Lesson learned

Hopefully, we have learned from these terrible examples. Here are some suggested tenets  

Needs determine priorities. According Maslow s Hierarchy of Needs, people must satisfy basic physiological needs before they can afford to focus on safety, love, self-esteem and self-actuaUzation.  

Those of us lucky enough to live in wealthy countries are justly proud of our recent environmental progress, which qualifies as self-actualization. But in poorer countries, people are less inclined to care about long-term dangers of pollution. After the nuclear accident at Chernobyl, the power plant ran for 14 more years because the Soviet Union (and then Ukraine) needed electric power and decided that it was too expensive to build a new plant. After 1986, the old plant was staffed by workers who lived in towns where the ambient radiation exceeded the safety threshold by a factor of nine. Despite a second accident in 1991, and despite daily reminders of the dangers radiation, the workers stayed on because they needed jobs and couldn t find other work. Without incentives from the European Community, the Chernobyl nuclear power plant might still be running today. 

Follow the rules. On their own or under duress, people ignore safety mles all the time, all over the world, not just in factories, but in homes and offices, on farms and highways. If we include exceeding the speed limit on public highways, it s safe to say that only a fraction of mle violations cause accidents. While the accidents can be tragic for the people who are involved, they seldom cause catastrophic damage to the environment. 

Encourage whistle-blowing. When told to raise the control rods too high, the Chernobyl operators hesitated, citing safety regulations. But when Diatlov insisted, the operators complied. Undoubtedly, the fear of losing their jobs 

Several important lessons were learned during this project. One of the first and most important was related to the equipment necessary for performing precision cleaning using supercritical fluid. The 

Supercritical fluids are a viable alternative for certain high value applications, but as with any alternative there is a learning curve 

From just these few examples, there are clear and powerful lessons to be learned about contemplating and initiating an SCM improvement project  

Make absolutely certain there is strong and continuing support for the SCM initiative from senior management before initiating a project. Without that support, the project will degenerate into a theoretical exercise, or worse, be seen simply as just another 

Create a cross-functional team or task force with strong, clearly identified leadership to guide and direct the conceptual and implementation phases of the project. Without that leadership, the project will flounder, go off course, or merely cease to function. 

Establish clearly spelled-out goals as to what the SCM project will accomplish, with specific metrics for results and clear time frames to ascertain results. 

Finally, for so complex a process as SCM to succeed, human oversight and intervention are essential. Software systems and codes are no substitute for knowledgeable judgment and functional experience. 

In the hope that my experiences through the many years of development of this international green chemistry programme will prove valuable to others as they embark on similar adventures. I conclude with a summary of some of the key lessons learned. 

The names, number, and types of zones vary based on the aetivities at the worksite. The important thing to remember is that work zones are established to proteet the workers and the publie. Everyone on the site should understand the hazard(s) and eontrol(s) neeessary to support eaeh identified zone. Wind direetion was mentioned as an important eri-terion in ehoosing the support or elean zone. In most parts of the eountry, wind direetion ean be highly variable. If this is the ease at a given site, how should the support zone be handled The answer may vary based on the eonditions. 

To illustrate this point, let s eonsider the example of a superfund ehemieal waste landfill remediation job. In this example, we will need to determine the eontaminants of eoneern. After making this determination, we next need to assess the eontaminants and how they may migrate from the site. We need to determine if ehanges in the wind direetion oeeur, how frequently, and how workers in the support zone will be aflfeeted. In most eases, the likelihood for workers in the support zone to be affeeted is minimal. 

However, if the eap on the landfill eontains a hazardous material sueh as lead eontaining dust that is being transported off site, there are a eouple of questions to ask. The first is, Wliat type of work aetivity will be taking plaee on site And seeond, Does work aetivity ereate dust  

If dust is being ereated, alternatives should be eonsidered. One alternative may be a ehange of loeation of the support zone. This may be more diflfieult than it sounds. Many times the support zones are trailers, 

Developing a Site-Specific Health and Safety Plan 67 

Daptomycin might not have been developed if Lilly did not have a group working on enzymatic bioconversions. Without this capability, the deacylase enzyme from A. utahensis10 would not have been discovered and so the chemical SAR studies around the lipid tail leading to daptomycin might not have been approachable. 

