Biomedical Engineering Reference
In-Depth Information
2. The mechanics started working on the wrong cooler (so the cooler
was still functioning and under a pressure of 5 bar), because the oper-
ator forgot his papers in the car and thought he had heard PSG-45D,
which hardly differs from what the shift leader said: PSG-45E.
3. The pipe leading to the valve was blocked with dirt. This pollution
could gather and stay there because the pipe and the valve are
located on the edge of the cooler and it is more troublesome to
access that point with cleaning materials.
In this case, they held no toolbox meeting, although there was a per-
fect opportunity at the moment that the shift leader inspected the working
papers of the contractors. He could have organized a short meeting in
which he was the chairman and in which the mechanics, a representative
of the control room, and the operator were involved. They too easily
assumed that everybody knew the task by heart, and they conducted no
check on whether the people involved had the same ideas on the task
involved. Part of the cause of the problem in this case was that there was
hardly any communication between the operator in the control room and
the mechanics. If this communication had occurred, the preparation and
the actual task might have fit better. Besides that, the LMRA was done
too quickly, without the people involved really checking each other
s
answers. In a thorough LMRA, the involved parties would have taken
this possible problem into account. The mechanics were also too accept-
ing of the fact that they hadn
'
t seen the papers and had even failed to reg-
isterthatfactontheLMRApaper.
'
Case 2
If the driving instructor explains at the end of each lesson what he is
going to do during the next lesson and what kind of problems will be
encountered in that lesson, students can prepare to a certain extent (for
example, by reading a specific part of the traffic regulations).
4.1.2 The Amount of Data Involved
The amount of data varies with the complexity of the assignment. The
more specific the plans that are prepared, the more
there is
that can be scanned, and easier for the brain to gain insights, antici-
pate risk, and develop risk understanding. Sharing in-depth plans with
all participants helps to fill the database of all those involved. It makes
work safer. When projects become more complex, the amount of time
needed to scan all the material is linear related to the amount of data
“
material
”
