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The blind man who should have seen

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“By the work one knows the workman”  Jean de la Fontaine


In their book The Wills Eye Manual; Office and Emergency Room Diagnosis and Treatment of Eye Diseases Adam Gerstenblith and Michael Rabinowitz states; “Copious but gentle irrigation using saline or Ringer lactate solution for at least 30 minutes.  Tap water can be used in the absence of these solutions and may be more efficacious in inhibiting elevated intracameral pH than normal saline for alkali burns.”

I know a guy, let us call him Abe (not his real name).  He was a 45 year old Quality Manager employed in a large manufacturing company.   The Plant operators went on strike and the office workers were asked to manage the critical tasks until they could safely stop production.  Two such tasks were offloading caustic soda (for process line cleaning) from road and rail tankers.  As Quality Manager Abe wrote the offloading procedures, trained the operators in it and also did Plan Job Observations on them as part of his regular activities, so management thought he was the ideal person to take over the offloading function.

Abe got ready to off load Caustic Soda from a road tanker but missed the 1st critical step!  He never opened the top loading hatch as required to offload that particular road tanker, because the offloading procedure did not identify the different road tankers, it generalized.

Abe connected the gravity hose, off-loading began but soon stopped.  He realized he had a vacuum problem and climbed on top of the road tanker to open the loading hatch.  In doing so his full face shield irritated him and he pushed it up so it was sitting like a peak cap on his forehead.  He bent down to open the hatch and caustic splashed back and into his eyes.

How he got off the road tanker and to the eyewash bottle is still open for discussion but by the time he was spotted doing emergency eye wash procedures on himself and someone helped him, the damage was done.  On arrival at hospital they rinsed both eyes out as best they could and transferred him to an eye unit.  Soon he received the verdict; “sorry you have 10% vision remaining in your right eye and 15% vision in your left eye”.

On doing the accident investigation we opened a ‘Pandora’s box’ of errors!  Those familiar with the Swizz Cheese effect will know that it very seldom is just one error that causes such a life changing event, normally more than one safety barrier must fail (not all at once either) and in Abe’s case, many had failed over a period of time and operators adjusted to them so they became ‘normal’.

This is definitely not the opportunity to apportion blame, the damage is done. However in closing I would like you to;

(1) please review your operating procedures regularly, they need to be specific and

(2) please check your continuation procedures in the case of labour strikes etc.

Although Abe’s story is not for sale, we can help you to make sure you will not have an Abe.  Call us on 0833864633 or email us on


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