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 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.

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

---

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.

_______________________________________________

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 a ‘voluntary recall’ of the Dodge Dakota in 2000 to install a "fix" that its safety office knew, and its engineers testified at trial they knew, did not fix the park-to-reverse problem,” stated Mr. Nealey. “The result is that today over a million vehicles, including 1988 to 2003 Dodge Dakota pickup trucks, on the road with the same defect that caused the death of Mr. Mraz.”

At trial, plaintiffs introduced into evidence a 1999 memorandum written by Antonius Brenders, Senior Manager in the Vehicle Safety Office at DaimlerChrysler. In the memo, Mr. Brenders discussed the pros and cons of doing a survey that the National Highway Transportation Safety Agency sought to determine the cause of the park-to-reverse incidents. One of the cons to doing such a survey was that doing so could provide “[p]roduct liability credence to a hypothesis we have long ignored” and “continually challenge.” This “smoking gun” document showed that DaimlerChrysler refused to properly investigate the cause of all the accidents, including deaths, for liability reasons.
Chuck D. Naylor, a maritime lawyer in San Pedro, California, originally represented Mrs. Mraz. Later, Scott P. Nealey and Robert J. Nelson of Lieff Cabraser Heimann & Bernstein, LLP, joined with Mr. Naylor in the representation due to their extensive expertise in vehicle defect litigation.

"Hopefully, the verdict will cause DaimlerChrysler to change its conduct and save the lives of others," noted Chuck D. Naylor. "Working as a team with Lieff Cabraser’s expertise on the defect issues and my expertise on the long shore aspects of the case was key to the successful resolution of the lawsuit.”

Reporters who wish to obtain a copy of the jury verdict and 1999 memorandum referred to above should contact attorney Stephen Cassidy at 415-956-1000 or by email at scassidy@lchb.com.

Vehicle owners who wish to learn more and contact plaintiffs’ counsel to report any injuries they have suffered as a result of the park-to-reverse defect should visit www.vehicle-injuries.com

About Lieff Cabraser

Lieff Cabraser Heimann & Bernstein, LLP is a fifty-plus attorney law firm that has represented plaintiffs nationwide since 1972. We have offices in San Francisco, New York and Nashville. We represent plaintiffs in class and group actions and in individual lawsuits in cases involving substantial injuries. For the last four years, the National Law Journal has selected Lieff Cabraser as one of the top plaintiffs' law firms in the nation.

Posted by Mark at 04:00 PM | Comments (0)

CSB to Conduct Full Investigation of Valero McKee Refinery Fire

Press Release from the CSB

Sunray, Texas, March 9, 2007 - The U.S. Chemical Safety Board today announced it is conducting a full investigation of the propane fire that occurred February 16 at the Valero McKee Refinery here, seriously burning three workers and forcing the shutdown of the facility. One worker who was critically injured remains hospitalized.

'At a time when our gasoline refining capacity is stretched thin, the fire at the Valero McKee Refinery underscores how just a single supply disruption can impact what Americans pay at the pump,' said CSB Chairman Carolyn W. Merritt, announcing the new investigation. 'All of us have a strong stake in preventing such accidents that cause both human suffering and economic hardship.'

CSB investigators have been working at the site since February 18. The team has interviewed numerous witnesses and made multiple entries into the area where the fire originated. Today, the remaining four investigators, including Lead Investigator Jim Lay, PE, are returning to Washington, DC, to continue the analysis of evidence gathered at the site. The team will return to the refinery as needed to conduct follow-up interviews and oversee the testing of key pieces of equipment

'The exact mechanical failure that led to the propane release remains to be identified,' Mr. Lay said. 'Further modeling and testing of piping, valves, and flanges will be needed to determine precisely what happened.' Investigators had said earlier that the release of propane liquid and vapor occurred in the refinery's propane deasphalting unit, which uses high-pressure propane to extract refinable substances from crude unit residues.

Mr. Lay said that Valero has been cooperating with the investigation and has provided drawings, written procedures, and testing and inspection records in response to CSB document requests. The CSB, OSHA, and Valero have entered into a written agreement to ensure the preservation and orderly testing of relevant evidence.

'Once the propane was released and ignited, the fire spread rapidly,' Mr. Lay said. 'Within minutes, a critical piping rack -- on which some of the support beams had not been fireproofed -- collapsed, breaking open pipes and adding fuel to the blaze. Operators could not access locally controlled pumps to shut them down or activate manually controlled firewater deluge valves and nozzles to cool exposed equipment. The rapid increase in the intensity of the fire led facility managers to pull emergency responders back and evacuate the refinery.'

Several one-ton cylinders of chlorine were damaged and released their contents, while a spherical propane storage tank was exposed to sufficient heat to damage its paint.

'As shown in the CSB's recent investigation of the fire at the Formosa Plastics Corporation Point Comfort complex, effective fireproofing and remote shutdown and deluge system capability are critical for keeping a fire contained and preventing catastrophic impacts on a facility,' Chairman Merritt said. 'We will be examining the design and layout of equipment at this refinery to determine if there are lessons for other facilities.' Valero acquired the McKee Refinery in 2001 when it purchased Ultramar Diamond Shamrock.

For more information, members of the news media should contact Daniel Horowitz at (202) 261-7613.

Posted by kenreed at 03:21 PM | Comments (0) | TrackBack

March 10, 2007

BP Annual Report Reveals Subpoenas for BP Texas City Refinery Blast and Bonus Cuts for Execs - More Reasons to Proactively Improve Performance by Using Advanced Root Cause Analysis

It's been almost two years since the March 23, 2005, explosion and fire at the BP Texas City Refinery, but the bad news hasn't stopped. Continuing bad publicity is just one of the many ignored costs of a major accident.

The most recent bad publicity came from BP's recently released 2006 Annual Report. BP had several references to the explosion, including: federal investigations (EPA, OSHA, and CSB), the Baker Commission Report, and an ongoing criminal investigation by the US Department of Justice. Newspapers picked up on a paragraph on Page 28 of the Annual Report that revealed that the Justice Department had issued subpoenas to BP for documents and testimony in a grand jury criminal investigation.

Also detailed in the report was pay for high level executives at BP. Again, reporters picked up on the fact that even though financial performance at BP was excellent for the year, outgoing CEO John Browne's total compensation was cut by almost $2 million dollars (28% according to an AP story in the Houston Chronicle).

The Chemical Safety Board had announced that it will release it's long awaited investigation root cause analysis report on March 20. This will no doubt mean another round of negative stories.

So what do you need to do to convince your management team to improve safety performance? Perhaps an example of potential criminal investigations and big pay cuts for executives will get their attention. Certainly these are more reasons among the many obvious reasons that companies should do everything in their power to prevent major accidents by using advanced root cause analysis proactively to improve performance before accidents occur.

For more on PROACTIVE use of root cause analysis to prevent accidents click on the button for the schedule of the Proactive Improvement Best Practices Track at the TapRooT® Summit.

Posted by Mark at 12:56 PM | Comments (0)

March 07, 2007

CSB To Release Root Cause Analysis of BP Texas City Refinery Explosion at Public Meeting on March 20

Board to Convene March 20 Public Meeting in Texas City, Texas, to Release and Vote upon Final Report on BP Refinery Disaster

March 7, 2007 - The U.S. Chemical Safety Board (CSB) announced today that it will convene a public meeting on the evening of Tuesday, March 20, 2007, at the Nessler Center in Texas City, Texas, to release its final investigation report on the explosion at the nearby BP refinery that took 15 lives and injured 180 on March 23, 2005.

The meeting will begin at 6 p.m. central time at the Nessler Center's Wings of Heritage Room, 2010 5th Avenue North, Texas City, TX 77590, (409) 643-5990. The Nessler Center is adjacent to the Doyle Convention Center, near city hall.

The meeting is open to the public, and there is no fee or pre-registration required to attend. The CSB investigative team will present its final draft report on the tragic explosion and will answer questions from the CSB board members in the public forum. The Board will then ask for any public comments on the report before proceeding to an expected vote on whether to approve the report and safety recommendations.

