Category Archives: Hazards

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

Canucks Hockey Flag
This entry is part 1 of 3 in the series Hierarchy of Controls

Special Co-​​Author, Tom Doyle

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

Worse than Worst?

 

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.

Hazard Identification — Engineered Nanoparticles

Identifying haz­ards is the first step in the risk assess­ment process, but to do this effec­tively the haz­ards must be under­stood. Engineered nanopar­ti­cles, like car­bon nan­otubes, are begin­ning to show up in a wide vari­ety of prod­ucts. The prob­lem is that their haz­ards are not well understood.

Check out this arti­cle from IHSN mag­a­zine on this subject

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