Category Archives: General

Hockey Teams and Risk Reduction or What Makes Roberto Luongo = PPE

Posted by on June 21, 2011 5 comments
Canucks Hockey Flag
This entry is part 1 of 3 in the series Hierarchy of Controls

Special Co-​​Author, Tom Doyle  (tjdotdoyleatindus­tri­al­safe­ty­in­te­gra­tiondotcom)  

Last week we saw the Boston Bruins earn the Stanley Cup. I was root­ing for the green, blue and white, and the ruin of my voice on Thursday was ample evi­dence that no amount of cheer­ing helped. While I was watch­ing the game with friends and col­leagues, I real­ized that Roberto Luongo and Tim Thomas were their respec­tive team’s PPE*. Sound odd? Let me explain.

Risk Assessment and the Hierarchy of Controls

Equipment design­ers need to under­stand  OHS* risk. The only proven method for under­stand­ing risk is risk assess­ment. Once that is done, the next play in the game is the reduc­tion of risks by elim­i­nat­ing haz­ards wher­ever pos­si­ble and con­trol­ling those that remain.

Control comes in a cou­ple of flavours:

  • Hazard mod­i­fi­ca­tion to reduce the sever­ity of injury, or
  • prob­a­bil­ity mod­i­fi­ca­tion to reduce the prob­a­bil­ity of a worker com­ing together with the haz­ard.

These ideas have been for­mal­ized in the Hierarchy of Controls. Briefly, the Hierarchy starts with haz­ard elim­i­na­tion or sub­sti­tu­tion, and flows down through engi­neer­ing con­trols, infor­ma­tion for use, admin­is­tra­tive con­trols and finally PPE. As you move down through the Hierarchy, the effec­tive­ness and the reli­a­bil­ity of the mea­sures declines.

It’s impor­tant to rec­og­nize that we haven’t done a risk assess­ment in writ­ing this post. This step was skipped for the pur­pose of this example—to apply the hier­ar­chy cor­rectly, you MUST start with a risk assess­ment!

So how does this relate to Hockey?

Hockey and the Hierarchy of Controls

Hazard Identification and Exposure to Risk

If we con­sider the goal as the worker — the thing we don’t want “injured”, the puck is the haz­ard, and the act of scor­ing a goal as the act of injur­ing a per­son, then the rest quickly becomes clear.

Level 1: Hazard Elimination

By def­i­n­i­tion, if we elim­i­nate the puck, we no longer have a game. We just have a bunch of big guys skat­ing around in cool jer­seys with sticks, maybe hav­ing a fight or two, because they’re bored or just don’t know what else to do. Since we want to have a game, either to play or to watch, we have to allow the risk of injury to exist. We could call this the “intrin­sic risk”, as it is the risk that exists before we add any controls.

Level 2: Hazard Substitution

The Center and the Wingers (col­lec­tively the “Forwards” or the “Offensive Line”), act as haz­ard “sub­sti­tu­tion”. We’ve already estab­lished that elim­i­na­tion of the haz­ard results in the loss of the intended function—no puck, no game. The for­wards only let the other team have the puck on rare occa­sion, if they’re play­ing well. This is a great idea, but still a lit­tle too opti­mistic after all. Both teams are try­ing to get the puck in the oppos­ing net and both teams have qual­i­fied to play the final game. If they fail to keep the puck beyond the other team’s blue line, or at least beyond the cen­ter line, then the next layer of pro­tec­tion kicks in, with the Defensive Line.

Level 3: Engineering Controls

As the puck moves down the ice, the Defensive Line engages the approach­ing puck, attempt­ing to block access to the area closer to the goal. They act as a mov­able bar­rier between the net and the puck.  They will do what­ever is nec­es­sary to keep the haz­ard from com­ing in con­tact with the net. As engi­neer­ing con­trols, their coör­di­na­tion and posi­tion­ing are crit­i­cal in ensur­ing success.

The sys­tem will fail if the con­trols have poor:

  • posi­tion­ing,
  • choice of mate­ri­als (players),
  • tim­ing, etc.

These risk con­trols fail reg­u­larly, so are less desir­able than hav­ing the Forward Line han­dle Risk Control.

Level 4: Information for Use and Awareness Means

In a hockey game, the infor­ma­tion for use is the rule book. This infor­ma­tion tells play­ers, coaches, and offi­cials how the game is to be played, and what the intended use of the game should be. Activities like spear­ing, trip­ping, and blind-​​side checks are not permitted.

The aware­ness means are pro­vided by the roar of the fans. As the puck heads for the home-team’s goal, the home fans will roar, let­ting the team know, if they don’t know already, that the goal is at risk from the puck. Hopefully the defen­sive line can react in time and get between the puck and the net.

Level 5: Administrative Controls

Information for use from the pre­vi­ous step is the basis for all the fol­low­ing con­trols. The team’s coaches, or “super­vi­sors”, use this infor­ma­tion to give train­ing in the form of hockey prac­tice. The Forward Line and Defensive Line could be con­sid­ered the Suppliers and Users. They all need to know what to do to avoid haz­ardous sit­u­a­tions, and what to do when one arises, to reduce the num­ber of poten­tial failures.

