Root Cause Analysis Blog: Accidents Archives

July 10, 2007

Senate Committee Webcast about to Begin on CSB Lessons Learned

The following press release is from the U.S. Chemical Safety Board, Washington DC

Senate Committee Webcast about to Begin on CSB Lessons Learned

Washington, DC, July 10, 2007 - U.S. Chemical Safety Board Chairman Carolyn W. Merritt will testify today as the first witness in a Senate hearing entitled, 'Lessons Learned from Chemical Safety Board (CSB) Investigations, Including Texas City, Texas.' The hearing is scheduled to begin at 10:00 a.m. eastern time today, in the Dirksen Senate Building, Room 406. Please visit http://epw.senate.gov to view the hearing webcast. The webcast link will be posted on the committee website once the hearing begins.

The hearing has been convened by the U.S. Senate Committee on Environment and Public Works, Subcommittee on Transportation Safety, Infrastructure Security, and Water Quality, chaired by Senator Frank R. Lautenberg (D-NJ). Senator David Vitter (R-LA) is the ranking member.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. 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.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.

For more information, please contact Jennifer Jones at (202) 261-3603 or Daniel Horowitz at (202) 261-7613.

Posted by Mark at 01:52 PM | Comments (0)

July 03, 2007

Root Cause Analysis of Strange Incidents

Sometimes investigations of accidents border on the bizarre.
The attached PowerPoint has been around the internet several times but I still find it amazing.

Where is my Dozer.ppt
click above to open PowerPoint

Imagine performing the root cause analysis of this strange accident...

Posted by Mark at 10:03 AM | Comments (0)

June 27, 2007

CSB Root Cause Analysis Work Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued

The following press release is from the U.S. Chemical Safety Board, Washington DC

CSB Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued

Raleigh, N.C., June 27, 2007 - The U.S. Chemical Safety Board (CSB) today announced it is issuing a Safety Advisory concerning the dangers of transporting and handling unspent aircraft chemical oxygen generators. The action follows a CSB investigative finding that the devices most likely contributed to the rapid spread of a fire at the EQ Industrial Services (EQ) hazardous waste facility in Apex, NC on the night of October 5, 2006. The fire resulted in the evacuation of thousands of residents of Apex, located about 16 miles southwest of Raleigh, and destroyed the EQ facility's hazardous waste building.

Chemical oxygen generators are used in commercial aircraft to supply supplemental oxygen to passengers in drop-down masks should the cabin depressurize. They are similar to the ones that started a fire in the cargo compartment aboard a ValuJet airplane that crashed in 1996 in Florida. The National Transportation Safety Board (NTSB) investigation report of that accident stated that expired but fully functioning chemical oxygen generators should be expended before being transported.

The devices that contributed to the EQ fire were past their projected service life but remained fully charged and hazardous. They originated at an aircraft maintenance facility in Mobile, Alabama, that did not expend the contents prior to transport. In addition, shipping documents did not identify them as unspent chemical oxygen generators as required by Department of Transportation regulations.

CSB Safety Advisories are issued during the course of investigations that develop information the Board believes should be communicated rapidly to prevent recurrence of accidents.

At a news conference held in Raleigh, CSB Board Member William B. Wark said, 'We issued this advisory to alert aircraft maintenance and hazardous waste facility personnel to the hazards associated with transporting and storing expired but unspent aircraft oxygen generators. These can be very dangerous and if mishandled can cause fires, property damage and personal injury.'

Lead Investigator Robert Hall, P.E., said, 'Our investigation found that the unspent oxygen generators were stored in the area where the fire is believed to have originated. The generators can be activated by heat, which results in the release of oxygen, further accelerating and intensifying the fire. When firefighters first arrived, the fire was small. But it quickly spread to an adjacent bay.'

The CSB earlier apprised the Federal Aviation Administration (FAA), U.S. Department of Transportation (DOT), and the NTSB of the CSB investigative finding in this case.

Chemical oxygen generators in passenger aircraft have a limited useful life and must be periodically replaced. Even after their expiration dates, they remain potentially hazardous materials. In this case, the CSB found, an aircraft maintenance facility in Mobile, Alabama, sent the chemical oxygen generators to a hazardous waste facility in Birmingham, Alabama, without activating and expending the contents as recommended by the NTSB. The receiving hazardous waste facility misidentified the oxygen generators as general oxidizer waste on shipping documents they prepared for aircraft maintenance facility.

The CSB issued an Urgent Recommendation - the third in the agency's history - to the maintenance facility, Mobile Aerospace Engineering, Inc. (MAE). Urgent recommendations are issued when in the view of the CSB Board Members, there is an 'imminent hazard.'

The CSB recommended the aircraft maintenance company revise or develop procedures to ensure the generators are expended before shipping, revise as necessary procedures for assuring hazardous waste is correctly described on shipping manifests, and that the company communicate to all of its waste brokers and waste facilities that the incorrect shipping name and code was or might have been used for unspent oxygen generators shipped from its facility.

The CSB investigation continues with a final report planned to be released by the end of the year.

Board Member Wark said, 'I want to emphasize that we are continuing to look at the operations at EQ, as well as the national regulations that govern the hazardous waste facilities. We are looking at fire protection practices; we note that there was no automatic fire detection or suppression system to extinguish the blaze after it started; we also note the lack of firewalls to separate hazardous materials from one another. And, there are issues concerning the lack of information available to emergency responders during this incident. We believe that even with the oxygen generators fueling the blaze, had the facility been equipped with automated fire detection and extinguishing systems, this accident may have been avoided.'

At the news conference, Investigator Hall played an edited version of a 1997 NTSB ValuJet investigation fire test involving unspent chemical oxygen generators. The generators contain sodium chlorate, which produces oxygen once activated by a small explosive contained in the device. Heat is also a byproduct of the exothermic reaction, and the outside temperature of the generator can reach up to 500 degrees Fahrenheit. The reaction may also be initiated by heat from other sources. The test video dramatically shows how quickly a fire results and spreads once the oxygen generator contents begin reacting.

For additional info see:

http://www.csb.gov/safety_publications/docs/EQ%20Safety%20Advisory%20Final.pdf

For more information, contact Sandy Gilmour, CSB Public Affairs, cell 202.251.5496; or CSB Public Affairs Specialists Jennifer Jones, 202.261.3603, cell 202.577.8448; Hillary Cohen 202.261.3601; or Kate Baumann, 202.261.7612, cell 202.725.2204. Mr. Gilmour and Ms. Baumann will be in Raleigh for the news conference.

This message was transmitted at 11:17 AM Eastern Time (U.S.A.) on June 27, 2007.

____________________________________________________

Posted by Mark at 03:01 PM | Comments (0)

A Wrong Site Surgery or a near-Miss Occurs Every Other Day in Pennsylvania, Reports the Patient Safety Authority

To read the article, click on the headline below:

Patient Safety Authority Releases Wrong-Site Surgery Data

Posted by Mark at 09:57 AM | Comments (0)

June 19, 2007

How Far Will Someone Go To Complete a Job?

See the incident report at:

http://info.ogp.org.uk/safety/SafetyAlerts/alerts/Detail.asp?alert_id=186

Posted by Mark at 12:02 AM | Comments (0)

June 18, 2007

Monday Accident and Lessons Learned - UK Rail Accident Investigations Board Recent Investigations, Root Cause Analysis, and Recommendations

RAIB reports released

The Rail Accident Investigation Branch (RAIB) has released its report into a runaway permanent way trolley incident at Notting Hill Gate on 24 May 2006. The RAIB has made nine recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report122007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a locomotive runaway near East Didsbury on 27 August 2006. The RAIB has made eight recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report132007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a fatal accident involving a train driver at Deal on 29 July 2006. The RAIB has made nine recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report142007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a derailment at Starr Gate on the Blackpool Tramway on 30 May 2006. The RAIB has made two recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report152007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into two near misses at Crofton Old Station No. 1 level crossing near Wakefield on the 01 and 18 May 2006. The RAIB has made six recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report162007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a tram collision at Soho Benson Road on Midland Metro on 19 December 2006. The RAIB has made three recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report172007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into the collision between a tram and a road vehicle at New Swan Lane level crossing on Midland Metro on 08 June 2006. The RAIB has made two recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report182007.cfm

RAIB investigation update

The RAIB is carrying out an investigation into a fatal accident at Ruscombe… see:

http://www.raib.gov.uk/publications/current_investigations_register/070429_ruscombe.cfm

The RAIB is carrying out an investigation into a collision at Pickering, North Yorkshire… see:

http://www.raib.gov.uk/publications/current_investigations_register/070505_pickering.cfm

The RAIB is carrying out an investigation into a derailment at King Edward’s Bridge, Newcastle upon Tyne… see:

http://www.raib.gov.uk/publications/current_investigations_register/070510_king_edwards_bridge.cfm

The RAIB is carrying out an investigation into a derailment at Fisherground, Cumbria… see:

http://www.raib.gov.uk/publications/current_investigations_register/070512_fisherground.cfm

The RAIB is carrying out an investigation into an incident at Camden Town station… see:

http://www.raib.gov.uk/publications/current_investigations_register/070610_camden_town_station.cfm

Questions

For questions, contact:

newsletter@raib.gov.uk

Posted by Mark at 07:09 PM | Comments (0)

June 16, 2007

New CEO aims to help BP overcome deadly past

Has BP learned from fatalities and the Alaska pipeline spill? The new CEO speaks out. For story see:

http://www.chron.com/disp/story.mpl/business/4892125.html

Posted by Mark at 02:48 PM | Comments (0)

June 14, 2007

CSB Press Release - Dangers of a Major Chlorine Release During Railcar Unloading

The following press release is from the U.S. Chemical Safety Board, Washington DC

CSB Issues Safety Bulletin on Dangers of a Major Chlorine Release During Railcar Unloading; Agency Calls on U.S. Department of Transportation to Expand Regulatory Coverage to Require Emergency Shutdown Systems

Washington, DC, June 14, 2007 - The U.S. Chemical Safety Board (CSB) today released a safety bulletin warning that some chlorine railcar transfer systems lack effective detection and emergency shutdown devices, leaving the public vulnerable to potential large-scale toxic releases.