The March 2005 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, causing a series of explosions and fires. Fatalities and injuries occurred in and around work trailers that were placed too near the ISOM unit and were not evacuated prior to the startup. It was the worst industrial accident in the United States since 1990.

The final report of the investigative team will detail the root causes of the accident, including technical, organizational, and human factors, and will include a number of new safety recommendations.

For more information, members of the news media should contact Jennifer Jones at (202) 261-3603 or Hillary Cohen at (202) 261-3601.

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

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

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 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

This message was transmitted at 2:38 PM Eastern Time (U.S.A.) on March 7, 2007.

To visit the CSB's BP Texas City Refinery Investigation Page see:

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

Posted by Mark at 04:18 PM | Comments (0)

February 28, 2007

CSB Final Report on Chlorine Release at DPC Enterprises in Glendale, Arizona

Report Notes Company's Lack of Engineering Safeguards

Phoenix, Arizona, February 28, 2007 - In a final report issued today, the U.S. Chemical Safety Board (CSB) concluded that insufficient safety margins, a lack of engineering safeguards, unclear procedures and training, and an absence of published guidance were among the causes of a release of up to 1,920 pounds of chlorine from the DPC Enterprises facility in Glendale, Arizona, on November 17, 2003.

The CSB report makes 14 recommendations to the company, local municipalities, and the Chlorine Institute.

CSB Board Member John Bresland said, 'Our investigation revealed several factors that led to the release. Chlorine is a highly toxic substance that needs appropriate safeguards to prevent releases and protect the public, facility personnel, and emergency responders.'

On the day of the accident, excess chlorine vented to a scrubber where it completely depleted the active scrubbing material (caustic soda), over-chlorinating the scrubber. The resulting decomposition reaction vented chlorine vapors to the atmosphere. Hazardous emissions continued for about six hours and led to the medical evaluation of five residents and 11 police officers, and the evacuation of 1.5 square miles of Glendale and Phoenix.

One of the root causes determined by the CSB is that DPC's single administrative safeguard, an operating procedure, did not adequately address the risk of over- chlorinating the scrubber. CSB Lead Investigator Jim Lay said, 'It is necessary to integrate appropriate layers of protection into all processes handling hazardous chemicals. In this case, we recommended that DPC adopt safety features such as additional interlocks, automatic shutdowns, and mitigation measures to prevent the release of chlorine to the atmosphere due to over-chlorination.'

The CSB previously investigated an August 2002 incident at the DPC Enterprises facility in Festus, Missouri, that led to the release of 48,000 pounds of chlorine, causing three workers and 63 residents to seek medical treatment.

The CSB report released today makes a total of 14 safety recommendations, including the following:

- Maricopa Department of Air Quality should revise DPC's permitted operating conditions to specify minimum scrubber caustic concentration;

- The Glendale Fire Department and Police Department should better integrate their incident command structure, improve communication, and hold joint hazmat training exercises;

- The Chlorine Institute, a technical research and safety institute for manufacturers and distributors of chlorine, should modify its 'Chlorine Scrubbing Systems, Pamphlet 89' and other pertinent publications to address safety issues associated with over-chlorination;

- DPC should modify its corporate engineering standards to require layers of protection on chlorine scrubbers at DPC facilities.

For further information, contact Dana Arnold (602) 402-2200 cell (Phoenix) or Hillary Cohen (202) 446-8094 cell (Phoenix), or Daniel Horowitz, in Washington DC, at (202) 261-7613 or (202) 441-6074 (cell).

Posted by kenreed at 10:19 PM | Comments (0) | TrackBack

February 27, 2007

Bus Crash near Uppsala, Sweden - The cause of the crash was not immediately clear...

AP/CNN reported that six people were killed and fifty people were injured in a bus crash near Uppsala in Sweden.

The story had an interesting quote:

"The cause of the crash was not immediately clear ..."

Those who analyze root causes know that this is ALWAYS true immediately after an accident. Even if you think the cause is obvious ... you are probably wrong! Finding root causes requires careful, systematic analysis of the facts.

For the complete story see:

http://www.cnn.com/2007/WORLD/europe/02/27/sweden.bus.crash.ap/index.html

Posted by Mark at 01:31 PM | Comments (0)

February 26, 2007

UK Train Wreck Interim Report by RAIB

The Rail Accident Investigation Branch in the UK has completed an Interim Report of the train derailment at Grayrigg, Cumbria, UK. Pretty amazing amount of information for a report turned around so quickly (the accident was Friday).

Download report at:

http://www.raib.gov.uk/publications/interim_reports/070226_I012007_grayrigg.cfm

Posted by Mark at 01:00 PM | Comments (0)

Monday Accident & Lessons Learned - Pipeline Safety Incidents

Interested in databases of pipeline incidents? See the PHMSA web site:

http://ops.dot.gov/stats/IA98.htm

See what lessons you can learn from others mistakes.

Posted by Mark at 12:28 AM | Comments (0)

February 24, 2007

More on the Friday Train Derailment in the UK

For the latest on the investigation and root cause analysis, see the Rail Accident Investigation Branch Web Site:

http://www.raib.gov.uk/publications/current_investigations_register/070223_grayrigg.cfm

The RAIB will publish a report at the conclusion of its investigation. The report will be available at the RAIB website. You can subscribe to automated emails notifying you when the RAIB publishes its reports. See:

http://www.raib.gov.uk/publications/newsletter_subscription.cfm

Posted by Mark at 06:44 PM | Comments (0)

What will the Courts Say About Testimony of BP CEO?

The investigations, root cause analysis, and lawsuits continue. On the lawsuit side of the accident, read about the latest legal maneuvering at:

http://www.chron.com/disp/story.mpl/business/4578434.html

Posted by Mark at 06:34 PM | Comments (0)

February 23, 2007

Virgin Train Derails in UK

The Virgin Train from London to Glasgow derailed Friday night. For intial information see:

http://www.guardian.co.uk/transport/Story/0,,2020412,00.html

We'll be waiting for reports on the root causes of the derailment.

Posted by Mark at 04:54 PM | Comments (0)

February 22, 2007

CSB Statement Concerning Valero McKee Refinery Fire

Statement of CSB Supervisory Investigator Don Holmstrom Updating the Public on the Investigation of the Valero McKee Refinery Fire

February 21, 2007 3:30 p.m. CST
Amarillo, Texas

Good afternoon and thank you for coming to this public briefing of the U.S. Chemical Safety Board. I have a prepared statement, and then I will take some questions.

We may have some reporters joining us by conference call; since there are some TV cameras here I'll ask everyone to hold their questions until I reach the end of the statement, and I'll ask those of you on the phone to mute your microphones if possible.

My name is Don Holmstrom, H-O-L-M-S-T-R-O-M. I am the supervisory investigator who has been here with our field team at the Valero McKee refinery near Dumas.

The Chemical Safety Board is an independent federal agency, established and funded by Congress in 1998. Our board members are appointed by the president and confirmed by the Senate, and we are structured similar to the National Transportation Safety Board.

The CSB conducts independent, scientific root-cause investigations of major chemical accidents. We do not issue fines, citations, or new rules but we do issue safety recommendations designed to prevent future chemical accidents across the country.

We issue lengthy, public reports on the root causes of accidents, and you can find examples of these report and much other information on our website, CSB.gov. You can also sign up there to get regular updates on our work, including this investigation, by email.

Many of you may know the CSB from our investigation of the major refinery explosion at BP Texas City back in 2005, which we plan to complete within the next month. In its history, the CSB has conducted more than 40 such investigations of major accidents at oil refineries, chemical plants, and other industrial facilities that handle or produce hazardous substances.

A five-member CSB team arrived in Texas late Saturday and began its work at the Valero McKee refinery early Sunday morning. We will be augmenting our team with several additional investigators this week; I will be returning to Washington this evening and briefing the agency on the investigation.