A “Permit to Work” is given to the play­ers by the coach when they form the lines. The coach ensures that the right peo­ple are on the ice for each set of cir­cum­stances, decid­ing when line changes hap­pen as the game pro­gresses, adapt­ing the peo­ple per­mit­ted to work to the spe­cific con­di­tions on the ice.

Level 6: Personal Protective Equipment (PPE)

All of this brings me to Roberto Luongo and Tim Thomas. So how is a Goalie like PPE?

Goalies are the “last-​​ditch” pro­tec­tion. It’s clear that the first 5 lev­els of the hier­ar­chy don’t always work, since every type of con­trol, even haz­ard elim­i­na­tion, has fail­ure modes. To give a bit of backup, we should make sure that we add extra pro­tec­tion in the form of PPE.

The puck wasn’t elim­i­nated, since hav­ing a hockey game is the point, after all. The puck wasn’t kept dis­tant by the Forward Line. The Defensive Line failed to main­tain safe dis­tance between the goal and the puck, and now all that is left is the goalie (or your pro­tec­tive eye­wear, boots, hard­hat, or what­ever). In the 2011 Stanley Cup Final game, Luongo equaled long pants and long sleeves, while Thomas equaled a suit of armour. The Bruin’s “PPE” afforded supe­rior pro­tec­tion in this case.

As any­one who has used pro­tec­tive eye­wear knows, par­ti­cles can get by your eye­wear. There are lots of fac­tors, includ­ing how well they fit, if you’re wear­ing them (prop­erly or at all!), etc. If the gear is fit­ted and used prop­erly by a per­son who under­stands WHY and HOW to use the equip­ment, then the PPE is more like Tim Thomas, and you may be able to “shut out” injury. Most of the time. Remember that even Tim Thomas misses stop­ping some shots on goal and the other guys can still score.

When your PPE doesn’t fit prop­erly, isn’t selected prop­erly, is worn out (or psy­ched out as the case may be), or isn’t used prop­erly, then it’s more like Roberto Luongo. Sometimes it works per­fectly, and life is good. Sometimes it fails com­pletely and you end up injured or worse.

Goalies are also like PPE because they are RIGHT THERE. Right before injury will occur. PPE is RIGHT THERE, pro­tect­ing you—5 mm from the sur­face of your eye, or in your ear, 2 mm from your ear drum. By this point the harm­ful energy is RIGHT THERE, ready to hurt you, and injury is immi­nent. A sim­ple mis­place­ment or bad fit con­di­tion and you’re blinded or deaf or… well you get the idea!

On Wednesday night, 15-​​Jun-​​2011, every­thing failed for the Vancouver Canucks. The team’s spirit was down, and they went into the game think­ing “We just don’t want to lose!” instead of Boston’s “We’re tak­ing that Cup home!”. Even the touted Home Ice Advantage wasn’t enough to psych out the Bruins, and in the end I think it turned on the Canucks as the fans real­ized that the game was lost. The warn­ings failed, the guards failed, and the PPE failed. Somebody got hurt, and unfor­tu­nately for Canadian fans, it was the Canucks. Luckily it wasn’t a fatal­ity! Even being #2 in the NHL is a long stretch bet­ter than fill­ing a cooler drawer in the morgue.

So the next time you’re set­ting up a job, an assem­bly line, a new machine, or a new work­place, check out your team and make sure that you’ve got the right play­ers on the ice. You only get one chance to get it right. Sure, you can change the lines and upgrade when you need to, but once some­one scores a goal, you have an injured per­son and big­ger prob­lems to deal with.

Special thanks to Tom Doyle for his con­tri­bu­tions to this post!

*Personal Protective EquipmentOccupational Health and Safety

Fukushima Dai Ichi — Live

Posted by on June 10, 2011 Comments Off

Web Cam Still from Fukushima Nuclear Power PlantIn a recent post on his Forbes blog, Edison 2.0, Osha Gray Davidson con­nects read­ers to a live web­cam installed by TEPCO at the Fukushima Dai Ichi nuclear plant. The ongo­ing cri­sis at the plant has made a fas­ci­nat­ing, slow-​​motion hor­ror story for the world to watch. The addi­tion of the live web cam, along with news reports deal­ing with the con­tin­u­ing attempts to bring the four stricken reac­tors under con­trol, make a great study in emer­gency plan­ning and cri­sis control.

New infor­ma­tion being released by TEPCO shows that the reac­tor cores melted down ear­lier than orig­i­nally believed, and in at least one case, the con­cern is now focused on the pen­e­tra­tion of the exter­nal shield build­ing by the molten core. If the core has actu­ally “left the build­ing” as some experts believe, the poten­tial for envi­ron­men­tal con­t­a­m­i­na­tion on an enor­mous scale exists.

