Jurisdictional Inspection Integrity and Ethics
The following presentation was delivered at the 80th General Meeting Monday afternoon session, May 9th, by Michael Zdinak. It has been edited for content and phrasing. A slide presentation of his address can be accessed here.
Michael Zdinak is assistant vice president and senior machinery breakdown territory technical specialist for Chubb Insurance’s Loss Control Services. He is responsible for overseeing operations of the machinery breakdown risk engineers, including jurisdictional inspection, for an area covering Ohio to California and Canada. His duties include working with the jurisdictional authorities to ensure all jurisdictional inspections are being completed in accordance with each jurisdiction’s laws and regulations. Mr. Zdinak is a National Board commissioned inspector and holds commissions in a number of jurisdictions. He is also a member of the National Fire Protection Association (NFPA), ASME, and The Association of Iron and Steel Engineers. He also serves as a representative for Chubb on the American Insurance Association Boiler Committee.
Mr. Zdinak: Greetings. Today I want to talk about service. Every National Board jurisdictional commissioned inspector has performed and is performing jurisdictional inspections. The information we are providing in this presentation is based on observations I have had and discussions with commissioned inspectors who work for authorized inspection agencies in the jurisdictions.
It's not intended to be a methodology that will work for everyone, or a cure-all. It's intended to present food for thought. The actions you take regarding the subject should be governed by the directions and requirements of your individual organizations.
Why We Perform Jurisdictional Inspections
We perform jurisdictional inspections for public safety. We want to prevent accidents, injuries, and specifically, loss of life. We also do them because in some cases it's mandated by the jurisdictional laws. We want to identify violations, and we want to provide a service. Now, service in this case for us probably refers more to insurance companies and third-party inspection agencies, but of course I believe jurisdictions and the jurisdictional inspectors are also providing a service to people out there.
A Little Bit of History
The National Board started tracking incidents in 1992 and posted the annual incident reports in the National Board BULLETIN. The incident reports track accidents, injuries and deaths. The reports track those incidents for specific objects and specific items for each object. The incident reports were discontinued in 2003. This slide shows you some of the things that were tracked.
In 2001 the National Board also started tracking violations. This report is also in the BULLETIN annually. The report tracks violations reported during jurisdictional inspections. The items tracked are broader than what was tracked in incident reports. Incident reports and violation reports are populated by data received from the jurisdictions and authorized inspection agencies. However, not all jurisdictions and AIAs submit data.
Violation reports are still being published each year. Incident reports track the causes of accidents and the resulting injuries and deaths. The violation reports track the specific problems that may or may not lead to an accident. If we look at the twelve years of incident reports, we see the results of the tracking.
Incident Reports versus Violation Reports
Here we see that in accidents, there were 26,490 reported in the twelve years, and that's about 2,208 a year. Injuries were 832, or about 69 per year. And deaths were twelve a year, which is twelve too many. It may be fair to say violations are not handled properly or not complied with. It may be fair to say violations that are not handled properly and not complied with could be the cause of an accident that could lead to injury or death.
For the years 2001 to 2003, incident reports and violation reports were both developed. If we compare these side by side, we derive the number of violations it takes to potentially cause an accident. This is not an exact science since we do not know if or which violations may or may not have caused the accidents reported during those years. However, having both reports does give us some sense of effectiveness of violations to accidents.
Integrity and Ethics
So what does this mean? Let’s define integrity and ethics. We need to look at the meaning of these words to ensure we apply them correctly as they pertain to jurisdictional inspections. Integrity is a firm adherence to a code of especially moral or artistic values in an unimpaired condition; the quality or state of being complete or undivided. When performing jurisdictional inspections, we are representing the organizations we work for and the jurisdiction. Our organization and the jurisdiction's character are judged by how we handle ourselves. Our credibility as jurisdictional inspectors is also judged. In the face of situations where violations have to be made and explained, our ability to handle them in a professional manner and not back down is also a measure of our integrity.
But what about ethics? An ethic is a theory or system of moral values. Our ethic is based on the ASME code, the National Board Inspection Code (NBIC), and the laws and regulations of the various jurisdictions. Ethics are the rules or standards governing the conduct of a person or a member of a profession. The contents of the ASME code, National Board Inspection Code, and the jurisdictional laws and regulations state our ethics.
Ethical is another word we need to review. It means being in accordance with the rules or standards for right conduct or practice, especially the standards of a profession, which we are all professionals. Integrity and ethics go hand in hand. You can't have integrity in the performance of a jurisdictional inspection if you don't have the ethics and the ethical behavior to back it up.
