This week accident information is from the US Chemical Safety Board …
CSB Chairperson Moure-Eraso Warns About Danger of Hot Work
on Tanks Containing Biological or Organic Material
Earlier this month a team of CSB investigators deployed to the Omega Protein facility in Moss Point, Mississippi, where a tank explosion on July 28, 2014, killed a contract worker and severely injured another. Our team, working alongside federal OSHA inspectors, found that the incident occurred during hot work on or near a tank containing eight inches of a slurry of water and fish matter known as “stickwater.”
The explosion blew the lid off the 30-foot-high tank, fatally injuring a contract worker who was on top of the tank. A second contract worker on the tank was severely injured. CSB investigators commissioned laboratory testing of the stickwater and found telltale signs of microbial activity in the samples, such as the presence of volatile fatty acids in the liquid samples and offgassing of flammable methane and hydrogen sulfide.
The stickwater inside of the storage tank had been thought to be nonhazardous. No combustible gas testing was done on the contents of the tank before the hot work commenced.
This tragedy underscores the extreme importance of careful hot work planning, hazard evaluation, and procedures for all storage tanks, whether or not flammable material is expected to be present. Hot work dangers are not limited to the oil, gas, and chemical sectors where flammability hazards are commonplace.
The CSB has now examined three serious hot work incidents—all with fatalities—involving hot work on tanks of biological or organic matter. At the Packaging Corporation of America (PCA), three workers were killed on July 29, 2008, as they were performing hot work on a catwalk above an 80-foot-tall tank of “white water,” a slurry of pulp fiber waste and water. CSB laboratory testing identified anaerobic, hydrogen-producing bacteria in the tank. The hydrogen gas ignited, ripping open the tank lid and sending workers tumbling to their deaths.
On February 16, 2009, a welding contractor was killed while repairing a water clarifier tank at the ConAgra Foods facility in Boardman, Oregon. The tank held water and waste from potato washing; the CSB investigation found that water and organic material had built up beneath the base of the tank and decayed through microbial action, producing flammable gas that exploded.
Mixtures of water with fish, potatoes, or cardboard waste could understandably be assumed to be benign and pose little safety risk to workers. It is vital that companies, contract firms, and maintenance personnel recognize that in the confines of a storage tank, seemingly non-hazardous organic substances can release flammable gases at levels that cause the vapor space to exceed the lower flammability limit. Under those conditions, a simple spark or even conducted heat from hot work can prove disastrous.
I urge all companies to follow the positive example set by the DuPont Corporation, after a fatal hot work tragedy occurred at a DuPont chemical site near Buffalo, New York. Following CSB recommendations from 2012, DuPont instituted a series of reforms to hot work safety practices on a global basis, including requirements for combustible gas monitoring when planning for welding or other hot work on or near storage tanks or adjacent spaces.
Combustible gas testing is simple, safe, and affordable. It is a recommended practice of the National Fire Protection Association, The American Petroleum Institute, FM Global, and other safety organizations that produce hot work guidance. Combustible gas testing is important on tanks that hold or have held flammables, but it is equally important—if not more so—for tanks where flammables are not understood to be present. It will save lives.
If you are having a bad day, have a look at these pictures and it might not seem so bad by comparison…
Enjoy the artistic and historic culture of Tulsa with TapRooT® at our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course on October 20th. Tulsa is filled with American Indian and Western heritage that will take you back in time. All the cultural attractions and food that you can venture out into are sure to be educational and fun. Come join us and explore deeper into root cause analysis training and Tulsa’s rich heritage.
Burn Co. Barbecue: When’s the last time you had perfectly smoked, delicious BBQ? Burn Co. Barbecue is one of the most popular restaurants in town with the best BBQ!
Savastanos Pizzeria: Authentic Chicago style pizza is the only way to go in Tulsa! Treat yourself to a thick, original Chicago style pizza and a beer!
Kilkenny’s Irish Pub and Eatery: Irish pubs always have a fun atmosphere, great beer and delicious food! Bring your friends to Kilkenny’s and enjoy a night out!
Native American Art Museum: A specialized, intriguing art museum containing only artifacts and archives from Native American history.
Tulsa Air and Space Museum and Planetarium: This museum is fun for all ages! Enjoy learning about the vintage airplanes used in the 1930’s and experience the interactive exhibits.
Marshall Brewing Co.: Come tour this unique, local brewery and taste their authentic ales and lager!
Have you registered for the course yet? Click here for more info or to register for our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course in Tulsa, Oklahoma held October 20-24, 2014.
Thanks to TapRooT® Instructor Marco Flores for these great photos of our September 8-12, 2014 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
Monday Accident & Lesson Learned: Fatal accident at Barratt’s Lane No.2 footpath crossing, Attenborough, Nottingham, 26 October 2013September 22nd, 2014 by Mark Paradies
The UK Rail Accident Investigation Branch issued a report about the fatal accident of a train striking a pedestrian at a footpath crossing near Nottingham, UK. See the entire report and the one lesson learned at:
Note: We have decided to republish articles from the Root Cause Network™ Newsletter that we find particularly interesting and still applicable today. These are used with the permission of the original publisher. In some cases, we have updated some parts of the text to keep them “current” but we have tried to present them in their original form as much as possible. If you enjoy these reprints, let us know. You should expect about two per month.