It may not be easy to duplicate the series of events that led to the discovery and development of daptomycin today, but there is reason to believe that other important molecules are yet to be discovered and there are approaches that integrate new biology and chemistry not available at the time of daptomycin discovery.23,77 

There are undoubtedly many stories that accompany the discovery and development of important drugs. The daptomycin story points out how fragile the process is, but success ultimately was achieved through a dedicated champion, Dr Francis P. (Frank) Tally. I had the privilege to work with Frank to help initiate the daptomycin project at Cubist68 and I dedicate this chapter to his memory. 

Julian, K. Kosowska-Shick, C. Whitener, M. Roos, H. Labishinski, A. Rubio, L. Parent, L. Ednie, L. Koeth, T. Bogdanovich and P. C. Apple-baum, Antimicrob. Agents Chemother., 2007, 51, 3445. 

Kamatsuzawa, T. Fujiwara, N. McCallum and M. Sugai, Antimicrob. Agents Chemother., 2004, 48, 4800. 

A cost accounting system that did not reflect the actual operations of the business had a significant impact on the way PlumbCo s management viewed the company. This distorted view caused it to make many decisions that led to deterioration in the company s profits. 

To effectively support management, a company s costing practices must provide an accurate cost model of its operations. It must also provide tools for supporting the variety of decisions for which cost information is an important input. Most importantly, it must promote an intellectual model in the minds of all members of management that helps them understand the true economic implications of every decision they make. 

Orders per year Average line items per order Average pieces per order Average pieces per box 26 30 1,200 30 26 780 31,200 5,800 per order 0,600 per line item 0,100 per piece  

Total EHstributioii, Marketing, and Administrative Costs Calculated Customer Margin FIGURE 36.1 

Average line items per order 10 1,040 0,600 per line item 624 

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The NFS shear successfully processed irradiated LWR fuel between 1966 and 1972. Among the lessons learned were that the chute that channeled sheared fuel pieces to the dissolver basket was susceptible to bridging, the gag drives required a disproportionate amount of maintenance, and insufficient throat clearance led to jamming of chopped fuel. 

After the incident, an investigation team determined that the first operator had not added the initiator when required earlier in the process. When the relief operator added the initiator, the entire monomer mass was in the reactor and the reaction was too energetic for the cooling system to handle. Errors by both operators contributed to the runaway. Both operators were performing many tasks. The initiator should have been added much earlier in the process when much smaller quantities of monomer were present. There was also no procedure to require supervision review if residual monomers were detected. The lesson learned was that operators need thorough training and need to be made aware of significant hazardous scenarios that could develop. 

Drogaris, G. 1993. Major Accident Reporting System Lessons Learned from Accidents Notified. Elesevier Science Publishers,B.V., Amsterdam. 

The main lessons learned from the workshop were (with some 5-year old... 

An inherently safer engineering system would have a mechanism to convert lessons learned from a project into guidelines and standard practices for later projects. 

It would also have an audit system to confirm that lessons learned were indeed captured. 

The DOE and private industry have learned many lessons from years of experienee in site remediation. This book will refer to seleeted lessons learned from the DOE, the Army Corps of Engineers, private industry, and personal experienee. After reading this book the reader should have a better understanding of how to interpret the hazardous waste requirements to make sure eomplianee is maintained at a high level for eaeh site-speeifie aetivity. Over and above eomplianee, the authors eneourage the development of health and safety programs to help build a sound and workable safety eulture that ean be utilized aeross all boundaries. 

Share lessons learned and help provide approaehes that have been implemented on hazardous waste and other sites... 

Incorporating lessons learned into work practices. 

