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Afterthoughts
Appendix E
Afterthoughts One cannot discharge one’s duty by making a monumental paper structure and then not implementing it. A counsel during the trial following the Longford explosion (see Section 34.2)
At every safety conference, speakers describe their safety management systems. I (TK) often wonder how well they are implemented. Descriptions of their company’s accidents might tell us more. Human language is a spectacular mechanism for transferring ideas from one mind to another, allowing us to accumulate knowledge over many generations… Daniel Hillis It is not the strongest of the species that survive, nor the most intelligent, but the ones most responsive to change. Charles Darwin I remember the first time I rode a public bus…I vividly recall the sensation of seeing familiar sights from a new perspective. My seat on the bus was several feet higher than my usual position in the back seat of the family car. I could see over fences, into yards that been hidden before, over the side of the bridge to the river below. My world had expanded. Ann Baldwin, Biblical Archaeology Review, May/June 1995
We need to look over fences and see the many opportunities we have to learn from accidents. Some years ago I went to a conference at which a newly appointed director of safety began his presentation with the assertion that “safety management is not rocket science.” And he was right. Rocket science is a trivial pursuit compared to the management of safety. There are only a limited number of fuel types capable of lifting a payload into space; but the variety of ways in which harm can come to people is legion. Writing a procedure to achieve some productive aim is not easy, particularly when the task is complex, but it is always possible. In contrast, there are not enough trees in the rainforest to support all the procedures necessary to guarantee a person’s safety while performing that activity. James Reason, Transactions of the Institution of Chemical Engineers, Vol. 80B, May 2002 759
760 Appendix E Several years ago after reading What Went Wrong, I realized I could use it to “wake up” my people to the dangers and horror others have experienced. All of the line supervisors and managers were given copies of the book and every month, during our regular meetings, each was to talk about something from the book that could happen here, and what we needed to do to be sure it didn’t. Not only was this educational and motivational, but it also was a way to get people to discuss and share feelings of vulnerability (something not easily articulated by many of this breed). Shelley Roth, Operations Manager of a chemical plant Before Columbus made his discovery the Spanish Royal family believed the Straits of Gibraltar to be the last output of the world. Their coat of arms depicted the Pillars of Hercules, the Straits of Gibraltar, with the motto Nec Plus Ultra (No More Beyond). After Columbus set sail the Royal family, with great economy, did not change their coat of arms. They merely erased the negative so that their motto now read Plus Ultra (More Beyond). Danny Abse, Goodbye, Twentieth Century At this point I bring my work to an end [and leave others to go beyond]. If it is found well written and aptly composed, that is what I myself hoped for; if cheap and mediocre, I could only do my best. For just as it is disagreeable to drink wine alone or water alone, so the mixing of the two gives a pleasant and delightful taste, so too variety of style in a literary work charms the ear of the reader. Let this then be my final word. The ending of 2 Maccabees (early 1st century BC) Thank you, Trevor, for allowing me the honour of going beyond. Paul Amyotte
Afterthoughts One cannot discharge one’s duty by making a monumental paper structure and then not implementing it. A counsel during the trial following the Longford explosion (see Section 34.2)
At every safety conference, speakers describe their safety management systems. I (TK) often wonder how well they are implemented. Descriptions of their company’s accidents might tell us more. Human language is a spectacular mechanism for transferring ideas from one mind to another, allowing us to accumulate knowledge over many generations… Daniel Hillis It is not the strongest of the species that survive, nor the most intelligent, but the ones most responsive to change. Charles Darwin I remember the first time I rode a public bus…I vividly recall the sensation of seeing familiar sights from a new perspective. My seat on the bus was several feet higher than my usual position in the back seat of the family car. I could see over fences, into yards that been hidden before, over the side of the bridge to the river below. My world had expanded. Ann Baldwin, Biblical Archaeology Review, May/June 1995
We need to look over fences and see the many opportunities we have to learn from accidents. Some years ago I went to a conference at which a newly appointed director of safety began his presentation with the assertion that “safety management is not rocket science.” And he was right. Rocket science is a trivial pursuit compared to the management of safety. There are only a limited number of fuel types capable of lifting a payload into space; but the variety of ways in which harm can come to people is legion. Writing a procedure to achieve some productive aim is not easy, particularly when the task is complex, but it is always possible. In contrast, there are not enough trees in the rainforest to support all the procedures necessary to guarantee a person’s safety while performing that activity. James Reason, Transactions of the Institution of Chemical Engineers, Vol. 80B, May 2002 759
760 Appendix E Several years ago after reading What Went Wrong, I realized I could use it to “wake up” my people to the dangers and horror others have experienced. All of the line supervisors and managers were given copies of the book and every month, during our regular meetings, each was to talk about something from the book that could happen here, and what we needed to do to be sure it didn’t. Not only was this educational and motivational, but it also was a way to get people to discuss and share feelings of vulnerability (something not easily articulated by many of this breed). Shelley Roth, Operations Manager of a chemical plant Before Columbus made his discovery the Spanish Royal family believed the Straits of Gibraltar to be the last output of the world. Their coat of arms depicted the Pillars of Hercules, the Straits of Gibraltar, with the motto Nec Plus Ultra (No More Beyond). After Columbus set sail the Royal family, with great economy, did not change their coat of arms. They merely erased the negative so that their motto now read Plus Ultra (More Beyond). Danny Abse, Goodbye, Twentieth Century At this point I bring my work to an end [and leave others to go beyond]. If it is found well written and aptly composed, that is what I myself hoped for; if cheap and mediocre, I could only do my best. For just as it is disagreeable to drink wine alone or water alone, so the mixing of the two gives a pleasant and delightful taste, so too variety of style in a literary work charms the ear of the reader. Let this then be my final word. The ending of 2 Maccabees (early 1st century BC) Thank you, Trevor, for allowing me the honour of going beyond. Paul Amyotte