PHMSA has decided to not move forward to amend HMR 49 CFR 171-180 that would require CMTV loaders and unloaders to perform a risk assessment prior to activities and implement safety procedures based on the results.
On March 11, 2011 PHMSA published a Notice of Proposed Rule Making (NPRM) based on their regulatory assessment, public comments and the completion of a supplementary policy analysis to address risks associated with loading and unloading operations. Also included in this proposal was additional training and qualification requirements for loading personnel.
PHMSA’s regulatory assessment cited “human error” as the reason for most cargo-related accidents. This decision was based on a 10 year study of CMTV incidents between 2000 and 2009. The study claimed that the human factor was attributed to inattention to detail while loading or unloading, attendance requirements, leaving valves in the open or closed position, failure to segregate incompatible materials, and improper hose connections and filling practices that result in over-pressurized CMTV’s. Over 3,500 of these incidents during the study period resulted in a total of $68 million in damages.
Public comments to the proposed amendment regarding performing risk assessments expressed concern over redundancy by facilities and carriers, as well as the record-keeping efforts for such a task, declared as “burdensome”.
Comments on PHMSA’s recommendation that operators perform an annual refresher under direct observation of actual duties and drills was strongly opposed citing underestimated time and cost analysis.
In order to be compliant with the proposed rule, many commenters suggested extending the compliance period to allow for facility review and implementation. A majority claimed that several facilities already have such procedures in place similar to the proposed rule and that an extension of compliance was not needed. If such measures are already in place, then why are there so many accidents?
The analysis performed by PHMSA determined that attempting to implement new regulations would be ineffective, since most of the incidents are attributed to human error and any new rules would just complicate things, even more. Instead of moving forward with the ill-fated rule change, PHMSA is recommending:
- Preparing a guidance document covering loading and unloading procedures
- Proper PPE
- Maintenance and inspection of equipment before use
- An outreach program
- A memorandum of understanding (MOU) to regulatory agencies defining enforcement criteria
- A Human Factor study associated with bulk loading operations.
The Human Factor study
This Human Factor study is where the “human error” molecule was discovered, long ago, as its flawed by-product. Often synonymous with the term “limitations” this seemingly dominant gene comes directly from the application of the Human Factor. It can be an inherited and/or learned trait.
Sanders and McCormick (1993) are authors of “Human Factors in Engineering and Design”. A book that can easily be re-titled “Why we build things the way we build them”. It is sort of the Bible on Ergonomics. They define Human Factors studies as “the focus on human interaction with products, equipment, and procedures used to complete tasks.”
According to Sanders and McCormick, we learn from our “limitations” or mistakes to build a better, or sometimes different mousetrap-better matching our capabilities, and limitations with the tools we have at hand. Sanders and McCormick compiled a list of some common Human Factors. See if any of these sound familiar, or could possibly be related to say, and increase in accidents-of any kind:
Impatience, limited memory, limited concentration, prone to make errors, misjudgment, distraction, fatigue, physical inability, require practice to become good at doing things, embarrassment can act as a limitation to accomplishing some tasks, Tendency to do things the easy way (never happens at my place of work), resistance to change, can be physically harmed by some tasks, act irrationally, miss details when tasks are memorized and performed cursorily, Prefer standard ways of doing things, constrained by time.
Oh yeah, this is a recipe for disaster! Yet, its also the cold hard truth for all of us.
Fielding conclusions as to why accidents happen, or why the rules are in place, yet not followed, it becomes too easy to point to the above mentioned Human Factors or even say “we didn’t plan it properly” or “we need more time/the right tools” or “it wasn’t executed correctly” or “the plan was poorly managed and staff were not trained” Perhaps as a whole we are subconsciously creating a company-wide tolerance for simply not following the rules. Best Management practices are only effective through careful and effective communication, from the top-down. However, even when we agree on rules, procedures, and standards, as individuals, and pass them on through proper communication, this does not always guarantee cooperation. Let’s practice what we preach.