Trains and Boats and Planes...
and Nuclear Power Plants
A couple of weeks ago, I participated in an event in Chicago where I gave a presentation that focused in part on safety culture for the nuclear power industry. When I proposed this as a topic, I had in mind not only commercial power plants, but also several other recent events, both in the US and abroad, where weaknesses in safety culture appear to have caused or exacerbated an incident.
The incidents I had in mind included the radioactivity releases at the US Waste Isolation Pilot Plant (WIPP) in February of this year that appear to be related to mistakes in packaging of the waste, and the revelation in 2012 and 2013 of the falsified documentation for nuclear power plant components in South Korea. On the non-nuclear side, I might have considered the Takata airbag problems, the General Motors ignition switch problems, and the sinking of the Sewol ferry in South Korea in April that resulted in the deaths of about 300 people, many of them high school students
My presentation time was limited, so rather than try to present an exhaustive list of incidents, I focused instead on the fact that there is often an element of safety culture evident in accidents and incidents, even when they seem to have another immediate cause (one example being the Fukushima accident in Japan). I also emphasized the need to learn from these events. Although I recognize that no individual or institution likes to "air its dirty linen in public," I pointed out that hiding mistakes is usually unsuccessful, and further erodes public confidence when the truth comes out. And even though not every event provides useful lessons for everyone, I noted that there are certainly lessons to be learned throughout an industry, and sometimes, even lessons that are transferable from one industry to another.
I had put safety culture in the back of my mind when I boarded a Frontier Airlines plane the next evening to return home. We boarded about 20 minutes late, but the announcement said that they hoped to make up the time. I thought nothing of that, either, as I know they often "make up time" in the air. (I'm a bit suspicious that they build in extra time on the published schedule to cover short delays, but that's another story.) We pushed back from the gate, and then the plane stopped. We wait. And waited. And waited. Finally, an announcement from the cockpit informed us that the tip of one wing had hit a barbed wire fence and was entangled in the barbed wire!
In the 4+ hours it took to have someone come to inspect the situation, have someone else come to cut away the barbed wire, pull the plane back to the gate, and have us wait until another plane arrived and was serviced, my traveling companions and I had ample time to discuss the situation. We still don't know for sure what happened, so anything I say is pure speculation, but almost anything I can imagine seems to me has an element of safety culture. The fence presumably didn't jump out at the plane. So...Were they rushing things a little to try to make up for the delay? Was there a miscommunication? Was the job in the hands of someone inexperienced? Was that corner of the airport badly designed?
To be fair, there are far worse things that could have happened than to be delayed 4 hours while safely on the ground. And to be fair, the other problems I encountered in my dealings with the Frontier Airlines staff that night had nothing to do with safety (lack of information from the pilot on what was going on for the 2-1/2 hours we were marooned on the plane, snarky stewardesses, ground personnel who promised food and drink vouchers but then rescinded the promise, and who also sent people to another gate to recharge their electronic devices but then said they would not be making boarding announcements on the PA system). However, the event brought home to me that even seemingly simple actions can go badly awry, and that some aspect of a failure of safety culture is often involved.
As I started thinking about writing this post, I realized that my comments were reflecting on both boat and air travel. At that point, the old Dionne Warwick song, "Trains and boats and planes" came to mind, not for the meaning, but just for the title. I at first tried to rephrase the title as "Nuclear power plants and boats and trains," but that just doesn't have the same ring. I then realized that my presentation had left out at least one fairly recent train incident I could have mentioned--the derailment of a train carrying crude oil in Lac-Megantic, Quebec in July 2013 that left over 40 people dead and leveled half the town.
Another country, another technological area, but once again, a problem fundamentally caused by a series of actions, many of which, at their core, reflected insufficient attention to safety. The message, I hope, is not that such incidents are inevitable, but rather, that each such incident should lead to corrective actions that reduce or eliminate the possibility of a recurrence. And to sharing the knowledge gained so that others don't suffer the same failures.