Category: Accidents

Construction Safety: Human Cost, OSHA Fines and Lawsuits…

June 5th, 2017 by

Knowing that each year about 900 construction workers do not come home to their families after work, safety on construction work sites must be taken seriously.

AGC, the Associated General Contractors of America recently published a study together with Virginia Tech, “Preventing Fatalities in the Construction Industry”. There are some interesting findings:

  • Dangerous Lunch Hour: construction site fatalities peak at noon, and are much lower on Fridays than Monday through Thursday
  • Small Contractors (less than 9 employees) are overrepresented in the statistics, with a fatality rate of 26 per 100,000 workers
  • Fully 1/3 of fatalities are from falls, and about 29% from Transportation incidents with e.g trucks or pickups
  • More experienced workers are not safer: fatalities start increasing after age 35 and keep growing so that 65 year olds are at the highest risk
  • Industrial projects are the most dangerous, followed by Residential and Heavy construction projects

The consequences of a fatality are devastating. There is a great human cost where families will have to deal with grief as well as financial issues. For the company there may be OSHA fines, law suits and criminal investigations. There really is no excuse for a builder not to have an active safety program, no matter how small the company.

Basic safety activities include providing and checking PPE and fall protection, correct use of scaffolding and ladders, on- going safety training, check- ins and audits. It is also a good idea to actively promote a safety culture, and to use a root cause analysis tool to investigate accidents and near misses, and prevent them from happening again.

The TapRooT® Root Cause Analysis methodology is a proven way of getting to the bottom of incidents, and come up with effective corrective actions. Focus is on human performance, and how workers can be separated from hazards like electricity, falls or moving equipment.

We can organize on- site training, or start by signing up for a public course. We offer the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as well as the introductory 2-Day TapRooT® Root Cause Analysis Training class.

Be proactive, do not let preventable accidents catch up with you… call us today!

#TapRooT_RCA #safety

Remembering an Accident: Ixtoc I Oil Spill

June 5th, 2017 by

On June 3, 1979, a major oil spill occurred. Pemex, a Mexican oil company, was drilling in a deep oil well using one of their rigs, Sedco 135. While drilling, mud began to circulate within the well and slowly fill the well column. As it began to fill with mud, the pressure became too much causing Sedco 135 to blow. This oil spill lasted months resulting in hundreds of thousands of barrels of oil spilled into the Gulf of Mexico. They implemented a variety of reactive measures to contain it such as putting steel, iron and lead balls into the well to slow the spill, drilling relief wells, placing barriers and skimmers nears bays and lagoons, and spraying chemical dispersants. This process lasted approximately 10 months costing Pemex close to $100 million.

This major oil spill was about 30 years prior to Deepwater Horizon. Why do these major oil spills happen? What can they do to prevent them? How can we learn from them?

(Resource: https://en.wikipedia.org/wiki/Ixtoc_I_oil_spill)

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

Screen Shot 2017 05 31 at 1 20 19 PM

Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

What does a bad day look like?

May 30th, 2017 by

You know it’s a bad day when:

You get to work and find a “60 Minutes” news team waiting in your office.

You turn on the evening news and they are showing emergency routes out of the city.

Nothing you own is actually paid for.

Your kids start treating you the same way you treated your parents.

The health inspector condemns your office coffee maker.

The gypsy fortune teller offers to refund your money.

You dig around in your purse for your iPhone, while you’re talking on it.

Your son calls you at 3 a.m., and he’s not doing a semester abroad.

You try to check in at the gym using your Starbucks Card.

The smoke detector starts beeping at 2:30 a.m. (why can’t the battery fail at 2:30 p.m.?)

Monday Accident and Lessons Learned: Gatwick Express Rail Accident, Balham

May 29th, 2017 by

August 7, 2016, a fatal accident occurred on the Gatwick Express that transports people to and from Gatwick Airport in London. When passing through Balham, South London, a passenger decided to stick his head out of the window at the same time the train passed a signal gentry going approximately 61 mph. The accident was fatal and tragic. Unfortunately the UK Rail didn’t have any regulations on securing the windows so passengers can’t open them. After investigating, two recommendations and one learning point were identified. Click here to read their results and the full story.

