We tested the emergency alarm system every 2nd Thursday at lunch. The alarms would jolt me out of focus and make my heart drop. As the alarms went off, I realized this could be real one day, because our reactors could cause massive destruction. Even though it wasn't likely, and we had several safeguards in place, it could happen.
One day, while working at my desk, the plant evacuation alarm went off. I thought, "What time is it?" It wasn't noon. I couldn't hear the announcements myself, but people near me with handheld radios could. "This is not a test!"
We were trained on how to respond due to the alarm checks every second Thursday. We were silent on the way to the muster point until we found someone with a radio to listen to messages.
We got to the muster point, waited for the all clear, and someone called out our names from the list to check we were accounted for. We heard the ambulance and fire truck sirens, but that wasn't unusual during a test. Finally, we heard it was an acetic acid release from a rail car unloaded by our resident contractor.
3 safety recordable injuries, no fatalities, and a lot of focus on root cause analysis resulted from that release. After a few days of interviews and investigation, they started sharing reports discussing the root cause and how to prevent it from happening again. We knew the preventative action plan had to be well crafted, because we needed to start rebuilding faith and trust in the plant's ability to operate safely.
The plan would begin the long journey of rebuilding trust, but something didn't feel right. Months passed, and morale was at an all time low for this department, as well as the plant in general. A lot of time was invested into this department to ensure no more injuries occurred. They'd had a horrible safely record leading up to the accident for the last 3 years straight. It was the worst in the plant, and everyone was at a loss of what to do.
As continuous improvement manager, I initiated and led a continuous improvement project with an approach to identify the root cause and satisfy this burning curiosity about what was really happening. I wasn't confident CI methods along with my approach would work to solve morale problems, but I trusted my intuition.
I found something that put it all together for me. It was my ah-ha moment. I found the root cause of the incident, which could have killed 3 people and injured many more.
The root cause was not negligence, incorrect procedures, failed equipment, design or failure to follow procedures. It wasn't any of the 4 mindsets that cause accidents, like rushing, frustration, fatigue or complacency. It was an 'inability to feel' problem.
My discovery showed that the entire department had learned to suppress their feelings about their work and life, just to survive. This discovery explained 'every' scenario I had experienced in manufacturing where positive results and change were difficult to create.
What was so amazing about my discovery was that it was (and is) an unknown factor in problem solving, also. It was why we felt stuck, maintained the status quo and repeated the same mistakes over and over again.
The department discovered the root cause of the incident during my workshop and won the oil company's safety award for several years afterwards. They went from being scrutinized to being praised in a matter of months. The department has not had a recordable injury in 6 years, and has the highest participation and contribution to the behavioral safety program. And, they did it without management oversight or constant interventions.
I like to call them the Chick-fil-A of safety, because their department is like experiencing the highest level of confidence and service from a safety aspect. The plant tour for visitors always includes this department, so visitors can see what is possible and share it.
If you manage a manufacturing plant, your problems are likely due to under feeling. It's likely the reason for your high inventory, too much unplanned maintenance, on-time delivery issues, and more. If you want to learn how to shift from under feeling to generating sustainable and repeatable solutions, message me that you are interested in exploring this opportunity for your business.
If you believe your plant could perform better, but uncontrollable circumstances and excuses are holding it back, send me a message with the word "interested."
It would be my pleasure to help.
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