The Board formally recommended that the U.S. Department of Transportation (DOT) expand its regulatory coverage to require facilities that unload chlorine railcars to install remotely operated emergency isolation devices to quickly shut down the flow of chlorine in the event of a hose rupture or other failure in the unloading equipment. The safety bulletin cites two previous incidents of accidental chlorine releases that occurred as a result of ruptured transfer hoses.

Chlorine railcars are equipped with an internal excess flow valve (EFV) that is designed to stop the flow of chlorine if an external valve breaks off while the railcar is in transit. However, these EFVs are not designed to stop leaks during railcar unloading, and the failure of a transfer hose may not activate the EFV and the toxic chlorine will continue to escape. Companies should install emergency shutdown systems that can quickly stop the flow of chlorine if a hose ruptures during the unloading operation, the bulletin said.

In August 2002 a hose ruptured at a DPC Enterprises plant near Festus, Missouri. The emergency shutdown valves did not close as designed due to poor maintenance, and the EFV did not close. The only way to stop the release of chlorine from the railcar was to send emergency responders through a four-foot deep yellowish-green fog of chlorine vapor to manually close shutdown valves located on top of the railcar. Incidents such as the one at DPC demonstrate why EFVs should not be relied upon to stop hazardous material releases during unloading operations.

However, in a survey of drinking water and wastewater treatment facilities conducted by the CSB, investigators found that approximately 30 percent of the bulk chlorine users contacted continue to rely solely on the EFV to stop chlorine flow in the event of a transfer hose rupture.

The DOT Hazardous Materials Regulations (HMR) regulate transportation of hazardous materials by rail, aircraft, vessel, and motor vehicle tank truck and currently require emergency shutdown equipment for motor vehicle tank truck chlorine transfer systems but not for railcar chlorine transfer systems.

CSB Board Member John Bresland said, 'Chlorine is a very useful but a highly toxic substance that needs appropriate safeguards to prevent releases and protect the public. Our safety bulletin reveals the importance of expanding current regulatory coverage to chlorine railcar unloading operations.'

The safety bulletin compares two chlorine releases from railcars that were investigated by the CSB. The first incident, discussed briefly above, involved a 48,000 pound release of chlorine at DPC Enterprises due to a ruptured transfer hose. As a result hundreds of residents were evacuated or were required to shelter in place, 63 residents sought medical attention and three were admitted to the hospital. The second incident occurred in August 2005 at Honeywell International's Baton Rouge chemical plant when chlorine began to escape from a railcar due to a transfer hose failure. There, the emergency shutdown system functioned properly and the release lasted less than one minute. There was no impact to the surrounding community.

Investigator Lisa Long said, 'In contrast to the 2002 incident at DPC, the rapid and successful activation of the emergency shutdown system at Honeywell prevented a major release and limited off-site impacts to the surrounding community.'

The CSB recommendation calls on DOT to expand regulatory coverage to require railcar unloading operations to have the following safeguards:

- Remotely operated isolation devices that will quickly isolate a leak in any of the flexible hoses used to unload a chlorine car
- The shutdown system must be capable of stopping a chlorine release from both the railcar and the equipment at the facility receiving the chlorine
- Periodic maintenance and operational testing of the emergency isolation system to ensure it will function in the event of an unloading system chlorine leak

ADDITIONAL CHLORINE INCIDENTS:

Although the incidents described below do not directly deal with chlorine railcar unloading operations they do indicate the severe hazards to the public in the event of a chlorine railcar leak and the importance of transporting and transfer of this deadly but useful chemical safely. These transportation incidents have been investigated by the National Transportation Safety Board (NTSB).

- June 28, 2004 - The collision of two trains near Macdona, Texas caused a release of liquefied chlorine from one of the train's tank cars. The chlorine vaporized, engulfed the area and led to the deaths of the train conductor and two local residents.

- January 6, 2005 - In Graniteville, South Carolina, a Norfolk Southern train collided with a stationary train, leading to a derailment, and the release of an estimated 120,000 pounds of chlorine. The derailment and resulting chlorine release caused 9 deaths, led to over 500 persons seeking medical treatment for possible chlorine exposure and the mandatory evacuation of over 5,000 residents.

For further information contact:

Sandy Gilmour 202.261.7614 or cell 202.251.5496, Public Affairs Specialist Jennifer Jones 202.261.3603 or cell 202.577.8448.

This message was transmitted at 10:59 AM Eastern Time (U.S.A.) on June 14, 2007.

Posted by Mark at 06:35 PM | Comments (0)

June 11, 2007

Deadly Construction Accident in Indianapolis

Men unhook harnesses at mall construction site to repair pin holding a bolt in place on scaffolding. "In the process there was too much weight placed on that end and the cable holding that scaffolding, suspended broke," explained Sgt. Matt Mount, from the Indianapolis Metropolitan Police Department.

Read the entire article here:

Deadly Construction Accident at Castleton Mall

Posted by barbara at 10:10 AM | Comments (1)

June 08, 2007

CSB Root Cause Investigation of Fatal Convenience Store Explosion Progresses

The following is a press release from the U.S. Chemical Safety Board, Washington DC ...

Test of Key Valve in Ghent, West Virginia, Fatal Convenience Store Explosion Points to Likely Source of Propane Release

Washington, DC, June 7, 2007 - The U.S. Chemical Safety Board today announced that initial testing of the propane tank recovered after a West Virginia convenience store explosion reveals that the liquid withdrawal valve on the tank malfunctions and leaks and was the likely source of the large propane release that exploded, killing four people and injuring five others.

The accident occurred on January 30, 2007, at The Little General Store in Ghent. On the day of the accident, investigators believe personnel involved in the installation of a new propane tank at the store removed a metal screw cap on the liquid withdrawal valve, in preparation for removing propane from the old tank. When operating normally, a spring-loaded actuator prevents the valve from leaking when the screw cap is removed.

Testing also demonstrated that the fill valve, relief valve, and the tank itself do not leak. Experts and representatives of other interest parties observed the testing, which was conducted yesterday at a West Virginia contract laboratory. The nondestructive testing was conducted by filling the tank with gas and observing the rate of leakage at a range of pressures.

Following the testing yesterday, the CSB removed the liquid withdrawal valve from the tank. The CSB will be developing additional testing protocols to determine the cause of the valve malfunction. Further testing of the valve will occur in the next few months after the protocols are developed.

For more information, contact Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613, cell 202-441-6074.

Posted by Mark at 05:17 PM | Comments (0)

June 05, 2007

Deadly Train Wreck in Australia

AP reports that at least 10 people were killed when a truck collided with a train. For more info see the AP article on CNN's web site:

http://www.cnn.com/2007/WORLD/asiapcf/06/05/australia.crash.ap/index.html

More details can be found in a story in The West, an Australian paper:

http://www.thewest.com.au/default.aspx?MenuID=28&ContentID=30616

Posted by Mark at 08:54 AM | Comments (0)

May 31, 2007

BP's Top Refining Executive Departing for Another Job

For the article in the Houston Chronicle, see:

http://www.chron.com/disp/story.mpl/business/4849376.html

Posted by Mark at 09:07 AM | Comments (0)

May 24, 2007

US Government May Stop Paying Hospitals Extra for Common Medical Errors

It's an interesting concept ... The hospital makes an error - like a caretaker contaminating a needle and causing a bloodstream infection - and the government then pays the hospital more to cure the disease they created.

This process seems to reward the hospital with additional payments for making errors. It certainly doesn't reward a hospital that spends more to stop medical errors.

An article in the May 22 edition of the Indy Star indicates that Medicare is rethinking this payment policy and may stop paying for the following conditions acquired after admissions:

1. Catheter-associated urinary tract infections.
2. Bed sores.
3. Objects left in after surgery.
4. Air embolism, or bubbles, in bloodstream from injection.
5. Patients given incompatible blood type.
6. Bloodstream staph infection.
7. Ventilator-associated pneumonia.
8. Vascular-catheter-associated infection.
9. Clostridium difficile-associated disease (gastrointestinal infections).
10. Drug-resistant staph infection.
11. Surgical site infections.
12. Wrong surgery.
13. Falls.

With Medicare being such a large payer of claims, this would certainly give hospitals a much bigger reason to improve - their profitability!

And as a taxpayer I can't see why they have waited this long.

For the complete article, see:

http://www.indystar.com/apps/pbcs.dll/article?AID=2007705220351

Posted by Mark at 04:35 PM | Comments (0)

May 21, 2007

Monday Accident & Lessons Learned: Can BP Learn from Texas City and Alaska Pipeline Failures

In the "Continue reading ..." section below is a Press Release from the CSB that says there are "striking similarities" between the root causes discovered by the CSB's investigation of the BP's Texas City Refinery Explosion and the causes of the pipeline leak at BP's Prudhoe Bay oil field as outlined in a study by Booz Allen Hamilton.

With the considerable turnover among BP's senior management ranks, it leaves one to wonder, can BP learn from these accidents, or will the senior management turnover just lead to a new culture without any real learning from the accidents?

Some may say that the disciplinary documents released recently point to a culture of blame - not a learning culture. If after a year and a half after the tragedy at Texas City, BP executives are still looking higher and higher in the corporation for people to blame, perhaps they haven't learned that they need to put strict systems in place rather than relying on managements' changing priorities to manage safety at highly hazardous workplaces.