At the point, we proceeding with our accident investigation on multiple fronts, but no formal decision has been taken by the Board on the scope of the inquiry. If we do proceed to an investigation to determine the root causes of this accident, it may be a year-long process. However, we will continue to update the public on our progress as events warrant.

As all of you know, a major fire occurred at the Valero McKee refinery on Friday afternoon, causing more than a dozen injuries. One contract worker, who was critically injured, remains hospitalized. All of the CSB express our sincere hope for his recovery.

Yesterday, CSB investigators inspected the scene of the fire, approaching to within about 200 feet of the fire affected area. We plan to make closer approaches over the next several days as soon as we can assure the safety of our investigators.

The CSB team observed substantial heat damage to equipment and piping in a section of the Propane De-Asphalting or PDA unit.

The PDA unit uses propane to extract refinable materials from a heavy residue of the refinery's crude oil unit. The PDA unit uses propane that is liquefied under high pressure of several hundred pounds per square inch.

No explosion damage was visible from our location. A pipe rack exposed to the fire was heavily damaged and deformed by the fire.

We do not have any estimate on how this damage might impact the restart of the refinery - which is outside the scope of our work -- and we would refer all questions on that issue to Valero.

We have interviewed many eyewitnesses to the accident. The testimony suggests that there likely was a release of liquid propane. At atmospheric pressure, liquid propane rapidly vaporizes and expands to form a vapor cloud. This cloud ignited a short time later.

We are continuing to interview refinery employees and contractors. We are also examining documents provided by the company. Valero is cooperating with the CSB investigation.

Based on interviews, we are particularly interested in a specific area in the north section of the PDA unit, which was the likely location of the initial release. Confirming this as the location will require closer examination. This area was heavily damaged by the fire and has not yet been inspected by the CSB. We plan to enter this area in the very near future, and we plan to inspect specific valves, piping, and equipment in this area.

Near the PDA unit there were a series of large propane storage spheres. We did not observe any visible damage to these spheres from the fire.

However, there were three one-ton chlorine cylinders nearby that were exposed to the fire and some of the contents of the cylinders were likely released. Chlorine is a toxic gas. We understand that these cylinders have now been secured by Valero.

Our investigation continues. Team members continue to interview witnesses and to request additional documents from the Company. We will maintain a team at the site through this weekend and into next week.

That concludes my prepared statement. I'll now be happy to take some questions from the media. Please state your name and affiliation. Reporters who are on the conference line are also welcome to ask questions; please just wait for a convenient pause and ask me to call on you.

[For more information, please contact Director of Public Affairs Daniel Horowitz in Washington, DC, (202) 261-7613 / (202) 441-6074 cell.]

Posted by kenreed at 11:43 AM | Comments (0) | TrackBack

Monday Accident & Lessons Learned - Pipeline Safety Incidents

Interested in databases of pipeline incidents? See the PHMSA web site:

http://ops.dot.gov/stats/IA98.htm

See what lessons you can learn from others mistakes.

Posted by Mark at 07:28 AM | Comments (0)

February 20, 2007

Chevron Richmond Refinery Reports to Contra Costa County on Crude Unit Fire

Chevron Richmond crude unit fire picture from the story below...

For the news article see:

http://cbs5.com/local/local_story_050104400.html

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

February 19, 2007

Monday Accident & Lessons Learned: Cost of an Investigation - CSB Spends More Than $2 Million Investigating BP Refinery Explosion

People of ask me, how long does it take and how many resources should we use investigating an accident and performing a root cause analysis?

Of course, the answer is: "It depends."

What does it depend upon? Here are just some of many factors:

The complexity of the accident.
Your knowledge of the site.
Your skill in performing investigations
The amount of documentation and proof you must produce.

But the answer for the CSB's investigation of the BP's Texas City Refinery explosion is: "Over $2 million dollars."

Where does the $2 million figure come from? From a comment by the CSB Chair & CEO, Carolyn Merritt.

Will the investment be worthwhile? We'll have to wait for the report to come out to see.

Posted by Mark at 12:15 AM | Comments (0)

February 15, 2007

Evidence Preservation - a Legal Perspective

I've been doing some research for the revision of the TapRooT® book and came across this very interesting article - written from a legal perspective - about evidence preservation and attorney/client privilege. If you think that your company might end up being sued over an accident, you should read this:

http://www.hollandhart.com/articles/Preserving_Evidence_of_Disaster.pdf

Posted by Mark at 12:56 AM | Comments (0)

February 12, 2007

Monday Accident and Lessons Learned: BP News from Reuters/CNN - BP Cuts '07 Forecast

These are the kind of quotes you don't like to see about your company:

"But the company's pessimistic outlook comes as BP struggles to regain investor confidence after a series of safety, environmental and legal problems in the U.S. and weeks after Chief Executive John Browne sought to address uncertainty over the firm's leadership by announcing he would step down 17 months early."

"The rise in BP's capex also reflects higher spending on safety at U.S. refineries where fatal accidents occurred, after internal and government investigations identified safety failings."

They are from a Reuters/CNN story.

They are one of the "costs" of an accident that aren't considered in most accident cost calculations.

How much BP has spent on advertising to improve its image? I remember a series of "environmental" adds by BP. And how much will they have to spend to recover their image after negative press like that quoted above?

The lesson learned here is fairly obvious. And ounce of prevention can sometimes be worth way more than a pound of cure. Or as another old saying goes ... Penny wise, Pound foolish.

The money saved skimping of safety initiative at BP's refineries and on pipeline maintenance on the North Slope were the pennies saved. The fines, losses of production, and PR black eye costs are the Pounds that will be paid after these accidents.

Whenever someone has an idea that cutting safety spending is an effective tool for increasing short term earnings, remember this example.

Posted by Mark at 02:54 PM | Comments (0)

February 05, 2007

Monday Accident and lessons Learned: Do Criminal Charges Stop Accidents? Do they Address the Root Causes???

See: http://www.cnn.com/2007/LAW/02/05/boat.overturned.ap/index.html

Do you think the criminal charges are addressing the root causes of this accident?

How would you know?

Are criminal charges revenge or do they keep future accidents from happening?

In this case they are charging the owner with having too FEW crew on board and OVERLOADED boat. The requirement was to have two crew on board. They only had one.

How would have an additional crew member kept an overloaded boat from overturning?

By the way, the boat was loaded to its "certified" maximum load minus the one crew member. But the certification was outdated after modifications had made that reduced the boat's stability.

Posted by Mark at 06:42 PM | Comments (0)

February 02, 2007

It's all fun and games until someone gets hurt...

Here's an example of "Range Safety Gone Bad"...

How close was THAT! Reading through the post, this thing apparently buried itself 4 feet into the ground.

Supposedly, they were following all the safety rules that had been agreed upon and put into place before the event. But when those safeguards failed, I wonder what was done immediately following the cratering event? Were people moved back? Were other failure modes analyzed? (In this case, the parachute failed to open, which would have caused the missile to land down-wind). Were any other assessments done, or did they launch another one 10 minutes later?

Posted by kenreed at 01:29 PM | Comments (0)

January 31, 2007

Rocket Explosion on the Pad

A rocket being launched from an ocean-going launch pad exploded a couple seconds after main engine ignition. Root Cause analysis is just beginning.

Sealaunch 1.png

Sealaunch 2.png

Sealaunch 3.png

Watch the video:

Posted by kenreed at 07:37 AM | Comments (0)

January 30, 2007

Are You Hungry for TapRooT® - Using TapRooT® to Improve Food Safety

Kevin McManus, a TapRooT® Instructor, has written an article about improving food safety by using TapRooT® to investigate food safety incidents. With all the high profile incidents that have received so much bad press (and cost the industry hundreds of millions in lost sales), food processing facilities should be interested in new ways to improve performance. If you are interested, see:

http://www.greatsystems.com/hungry.html

Posted by Mark at 12:07 AM | Comments (0)

January 22, 2007

Investigator: Controllers share blame in Brazil crash

In September of last year, a small business jet collided with a Boeing 737 over the Amazon rain forest, killing all those on-board the 737. Initial reports indicate that the pilots of the business jet, which landed safey, will share the blame for the collision with air traffic contollers. Questions still remain as to why the jet’s collision warning system was not working, and why the pilots were not following their flight plan. See the story here:

Investigator: Controllers share blame in Brazil crash - CNN.com.