Once adopted, plans should be periodically reviewed (depending on the project) and evaluated for effectiveness and cost/benefit. If the scope of work or any worksite hazards change significantly or if lessons learned indicate a review, the plans should be revised promptly... 

Lessons learned provide valuable information for managing health and safety programs. This information addresses conditions to be avoided or recommended practices. Lessons learned typically have the potential for wide-ranging application. Effective identification of lessons learned requires an awareness of emerging practices, programs, and technologies related to hazardous waste activities [3]. 

The safety alert concept is another tool that can be used by large or small businesses to communicate past best practices and indicate a path forward. On a daily basis, lessons learned should be communicated in a site safety meeting. A worker or supervisor may have discovered that a current practice could cause a potentially dangerous situation. Many times the correction or long-term fix for a hazard involves engineering... 

In the DOE environment, the term lesson learned is defined as a good work practice or innovative approach that is captured and shared to promote application. It may also be an adverse work practice or experience that is captured and shared to avoid recurrence. This term is used by DOE and other federal and private-sector institutions, to describe the following ... 

The authors believe that although the following information is speeifie to superfund sites, the general findings are universal. As you review this information, you will notiee some areas of bold print. Within these bolded areas, the authors have added their own analysis, eomments, and lessons learned while performing field aetivities at sites of all sizes that deal with hazardous materials. 

Hands-on training, where employees actually apply lessons learned in simulated or real situations, will enhance learning. For example, operating personnel, who will work in a control room or at control panels, would benefit by being trained at a simulated control panel. Upset conditions of various types could be displayed on the simulator, and... 

An early version of MET methodology was applied in the Interim Reliability Evaluation Program (IREP) that analyzed the ( ill vert Cliffs and Arkansas Nuclear other applications. Although MET is an extension of the fault tree analysis (Section 3.4,4), it warrants a. separate discussion (see NUREG/ CR 3268). Objectives of MET are ... 

Tlie DOE Office of Environmental Safety and Health distributes monthly summaries ba.scd on data retreived from the DOE Occurrence Reporting and Processing System (ORPS) to share chemical safety concerns throughout the industry to alert operators of similar processes. In addition quarterly and annual reviews feature lessons learned from ORPS by trending analyses of ini an... 

Lessons learned from earlier PSAs incorporated in the CANDU 9 design are ... 

Butikofer, R, E 1986, Safety Digest of Lessons Learned, Amer, Pet. Inst, API publication 758. 

Nimmo, S. R. Nunns, and B. W. Eddershaw, Lessons Learned from the Failure of a Computer System Controlling a Nylon Polymer Plant, Paper presented at Safety and Reliability Society Symposium, Altrincham, UK, Nov. 1987. 

Safety Digest of Lessons Learned, Vols. 2-5, American Petroleum Institute, New York, 1979-1981. 

Lessons Learned. It s very early in the game to make predictions about what changes may be needed as a result of the Manwood test. However, there are already some useful insights that the Task Force expects to factor into the PSM installation plan for the division. These include 1) We need to be very clear in introducing PSM to our employees, and take time to answer their questions. Orientation meetings should be at least 90 minutes, not the one hour we had scheduled. 2) Getting valid feedback takes some effort personnel need to know we mean it when we say we want constructive criticism. 3) Close collaboration between the Task Force and the facility manager is absolutely vital. 

On-the-job. Learning on the job has the advantage of being very tangible lessons learned on the job tend to be retained. The downside can include lack of continuity and followthrough, as well as potential problems with consistency. 

If procedures are obviously out of date or do not take into account lessons learned throughout a system, they rapidly lose their credibility and are likely to fall into disuse. 

Ask about lessons learned and pitfalls avoided, not just how the process currently works. 

After Benefits and costs, lessons learned and changes to overall project... 

Keep the pilot project design and installation as similar to the full project as possible. In this way, any lessons learned from the pilot will be most easily transferred to the full project. 

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