Incident Prevention Magazine

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Production, Quality, Safety and the Bermuda Triangle

We’ve all heard or read about the Bermuda Triangle, a loose geographic area with Miami, Bermuda and San Juan, Puerto Rico, serving as the triangle’s three points. Legend has it that lots of strange things have happened in the Bermuda Triangle, mostly the unexplained disappearances of ships and airplanes that sailed or flew through the area. You may remember the story of Flight 19, a group of five torpedo bombers that disappeared on December 5, 1945, over the Bermuda Triangle while on a training mission. Fourteen airmen were lost in the incident.

There is a part of the story that a lot of people don’t know about. Those in command responded to the missing Flight 19 by sending a flying boat – a plane that can land on water – to search for the lost planes. It is believed that the rescue plane had a small, undetected fuel leak that caused a vapor buildup in the fuselage. The plane exploded in midair, and all 13 crew members were lost while they were looking for Flight 19.

Experts think the five planes of Flight 19 may have been uniformly underfueled due to a faulty gauge on the tanker that fueled them before they took off. Because systems for checking the gauge failed to discover that problem, 14 men died and 13 more died searching for them. If a quality equipment inspection had found the faulty gauge on the truck, or the operator of the truck had questioned why the filling operation had been completed so quickly, or the flight crew had asked for a recheck, the Flight 19 mission might have gone off without any problems. If that had happened, the rescuers would not have died because their flight would have been unnecessary.

Another Kind of Triangle
There is another kind of triangle that also can make bad things happen. It’s called the Production, Quality, Safety Triangle.

The triangle formed by the success factors of production, quality and safety often has been described as a three-legged stool, and it is an apt comparison. If one of the three legs is shorter or longer than the others, the stool is of little value because it wobbles when used for its intended purpose. The stool works best when all three legs contribute equal support to the seat.

In the remainder of this article, we’ll consider how the relationship between production and quality can affect the safety of those who perform the work. The construction version of Flight 19 is reworking something that has already been done before. Following is a real-life occurrence that illustrates the point.

An electrical crew got the assignment to build a four-pole overhead 12-kV tap line into a cabinetry shop. They installed the four poles, framed them and installed the three-phase conductors. The crew’s last task was to connect the new conductors to the distribution circuit by running a riser from the underground 12-kV distribution circuit running parallel to the street to the pole top.

They measured the distance from the splice box to the top of the pole and cut a piece of the appropriate 12-kV cable that was long enough to complete the riser. They ran the cable up the pole, and a lineman connected the three phases. He was in a bit of a hurry because it was almost quitting time. He should have taken the time to trim a few inches off the riser because it was too long, but instead the lineman forced the cable a little more and made the connections.

A week later, the utility inspector inspected the crew’s work so he could approve it as built. The bend in the riser was clearly out of specified requirements for the installation, so the inspector called the crew back to make the correction. Of course, the crew was angry about having to redo the riser. The lineman went up in the bucket and waited for other crew members to tell him that they had de-energized the line. Due to a miscommunication, the lineman believed he was cleared to rework the connection. While disconnecting the poorly installed riser from the overhead conductors, he was electrocuted. 

Lessons Learned
There are four key takeaways from this situation:

  1. Rework often puts us in a bad frame of mind, and we get distracted from the basic rules that keep us healthy and alive.
  2. Whenever we have to correct an error we made due to haste, ignorance or sloppy work habits, we needlessly face hazards that we already faced once. These revisited hazards can cause injury or death.
  3. If we take the time to do things right in the first place, we eliminate hazards.
  4. While we are eliminating work hazards by doing things right the first time, we also are increasing our productivity and our company’s profit margin. We are not doing work twice that we were paid to do just once.

There is a story told of a farmer who hired a farmhand whose only qualification was that “he could sleep when the wind blows.” A few days after hiring the man, the farmer saw that a large storm was approaching his farm. He ran to find his farmhand and found him sleeping. In a panic, he woke his employee and asked him for help getting the farm ready to weather the storm. The employee told his boss there was no need and went back to sleep. The farmer then went to look at his outbuildings and house and found that every single preparation for the storm had been completed, right down to closing the shutter on the outhouse window.

If we all prepare for our daily storms with proper mitigation of all the hazards the storms can bring, we’ll all be well.

About the Author: Kelly Sparrow, CUSP, J.D., is a West Coast safety consultant with broad experience supervising safety during construction and maintenance of electrical transmission and distribution facilities in many parts of the U.S. His experience includes working storm response in the Northeast, Puerto Rico and the Gulf Coast. Sparrow has written safety systems that qualified several small companies as contractors for major public utilities and did follow-up field work to ensure employees were part of the company safety system. He currently works as a safety coordinator for a transmission and distribution contractor in Northern California.

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Wednesday, 14 November 2018

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