IIAR

BY KEM RUSSELL

We can all learn some valuable lessons from other people’s challenging experiences, and those lessons are even more important when they help others prevent future accidents.

Astronaut Mike Mullane, who spoke at the March 2014 IIAR Conference, had a lot to say about learning safety lessons from experience. In his presentation, Mike outlined the problems that can occur when “normalization of deviance” causes oversights that lead to horrific accidents – like the space shuttle Challenger disaster – even in environments where people have huge amounts of safety experience.

The lesson learned in these situations, it turns out, is not about the factors that create safety, but rather how vigilant we are in remembering their importance.

Another way we can look at this concept is by thinking about safety in terms of “experience complacency.” In this column, I’ll describe two experiences, one outside and one inside the ammonia refrigeration industry that illustrate how experience complacency can lead to trouble.

As a volunteer Search and Rescue responder in one of the nation’s most rugged wilderness areas, I often see the consequences of experience complacency firsthand. In one case, I was involved in a search and rescue effort to find a missing long distance hiker eight days after she went missing.

She had walked over 2,200 miles in about four months and had reached a resupply location where she stopped to check in with family members and restock supplies.

This is where she made her first oversight, one that was entirely due to the kind of confidence that puts experienced people in harm’s way when they are dealing with the kind of routine judgment calls they make every day.

While at the small resupply town, the hiker called her father to check-in. He mentioned that the weather was changing and a storm was coming. Her response was, “no problem Dad. I’ve been wet before and I’ve just hiked over 2,200 miles. A little rainstorm isn’t going to stop me!”

At this point, it’s interesting to note that rather than prompting just one risky decision, experience complacency happens when confidence in experience prompts a person to make several small bad decisions, or ignore a string of small clues that the developing situation is out of the norm.

The next day another man spoke to the hiker about the coming storm, but she again said she would be fi ne. That afternoon, she got a ride up to the trail and with a light rain falling, headed out. Those who dropped her off wondered how she was going to do in the rain and with a storm on its way, but she was a long distance hiker, she should know what she’s doing, right?

The answer is actually yes, she did know what she was doing, just not in this situation, and her own experience prevented her from seeing the very warning signs an experienced hiker should see, precisely because they came slowly, as a series of small decision points.

The next day, the weather was still wet, and as she gained elevation, it got progressively worse. By early afternoon, as the rain mixed with snow made hiking further that day a bad idea, she set up her tent, crawled into her warm sleeping bag and tried to sleep as the weather beat down.

But the next morning, she opened the tent to step outside and found three feet of new fallen snow. After four months of effort, hiking in the heat, the rain, the wind, at low and high elevation she knew she would not be going any further.

After that, the weather remained bad for several more days before it finally started to improve. By now, the hiker was at serious risk, with no way to call for help. A helicopter was even sent into the area to rescue another group of hikers, but no one knew she was near.

Throughout the week, other aircraft searched for her, but could find no trace of her presence on the mountain. Finally after seven days, she decided to head across country searching for a way to a lower elevation.

After a struggle through deep snow she made it below the snow line and reached a forest service road where a man riding a motorcycle found her and directed her to a search and rescue vehicle less than a fourth of a mile away.

On entering the search and rescue command post, she ran to her father with words I won’t soon forget, “Dad, I thought I was going to die! I thought I was going to die!”

Our hiker’s experience over the previous several months had shown her she could do some amazing things. She could walk thousands of miles, handle rugged mountain terrain, and keep going when she was hungry and thirsty. It had also shown her the very real danger of experience complacency.

She had become complacent due to her past experience, and too confident in what she could handle. With a storm coming, she had ignored the signs and suggestions from other people, a level of complacency that nearly cost her life.

At the surface, this example of an overconfident hiker may seem like it stands alone, simply as a warning of the limitations of any human in a threatening environment. But our hiker was extremely experienced, not unlike the professionals at mission control in the days leading up to the Challenger disaster.

Looking closer, this is a lesson on the importance of vigilance, and never taking experience for granted, in any field. Experience complacency can set in anywhere.

Now let’s look at an incident that occurred within the ammonia refrigeration industry. In this case, a new employee was moved into the refrigeration department at a large ammonia facility. Being new to refrigeration, his responsibilities would be limited until he was properly trained and had sufficient experience.

The more experienced refrigeration personnel on staff began educating the new guy on how to properly perform some of the commonly required tasks, one of which was the draining of oil from oil pots.

At this point, the new employee’s training was being carried out correctly. There was a written oil pot draining procedure, which the new employee was required to read and understand. After that, he observed one of the experienced refrigeration men perform the oil drain procedure then under supervision he did the procedure himself. As the training process went along, this newer refrigeration employee finally became qualified to perform the oil pot draining procedure without supervision. He had the training, he had done the procedure himself while under supervision and he felt confident he could do it alone.

However, as he began to perform the oil draining procedure, he neglected to follow important steps in the written procedure on which he had been trained. In other words, he didn’t have experience with his own experience.

Again, several errors, all caused by complacency, combined. He did not wear the appropriate personal protective equipment, then he opened the incorrect sequence of valves applying higher than recommended pressure to the oil pot. Finally, when he incorrectly opened the drain valve, the pressure in the oil pot blew oil and ammonia out of the drain valve covering one of his hands.

He suffered blistering to his thumb, forefinger, mid-finger, and the back of his hand. Again, experience complacency almost cost a life. He was very lucky blistering is all that happened.

So what’s the lesson learned from these two stories? The answer is that whether a person has weeks, months, or years of experience, becoming complacent is far too easy.

Not following safety procedures exactly, in every case, in any field where missteps can end in real harm, can lead any person with any level of experience to ignore the signs and warnings of potentially serious situations.

In a nutshell, experience inappropriately applied or ignored can be dangerous.

If we accept that simple idea, we don’t have to make mistakes ourselves to learn. We can learn from the experiences of other people, and remember the importance of doing the right thing no matter what, even if our own experience tempts us to consider deviation from the norm.

One of the great men in ammonia refrigeration was Mr. Milton Garland. Mr. Garland worked in our industry for many decades, and he credited his long life (he was over 100 years old) to the fact that he “never did anything stupid.”

Experience complacency can lead to a series of bad decisions that can hurt you or those around you. Don’t be the one with the story. Don’t make your experience one where you say, “I thought I was going to die!”