Escalating Bad Things

Four anecdotal health and safety tales from memory. These are encounters from a span of two decades that serve to illustrate how things might escalate to tragedy. And special for today, a bonus with a cautionary afterward.

Morocco

We pulled over to the side of the road that took us through rugged desert terrain. We carried surface geology maps that indicated we were driving across Palaeozoic shales and there was what seemed to be a good exposure at the edge of the road. We could have walked to lots of other exposures but this was an area littered with the remnants of war, not all visible. The zone around the outcrop was marked with little flags to indicate it had been swept for land mines. So we confidently clambered up onto the rugged rocks and looked around.

‘Is this a fossil gastropod?’ said a colleague who should have known better, turning over something in the palm of his hand.

‘No’, said a security adviser, ‘it’s the tip of a mortar round. They must have used this prominence for target practice’.

Texas

A friend I’ll call ML told me that shortly after 9/11 he was treated to a spread-eagled interrogation in Houston airport when his day-pack set off chemical sniffers.

It turned out he’d used the bag just once, ten years before. It had languished, empty, unused in a bedroom closet at home for the decade. It still carried the logo of the facility where he acquired it. A place where geophysical experiments are routine, where energy source tests are often conducted. Unfortunately, he’d used the bag to carry some explosive charges while walking to the site of a geophysical experiment.

He missed his flight while trying to convince the Homeland Security officers that his foreign accent and positive chemical test were not a threat. His vast scientific publication oevre on the subject calmed them but wasn’t reassurance enough to secure his release. Reassurance came via telephone calls that reached the right people. The bag destroyed, he was released but presumed his name stayed on an eternal list.

UK

Another guy in our industry, not personally known to me, was stopped in Gatwick in the mid-90s. He was taken to a small room for a long time while the police worked out how he had carried two detonators undetected through two Asian airports, boarded two planes and had flown to London.

The metal detectors in Gatwick had worked, finding two detonators in a trouser pocket. The bomb disposal squad was called to deal with their removal. This case was an absolute breach of many field protocols as well as an alarm bell regarding the international security standards of the day.

Detonators are very dangerous at the best of times. A static discharge can detonate one and each has enough energy to blow a significant hole in a pressurised commercial jet. Not to mention the myriad of other explosion related hazards that aren’t as dramatic as downing an airliner.

Leaving aside the airport security failures, the rigid rules for accounting for each and every detonator had failed. Within the global seismic industry, very robust handling and inventory procedures are informed by nearly a century of operations, enhanced by manufacturers constantly evolving advices and are always vetted by the local military and other authorities. The detonators get counted, checked out against a list, used by list, the excess checked back in and all counted again. Tallies compare what went out versus those that were used versus those that were returned. There should have been at least quadruple redundancy, four or more places where discrepancies might be detected. The gap in this case was caused by an unusual mix of circumstances. Chief among them was that the charges were supposedly being double-detonated. Unfortunately, some charges were mistakenly single detonated.

The rigid rules of carrying detonators had failed. Not one but two had ended up in a lower leg pocket of field overalls. Extra detonators would have been clear evidence that some charges were single detonated. Admitting this might have been considered a technical failure. It turned out that the shooters were of the habit of triple detonating charges to hide the technical failures that were common due to the arduous operating conditions. They were working in very uneven, river-cut terrain in a jungle during monsoon conditions.

The rules for clothing had also failed. The man had travelled in his work clothes. The prohibitions against this were clear but his civvy-street clothes were left behind in a hastily organised rush to the airport after flooding had disturbed travel plans, itineraries and schedules.

I ended up with a small role in the re-examination of my own employer’s protocols after this incident. That’s how bad things get fixed. Transparency. I knew of the breach from the boss of a competing company. He told me how his company had responded to the serial breaches of protocols that would have been considered impossible. Considering something to be impossible was once a common mistake among environmental, health and safety managers. Chernobyl reminds us that improbability is the better metric.