Posted by kenreed at 11:41 PM | Comments (0) | TrackBack

January 17, 2007

Arc Flash Injuries

Arc_flash A recent report from a DOE site discussed an injury sustained by an electrician operating a hi-voltage switch on the front panel of a 480V switchboard. A ground fault in the down-stream circuit cause a fire-ball to exit the vents on the switchboard when the switch was shut, causing serious burns and eye injury. The report stressed that, if the electrician had been wearing proper PPE (flame-retardant shirt, safety glasses), his injuries would have been much less severe.

First, I’d like to stress that I don’t disagree with that particular finding. Wearing proper PPE is an important safeguard in any potentially–hazardous process. However, buried near the end of the report, other findings were mentioned:

– By the way, the ground detector that was installed didn’t work.

– By the way, preventive maintenance was not scheduled for the ground detector.

– By the way, the ground detector was the wrong type.

– By the way, PPE requirements were not posted on the panel as required.

– By the way, work control procedures already in place were not followed.

Arc Flash PPE

These are the kinds of things that you can easily find with a frequent, comprehensive proactive audit plan. It is good to see that these problems were found by the investigating team. It would have been even better if they had been found by an audit team. Compare your work practices with industry standards, such as NFPA 70E: Electrical Safety in the Workplace. Take a look at your high-voltage, hazardous operations, and see if you have the right controls in place. Everything may seem to be operating just fine, until an unknown failure pushes the deficiencies in work control to your attention. Don’t wait for the fire-ball to find you.

Posted by kenreed at 05:02 PM | Comments (0) | TrackBack

January 16, 2007

Mark's Computer Hard Disk Goes Clunk

You know you had a bad day when:

1. Your hard disk crashes.

2. You replace the hard disk and try to load your "daily" automatic backup and it's blank.

3. You load your last "complete" automatic backup (about three weeks old) and it is blank too.

4. You finally find a backup that's not blank and it is 4 months old.

5. You send the broken hard disk off to the people who are the experts in disk recovery and they say - "Sorry - it's unrecoverable."

That's what happened to me last week.

Luckily, I have a wonderful staff and they are helping me recover.

But for now, I won't be posting on the blog or responding to routine e-mails.

Ken and Barbara will be keeping you up-to-date on the blog.

Barbara will be answering my e-mails.

And I will be on a one month sabbatical to get the new version of the TapRooT® Book completed.

By the way, the book writing process is going well and I will post some samples on this blog as we progress.

As for our "investigation" of the failure, it is complete and the corrective actions have been implemented. Next time, there will be a backup and an additional backup. And they will be checked as working appropriately on a weekly basis.

Posted by Mark at 01:15 PM | Comments (0)

BP Texas City Refinery: Independent Panel Final Report

The BP Refineries Independent Safety Review Panel, headed by former Secratary of State James Baker, has released its final report concerning the circumstances around the 2005 explosion. The 374 page report is located here.

The Review board was convened at the request of the Chemical Safety Board, and included many distinguished members, including the former head of the U.S. Navy’s Nuclear Propulsion Program, Admiral Skip Bowman, and former Washington State Senator Slade Gorton.

Posted by kenreed at 12:14 PM | Comments (1) | TrackBack

January 15, 2007

Texas City report due out tomorrow

A safety panel headed by the former U.S. Secretary of State James Baker and commissioned by the U.S Chemical Safety Board is due to release its report on Tuesday. No other details are yet available.

http://money.cnn.com/2007/01/15/news/companies/bp/index.htm?section=money_email_alerts

Posted by kenreed at 11:28 AM | Comments (0) | TrackBack

December 22, 2006

FRIDAY JOKE: Christmas Hunting Incident

Friday joke time. And since Christmas is right around the corner...

Do you remember the Christmas Hunting Incident that I posted last year?

Click on this link to see the Christmas Incident. (You'll need Flash to be able to view.)

For another politically incorrect Christmas joke, see:

http://www.mistletoeandmeat.com/

Merry Christmas!

Remember: Don't Drink and Drive (or hunt) during the holiday season.

Also ... I will be on vacation next week so don't expect many (or perhaps any) postings!

And have a Happy New Year!

Posted by Mark at 12:48 AM | Comments (0)

December 18, 2006

Monday Accident & Lessons Learned: Minor Accident or Near-Miss?

Below is a Safety Flash that was released after a minor incident. Let me know what you think.

What was the root cause of this minor incident?

Was the corrective action adequate?

What else might you have done to improve on this safety flash?

Thanks for your comments and for the person who sent the safety flash to me for this blog.

ENVIRONMENT, HEALTH SAFETY & SECURITY - SAFETY FLASH

October 2006

Subject : Burst Vehicle Tyre (Manufacturer FALKEN )

What Happened:

A tractor and trailer arrived onsite to off load materials. The vehicle and trailer was parked for approx. 3 hrs prior to unloading .

During unloading of shell plate three (3) employees were standing alongside the trailer near the underbed carrying frame of the spare wheel. Without warning the spare wheel burst causing minor scratches to the thighs of the 3 employees.

Description of Product: Vehicle tyre manufactured by FALKEN 12.00R 24- 18PR.156/153 k Radial

Safety Warning : Always check spare wheel and tyre for damage or overinflation.

A check of the tractor and trailer operational tyres revealed all MICHELIN radials were in good condition. Lessons to be Learned: The seperation and release of wire strands and / or parts of the main tyre component at high pressure has the potential to cause damage, puncture of the skin, damage to property.

Recommendations:

Daily inspection of vehicle tyres including the spare may seem onerous or over the top to some drivers. The stringent requirements have been developed to safeguard personnel from faulty equipment if they are followed .
Ensure equipment is fit for use and conforms to approved standards
Vulnerable components guarded to protect others against impact damage, puncture of the skin damage to property.

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

December 15, 2006

Pilots Talk About Brazilian Crash

From Reuters:

"Two U.S. pilots said Friday they were not at fault for a collision between their small plane and a Brazilian airliner, which subsequently crashed over the Amazon and killed all 154 people aboard."

For the complete article see the CNN web site:

http://www.cnn.com/2006/WORLD/americas/12/15/brazil.crash.reut/index.html

Posted by Mark at 11:39 AM | Comments (0)

December 14, 2006

CSB Root Cause Analysis of Daytona Beach Wastewater Plant Explosion says, "Inadequate Engineering and Lack of Public Worker Safety Coverage" Are Causes

CSB Press Release about Daytona Beach Wastewater Plant Explosion Investigation available by clicking on "continue" link below.

The investigation web page is at:

http://www.csb.gov/index.cfm?folder=current_investigations&page=info&INV_ID=57

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

CSB Releases Findings from Fatal Daytona Beach Wastewater Plant Explosion Investigation at Public Meeting; Cites Inadequate Engineering, Lack of Public Worker Safety Coverage

Daytona Beach, FL, December 14, 2006 - At a public meeting here today, the U.S. Chemical Safety Board (CSB) will release preliminary findings and hear testimony from experts regarding the January explosion that killed two municipal employees at the Bethune Point Wastewater Plant.

The meeting is scheduled to begin at 9:30 a.m. at the Daytona Beach Resort & Conference Center, Tides A Meeting Room, 2700 North Atlantic Avenue. CSB Chairman Carolyn W. Merritt will preside, accompanied by the other four Board members. Following the presentations by investigators and panelists, the Board will ask for public comments on the issues raised by the case.

