This Safety Moment can be downloaded in .pdf format from www.iansutton.com/downloads/No-Contest.pdf.
This week’s Safety Moment shows an incident that occurred in my home town about half a mile from where I live just a couple of weeks ago. A security camera filmed the whole incident, which can be seen here. Since the complete video is quite lengthy (4:58) we have created a shorter version here (1:54).
Summarizing the event:
- The driver of a car intended to turn left after crossing two rail tracks.
- He turned too soon and landed on and between the tracks.
- The car was stuck.
- He and a passenger got out of the car and moved away from the scene.
- The police arrived and informed the railroad company as to what had happened.
- Nevertheless, it was too late — a full size freight train approaching the intersection could not stop in time.
- The train hit and destroyed the car.
We are not informed as to the causes of this incident. However, events such as this occur surprisingly frequently. Common causes are (1) the driver of the car is inebriated, or (2) the driver follows the instructions of the GPS too literally (the GPS says “turn left” and he turns left, even though he is still on the tracks).
The crucial lesson learned here is that if a situation is out of control it is best for those involved simply to get away from the scene. In this incident and also in the Safety Moment Vehicle Static the persons involved did just that.
A second lesson is to treat instructions from automated systems with a dose of common sense; don’t turn left because the GPS say so.
A third, more subtle, issue is that systems such as GPS and mobile phones cause the driver to focus his or her attention on what he is hearing, and not to pay enough attention to what is in front of him.
And finally, to state the obvious, freight trains are much, much heavier than automobiles. In the event of a collision it is no contest.
When reviewing an incident such as this it is useful to determine which elements of Process Safety Management (PSM) failed and which were effective. There are many PSM systems; they vary from country to country and company to company. But they are all broadly the same. There are different ways of organizing these elements. The system that we use for these Safety Moments is that developed by the Center for Chemical Process Safety (CCPS).
- Process Safety Culture
- Workforce Involvement
- Stakeholder Outreach
- Knowledge Management
- Hazard Identification and Risk Management
- Operating Procedures
- Safe Work Practices
- Asset Integrity / Reliability
- Contractor Management
- Training / Performance
- Management of Change
- Operational Readiness
- Conduct of Operations
- Emergency Management
- Incident Investigation
- Measurement and Metrics
- Management Review
The two elements that we highlight for this incident are 9. Safe Work Practices and 16. Emergency Management.
The lack of Safe Work Practices is self-evident — the driver of the car did not understand what he was doing (which relates also to the Training element). The Emergency Response element was actually well managed; the driver and his passenger moved away from the scene and the emergency services did not carry out any heroics in the path of an on-coming freight train.
It is very easy, when viewing an event such as this, to make fun of the parties involved. But the reality is that we all make errors. So, if you are using this Safety Moment in a meeting, I encourage you to ask people in the room of a situation where they did something dumb and what lessons they take away from that event.