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"Implementing Operational Success"

"Implementing Operational Success"

Maintenance and the Safety Envelope




Throughout our travels, we are impressed by the knowledge, skill, and dedication of these industrial teams and their leaders. Yet, as we continue to hear stories and study reports of accidents and near misses, we are now even more convinced of the need to instill the disciplined habits of systematic operations and maintenance to all elements of the workforce; for, in nearly every case we review, the events could have been easily prevented through application of a few simple techniques (Vital Operating Skills) as discussed in The Industrial Operator's Handbook.

For that reason, we have begun a new stage in our mission to provide insight and instruction to the supporting elements of industrial teams regarding application of the principles and skills essential to safe and effective performance. In that vein, we have set out to produce a series of supplemental resources focusing on specific topics and dedicated to specific work groups. Maintenance and the Safety Envelope is the first in that series. It is dedicated to the maintenance teams whose efforts provide safe and reliable machinery and processes that function as intended by design. Without properly performed maintenance, neither objective (safety and reliability) is possible.

This book begins with a review of accident causes and practices that prevent accidents with particular emphasis on their application to maintenance.

It continues with a detailed discussion of the Safety Envelope and its specific relevance to the maintenance function.

Four maintenance-related case studies are reviewed and discussed in depth to illustrate these principles, again focusing on the role of maintenance in providing a safe and efficient industrial environment.

Although Maintenance and the Safety Envelope is extremely useful as a stand-alone text, it is particularly effective when used as a supplement in conjunction with The Industrial Operator's Handbook.






Preface

The Industrial Operator's Handbook cover

Since publication of the first edition of The Industrial Operator's Handbook in October, 1995,we have been overwhelmed with the response of industry to the concepts presented in the book.Thousands of readers have consulted the text for application in their industries and thousands more-operators, maintenance technicians, laboratory analysts, engineers, and managers of all levels-have participated in the seminars we have presented across the United States,Canada, and other countries. Our travels have taken us to a myriad of North American electrical generators powered by nuclear, coal, gas, and oil fuels as they provide the electrical needs of their communities.We have visited Department of Energy sites throughout the U.S. whose teams engage daily in sampling, characterizing, processing, packaging, shipping, and storing radiological contaminants and other hazardous waste. And we have evaluated the activities and taught the staffs of oil refineries and chemical production plants in places as far-ranging as Trinidad.

Nearly always, we are impressed by the knowledge, skill, and dedication of these teams and their leaders. At the same time, we are amazed at what they are able to accomplish in accident prevention as cutbacks in the sizes of workforces and resources have swept each industry. Clearly, "doing more with less" is a challenge to the best teams as they try to balance mission accomplishment with reasonable safety.

Yet, as we hear the stories and study the reports of our clients' accidents and near misses (and those of industry at large), we are now even more convinced of the need to instill disciplined habits of systematic operations and maintenance to all elements of the workforce-for, in nearly every case we review, the events could have been easily prevented through application of a few of the simple techniques discussed in Section III (Vital Operating Skills) of The industrial Operator's Handbook, 2nd Edition.

For that reason, we have begun a new stage in our mission to provide insight and instruction to the supporting elements of industrial teams (elements such as maintenance and engineering) regarding application of the principles and skills presented in the main work. In that vein, we have set out to produce a series of supplemental resources focusing on specific topics (and dedicated to specific work groups).

This book is the first in that series. It is dedicated to the maintenance teams whose efforts provide to the operating crews equipment which functions as intended by design-machinery and processes which are safe and reliable. Without properly performed maintenance, neither objective is possible. We hope you enjoy your journey!



  • Chapter 1 1
  • Introduction and Review
  • The Causes of Accidents 2
  • Practices That Prevent Accidents 4
  • Application to Maintenance 5

  • Chapter 2 7
  • Maintenance and the Safety Envelope
  • Maintenance Terms and Definitions 7
  • The Safety Envelope 8
  • Hard and Soft Barriers 10
  • Defense In-Depth 11
  • The Most Important Barrier? 12
  • Keeping the Fabric Intact 12
  • Think About It 13

  • Chapter 3 15
  • Even Small Errors Have Major Effects
  • Eastern Airlines Flight 855, May 1983 15
  • Damage to the Aircraft 19
  • Cause of the Occurrence 21
  • Failed Maintenance 22
  • Conclusions 27
  • Learning from Flight 855 28
  • Case Study References 29

  • Chapter 4 31
  • Integrity of the Envelope
  • Bright Field Freighter Allision, December 1996 31
  • Troubled Voyage 32
  • Arrival in U.S. 34
  • Returning to Sea 36
  • Freighter Out of Control 38
  • Striking the Wharf 42
  • The Cost 44
  • Causes and Contributing Factors 44
  • Deficient Engine Maintenance 46
  • Contaminated Lube Oil 48
  • Deficient Maintenance Support 50
  • Factors Affecting Command and Control 51
  • Learning from Bright Field 54
  • Case Study References 56

  • Chapter 5 57
  • In Accordance With Approved Procedures
  • Gannon Station Explosion, April 1999 57
  • Preparing for Outage 58
  • The Accident 61
  • Causes and Contributing Factors 63
  • Failure to Follow Procedure 64
  • Ineffective Lockout/Tagout 67
  • Inadequate Job Briefing 68
  • A Broken Team 71
  • Learning from Gannon Station 72
  • Case Study References 73

  • Chapter 6 75
  • Last Line of Defense
  • Railroad Grade Crossing Collision, September 1999 76
  • Description of the Grade Crossing 77
  • Pre-Accident Maintenance Events 78
  • Maintenance Requirements Discussion 80
  • Accident Response and Investigation 81
  • Questions of Integrity 83
  • Findings and Underlying Cause 84
  • Learning from the Crossing Accident 85
  • Case Study References 86

  • Chapter 7 87
  • It All Depends on You!
  • Recounting the Lessons 87
  • Competence and Character 88
  • It All Depends On You! 88




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