The 88th General Meeting Speaker Presentation
“Complacency Can Kill”
Dan Hegyi
The following presentation was delivered at the 88th General Meeting Monday General Session, May 6, 2019. It has been edited for content and phrasing.
INTRODUCTION: Dan Hegyi is a regional manager for Zurich North America. Mr. Hegyi has over 40 years of experience in the insurance risk engineering industry and is responsible for managing jurisdictional and machinery breakdown risk engineering services in the Midwest. He is also vice president of the Wisconsin Boiler Inspectors Association.
Mr. Hegyi’s slide presentation can be accessed here.
MR. HEGYI: We have talked a lot about codes. We have different codes, equations, materials, and repair codes, but I want to switch gears here and talk about the human element, the human element in our industry.
It's the inspector. We have the codes, but somebody has to enforce them and keep track of them. We heard a lot about the history, we heard a lot about how many lives were saved. It was really impressive to hear that, and I try to keep that in front of my people as to what they do.
To get started, complacency can take your commission. If you are a commissioned inspector, a little complacency, and your commission can be gone.
It can take your career. Like all inspectors, without our commission, what are we?
It can take you to court. I think Joel said that we have over 1.2 million attorneys out there. And if we make mistakes, if we are complacent, if we don't follow the code and procedures, we could end up in court.
It can take your life – not only by a boiler or pressure vessel exploding, but if you don't follow the proper procedures while you are doing the inspections. What we do is dangerous. It's a physical job.
And complacency can kill.
Today we are going to talk about what complacency is, what are complacency and risk behaviors, what might cause complacency, the potential impact on the quality of our inspections, and identifying and controlling it.
So let's first define it. Complacency is satisfaction, especially when accompanied by unawareness of actual dangers or deficiencies.
Now, I need your imagination here because I'm going to demonstrate a little complacency. Have any of you ever seen a race? I'm a long-distance runner; right? Let's say I'm in the lead of this long-distance race. I see up there twenty or thirty yards ahead the finish line, and I know that the guy in second place, he's about twenty yards behind me. In my mind, I know I've won this race. I'm going to put my arms up, and I'm happy as can be. In doing so I break my stride. I get up to the finish line, and I'm just about to hit it, and four inches in front of me the other guy comes. I was too comfortable, and I was convinced that I was going to win this race. I took my mind off it, and I lost.
Another one might be, we all drive down the same streets, maybe going to work hundreds of times. We get used to it. We know where the corners are. Sometimes we think we can take our minds off the driving because we know how to drive. But someday maybe somebody in front of you stops, a deer runs in front of you. So we are getting too comfortable with it. We have to keep on top of these things.
Risk. Risk is exposing yourself to danger or hazards.
So I used to ride motocross. And what I did back in the '70s was nothing like what they do today. I watch what they do in these extreme sports; I see guys with motorcycles doing flips, doing a superman, where they are basically forty feet vertical and probably traveling seventy feet, they let the bike go, fly over it and then grab it again, hopefully. We see that and think how cool is that. We don't see all the times the helicopter takes off from the practice area where they are doing it.
People take risks. I am not a huge risk-taker. I know people that are. I knew one guy who wanted to see how close he could get to a moose, just to get too close to it. I wouldn't do it, but other people would. That's risk. When you take complacency and risk and put them together, you are going to find there to be danger.
Distracted driving. How many people here have been on the highway and saw the car in front of you either weaving a little bit, or maybe going twenty miles under the speed limit, only to see they are on the phone? Twenty-five percent of all motor vehicle fatalities are caused by distracted driving. A huge number.
Selfies and texting. People are dying to get the perfect selfie. Take the Grand Canyon, for example. People are falling off the edge. They are not aware. They are too comfortable with what they are doing. They are not paying attention to where they are, and they either fall off a cliff, step in front of a bus, or something like that. There have been 259 incidents like that according to what I saw on the web. I imagine it's a lot higher than that now.
