SlideShare uma empresa Scribd logo
1 de 26
Lucky Barriers ,[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lucky Barrier Anything that does or did protect something worth protecting, but is so fragile as to be "lucky."   © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
A Picture is Worth 1000 Words. Without the Lucky Barriers  near misses would be Real McCoys © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Fragility of Effective and Unchallenged Barriers Positive Control  Of Tools Pre-job Brief Lanyards For Tools Restraining Lip on Scaffold Deck Situational Awareness Preventing  Work Under  Scaffold (Luck) Hard Hat First Aid Assistance Medical Assistance Ineffective: See actual hazards. Ineffective: Worker set hammer down. Ineffective: Hammer not tethered. Ineffective: Gap in restraining lip. Ineffective:  Worker A Kicks  Hammer  Off Deck.. Ineffective: Worker B Under Scaffold Effective Barrier: Hammer Misses Worker B Not  Challenged Not  Challenged Not  Challenged ?? © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Ineffective: See actual hazards. Ineffective: Worker set hammer down.
© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu The Lucky Barrier comes in here!!
© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Eight Questions For Insight Quality & Safety Impact What were the event consequences? What was the event significance? Vulnerability What set us up for the event?  What triggered the event?  What made the event as bad as it was? What kept it from being a lot worse? Learning: What should be learned from the event? Doing:  What should be done about it? Consummation Exacerbation Mitigation Corrective Action  (closeout) The Lucky Barrier comes in here!!
 
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lucky Barrier
Lucky Barrier Case © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
Lucky Barrier  Case ,[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Lucky Barrier
Lucky Barrier Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu 5 Lucky Barriers
Other Lucky Barrier Cases ,[object Object],[object Object],[object Object],[object Object]
Send your favorite Lucky Barrier case to [email_address]
Lucky Barrier Facts ,[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lucky Barrier Lessons to be Learned ,[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lucky Barrier Lessons to be Learned ,[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Lucky Barrier(LB) Action Items ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Oh, by the way. ,[object Object],[object Object],The Sailor who noticed the high oxygen. © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
Send your favorite Lucky Barrier action items and pictures to [email_address]
Lucky Barriers  Bottom Line ,[object Object],[object Object],[object Object],© 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu is a
Subscribe to “The Firebird Forum” by sending an e-mail to: [email_address]

Mais conteúdo relacionado

Último

Why Teams call analytics are critical to your entire business
Why Teams call analytics are critical to your entire businessWhy Teams call analytics are critical to your entire business
Why Teams call analytics are critical to your entire business
panagenda
 
Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024
Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024
Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024
Victor Rentea
 
Cloud Frontiers: A Deep Dive into Serverless Spatial Data and FME
Cloud Frontiers:  A Deep Dive into Serverless Spatial Data and FMECloud Frontiers:  A Deep Dive into Serverless Spatial Data and FME
Cloud Frontiers: A Deep Dive into Serverless Spatial Data and FME
Safe Software
 

Último (20)

Repurposing LNG terminals for Hydrogen Ammonia: Feasibility and Cost Saving
Repurposing LNG terminals for Hydrogen Ammonia: Feasibility and Cost SavingRepurposing LNG terminals for Hydrogen Ammonia: Feasibility and Cost Saving
Repurposing LNG terminals for Hydrogen Ammonia: Feasibility and Cost Saving
 
How to Troubleshoot Apps for the Modern Connected Worker
How to Troubleshoot Apps for the Modern Connected WorkerHow to Troubleshoot Apps for the Modern Connected Worker
How to Troubleshoot Apps for the Modern Connected Worker
 
Why Teams call analytics are critical to your entire business
Why Teams call analytics are critical to your entire businessWhy Teams call analytics are critical to your entire business
Why Teams call analytics are critical to your entire business
 
EMPOWERMENT TECHNOLOGY GRADE 11 QUARTER 2 REVIEWER
EMPOWERMENT TECHNOLOGY GRADE 11 QUARTER 2 REVIEWEREMPOWERMENT TECHNOLOGY GRADE 11 QUARTER 2 REVIEWER
EMPOWERMENT TECHNOLOGY GRADE 11 QUARTER 2 REVIEWER
 
Artificial Intelligence Chap.5 : Uncertainty
Artificial Intelligence Chap.5 : UncertaintyArtificial Intelligence Chap.5 : Uncertainty
Artificial Intelligence Chap.5 : Uncertainty
 
AWS Community Day CPH - Three problems of Terraform
AWS Community Day CPH - Three problems of TerraformAWS Community Day CPH - Three problems of Terraform
AWS Community Day CPH - Three problems of Terraform
 
Apidays New York 2024 - Passkeys: Developing APIs to enable passwordless auth...
Apidays New York 2024 - Passkeys: Developing APIs to enable passwordless auth...Apidays New York 2024 - Passkeys: Developing APIs to enable passwordless auth...
Apidays New York 2024 - Passkeys: Developing APIs to enable passwordless auth...
 
