From: Ray Cook <raycook**At_Symbol_Here**APEXHSE.COM>
Subject: Re: [DCHAS-L] Seeking subject expert
Date: Sat, 20 Mar 2021 14:28:19 -0500
Reply-To: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**Princeton.EDU>
Message-ID: E634E8F4-2C02-4B91-AD28-996E79A04BB0**At_Symbol_Here**
In-Reply-To <008601d71d18$54db2e70$fe918b50$**At_Symbol_Here**>

Sure Bruce.

I am a part time instructor for the vPSI group, and this is just s little bit of what we teach about learning from incidents.


Ray Cook, MS, CIH 2000-2016
CSP ret.
I Cor 1:18
In omnia paratus
Sent from my iPhone

On Mar 19, 2021, at 6:50 PM, Bruce Van Scoy <bvanscoy**At_Symbol_Here**> wrote:




Outstanding.  Can I use your material?


Bruce V. Van Scoy, CSP


From: ACS Division of Chemical Health and Safety <DCHAS-L**At_Symbol_Here**Princeton.EDU> On Behalf Of Ray Cook
Sent: Friday, March 19, 2021 9:38 AM
To: DCHAS-L**At_Symbol_Here**Princeton.EDU
Subject: Re: [DCHAS-L] Seeking subject expert
Importance: Low


Hey Paul,


Here are a couple of other points you might want to consider:


An incident usually starts when some activity or step thereof diverges from our expectations.  The consequences may result in a loss, or maybe not. Incidents without loss (near-misses) are key to identifying problems occurring in an operation and must be reported and acted upon (if preventable & significant) if it is to be prevented in the future.  Unfortunately, people are often concerned with reputation damage, or in some cases repercussions, so they often go unreported. Basing your culture on no-jeopardy reporting and reward/recognition for reporting will help reduce repeat incidents, assuming the problem reported is addressed.


Some research has indicated a typical person tends to make as many as 5 to 10 errors per hour. Most go unnoticed and have no discernable consequences.  But consider for a moment if a person works 2080 hours in a year; that would be 10,400 human errors/person on the low side. Have 100 people? Make that 1,040,000 errors per year. (And some human errors are unpreventable).  Some of these errors will result in incidents, and a smaller subset in loss. The very perception that all unplanned events can be prevented is na=C3-ve, but management is usually sincere in saying it.  So zero incidents is not reality, perhaps zero injuries (if you're lucky) or some target loss amount is a better goal.


The next very real problem is that people are not as good at fixing problems as they believe.  It isn't their fault, it's a human perception problem.  We get distracted by the damage and/or injuries and most of the time fail to actually fix what went wrong. In reviewing countless incident investigations, about 75% of the time the thing that went wrong was not prevented from happening again. (The events just hadn't repeated yet, & some were fatality events!). Rather, safeguards were provided instead. I recall in a course in college (a lifetime ago) the instructor stating "identify what happened and safeguard it, then if it happens again loss will be minimized." My goal is always to prevent the unplanned event from happening again, thus eliminating potential consequences. But we, as people, do not inherently do this. It is actually quite a wake-up call to realize this happens.


Of course, there are times all you can do is reduce the probability of an event reoccurring to an acceptable level, and sometimes events are not worth preventing (no possibility of injury or loss).


There is a consulting company that helps organizations recognize and address these issues. (not mine)


Best of luck!





Raymond L. Cook, Jr.,  MSIH, CSP ret., CIH =AE 2000-2016

President & Principal Consultant





From: ACS Division of Chemical Health and Safety [mailto:DCHAS-L**At_Symbol_Here**Princeton.EDU] On Behalf Of Harrison, Paul
Sent: Wednesday, March 17, 2021 1:34 PM
To: DCHAS-L**At_Symbol_Here**Princeton.EDU
Subject: [DCHAS-L] Seeking subject expert


Dear list members:

At our University-wide safety meeting this morning, while we were reviewing incidents on campus, our VP (Admin) asked what I think is a critical string of questions:


How do some organizations achieve a zero incident level?  Examples include the nuclear industry, and our local fire station.  Clearly they have a strong safety culture.  So, how do we enhance our safety culture to bring us towards that goal?  Could we get an expert to advise us?


This is not a chemistry question, but an institutional one.  But I immediately thought of the D-chas group, where there are so many experts on safety.  


If there is anyone out there who would be interested in exploring this through giving us a seminar, and/or or spending perhaps a day with us, do please contact me off-list.  Some knowledge of the Canadian safety landscape would be useful, but we are really looking at the bigger picture.  We do not have an approved budget, but some compensation may well be possible.  This could take place on-line, or perhaps in-person once the border re-opens.


Best wishes and safe work to all.





Paul Harrison, B.A. Hons. (Oxon), Ph.D.

Associate Professor and Associate Chair (Undergraduate)

Chemistry & Chemical Biology

Dept. of Chemistry & Chemical Biology
McMaster University
1280 Main St. West.
Hamilton, ON L8S 4M1

Map icon=E2=80=82location: ABB-418
Phone icon=E2=80=82phone: (905) 525-9140 x 27290
Envelope icon=E2=80=82email: pharriso**At_Symbol_Here**

McMaster University Brighter World logo


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