You may consider this to be a harsh evaluation, but getting beyond blame and putting effective systems in place - systems that are supported by management - is the only way to stop the kind of unwise cost cutting that lead to unsafe conditions at the BP Texas City Refinery and the BP Prudhoe Bay Oil Pipeline.

The following message is from the U.S. Chemical Safety Board, Washington DC.

CSB Chairman Carolyn Merritt Tells House Subcommittee of 'Striking Similarities' in Causes of BP Texas City Tragedy and Prudhoe Bay Pipeline Disaster

Washington, DC, May 16, 2007 - U.S. Chemical Safety Board (CSB) Chairman Carolyn W. Merritt today told members of a U.S. House of Representatives subcommittee that she found 'striking similarities' between the causes of the fatal BP accident in Texas City, Texas, in 2005, and the company's pipeline failure at Prudhoe Bay, Alaska, in 2006 which resulted in the leakage of more than 200,000 gallons of oil. The pipeline suffered extensive corrosion due to lack of maintenance over several years.

While the CSB did not investigate the Prudhoe Bay accident, Chairman Merritt was asked by the House Committee on Energy and Commerce Subcommittee on Investigations and Oversight to review a BP internal audit of the accident completed by Booz Allen Hamilton. Chairman Merritt told the subcommittee, 'Virtually all of the seven root causes identified for the Prudhoe Bay incidents have strong echoes in Texas City.' These included, she said, the 'significant role of budget and production pressures in driving BP's decision-making - and ultimately harming safety.'

The hearing, chaired by Rep. Bart Stupak (Michigan), was entitled '2006 Prudhoe Bay Shutdown: Will Recent Regulatory Changes and BP Management Reforms Prevent Future Failures?' Other panel members included representatives from the Occupational Safety and Health Administration (OSHA), the Alaska Department of Natural Resources, and the pipeline and hazardous materials safety division of the U.S. Department of Transportation. Featured on a second panel was Robert. A. Malone, Chairman and President of BP America, Inc.

Chairman Merritt told the committee of further comparisons of safety culture similarities at Texas City and Prudhoe Bay. Both investigations, she said, found deficiencies in how BP managed the safety of process changes. In Prudhoe Bay, Booz Allen Hamilton found 'a normalization of deviance where risk levels gradually crept up due to evolving operating conditions.' This compared, she said, to Texas City, where at BP's refinery 'Abnormal startups were not investigated and became routine, while critical equipment was allowed to decay. By the day of the accident, the distillation equipment had six key alarms, instruments and controls that were malfunctioning. Trailers had been moved into dangerous locations without appropriate safety reviews.'

Similarly, Ms. Merritt noted BP's own internal audit findings concerning its Prudhoe Bay pipeline problems did not result in repairs or improved maintenance. Ms. Merritt quoted the company's audit as saying the findings faced 'long delays in implementation, administrative documentation of close-out even though remedial actions were not actually taken, or simple non-compliance.'

Other common findings at both Texas City and Prudhoe Bay included, the chairman said, 'Flawed communication of lessons learned, excessive decentralization of safety functions, and high management turnover. BP focused on personal safety statistics but allowed catastrophic process safety risks to grow.'

For more information, contact:

Sandy Gilmour 202-261-7614 or cell 202-251-5496, Public Affairs Specialist Kate Baumann 202-261-7612 or cell 202-725-2204, Public Affairs Specialist Jennifer Jones 202-261-3603 or cell 202-577-8448, or Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613 or cell 202-441-6074.

Posted by Mark at 01:05 PM | Comments (0)

May 16, 2007

A Few More Photos of the Buncefield Fire

Recently received these photos ... once again was amazed ...

Posted by Mark at 12:03 PM | Comments (0)

May 14, 2007

Monday Accident & Lessons Learned - Blackberry Outage Shows Need for IT Root Cause Analysis

Several of weeks ago, the network that carries BlackBerry messages went down. Why? That's a question for a good root cause analysis.

For details see these articles ...

http://www.informationweek.com/news/showArticle.jhtml?articleID=199100624

http://www.canada.com/nationalpost/financialpost/story.html?id=fff9217c-651c-40c7-8aad-73586d2a953a&k=32960

What is the lesson learned? That IT folks need thorough, systematic root cause analysis as much as safety, equipment, environmental, or hospital quality improvement people do.

One common root cause analysis problem is that investigators stop with the symptoms of the failure and call these symptoms the cause. The don't dig deep enough to find the true system root causes. They don't know the questions to ask to get beyond the symptoms.

That's one of the benefits of TapRooT® - it helps investigators get beyond symptoms to the fixable root causes and generic causes of accident, incidents, qiality problems, equipment failures, and even IT problems.

For more information about TapRooT® see:

http://www.taproot.com/about.php

And for a success story about improving network reliability at BellSouth, see:

http://www.taproot.com/about.php?s=9

Posted by Mark at 02:27 PM | Comments (0)

May 07, 2007

Monday Accident & Lessons Learned: Do Heads Need to Roll to Make People Happy?

After a major flooding incident at a mine in Canada, Cameco published a report on their root cause analysis of the accident. The Regina Leader-Post published an article about the report and the reaction of some financial analysts that I thought was quite interesting.

First, the article said:

"The root-cause report into that flood concluded neither Cameco nor its contractor had identified risk scenarios, nor did they have necessary controls in place to prevent the flooding of the shaft."

Later in the article it provided some quotes from analysts. One analyst was quoted as follows:

"William Vogel, an analyst with Harbor View Growth Equity Management in Connecticut, said Cameco appeared to have a 'lax' corporate culture. He said he would have expected the company would 'have fired a lot of people,' considering that lives were at stake in the mine. 'I don't think you have a standards problem. I think you have a people problem,' Vogel said."

What can you learn from this article?

Some people just aren't happy until heads roll (discipline is taken by firing people).

This brings up the whole issue of the basis of performance improvement.

Do we BLAME incidents on people and fire them to improve performance OR do we find the system problems and fix them to ensure improved performance?

It seems that the analyst is in the blame camp. Without performing an investigation, he knew the answer ... fire a lot of people!

Where does your corporate performance improvement philosophy fall? Is it oriented toward blame or system improvements? And what approach will yield the best long term results? This could be a major lesson learned!

Posted by Mark at 12:04 AM | Comments (0)

May 04, 2007

Houston Chronicle Story About Internal BP Texas City Explosion Firing Recommmendations

For the complete story see:

http://www.chron.com/disp/story.mpl/business/4774310.html

To read the internal BP report see:

http://partners.ibctv.com/Bonse%20Main%20Report.pdf

The article starts out saying:

"An internal BP investigation, detailed for the first time Thursday, recommended that four executives be fired for management shortcomings in a "culture of risk taking" leading up to the 2005 explosion that killed 15 people at BP's Texas City refinery.

The two-part report of the "management accountability" probe also chastised John Manzoni, the London-based company's chief executive of refining and marketing, but didn't call for his termination.

The plant blast investigation, led by BP group vice president Wilhelm Bonse-Geuking, was finished in February but remained under wraps until Thursday, after a Texas appeals court upheld a state district judge's order that it be made public. BP fought to prevent public identification of the men recommended for firing."

For the complete article, see the link above.

Posted by Mark at 09:56 AM | Comments (0)

April 30, 2007

Tank Explosion Video

For a cool video of a tank explosion, see:
Watch flames shoot from tank as it explodes
For the story at CNN's web site see:

http://www.cnn.com/2007/US/04/28/tanker.fire.ap/index.html

Posted by Mark at 05:39 PM | Comments (1)

April 16, 2007

Monday Accident & Lesson Learned: The Deposition

I was looking on-line for video footage of the BP Texas City Explosion and I ran across the BP Texas City Explosion web site site up by Brent Coon, an attorney handling one of the lawsuits filed against BP.

What an eye opener!

If you work in safety or management of a highly hazardous facility, review this site in detail. Read the depositions. Watch the videos. Think of how you could answer the questions if something was to go wrong at your site.

Especially watch these three videos of deposition:

Kathleen Lucas - Operations Manager at BP Texas City

Joe Barnes – Head of HSSE at BP Texas City

Bill Ralph – Head of Process Safety at BP Texas City
Are you adequately trained to perform your job? How much training in process safety and root cause analysis do you need? Could your qualifications stand up to a deposition?

Posted by Mark at 10:44 PM | Comments (1)

April 09, 2007

Monday Accident and Lessons Learned: Safety Engineer Killed During Preparation for Safety Training

We've all heard stories about people being injured doing root cause analysis. The most famous that I can remember was the investigator who lost his fingers when he demonstrated how someone else had lost their fingers. But I've never heard of a safety engineer being killed getting ready for safety training. Read the article below and see what you can learn.

http://phoenix.swarthmore.edu/2007-03-22/news/17058

Posted by Mark at 10:01 AM | Comments (0)

April 02, 2007

Monday Accident and Lessons Learned: Root Cause Analysis is Essential ... Network Rail Fined £4 Million for Paddington Rail Disaster

Here's a quote from an article in the Gardian Unlimited in the UK:

- - -

Officials from Railtrack, the precursor to Network Rail, were warned at least five years before the collision that a set of signals was badly laid out and so difficult for drivers to interpret that a serious incident was likely to happen, the hearing was told.

The signals had been misinterpreted by drivers at least seven times in the previous five years, and had been the subject of internal inquiries.

The Paddington disaster, which was likened in court to a "senseless and unnecessary terrorist attack", would never have happened had it not been for a string of safety blunders.

Failures spanned several years and flowed from "the culture at the top" of the company, the court heard.

