risk reduction. PtD can be incorporated into all aspects from design of facilities to design of the operational procedures. PtD injects people into the system and assumes that people will be people. PtD builds resiliency and addresses the second fire.


“To err is human. To forgive – design”

Alphonse Chapanis. Father of human factors

engineering.

QUESTIONS?

Paul Gantt, CSP, CET

42

Please fill out an evaluation. Your opinions matter! Slides available on SafetyNet and at http://www.scm-safety.com


Example 1: BUILDING CODES Exit corridors must have fire protective construction v  All openings into corridor be fire resistive v  Doors must:

ü Have self closing hardware ü Be fire rated ü Have smoke gaskets ü Be kept closed when not in use

IMAGE OF FIRE DOOR PROPPED OPEN WITH EXTINGUISHER


Example 2: FIRE CODES Storage of flammable/combustible liquids requires: v  Reduction or elimination of electrical sources

ü Explosion-proof wiring

v  Increase in ventilation systems v  Special techniques for transferring materials

ü Bonding and grounding of vessels


The Fire Service quantifies success on reduced numbers of fires and resulting injuries – failure of the systems and codes

Heating equipment was involved in one of every five home fire deaths. Heating equipment ranked second in reported home fires, home fire deaths and home fire injuries. Portable and fixed space heaters, including wood stoves, are involved in more fires than central heat. These fires are also more likely than central heating fires to result in death.11 Intentional fires are the third leading cause of home fires. According to FBI statistics, roughly half of the people arrested for arson in recent years were under 18.12 Electrical distribution or lighting equipment was the fourth leading cause of home fires. A study by the Consumer Product Safety Commission (CPSC) found that homes with older wiring face an increased risk of electrical wiring fire.13 Electrical factors can play a role in any fire involving equipment powered by electricity. Electrical failures were factors in 13% of home fires. Candles were the fifth leading cause of home fire injuries. These fires nearly tripled from 1990 to 2001 with the increase in candle sales but have since fallen back to the mid 1990’s levels. Candles used for light in the absence of electrical power caused 1/3 of fatal candle fires.14 Younger children are more likely to set fires in homes, while older children and teenagers are more likely to set fires outside. Most child-play home structure fires are started by lighters or matches. Two out of five child-playing home structure fires begin in the bedroom.15

Almost all U.S. homes have at least one smoke alarm, but 62% of home fire deaths resulted from fires in homes without working smoke alarms. People who are under the influence of alcohol, drugs or medications, have disabilities, or are very close to where the fire started, may not be able to act on a smoke alarm’s warning.16

Nuisance alarms are the leading reason for disabling smoke alarms.17

Sprinklers decrease the fire death rate per 1,000 reported home fires by 83% and the average loss per home fire by 71%.18 NFPA’s Fire Sprinkler Initiative: Bringing Safety Home is a nationwide effort to encourage the use of home fire sprinklers and the adoption of fire sprinkler requirements for new construction. See www.firesprinklerinitiative.org.

Children under 5 and older adults face the highest risk of home fire death, but young adults face a higher risk of home fire injury.19

Relative Risk of U.S. Home fire Deaths and Injuries by Age Group: 2003-2007

States with the highest fire death rates tend to have higher percentages of Adults who did not finish high school, Black or Native American residents, Smokers, Households living in poverty, and People living in rural areas.20

Source: NFPA’s Fire Analysis and Research Division. References are available at http://www.nfpa.org/assets/files//PDF/FireOverviewReference.pdf. September 2012.

1.2 1.1

0.3 0.5

2.1 2.4

0.7 1 0.5

1.3

2.3

1.1

0.0

0.5

1.0

1.5

2.0

2.5

< 5 5-14 15-19 20-34 35-64 65+

Deaths Injuries


Safety Professionals quantify success on reduced number of fatalities, lost work days, injuries – failure of safety systems and regulations

Our efforts to prevent serious injuries and fatalities has not been effective... Rates in these areas have not continued to decrease and have now plateaued.

3

Illness Classification System (OIICS) added the capability of recording the height of the fall. In 2011, the height of the fall was reported in 451 of the 541 fatal falls from higher level. Of those 451 cases, about one in four (115) occurred after a fall of 10 feet or less. Another fourth (118) occurred from a fall of over 30 feet. A total of 472 workers were fatally injured after being struck by objects or equipment, including 219 workers who were struck by falling objects or equipment and 192 who were struck by powered vehicles or mobile equipment not in normal operation.

Chart 1. Fatal occupational injuries by major event, 2011*

Transportation incidents41%

Roadway incidents23%

Homicides10%

Contact with objects and equipment 15%

Struck by object or equipment

10%

Falls to lower level

12%

Exposure to harmful substances and environments 9%

Fires and explosions 3%

*Data for 2011 are preliminary.NOTE: Event data for 2011 are not comparable to prior years due to the implementation of the revised Occupational Injury and Illness Classification System (OIICS) 2.01. See http://www.bls.gov/iif/osh_notice11.htm . Percentages may not add to 100 due to rounding.SOURCE: U.S. Bureau of Labor Statistics, U.S. Department of Labor, 2012.

Total=4,609

Violence and other injuries by persons or animals 17%

Falls, slips, and trips14%

There were 152 multiple-fatality incidents in 2011 (incidents in which more than one worker was killed) in which 354 workers died. For more detailed information on fatal injuries by incident, see the 2011 tables at www.bls.gov/iif/oshcfoi1.htm. Profile of fatal work injuries in 2011 by industry sector The number of fatal work injuries in the private construction sector declined by 7 percent in 2011. Fatal work injuries in construction have declined every year since 2006 and are down nearly 42 percent over that time. Economic conditions may explain much of this decline. Despite the lower fatal injury total, construction accounted for the second most fatal work injuries of any industry sector in 2011 with transportation and warehousing having the most fatal work injuries. (See chart 2.) Private sector mining fatalities were down 10 percent to 154 in 2011 from 172 in 2010 after rising 74 percent in 2010. Fatal work injuries were down sharply in coal mining to 17 in 2011 from 43 in 2010;


BUILDING CODES


Background v  Uniform Fire Code

v  Uniform Building Code


Automobile Industry Approach to Safety:

• They assume people will make mistakes. • They design the system to be tolerant of common

mistakes - e.g. bumps in the road keep the accident . • Airbags and other crash protection reduce the

consequences of the initial incident.


• Error Traps


What do you think of when you hear ANSI/ASSE 590.3-2011 Prevention

through Design . . . ?

Too Complex

Others

Reactive Safety Posture:

Preventive Safety Posture:

The Deliberate Leadership Shift… From event reaction to prevention learning

Accident Investigations, Non-compliance,

Corrective Actions, Critiques, Failures, Fines, Regulatory

Actions, Surprises…

Problem Identification, Error, Audits & Assessments,

Verification, Validations, Operational Experience,

Learning, Few Surprises…

Conklin

there’s no glory in fighting a fire that could have … · there’s no glory in fighting a fire...

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