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Safety, Security, and Unintended Consequences

Posted 10/1/2008

"(An) example of how the best intentions can produce unexpected and unintended outcomes." 

By R. Bruce Wright, CPCU

As the poet said, sometimes "The best laid schemes o' Mice an' Men, gang aft agley." (That last bit’s how the Scots say 'often go wrong.') Here’s a modern example of how the best intentions can produce unexpected and unintended outcomes.

Ever since the events of September 11, 2001, security issues that were once low priorities to most of us have moved closer to the top of the list. Whether or not local power distribution systems offer likely targets for terrorists, most systems we visit have beefed up their site security efforts. We tend to see this as good result, regardless of the reason. Not that long ago it was typical for gates to stand open through the workday, building doors were typically unlocked, lobbies offered open access to interior offices, and, in fact, many consumers, suppliers and contractors were free to come and go without so much as a by-your-leave, much less need any approval or authorization.

Now, as we visit systems across the country, things have certainly changed. Most of the time we find lobbies secured, staff in reception and cashier functions protected by barriers, rear doors locked, and even power gates used to limit entry into the warehouse and yard areas. These steps are sensible and we generally applaud them, but in at least one case, tight security led to a concern that no one anticipated. Here’s story told to me on a recent consultation visit.

One of our member systems took thorough steps to secure access to their new, modern building. In addition to all the basics, they provided electronic locks on the exterior doors and took the extra step of investing in a timer system that automatically locked and unlocked the doors according to the timer’s program, so that no one had to set the locks at the end of the business day, or remember to unlock the main entrance when the office opened. What a great idea! By removing the human factor, they hoped to make sure that their investment in the security system was not undermined by forgetfulness or error. This is a good example of how to think through a process, identify likely problems and take preventative steps to prevent them.

Every weekday, the timer unlocked the front door in the morning and locked it in the afternoon. It kept the doors locked every weekend. Of course, authorized employees could use their key cards to gain entry whenever they needed to, so staffers who worked after hours, such as the night dispatcher, could always get in as needed. This approach worked well for some time, until the unexpected reared its head.

One night, while working alone, the night dispatcher had a medical problem. The chest pains he suffered were excruciating; he could barely use the telephone to call for help. Fortunately, he was able to dial 911 and give enough information to communicate the immediate need for an emergency squad to come aid him, before collapsing on the floor. The EMTs arrived promptly, dashed to the door and… Well, you have undoubtedly guessed it. The door was locked, they had no way to get in, and the victim was no longer mobile enough to get from the dispatch office to the door. Happily the EMTs were resourceful, well trained and properly equipped. In short order the squad gained entry, but the large plate glass window through which they entered did not survive the experience.

So, what is the solution to this problem? What would you do if this had happened at your system? Consistent with their careful and thoughtful approach to problems, these folks considered the issue, weighed alternatives, and came up with a practical, cost effective solution. Now, next to the front entrance is a prominent, well marked, emergency override key mechanism, the same type of unit that you have seen in every elevator you have ridden in. This “lock” allows all emergency workers, (first responders) to use their standard key to override the system and unlock the door. What a great fix!

The lesson here is simple, although the range of problems to consider may be complex. As we endeavor to improve our efforts -- in safety, security, or any work process -- our “improvements” may also create new and unexpected issues. Since no one person is likely to have the breadth of knowledge or facility of mind to anticipate every potential snag, it is good practice to have a group of people review your plans before putting them into practice. An “ad hoc” committee or a formal vetting review process can help you uncover and anticipate the unexpected.

I often say that while experience is the best teacher, learning from other peoples’ experiences is much less costly. If you lock the doors at your office after hours, but have situations where only one person may be in the office, you can take a lesson from this experience.