Your First Jurisdictional Inspection
Let's take a step back in time and look at how we become National Board certified inspectors. We start by taking a National Board exam. To prepare for the exam, we study the ASME code, the NBIC, and various jurisdictional laws and regulations. These are the ethics of our profession. We reinforce with the National Board test preparation class, practice exams, and doing on-the-job training. How many remember taking your National Board exam? I know I do. It was December 12th, 1979. I took it in Harrisburg, Pennsylvania. I found out I passed the exam a couple of weeks later, and I received my Pennsylvania commission in January. And I was ready to conquer the world; there wasn't anything I couldn't do.
So you go out to do your first inspections, and you are proud, enthusiastic, conscientious, and frightened at the same time. You just took an exam, you have been through training, you have been out with a lot of people, and you feel very confident when you are with somebody. But now you’re out on your own. It's all up to you. You’ve got to perform your first inspection as a commissioned inspector. Your integrity and ethical behavior at this point is probably the highest it will ever be in your career.
Inspection Tools of the Past
The reason we look into the past is it will give us insight into some of the behaviors that we are dealing with today. So when we did inspections thirty years ago, we had certain tools we used. We had coveralls, a boiler hammer, a clipboard and flashlight, screw driver, state inspection forms. We were doing a lot of the stuff by hand. We even had ASME code books, the NBIC, and some of us had jurisdictional regulations for the jurisdictions we were inspecting at that time. And if we were performing internal inspections, we changed, crawled into the boiler, and went to work.
We looked at every valve, appurtenance, and everything we were supposed to. We walked around the boiler; we made notes, usually with a person from the plant accompanying us. When we were finished, we sat down with the person in authority and talked about what we found. If we found violations, we explained how those violations were going to be taken care of, and how we were going to follow up on those violations to make sure we could submit a report to the jurisdiction that was accurate and stated the equipment was safe to operate.
There are always outside influences affecting what we do. In the early days we wanted to be good representatives of our companies; of the jurisdiction. We wanted to ensure public safety. Public safety was one of the primary reasons we were out there. Back then we would be going in, and people would have their equipment prepared for inspection. They knew you were coming, and they knew what they had to do to have it ready for inspection, and 99 out of 100 times you could go to work. We had sufficient time to complete a thorough inspection and to build a relationship with those people. But even then, as today, we had other duties outside of jurisdictional inspections we were responsible for as well.
If you worked for an AIA, you did different things. You did surveys, but you could also be doing accident investigations, or many other different things. Your whole day is not necessarily – or your whole career is not based on just doing jurisdictional inspections.
Jurisdictional Inspections Today
So what about today? Today we still go out to inspect. We are proud. We are enthusiastic. We are conscientious and we are confident, at least we should be. But we have different tools. Let's compare. We still have coveralls, clipboards, flashlights, and mirrors, but there is now confined space equipment; lock-out tag-out equipment and borescopes and computers and tablet computers.
It's really changed because technology has taken off, and we have a number of different things we have to do. Inspections today are not as simple as walking in and everything is ready and we perform the inspection. Because what we find is that a lot of times we go in and the boiler is not ready and the person didn't prepare it properly. Maybe they didn't even know how to prepare it properly. So that takes extra time. Now we have to do the lock-out tag-out, and that is extra time. We have to do the confined space, because we can't break the plane of these spaces unless we have done the testing. So these are all taking more time than we did before, but it's made us safer. It wasn't done to make it harder for us to do an inspection. It was done and mandated by federal law because we had accidents and we had incidents and we had deaths, and we found out ways to take care of that, and that's what brought these things about.
The thing I didn't mention was the NBIC. Today the NBIC is in three sections. Section 1 is installation, Section 2 is inspection, and Section 3 is repairs and alterations. We are going to talk more about the inspection section, Section 2, than anything on this topic. It's available to us in a hard copy if we care to purchase it. It’s available to us electronically – we can buy it and have it downloaded onto computers and different ways people can look at it; and you can buy it through a subscription service called IHS.
The inspection section has a multitude of information. There is technical information. There are inspection requirements. We can go to the National Board website and look in a section for commissioned inspectors, and there is a subsection called Inspection Guidelines and Topics of Interest. In there they have specifically laid out some things that we see on a regular basis: Information about air tanks, fire-tubed boilers, operating controls and appurtenances, safety relief valves. In there it gives a little bit of history, gives technical information, and it states what we as inspectors should be looking for when we go out to do inspections.