Interviewing & Evidence Collection Tip: The Value of a Planning SnapCharT®

May 24th, 2017 by

Hello and welcome to our new weekly column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.

If you are a TapRooT® user, you know that the SnapCharT® is the first step in conducting a root cause investigation.  It doesn’t matter if you’re investigating a simple incident or major accident – SnapCharT® is always the starting line.

A SnapCharT® is a simple method for drawing a sequence of events.  It can be drawn on sticky notes or in the TapRooT® software.  Sometimes we refer to the SnapCharT® in it’s initial stages as a “planning” SnapCharT®. So why is a SnapCharT® essential for evidence collection and interviewing?

When you begin an investigation, you are working with suppositions, assumptions and second hand information. The planning SnapCharT® will guide you to who you need to interview and what evidence you need to collect to develop a factual sequence of events and appropriate conditions that explain what happen during the incident. Remember, a fact is not a fact until it is supported by evidence.  

The planning SnapCharT® is used to:

  • develop an initial picture of what happened.
  • decide what information is readily available and what needs to be collected immediately.
  • establish a list of potential witnesses to interview.
  • highlight conflicts that exist in the preliminary information.
  • plan the next steps of interviewing and evidence collection.

The SnapCharT® provides the foundation for solid evidence collection.  Learn how to create a SnapCharT® by reading, “Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents or register for our 1-day Interviewing and Evidence Collection Course in Houston, Texas on November 8, 2017.  We also offer this course as a one or two-day onsite course that can be customized for your investigators.

How has SnapCharT® helped you plan your investigative interviews and evidence collection?  If you’ve never used a SnapCharT®, how do you think a planning SnapCharT® would be helpful to you? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

See you next week!

What does a bad day look like?

May 23rd, 2017 by

It could start like this! One of our instructors captured this photo. It would only take a second for this scenario to turn into a very bad day.

Remembering an Accident: West Loch Disaster, Pearl Harbor Base

May 23rd, 2017 by

On the Pearl Harbor U.S. Naval Base on May 21, 1944, there was a major explosion. Of course this was during World War II so one would think or assume it was another attack, but in fact, this was caused by the U.S. Navy themselves. Before they knew it, a large fire broke out where they kept the Landing Ships, Tanks. This fire then spread onto the Operation Forager that was being prepared for another Japanese attack. The final result of this massive fire was six sunken Landing Ships, Tanks, 163 fatalities and 396 injuries.

So, what exactly happened? The probably cause was determined to be an operation error when unloading a mortar round. It detonated on the spot and the fire spread from there. The U.S. Navy couldn’t let this incident repeat so they immediately began implementing a corrective action to change their weapon handling practices.

(Resource: https://en.wikipedia.org/wiki/West_Loch_disaster)

Monday Accident and Lessons Learned: Baltimore School District and Maryland Public Transit Driver Qualifications

May 22nd, 2017 by

In 2016, there was a collision between a school bus and a public transit bus. After an investigation, they found that the process for checking the qualifications of the drivers initially and continuing to do so over time was severely inadequate. As a corrective action, they implemented a new process to audit the drivers’ qualifications and the hiring process to ensure the future drivers are up to par.

Read more here:

https://www.ntsb.gov/investigations/AccidentReports/Pages/HSR1702.aspx

What does a bad day look like?

May 9th, 2017 by

Well, it could start with shenanigans like this.

Freeze on New RMP Rule linked to the ATF announcement about the West, TX, Fertilizer Explosion

May 5th, 2017 by

The new EPA RMP rule which had an effective date March 14, 2017, has been “frozen” under the Trump administration regulatory freeze until February 19, 2019.

