I found this interesting video in YouTube and I gave this link below. I thought to share as there are quite a few interesting things to Learning from QMS and OHSMS perspective.
What Went Wrong ? The Causal Factors
I tried to find what was going wrong here. Quite a few things indeed were missing .
What I found first is there was no Planning for Product and service Provision. ISO 9001:2015 Clause No. 8.1 before they started the first Lift
There was no effective Hazard Identification and Risk assessment and Controls as per ISO 45001:2018 Cl No 8.1.2 before they started the first Lift
After the first Incident, they did not seem to have Performed an Incident investigation and Root cause Analysis and Did not take Corrective action ISO 9001:2015/ISO 45001:2018-Cl 10.2 .
Even if the RCA was done after the first accident, and Corrective action was taken , the actions were not effective to prevent a recurrence.
ISO 45001:2018 Cl No 10.2 c) review existing assessments of OH&S risks and other risks, as appropriate after an accident
ISO 45001:2018 Cl.No 10.2 d) determine and implement any action needed, including corrective action, in accordance with the hierarchy of controls
Competence of People ? Look at whether people were competent. ISO 45001:2018 ,7.2 Competence requires the organization to :
a) determine the necessary competence of workers that affects or can affect its OH&S performance;
b) ensure that workers are competent (including the ability to identify hazards) on the basis of appropriate education, training or experience
Also we need to see whether there was issues with Resources-The Cranes for examples. Suitable resources/Machinery and equipment
Estimated Cost of Incident:
Imagine How much those failures would have Costed them?
Car Lost: KD 5000 (small Car)
1st Crane Lost-KD 20000?
2nd Crane Lost KD 20000 ?
Labour and Other : KD 500?
Close to KD 45500? (USD 150,000)
So ISO Standards work.
We Fail it due to our own limitation or ineffective application or effective implementation. Lack of Knowledge? Behavior? Other factors?
A well established Management system Saves Lot !
A Great Training Saves Lot of Money and resources and prevent operational disruption!
Graduated in 1985 as Mechanical Engineer from Calcutta University, India . Had decades Multi-discipline experience, lucky enough to work with some of the finest organizations worldwide and working with some great people who shape my professional standing where I am standing today. I was involved in steering organizations from the top and working with my people. Had great exposure in Corporate Management and Technical exposure in Engineering, Offshore & Onshore Oil/Gas and Petrochemical sectors. Could develop expertise in Quality control and assurance in various types of organization from automotive, Heavy industry, rolling stock, paper, mining equipment, cranes. During the course of self development I became familiar with International codes like AWS, ASME, ANSI, API etc. Expertise in QMS EMS and OH&S audit, API Q1 consultation & Training. Welding, Painting Technology.