On January 11, 2006, two municipal workers died and another was seriously injured while using a cutting torch to remove a steel roof over a storage tank containing highly flammable methyl alcohol (methanol) at the Bethune Point Wastewater Plant, owned and operated by the City of Daytona Beach.

Methanol vapors coming from the tank vent were ignited by the torch used on the roof above. The flame then flashed back into the storage tank, causing an explosion inside the tank that led to multiple piping failures and a large fire that engulfed the tank and workers.
At the public meeting, the CSB investigative team will present key findings from the ongoing investigation. The team, led by Robert Hall, P.E., found that the City of Daytona Beach has no program to control hot work, such as welding or high-temperature cutting, at city facilities nor does the city require work plan reviews to evaluate the safety of non-routine tasks.

The team also found that the storage tank did not comply with National Fire Protection Association (NFPA) Code 30, Flammable and Combustible Liquids Code. The piping and valves attached to the tank were plastic (PVC) instead of steel, and they fractured after the initial explosion.

'If the facility had ensured that the tank complied with NFPA 30 by using steel piping and valves, this accident likely would not have resulted in the two fatalities. Plastic piping should not have been used for this process,' said Investigator Hall.

Another investigation finding is that the tank's flame arrester - a safety device that prevents ignition inside a tank from an external fire - had not been inspected or cleaned since its installation in 1993. The flame arrester was constructed from aluminum, a metal that is not recommended for methyl alcohol service. By the time of the accident, the flame arrester was badly corroded and did not prevent flames from entering the tank and causing an explosion.

At the public meeting, an expert panel will discuss the issue of worker safety regulations for Florida state and municipal employees. The panel will have representation from the Florida Section of the American Industrial Hygiene Association, American Federation of State, County, and Municipal Employees, and the American Society of Safety Engineers.

The CSB investigation team found that since 2000 no Florida state laws or regulations exist to require municipalities to communicate chemical hazards to municipal employees. Florida municipalities are not covered by OSHA workplace safety standards, and no state or federal oversight of public employee safety exists in Florida.

The expert testimony will be considered as the CSB develops new safety recommendations to prevent similar accidents in the future. The final report and recommendations are expected to be released in early 2007.

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. For more information, please visit CSB.gov.

For more information, contact CSB Director of Public Affairs Dr. Daniel Horowitz, (202) 441-6074 (cell); Sandy Gilmour (202) 251-5496 (cell); or Jennifer Jones (202) 577-8448 (cell).

Posted by Mark at 10:04 AM | Comments (0)

December 12, 2006

Chemical Accident Root Cause Analysis in the USA - Chemical Safety Board Web Site has reports and a list of accidents.

The Chemical Safety Board performs root cause analysis of chemical accidents and posts the results of thier investigations and news about other chemical accidents at:

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

Posted by Mark at 09:19 AM | Comments (0)

December 11, 2006

Monday Accident & Lessons Learned - Accident OR Near-Miss??? Great Photos ... Please send me more!

First one tire blows ...

Then another ...

Hang on for a wild ride!

Any landing you can walk away from is a good landing...

Having a tire blow isn't lucky ... But walking away without a scratch from this near-miss (near-miss to a more serious accident) is lucky. The question in my mind is ... Did they do a thorough root cause analysis and learn all they could have learned?

This sequence was recorded by a photographer for AirshowTraveler.com - a great place to visit for military and civilian air show photographs. The pictures were originally published at ARC Air Discussion Forums.

Thanks to Gary Snyder (retired from the Navy and now working at Fluor - and a TapRooT® User) for pointing these great accident/near-miss photos out.

One more question ...

Would YOU say this was an accident of a near-miss?

Click on the comment link below to leave your opinion.

Thanks

Mark

Posted by Mark at 12:06 PM | Comments (1)

December 08, 2006

Do What a Brazilian Air Traffic Controller Says - And Go To Jail!

Three previous posting on this accident are:

Blame in Brazil

Bad Day for Brazilian Traffic Controllers

Series of Errors

Criminal charges have been filed against two pilots that, by the evidence, were flying at the altitude prescribed by controllers when they collided with a 737 over the Amazon.

For the most recent story see:

http://www.cnn.com/2006/WORLD/americas/12/08/brazil.pilots.ap/index.html

Posted by Mark at 02:40 PM | Comments (1)

Construction Accident at Virginia Site - AP News at CNN Web Site

Wet concrete collapses and traps construction workers.

For information see:

http://www.cnn.com/2006/US/12/08/construction.accident.ap/index.html

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

December 04, 2006

Monday Accident & Lessons Learned - The UK Ladbroke Grove Rail Accident Once Again Proves That Failing to Perform Root Cause Analysis and Fix Incidents Can, and Usually Does, Precede Major Accidents

I often have people question the need for root cause analysis of incidents and near-misses. But failing to perform good root cause analysis and fix the causes of incidents is almost always a precursor for a serious accident.

As the case against Network Rail slowly makes it's way through the UK courts (it's been 7 years since the accident at Ladbroke Grove that killed 31 and injured 400), The London Times reported that there had been six incidents when signals were passed when red between 1996 and 1998 at that same sight and either the incidents were not investigated or corrective action was not implemented prior to the accident.

Since that accident, Network Rail has implemented a "Train Protection Warning System" or "TPWS" that Network Rail says would greatly reduce the chance of this type of accident.

However, the London Times says that in 2006:

The number of trains passing danger signals has risen sharply.
Between July and September of 2006, there were 94 cases of signals being passed at danger (SPADS) and that four of them were "potentially severe" (that sounds really bad).

So ... This leads UK train riders to wonder:

"Are current SPADS being investigated adequately with advanced root cause analysis
and are effective corrective actions being implemented in a timely fashion?"

When I see 94 SPADS in three months, I really have a hard time believing that they are doing effective root cause analysis.

So it doesn't sound to me that they learned from the lessons of the Ladbroke Grove disaster.

Under the TapRooT® System this failure to learn would fall under the Management System - Corrective Action - Corrective Action Needs Improvement root cause.

Posted by Mark at 11:20 AM | Comments (0)

December 02, 2006

CSB Continues Root Cause Analysis Investigation of Massachusetts Chemical Plant Explosion: Statement of Lead Investigator John Vorderbrueggen

The following press release is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

December 1, 2006, 4:00 p.m.

CSB Investigator-in-Charge John Vorderbrueggen, PE, issued the following factual update to the investigation of the Danvers, Massachusetts, chemical plant explosion on November 22, 2006:

Today, 11 CSB investigators were in Danvers, including CSB Investigation Manager Stephen Selk, P.E., P.Eng., an expert in accident and blast reconstruction, who met with CSB blast modeling specialists and other team members.

Since gaining access to the site on November 28, 2006, CSB investigators have completed three entries into the explosion site for close observation and photography of the equipment, structure, and debris.

Two three-member teams of investigators have worked in the surrounding community interviewing residents and documenting structural damage. The data will be used in an effort to calculate the nature of the shockwave that caused damage to scores of homes and businesses. The work in the community is expected to be completed today.

Investigators have interviewed key employees from Arnel Co., and remaining interviews will be conducted over the next several days. Interviews with CAI employees are expected to begin Monday morning.

CSB investigators will continue to work through the weekend as the investigation continues. On Saturday, investigators will “walk down” the process equipment among the plant remnants with key operating employees of both companies, seeking to understand the process activities that were underway preceding the early morning explosion.

On Monday, investigators plan to draw samples from underground storage tanks where the bulk raw materials were stored. Those samples will be sent for laboratory analysis.

After conferring with the CSB blast modeling experts, Mr. Vorderbrueggen said, “This was a powerful explosion, even compared to other significant chemical accidents. More than 30 windows were broken at a high school one half-mile from the explosion origin. Our initial assessment shows that under slightly different circumstances – for example if people had been outdoors instead of asleep in their homes – it is likely that public fatalities could have occurred.”

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and government agencies. Visit the CSB website, www.CSB.gov.

