The Weekly Reflektion Week 37 / 2020
We have recently had a lot of new subscribers to the Weekly Reflektion and it is good to hear that there is a growing interest in what we are trying to do. Richard Heyerdahl from Proactima is one of these and he sent us some experience from an investigation he was once asked to carry out offshore at short notice. When he arrived on the platform, he was informed that the incident was already investigated, it was operator error and that further investigation was not required. He received an apology for the inconvenience. Before he returned onshore, he left them with a different picture of why the incident had happened and some points to reflect over. As we have mentioned in previous Reflektions human error is just the start of the journey to find out why an incident has occurred. It is never the destination.
Why do people do ‘stupid’ things that could lead to a dangerous situation?
The accommodation module on an offshore platform contains multiple floors and lifts are installed for the transport of personnel and supplies. Any problems with the lifts can affect the operation and will affect the working environment so keeping them going is important.
One day a person on the 5th floor called on the lift. The lift arrived, the door opened, and the person made to walk into the lift. Luckily, he was not distracted, and he stopped in time to see that the lift was still at the first floor. He reported the incident and reflected over how lucky he had been to be able to report the incident. Had he walked into the lift he would have been killed or seriously injured.
The lift was designed such that the door could not be opened unless the lift was actually at the floor. The mechanism for ensuring this was mechanical. When the lift arrived at a floor a pin was pushed into a ‘door open’ position and this released an interlock with the pushbutton for lift operation. This push button initiated the call for lift if the lift was not at the floor and opened the door if the lift was at the floor. The pin was spring loaded so that it returned to the ‘door closed’ position when the lift departed the floor.
The lift was old, the wires were stretched, and the lift did not always stop at the right place when called. When the lift was a few centimetres above or below the right level then pin would not be pushed back allowing the door to open. Sometimes the lift had to be operated several times before the door could be opened. This required walking down to another floor, call the lift, walk up and call the lift again. The problem had been reported on several occasions however, had never risen to the level of a prioritized activity. The people were resigned to the fact that the lift would not be fixed and that they would need to live with the consequences. Then the innovative nature of people kicked in and a solution was found. When the lift arrived at the floor and it was too low or too high it was possible to push the pin manually into place and allow the door to open. This required a bit of fiddling with a screwdriver or some other object in a tight space, but it was possible. One day someone used the glass in a fire alarm call point to push the pin into place. When the glass was removed it broke and a piece remained in place. When the next person called for the lift on the 5th floor the door immediately open as the pin was still jammed in the ‘door open’ position.
Was human error a factor in the incident? Undoubtably. Was human error the cause and the only cause of the incident? By no means. Was there a technical cause? Of course there was. Was this a practice that many people had adopted? Yes, it was. Was there a remedial action that would have taken away the need for this practice? Yes, there was. After Richard left the platform, they had several organisational causes to ponder and reflect over.
When any job is made unnecessarily difficult for a person they will inevitably try to work around the problem and find an easier way to do it. Their intentions may be understandable however the results may be disastrous. Instead of blaming people when their weaknesses contribute to a serious incident, try to help them with the day to day problems that they experience in trying to do a good job.