Incidents Continue to Happen
“Key Largo, FL, January 2017 – Three underground utility workers died after entering a confined space without the proper personal protective equipment or gas monitoring equipment. According to initial inquiries, the first man entered a 15-foot deep drainage hole and became unresponsive. The second worker entered the opening with the intention of savings the first man but also lost consciousness. The third man climbed in to help his coworkers and was overcome.”
– EHS Today, 2017
“On average, two people will go to work this week somewhere in the United States and not return home to their families as a result of entering a confined space. According to the annual Census of Fatal Occupational Injuries, compiled by the Bureau of Labor Statistics, 136 U.S. workers died in incidents associated with confined spaces in 2015.”
– NFPA Journal, March-April 2017
“The accident took place on a container ship while on port. After giving instructions to the engine room department, the 2nd Engineer along with the engine room fitter went into the ship’s tunnel to overhaul a leaky storm valve. The 2nd Engineer and the fitter started their work in the confined space of the tunnel. They isolated the line and slackened the valve from the place. However, they neglected the point that the line can have trapped poisonous gases inside it. As soon as the valve was removed, the toxic gas escaped into the confined space tunnel. The 2nd Engineer and fitter collapsed instantly. This was not all. After some time, the 4th Engineer went into the tunnel looking for the 2nd Engineer. Unaware of the situation, the 4th Engineer also collapsed because of the poisonous gases as soon as he entered the confined space. After few hours, the 3rd Engineer on not finding 2nd and 4th Engineers, informed the Chief Engineer about the situation. A team entered the tunnel after taking proper precautions to rescue people from confined space along with breathing apparatus and discovered that 2nd Engineer, 4th Engineer and fitter had died due to suffocation by poisonous gases in the confined space.”
– Marine Insight, April 2017
Maintain a Sense of Vulnerability
A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!
- Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
- Do you require consistency in practice from everyone in the organization?
- Do you have systems in place to determine if inconsistencies exist?
- Do people believe that “yes, it can happen here”?
- Do people believe that “yes, we have similar vulnerabilities”?
- Have you experienced similar incidents but without consequences (i.e., near misses)?
Do you combat organizational overconfidence that can be stimulated by past good performance?
Prevent Normalization of Deviation
Normalization of deviation is defined as…..
“The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.”
Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)
“A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.”
- CCPS Glossary (iPhone Application)
Signs of Normalization of Deviations – Does this describe your organization?
- If a deviation is necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
- Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
- Are your expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
- Do you allow operations outside established safe operating limits without a detailed risk assessment?
- Are willful, conscious, violations of established procedures tolerated without investigation or without consequences for the persons involved?
- Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
- Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? For example:
o Entering a vessel skirt without a proper confined space permit?
o Not assuring that confined space to be entered is tested properly for hazards including lack of oxygen?
o Not using confined space permit for excavations?
- Are all employees empowered to stop work for any situation deemed unsafe?
Evaluate Your Program
Do you audit your Confined Space Entry program to ensure the program is yielding the intended results?
Do you review the following items:
- Written Confined Space Entry procedure?
- Confined Space Entry permits?
- Roles and responsibilities of persons involved in Confined Space Entry activities?
- Training and competency provided to persons involved in Confined Space Entry activities?
- Hazard assessments performed before Confined Space Entry activities are conducted?
- Job observations performed on Confined Space Entry activities?
- Personal protective equipment requirements for Confined Space Entry?
- Proper isolation techniques including blinds or physical disconnects?
- Proper draining and cleaning equipment before Confined Space Entry?
- Atmosphere testing procedure that includes testing for toxics and oxygen at different levels/locations in the equipment to be entered?
- Equipment properly locked out?
- Rescue procedures and equipment in place?
- Fault interrupters used for electrical equipment?
- Pneumatic tools not operated by nitrogen?
- Proper ventilation and lighting provided?
Have you audited your Confined Space Entry permits and discussed the results of the audits? Was there evidence that:
- Permits were not completely filled out (i.e., last hazardous material contained in the line not identified?).
- Permits were not signed?
- Proper PPE requirements not identified?
- The permit writer was not trained?
- Equipment not properly cleaned or drained?
- Equipment not isolated properly (blinds or disconnects)?
- LOTO procedures not followed?
- Rescue procedures and equipment were not available?
- Permit conditions were not communicated within the subject work team?
- Atmosphere was not tested for flammables (if handled), toxics and oxygen?
- Proper ventilation and lighting not provided?
- Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
- Work extended beyond the authorized period of time?
Have you evaluated your Confined Space Entry audit program?
- To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
- To ensure the competency levels of the auditors?
- Does your Confined Space Entry procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
o Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
- Does the execution of the procedure yield the intended results? Are you evaluating your program for:
o Procedural Compliance – are actions and tasks in compliance with procedural requirements? (Paper Control), and
o Program Health – is your system providing the intended results? (Actual Execution)
- Do you know of any site or company incidents related to Confined Space Entry?
o Have you discussed the results and causes within your organization?
- Do you know of any site or company near misses related to Confined Space Entry?
o Have you discussed the results and causes within your organization?
Continually Improve Your Program
Are you considering improvements to prevent future incidents? Here are some ideas you may want to consider:
- How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
- Do you track specific confined space entry-related metrics that can be used to determine program effectiveness and improve performance?
- Have you benchmarked your program against other programs in your industry?
- How often do your senior managers visit the field to watch confined space entry activity?
- Do you have a requirement to periodically update your program?
- Do your workers (those closest to the work) have an easy method to suggest improvements to your program?
A successful Confined Space Entry program depends on the actions of individuals within the organization. Do the values and behaviors of your organization determine the manner in which your Confined Space Entry program is managed and executed?
- Does management and supervision reinforce desired behaviors to ensure they become integrated into the group’s values?
- Are high standards of Confined Space Entry program performance clearly established?
- Is open and effective communication encouraged and supported?
- Has management established safety as a core value?
- Does management and supervision provide strong leadership?
- Has management formalized the safety culture emphasis and approach?
- Does management work to ensure employees maintain a sense of vulnerability?
- Are individuals empowered to successfully fulfill their safety responsibilities?
- Does management ensure open and effective communication exists?
- Does management support and foster mutual trust?
- Does management establish and enforce high standards of performance?
- Does management defer to expertise?
- Has management established a questioning/learning environment?
- Does management require timely responses provided to safety issues and concerns?
- Does management provide continuous monitoring of performance?