For more information, contact Daniel Horowitz at (202) 261-7613 / (202) 441-6074 cell.

This message was transmitted at 8:32 PM Eastern Time (U.S.A.) on December 1, 2006.

Posted by Mark at 04:25 PM | Comments (0)

November 29, 2006

Vote What the Verdict Should Be

I received the e-mail, available by clicking on the continue link below, that allows you to vote on your opinion of a legal case.

Interesting concept. I didn't give them my e-mail address but you might consider it.

From: cases@legalvote.com
To: Mark Paradies

We would very much appreciate your input on this legal case pending in your state. A truck driver died in a fiery crash.

Who is responsible?

That's what we need you to decide. This is a REAL case involving REAL people. Your input can help resolve this dispute, or affect the way that it is tried. If you are one of the first 100 people to complete the study, you will be eligible to win $100 in a drawing.

To participate, please click onto the following link: http://www.legalvote.com/study/study82149.phtml
(If you cannot click onto the above link, please copy and paste it into your browser)

If you would like to participate in this drawing without completing the case study, please send a self-addressed, stamped postcard with your name to: Legalvote.com, PMB#215, 8927 Hypoluxo Road - Suite A4, Lake Worth, FL 33467-5249.

Thank you for your valuable input!

If you would prefer not to receive this type of mailing, please click the link below to unsubscribe:

http://www.vote.com/c/s.phtml?u=4ccf4T5&ref=lv&ov=1&nv=1

(NOTE: If your e-mail software does not make the above link active, please copy & paste it into your web browser and press the Enter key.)

Posted by Mark at 02:24 PM | Comments (0)

November 27, 2006

Monday Accident & Lessons Learned - Blame in Brazil

How does blame impact an accident investigation?

Imagine that your were the two pilots that successfully landed a Embraer Legacy jet after a midair collision with a Boeing 737. That you were bring the plane back to the US. That you had done exactly what the air traffic controllers had told you to do - which matched your flight plan - and that this was verified by the cockpit tapes. Yet you had been held under house arrest in Brazil since September and the judge in the case said that you may have to cool your heals for another 10 months.

How would you feel about cooperating with what is current a criminal investigation?

I always joke that you should start your root cause analysis interviews with:

"You have the right to remain silent ... Anything you say can and will be used against you in a court of law."

That's a great way to put people at ease!

For an AP story about the investigation and see CNN's web site:

http://www.cnn.com/2006/WORLD/americas/11/23/union.brazil.ap/index.html

Posted by Mark at 08:03 AM | Comments (0)

November 24, 2006

Friday Joke - Corrective Action ... Parking Lessons?

Richard Gerow, a TapRooT® User in Canada, sent me this joke e-mail and what appears to be a real accident photo.

- - -

E-mail:

To my dear husband,

Before you return from your business trip, I just wanted to let you know about the small accident I had with your pickup when I turned into our driveway today.

Fortunately, it wasn't too bad and I'm not hurt, so please don't worry about me. I was coming home from the store and when I turned into the driveway I accidentally hit the gas instead of the brake. The garage door was down so it got bent a little but fortunately the pickup stopped when it bumped into your car.

Isn't it great that your motorcycle wasn't damaged?

I am really sorry but I know you have a kind heart and will not hold this against me. I love you and can't wait to hold you in my arms again. I'll see you tomorrow.

Your loving wife,

xxxx

Click on the link below for the picture...

(click on the picture to enlarge)

Posted by Mark at 12:49 AM | Comments (0)

November 22, 2006

CNN Link to DANVERS Chemical Plant Explosion

See:

http://www.cnn.com/2006/US/11/22/explosion.fire.ap/index.html

Posted by Mark at 05:50 PM | Comments (0)

CSB Sends Team to Danvers, MA Explosion

The CSB will be investigating the explosion at a Danvers, MA facility that exploded early this morning. 90 homes were damaged, but thankfully, only 10 minor injuries were reported.

Click here for details.

Posted by kenreed at 04:38 PM | Comments (0) | TrackBack

Will There Be a Massachusetts Law Calling for Jail Time for Executives of Companies that Cause Fatalities?

The construction injury is one of the most hazardous in the US. Deaths at construction sites top the list of work related fatalities. And the root causes of these deaths often point to management failures.

If you frequently visit this blog you've read the "One Step Away from Death" article and the "Stop the Sacrifices" article. Once you read these, you know what my thoughts are.

After a fatal scaffolding accident, the Massachusetts legislature may take action to pass a law that would put executives behind bars. For more information see:

http://cbs4boston.com/topstories/local_story_285092929.html

http://www.insurancejournal.com/news/east/2006/10/13/73262.htm

Good management prevents fatalities - thus there is no one to blame.

Bad management blames the worker - or anyone else besides themselves.

Posted by Mark at 07:51 AM | Comments (0)

November 20, 2006

Train Wreck in Berlin

We have many training and light rail TapRooT® Users so I thought I would pass along news of a wreck in Germany. See the CNN web site for an AP story.

Sounds like they need root cause analysis to find the root causes of the collision.

Posted by Mark at 09:42 AM | Comments (0)

Monday Accident & Lesson Learned - Beverly Inman-Ebel Hurt by Metal Screw in Sandwich

Sometimes accident strike closer to home. In this case one of our frequent Summit speakers, Beverly Inman-Ebel, was hurt last month when she bit into a screw in a sandwich.

What is the lesson learned? Read Beverly's e-mail below (reprinted by permission) and my reply and Beverly's reply and then think what kind of response your company would give if someone was hurt by one of your products.

Seems like the accident, and the response, are good candidates for root cause analysis.

- - -

Beverly's original e-mail:

From: Beverly J. Inman-Ebel
Subject: Beverly Inman-Ebel finds screw in Arby's sandwich
Date: Thu, 16 Nov 2006 10:14:03 -0500

Dear Clients and Friends,

I am concerned about customer service, quality control and the lack of communication between Corporate America and its ultimate consumer. Here is my story.

On October 30, 2006 I purchased an Arby's sandwich and it contained a screw that I bit down upon. (Pictures are at http://www.imagestation.com/album/pictures.html?id=2099380055&code=25248625&mode=invite&DCMP=isc-email-AlbumInvite.) I immediately called the store reporting the incident, leaving my name and cell number, and informing them I would come by the store with the evidence between 4:00-4:30 p.m. The store manager was not present when I arrived and the 2 people in charge refused to give me the franchise owner's contact information. They informed me the owner had been called and the manager had my name and number. I told them I had hurt my mouth and had a dental appointment the next day.

No one called Monday, Tuesday, or Wednesday. On Wednesday, a local reporter told me his station would want to run the story. I refused and used Hoover's database to locate and call a Senior Vice President of Franchises at Arby's Restaurant Group in Atlanta. She promised that someone would call me by noon the next day or that she would call me. No one called.

The reporter called me again on Thursday, November 2nd and asked to run the story. I agreed. Reportedly, the TV crew went to the restaurant first and interviewed the manager and owner, then came and interviewed me. I was told the story would run 4 times that day. The owner called me placing blame on his managers for not calling me and on Arby‚s for the screw stating that he purchases the chicken salad mix and only cuts the apples and grapes at the restaurant. He said he would report this incident to his insurance company and they would pay for my teeth damage. The TV reporter called me minutes later to tell me the station was not going to run the story.

On Friday, November 3rd, I called again to Arby's Restaurant Group and spoke to a representative in Customer Relations. She promised to call me back in an hour. No one called.

The insurance company has contacted me. Other than the one call from the franchise owner after a television crew appeared at his restaurant, no one from Arby's has called me.

As a consumer, I expected to be important enough to receive immediate communication from Arby's. I expected this to matter. Originally, all I wanted was to know how the screw really got in my sandwich, what Arby's was going to do to prevent it from happening again, and to get my teeth fixed. Now I want to be heard and I feel I have a very small voice. If you are also concerned about customer service and/or quality control, please share this with others. They can Google my name and realize I am a real and reputable person. If you do, you make my voice a little louder.

