Discussion Central

Expand all | Collapse all

Trump to Propose New Member to the Chemical Safety Board

  • 1.  Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-14-2019 21:36
    The Chemical Safety Board may not be on the road to extinction, but it still remains endangered.  This is at least a start!
    https://www.whitehouse.gov/presidential-actions/president-donald-j-trump-announces-intent-nominate-personnel-key-administration-posts-74/

    There is still at least one more Board Member 
    appointment needed to bring the current board up to full strength, and (ultimately) three more to replace the expiring terms of current Board Members by the end of August 2020.


    ------------------------------
    Richard Rosera BSChemE,MSChemE,MBA
    Board Member and Executive Advisor
    EHS GRADES International
    White Rock NM
    ------------------------------


  • 2.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-18-2019 10:56
    Katherine Andrea Lemos's background in human factors and change management is a good perspective to have. I am glad to see that this administration's attitude towards the CSB has moved from active hostility through neglect to at least filling one of the vacancies.

    ------------------------------
    Valerie Young
    Department Chair
    Ohio University
    Athens OH
    ------------------------------



  • 3.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-19-2019 18:53
    I know that any board can be pecked at by different viewsides, but I thought both industries and the public advocacy groups have a use for the CSB.




  • 4.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-20-2019 01:25
    Edited by Steve Cutchen 06-20-2019 01:28
    During attempts to zero out our budget, my heart has been warmed by the support from both industry and watchdog stakeholders. We try very hard to be a non-partisan, scientific organization. We have no power to force our recommendations to be followed; we exhort through the credibility of our work. We cannot enforce regulations and we do not issue fines. The cooperation we receive while conducting an investigation hinges totally on our reputation of scientific rigor combined with fairness.

    I spent 33 years in industry. I co-developed and then taught advanced incident investigation techniques at plants throughout the US and in Europe. Investigating as an outside agency is so different because we know so little when we arrive.  Inside, I know I can go to Ellen's office and get a copy of that chart I saw her present at a meeting in February. I can pick her brain, and I know I should. I know so many details. Outside, I don't even know who Ellen is when I first arrive. It's very different, and it takes a lot longer. But I'm proud of the work we do.

    BTW, I'm glad so many use the videos, but also read the reports to get the details that you can implement.

    My favorite one line advice snippets:
    • Make it easier to do things right and harder to do things wrong.
    • Find one PSM thing that bugs you and fix it. Just one. Other folks will see your success and they will go fix something that bugs them. On and on.
    • When you have a near miss, realize you were lucky. You got the lesson without the consequences. Figure out what was different this time, why you had the event. Then fix it.
    • Plan ahead for team-based Conduct of Operations during abnormal conditions when procedures don't exist. Predetermine the hierarchy of decision making. Know the boundaries of safe operation. Empower those at the pointy end of the spear.
    • Safety is not caused by preventing fallible biological machines from making errors in normal situations. Safety is caused by people doing the right thing almost always in unusual situations. In an investigation, figure out why what people did made sense at the time.

    ------------------------------
    Steve Cutchen
    Investigator
    US Chemical Safety Board
    Houston TX
    ------------------------------



  • 5.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-21-2019 07:19
    "Safety is not caused by preventing fallible biological machines from making errors in normal situations. Safety is caused by people doing the right thing almost always in unusual situations. In an investigation, figure out why what people did made sense at the time."

    Now that is something I had not heard before. I am sure you have experience behind that approach to back it up.




  • 6.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-21-2019 10:07
    Edited by Steve Cutchen 06-21-2019 10:48
    Safety is not caused by preventing fallible biological machines from making errors in normal situations. Safety is caused by people doing the right thing almost always in unusual situations. In an investigation, figure out why what people did made sense at the time.

    "Now that is something I had not heard before. I am sure you have experience behind that approach to back it up."

    Yes, I do. But it is not simply based on my experiences.

    There are three key concepts. Complicated versus Complex tasks, Safety II, and Resilience. There's not enough room here to fully explore them, but here's some quick comments and references.

    The Cynefin Framework is a tool for describing a hierarchy of task types that we deal with. Among these, Complicated tasks are those where we see a cause and effect relationship beforehand, we select a good practice from a chosen subject matter expert, and we follow their procedure to accomplish the task. This is the procedural portion of Operational Discipline. Example: making a cheesecake, or cleaning an exchanger on-line. For Complex tasks, cause and effect relationships are not known ahead of time, so there can be no predetermined procedure. We probe for a way forward, ideally within predetermined boundaries and under predetermined guidelines. This is the teamwork-based Conduct of Operations portion of Operational Discipline. Example: raising a child, or troubleshooting unexpected circumstances.

    Safety I: The condition where adverse outcomes are minimized
    • Hazards are foreseen and anticipated
    • Systems are well designed and maintained
    • Procedures are complete and correct
    • People are compliant and behave as trained
    • Adverse Outcomes result from unusual actions in usual conditions
    Safety II: The condition where adaption and recovery to safe conditions are maximized
    • Systems are subject to unanticipated change
    • People do what makes sense at the time to achieve goals
    • Adverse Outcomes result from usual actions in unusual conditions
    See these references:
    Erik Hollnagel, et al, "From Safety I to Safety II - A White Paper," |  EUROCONTROL, Directorate Network Management Safety, September 2013.
    Erik Hollnagel, "Is Justice Really Important for Safety?" | Hindsight 18, Winter 2013.
    Steven Shorrock, "If It Weren't For The People" | Hindsight 20 Winter 2014.
    Todd Conklin's PreAccident Investigation Podcast 15 - Sidney Dekker.
    Todd Conklin's PreAccident Investigation Podcast 69 - The New View of Safety - Zach Woods and Mike Rayo.