The main reason for the freeze in the case of the RMP rule is that the rule modifications were largely based on the West, TX fertilizer explosion. However, two days before the comment period ended, the ATF announced that they suspected that the West, TX, fertilizer explosion was NOT an accident, but rather was an intentional act.

Now the whole rule is being reconsidered.

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

What does a bad day look like?

May 2nd, 2017 by

It could begin innocently enough.

What does a bad day look like?

April 25th, 2017 by

Well, it could start like this…

Remembering an Accident: Oppau Explosion in Germany

April 21st, 2017 by

The explosion occurred September 21, 1921, when a silo that was storing 4,500 tonnes of an ammonium sulfate and ammonium nitrate fertilizer mixture exploded at the Oppau plant in Germany. It killed between 500 – 600 people and there were about 2,000+ people who were injured. The blast was felt for miles, damaging the factory and the surrounding community.

What Happened? 

In 1911 the plant was producing ammonium sulfate when Germany was unable to obtain the necessary sulfur during WWI. It was also producing ammonium nitrate during the same time period. The combination of the two plus the pressure of its own weight, turned the mixture into a plaster-like substance.

The workers had to take pickaxes to remove the plaster-like substance from inside the silos. To make their work easier the workers took small charges of dynamite to loosen the mixture. Before the explosion happened it was estimated that there where as many as 20,000 firings before that fatal day. It is now a well known fact that ammonium nitrate is highly explosive even when mixed, due to this tragic incident.

To read more about this tragic accident please click on the link below.

http://en.wikipedia.org/wiki/Oppau_explosion

To find out how to find and fix root causes at your facility to avoid disasters large and small, visit:

http://www.taproot.com/products-services/about-taproot

Remembering an Accident: Western Airlines Flight 470

March 31st, 2017 by

Western_Airlines_Boeing_737_N4528W_01

On a short, domestic flight on March 31, 1975, a Western Airlines flight had a horrible accident. The plane overran the runway causing major damage to the Boeing 737. Out of the 96 passengers and 6 crew members, only 4 injuries and no deaths occurred. But, what happened?

According to the investigation that was performed in October 1975 (7 months later), the root cause was “poor judgement” by the pilot-in-command. The crew recounted the accident stating there was poor weather and visibility, which caused them to misguide their callouts to the pilot. Was it someone’s fault? Should there be better processes for landing aircrafts in poor weather? Should there be a better way to determine if the weather is even safe to fly in? Should there be improvements on runway lighting/guidance? These are questions that should be asked to develop more effective corrective actions and avoid future, potentially fatal, accidents.

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

Carnival Pride NTSB Allision Report – Causal Factor Challenge

March 7th, 2017 by

collision, allision, carnival

The NTSB released their report on the allision of the Carnival Pride cruise ship with the pier in Baltimore last may. It caused over $2 million in damages to the pier and the ship, and crushed several vehicles when the passenger access gangway collapsed onto them. Luckily, no one was under or on the walkway when it fell.  You can read the report here.

Pride

The report found that the second in command was conning the ship at the time.  He had too much speed and was at the wrong angle when he was approaching the pier.  The report states that the accident occurred because the captain misjudged the power available when shifting to an alternate method of control to stop the ship.  It states there may have been a problem with the controls, or maybe just human error.  It also concluded that the passenger gangway was extended into the path of the ship, and that it did not have to be extended until ready for passengers to debark.

collision, allision, carnival

Gangway collapse after allision

While I’m sure these findings are true, I wonder what the actual root causes would be?  If the findings are read as written, we are really only looking at Causal Factors, and only a few of those to boot.  Based on only this information, I’m not sure what corrective actions could be implemented that would really prevent this in the future.  As I’m reading through the report, I actually see quite a few additional potential Causal Factors that would need to be researched and analyzed in order to find real root causes.

YOUR CHALLENGES:

  1. Identify the Causal Factors you see in this report.  I know you only have this limited information, but try to find the mistakes, errors, or equipment failures that lead directly to this incident (assuming no other information is available)
  2. What additional information would you need to find root causes for the Causal Factors you have identified?
  3. What additional information would you like in order to identify additional Causal Factors?

