Monday, 28 January 2008

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.

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