An audit team was touring a newly installed load/unload station when a team member saw two hose reels near the station, both with the same-colored hose and the same connectors (Figure 1). One was labeled compressed air, and the other was labeled nitrogen. The team member asked how the hoses were used. The air hose was designated to be used with pneumatic tools, and the nitrogen hose was used to create an inert atmosphere inside of tank trucks during loading.
▲Figure 1. During a safety audit, an individual noticed that two identical hose reels were used for two entirely different processes, and accidentally using one hose for the wrong process would end in a serious safety incident. This hazard would not have been resolved if it were not for one individual speaking up.
The team member pointed out that if those identical hoses were reversed, a tank truck that was supposed to be nitrogen-inerted could instead be in the flammable range. A second hazard also existed. If someone connected nitrogen to an air-powered tool, they could be exposed to an oxygen-deficient atmosphere and pass out. No one during the design reviews or the pre-startup safety review identified this hazard. Both hose reels were locked out until the situation could be reviewed and a solution implemented using a management of change (MOC) process.
This is an example of someone asking a simple question that may have prevented two potentially serious incidents. It emphasizes the need to speak up when something appears to be incorrect.
Did You Know?
- “Weak signals” are signs from our surroundings that something may be wrong. They indicate an impending problem. In Figure 1, the weak signal is the identical hoses and the potential to use the wrong one.
- Equipment making a strange noise or vibrating are both weak signals that something is wrong and needs attention.
- Weak signals often increase until they become strong signals, such as an equipment failure or leak that cannot be ignored.
- Many major incidents had weak signals or warning signs that were ignored before the incident. After the incident, these signals were obvious.
- Notify others about a weak signal. It is better to review the situation and know that nothing is wrong instead of hoping it’s not important.
- People notice differences, which is good. However, if the differences are not made known to someone who can review them and take action to correct them, the hazard will persist.
- A poorly written procedure is also a weak signal. Unclear procedures may be fine for an experienced operator but confuse a newer employee.
What Can You Do?
- When you see something that does not seem correct, notify the area supervisor. They can bring the right resources to review the situation and start repairs if needed.
- During rounds or field inspections, watch for things that changed since your last inspection. Make note of them and ask about them later.
- Confusing procedures should be corrected. If adding a diagram or picture would improve the procedure, suggest that to your supervisor.
- Watch for specific issues while in the field — open electric boxes, sample taps with no plug, or unreadable gauges are all situations that must be corrected to prevent a possible incident.
If something looks wrong, ask! You may save a life!
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