Sincerely,

Beverly Inman-Ebel

- - -

Here was my reply:

Beverly,

Hope your mouth is feeling better.

On the one side, you are lucky you weren't gulping your food. You could have swallowed the screw and choked and died or required surgery to remove it.

On the other side, it certainly isn't luck to get a screw in your sandwich.

On the sympathy side for the owner, many franchisees aren't real savvy about customer service and ASSUME that these kind of incidents are part of a rip-off. They may have been advised by an attorney (or the insurance company) NOT to talk to you. There are well document product tampering cases from Wendy's (a thumb in chilli), Pepsi (syringe), Cambell's Soup (drugs), and Tylenol (cyanide poisoning).

For the Pepsi story see:

http://www.roadsideamerica.com/rant/pepsipanic.html

It's a sad world when honest people are looked at with suspicion because of the action of others, but that's the world that we live in.

Do you mind if I post your story and my response on my blog?

Thanks

Mark

- - -

Beverly replied:

From: Beverly J. Inman-Ebel
To: Mark Paradies
Subject: Re: Beverly Inman-Ebel finds screw in Arby's sandwich
Date: Fri, 17 Nov 2006 10:19:03 -0500

Please post it. When I called the Senior VP at Arby's, I told her I was not suing and that I wanted to understand how it happened and what they were doing to prevent it from happening again. In my email I did not mention names of people at Arby's that I called because I assumed they were being told by legal or the Risk Management Department to remain quiet. My point is that somewhere in their process there needs to be someone from the company who returns a call. Thanks for the reference to the Pepsi case. I am continuing to do research on this topic and will appreciate any references.

Smiles,
Beverly

- - -

So what would your company do? Are you prepared?

Posted by Mark at 07:30 AM | Comments (2)

November 18, 2006

Crane collapses on apartment; one killed

AP story on CNN web site, see:

http://www.cnn.com/2006/US/11/17/crane.collapse.ap/index.html

Posted by Mark at 12:28 AM | Comments (0)

November 13, 2006

Monday Accident & Lessons Learned: Marine Accidents in the UK

Since I'm in the UK teaching a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Aberdeen, I thought this topic was definitely appropriate for the Monday Accident.

What can you learn from UK Marine Accidents from 1990 to 2006?

Go to the UK Marine Accident Investigation Branch (MAIB) web site, read the reports, and find out!

See:

http://www.maib.gov.uk/publications/investigation_reports/2006.cfm

If you would like to look at just the 10 most recent reports, see:

http://www.maib.gov.uk/publications/index.cfm

Posted by Mark at 06:44 AM | Comments (0)

November 11, 2006

CSB Votes to Approve Final Report on Combustible Dust Hazards at Public Meeting

For details see:

http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=324

Posted by Mark at 08:19 AM | Comments (1)

November 06, 2006

CSB Investigator Deployed to Fatal Incident at South Carolina Chemical Manufacturer

The following press release is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Investigator Deployed to Fatal Incident at South Carolina Chemical Manufacturer

Washington, DC, November 5, 2006 – An investigator from the U.S. Chemical Safety Board (CSB) has been deployed to the site of a fatal incident yesterday at 3V Inc., a chemical manufacturer in Georgetown, South Carolina, northeast of Charleston. Reports indicate that one worker died and another was injured inside a confined space, a dryer. The company has told CSB staff that the interior of the dryer had an oxygen-deficient atmosphere.

CSB Investigator Randy McClure will arrive in South Carolina later today to probe the circumstances of the incident.

According to its website, 3V is a producer of specialty chemicals and additives that operates five manufacturing sites and has headquarters in Italy. The Georgetown site is the sole manufacturing facility in the U.S.

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 safety management systems, regulations, and industry standards.

For more information, contact Sandy Gilmour at (202) 251-5496 cell or Dr. Daniel Horowitz at (202) 441-6074 cell.

This message was transmitted at 11:06 AM Eastern Time (U.S.A.) on November 5, 2006.

________________________________________________________

Visit the CSB Web Site at http://www.csb.gov

Posted by Mark at 04:31 PM | Comments (0)

Monday Accident and Lessons Learned: CNN Reports "Series of Errors" in Jet Collision - Root Cause Analysis Seldom Finds Just One Root Cause

A report at the CNN web site includes the following quote:

"The tower instructions reported by Folha may have been the first of a series of problems that led to the crash."

The term "root cause analysis" can be confusing to some. Why? Because they may believe that it is possible to find a single "root cause" for a major accident or incident.

In TapRooT® Courses we train investigators that major accidents are caused by a series of events. These events have causes. Usually several of these causes could have been prevented, or significantly reduced the consequences of, the accident and thus are labled "causal factors". We train investigators to analyze these causal factors using the Root Cause Tree® to find the fixable root causes that can be corrected to prevent future repeats of the causal factors and thus the accident.

Thus root cause analysis is actually a way to find many - not just one - ways to improve performance and prevent accidents.

Posted by Mark at 12:00 AM | Comments (0)

November 03, 2006

Friday Joke: Is Winter Coming?

Richard Gerow, a TapRooT® Users that works for Timberwest Forest Corporation in British Columbia, sent the picture above (click on it to enlarge).

He was up in northern BC doing an audit of a helicopter company and he says they "got a little bit of snow".

The snow came down in just 37 hours.

The person you can see is STANDING UP.

And Richard says that the bad news was that the DROVE to the audit - which would normally take 6 hours. The drive home wouldn't be fun.

Maybe it is time to start thinking about winter driving?

Here's a video (click on object below) to watch.

Winter presents special challenges for driving, walking, ... all sorts of outdoor activities.

Are your facilities ready?

Have people prepared their cars (and company cars) for winter driving?

• snow tires
• chains
• window washer full and appropriate anti-freeze
• blankets and supplies if stranded
• what else???

Have you had your winter preparation safety meeting?

The further NORTH your plant is, the more likely you are to prepare. But I've seen plants in the deep south damaged do to freezing of outdoor pipes. Why? People didn't get ready for mother nature.

So don't let a lack of preparation be the root cause of winter problems at your plant. If global warming takes this winter off, be prepared!

It is NOT a JOKE when preventable winter weather related accidents happen.

Posted by Mark at 09:40 AM | Comments (1)

November 02, 2006

CSB Releases Safety Video with Computer Animation; Valero Refinery Delaware City, Delaware

Press Release from the Chemical Safety Board:

Washington, DC, November 2, 2006 - The U. S. Chemical Safety Board (CSB) today issued a Safety Video on the November 5, 2005, nitrogen asphyxiation incident at the Valero Refinery in Delaware City, Delaware.

The video includes a computer animation depicting events leading to the accident, and features commentary by Lead Investigator John Vorderbrueggen, Board Member John Bresland, and a field expert.

The CSB video on the accident, entitled "Hazards of Nitrogen Asphyxiation: Fatal Accident at Valero Refinery," is available for streaming or download on www.CSB.gov, and may be ordered on a DVD by filling out a request form on the video player.

The video shows an animated re-enactment of two possible scenarios that led to the asphyxiation of two workers and presents recommendations for the prevention of this accident in the future.

The CSB determined that after the workers discovered a roll of duct tape lying inside a reactor on a tray about five feet below the opening they decided to attempt to remove it with a long wire hook. Repeated attempts by one of the workers to remove the tape were unsuccessful. He entered the reactor and was asphyxiated soon after. Another worker, seeing his co-worker lying on the tray five feet down inside the reactor, quickly inserted a ladder through the opening and climbed inside. He too was overcome by the oxygen-depleted environment and also succumbed.

"This new safety video should be viewed by management and employees of all U.S. oil and chemical plants," said CSB Chairman Carolyn W. Merritt. "Oxygen deprivation is a major hazard and this video will send the
message that this hazard must be recognized and properly denoted in facilities."

