Author Archives: Mark Paradies
“Responsibility is a unique concept,
it can only reside and inhere in a single individual.
You may share it with others, but your portion is not diminished.
You may delegate it, but it is still with you.
You may disclaim it, but you cannot divest yourself of it.
Even if you do not recognize it or admit is presence, you cannot escape it.
If responsibility is rightfully yours, no evasion, or ignorance,
or passing the blame cna shift the burden to someone else.
Unless you can point your finger at the man who is responsible when something goes wrong,
then you never had anyone really responsible.”
Certainly was an impressive way to arrive for the prom. But a bad day for the pilot!
The following sequence is from the Clarence Bee …
First, an air conditioning unit for a power supply room failed.
No big deal … There’s an automatic backup and a system to notify the engineer.
Oops … It failed too.
Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?
Sorry. In the “heat” of the moment, he pushed the “kill” button.
Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it.
Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.
What can you learn from this incident?
- Do your people know what to do when things go wrong?
- Do you do drills?
- Are things clearly labeled?
- Are there response procedures?
- How long has it been since people were trained?
This is a great flashback. Remember when we were this young? It wasn’t all that long ago. And everything we said then is still true today – just even more so!
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The CSB press release starts with:
“Washington, DC, April 13, 2016 – Offshore regulatory changes made thus far do not do enough to place the onus on industry to reduce risk, nor do they sufficiently empower the regulator to proactively oversee industry’s efforts to prevent another disaster like the Deepwater Horizon rig explosion and oil spill at the Macondo well in the Gulf of Mexico, an independent investigation by the U.S. Chemical Safety Board (CSB) warns.”
For the whole report, see:
COMPLETE SERIES – Admiral Rickover: Stopping the Normalization of Deviation with the Normalization of ExcellencePosted: April 14th, 2016 in Documents, Performance Improvement, Pictures
You may have dropped in on this series of articles somewhere in the middle. Here are links to each article with a quick summary…
Point of this article is that deviation IS NORMAL. Management must do something SPECIAL to make deviation abnormal.
A brief history of how Admiral Rickover created the first high performance organization. The Nuclear navy has a history of over 50 years of operating hundreds of reactors with ZERO process safety (nuclear safety) accidents. He stopped the normalization of deviation with the NORMALIZATION OF EXCELLENCE. Excellence was the only standard that he would tolerate.
This article describes the first of Rickover’s three keys to process safety: TECHNICAL COMPETENCE. The big difference here is this isn’t just competence for operators or supervisors. Rickover required technical competence all the way to the CEO.
The second key to process safety excellence (the normalization of excellence) – RESPONSIBILITY.
Do you think you know what responsibility means? See what Rickover expected from himself, his staff, and everyone responsible for nuclear safety.
FACING THE FACTS is probably the most important of Rickover’s keys to achieving excellence.
Read examples from the Nuclear Navy and think about what your management does when their is a difficult decision to make.
Here is the other 18 elements that Rickover said were essential (as well as the first three keys).
That’s right, the keys are the start but you must do all of these 18 well.
Here is Rickover’s own writing on what makes the Nuclear Navy special. What to this day (over 35 years after Rickover was retired) keeps the reactor safety record spotless.
That’s it. The whole series. I’m thinking about writing about some recent process safety related accidents and showing how management failed to follow Rickover’s guidance and how this lead to poor process safety performance. Would you be interested in reading about bad examples?
And it could have been much worse!
Press reports that the ex-CEO of Massey Coal faces a year in prison as a result of Upper Big Branch Mine explosion. As a CEO, putting the safety of your workers at risk to improve profits can be costly.
Here’s the article …
They have already fired the Commanding Officer … so don’t worry … they won’t start up gears without lube oil again. More video below.