Reading through this incident, it is apparent to me that there is a lot of missing information.  The problems identified are not related to human performance-based root causes; there are only a few Causal Factors identified.  Unfortunately, I’m also pretty sure that the corrective actions will probably be pretty basic (Train the officer, update procedure, etc.).

BONUS QUESTION:

For those that think I spelled “collision” wrong, what is the meaning of the word “allision”?  How many knew that without using Google?

Avoid the Danger of New Hires

March 1st, 2017 by

 

Is your safety program ready?

Is your safety program ready?

There is a feeling of cautious optimism in the oil sector, as the price of oil seems to have stabilized above $50/barrel. Rig count in the Permian has more than doubled since last spring. US EIA and JPMorgan are forecasting US production at near record levels of over 9.5 million barrels per day by the end of next year. US exports are up, with China ramping up oil purchases from the US, while OPEC production cuts are holding.

This all sounds good for the US oil sector. It is expected that hiring will start picking up, and in fact Jeff Bush, president of oil and gas recruiting firm CSI Recruiting, has said, “When things come back online, there’s going to be an enormous talent shortage of epic proportions.”

So, once you start hiring, who will you hire? Unfortunately, much of the 170,000 oil workers laid off over the past couple of years are no longer available. That experience gap is going to be keenly felt as you try to bring on new people. In fact, you’re probably going to be hiring many people with little to no experience in safe operation of your systems.

Are you prepared for this? How will you ensure your HSE, Quality, and Equipment Reliability programs are set up to handle this young, eager, inexperienced workforce? What you certainly do NOT want to see are your new hires getting hurt, breaking equipment, or causing environmental releases. Here are some things you should think about:

– Review old incidents and look for recurring mistakes (Causal Factors). Analyze for generic root causes. Conduct a TapRooT® analysis of any recurring issues to help eliminate those root causes.
– Update on-boarding processes to ensure your new hires are receiving the proper training.
– Ensure your HSE staff are prepared to perform more frequent audits and subsequent root cause analysis.
– Ensure your HSE staff are fully trained to investigate problems as they arise.
– Train your supervisors to conduct audits and detailed RCA.
– Conduct human factors audits of your processes. You can use the TapRooT® Root Cause Tree® to help you look for potential issues.
– Take a look at your corrective action program. Are you closing out actions? Are you satisfied with the types of actions that are in there?
– Your HSE team may also be new. Make sure they’ve attended a recent TapRooT® course to make sure they are proficient in using TapRooT®.

Don’t wait until you have these new hires on board before you start thinking about these items. Your team is going to be excited and enthusiastic, trying to do their best to meet your goals. You need to be ready to give them the support and tools they need to be successful for themselves and for your company.

TapRooT® training may be part of your preparation.  You can see a list of upcoming courses HERE.

Remembering an Accident: Montana Coal and Iron Company

February 27th, 2017 by

Two small communities in Montana were tragically touched by a mining accident this day in 1943.

smith-mine-disaster-sign

The Montana Coal and Mine Company employed most men living in Washoe and Bearcreek, Montana. There had never been any major accidents like the one that took place on February 27, 1943. That morning, a massive explosion in mine #3 occurred. It was so powerful that families in both local communities heard and felt it. As the supervisors tried to find the cause of the explosion, they couldn’t find anything. No exact root cause. No evidence to tie together to ensure it doesn’t happen again. Sadly, all they could do was inform the families of their losses and shut down for good. The final fatality count was 74 out of 77 miners. All but 3. It was the largest accident they had ever had.

It’s stories like these that we can learn from. How could they have investigated better to find the root cause? What kind of corrective actions could have been implemented to keep these sort of explosions of happening again?

What does a bad day look like?

February 20th, 2017 by

rattlesnakers

Rattlesnake turns up in toilet bowl in snake-infested U.S. house. Read article on Wingate Wire

 

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