Job-related accidents. In 2017, there were over five thousand fatalities – electrocutions, falls, et cetera. Complacency is a factor. When you do something over and over again, you get complacent. If you work as an electrician, you are going to open this panel. Well, you didn't check the breaker. You didn't make sure it was locked out. That's on the other side of the plant. Maybe you are in a hurry, but you can be electrocuted.
Boiler and pressure vessel inspections, this is what we do. As you are approaching an inspection, you can become complacent; right? That's what we are talking about, the human element. Sometimes you assume there are no changes since the last inspection. You inspect this high-pressure boiler every year. Maybe you know who did it before. It looks the same. There are probably no changes. That safety valve up there looks kind of old. You bet it's the same one.
Sometimes you assume the data on file is correct. You get that data report or report from JO. You assume the safety valve settings and such are right. You assume the stampings are correct. Maybe they aren’t.
You're assuming the owner will take care of any problems you find. Are you going to trust that person?
Could it happen again? We talked history, and there was one incident, and I was around when this happened. That was Star Elementary.
And this one, every time I talk about it, it really affects me; it really brings shivers to me. Because the National Board had put material out on it, and it was a long time ago, but we had an incident with a water heater. It's just a water heater; right? It's not a big boiler. It's not a huge power boiler.
I often say what would you rather sleep next to, a utility power boiler or a dry cleaner boiler? So it's not the size that matters.
But anyway, six children and one teacher were killed and 34 were injured. And seeing the pictures from that incident was just horrific. I mean, it really, really affected me.
The investigation revealed that complacency was a factor. The water heater had a gas valve, which had been replaced with a used gas valve that they found on the shelf. The safety valve had the temperature probe cut off. Because of the way it was positioned in there, they couldn't get it in.
Rather than take the steps to do it right, they were complacent. They were in a hurry or whatever, but this is what resulted. And that was just a water heater.
So let's talk a little bit about factors that can lead to complacency.
Past experience.
Have you ever either yourself or had somebody say "I have never seen that happen"? Every time I take my car into the dealer for a problem, I hear that: "Well, I have never seen that happen." I always tell them as long as the doctor doesn't say that, I'm okay.
But I have seen that, and that can erode fear in people. Unless somebody has seen something happen or they're made aware of it either by a presentation, a movie, or a news report, they are unaware of it, or they don't think it's that important.
Repetition.
Here is one. How many pressure vessels do you think I’ve inspected over forty years? Thousands. Boilers, the same type of vessel, the same type of boiler, over and over and over again. In some plants, I've inspected hundreds over a few-day period.
Say you have done thirty inspections today, and never found any that have been a problem. And then you have that one that's going to be hard to get to, maybe that one I can just write off. That is the ultimate no-no. I don't care if there is one or a hundred objects. If you don't inspect it, if you just skip over one, that's the same as a drive-by inspection as we used to call them.
The more inspections you do, the more complacent you can get, especially if there isn’t an incident.
Time pressure/production.
We are in business; right? I work in the insurance industry. We have goals. We have production goals. Sometimes that can get in the way. You put it in your mind I have to get so many done.
We have to remind ourselves that although it's our job, our business, et cetera, we are also public safety. That's the ultimate thing. We shouldn't be rushed through it. Don't overschedule yourself, because you are just going to try to rush through it.
Unexpected delays.
How many people here have walked into the boiler room ready to do that internal inspection, and they say, “Well, we just started draining it.” Or “we are not ready for you,” or “it's not properly prepared.”
I have done press inspections. I open the vault door, and it's basically all hydraulic oil down there. They have to pump it out.
Maybe it’s the weather. We drive a lot. Maybe we are stuck in a snowstorm. So all of those things can be pressures that could lead you to be complacent, to rush through.
Maybe it’s the location of objects. Some are mounted high. I have been in steel mills, and I ask where the vessel is. And they point way up in the girders. How do I get to that? We have to work through those things. It takes time.
Obstructed.
