In previous blogs I have written about the three biggest mistakes that many managers often make that can lead to disaster.
These are putting production first, allowing the technology to drift and blocking communications. A disaster occurred recently in a chemical plant in La Porte, TX when 3 men and 1 woman were killed with a 23,000-pound release of methyl mercaptan. Methyl mercaptan has an An Acute Exposure Guideline (AEGL-3; EPA) of 120 ppm for a 10-minute exposure. Methyl mercaptan is seen more as an irritant and badly-smelling material, but this release in a confined area completely overwhelmed the people by displacing the oxygen in the closed, operating building.
In reading the various, publicly-available reports, it looks as if all three of these big mistakes were probably made. The push for production was dominant, piping changes had been made without documentation, the safety procedures were modified or ignored, operating problems were not properly addressed and tolerated, previous practices allowed the draining of small quantities of material right into the room, and the communications were such that people probably could not or would not tell their management, who probably were not listening anyway, all the problems.
It would be easy to blame the 4 operating people for their errors, but this mess runs far more deeply in this culture. Three of the people were experienced operators and one was much less experienced. With the press for production, training was probably inadequate. While site management was probably responsible for the three big mistakes, they too were under a lot of pressure from the business division, product management people, in headquarters far away from the site, who were driving earnings at all costs.
But it does not stop here. The mistakes run even more deeply than these more immediate problems. The safety culture of the entire corporation appears to have slipped drastically over the last 4-5 years. Was everyone taking their eye off the ball for the sake of faster production and higher earnings and allowing standards to slip everywhere? Even though there had been a culture of many layers of protection in the safety systems and very high standards of performance and accountability, these seem to have weakened and some disappeared.
This entire disaster episode clearly shows the importance of the interconnectedness of all the parts of the whole system. Simple cause/effect relationships do not come close to telling the entire story. Getting on top of this deeply flawed culture and at all the organizational levels will take hard, honest, open work by safety professionals, operators, mechanics, supervisors, HR professionals, site management, business division product management and corporate management. They all need to come together to hold the conversations, each accepting their part in the disaster, learning together and co-creating their journey to a safety future of excellence.
Based on previous experience, tough regulators, OSHA fines, bad press, and law suites, all of which will come, will not lead to safety excellence. The people in this system, coming together in Partner-Centered Safety™ can and will make the needed difference.
I hope that they can and will rise to the occasion!
Postscript: Important!
While some people may be concerned that Partner-Centered Safety will cost too much, I have found just the opposite to be true. Earnings are improved in two ways.
First, the losses from injuries ($50,000/OSHA Record able Injury) and incidents are greatly reduced.
Second, the shift in culture that occurs when people are working this way results in a lot of waste being removed and improvements made. For example, when we learned to work together in Partner-Centered Safety when I was the Plant Manager at the DuPont Belle, WV Plant, injury rates dropped by over 96%, productivity rose 45%, emissions dropped 85%, and earnings rose 300%. We can all be winners in Partner-Centered Safety.
At a recent safety conference I learned about a way to quickly assess whether a manufacturing site was cutting corners and trying to get by on less than the best. The person speaking, Ewan Alexander of BHP Billiton, said that he looked for improvised tools being used. 
