A wise and safety-conscious mechanic taught his son how to change the engine oil in the family’s two cars long before the kid knew how to drive. The purpose of this was to teach the importance of check steps. The precipitating event was a neighbor who changed the oil in his truck the night before a 1,400 mile vacation trip with his boat in tow. The neighbor had inadvertently knocked the oil pan plug off the work bench where he had set it. As he continued the job, it came time to add the oil to the new empty crankcase. He added all five quarts, cleaned up, and went in for a good night’s sleep before his trip. What he didn’t realize is all five quarts ran out of the drain hole of the oil pan into the gravel where the truck was parked.
The next morning, he started up his engine and barely got out of his driveway when the engine seized up. The wise and safety-conscious mechanic told his son about this, and then asked, “What if he had left out a jack stand? Or a wheel chock?”
Thus began the training in how to perform this task with seemingly ridiculous check steps inserted. The first step in the job was to assemble all of the tools and supplies in one place. Then count them. Then count them again, as you complete each step of the job. In the second oil change training session, the wise and safety-conscious mechanic sneakily removed one wheel chock from the assembled tools and supplies. Once his son had the side of the car raised, the wise and safety-conscious mechanic asked him if both wheel chocks were in place. The son looked a the tools and supplies, saw no wheel chocks, and said both were in place. “Just like the oil pan plug,” the father retorted, producing a wheel chock. The son should have verified there was one behind each wheel and that it was correctly in place.
The wheel chock mistake has a parallel at a Tennessee appliance plant where an electrician duly did the lockout and tagout for the motor of a large punch press as part of a repair procedure. He’d asked a junior mechanical maintenance tech to take care of the mechanical equivalent, but he did not check for himself because, as he explained later, “It’s not my area.” He did not even know what the mechanical equivalent was.
He would have been working unprotected under the ram, which wasn’t blocked to prevent it from falling on him. Clearly, his father wasn’t the wise and safety-conscious mechanic! But his supervisor stepped into that role and had that electrician start from the beginning. The supervisor had a printed copy of the repair procedure, and on that he wrote check steps as they occurred to him while he was watching the electrician (and having him do those check steps).
For jobs that you perform regularly, you should have both written and memorized check steps. For example, you’re the electrician who does maintenance on the scrap grinder. In addition to locking out and tagging out the disconnect that supplies the drive motor, you engage the auger lock so it can’t possibly turn (as it might if you inadvertently fell on it or reached down to grab a dropped tool). You know that before actually doing any work, you visually check that lock. You just always do that. Another check step is you visually check the lock to ensure it’s disengaged as soon as you are done counting your tools and putting them away. You just always do that also. It’s part of your job process. What if the scrap grinder doesn’t have an auger lock? Such was the case at a Kentucky plastics plant; that electrician always used a block of wood inserted just so.
For jobs that you do not perform regularly, take the time to visually walk through it. Observe natural places for check steps. These are places where something could go very wrong if you forget the (now) proverbial oil pan plug.
For example, you are tasked with a wiring job that puts you on the fifth floor of a five-story structure in a chemical process area of a large plant. You briefly discuss the job with the senior operator (who has command over the plant) and walk off to do it. Your natural check step is to look in the activities log before leaving the control room.
This step was skipped at a paper mill in South Carolina. On the senior operator’s desk was a written log of who was doing what and when. After two electricians with that very wiring job left without signing into the logbook, but an operator did sign into the logbook to perform work that involved releasing sulfur dioxide into the air within the building. It was a fairly open structure internally, so fumes were quickly evident five stories up. The electricians shouted down as they descended the five flights of stairs, and the operators quickly shut off the valves and engaged the emergency ventilation. This was a near-miss double fatality situation — all because neither electrician did the check step of actually looking at the activities log to see their entry. Each of them may have “thought” the other guy entered the information, but neither of them bothered to check.
The practice of using check steps has its detractors because these checks take time, and they are for silly things that nobody ever gets wrong like leaving out the drain plug.