Passing sentence, Mr Justice Bean said Railtrack had admitted that its failure to carry out "adequate root cause analysis" of signals passed at danger (Spads) had been "systemic and unacceptable".

Quoting from his judgment, he added: "It was due, as counsel to the [Lord Cullen] inquiry submitted, to a combination of incompetent management and inadequate process, the latter consisting in the absence of a process at a higher level for identifying whether those who were responsible for convening such committees were or were not doing so.

- - -

What can you learn? That root cause analysis is essential for safety of your passengers and employees in the transportation business. If your company has responsibility for the safety of your customers, you had better throughly investigate safety errors and near-misses (close-calls).

To read the complete article, see:

http://business.guardian.co.uk/story/0,,2046717,00.html

Posted by Mark at 10:00 AM | Comments (0)

March 27, 2007

Should We Criminalize Bad Safety Management? Is There a Better Option?

The articles/speeches at the end of this article and a CSB press release posted at the "continue" link below seem to indicate that the path to improved worker safety is more aggressive regulation and increased criminalization of bad safety management.

As you all know, I'm in favor of improved safety. But I think we should carefully consider if the paths being suggested are the best way to get there.

For example, let's just do a quick estimate of the $$$ cost of criminalization of bad safety management .... (Yes - I know there are costs besides dollars and I value human life more than dollars but ... I think looking at the potential dollar cost is eye opening when evaluating the options.)

The CSB spent more than $2 million investigating the BP Texas City Explosion. Why did they spend so much? Because it takes an exhaustive investigation to prove that BP had bad safety management. (From what I've heard so far, the criminal part of the investigation by the DOJ is just starting to get into full swing.) So let's just use $2 million as an average investigation cost for one of the exhaustive investigations with senior management implications.

There are about 5,000 fatalities at industrial sites per year in the US. That doesn't count the 98,000 deaths due to medical errors - which also could be due to bad management ... and may be subject to criminalization of bad safety management. So a conservative guess would be 2,000 investigations per year at a cost of $2 million each.

Thus the government cost will be $4 billion per year for investigations. This does not including the cost of criminal prosecutions that result.

Of course, no rational manager would allow a federal investigation without conducting an equally costly investigation to prove they are innocent. Therefore, industry will match governments costs and spend $4 billion investigating their management in defense of the government investigation.

So far ... $8 billion per year without legal costs. (Investigators - Get ready - This looks like a growth industry!)

Now for legal costs ...

Let's guess that 10% of the investigations go to prosecution ...

That's 200 per year.

How much will the high priced attorneys, expert witnesses, government experts, court costs, depositions, management time, ... cost?

Let's guess twice the investigation cost. That's $8 million for each side or $16 million total for one case. (Look at the cost of special prosecutors if you think these costs are way off.)

200 X $16 million (cost for both sides) = $3.2 billion more.

That's over $10 Billion/year invested in criminalization of un-safe management practices.

Of course, this is only a guesstimate... Problems with the estimate could include -

Government could get more efficient ...

Bad management could improve ... reduce costs

Industry could just leave US ... avoid potential for prosecution

Courts - already overloaded - may not be able to handle 200 high priced cases with contentious corporate lawyers ...

We may include the medical examples and the number would go up by a factor of 100 or more.

Is this really the best investment we can make in improving safety performance and saving lives?

I always think that instead of believing that the government (OSHA?) is the answer and is responsible for worker (or patient) safety, the managers and employees should be primarily responsible. Thus, System Improvements' focus has always been on educating management and employees so that they can see the value of implementing best practices to improve performance and avoid disaster.

I know this may sound corny and optimistic ... and it doesn't always work ... but I think it is the best way to change performance across industry in the US and around the world.

Don't get me wrong. I understand the need for regulation. But I think that industry should be improving to the point that regulations look antiquated and unnecessary. Industry should "peer pressure" the bad performers (AND THERE ARE BAD PERFORMERS!) to improve (much as they have in the nuclear industry) to stay free of burdensome, inefficient regulations.

If we can't make improvement happen without heavy handed regulation, I'm afraid that we will "regulate" ourselves out of jobs. Excessive new regulations and criminal cases will be just one more reason for companies move production to less regulatory intense parts of the world.

That's why I need your help.

Let's spread the word about proactive improvement, advanced root cause analysis, and stopping human errors. Let's get management trained to understand the right way to improve performance. Let's spread good practices around your company and industry.

If you think this sounds like a good idea, let me suggest that you start but attending one of the Best Practice tracks at the TapRooT® Summit. This is a great way to learn best practices and network with industry leaders. And if you can find several other people - including managers - who will attend with you, you can put together a high performance improvement team to change your site, your company, and perhaps start changing your industry.

That was MY GOAL when I started the Summit in 1994. And with your help, perhaps we can save jobs and lives by making improvement happen without excessive regulation. At least that is my hope.

I look forward to seeing you at the Summit in San Antonio on April 25-28, 2007.

- - -

Articles/speeches that got me thinking about this:

http://www.chron.com/disp/story.mpl/business/4654446.html

http://www.house.gov/apps/list/speech/edlabor_dem/RelMar20BPReport.html

http://www.house.gov/apps/list/speech/edlabor_dem/rel032207.html

Testifying before House Committee on Education and Labor, Chairman Carolyn W. Merritt Calls for Increasing Oversight of Refining Industry by OSHA

Washington, DC, March 22, 2007 - Carolyn W. Merritt, Chairman of the U.S. Chemical Safety Board (CSB), told a congressional committee today there should be increased oversight of the oil refining industry by the Occupational Safety and Health Administration (OSHA) in order to prevent accidents such as the one that occurred at the BP refinery in Texas City, Texas, in 2005. She spoke before the House Committee on Education and Labor, chaired by U.S. Rep. George Miller of California who convened the hearing 'to examine what we can learn from the missteps that preceded this disaster in order to help prevent future ones.'

Chairman Merritt said the CSB's exhaustive investigation into the BP accident, the results of which were released two days ago in Texas City, showed the company had not followed OSHA process safety regulations, and that OSHA had not adequately inspected the facility to see if BP was complying with those regulations. As a result, she said, cuts in training, staffing, maintenance, equipment modernization, and safety, which the investigation found were a result of significant budget cuts ordered by BP, left the Texas City facility vulnerable to catastrophe.

Ms. Merritt said, 'The CSB found that regulatory oversight of this refinery was ineffective. In recent years, OSHA has focused its inspections on workplaces with high injury rates, but these rates do not predict the likelihood of a catastrophic process accident at a facility.'

Ms. Merritt noted that the BP facility, like thousands of other petrochemical plants, is regulated under OSHA's Process Safety Management standard, issued in 1992. 'Rigorous application and enforcement of this rule - including its preventative maintenance and incident investigation requirements - would almost certainly have prevented this tragedy,' she said. She noted the BP refinery had a long history of deadly accidents and dangerous hydrocarbon releases from the same equipment that was involved in the Texas City accident.

The work of the CSB received bipartisan praise from committee members for the CSB's investigation of the BP tragedy and other accidents. Several expressed concern about the paucity of regulatory inspections in the petrochemical industry.

Chairman Miller said, 'Protecting the safety of refinery and chemical workers is reason enough to get this right. But the safety of our refineries and chemical facilities also has broader implications for the communities surrounding these plants. The disaster at BP Texas testifies to the steep price we pay as Americans for not enforcing the nation's laws that are supposed to protect working men and women in this country.' He said further hearings may be convened.

Following Chairman Merritt's testimony, other panelists addressed the committee, including Eva Rowe, who lost both parents in the explosion. They were among the 15 contract workers meeting in work trailers at the time of the blast. The CSB found the trailers were sited in a hazardous location at the plant, near a blowdown drum which spewed highly flammable hydrocarbons that were ignited by an idling pickup truck. The agency has recommended to the American Petroleum Institute (API) that trailer siting guidelines be revised.

Other panelists included Kim Nibarger, health and safety specialist for the United Steelworkers (USW), Frank L. 'Skip' Bowman, retired admiral and member of the BP Refineries Independent Safety Review Panel, which was instituted on the recommendation of the CSB and headed by former U.S. Secretary of State James Baker III, and Red Cavaney, American Petroleum Institute president and CEO.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.csb.gov.

For more information, contact Sandy Gilmour at (202) 261-7614 / (202) 251-5496 cell.

This message was transmitted at 5:14 PM Eastern Time (U.S.A.) on March 22, 2007.

Posted by Mark at 08:00 AM | Comments (0)

CSB Root Cause Analysis of BP Texas City Explosion is posted at the CSB Web Site

To see the report go to:

http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=52

I'll try to read and comment on it by the time I come home from England (next week).

Posted by Mark at 03:38 AM | Comments (0)

March 26, 2007

Monday Accident & Lessons Learned: Keep Up With Incidents Around the USA

The Chemical Safety Board has a web page that collates press reports about incidents from around the USA. See:

http://www.csb.gov/index.cfm?folder=circ&page=index

Keeping up with what is going wrong is a good way to learn lessons from other's misfortune.

Posted by Mark at 09:18 AM | Comments (0)

March 22, 2007

CSB to Post BP Texas City Explosion Root Cause Analysis Report and Recommendations Next Week

For those who have been checking the CSB web site and are wondering ...

"How come the BP report isn't posted?"

The answer is that there were slight amendments made by the Board at the public meeting on Tuesday and those wording changes need to be made before the report is posted on the CSB web site.

When will the report be posted? Probably next week. So stay tuned.

Posted by Mark at 09:05 AM | Comments (0)

March 21, 2007

Deposition of BP Exec Shows How Hard It Is To Justify Performance After an Accident

Difficult but interesting reading, this deposition provides insight into the management of the Texas City Refinery.

