The Dangers of Change

There is a rather interesting article on the 'Crackunit' blog run by Iain Tait. The short article lightly pokes fun at the current air of security paranoia.
Read the full article here - http://www.crackunit.com/2008/01/28/the-dangers-of-change/

Sign of the times

Are signs good risk management or have they proliferated to such an extent that their impact has been lessened? Would removal of signs assist in some situations and if so what would they be?

Are signs more effective in some cultures than others? It was remarked by British engineers working at my company’s factory in Japan that a sign on the door saying "Danger,Do Not Open" was scrupulously observed by the Japanese, where in the UK it would be seen as a challenge to open.

That said the Japanese engineers at Tokaimura , whose management was criminally negligent when organising the movement of radioactive material, clearly had no training as to the danger and no signs would have helped them, the safety culture was non-existent. It is having a workforce that thinks and discusses about downside risk that creates a good safety culture.

Signs are for strangers, like the one the farmer is taking away. If you know your business in great detail you don't need signs.

In place of a sign, how about reviewing the Tokaimura accident and asking what lessons can be learned? Here it is, culled from various sources.


Tokaimura Accident
On September 30th 1999 the most serious nuclear radiation accident in Japan’s history to date occurred at Tokaimura northeast of Tokyo . The accident occurred at JCO’s plant, a subsidiary of Sumitomo Metal Mining Co.

Wikipedia notes
The direct cause of the criticality accident was workers putting uranyl nitrate solution containing about 16.6 kg of uranium, which exceeded the critical mass, into a precipitation tank. The tank was not designed to dissolve this type of solution and was not configured to prevent eventual criticality. Three workers were exposed to (neutron) radiation doses in excess of allowable limits, and two of these workers died; a further 119 received lesser doses of 1 mSv or greater.[1]
Dozens of emergency workers and nearby residents were hospitalised and hundreds of thousands of others were forced to remain indoors for 24 hours.

The New York Times asked

Why were workers mixing vastly excessive amounts of enriched uranium manually rather than with the plant's sophisticated machines that were meant to insure precise measurements?

Why was no alarm sounded at the fuel enrichment plant after an accident that produced 10,000 to 20,000 times normal radiation levels in the immediate area?

Why was the plant itself not clearly marked as a nuclear production site and equipped with a battery of anti-radiation and security measures, even though it is situated in the midst of a residential area?

The Tokaimura uranium refining plant did not have any markings identifying the site as dangerous, its staff lacked proper protective shields, it had no alarm system, and it had never been equipped with a safety manual.

BBC said Hideki Motoki, operator of the JCO Company, admitted using illegal standards for uranium processing for the past four years. Among several known violations, the firm changed its procedures manual without government approval in order to speed up processing and allowed workers to transport uranium in stainless steel containers similar to buckets instead of relying on high-tech equipment. It has also been reported that the workers never received proper training.

Japan Times. "JCO Chief Admits Workers were Poorly Trained."The head of JCO Co.'s uranium processing plant, Kenzo Koshijima, admitted that the firm had never educated its workers regarding criticality or its effects and that portions of the procedures in a manual were skipped "for the sake of efficiency."

Koshijima explained that his workers used stainless steel buckets to melt highly enriched uranium because using the melting tower--required by standard procedure--left residue that in turn raised questions as to the purity of the end product. He added, "It was also true that doing things manually was more effective in getting the job done at times."

This was a small company where they got lazy despite the extreme danger of what they were handling and they stopped thinking and reinforcing the imperative need to manage the risk and to adhere to the strict standards of the industry.

Internal Hackers

When you ask people to rate the impact on their organisation of an internal hacker, they often say medium to low and when asked about the probability, it is usually low. Yet all the evidence says that when an internal attack occurs the impact, because of the inside knowledge, is in fact high. In the case of Societe Generale where the hacking was internal the impact was very high, but not yet as high as Barings. No wonder organised crime aims to place its own on the inside of financial organisations.

Neanderthals didn't send Christmas cards

The way risk is managed is one measure of a society and its reach. Modern man,with more extended kinship links, had a greater network than the Neanderthals, whose artefacts’ origin indicate a much smaller territorial range. In the event of adverse conditions a strong and widespread network remains a valuable protection against downside risk and ,on the principle of “it’s not what you textmessage it’s who you textmessage” it can be argued that networks provide opportunities for advancement, which is all around managing upside risk.


The City of London is a very advanced and venerable network, arguably the best in the world. It owes some of its success and many of its failings to the old boy element, but some of the newcomers are impressed by the way the physical proximity allows for ideas to be brought to the attention of many key players quickly and for them to be honed through discussion with many different interested parties. Market research is one of the ways to manage upside risk, to reduce the uncertainties in a proposition and the London Market and the network it represents have an edge in this area.

The fact that newcomers are quickly involved into the London Market network strengthens it. It is not a closed shop, it does not try to exclude foreigners, quite the contrary they are key to its purpose. It suffers like any long established network from unnecessary activities and some downright dubious ones. It is protean through constant renewal, not only by accepting new people, but by offering opportunities for people to recycle themselves. Having lived in Japan for 18 years I can say that it can offer far better opportunities than any Japanese network that I know of. It provides individuals with upside risk opportunities to find employment, promote services, create new businesses, solve problems and to take risks.

Thinking legacies

Great teachers leave many legacies and I am sure that this is true of Peter Lipton who died when playing squash in November last year. He was the Head of the Department of History and Philosophy of Science at Cambridge and a famously exciting lecturer. The Guardian obituary reports that when asked on www.askphilosophers.org what the purpose of philosophy was he responded that "reading the philosophical questions on the site might make you more aware, thinking about them just might make you more intelligent."

I like the note of decent doubt which the "just" implies, signifying very low probability but nevertheless holding out rewards. Think about risk and who knows?

Best practice at Royal Marsden

Organisations that deal with other people's emergencies also have the skills to deal with their own. The Royal Marsden Hospital in London, one of the top cancer treatment facilities in the country, which suffered a serious fire on January 2nd demonstrated just the sort of crisis management that gives confidence to the general public.

Not only did they arrange for all patients affected to be cared from at the Brompton hospital nearby, they completed operations even as the fire was taking hold, no one was injured and they are already back in the business of seeing and treating patients.

Such a good result is not luck, but good planning, practice and resilient teamwork - a good example of how it should be done. What still remains is to determine how a fire was started - hospitals have a poor record of toaster fires, interestingly during the last fireman's strike toaster use was banned in most hospitals with positive results. But a toaster at the Royal Marsden, surely not .

Hot pants

Which is more use when you have an oil fire in your frying pan - a bowl of water or a large pair of ladies' underwear?

Last week in northern England , faced with a frying pan fire when cooking fried bread the owner's son ,18, threw water over the flames and made the fire a whole lot worse. His cousin then grabbed a pair of his aunt's knickers size 18-20 from a nearby washing pile and used them to successfully smother the flames.

Think risk, smarter decisions.

Work helps

The Financial Times reports today that in May 2007 the Department of Work and Pensions reported that 504,000 people below the age of 35 were signed on for incapacity benefits or severe disablement allowance. This compared with 443,000 under 35 who were claiming job seeker's allowance.

Additional comment points out that "in many cases it was worklessness, with its attendant financial problems and absence of purpose that made people depressed." It is depression,stress and anxiety which qualify people for incapacity benefits.

There are very definite mental health benefits from work. The importance of rehabilitation is widely accepted and AIRMIC has two free publications on its site www.airmic.com on the subject. However, given the size of the problem as reported by the FT, it is going to need a lot more than companies working at rehabilitation to get the numbers down.