(54an) Three Cases: Process Safety Fatalities and a Better Way to Communicate What Happened

Three Cases: Process Safety Fatalities and a Better Way to Communicate What Happened

There is a serious process safety incident and an employee dies. Once the investigation ends, the communication can begin. But the way we currently communicate the findings does almost nothing to make sure the incident never happens again.

I will look at three specific process safety fatalities:

1. Contract cleaner dies when gas storage tank explodes
2. Welders dies when hit by an ejecting pneumatic plug during a pipe tie-in
3. Employee dies from nitrogen asphyxiation while cleaning a 48-inch pipe flange

I will show the communication that happened, and more importantly, the communication that should have happened.

The biggest communication mistake in these three cases is an over reliance on data and analysis; and a near total absence of emotion.

This is wrong because professional communicators know that emotion cements the learning in memory and causes the most behavior change.

The way we typically communicate fatalities is explained by two strongly held desires: the desire to avoid any further pain and embarrassment for workers and managers who may share some responsibility for this tragedy; and the desire to avoid saying anything that may create a legal risk for the company.

These are important desires, but they should not be the primary ones. Nothing should be more important than making sure this tragedy never happens again. The primary goal must be making sure we do not have a similar process safety mistake and another dead employee.

Once you make a commitment to this never happening again, the communication changes completely. Across these three cases, I will show the communication (mixing analysis and emotion) that maximizes the behavior change caused by this tragedy and minimizes the chances of it ever happening again.