There’s an old saying: “If you think safety is expensive, try an accident.”
The first choice after an accident is to say “How can we improve the design so this can’t happen? How can we remove the opportunity for errors?”
In a well-designed plant, a simple error like closing the wrong valve shouldn’t result in an accident.
For a long time, most people were saying that most accidents were due to human error. This is true in a sense, but it is not very helpful. It’s like saying falls are due to gravity.
— Trevor Kletz (1922-2013)
Trevor Kletz was the founder of process safety management/engineering. Process Safety deals with major accidents and defects in the process, as opposed to accidents on a personal scale. The ideal process is designed to be resilient and capable of dealing with human error.
When you change a process, you need to carefully consider how the change affects the other processes at the plant. If you don’t, a seemingly minor change could have terrible results. Replace that damaged reactor with stretch of pipe with expansion bellows, it will let you keep the system running; the result was Flixborough. Deactivate the flare stack and scrubber while the plant is shut down – it should not be a problem. Don’t tell workers about the potential for catastrophic events if the chemicals react with water. The result was Bhopal.
I highly recommend his book What Went Wrong? Case Studies of Process Plant Disasters to anyone who works in manufacturing, processing, etc. Rent it from your local library, as the Amazon price is insane. It’s written for the operator and foreman, with clear descriptions of how things can go off the rails. At the end of the book, he discusses is how analysis of change is applicable outside of the chemical industry. ICI corporation engaged in massive acquisitions without considering the effects on their viability. The result was bankruptcy and the company getting carved up.
You could say that the field of process safety is inherently conservative, in the broad sense. The famous Chestertonian Fence is basically a management of change review. Conservatism is the reminder that new does necessarily mean improved. That new program might just make things worse or waste money to no effect. Why, yes, despite our health care system having problems, we could get worse. Much worse. It is no accident that liberal plans tend to fail – they do not stop to consider the unintended consequences. That also could describe a good portion of the disasters in What Went Wrong?
The Constitution is designed deliberately to be resilient against minor errors, and remain enduring. Conservative policy should be designed similarly — carefully crafted to be resistant to mistakes, corruption, and leftists.
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