Recommendations to Provide

  From FTA chats, we can obtain a lot of measures to prevent similar incidents in the future.  I already mentioned that some of them look like practical and some are not.  Sometimes we see a serious problem of the organization.  In such case, we have to consider the safety management system of the organization and it cannot be improved in a short time.  On the other hand, the organization will need to continue their commercial activities as a going concern.  We cannot wait for a long time.

  When we re-build a Safety Management System of an organization, we have to grasp the current safety system, available resources (man-power, materials, money, time, etc.), business condition, and future vision of the organization and so on.  Based on these information, we have to design the new Safety Management System by order made.  Then it can be infinite variety and cannot be made in a short time.

  But the organization must continue their business and cannot wait for the new Safety Management System rooted in people.  We have to have an effective and easy measure for a short time to prevent a similar incident.  It can be a tentative measure but we should not start operation without any measure.  In the oil spilling case, to clean the floor was a measure which we can do soon.  We may decide a short time rule "anyone who found oil spilling on the floor shall clean it soon".  This is easy and will not take long.  Such concept will be involved in the new Safety Management System eventually and the tentative measure will finish the role at the time.

  It is essential to eliminate the direct causes of the incident before start the operation again.  But also a short time measure is very important to make people to feel safe to work.  From the FTA charts can give us many ideas to prevent the "undesirable conditions" and "human errors".  Based on these ideas, you may conceive some other ideas too.  Please list them up as many as possible.  You do not have to do all of them.  Please examine the measures one by one on the FTA chart and confirm the efficiency and practicality.  Select one or a set of measures which all the workers can feel safe.

  There are many methods to select the best measure, but to evaluate the efficiency and the practicality s one of the common way.  Sometimes we find a measure has the same meaning of other but only the words are different.  Don't spend too much time on these difference.  We can unify them before the selection work.  Also sometimes one measure is not enough to prevent similar incident.  We could avoid the incident of Mr. B to fail on acknowledgement of oil on the floor if we turn on the light of the path.  But if the problem was that there were many stains on the floor and was hard to distinguish the stains and oil spill, just turn on the light may not be effective enough.  If we could provide a physical measure, it may be more effective.  If we could separate the pedestrian's path from the dolly's path or forklift track path, we can ensure the safety of pedestrians.  Most of the time, no measure can be 100% reliable.  Then please consider a set of measures until you feel it safe and practical.  Sometimes we have to add a comment "Our short time measure is not perfect, please pay attention on safety.  We are now working on the new Safety Management System and is expected to be completed by such and such date".

  If the current Safety Management System was considered as poor, we have to design the long term strategies.  If "error on judgment" occured because the person did not have enogh knowledge, we can say the training was not enough.  We have to check the methods of safety trainings, frequescies, the confirming method of understanding level, lisence system, educational records and etc.

Design procedure of a long term strategy will follow the next steps. 

   1. Understand the current safety system. 

   2. Ideal state of the safety system.

   3. Grasp the gap between the current and ideal systems. 

   4. The methods to fill the gap. 

   5. Resource planning.

   6. Detail schedule.

  It is important that the top managements agree with the ideal state.  It can be different by the business type, size of organization, business condition, and future vision.  For a small company it is not practical to do the same as a huge company.  It is like a child wear a suit of adult.  Also when the organization is growing rapidly, we need a good plan to catch up the growth.

  Once we planned a long term strategy, we have to do it as a project.  In case of a tinny organization, the number of people to attend the project will be limited.  If the organization is large, many people must be involved.  In any case, it is important to organize the project and make progress.  The project may not make progress as scheduled.  We may have to re-schedule the project because of unknown obstacles.  People's role may be changed.  To handle all these and complete the project is the role of Project Manager.

  In such sense, the selection of the project manager is very important and the most required ability of project manager is communication skill.

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