Thursday, August 14, 2014

Holes In The Cheese And Bad Apples Are Causing Accidents

It's neither true that when holes in the cheese lines up accidents happens, nor is it true that bad apples cause accidents. And if the facts were that every major accident is proceed by a few minor accidents and several incidents, there would be no management of safety. Safety would then be managed like a bag of marbles being dropped to spread in random patterns. 


A ridged process runs over variables instead of managing.
The holes in the cheese lines up because of a decision to slice the cheese in a certain way. If the objective was to slice the cheese in a way that the holes would not line up, a thorough analysis and risk assessment prior to slicing would be required. Holes lined  up in the cheese don't cause accidents. It is the outcome of how things are done during day to day of normal operations that are causing these events. When managing safety, daily routines and practices must be analyzed and then proceed to slice the task to manage the holes in the processes.

Bad apples don't cause accidents. Imagine a box of apples, open it and there are one or two bad apples on top. These apples were bad because they were not given proper treatment prior to be placed in the box. A week later, when opening the box again, there are several more bad apples that are discarded, and this goes on until the box is empty. When all bad apples are gone the goal is reached: To have no more bad apples.

People perform their job to the bar of a bad apple to what degree they are allowed to experience proper treatment. By keeping apples at the proper moisture and temperature, they remain good apples. Personnel that are trained property excel in their job to levels well above the bad apple bar. If they are not trained to perform and understand the processes their performance level rapidly decreases to a level of bad apples where they feel accountable to operate. 

When going down the slide for the first time hazards are carefully analyzed. On the next ride they are integrated in the process.
When marbles are dropped they spread in a random pattern. The location where each marble stops are determined by laws of physics; where each marble is in the group at the time of release; how each marble interact at point of impact; and the condition of the surface of impact. If this exact condition could be replicated the marbles would stop at exact same point every time. The reason they are spreading out differently is that the conditions cannot be reproduced. In theory the same result should be achieved, but due to special variables it is impossible to manage to get same result.

Reactions to these unknown and special variables must be applied at the time and location of where each variable occurs.  The key to manage safety is to reduce special variable and take more proactive than reactive measures.

There are no reasons to accept that accidents are inevitable just because a magic number of incidents are reached. Managing safety is to discover and learn about as many as possible of variables and then integrate these variables as a part of normal operation. 

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