The object may be back in the corner, and we have all of this production material in front of it. So what do we do? We have to move that material. Just for that one object, maybe we have to come back another day, but we have to do it.
And the operating room. I have done a lot of hospitals. I can't always get in, like for sterilizers. They are doing procedures; I don't want to go in there. So, we can't always get to them during certain times.
Some require lifts or other special things. Maybe we are not qualified to use a lift, so we have to rely on other people to go with us.
Inspection environments may be unpleasant. Everywhere we go is 70 degrees and just clear air; right? Not in my world. Unpleasant environments could be hot, cold, damp, nasty.
Anybody been in a rendering plant? Were you allowed to go back home after being in a rendering plant? No, we had a little burn bin out there for our clothes because we didn't want to take them in the house. But rendering plants have Dupps cookers, and they are dangerous, so we have to take our time there. As unpleasant as it is, we have to go in and make sure everything is safe.
Some things are in hazardous areas as well. You might need protective gear, et cetera.
And personal life issues.
We are talking about people. That's what we are, the human element. I'm like everybody else. I've had great days. I've had bad days. Things are on our minds. So we have to be aware of that and try to work through it.
Tenure and complacency.
Seniority doesn't really guarantee quality. I have been in this business for forty years. Does that mean I do the very best inspection, better than the person with two, three years' experience? I bring a lot to it, but am I going to do the best inspection? Maybe.
I was talking to Tony Oda, the National Board member in Washington, and he has an audit program from his jurisdiction that looks at objects after they have been inspected. And in our discussion, he let me know that a majority of the missed violations were from people that he called veteran inspectors.
Now, as I look around the room, there is a lot of gray; right? I'm a member of that club, so maybe there are a lot of veteran inspectors.
But it’s just counter-intuitive. You would think that people that have been doing it for a long time would be on top of everything, would be very thorough. But it's not always the case.
So as we are going on -- and this is especially for people that have been doing it a lot -- we have to approach all the inspections as if it was the first inspection. That's my advice. That's how I try to do it, and I've tried to do it all along.
And we have to keep current with technology.
When I started, a cast iron boiler or a hot water boiler were nothing like now. You walk in there, and you say, “Where is the boiler?” Oh, it looks like the podium here now.
Where is the low-water cutoff? Well, you have to get out the manual and look. We have to keep up with that. Things change.
Let's talk about signs of complacency.
I'm not trying to turn everybody into an industrial psychologist. I’m certainly not one. But we are just trying to be aware of this, so here are a few quick notes.
If you have people on your team that don't engage in discussions or ask questions, just kind of get through the day, they don't take on any challenges, they only do the minimum required, maybe take shortcuts, in our industry that is very dangerous.
Somebody who doesn't submit violations, that's something to really become aware of. I have been out there, and there are problems. The same boiler or pressure vessel can have problems, but you get a feel for how many violations you'd find for the number of inspections you perform. So if somebody is not submitting any violations, it's something to look at.
They also don't refer to references or codes.
And the big one is: “I have been doing this for many years. I don't need training.” I don't know if you guys have heard that. I unfortunately did years ago, and it's just a big red flag.
So how do we keep complacency in check? A couple suggestions.
If you are a manager, you have a team. Reinforce the purpose and impact of what you do.
We saw a lot of things earlier today with accidents. We are all familiar with Star Elementary and Loy-Lange. We have to keep that in front of the people that are out in the field doing these numerous inspections so they know that they save lives, they save jobs, they save companies, and can save communities. So we just have to keep that in front, it is an important job.
Recognition. When somebody does something well, we have to reward them.
We all like getting patted on the back; right? It's nice. When somebody does something well, it not only rewards that person, but the other person is going to say, “Oh, wow, I should keep track of that. Maybe I'll get a reward.”
Urgency. When accidents happen, we want to make sure that everybody knows about it. We want to go into detail. We want to dig into it, find out what the problem is. When you see an accident, it will help reinforce just how important our job is.