And as I said, these same things are available today to our clients. These are just some pictures of different things that we look at when we do an inspection.
But today we still have outside influences, just like we did thirty years ago. We still want to be good representatives of our company. We still want to be good representatives of the jurisdiction. We want to ensure public safety. But what we are finding out is sometimes we go in there and the equipment is not prepared. Why is that? My opinion is that the people that we are dealing with today don't have the same knowledge of the equipment as they did twenty or thirty years ago. It takes longer to prepare for the inspection because of that. You still have other duties outside the jurisdictional inspections. For some, the authorized inspection agencies, third-party inspection agencies, and I think even for the jurisdictions, the duties of the men and women that are doing the day-to-day operations are enhanced.
There is more to do than there was twenty or thirty years ago. There is more work and less time to complete it. We have advanced to a spot because of our technology that we believe that we can get more done and be more efficient and effective. I think we can, but there are times now that we are outstretching our resources when it comes to getting a good thorough inspection done versus the time. You don't feel you have sufficient time to do the inspection, and you can't build a relationship, you are in and you are out. I have a thing I talk to a number of inspectors about that I call backdoor inspectors versus front door inspectors. My opinion is and some of my observations are we have a lot of backdoor inspectors. A backdoor inspector is the guy that knows where he has to go. As he's going down the street, he's looking for a stack, and when he sees that stack, he pulls into that parking lot, and he walks in the back door of the boiler room and he does his inspection. There is a chance that the operator or someone in charge will be there, but today there is a chance that someone isn't there, because not everything is manned 24-7, et cetera. So he or she goes in and they do their inspection. When they are done, they talk to the persons there, and they may have some violations or recommendations they want to give them. When they are done, they walk out, they get into their car, and they go to the next place and look for the next stack. That's the backdoor inspector.
I think we need to be front door inspectors. The front door inspector is the person that goes in and talks to someone in authority to make sure that they know that they have been there. And it's especially important if you find violations or some kind of recommendation, especially if they are safety-oriented, that you get to the person in authority. The reason being is if you talk to the operator or someone in the plant and you say to them, “These are the things I found, please tell your boss I will be sending you a letter of recommendation,” there is a chance that he or she may give them that information, and there is a chance that they won't. And if they don't, the next time you hear about it is when someone very angry calls you and wants to know what this is all about. So making sure you get to the person in authority that can effect this is a very, very important part of doing a thorough inspection.
The other thing that influences today is some people just aren't comfortable with the new technologies. I am not one of those; I am very comfortable with the new technologies and using the computers and the electronic systems and the laptops and tablets and everything we have. But the fact of the matter is we have some that aren't. The other fact is that these are not going away. They are here, they are here to stay, and it's a behavioral change that we need to address with those that don't want to embrace that. And the key is to embrace it ourselves and lead by the example.
Technology is here. It's not going away. Technology affects everything we look at. Look at the technology of boilers and pressure vessels and everything we look at today. Think about a boiler that you may have looked at, like I did, back in 1980 compared to that same one today. The controls are different. We still have some stuff that's basic, but there are a lot of things that have gone electronic, computer controls. We see this every day. We need to embrace that.
Negative Results of Influences
One negative result of influences is complacency. We know there is complacency out there. People take shortcuts: not making people open low-water cutoffs when they should (or other appurtenances), saying, “Oh, well. Okay. You have got that violation; I know you are going to take care of it. I don't need to come back.”
Well, yes, you do. If that's what it requires, you need to go back. If it's a violation, you need to report it. Even if the violation is repaired while you are on site, it's important to make those reports to the individual jurisdictions. The reason being is if we know about those violations, we will have a better understanding of what's going on out there and what we need to address.
Another negative result is not following inspection requirements. Again, we have many inspection requirements available to us through the NBIC. We have them available through a number of ASME code books and in other places, but we are not following them. We take shortcuts. We are not doing the inspections we should. We have borescopes today allowing us today to look at places we couldn't look at before with just an inspection mirror and a flashlight. If we have such technology and it's available to us, we should be using it.
Another negative result: Conducting inspections when there is not anyone else present. It’s the back door versus front door issue I mentioned. We can't do that. I think more people probably get themselves in trouble through this practice. Especially if they reported a violation or a recommendation and the client calls back and says, “He wasn't here. I don't know what you are talking about,” when the inspector was there and did the inspection when no one else was present. As far as anybody else is concerned, he or she probably wasn't there.