Deposition (1st half):

http://galvestondailynews.com/photos/2006.December/BP-Parus-1.pdf

Deposition (2nd half):

http://galvestondailynews.com/photos/2006.December/BP-Parus-1.pdf

Posted by Mark at 06:48 AM | Comments (0)

UK HSE Published Thermal Oxide Reprocessing Plant (THORP) Leak Investigation and Consent to Restart

The UK Health & Safety Executive has issued the following press release:

- - -

NII issued a Consent on 09 January 2007 to allow THORP to reopen because it is satisfied that the licensee, British Nuclear Group Sellafield (BNGSL) has done all the work necessary to ensure it can be restarted safely. The actual date on which reprocessing of fuel at THORP recommences is a matter for BNGSL. HSE/NII will continue to regulate BNGSL to ensure safety is maintained across the Sellafield site and elsewhere.

Background

In April 2005, a camera inspection of the THORP Feed Clarification Cell identified the failure of a nozzle on an accountancy tank. This inspection also identified a quantity of liquor had leaked on the cell floor. Production operations in the cell ceased on the discovery of the liquor and have since remained embargoed across the whole of THORP, with the exception of work carried out to return the liquor to primary containment and to understand the reasons for the failure.

NII issued a notification on 09 January 2006 under Licence Condition 21(8) notifying the licensee to submit the safety case for the modified THORP and not to commence movement of fuel from the Feed Pond to the Shear Cave without its Consent. BNGSL applied for a Consent to commence movement of fuel from the Feed Pond to the Shear Cave in THORP, on 14 December 2006.

Reports

HSE has published a report on its invesigation into the leak which describes in detail how the leak occurred, how it was discovered and why it was not detected earlier, together with background information on the plant. It outlines 55 recommendations and actions arising from the investigation and discusses lessons for BNGSL and the wider nuclear industry.

Report of the investigation into the leak of dissolver product liquor at the Thermal Oxide Reprocessing Plant (THORP), Sellafield [PDF 310kb]

NII has also produced a report describing NII's assessment of BNGSL's application for consent to restart THORP, which includes consideration of BNGSL’s response to the 55 recommendations.

- - -

Posted by Mark at 12:09 AM | Comments (0)

March 20, 2007

Was Cost Cutting a Root Cause of the BP Texas City Explosion? This Will Be the Major Controversy of CSB Report According UK Press

Since I'm over in the UK teaching I can't get to the public meeting on the BP Texas City explosion being held by the CSB today. But I'm trying to keep up on the news. In the UK, the controversy seems to be over the findings of cost cutting that, according to the press reports about what the CSB has found, are root causes of the explosion at the refinery.

For a sample of a press report in the UK, see:

http://observer.guardian.co.uk/business/story/0,,2031053,00.html
Here are a few of the key quotes from the story ...

"The CSB says it has evidence in emails and other documents of budgetary considerations taking precedence over investment."

"Merritt says that internal and external reports between 2002 and 2005 pointed to problems: 'There was a complete failure to listen to the evidence that they were hearing: that this facility had been squeezed to the breaking point. That was received from their managers as well as from surveys by consultants.'"

"CSB has emails indicating Texas City managers turned down requests for funding, claims Merritt. 'We know that pleas from the plant managers were dealt with by instructions to continue cost cutting,' she says. One such came from Walter Wundrow, a refinery investment manager, who refused an engineer's request to install a flare, instructing him to 'bank $150m savings'."

"Merritt says there is an 'iron-clad' case of a causal link between cost savings and the accident. However, she emphasises that much had been done since the explosion. 'There are huge changes going on in Texas City and a great deal of determination and effort to put things straight. But real culture change is very difficult.'"

I'm sure that by the time I wake up in the UK tomorrow, there will be a report posted on the CSB web site that I will need to read to see the totality of the evidence that the CSB has been collecting.

Posted by Mark at 07:17 PM | Comments (0)

Was Fatigue a Root Cause of BP Texas City Explosion?

From the CSB Press Release about the root cause analysis of the BP Texas City Refinery explosion, I found the following comment:

By March 23, operators had been working 12-hour shifts for 29 or more consecutive days. "Fatigue causes cognitive fixation and impaired judgment and could lead operators to fixate on one operational parameter - such as the apparently declining liquid level - to the exclusion of other indicators," Ms. MacKenzie said. Fatigue has been recognized as a cause of major accidents in the transportation sector. Fatigue prevention regulations have been developed for aviation and other transportation sectors, but there are no fatigue prevention guidelines that are widely used and accepted in the oil and chemical sector.

- - -

29 days on 12-hour shifts.

I remember the feeling. In my own experience at day 46 on 12-hour shifts we had an electrician almost get electrocuted (a near-miss). We didn't conclude that fatigue was a factor (This incident occurred way before I invented TapRooT®). But now I know that it was related to fatigue.

When I hear that operators were on day 29 of 12-hour shifts ... the "bad decisions" made based on faulty indicators just before the BP Texas City explosion start making much better sense. And firing the operators and supervisor after the accident make much less sense.

If you are interested in a way to judge if fatigue is a cause of an incident, you should attend the TapRooT® Summit to hear Bill Sirois talk about the FACT technique for assessing fatigue during an accident investigation. For a complete Summit schedule see:

http://www.taproot.com/summit.php?sched=1

Posted by Mark at 05:52 PM | Comments (0)

More on the Upcoming CSB Root Cause Analysis Investigation Report

BP has posted a press release on their web site in response to the yet to be released to the public CSB root cause analysis investigation report of the explosion at BP's Texas City Refinery.

To me, the most interesting statement in the release was:

Notwithstanding the Company’s strong disagreement with some of the content of the CSB report, particularly many of the findings and conclusions, BP will give full and careful consideration to CSB’s recommendations, in conjunction with the many activities already underway to improve process safety management.

(italic emphasis above added by me)

To see the release go to:

http://www.bp.com/genericarticle.do?categoryId=2012968&contentId=7031189

Posted by Mark at 03:32 PM | Comments (0)

BP Texas City Refinery EXPLOSION - CSB Press Release About Final Root Cause Analysis Report

The following message is from the U.S. Chemical Safety Board, Washington DC

U.S. Chemical Safety Board Investigators Conclude 'Organizational and Safety Deficiencies at All Levels of the BP Corporation' Caused March 2005 Texas City Disaster That Killed 15, Injured 180.

Full Board to Weigh Recommendations to OSHA, Oil Industry, BP, and Union to Improve U.S. Refinery Safety at Public Meeting Tonight

Houston, Texas, March 20, 2007 - In a 335-page final report released today, federal investigators from the U.S. Chemical Safety Board (CSB) conclude that 'organizational and safety deficiencies at all levels of the BP Corporation' caused the March 23, 2005, explosion at the BP Texas City refinery, the worst industrial accident in the United States since 1990. The report calls on the U.S. Occupational Safety and Health Administration (OSHA) to increase inspection and enforcement at U.S. oil refineries and chemical plants, and to require these corporations to evaluate the safety impact of mergers, reorganizations, downsizing, and budget cuts.

CSB Chairman Carolyn W. Merritt said, 'It is my sincere hope and belief that our report and the recent Baker report will establish a new standard of care for corporate boards of directors and CEO's throughout the world. Process safety programs to protect the lives of workers and the public deserve the same level of attention, investment, and scrutiny as companies now dedicate to maintaining their financial controls. The boards of directors of oil and chemical companies should examine every detail of their process safety programs to ensure that no other terrible tragedy like the one at BP occurs.'

The CSB report calls on BP to appoint an additional member of the board of directors with expertise in process safety, and calls for BP senior executives to establish an improved incident reporting program and use new indicators to measure safety performance.

The independent Baker panel, formed and funded by BP in response to an urgent CSB safety recommendation, issued its final report in January 2007. It found 'material deficiencies' in the safety of BP's five U.S. refineries in Texas, California, Indiana, Ohio, and Washington. The 11-member panel also issued ten safety recommendations, including calling on BP's corporate board to closely monitor safety performance at its facilities. The Baker panel was not charged with determining the root causes of the March 2005 explosion.

CSB Investigation Background

Chairman Merritt said, 'Our investigation of BP was the largest and most complex undertaking in the agency's nine-year history. Under the leadership of Supervisory Investigator Don Holmstrom, the team interviewed 370 witnesses, reviewed more than 30,000 documents, and conducted a far-reaching program of equipment, instrumentation, and chemical testing.' The final report is scheduled to be presented at a CSB public meeting beginning at 6 p.m. tonight at the Nessler Center, Wings of Heritage Room, located at 2010 5th Avenue North in Texas City. The report and recommendations are subject to approval by the full Board at the public meeting.

BP cooperated with the investigation, furnished documents and interviews on a voluntary basis, and committed to widespread safety improvements and investments following the accident. BP published its own report on the explosion in December 2005, pledged the total elimination of the kind of unsafe disposal equipment that led to the explosion, and developed a new siting policy to remove trailers from hazardous process areas. All 15 fatalities occurred in or near trailers that were sited as close as 121 feet from a blowdown drum that vented flammable liquid and vapor directly to the atmosphere.

Safety Harmed by Cost-Cutting, Production Pressures, and Failure to Invest

BP acquired the Texas City refinery when it merged with Amoco in 1999. The CSB report found that 'cost-cutting in the 1990s by Amoco and then BP left the Texas City refinery vulnerable to a catastrophe.' Shortly after acquiring Amoco, the BP Group Chief Executive ordered an across-the-budget 25% cut in fixed spending at the corporation's refineries. The impact of the cost cuts is detailed in many of the more than 20 key investigative documents the CSB made public today, including internal BP safety audits, reviews, and emails. Among other things, cost considerations discouraged refinery officials from replacing the blowdown drum with a flare system, which the CSB previously determined would have prevented or greatly minimized the severity of the accident.