In the mean time, TEPCO work­ers and con­trac­tors con­tinue to try to clean up the site, remov­ing piles of debris left from the explo­sions back in March. IEEE Spectrum reports that a tele­op­er­ated (remote-​​controlled) exca­va­tor acci­den­tally blew up an oxy­gen cylin­der that was hid­den in a pile of debris. TEPCO claims that no dam­age was done, and that the machine is still in operation.

The result of this nuclear acci­dent is a global turn-​​around in what was a resur­gence in inter­est in nuclear power. Reports indi­cate that Germany will be tak­ing all their nuclear power plants off-​​line and decom­mis­sioned by 2023. An uncon­firmed report says that Japan is plan­ning to decom­mis­sion all 54 nuclear plants on the islands in the near future. A report on the Ahram Online blog indi­cates that the Swiss are also respond­ing to pub­lic pres­sure to decom­mis­sion that country’s reac­tors, with the first going offline in 2019 and the last by 2054. As usual, the prag­matic Swiss approach is to allow the reac­tors to live out their design life­times and decom­mis­sion rather than refur­bish them at that time.

The Japanese nuclear indus­try, once con­sid­ered  a model of safety by the inter­na­tional nuclear com­mu­nity, has had its dirty laun­dry exposed. In March, just six days after the earth­quakes and tsunamis, Yuri Kageyama wrote an exposé of the industry’s scan­dals on MSNBC’s World Business blog. His arti­cle cited a cul­ture of secrecy in the indus­try that pre­vents improve­ments and encour­ages cover-​​ups and corner-​​cutting.

The oppor­tu­ni­ties that Fukushima is giv­ing us are man­i­fold. First, the nuclear indus­try gets an oppor­tu­nity to learn from the cat­a­stro­phe at the plant, and to see some of the ways that the orig­i­nal boil­ing water reac­tors can fail. This may result in design improve­ments to sim­i­lar plants that remain oper­a­tional in other coun­tries, help­ing to reduce the like­li­hood of this kind of dis­as­ter re-​​occurring in the future. Second, it allows emer­gency response spe­cial­ists to learn from the suc­cesses and fail­ures that occurred at the plant, improv­ing the emer­gency response plans at other nuclear and non-​​nuclear facil­i­ties where a dis­as­ter could have broad envi­ron­men­tal and eco­nomic impacts. Third, it has given gov­ern­ments, reg­u­la­tors and the International bod­ies a wake-​​up call about the nuclear indus­try. This is a tech­nol­ogy that can be safe and effi­cient if man­aged prop­erly, but when cor­ners are cut and prob­lems are cov­ered up, the caged nuclear drag­ons can escape and wreak havoc.

Our world is enter­ing an amaz­ing, scary, exhil­a­rat­ing, time of change. Nuclear power, once seen as the Golden Fleece that would light the world for hun­dreds of years, has shown its dark side again. Alternate forms of energy gen­er­a­tion are start­ing to come online, with wind farms and solar farms spring­ing up around the world. Even these more benign forms of gen­er­a­tion have their down­sides, and there isn’t enough installed base to sup­port our energy needs — yet.

So, while we watch the grainy video stream­ing from Fukushima, we need to con­sider our way for­ward, and learn the lessons paid for by the peo­ple of Japan.

Worse than Worst?

Posted by on April 12, 2011 4 comments

 

Past and current International Nuclear and Radiological Event Scale for the Fukushima Dai Ichi disaster

Updated INES Level for Fukushima Dai Ichi

The increase to the inci­dent level at the Fukushima Dai Ichi nuclear plant today by the Japanese Nuclear Regulatory Authority has brought the con­tin­u­ing dis­as­ter at the crip­pled plant back into the head­lines. IEEE Spectrum has pub­lished a series of arti­cles recently writ­ten by Bill Sweet on the Fukushima Dai Ichi nuclear dis­as­ter. From the human per­spec­tive, this has been a ter­ri­ble dis­as­ter, although by some accounts not as bad as Chernobyl. I am not qual­i­fied to speak on the tech­ni­cal aspects of nuclear power, but from a risk assess­ment per­spec­tive, this dis­as­ter brings some inter­est­ing lessons. I explored some of these ideas in another arti­cle called “How Risk Assessment Fails”. If you want to learn more about the dis­as­ters, I encour­age you to check out Mr. Sweet’s articles:

 

You might also want to read the New York Times’ arti­cle “Japanese Workers Braved Radiation for a Temp Job”.

Much can be learned from the nuclear inci­dents and acci­dents at Three Mile Island, Chernobyl, and now Fukushima. As engi­neers and safety prac­ti­tion­ers we need to be acutely aware that bas­ing our assess­ments on sin­gle fault analy­sis, and the cor­re­spond­ing fail­ure to exam­ine the pos­si­bil­ity of com­mon cause fail­ures that can result in epic scale dis­as­ters like these is false secu­rity. You can­not hide from con­se­quences like these. We must begin to con­sider the ‘worse than worst’ sce­nar­ios that exist in our designs and in our work­places. We may not be deal­ing with risks on a national scale like those present in these facil­i­ties, but the con­se­quences to those we work with can be just as devastating.

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