BEAT ‘EM OR LEAD ‘EM
A TALE OF TWO PLANTS
You’re the VP of a 1000 MW nuclear power plant. A senior reactor operator in the control room actuates the wrong valve.
The turbine trips.
The plant trips.
If the plant had just 30 more days of uninterrupted operation, your utility would have been eligible for a better rate structure based on the Public Service Commission’s (PUC) policy that rewards availability. Now you can kiss that hefty bonus check (that is tied to plant performance goals) good-bye.
To make matters worse, during the recovery, a technician takes a “shortcut” while performing a procedure and disables several redundant safety circuits. An inspector catches the mistake and now the Nuclear Regulatory Commission (the plant’s nuclear safety regulator – the NRC) is sending a special inspection team to look at the plant’s culture. That could mean days, weeks or even months of down time due to regulatory startup delays.
What do you do???
PLANT 1 – RAPID ACTION
He who hesitates is lost!
Corporate expects heads to roll!
You don’t want to be the first, so you:
- Give the operator a couple of days off without pay. Tell him to think about his mistake. He should have used STAR! If he isn’t more careful next time, he had better start looking for another job.
- Fire the technician. Make him an example. There is NO excuse for taking a shortcut and not following procedures. Put out another memo telling everyone that following procedure is a “condition of employment.”
- Expedite the root cause analysis. Get it done BEFORE the NRC shows up. There is no time for detailed analysis. Besides, everyone knows what’s wrong – the operator and technician just goofed up! (Human error is the cause.) Get the witch-hunt over fast to help morale.
- Write a quick report. Rapid action will look good to the regulator. We have a culture that does not accept deviation from strict rules and firing the technician proves that. Tell them that we are emphasizing the human performance technology of STAR. Maybe they won’t bother us any more.
- Get the startup preparation done. We want to be ready to go back on-line as soon as we can to get the NRC off our backs and a quick start-up will keep the PUC happy.
PLANT 2 – ALTERNATIVE ACTION
No one likes these types of situations, but you are prepared, so you:
- Start a detailed root cause analysis. You have highly trained operations and maintenance personnel, system and safety engineers, and human factors professionals to find correctable root causes. And your folks don’t just fly by the seat of their pants. They are trained in a formal investigation process that has been proven to work throughout a variety of industries – TapRooT®! It helps them be efficient in their root cause analysis efforts. And they have experts to help them if they have problems getting to the root causes of any causal factors they identify.
- Keep the NRC Regional Office updated on what your team is finding. You have nothing to hide. Your past efforts sharing your root cause analyses means that they have confidence that you will do a thorough investigation.
- “Keep the hounds at bay.” Finding the real root causes of problems takes time to perform a trough investigation. Resist the urge (based on real or perceived pressure) to give in to knee-jerk reactions. You don’t automatically punish those involved. Yoiu believe your people consistently try to do their best. You have avoided the negative progression that starts with a senseless witch-hunt, progresses to fault finding, and results in future lies and cover-ups.
- Check to see that the pre-staged corrective maintenance has started. Plant down time – even unscheduled forced outages – is too valuable to waste. You use every chance to fix small problems to avoid the big ones.
- Keep up to date on the root cause analysis team’s progress. Make sure you do everything in your power to remove any roadblocks that they face.
- Get ready to reward those involved in the investigation and in developing and implementing effective corrective actions. This is a rare opportunity to show off your team’s capabilities while in the heat of battle. Reward them while the sweat is still on their brow.
- Be critical of the investigation that is presented to you. Check that all possible root causes were looked into. Publicly ask: “What could I have done to prevent this incident?” Because of your past efforts, the team will be ready for good questions and will have answers.
Which culture is more common in your industry?
Which plant would you rather manage?
Where would you rather work?
What makes Plant 1 and Plant 2 so different? It is really quite simple…
- Management Attitude: A belief in your people means that you know they are trying to do their best. There is no higher management purpose that to help then succeed by giving them the tools they need to get the job done right.
- Trust: Everyone trusts everyone on this team. This starts with good face to face communications. It includes a fair application of praise and punishment after a thorough root cause analysis.
- Systematic Approach and Preparation: Preparation is the key to success and the cause of serendipity. Preparation requires planning and training. A systematic approach allows outstanding performance to be taught and repeated. That’s why a prepared plant uses TapRooT®.
Which plant exhibited these characteristics?
HOW TO CHANGE
Can you change from Plant 1 to Plant 2? YES! But how???
The first step has to be made by senior managers. The right attitude must be adopted before trust can be developed and a systematic approach can succeed.
Part of exhibiting the belief in your people is making sure that they have the tools they need. This includes:
- Choosing an advanced, systematic root cause analysis tool (TapRooT®).
- Adopting a written accident/incident investigation policy that shows managements commitment to thorough investigations and detailed root cause analysis.