Chairman Merritt said, 'The combination of cost-cutting, production pressures, and failure to invest caused a progressive deterioration of safety at the refinery. Beginning in 2002, BP commissioned a series of audits and studies that revealed serious safety problems at the Texas City refinery, including a lack of necessary preventative maintenance and training. These audits and studies were shared with BP executives in London, and were provided to at least one member of the executive board. BP's response was too little and too late. Some additional investments were made, but they did not address the core problems in Texas City. In 2004, BP executives challenged their refineries to cut yet another 25% from their budgets for the following year.'

Blast Modeling Shows Vulnerability of Temporary Trailers

The March 23 accident occurred during the startup of the refinery's octane-boosting isomerization (ISOM) unit, when a distillation tower and attached blowdown drum were overfilled with highly flammable liquid hydrocarbons. Because the blowdown drum vented directly to the atmosphere, there was a geyser-like release of highly flammable liquid and vapor onto the grounds of the refinery. A diesel pickup truck that was idling nearby ignited the vapor, initiating a series of explosions and fires that swept through the unit and the surrounding area. Fatalities and injuries occurred in and around occupied work trailers, which were placed too close to the ISOM unit and which were not evacuated prior to the startup.

CSB Investigator Mark Kaszniak, who led the CSB's vapor and blast modeling effort, stated, 'The CSB was able to calculate that approximately 7,600 gallons of flammable liquid hydrocarbons - nearly the equivalent of a full tanker truck of gasoline - were release from the top of the blowdown drum stack in just under two minutes.' The ejected liquid rapidly vaporized due to evaporation, wind dispersion, and contact with the surface of nearby equipment. High overpressures from the resulting vapor cloud explosion totally destroyed 13 trailers and damaged 27 others. People inside trailers were injured as far as 479 feet away from the blowdown drum, and trailers nearly 1000 feet away sustained damage.

'Industry trailer siting guidelines did not predict the level of trailer damage that we actually saw,' Mr. Kaszniak stated. In October 2005, the CSB issued an urgent recommendation to the American Petroleum Institute to develop new guidance to prevent trailers from being sited near hazardous areas of refineries and chemical plants, where occupants could be injured or killed. 'A human being is more likely to be injured or killed inside a trailer - which can shatter during an explosion - than if he is standing in the open air. For that reason, occupied trailers have no place near hazardous process areas of refineries and chemical plants,' Mr. Kaszniak said.

Human Factors Analysis: Fatigue, Other Conditions Made Errors More Likely

The tower overfilled because a valve allowing liquid to drain from the bottom of the tower into storage tanks was left closed for over three hours during the startup on the morning of March 23, which was contrary to unit startup procedures. The CSB investigative team examined various conditions and human factors that led to this error.

'BP relied on operators taking correct and timely actions and following procedures to prevent excessive liquid levels in the tower. While procedures are essential to any process safety program, they are the least reliable safeguard to prevent process accidents,' Mr. Kaszniak said. 'Modern control systems utilize automatic safety controls to shut down liquid flow to a tower and prevent dangerous overfilling.'

According to a definition by U.K. safety authorities, human factors are those environmental, organizational, and job-related factors that influence behavior at work and can impact safety performance. CSB Investigator Cheryl MacKenzie, who led the human factors analysis, said, 'Although errors and procedural deviations occurred during the startup, it is important to recognize that individuals do not plan to make mistakes. They are doing what makes sense to them at the time, given the work environment, the organization's goals, and other job-related factors. Understanding and correcting these factors will help prevent future accidents at BP and throughout the industry.'

In particular, the investigation found that procedural deviations, abnormally high liquid levels and pressures, and dramatic swings in tower liquid level were the norm in almost all previous startups of the unit since 2000. Operators typically started up the unit with a high liquid level inside and left the drain valve in manual - not automatic - mode to prevent possible loss of liquid flow and resulting damage to a furnace that was connected to the tower. These procedural deviations - together with the faulty condition of valves, gauges, and instruments on the tower - made the tower susceptible to overfilling, investigators said.

None of the previous abnormal startups was investigated by BP, nor were operating procedures updated to reduce the likelihood or consequences of flooding the tower. As American Petroleum Institute safety guidance notes, when operating procedures are not updated or correct, 'workers will create their own unofficial procedures that may not adequately address safety issues.' At the Texas City refinery, 'Procedural workarounds were accepted as normal,' Investigator MacKenzie said.

On March 23, the control board operator's decision to keep the drain valve closed was influenced by ineffective communication and by false instrument readings from the tower. Alarms and gauges that should have warned of the overfilling equipment failed to operate properly. In addition, the operator believed he had been instructed not to send any liquid from the bottom of the tower to storage tanks, and the CSB determined that these storage tanks were in fact noted as nearly full. 'BP had no policy for effective shift communication or requirements for shift turnover,' Ms. MacKenzie said. 'This important instruction to the operator was given over the phone and was not contained in the log book or the startup procedure.'

Although a high tower liquid level alarm did activate in the control room in the early morning hours, a second high-level alarm malfunctioned and the faulty tower level transmitter later indicated that the liquid level was below nine feet and falling. The normal liquid level in the tower was six-and-a-half feet. Unknown to operators, the level was actually rising rapidly, reaching 158 feet by 1 p.m. on March 23, twenty minutes before the explosion. The CSB determined that the level transmitter was miscalibrated, using a setting from outdated data sheets that likely had not been updated since 1975.

The tower lacked basic process indicators, such as a bottom pressure indicator, that could have provided operators with an accurate picture of the high level inside the tower. The control panel also did not display the flows in and out of the tower on the same screen, and did not automatically calculate how much total liquid was in the tower, even though it could have been configured to do so.

The CSB team used an NTSB methodology to conclude that ISOM unit operators were likely fatigued when the startup occurred. By March 23, operators had been working 12-hour shifts for 29 or more consecutive days. 'Fatigue causes cognitive fixation and impaired judgment and could lead operators to fixate on one operational parameter - such as the apparently declining liquid level - to the exclusion of other indicators,' Ms. MacKenzie said. Fatigue has been recognized as a cause of major accidents in the transportation sector. Fatigue prevention regulations have been developed for aviation and other transportation sectors, but there are no fatigue prevention guidelines that are widely used and accepted in the oil and chemical sector.

The report recommends that the American Petroleum Institute, a leading trade organization, and the United Steelworkers International Union (USW), the largest union representing refinery workers, work together to develop a new consensus standard for fatigue prevention in the oil and chemical industry.

The investigative team also pointed to a significant downsizing that occurred in operations and training at the refinery. Following BP's global 25% cut to fixed costs in 1999, the Texas City Refinery halved the number of control board operators in the ISOM area, from two to one. Then in 2003, the sole remaining operator was given a third process unit to control. Each refinery unit is a complex network of equipment, piping, valves, and instruments. The ISOM unit itself, one of the smaller units of the refinery, was the size of a city block and contained four major subunits. A 2003 BP hazard review recommended that a second operator be present during startups, but this recommendation was never implemented. The 25% budget cut from 1999 also resulted in significant training reductions for operators, and cost pressures prevented the refinery from using simulators to train operators for handling abnormal situations and process upsets.

Refinery Had Longstanding Process Safety Deficiencies

Like other refineries and chemical plants that handle highly flammable, toxic, or hazardous substances, the Texas City Refinery is regulated under the Process Safety Management (PSM) standard of the U.S. Occupational Safety and Health Administration (OSHA). The standard was promulgated in 1992 as a result of provisions in the 1990 Clean Air Act, which responded to major chemical accidents in the U.S. and overseas. The PSM standard requires covered facilities to implement 14 specific management elements to prevent catastrophic releases of hazardous substances. These include hazard analysis, operator training, preventative maintenance programs (mechanical integrity), and management of change reviews.

Investigator Mark Kaszniak stated, 'If the Process Safety Management standard had been thoroughly implemented at the refinery, as required by federal regulations, this accident likely would not have occurred.' Mr. Kaszniak said that numerous requirements of the standard were not being followed in Texas City and cited ineffective incident investigations, lack of effective preventative maintenance, lack of change reviews and pre-startup reviews, and incomplete hazard analyses.

OSHA rules require internal investigations and corrective actions for any serious process incidents or near-misses. But the CSB found that the refinery only investigated three of the eight known previous ISOM blowdown release incidents, where flammable and potentially explosive vapor was released from the same blowdown drum involved in the March 23 accident. In 2004, an internal BP audit graded the refinery's analysis of incident information as 'poor.'

The CSB also determined that both the blowdown drum and the relief valve disposal piping were undersized, which led to the blowdown drum overflowing with liquid. Under the PSM standard, BP was required to conduct a study of the tower's pressure relief system to ensure its safety. Despite the federal requirement, BP was not able to produce any documents indicating the study had even been done. 'By 2005, the required relief valve study was 13 years overdue,' Investigator Kaszniak said. 'Without the study, there was no assurance that the equipment could handle all the credible relief scenarios, including the one that actually occurred on March 23.' The report noted that an internal BP audit from 2004 found that design calculations did not exist for many relief valves at the refinery and that the problem had existed for nearly 10 years.

In October 2006, the CSB issued recommendations to OSHA and API aimed at eliminating similar atmospheric blowdown systems from U.S. refineries and chemical plants in favor of safer alternatives, such as flare systems.

The investigative team also noted a number of problems with the facility's preventative maintenance program that were causally related to the March 23 accident. The report concluded that BP supervisory personnel were aware of the equipment problems with the level transmitter before the March 23 startup but still had signed off on equipment checks as if they had been done, which the report said reflected the prevalence of production pressures at the refinery.

