Fred’s Story: What Happens When Safety Fades

Organizations Have No Memory

Story-Telling

A few days ago, we shared a fictional story of Jodi, a young engineer who led an incident investigation that became the start of her successful process safety career.

The central point of that post was that humans communicate best by telling stories to one another. We are all familiar with the term Death by Powerpoint, and we struggle to follow the typical process safety report. Yet we engage with incident reports (which are stories).

Today, we continue this theme: that stories make process safety memorable.

This particular story is told by Jodi’s mentor, Fred.

Note: This story This story echoes one told many years ago by Trevor Kletz and his colleagues. Unfortunately, I cannot trace the source. If anyone can help me track it down, let me know.

Here is Fred’s story. It is about another young engineer.

Fred’s Story

Fred

Fred is talking to Jodi.

“There was a young engineer once — fresh out of school, just like you. It was his first day on the job. He had just been called into the plant manager’s office for a courtesy greeting. He had just entered the office ― he always remembered the beige carpet ― when the ground shook. Not a little: a lot. He looked out of the window to see black smoke rising from the Depropanizer unit. In a near panic, he said,

The Depropanizer just blew up.

Three people dead. Dozens injured. Plant shut down for months. Huge economic losses. The young engineer never could forget the sight of the ambulances taking people out.”

Fred paused, letting the silence sit. He continued,

“The follow-up investigation showed that the pressure relief system wasn’t connected to the flare, the reboiler controls had been bypassed, a level transmitter was stuck ― everyone knew about it, but had learned to live with it, the manual isolation block valves around the unit were inaccessible, and so on and so on.

In spite of what he had seen, the engineer stayed. He joined the investigation team. Over the next twenty years he and his colleagues built a process safety management system that did it all: prestartup reviews, MOC, HAZOPs, training, culture, constant audits and inspections.

And it worked. The plant became a benchmark. Executives showed off the stats at conferences. Regulators backed off. Bonuses got fatter. Papers were published in prestigious journals.

But gradually, the memory of the explosion faded.

Then came a merger: new owners, leaner budgets. The training center was mothballed. The PHA cycle went from three years to five. Criteria for incident investigations were relaxed. Pressures and temperatures were raised ever closer to their safe limits so as to maximize production. One by one, they reassigned the old safety staff.”

Fred looked over his cup at Jodi.

“You know what happened on that engineer’s last day?”

Jodi shook her head.

“The now middle-aged engineer had accepted ‘the package’. He was closing his laptop for the last time when the alarm sounded. Same smoke. Same column. This time, no fatalities, but two people burned. The unit was down, maybe for good.

That engineer walked into the plant manager’s office — same layout, same beige carpet — and said,

“The Depropanizer just blew up.”

Jodi finally understood what Trevor Kletz meant when he said:

Organizations have no memory. Only people do. And once those people retire, forget, or move on... the clock resets.

Trevor Kletz (1922-2013)

Your Stories

This is why we tell stories. Not just to remember what went wrong, but to pass on the memory before it’s too late.

What stories do you remember?

Which ones are worth telling again?