“I did everything right.  I don’t understand why it happened.”— Aleksandr Akimov, Chernobyl engineer

You’ve probably heard of the new HBO miniseries, Chernobyl.  The show is a fairly accurate retelling of the events preceding and immediately follow the nuclear disaster that occurred in Pripyat, Ukraine on April 26, 1986.  Like any dramatized television production, it takes some liberties, but mostly remains true to the details surrounding the actual explosion of the nuclear core.

The show refers to Akimov’s often-repeated statement, “I did everything right. I don’t understand why it happened.”  It’s a phrase the Chernobyl engineered repeated as long as he could talk, until his death on May 11, 1986.  The fact is that you can do everything right and an incident can still occur.

What Causes Incidents?

In a previous blog, “It Won’t Happen to Me”: Why We Do Things We Know Are Unsafe, I touched on W.H. Heinrich’s idea that incidents are the result of two things: unsafe behaviors and unsafe conditions.

Companies spend a lot of time and money improving safety. Often, though, they reach a plateau where some incidents appear to be resistant to all efforts to prevent them.  This is because approaches to safety often only address unsafe conditions.  Recognizing the existence of unsafe behaviors is equally important, however, because any successful approach to safety must address both.

What Are Unsafe Conditions?

An unsafe condition is exactly that – a condition in the workplace that is likely to cause injury.  Examples of unsafe conditions in an industrial setting include:

  • Defective equipment or tools
  • Inadequate guards
  • Hazardous air conditions
  • Overly congested areas
  • Inadequate warning systems
  • Fire and explosion hazards
  • Poor housekeeping
  • Lack of adequate PPE
  • Exposed live wires

Unsafe conditions exist all around us, at work and away from work.  Snow and ice storms create unsafe driving conditions, lightning storms create unsafe outdoor conditions, and harsh chemicals in enclosed spaces create unsafe breathing conditions.  Most of the time we safely negotiate the hazards by behaving safely; we drive slower in the snow and ice, we stay indoors during lightning storms, and we assure good ventilation when we are using harsh chemicals.

What is Unsafe Behavior?

Unsafe behaviors are more difficult to recognize and correct because they involved human factors.  An unsafe behavior is any act or behavior that deviates from a generally recognized safe way or specified method of doing a job and which increases the probabilities of an accident.  Examples of unsafe behaviors in an industrial setting include:

  • Lack of/improper use of PPE
  • Bypass or removal of safety devices
  • Knowingly using defective equipment
  • Operating equipment without proper qualification or authorization
  • Walking beneath a suspended load
  • Taking shortcuts
  • Working at a pace not intended by equipment manufacturers

Many are quick to blame unsafe behaviors on untrained or inexperienced workers.  However, behavior isn’t directly related to skill level.  In fact, the more skilled and seasoned an employee is, the more likely they are to engage in unsafe behavior because the behavior has been reinforced over time. If an employee has never been hurt while doing their job in an unsafe manner, it’s more difficult to convince them that the consequences are real.

When Unsafe Conditions Meet Unsafe Behaviors

Unsafe conditions and unsafe behaviors can exist either independently or concurrently. An incident can be the result of one or the other, or it can be the result of a combination of the two.  Unsafe behaviors, more than unsafe conditions, are responsible for the majority of occupational injuries and incidents.  Approximately 80-95% of all incidents are triggered by unsafe behavior.   Unsafe behaviors also make unsafe conditions worse.  When snow and ice storms create unsafe driving conditions, these unsafe conditions are even more dangerous when drivers go too fast or do not leave safe stopping distances.  The risk of an incident increases when multiple factors are at play, rather than the unsafe condition alone.  When an unsafe condition exists, we must further alter our behavior to negotiate it safely.

Unsafe Conditions + Unsafe Behaviors = Chernobyl

The Chernobyl incident is a prime example of what happens when unsafe conditions and unsafe behaviors collide.  The role of the power plant workers in the explosion is well known.  They began a safety test with the power in the reactor far too low. In an attempt to raise the power level, they left far too few rods in the core to control the nuclear reaction. This was all at the insistence of Anatoly Dyatlov, the supervisor during the safety test. This was the unsafe behavior.

There was a flaw in the reactor design – the unsafe condition – that the unsafe behavior revealed.  When the reaction began to run out of control, staff tripped the emergency shut down, sending all of the control rods into the reactor to regain control and stop the reaction.  Instead, due to poor reactor design, the graphite-tipped control rods plunged into coolant water, briefly increasing the fission in the core.  The reactor created more steam than it could vent. The resulting explosion and its effects will be a reminder of the consequences of combining unsafe behavior and unsafe conditions for thousands of years to come.

Raise the Alarm

Due to the secrecy and information control of Soviet society, the engineers at Chernobyl were unaware of the unsafe condition that ultimately resulted in the loss of thousands of lives.  In a more open society, it should be much more difficult to conceal unsafe conditions or for them to go unrecognized.  When you notice something that doesn’t seem safe, speak up!  Whether it’s a condition or a behavior, don’t be afraid to raise the alarm, your concern deserves a response. If it’s not unsafe, it will still be worth the time thinking through the safety implications. If it is unsafe?  You might anger a co-worker for a short time, but you may also be saving the lives of thousands.