In addition, there was no documented test method for the blowdown drum high-level alarm, which failed to sound on March 23, and the testing method in actual use was contrary to the manufacturer's recommendations. The refinery's computerized maintenance management system allowed maintenance work orders to be closed even if no repair had been done. Many action items from previous hazard analyses and incident investigations - such as a 1994 action item to review the adequacy of the ISOM blowdown system following two serious incidents that year - were never completed.

Dysfunctional Safety Culture Existed at All Levels of BP

For the first time in its nine-year history, the CSB conducted an examination of corporate safety culture. 'As the science of major accident investigations has matured, analysis has gone beyond technical and system deficiencies to include an examination of organizational culture,' Supervisory Investigator Don Holmstrom said. 'Effective organizational practices such as encouraging the reporting of incidents and allocating adequate resources for safe operation, are required to make safety systems work successfully.'

Mr. Holmstrom pointed to the unusual history of fatal incidents at the Texas City Refinery. Over a thirty-year period spanning Amoco and BP's ownership, 23 workers died at the facility - not counting the 15 workers killed in March 2005. 'Many of the safety issues that led to the March 2005 accident were recurring safety problems that had been previously identified in internal audits, reports, and investigations. Our findings show that both BP Group executives and Texas City managers became aware of serious process safety problems at the refinery beginning in 2002 and continuing through March 2005,' Mr. Holmstrom said.

Mr. Holmstrom also cited a series of three serious incidents at the BP refinery in Grangemouth, Scotland, in 2000, which were investigated by the U.K. Health and Safety Executive. BP officials wrote that meeting 'cost targets' played a role in the Grangemouth incidents and stated that 'there was too much emphasis on short term cost reduction - HSE [health, safety, and environment] was unofficially sacrificed to cost reductions, and cost pressures inhibited the staff from asking the right questions.' The lessons from the Grangemouth investigation were not effectively implemented at the Texas City Refinery, however.

Mr. Holmstrom stated that in each year from 2002 to 2005, BP made its own significant findings about the culture and safety of the Texas City site. In 2002, the new refinery manager found the infrastructure and equipment to be 'in complete decline.' A follow-up study by BP found 'serious concerns about the potential for a major site accident' due to mechanical integrity problems. Later in 2002, another internal report explicitly connected the safety problems to earlier cost-cutting, stating, 'the current integrity and reliability issues at TCR [Texas City Refinery] are clearly linked to the reduction in maintenance spending over the last decade.' The prevailing culture at the Texas City refinery was to accept cost reductions without challenge and not to raise concerns when operational integrity was compromised.'

Similar findings were made in 2003, when a study of maintenance found that 'cost cutting measures have intervened with the group's work to get things right - usually reliability improvements are cut.' An external BP safety audit found inadequate training, a large number of overdue action items, and a concern about 'insufficient resources to achieve all commitments.' The report stated that 'the condition of the infrastructure and assets is poor.'

The year 2004 was marked by three major accidents at the refinery, including a $30 million process fire and two other accidents that caused three deaths. Meanwhile, an analysis conducted by BP's internal audit group in London found common safety deficiencies among 35 BP business units around the world, including widespread tolerance of non-compliance with basic health, safety, and environment rules and poor implementation of safety management systems.

'In 2004, BP documents do show that maintenance spending increased, but we found that the increases were largely due to complying with environmental requirements and responding to major accidents and outages. There was still not an adequate focus on preventative maintenance before accidents occurred,' Mr. Holmstrom said. The investigation found that BP's executives relied unduly on injury statistics in assessing the safety of their facilities.

Mr. Holmstrom said. 'BP managers and executives attempted to make improvements from 2002 to 2005 but they were largely focused on personal safety - such as slips, trips, falls, and vehicle accidents - rather than on improving process safety performance, which continued to deteriorate.' The report calls on API and the USW to develop a new consensus standard defining performance indicators for process safety. The consensus process should draw on representatives from industry, labor, government, public interest, and environmental organizations.

Later in 2004, a safety culture survey of the refinery was conducted and endorsed by the site leadership. The study, known as the Telos report, pointed to 'an exceptional degree of fear of catastrophic incidents' among other conclusions, and it stated respondents' belief that 'production and budget compliance gets ... rewarded before anything else.' Finally, a safety business plan for 2005 cited as a 'key risk' the possibility that 'Texas City kills someone in the next 12-18 months.'

'The investigation found that BP executives made spending cuts without assessing the safety impact of those decisions,' Mr. Holmstrom said. The report recommends that OSHA amend its Process Safety Management standard to require companies to perform a management-of-change safety review on organizational changes - including mergers, acquisitions, reorganizations, personnel changes, policy changes, and budget reductions. The CSB report cited previous good-practice guidance from the American Chemistry Council, then known as the Chemical Manufacturers Association, calling for such safety reviews. The report also included a new recommendation to the Center for Chemical Process Safety to develop guidelines for how to conduct the organizational management-of-change reviews envisioned in the recommendation to OSHA.

OSHA Should Increase Petrochemical Inspections, Enforcement

As part of its investigation, the CSB looked at the role of OSHA in inspecting and enforcing safety regulations at refineries and chemical plants. Although the refinery had experienced numerous fatal incidents from 1985 to 2005, the investigation found that OSHA conducted only one planned PSM inspection at the Texas City Refinery, in 1998. Other, unplanned OSHA inspections of the Texas City Refinery occurred in response to accidents, complaints, or referrals; the report said that unplanned inspections are typically narrower in scope and shorter than planned inspections. Proposed OSHA fines during the twenty years preceding the March 2005 disaster - a period when ten fatalities occurred at the refinery - totaled $270,255; net fines collected after negotiations totaled $77,860. Following the March 2005 explosion, OSHA issued the largest penalty in its history to BP, over $21 million for more than 300 egregious and willful violations.

'OSHA's national focus on inspecting facilities with high injury rates, while important, has resulted in reduced attention to preventing less frequent, but catastrophic, process safety incidents such as the one at Texas City,' the report reads. The report found that when the PSM standard was created, OSHA had envisioned a highly technical, complex, and lengthy inspection process for regulated facilities, called a Program Quality Verification or PQV inspection. The inspections would take weeks or months at each facility and would be conducted by a select, well-trained, and experienced team.

The CSB investigation found that few PQV inspections were done between 1995 and 2005. Federal OSHA conducted only nine such inspections in the targeted industries over that ten-year period, and none in the refining sector. State agencies in the 26 states that operate their own workplace safety programs conducted a total of 48 PQV inspections, including six at refineries. However, a number of states - including Texas, Louisiana, and New Jersey, where much of the U.S. oil and chemical industry is concentrated - rely upon federal OSHA to enforce workplace safety rules.

'On average from 1995 to 2005, only 0.2% of the approximately 2,816 facilities in targeted, high-hazard industries received a planned OSHA process safety inspection each year. That's about one planned inspection per 500 facilities,' Mr. Holmstrom said. The total number of U.S. facilities covered under the PSM standard is not known, since covered facilities are not required to identify themselves to the government; however, a similar regulatory program administered by the Environmental Protection Agency covers an estimated 15,000 sites.

The report noted that California's Contra Costa County, which has its own industrial safety ordinance, inspects each covered facility every three years. A county staff of five engineers performs an average of 16 inspections per year. The U.K. Health and Safety Executive, which oversees a much smaller oil and chemical industry than do U.S. authorities, has 105 inspectors for high-hazard facilities; each covered facility in the U.K. is inspected every five years. Although OSHA did not provide requested information to the CSB investigation, available evidence indicates that OSHA has an insufficient number of qualified inspectors to enforce the PSM standard at oil and chemical facilities.

The report calls on OSHA to 'identify those facilities at the greatest risk of a catastrophic accident' and then to 'conduct comprehensive inspections' at those facilities. The report also recommends that OSHA hire or develop new, specialized inspectors and expand the PSM training curriculum at its National Training Institute.

'Rules already on the books would likely have prevented the tragedy in Texas City,' Chairman Merritt said. 'But if a company is not following those rules, year-in and year-out, it is ultimately the responsibility of the federal government to enforce good safety practices before more lives are lost. OSHA should obtain and dedicate whatever resources are necessary for inspecting and enforcing safety rules at oil and chemical plants. These facilities simply have too many potentially catastrophic hazards to be overlooked.'

For more information, please contact a member of the CSB public affairs office:

(1) Daniel Horowitz, (202) 441-6074 cell
(2) Sandy Gilmour (202) 251-5496 cell
(3) Jennifer Jones (202) 577-8448 cell
(4) Hillary Cohen (202) 446-8094 cell
(5) Kate Baumann (202) 725-2204 cell

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A Chronology of the CSB Investigation

March 24, 2005 - CSB investigators arrive at the BP Texas City refinery

March 26, 2005 - The CSB team points out the hazard of placing trailers so close to operating refinery units

April 1, 2005 - CSB investigators make initial entry into the damaged ISOM unit and identify the atmospheric blowdown drum as the likely source of the release

April 28, 2005 - CSB investigators say diminished outflow from an ISOM unit distillation tower resulted in overpressurization and flooding and led to the flammable release during startup

June 28, 2005 - CSB Lead Investigator Don Holmstrom announces that a review of computer records shows that two alarms and a level transmitter, which could have warned operators of the flooded condition of ISOM unit equipment, failed to operate properly in the hours leading to the explosion

July 28, 2005 - The Texas City refinery experiences a serious hydrogen fire in the Resid Hydrotreater Unit that causes $30 million in property damage and forces residents to take shelter

August 10, 2005 - Another incident related to mechanical integrity in the refinery's Gas Oil Hydrotreater forces another community shelter-in-place alert

August 17, 2005 - The Chemical Safety Board issues its first-ever urgent safety recommendation, calling on BP to convene an independent panel to assess safety culture and oversight at all five of its North American refineries

