The $10 Solution That Trumped a $275,000 Program
There once was an Operations Manager of a nuclear power plant who was experiencing a safety problem. Over the prior few years there had been several instances of auxiliary operators (those responsible for the physical manipulation of equipment in the field) sustaining minor injuries and causing equipment damage through the practice of climbing on piping and railings to perform valve and switch manipulations.
Though several safety messages had been issued, the practice was continuing unabated and the OM feared that eventually a much more serious injury or accident would occur. Through ever-increasing efforts he finally contracted an outside safety firm, who sold and installed safety equipment, to assess the issues and make any recommendations they felt would correct the issue and prevent future occurrences.
What do you think they recommended?
Exactly. They determined that the site needed additional safety equipment (in the form of step-ladders, fall arresting harnesses and safety training) to the tune of $275,000. Convinced this would finally solve his problem the OM paid the fee and authorized the contractor to go to work.
Over the course of the next five weeks the firm installed 17 “ladder stations” strategically around the plant to ensure proper safety equipment was convenient to the operators at all times. They conducted both classroom and practical training to demonstrate the proper use of said ladders, which now required a buddy-operator to act as a safety watch and personal safety harnesses which were now required to be utilized when the operator was more than six feet off the ground.
Like most any other operations, when a nuclear power plant is online, operating at capacity, very few equipment manipulations occur. The “machine” is humming along as designed and everything is fairly static, like a car traveling at 75mph in cruise control. However, when a scheduled refueling and maintenance shutdown is planned virtually the entire plant’s configuration is cycled; including valves at height.
I was engaged prior to one such shutdown to oversee and assess the effectiveness of the safety program and, basically, enforce it’s mandates. Having been an operator myself for the first half of my career I had reservations about the program’s effectiveness in addressing the root cause.
Yes, the behavior of climbing on piping and railings needed to stop, but the requirements of donning harnesses and calling-in a safety spotter seemed to be counter-intuitive to the root cause which, I suspected, was time pressure. Operators are notoriously under the gun to get things done as quickly as possible and when considering the choice between finding an appropriately sized ladder, putting on a harness, waiting for a spotter or just putting a foot on a railing and reaching to a valve that’s just out of reach…well, right or wrong the reward outweighs the risk.
Know Your Population
Anytime undesired behavior is observed or suspected you MUST learn the facts and motives of those whose behavior is in question. As uncomfortable as it may be it is absolutely essential that you see the issue from those experiencing it first hand. Challenge your own assumptions and at a minimum learn what barriers there are to the preferred method or performance standards.
The week before the shutdown I went to talk to the operators about their expectations of the program and, hopefully, to illicit some uncensored feedback. To my surprise my visit was the first of its kind. No one, not the OM, the safety equipment contractor, or the site Environmental Health & Safety staff had talked to the operators about the issues or their circumstances other than to reiterate site policies and expectations and to threaten punitive steps if ignored. First Mistake.
Rule number one for getting a program to stick is to get buy-in from the end-user as early as possible. This management team, in its various forms, had ignored the motives of those closest to the issue and assumed a mindset and therefore a solution.
Obviously, it’s a conflict of interest for an outside safety equipment company to perform your assessment for you. They’re motivated by selling safety equipment and they see everything through a lens of missing safety equipment. Their recommendations were as predictable as being asked “do you want fries with that?”
Additionally, if the management staff had talked to the operators and asked if equipment availability was an obstacle to its use they would have learned that, no, it wasn’t. Operators had plenty of equipment and knew how to use it properly, they had other reasons for not using the gear none of which stemmed from an issue a safety equipment company could address.
Know Your Data
The next in successfully solving and issue is to review the data from the events that actually resulted in the undesired outcome, in this case damage or injury. The site’s Condition Reporting System failed to capture key metrics about the incidents, like the height of the equipment off the ground, so right out of the gate their issue collection system was lacking.
So, time to roll up your sleeves and do some field work and walk down each and every recorded incident. In every instance the equipment being manipulated was found to be between 7 and 10 feet off the ground. Every. Single. Instance. 100% Again the management staff had lumped equipment at “height” into a generalized category instead of taking the time and effort to find precisely where the issues were being felt.
Obviously, equipment that could be accessed from the ground wasn’t going to result in a fall and equipment that was more then ten feet off the ground was being accessed in full compliance with the safety at heights program. But what about this population of equipment that was being reached ‘improperly’?
Clearly the field operators had a different risk tolerance than the program administrators.
Know Your Outcome
Finally, since the management team was convinced that the issue was administrative (i.e., write a rule that prevents a certain behavior and enforce it) their solution was administrative. The problem with an administrative solution is that you rely on compliance, not a sound or physical prevention method, for results.
Developers of the USB drive could have written instructions that would accompany each drive to tell you that you must install the drive ‘right-side-up,' but instead they designed it so that it could only be inserted the correct way removing all subjectivity and thought. See the difference?
What the whole team really wanted was a safe and efficient work environment. What the team needed was to keep the operator’s feet on the ground as frequently as possible. What they got was a cumbersome program with a conflicting set of directives from the existing procedures.
When you know your desired end result you are less attached to the solution and much more likely to implement what works and achieves your goal instead of a predetermined program or tool because it’s convenient or appears on the surface to address the problem as you interpret it.
In the end, 100% of illegal climbing operations were ceased by a solution that cost less than $10.
Since the real issue was access to valves in the seven to ten foot high range I had constructed a valve extension handle that virtually eliminated the need for operators to leave the ground except in rare occasions when the full program rigor could be brought to bear.
A valve extension handle is a fancy way of saying I asked the site welder to attach a valve handle to both ends of a four foot long rod. Operators could then quickly, easily and safely operate valves too high off the ground to reach, but too low to justify the effort to haul out all the equipment necessary for full program compliance.
Think about a nagging problem that has plagued your organization for as long as you can remember or about an expensive solution that never really made lasting change in your organization and I guarantee the above steps were ignored or at least under-executed.