Argentina

GL was a bully and GL was in charge. He wasn’t Argentinian and he was generally disliked because his management style was dictatorial.

He demanded that the seismic crew break one of the cardinal safety rules universally adopted for geophysical operations when using explosives as an energy source. The heads of department pushed back on his demands to no avail.

The rule was very simple. There should only be one shooter. The shooter is the one with the firing line that joins the detonator cap to a box that generates an electrical impulse that detonates the explosive. Serial detonation of charges is slow but very safe. Twenty per hour would be good going.

GL was behind schedule. He thought he could increase production by adding a second shooter, maybe get to thirty per hour for a week in order to get back on schedule. Like a wrist with two watches showing different times, the seismic line with two shooters might confuse their firing lines.

The first shooter blew the second shooter to bits. The second shooter was connecting a firing line to a charge but took hold of the wrong firing line. The terrain was hilly and he was out of sight of the first shooter. The wind carried the standard warning call of immanent detonation in the wrong direction.

The 25 year-old was blown apart as the explosives he was holding detonated. The explosion was loud enough that a passing car heard it, stopped and the people got out to see what happened. A young woman was the first on the scene. She was by coincidence, one of four new hires sent by the exploration company out on a field trip, making their first visit to a seismic recording crew. Her first sight of geophysical operations was of a man cleaved into two pieces, the abdominal segment of his torso vaporised by the explosion.

The next day, a colleague arrived from Texas to head up the accident investigation team. He was very senior, very experienced and became traumatised when visiting the site where he found the young man’s palm in a bush. The young man was the same age as his own son.

The reader will have many questions. The deceased was married less than a year, his wife was eight months pregnant. GL refused to acknowledge his role throughout. He was forced eventually into retirement. There are many more questions. It’s an ‘industrial’ accident I won’t forget because it should never have happened.

Afterwords

I once worked with a very major company whose chairman and president announced to the shareholders one January that the calendar year would have zero Lost Time Incidents. This promised there would be no injuries or worse that prevented any one person from doing their job for a day among a global diaspora of 140,000 employees working for a whole year. I would see that as improbable given that people have a bad habit of falling in stairwells.

The real problem was that the industry standard was in transition. Health and safety accounting rules were being modified to include the entire employment chain within the responsibilities of the primary employer. The boundaries were unknown because the boundaries had only just been altered. The new rules meant the primary employer had to account for double the number of people given that there was approximately one contractor for every employee.

I was in the field on the crew that had the first Lost Time Incident two weeks later. A man slipped on exiting a very high sided vehicle and broke his leg.

The man was an illiterate, heavy vehicle driver sub-contracted by a contractor for just a few months. His employment agency declined responsibility for him (but still took their fee out of his wage). The geophysical contractor for whom he was temporarily driving argued they had responsibility for him and that it was an LTI (Lost Time Incident) not an RWC (Restricted Work Case). The major company that employed the geophysical contractor was trying to avoid any liability of any kind.

It took more than two months for the accident to be categorised as an LTI. It seemed like no one had the guts to go against the promises of the Chairman of the Board. Meanwhile, the man was in hospital with a badly broken leg and was having paperwork flown to him so that he could do light work from his hospital bed. All this so the incident could be categorised as a Restricted Work Case, one category less than the dreaded LTI.

And another thing. I once spent four hours on the phone with two corporate lawyers, one who specialised in contract law and the other, an accomplished litigator. They were teaching me litigation law and advising me to be careful about extrapolating scenarios into the future. They pointed out the potential consequences of imagining bad outcomes while supervising field operations. I had been taught the habit of imagining that an accident had occurred and back-tracking to see what series of events might have have contributed to the imagined incident.

It was OK if that was in my head. It was not OK if that was in an email and by coincidence, a similar event actually occurred. The email would be fully discoverable and could be misinterpreted to indicate that I foretold an incident but did nothing to prevent it. That wouldn’t be considered negligence. It might convince a jury that it was a wilful oversight.