- Creating a database to trend incident causes and track corrective actions to completion.
- Training people to use the root cause analysis tool and the databases that go with them.
- Making sure that people have time to do proper root cause analysis, help if things get difficult, and the budget to implement effective corrective actions.
- Providing a staff to assist with and review important incidents, to trend investigation results, and to track the implementation of corrective actions and report back to management on how the performance improvement system is performing.
Once the proper root cause analysis methods (that look for correctable root causes rather than placing blame) are implement and experienced by folks in the field, trust in management will become a forgone conclusion.
YOU CAN CHANGE
Have faith that your plant can change. If you are senior management, take the first step: Trust your people.
Next, implement TapRooT® to get to the real, fixable causes of accidents, incidents, and near-misses. See Chapter 6 of the © 2008 TapRooT® Book to get great ideas that will make your TapRooT® implementation world class.
_ _ _
Copyright 2014 by System Improvements, Inc. Adapted from an article in the March 1992 Root Cause Network™ Newsletter (© 1992 by System Improvements – used by permission) that was based on a talk given by Mark Paradies at the 1990 Winter American Nuclear Society Meeting.
Having a bad day? look at these pictures and your day might not seem so bad…
Thanks to Diana Munevar for these great photos of our August 27-29, 2014 course in Bogota, Colombia.
Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioSeptember 16th, 2014 by Mark Paradies
Final presentations by the teams after performing a root cause analysis on their incident that they brought to the course…
He didn’t die … but his boss was fined £5,000 by the HSE.
Linda Unger Teaching the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
Teams Working on Their SnapCharT®s at the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
You have to understand what happened before you can understand why it happened. The SnapChart helps you do just that. These folks at the 2-Day class in Dayton are practicing their newly learned skills…
View more photos here.
For the next public TapRooT® Course near you, click on your continent at:
The UK Rail Accident Investigation Branch has published a report about two accidents where things (a wheelchair and a baby stroller) rolled onto the tracks.
To see the report and the one lesson learned, CLICK HERE.
A man can be as great as he wants to be.
If you believe in yourself and have the courage,
the determination, the dedication, the competitive drive and
if you are willing to sacrifice the little things in life and
pay the price for the things that are worthwhile,
it can be done. ~ Vince Lombardi
Mark Paradies Teaching a Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
On August 21-22, we held a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Bogota, Colombia. Course Planner Diana Munevar shared these photos of the Marble Game, SnapCharT® creating, and interviewing during the course. Enjoy!
Are you interested in learning to find and fix the real root causes of problems in your workplace? Click here to learn more about our South America TapRooT® Courses.
Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Sao Paulo, Brazil held August 4-8, 2014 went fantastically! Thanks to TapRooT® Instructor Boris Risnic for these photos and a great course.
I heard an interesting speaker last week talk about technology adoption. He spoke about how valued brands developed a “tribe” of users who often networked and shared best practices. This often made the technology (the brand) better and more valuable.
That’s when I realized that TapRooT® Users were a tribe that constantly made TapRooT® a more valuable technology/brand.
And once a year, the tribe gets together at The Global TapRooT® Summit.
Think of this like the tribal meetings of old. Or mountain men getting together at the rendezvous. Or, if you are from a Norse heritage, a þing (things).
If you’ve never been to the Summit, now is the time to start planning to attend. Mark out the dates (June 1-5, 2015) on your calendar. Get any budget requests to travel authorizations started (or at least planned for). See if you can get a team of your best performance improvement experts to register as a group.
You’ll return to work from the Summit energized to make improvement happen with great ideas and best practices from around the world. General Summit information is available HERE. The Summit schedule of events will be posted shortly.
Looking forward to seeing you and the rest of the tribe next June.
President, System Improvements
The TapRooT® Folks
Monday Accident & Lessons Learned: NTSB Investigation – Grounding and Sinking of Towing Vessel Stephen L. Colby”September 8th, 2014 by Mark Paradies
Below is the NTSB investigation PDF. Read it and see what you think of the “probable cause” of the accident … “The National Transportation Safety Board determines that the probable cause of the grounding and sinking of the Stephen L. Colby was the failure of the master and mate to ensure sufficient underkeel clearance for the intended transit through the accident area.“
See the whole report here:
You measure the size of the accomplishment
by the obstacles you had to overcome to reach your goals. ~ Booker T. Washington
We recently held an onsite TapRooT® course in Villahermosa, Mexico. Our August 6-8 course went great, and we have TapRooT® Instructor Marco Flores to thank for that and for these photos. Enjoy!
Want to learn how TapRooT® can teach you to find and fix root causes?
What happens after hours at the TapRooT® Summit? People relax and share their experiences. In the picture below, TapRooT® VP Linda Unger is having dinner with three TapRooT® Users at the 2003 TapRooT® Summit.
When and where is the next TapRooT® Summit that you can network, share best practices, and learn the latest new ideas? June 1-5 in Las Vegas. Click here for more information.
Did this post bring back any favorite memories from a Global TapRooT® Summit you have attended? Tell your story by leaving a comment below!