Blame

Pratt K J, Williams S K and Jarrell B E 1989 Enhanoed adherenoe of human adult andethelial sells to plasma disoharge modified polyethylene J. Blamed. Mater. Res. 23 1131-47... 

As argued above, it is not Renner who should be blamed for his paper being forgotten for almost 25 years. The reason is that the experimentalists needed this much time to obtain the first spectrum showing the features predicted by him [9,10], The effect that might have looked exotic in the 1930s has become one of... 

NCI3 > NHCI2 > NH2 Cl. Chloramines (primarily NHCI2 and NCl ) are usually responsible for complaints of eye irritation. Swimmers may blame this condition on too much chlorine, but the problem is caused by insufficient chlorine. Because inorganic chloramines are decomposed by sunlight, they pose less of a problem for bathers in outdoor swimming pools than in indoor pools. 

If the pump is put into service with a bent or unbalanced shaft assembly, its premature tailure can be traced to inadequate maintenance practices. The evidence does not lie. However, if the premature failure leaves evidence of a deflected shaft, this would be an operations or design failure. All too often, the mechanic is blamed. The two pictures above show how a deflected shaft appears when rotated 180 degrees (Figure 9-11 and Figure 9-12). 

Most often, the bearing or the lubricant is blamed for the failure. This is like blaming the fuse for an electrical failure. The failure is most likely a result of some abnormal operating condition, or lack of proper maintenance. In short, something causes the bearing to fail prematurely. 

It has always seemed strange to us that the mechanics, or the manufacturer, are blamed when a mechanical seal fails after 3 months of service. If the seal fails on start-up, maybe you could point to the mechanic or the seal, but not after 3 weeks or 4 months of operation. This would most likely be an operational failure (a failure in operations), or a design failure (a failure in the system s design). And what is really amazing is that this statement and these words have never been recognized or said before.)... 

The noise and the seal failure are actually symptoms and not the problem. This is like the electrician blaming the fiise for an overloaded electrical circuit. The problem is the overloaded circuit and the symptom is the burned fiise. Likewise, in the maintenance shop, the noisy pump, the failed seals and bearings arc the Symptom of a problem that probably occurred outside the pump. 

Small impellers with high motor speeds may produce the necessary pump pressure. This ty pe of combination produces high fluid velocities that will wear pump parts much faster than desirable. This is in the Affinity Laws. In addition the impeller suffers rapid wear due to high tip velocities. When a pump is disassembled and excessive wear is found, 95% of the time high velocity fluid is to blame. 

This model v/as used by Atwood et al (1989) to compare the performance of 12 m and 1.2 m long tubular reactors using the UCKRON test problem. Although it was obvious that axial conduction of matter and heat can be expected in the short tube and not in the long tube, the second derivative conduction terms were included in the model so that no difference can be blamed on differences in the models. The continuity equations for the compounds was presented as ... 

Bacteria are smaller than protozoa and are responsible for many diseases, such as typhoid fever, cholera, diarrhea, and dysentery. Pathogenic bacteria range in size from 0.2 to 0.6 /tm, and a 0.2 /tm filter is necessary to prevent transmission. Contamination of water supplies by bacteria is blamed for the cholera epidemics, which devastate undeveloped countries from time to time. Even in the U.S., E. coli is frequently found to contaminated water supplies. Fortunately, E. coli is relatively harmless as pathogens go, and the problem isn t so much with E. coli found, but the fear that other bacteria may have contaminated the water as well. Never the less, dehydration from diarrhea caused by E. coli has resulted in fatalities. 

Employees in the process area where the incident occurred should be consulted, interviewed, or made members of the team. Their knowledge of the events represents a significant set of facts about the incident that occurred. The report, its findings, and recommendations should be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigative process should clearly deal with all involved individuals in a fair, open, and consistent manner. 

The CPI would benefit from the application of human factors principles to improve safety, quality, and productivity. These arise from applying quality management to get at the underlying causc-.s of errors rather than after-the-fact blame or punishment. Crosby (1984) advocates error cause... 

The fire department blamed the accident on welders cutting in hazardous areas without a fire watch, highly combustible structural components (fiber-glass-resin), high-density storage of highly flammable and detonable material, spilled ammonium perchlorate about the plant, and high w ind conditions. 

A slow response to a smoldering mix of chemicals at the Napp Technologies plant in Lodi, NJ is blamed for an April 21,1995 explosion and fire that killed four workers and injured dozens of others. The blast destroyed more than 70% of the plant, which made pharmaceutical and cosmetic iiuerniediate products, and employed 110 workers. The explosion wrecked several stores housed in (he Napp building, damaged nearby buildings, and forced evacuation of 400 residents for about 13 hours. Chemicals leaked into a nearby river, killing hundreds of fish. 

Again, it is easy to blame the man. But he had been asked to do a Job that was difficult to perform while wearing an air mask. The plant staff members resisted the temptation to blame him—the easy way out. Instead, they looked for suitable lifting aids [7]. 

Section 3.2 discusses similar incidents. Rather than blame workers who make mistakes or disobey instructions, we should try to remove the opportunities for error by changing the work situation, that is, the design or method of operation. 

This incident is typical of those that would at one time have been blamed on human failing—the operator was at fault, and there was nothing anyone else eould have done. In faet investigation showed that ... 

An interesting feature of this incident was that no one blamed the operator. The manager said he would probably have made the same mistake because the eheck instrument was at a low level (about 1 m above the floor) and because a change in one temperature on a six-point recorder in that position is not obvious unless you are actually looking for it. It is not the sort of thing you notice out of the comer of your eye. 

If the operator had not opened the valve when he found it shut, the explosion could have been avoided. However, it is hard to blame him. His action was instinctive. What would you do if you found something undone that you should have done some time ago ... 

The original report blamed the operator for the explosion. But his failure to open the valve might have been foreseen. 

Static electricity (static for short) has been blamed for many fires and explosions, sometimes con ectly. Sometimes, however, investigators have failed to find any other source of ignition. So they assume that it must have been static even though they are unable to show precisely how a static charge could have been formed and discharged. 

At Bhopal, there had been changes in staff and reductions in manning, and the new recruits may not have been as experienced as the original team. However, I do not think that this contributed significantly to the cause of the accident. The errors that were made, such as taking protective equipment out of commission, were basic ones that cannot be blamed on inexperience of a particular plant. 

A top-quality London hotel was horrified to find that its house champagne, for which it charged 60 per bottle, lost its bubbles a few moments after it was poured. At first the hotel blamed the suppliers, but... 

Chapter 1, The Role of Human Error in Chemical Process Safety, discusses the importance of reducing human error to an effective process safety effort at the plant. The engineers, managers, and process plant personnel in the CPI need to replace a perspective that has a blame and punishment view of error with a systems viewpoint that sees error as a mismatch between human capabilities and demands. 

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