MINDCTI Revenue Release Quarter One 2024
MINDCTI Revenue Release Quarter One 2024MINDCTI Revenue Release Quarter One 2024
MINDCTI Revenue Release Quarter One 2024
 
Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024
Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024
Modular Monolith - a Practical Alternative to Microservices @ Devoxx UK 2024
 
Polkadot JAM Slides - Token2049 - By Dr. Gavin Wood
Polkadot JAM Slides - Token2049 - By Dr. Gavin WoodPolkadot JAM Slides - Token2049 - By Dr. Gavin Wood
Polkadot JAM Slides - Token2049 - By Dr. Gavin Wood
 
Cyberprint. Dark Pink Apt Group [EN].pdf
Cyberprint. Dark Pink Apt Group [EN].pdfCyberprint. Dark Pink Apt Group [EN].pdf
Cyberprint. Dark Pink Apt Group [EN].pdf
 
CNIC Information System with Pakdata Cf In Pakistan
CNIC Information System with Pakdata Cf In PakistanCNIC Information System with Pakdata Cf In Pakistan
CNIC Information System with Pakdata Cf In Pakistan
 
Ransomware_Q4_2023. The report. [EN].pdf
Ransomware_Q4_2023. The report. [EN].pdfRansomware_Q4_2023. The report. [EN].pdf
Ransomware_Q4_2023. The report. [EN].pdf
 
Apidays New York 2024 - Accelerating FinTech Innovation by Vasa Krishnan, Fin...
Apidays New York 2024 - Accelerating FinTech Innovation by Vasa Krishnan, Fin...Apidays New York 2024 - Accelerating FinTech Innovation by Vasa Krishnan, Fin...
Apidays New York 2024 - Accelerating FinTech Innovation by Vasa Krishnan, Fin...
 
Strategies for Landing an Oracle DBA Job as a Fresher
Strategies for Landing an Oracle DBA Job as a FresherStrategies for Landing an Oracle DBA Job as a Fresher
Strategies for Landing an Oracle DBA Job as a Fresher
 
Navigating the Deluge_ Dubai Floods and the Resilience of Dubai International...
Navigating the Deluge_ Dubai Floods and the Resilience of Dubai International...Navigating the Deluge_ Dubai Floods and the Resilience of Dubai International...
Navigating the Deluge_ Dubai Floods and the Resilience of Dubai International...
 
TrustArc Webinar - Unlock the Power of AI-Driven Data Discovery
TrustArc Webinar - Unlock the Power of AI-Driven Data DiscoveryTrustArc Webinar - Unlock the Power of AI-Driven Data Discovery
TrustArc Webinar - Unlock the Power of AI-Driven Data Discovery
 
ICT role in 21st century education and its challenges
ICT role in 21st century education and its challengesICT role in 21st century education and its challenges
ICT role in 21st century education and its challenges
 
Biography Of Angeliki Cooney | Senior Vice President Life Sciences | Albany, ...
Biography Of Angeliki Cooney | Senior Vice President Life Sciences | Albany, ...Biography Of Angeliki Cooney | Senior Vice President Life Sciences | Albany, ...
Biography Of Angeliki Cooney | Senior Vice President Life Sciences | Albany, ...
 
Cloud Frontiers: A Deep Dive into Serverless Spatial Data and FME
Cloud Frontiers:  A Deep Dive into Serverless Spatial Data and FMECloud Frontiers:  A Deep Dive into Serverless Spatial Data and FME
Cloud Frontiers: A Deep Dive into Serverless Spatial Data and FME
 

Destaque

How Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental HealthHow Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental Health
ThinkNow
 
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
Kurio // The Social Media Age(ncy)
 

Destaque (20)

Product Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage EngineeringsProduct Design Trends in 2024 | Teenage Engineerings
Product Design Trends in 2024 | Teenage Engineerings
 
How Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental HealthHow Race, Age and Gender Shape Attitudes Towards Mental Health
How Race, Age and Gender Shape Attitudes Towards Mental Health
 
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdfAI Trends in Creative Operations 2024 by Artwork Flow.pdf
AI Trends in Creative Operations 2024 by Artwork Flow.pdf
 
Skeleton Culture Code
Skeleton Culture CodeSkeleton Culture Code
Skeleton Culture Code
 
PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024PEPSICO Presentation to CAGNY Conference Feb 2024
PEPSICO Presentation to CAGNY Conference Feb 2024
 
Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)Content Methodology: A Best Practices Report (Webinar)
Content Methodology: A Best Practices Report (Webinar)
 
How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024How to Prepare For a Successful Job Search for 2024
How to Prepare For a Successful Job Search for 2024
 
Social Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie InsightsSocial Media Marketing Trends 2024 // The Global Indie Insights
Social Media Marketing Trends 2024 // The Global Indie Insights
 
Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024Trends In Paid Search: Navigating The Digital Landscape In 2024
Trends In Paid Search: Navigating The Digital Landscape In 2024
 
5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary5 Public speaking tips from TED - Visualized summary
5 Public speaking tips from TED - Visualized summary
 
ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd ChatGPT and the Future of Work - Clark Boyd
ChatGPT and the Future of Work - Clark Boyd
 
Getting into the tech field. what next
Getting into the tech field. what next Getting into the tech field. what next
Getting into the tech field. what next
 
Google's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search IntentGoogle's Just Not That Into You: Understanding Core Updates & Search Intent
Google's Just Not That Into You: Understanding Core Updates & Search Intent
 
How to have difficult conversations
How to have difficult conversations How to have difficult conversations
How to have difficult conversations
 
Introduction to Data Science
Introduction to Data ScienceIntroduction to Data Science
Introduction to Data Science
 
Time Management & Productivity - Best Practices
Time Management & Productivity -  Best PracticesTime Management & Productivity -  Best Practices
Time Management & Productivity - Best Practices
 
The six step guide to practical project management
The six step guide to practical project managementThe six step guide to practical project management
The six step guide to practical project management
 
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
Beginners Guide to TikTok for Search - Rachel Pearson - We are Tilt __ Bright...
 
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
Unlocking the Power of ChatGPT and AI in Testing - A Real-World Look, present...
 
12 Ways to Increase Your Influence at Work
12 Ways to Increase Your Influence at Work12 Ways to Increase Your Influence at Work
12 Ways to Increase Your Influence at Work
 

Tff V11 N01 Lucky Barriers Updated 2010 03 01

  • 1.
  • 2. Lucky Barrier Anything that does or did protect something worth protecting, but is so fragile as to be "lucky." © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
  • 3. A Picture is Worth 1000 Words. Without the Lucky Barriers near misses would be Real McCoys © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
  • 4. Fragility of Effective and Unchallenged Barriers Positive Control Of Tools Pre-job Brief Lanyards For Tools Restraining Lip on Scaffold Deck Situational Awareness Preventing Work Under Scaffold (Luck) Hard Hat First Aid Assistance Medical Assistance Ineffective: See actual hazards. Ineffective: Worker set hammer down. Ineffective: Hammer not tethered. Ineffective: Gap in restraining lip. Ineffective: Worker A Kicks Hammer Off Deck.. Ineffective: Worker B Under Scaffold Effective Barrier: Hammer Misses Worker B Not Challenged Not Challenged Not Challenged ?? © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Ineffective: See actual hazards. Ineffective: Worker set hammer down.
  • 5. © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu The Lucky Barrier comes in here!!
  • 6. © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu Eight Questions For Insight Quality & Safety Impact What were the event consequences? What was the event significance? Vulnerability What set us up for the event? What triggered the event? What made the event as bad as it was? What kept it from being a lot worse? Learning: What should be learned from the event? Doing: What should be done about it? Consummation Exacerbation Mitigation Corrective Action (closeout) The Lucky Barrier comes in here!!
  • 7.  
  • 8.
  • 9.
  • 10. Lucky Barrier Case © 2010, William R. Corcoran, NSRC Corp., 860-285-8779, firebird.one@alum.mit.edu
  • 11.
  • 12.
  • 13.
  • 14.
  • 15.
  • 16.
  • 17.
  • 18. Send your favorite Lucky Barrier case to [email_address]
  • 19.
  • 20.
  • 21.
  • 22.
  • 23.
  • 24. Send your favorite Lucky Barrier action items and pictures to [email_address]
  • 25.
  • 26. Subscribe to “The Firebird Forum” by sending an e-mail to: [email_address]

Notas do Editor

  1. The venue is a four unit generating station in which all four units are in one huge building. Workers erroneously ground into a hydrogen line that was unintentionally pressurized. This could have resulted in filling the building with a hydrogen-air mixture, leading to a high-energy explosion or deflagration. The situation was saved when the grinder sparks turned the hydrogen jet into a "Bunsen burner." Oh, and to top things off, the Bunsen burner line-of-fire did not include any flammable materials.