    Most are aware of Routine and Non-Routine situations.
    Routine Operations
    • Normal day-to-day operations
    Non-Routine Operations
    • Planned operations that occur infrequently
    • Startup
    • Shutdown
    • Online exchanger cleaning
    The current colloquial definition of Operating Discipline, "Always follow the procedure," works well
    But is that it? Routine and Non-Routine Operations?

    Abnormal Operations
    • Unplanned, unanticipated
    • Response is troubleshooting, developed in real time at the moment of need
    • Abnormal Operations are the initiating event type for the majority of CSB investigations
    If it just means "always follow the procedure," how does Operational Discipline help?

    The ability to handle Complex tasks is a sign of Resilience. The concepts behind Safety II are the tools that enable Resilience. And it is people that implement it. During Abnormal Operations with no predetermined path, they are the SOURCE OF SAFETY
    • resolve conflicts,
    • anticipate hazards,
    • accommodate variation and change,
    • cope with surprise,
    • workaround obstacles,
    • close gaps between plans and real situations,
    • detect and recover from miscommunications and misassessments.
    Workers adapt and recover the process, and do so correctly almost all of the time.
    Resilience. Bend without breaking.
    This cannot be automated or proceduralized.
    Workers are not error-prone biological machines.

    Sydney Dekker, "Resilience (Full Lecture)"
    Mary Douglas, as related by David Snowden, “How not to manage complexity” | State of the Net 2013.
    Doug Wiegmann & Scott Shappell, A Human Error Approach to Aviation Accident Analysis: HFACS, 2003, pp. 45-71.
    E. Hollnagel, "From Safety I to Safety II: A Brief Introduction to Resilience Engineering."
    David Woods & Richard Cook, "Perspectives on Human Error: Hindsight Bias and Local Rationality" | National Interagency Fire Center, March 2010.

    ------------------------------
    Steve Cutchen
    Investigator
    US Chemical Safety Board
    Houston TX
    ------------------------------



  • 7.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-21-2019 22:00
    I did not expect a semester syllabus, or a highly impressive presentation and ready use of references (!!) to my comment. Thank you for all of them to read when I'm not tired out after a dubious day at work.




  • 8.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-24-2019 10:22
    Steve

    Thank you for the explanation and references. The distinction between complicated and complex is well-described, and useful to me.

    Val

    ------------------------------
    Valerie Young
    Department Chair
    Ohio University
    Athens OH
    ------------------------------



  • 9.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-24-2019 10:32
    Thank you for the kind words, Val.

    The idea that there are tasks for which there can be no procedure is a weird concept for a lot of folks. Another example is driving to work. We handle it every workday, and it is different in the details every day. Probe, Feedback, Anticipation, Guidelines, Rules... The difficulty in trying to make this complex task merely complicated is the struggle that folks have with self-driving car development.

    ------------------------------
    Steve Cutchen
    Investigator
    US Chemical Safety Board
    Houston TX
    ------------------------------



  • 10.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-24-2019 21:36
    A question about the items describing Safety II. How do the last two items

    * People do what makes sense at the time to achieve goals
    * Adverse Outcomes result from usual actions in unusual conditions

    cover a panicking operator (or engineer!) when a situation is unusual as to be unnerving? I know we can't totally control emotion, and in a hazardous process or operation fear could derail someone's thinking.




  • 11.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-24-2019 22:36
    Edited by Steve Cutchen 06-24-2019 22:37
    Keith McIver:

    This type of discussion is better in a couple of comfy leather chairs by a fireplace where we can talk back and forth than it is exchanging typewritten text in a forum format, but I'll try to reply. In general, the situation you are describing is not contradictory to the two items you took from the Safety II discussion.

    Even in a panic situation, people still do what makes sense. And people tend to pattern match when problem-solving (see the Mary Douglas reference), so they tend to respond as if the situation they are faced with is within their frame of reference.  Think about the old adage: If there are hoof prints in the pasture, it's more likely to be a horse than a zebra.

    One of the primary concepts behind preparing for Abnormal Situations, behind Operational Discipline being much more about Conduct of Operations than Follow the Procedure, is that with preparation and collaboration, people are better equipped to handle Complex situations.

    ------------------------------
    Steve Cutchen
    Investigator
    US Chemical Safety Board
    Houston TX
    ------------------------------



  • 12.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 06-24-2019 22:54
    I wish we had some armchairs by a fire. I would actually take a train to the City to our HQ for that if I could meet persons like you there.

    Your response makes me realize I do not know what actually happens when someone "panics". I always assumed it was the literary description of action without conscious thought or memory record rather. Let me read that reference you specifically cite and I will see where that takes me.

    I do have to postpone reading it if I am going to be fit for duty tomorrow at work.

    Thank you, K.




  • 13.  RE: Trump to Propose New Member to the Chemical Safety Board

    SENIOR MEMBER
    Posted 07-24-2019 00:56
    Katherine Andrea Lemos is President Donald Trump's pick to head the U.S. Chemical Safety and Hazard Investigation Board, the White House announced July 22.

    Lemos, a director of autonomy research and technology at Northrop Grumman, was picked in June to be a member of the independent agency that investigates major chemical incidents.  This latest nomination elevates that position to chair for a five-year term.

    ------------------------------
    Richard Rosera
    EHS GRADES International
    White Rock NM
    ------------------------------