We don't see a lot of boiler explosions; right? They are there, but there aren't a lot. And I have heard people say, “Well, why do you guys inspect? They don't blow up often.”
You say, “They don't blow up often because we inspect.”
The more you know, the more you keep that in your mind, and the people in the field, if they see that picture, it will help them.
Challenge staff with new assignments.
We talked about doing the same thing. You don't want it to be monotonous. Give them something different to do. Maybe training. Maybe, hey, I want you to study up on this and train the rest of the group. Just keep things fresh.
Avoid routines.
It’s not always possible. If it is this person's job to inspect the objects in this territory, you can't always move it up a lot. Maybe we can do some things to switch it up for him.
Reset repetition.
We talked about repetition and doing thousands of inspections. Well, we can reset that clock, if you will, or that clicker, by either showing those accidents or maybe reviewing violations, the reasons why we inspect. You need something that will take them off that white-line syndrome – where you’re out on the highway, and you keep seeing the white line in the middle, and you’re going on and on and on. You've got to have something to distract and get you to come back in.
Communication.
In my team, we have remote workers. They don't come into an office. Our communication is by telephone. More and more it's e-mail or texting. But remember that we are all human, and we all like to be around other people. And that's why when I go into the office, I love being there. But remember to communicate, especially with your team members.
At Zurich, we have weekly huddles. I do it every Monday morning from 8:00 to 8:30, just a quick huddle with my team. We talk about what's going on, what's coming up, if they have any questions, problems. We get a lot done, a lot of communication. It just brings the team together, so it's really important.
Mentoring. Team up staff to learn from each other.
We have some really seasoned people out there with a lot of experience, and we've got some young people that don't have that experience. We have to get them together. When somebody older and some of our younger folks get together, the amount of information and learning from one to the other on the technical end is great. I have seen it happen.
But then the younger generation helps just as much with how to use the computer or may offer different ways of looking at things. There is always a different way of looking at everything. That's where they come in.
Training, training, training. Huge, huge, huge, huge, in keeping complacency down.
Back to the basics. I talked about the older generation, and we have to sometimes take a step back and say, “I have to hit everything here – technical updates, code reviews, procedures.”
The NBIC is just fantastic. That is the best document for inspection and training. The National Board offers training. Attend jurisdiction and association meetings, like the WBIA. As much training as we can get is fantastic. It doesn't always have to be a two-day item. It can be a ten-, fifteen-minute thing, so we can incorporate that in our everyday schedules.
Tools. Inspection guides.
Sometimes it's a good idea to have a piece of paper with just some notes to say make sure I check this, this, this, this. Not a check sheet, because check sheets just become something to check off. But just a guideline to help remind us once in a while – maybe we haven't looked at a certain kind of boiler for a while, and there are so many different ones out there.
Quality reviews.
Have jurisdictional audit programs like what Tony is doing in Washington. All these things really help. Managers of the various companies, get out with your people and review their reports.
The pilot's mind-set.
Most of us flew here today, yesterday or the day before. When I board a plane, I will often look in and see the pilot and co-pilot, and they have a little book. They are flicking all the buttons and setting all the dials. They are going through a preflight checklist. These are routine activities that they do before every flight.
Some of these people are very highly qualified pilots. Some have a military background. They have been doing this for years. Every day they are doing several flights.
But they know that failure to complete it and failure not to have every setting just right could result in a really horrific, catastrophic event. That's why they go through that procedure. I think that's why we need to instill that same mind-set in inspectors.
And we need to inspect every vessel as if it's the first time we have seen it and don't have any paper. Walk in with a blank sheet.
The first thing I always do is say, “Let's open up, I want to see the code stamping.” And I can't tell you – I wish I had a nickel every time someone says, “Oh, no one has ever asked to see that before.” I will do it even if I did the boiler last year. I do the same thing. I get into that routine.
Complacency, we need to control it. And if we do, we will keep our commissions, we will keep our careers, keep out of court, keep our lives, and keep our communities safe.
Thank you.