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The person responsible for receiving the shipment saw that the deadly poison was the wrong chemical.
He raised the alarm and the truck was removed hurriedly from the waterworks.
Investigations are now in progress to find out why a truckload of gold mining chemical was sent to a water works.
Even if the staff at Morton Jaffray had been fast asleep, accepted the shipment and actually used it, it is highly unlikely that any resident would have been poisoned. Aluminium sulphate is used to clarify dirty water, coagulating all the muck and depositing it in the tanks, so clear water can be drawn off for the next stage.
Solutions of cyanide salts do not do this. So engineers would have investigated when they found the chemical was not working, read the label and taken action, which would presumably have involved draining and scrubbing the settling tanks and removing every trace of cyanide salts.
So Harare and its surrounding towns would not have had water for several days, not a drop. That was the real danger.
Fortunately the receiver at Morton Jaffray did his job, checked the shipment against delivery and found the error.
So no harm was done
But while Harare City Council staff followed the standard commercial and safety rules, the same cannot be said by their supplier.
Someone either miss-entered the municipal order, or despatched a truck meant for a gold mine to the water works.
And the supplier obviously does not have adequate checks in place to ensure the right order goes to the right customer, a serious fault in a chemical company.
Zimbabwe has stringent rules and regulations over labelling of chemicals, so at least everyone knows what is in the sack or container, whether this is some totally innocuous substance like charcoal or a deadly chemical like sodium cyanide.
So it would have taken a chain of human errors loading the wrong chemical into the containers, sending these containers to a wrong destination and no checks done on receipt, not impossible but unlikely.
What this episode shows is that safety and a willingness to follow standard rules can never be eased or abandoned.
No matter how urgent something is, no matter if the last 10 000 deliveries have been correct, there is always a next time and the checklists must be made out and the safety procedures followed.
One reason why air travel is now so safe is that pilots simply do not take off until a lengthy series of checks, all laid down on a checklist, have been completed satisfactorily. Unless everything works, unless the right fuel in the right quantity has been loaded, unless all luggage has been checked and unless all passengers are present or accounted for, the plane stays on the ground.
So successful has the airline industry been in eliminating almost all mechanical and human errors, that it has become the benchmark, and the techniques it pioneered have been adopted across a wide spectrum of other industries, right up into the complex surgery in the medical profession. If there are no mistakes then there are mistakes.
We hope the investigation into the cyanide delivery is completed quickly and the appropriate action taken. Human error is always a possibility, but safety systems, through checks, are supposed to eliminate the adverse results.
We need to know what happened, and we need to be sure that action is taken, not particularly against the unfortunate person who send the wrong chemical out, but against his superiors who obviously did not enforce the standards laid down by their own industry and the law.
Making a mistake is not a crime. Not following safety procedures can easily be one.
Online Reporter