Tank Entry and Gas Detection
Published: 06th Apr 2012
The best equipment, correctly maintained, and people properly trained to use it, are an essential for safe operations. Clear, well written procedures related to the task are also a necessary safety tool. When you think about it, though, having the best tools and great procedures are useless unless we use them properly - and that comes down to behaviours.
Here’s an example using a case study, adapted from an actual incident. At the end of the article I’ll make clear the three behavioural lessons.
Fatally high risk scenario
A contractor was hired by a vessel owner to remove Oil Based Mud (OBM) residues from four tanks. Three men - two to do the cleaning, one as ‘watchman’, plus the contractor supervisor - were involved. Both vessel and contractor supervision realised the high risk nature of tank entry and numerous precautions were taken including:
• The contractor supervisor taking control of the pre-task HSE planning
• A Confined Space Entry Permit
• A General Work Permit
• A Contractor Job Safety Analysis
• The Vessel’s Enclosed Space Checklist/Permit to Work (PTW)
Before work commenced there was a full toolbox talk and all four tanks were naturally ventilated. The atmosphere sampling on all four tanks was conducted by the contractor supervisor using his multi-test meter. The vessel Chief Officer, however, who was observing the atmosphere test, expressed concern about the short sampling probe. He offered the use of the vessel testing equipment, but this was declined. He was also not happy about the air circulation system comprising a funnel for placing outside the tank, a wide diameter flexible hose attached to the funnel and leading into the tank entrance, and an air hose from a compressor unit connected to the base of the funnel.
Three of the tanks were successfully cleaned, but during cleaning of the fourth tank, one of the men collapsed. His mate attempted to help him out of the tank but he also collapsed. The safety watchman seeing his two mates unconscious went to help them and he also succumbed. When the contractor supervisor saw what was happening he donned his breathing apparatus, but for some reason it was not working properly.
There was a three minute delay while the vessel’s apparatus was fetched. Unfortunately the three men died. Although all the paperwork was in place and the equipment was there, I am sure most readers would agree that the risk assessment for this job was poor. The defective rescue equipment should have been picked up. Perhaps there was also a lack of training about the rules of tank entry. If these two things had been in place there would probably not have been an accident.
Learning the survival lessons
Some behavioural insights could have prevented this accident in the first place, and in the second place could have saved at least two people once the accident got underway. The first behavioural lesson is to pay more attention to your ‘gut feelings’. We get these inexplicable, unconscious ‘messages’ all of the time, but we don’t necessarily pay attention to them - yet we might benefit from listening to these ‘inner voices’, since, often as not, what they’re saying to us is often rooted in common sense and sound rationale.
How many times, for example, have you said to yourself ‘If that continues, x, y and z will happen’? Your gut feelings about what will happen in the future are perfectly logical, and based on the simple principle of cause and effect. These instincts are based on information you already know. If the vessel supervisor had acted on his gut feeling about the ineffective gas testing meter and the ineffective ventilation method, this accident may not have happened.
The second behavioural lesson to be drawn from this incident is not to worry about offending people. When the vessel supervisor offered the use of the vessel’s own gas testing equipment, it was declined, with the contractor taking offence at the suggestion that his equipment was not good enough. Do you agree the vessel supervisor, as the client, should have insisted on his meter being used?
The third behavioural lesson here is to become aware of diminishing the risk. As competent human beings we want to go ahead and get jobs done properly and on time. Sometimes we say things in our heads which trick us into going ahead with a certain course of action when we know we shouldn’t. Examples of some of the things we might say in such instances include:
• ‘We have done this 100 times before, it’ll be fine’
• ‘It will only take two minutes’
• ‘It’s only a small job’
These are some of the phrases we use to diminish the risk and give ourselves permission to go ahead and do something we actually know is risky. In the above incident, the ‘carry on regardless’ approach was evidently perpetuated by a thought such as ‘We have already cleaned three tanks successfully, so the fourth is bound to be fine too’. We often call this complacency, but it isn’t really that - it’s just human nature to fall into the trap of diminishing the risk.
The fourth behavioural lesson to be learned from this scenario is the hardest of all - don’t help people, unless it is safe to do so. Do you agree that this is the most difficult behaviour to follow? We don’t want to be seen as the coward who let his mate die. When a fellow human is in danger and needs help, it is an automatic reaction to go and help. We clearly have to learn to fight this automatic reaction, because in this case two people died trying to help their colleagues.
Did entering the tank really help anyone? No.
We just need to change perspective slightly, even in our daily lives, when perhaps rescuing someone from a burning motor vehicle, or even encouraging a pedestrian to cross the road from the safety of our cars - how often do we read of pedestrians killed in this way as they walk into an unseen car in another lane? Yes, we will help people in the best way - but in a way that increases the chance of survival for both my mate and me. In this case study that means going to get the breathing apparatus before entering the tank.
In pursuit of an ideal situation
Most of us are working and striving for perfection - that is, zero incidents and accidents. We are, however, human, and sooner or later, even with all the right procedures in place and the best equipment to hand, someone will not do what they should have done. In these instances remembering the four behaviour incidents mentioned earlier may lessen the harm to people. As a senior manager or HSE manager you’re doing everything you know how to help your people behave in ways that promote even more safe working.
As a safety officer or adviser at the ‘coalface’, you want ideas and activities to engage the people at your worksite. The behavioural safety approach may be just what your workforce needs.
I bet you sometimes wonder, ‘What more can we do’?
• We have tons of procedures but sometimes people don’t follow them
• We have great PPE but sometimes people don’t wear it
• We give extensive training but sometimes people don’t act on what they’ve learned
• We selected our people with care, but sometimes they don’t use their intelligence or common sense
A down to earth behavioural approach helps
Looking at your safety issues from a behavioural standpoint is simpler, less bureaucratic, less time consuming and more enjoyable than you might think. There are numerous practical behavioural safety workshops available that can prompt you towards improving your existing systems - particularly when they steer clear of safety ‘gobbledygook’ and complex ‘models’, and use plain English to explain simple human behaviours that are helpful.
Behavioural safety without the ‘Guru-speak’
It is possible to reach zero incidents and accidents and stay there longer by making simple improvements to your existing safety systems and by involving people in practical, yet powerful behavioural safety workshops. Behavioural safety does not necessarily require new initiatives. You can instead support your existing policies and efforts.
Working hard is good - but work smart is better
Most people try hard for safety and know the right things to do. Therefore, lectures and shock tactics are not effective. A good alternative is to look at the evidence based on hard-won, real-life experience, and expose people to scenarios and case studies that make them think about their own behaviours - such as the scenario mentioned earlier. Discussion is pivotal to this - when you debate and think enough, you are confronted with your own resistance to doing what is right and it is this that helps people change for the long term.
Just as with any job you approach, you need the right tools to do it with - and the tools for introducing and implementing the benefits of behavioural safety approaches in your workplace fall under one of three headings: • Systems - ensure that your permit to work, risk assessment and safety observations systems, for example, are working well • Culture - reduce the fear factor and have constructive safety conversations - this alone gives tremendous gains in safety behaviours • People - it’s important to show people how to avoid the six behavioural traps
Published: 06th Apr 2012 in Health and Safety International