Next is compromised safety. Don't compromise safety. That's what we are doing when we don't do our inspections the way we should. We are compromising the safety of the equipment, we are compromising the safety of the property, but most of all we are compromising the safety of the individuals.
Falsifying reports is another. Whether we like it or not, it's happened, and it happens today. People are doing drive-by inspections, and sooner or later they get caught. And when they do, that's it, you know. But there are people out there who falsify inspections, and they use these outside influences and say things such as, “I had so much work to do, I didn't have time,” or, “My computer crashed.”
Missing violations is another negative result of influences. Again, as I said, people aren't using the NBIC and they are missing violations; they are not reporting them. Or if they see them and they are fixed, they are still not reporting them and say the violation was repaired at the time of inspection. This creates a higher potential for incidents.
How Can We Help?
So how can we help? How can all of us make this better? Well, if there is more work than one person can do properly, then we need to look at that. Are we really overworking our resources? Are we outselling our resources? Are we asking people to do too much in too little time? Are we saying, “Okay, based on our model, et cetera, et cetera, you have twenty-five, thirty minutes in each place because this is a cast iron boiler and that's a fire-tube boiler”?
We are making assumptions that an inspector will go in and look at a boiler ready for inspection with no problems. But what if it's not? We need to make sure we are not outselling our resources; that inspectors are able go and do the inspection required by the jurisdiction and by the laws and regulations of that jurisdiction.
Does the person need technology training? We talked about it. Technology is here and it's not going away. We need to identify the people who are struggling with technology and find ways to help them. I am a believer there isn't anybody I can't teach to use technology, at least enough to be able to report inspections if that's what they need to do. Maybe I am naive, but I believe most of these things are behavioral changes, and we are talking about people and being able to deal with them.
We can help through annual inspection code of conduct training. One thing we have decided to do in our company is develop an annual code of conduct training. Just like most companies have code of conduct training for their professionals, we are going to do it for jurisdictions. We are putting together a presentation and say annually, every one of our commissioned inspectors has to take this course online. We are going to use technology and we are going to be able to identify those who have completed it, and ensure that every year they are getting a review of what is expected of them.
Next are audits. Audits are required by our quality control manuals. If you look at NB-369, one of the pieces says we should be doing audits. Are we doing audits? We need to. If we are supervisors or managers, we need to periodically be out there to look and see if our inspectors are completing the inspections the way they are supposed to. Are they following the minimum standards? Are they looking at all of the appurtenances and having them opened and prepared the way they should be? If they are not, we need to say something to them. Because if we don't and we let it go, it becomes one of those habits, it becomes one of those things that they are going to do and continue to do because no one told them differently.
The other thing today is that a number of jurisdictions do audits on their own, and some of them are doing it unannounced. They will come in behind the inspector and say, “Okay, we know this inspector for this company was here. What did he or she do? Did they do this?” They have a whole list of things. They look at the equipment and see if they find any violations they felt should have been reported. If that's going on, we should hope the jurisdiction is sending us a copy of the audit. If they are not, we should ask them to.
Completing joint visits and providing feedback is key for us at the root level to be able to ensure people are doing what we expect them to do and what they need to do. Talk to the jurisdictions. Again, some of them are doing audits – make sure you are getting the results. Make sure they are getting the results that they want. Ask them about what you are doing or the different types of inspections. Has there been anything they question but maybe haven't told you, or they are sitting there and saying, “Well, if I see this again I am going to call and ask them about it.” But having that regular conversation with the jurisdiction is very important.
I wanted to close with a poem I got a number of years ago. I printed and framed it and I keep it in front of my desk. I send it to new inspectors – inspectors who start with us; people who have just had their commissions. It's called, "I Chose to Look the Other Way."
I could have saved a life that day,
But I chose to look the other way.
It wasn't that I didn't care,
I had the time, and I was there.
But I didn't want to seem a fool,
Or argue over a safety rule.
I knew he'd done the job before,
If I called it wrong, he might get sore.
The chances didn't seem that bad,
I've done the same; he knew I had.
So I shook my head and walked on by,
He knew the risks as well as I.
He took the chance, I closed an eye,
And with that act, I let him die.
I could have saved a life that day,
But I chose to look the other way.
Now every time I see his wife,
I'll know I should have saved his life.
The guilt is something I must bear,
But it isn't something you need to share.
If you see a risk that others take,
That puts their health or life at stake,
The question asked or thing to say
Could help them live another day.
If you see a risk and walk away,
Then hope you never have to say,
I could have saved a life that day,
But I chose to look the other way.