Paul Grant, Energy Sector Manager at HSE’s Health and Safety Laboratory, looks at what can go wrong when cumulative tiny changes go unnoticed or become accepted as ‘normal’…
I’ve started cycling to work and as a result I have been using my car less and less.
For the past few weeks, the car has struggled starting, eventually spluttering into life after a lengthy and painful grumble. I put this down to the Buxton climate and the fact that I wasn’t using it as frequently.
And then the inevitable happened.
It wouldn’t start on the very morning I needed it most. And it was blocking the other car that I could have used. ‘Middle Aged Man in Lycra’ is not an acceptable look for an important meeting but – hey! – I survived.
When I got a new battery, the mechanic’s observation was “you really should have known this was going to happen; batteries these days should be more than capable of not being used for long periods of time and still be fine… did you not notice it was taking longer and longer to start”?
Well, I think I did, but I just got used to the car being a “difficult starter”…
… but as it turned out, I’d been a victim of ‘creeping change’. This phenomenon has been identified as a contributory factor in many major accidents, including the catastrophic explosion of an RAF Nimrod fighter plane over Afghanistan in 2006, the disintegration of the Space Shuttle Columbia upon re-entry in 2003 and the King’s Cross Underground station fire in 1987.
Creeping change is the accumulation of small changes which often go unnoticed, but which can ultimately add up to a significant change. Because, by their nature, they are gradual, unseen and not planned, creeping changes can be difficult to monitor.
Clearly, the consequence of not identifying and managing such creeping changes is considerably greater in high hazard industries than it is for a budding Peak District-based Bradley Wiggins.
Creeping changes are a safety risk that has only relatively recently been highlighted as a significant issue. The Health and Safety Executive’s (HSE) Key Programme 4 (KP4) on Ageing and Life Extension in the offshore oil and gas industry identified ‘creeping changes’ as a challenge to safety offshore and found that there were insufficient systems to deal with this risk. One of the recommendations from KP4 was to use audits to identify and manage creeping change.
As a result, HSE’s Health and Safety Laboratory has developed a creeping change hazard identification technique (CCHAZID). This helps to detect creeping changes and can be used anywhere where there’s a reliance on ageing equipment that could be subject to many or compound changes (so it’s useful outside high-hazard industries too).
CCHAZID uses a similar approach to that used in a conventional HAZID study, in that keywords are used with a team of people from a wide range of appropriate disciplines (including operations and maintenance personnel) to trigger discussions and brainstorm any potential issues. These issues can then be discussed by the specialists to resolve the problem, or be subject to follow up actions once the HAZID is finished.
Based on the report of a successful pilot study of the technique at a gas fired power station, an onshore gas terminal and an offshore gas storage facility it’s anticipated that industry guidance will soon be made available.
In the meantime, the report’s lead author, Richard Goff, will be presenting a more in-depth analysis of the study at this year’s Hazards conference on Friday 12th May. HSL is also sharing the methodology on our updated training course: “Managing Ageing Assets”.
For now, though, you’ll be pleased to know that my car is starting perfectly every time.
Mind you, the exhaust is rattling a bit…
Have any questions or thoughts about creeping change? Share them with us by leaving your comment below.