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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]

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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.