October 24, 2005 - BP announces formation of the 11-member panel of experts, chaired by former U.S. Secretary of State James A. Baker III

October 25, 2005 - The Chemical Safety Board issues new urgent safety recommendations calling on the American Petroleum Institute to develop new safety guidance for the placement of trailers away from hazardous process areas

October 27, 2005 - In preliminary findings released at a public meeting in Texas City, CSB investigators describe a history of abnormal startups in the ISOM unit, previous vapor releases, and mechanical failures; they refer to the unit's blowdown system as 'outdated and unsafe'

November 10, 2005 - CSB Chairman Merritt testifies before the newly established Baker panel, notes the role of worker fatigue and operator downsizing in the accident

December 22, 2005 -The CSB releases a narrated computer animation of the events leading to the accident; the video is viewed in refineries and chemical plants worldwide

June 30, 2006 - The CSB releases blast damage information for 44 trailers located near the ISOM unit; notes serious damage to a distance of almost 600 feet from the center of the explosions

October 15, 2006 - The CSB issues a safety bulletin based on the July 28, 2005, hydrogen fire, calling for expanded use of positive material verification to prevent accidental releases

October 30, 2006 - CSB Chairman Merritt releases new preliminary findings from the investigation, pointing to the role of organizational factors and cost-cutting in setting the stage for the accident

October 31, 2006 - The CSB issues new safety recommendations, calling on the U.S. oil industry to eliminate the use of unsafe blowdown drums similar to the one involved in the Texas City accident and calling on OSHA to establish a refinery special emphasis program to promote the replacement of the drums with safer alternatives

January 16, 2007 - The independent refinery safety panel chaired by Secretary Baker issues its final report at a news conference in Houston, revealing systemic safety problems in BP's North American refineries

March 20, 2007 - At a public meeting in Texas City, the CSB releases its final investigation report and recommendations, three days prior to the second anniversary of the explosion

This message was transmitted at 11:06 AM Eastern Time (U.S.A.) on March 20, 2007.

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Visit the CSB on the World Wide Web at http://www.csb.gov

Posted by Mark at 11:55 AM | Comments (1)

CSB's BP Texas City Explosion Root Cause Analysis Report to be Released Today. Carolyn Merritt's Speech Foreshadows Report at NPRA Meeting

In an article from the Houston Chronicle, I found the following quotes from a speech at the National Petroleum Refiner's Association made by Carolyn Merritt, Chairperson of the Chemical Safety Board:

The "ineffective or nonexistent" oversight of safety by the British oil company's board of directors also played a direct role...

"Somebody has to be asking the question: 'What is happening, and is this being done?' " ... Yet those questions were rarely asked, she said.

With this information foreshadowing the report to be released today by CSB, BP's management should be ready for a report that will be highly critical of their safety management efforts.

Posted by Mark at 09:27 AM | Comments (0)

March 19, 2007

CSB Root Cause Analysis Report on BP Texas City Refinery Explosion to be Released Tomorrow

For more info see:

http://www.taproot.com/blog/2007/03/csb_to_release_root_cause_anal.html

Posted by Mark at 12:01 AM | Comments (0)

March 12, 2007

Monday Accident & Lessons Learned: Failure To Do Root Cause Analysis and Take Corrective Action Costs DaimierChrysler $50 Million in One Lawsuit

What can you and your executive team learn from this press release from Lieff Cabraser Heimann & Bernstein, LLP? Read the release and see...

$55 Million Verdict Imposed Against DaimlerChrysler Corporation For Failing To Fix Known Transmission ``Park-to-Reverse'' Defect That Killed Young Father At San Pedro/Long Beach Maritime Terminal

-- Millions Of DaimlerChrysler Vehicles In Use With Similar Park-to-Reverse Defect

Robert J. Nelson, Scott P. Nealey, and Chuck Naylor, counsel for Adriana Mraz and her three children in a wrongful death action against DaimlerChrysler Corporation, announced that a California-state jury today returned a $50 million punitive damages award against DaimlerChrysler for knowing and intentional failure to cure a defect in millions of its vehicles. On March 2, 2007, the same jury found DaimlerChrysler liable for the death of Richard Mraz and returned a verdict of $5.2 million in compensatory damages for Mrs. Mraz and her children.

On April 13, 2004, Mr. Mraz suffered fatal head injuries when the 1992 Dodge Dakota pickup truck he had been driving at his work site, the San Pedro/Long Beach Maritime Terminal, ran him over after he exited the vehicle believing it was in park. The jury found that a defect in the Dodge Dakota’s automatic transmission, called a park-to-reverse defect, played a substantial factor in Mr. Mraz’s death, and that DaimlerChrysler was negligent in the design of the vehicle, for failing to warn of the defect, and then for failing to adequately recall or retrofit the vehicle.

“Richard was a loving husband and father who was just 38 years old when he died,” stated Adriana Mraz. “He struggled for 17 days to stay alive after the accident and never regained full consciousness. When I found out many people have been injured by the same defect, and some even killed, I was determined to hold DaimlerChrysler accountable. I am deeply grateful to the members of the jury for their hard work and for sending a strong message to DaimlerChrysler that it must finally fix the defect in millions of its vehicles.”

“Mr. Mraz died and left behind a wife and three children because DaimlerChrysler put short-term profits ahead of the safety of its customers,” commented Robert J. Nelson. “Had DaimlerChrysler dealt with the defect many years ago when customers first complained about park-to-reverse problems, Mr. Mraz and others would be alive today.”

Plaintiff's co-counsel Scott P. Nealey noted, “The evidence was clear that the park-to-reverse defect in the Dodge Dakota, Ram, and Jeep Grand Cherokee allows a driver such as Mr. Mraz to place their vehicle into what appears to be the park position. The vehicle does not move when the driver pulls their foot from the brake, but in fact, the transmission is between gears. From this position, the vehicle can have a dangerous delayed engagement of powered reverse after a few seconds or an even longer period."

The evidence presented at trial included that DaimlerChrysler had received well over a thousand park-to-reverse complaints, including complaints with 1988 through 2003 Dodge Dakotas, certain 1988 through 2006 Dodge Rams, and certain 1993 through 2004 Jeep Grand Cherokees, over a period spanning more than a decade before Mr. Mraz was killed. These complaints were based on same common defect. Senior management at DaimlerChrysler, however, failed to investigate the full extent of the problem out of fear it could expose the corporation to liability for injuries that had already occurred and it would require a massive recall.

Plaintiffs’ counsel introduced evidence that the defect could have been remedied with corrective action, which would have meant conceding a safety-related defect in much of DaimlerChrysler’s fleet. Faced with this expensive prospect, DaimlerChrysler never had its engineers conduct the “root cause analysis,” or utilize the type of design failure mode effects analysis required as vehicle designs change — which would have quickly isolated the failure in its design and identified a proper fix.

“When DaimlerChrysler finally determined that it had to do something about the problem in 2000 due to an ongoing NHTSA investigation, it chose to issue

TapRooT® Blog Category Archive

July 10, 2007

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July 03, 2007

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June 27, 2007

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June 19, 2007

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June 18, 2007

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June 16, 2007

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June 14, 2007

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June 11, 2007

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June 08, 2007

CSB Root Cause Investigation of Fatal Convenience Store Explosion Progresses

June 05, 2007

Deadly Train Wreck in Australia

May 31, 2007

BP's Top Refining Executive Departing for Another Job

May 24, 2007

US Government May Stop Paying Hospitals Extra for Common Medical Errors

May 21, 2007

Monday Accident & Lessons Learned: Can BP Learn from Texas City and Alaska Pipeline Failures

May 16, 2007

A Few More Photos of the Buncefield Fire

May 14, 2007

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May 07, 2007

Monday Accident & Lessons Learned: Do Heads Need to Roll to Make People Happy?

May 04, 2007

Houston Chronicle Story About Internal BP Texas City Explosion Firing Recommmendations

April 30, 2007

Tank Explosion Video

April 16, 2007

Monday Accident & Lesson Learned: The Deposition

April 09, 2007

Monday Accident and Lessons Learned: Safety Engineer Killed During Preparation for Safety Training

April 02, 2007

Monday Accident and Lessons Learned: Root Cause Analysis is Essential ... Network Rail Fined £4 Million for Paddington Rail Disaster

March 27, 2007

Should We Criminalize Bad Safety Management? Is There a Better Option?

CSB Root Cause Analysis of BP Texas City Explosion is posted at the CSB Web Site

March 26, 2007

Monday Accident & Lessons Learned: Keep Up With Incidents Around the USA

March 22, 2007

CSB to Post BP Texas City Explosion Root Cause Analysis Report and Recommendations Next Week

March 21, 2007

Deposition of BP Exec Shows How Hard It Is To Justify Performance After an Accident

UK HSE Published Thermal Oxide Reprocessing Plant (THORP) Leak Investigation and Consent to Restart

March 20, 2007

Was Cost Cutting a Root Cause of the BP Texas City Explosion? This Will Be the Major Controversy of CSB Report According UK Press

Was Fatigue a Root Cause of BP Texas City Explosion?

More on the Upcoming CSB Root Cause Analysis Investigation Report

BP Texas City Refinery EXPLOSION - CSB Press Release About Final Root Cause Analysis Report

CSB's BP Texas City Explosion Root Cause Analysis Report to be Released Today. Carolyn Merritt's Speech Foreshadows Report at NPRA Meeting

March 19, 2007

CSB Root Cause Analysis Report on BP Texas City Refinery Explosion to be Released Tomorrow

March 12, 2007

Monday Accident & Lessons Learned: Failure To Do Root Cause Analysis and Take Corrective Action Costs DaimierChrysler $50 Million in One Lawsuit