For more information, contact Sandy Gilmour, 202-261-7614, cell 202-251-5496, or Dr. Daniel Horowitz, Director of Public Affairs, 202-261-7613, cell 202-441-6074.

This message was transmitted at 12:15 PM Eastern Time (U.S.A.) on November 2, 2006.

Posted by Mark at 02:28 PM | Comments (0)

Legal Woes and Root Cause Analysis - BP Texas City Explosion

When a major accident happens, the lawsuits can get nasty.

I ran across a document posted on the web that looks to be part of a lawsuit related to Sarbanes-Oxley compliance or the Sherman Anti-Trust laws in the US. I don't know why individuals would be filing this suit, but lawyers might be able to explain it. The web site where the document is posted certainly does seem to focus on any negative information that can be found about BP. The document is posted at:

http://www.bpconcerns.com/Documents/CharlesHamelLetter2/tabid/76/Default.aspx

Why is a document posted at an "anti-BP" (my interpretation of the site) web site interesting?

1. When you read Attachment C you start to see the types of problems and expenses that can be generated by evan a simple request for documents that might occur because of a lawsuit after an accident. Here is just one item from the 20 item list:

"13. From 1998 to present, provide all emails warning of
problems on the Isomerization Unit from Petrospect
Inspection and Jacobs Engineering."

Imagine how hard it would be to make sure that you had collected all (every) e-mail that anyone had written that warned of "problems" from a "Petrospect Inspection" and from a contractor - Jacobs Engineering. And remember, that's just one of 20 information requests.

2. The document claims that "benchmarking" - and more specifically the Solomon Refinery Benchmarking Studies - is the root cause of the explosion at the BP Texas City Refinery.

The document points to the studies and management's actions and then blames the explosion on senior BP managers wanting to increase their pay by improving their results in the benchmarking studies. Thus "benchmarking" is the root cause of the explosion. That's the claim the letter at the web site makes.

WOW! And I thought my interpretation of the information released from the CSB was critical.

There is much that can be learned from the document - but let's just look at a few of the less obvious points:

1. You never know when someone will subpoena your e-mails!

2. One item that you should consider is that you are probably underestimating the costs of an accident. When you estimate the costs, don't forget the legal woes that can result from an accident.

3. Another unanticipated "cost" is the people who can loose their jobs over the residual blame that will, no doubt, ruin the reputations and careers of many. This started with those who were directly involved at the unit that exploded. But senior BP management is also finding out how far the blame can spread.

4. The PR nightmare after an accident is not a minor issue.

These less obvious costs of an accident aren't the primary reasons to prevent accidents, but they are issues that are real and often overlooked when considering the benefits of maintaining excellent performance.

A Note for TapRooT® Users:

As you know, the TapRooT® System isn't designed to place blame. Instead, it is designed to discover ways to improve performance. Therefore, the "root causes" hinted at (benchmarking and greed) in the document cited above aren't a part of the TapRooT® System.

Instead, TapRooT® would look at the company's standards, policies, and administrative controls related to specific causal factors that caused the accident. These "SPAC" should have been stringent enough to prevent the accident that occurred. If they weren't - that's a problem ... a near-root-cause in the TapRooT® System.

Or, if the SPAC were adequate, then they must not have been used (followed). That too is a problem ... another potential near-root-cause.

A more detailed analysis of BP's standards, policies, and administrative controls and the compliance with those SPAC is no doubt one of the things that the CSB has undertaken as part of their investigation and root cause analysis of the explosion at the refinery.

Everyone concerned about improving refinery safety - and process safety management - will be waiting for the final CSB investigation to get a more thorough understanding of the facts related to the failures that lead to this tragic explosion and fire and any failures in BP's implementation of the Process Safety Management regulation (a SPAC) that lead to the explosion. Until the complete report is released, we will be left wondering about the causes - the complete root cause analysis - of the explosion, fire, and resulting 15 deaths.

A Note for TapRooT® Summit Attendees:

Judge Andrew Napolitano will be one of the Keynote Speakers at the TapRooT® Summit. His talk is titled:

Accident Investigation Lessons from the Courtroom

This talk will provide you with even more ideas about the legal complications and liabilities possible when performing an investigation. If you know others who are interested in this topic, tell them about the Summit.

Posted by Mark at 01:22 PM | Comments (1)

October 31, 2006

CNN Reports 2 Killed in Aluminum Smelting Explosion at Arkansas Aluminum Alloys

CNN/AP report ... Click on link below for more info...

HOT SPRINGS, Arkansas (AP) -- An explosion at an aluminum recycling plant early Tuesday killed two people and injured a third, a company spokesman said.

Posted by Mark at 03:47 PM | Comments (0)

CSB Release a Statement at a News Conference in Houston About BP Texas City Refinery Explosion

Click on photo above for bigger view.

Click here for a pdf of the News Conference Statement.

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

CNN/Reuters Report that Network Rail Pleaded Guilty to Criminal Health & Safety Charges as a Result of the Ladbroke Grove Train Wreck

Click here for CNN Story about criminal charges that resulted from the Ladbroke Grove train wreck.

Posted by Mark at 02:49 PM | Comments (0)

CSB Calls on Oil Industry to Eliminate Atmospheric Blowdown Drums Similar to Equipment at BP Texas City Refinery; Urges New OSHA "Emphasis Program" throughout U.S.

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

Houston, Texas, October 31, 2006 - On a unanimous vote of 5 to 0, the U.S. Chemical Safety Board (CSB) today issued new safety recommendations calling on the U.S. oil industry to improve safety practices for refinery pressure relief systems, eliminating the type of atmospheric vent that caused the hydrocarbon release and explosions that killed 15 workers and injured 180 at the BP Texas City refinery on March 23, 2005.

The 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, causing a series of
explosions and fires that killed workers in and around nearby trailers.

The announcement followed by one day the release of new preliminary findings in the CSB's ongoing, independent federal investigation of the accident. The Board's final report is expected in March 2007.

The first recommendation calls on the American Petroleum Institute (API), a leading oil industry trade association that develops widely used safety practices, to change its Recommended Practice 521, Guide for Pressure Relieving and Depressuring Systems. The revised guidance should warn against using blowdown drums similar to those in Texas City, urge the use of inherently safer flare systems, and ensure companies plan effectively for large-scale flammable liquid releases from process equipment.

Further recommendations call on the U.S. Occupational Safety and Health Administration (OSHA) to establish a national emphasis program promoting the elimination of unsafe blowdown systems in favor of safer alternatives such as flare systems. OSHA should also emphasize the need for companies to conduct accurate relief valves studies and use appropriate equipment for containing liquid releases, the Board said. A national emphasis program results in a concerted inspection and enforcement effort around a specific safety hazard.

CSB Chairman Carolyn W. Merritt said, "Unfortunately, the weaknesses in design, equipment, programs, and safety investment that were identified in Texas City are not unique either to that refinery or to BP. Federal regulators and the industry itself should take prompt action to make sure that similar unsafe conditions do not exist elsewhere. Taken as a package, the new CSB safety recommendations we issued today will provide for effective guidance, outreach, and regulatory enforcement to reduce the risk of similar tragedies in the future."

Lead Investigator Don Holmstrom noted that the ISOM unit blowdown drum at the BP Texas City refinery had a number of safety problems. "This drum simply wasn't large enough to hold all the liquid released from the
distillation tower if it flooded. Not only could the blowdown drum not hold enough liquid, but it could not assure safe dispersion of flammable vapors through the vent stack," Mr. Holmstrom said. He added that safe
dispersion of flammable vapors would require a high exit velocity that could never be guaranteed when handling multiple discharges through a complex piping system.

That design weakness resulted in unsafe conditions in Texas City prior to the March 23, 2005, accident. The CSB documented eight previous releases of vapor from the same blowdown drum from 1994 to 2004. In six
cases, dangerous flammable vapor clouds formed at ground level but did not ignite; in two other cases, the blowdown stack caught fire.

Prior to the 2005 accident, BP operated 17 blowdown drums for disposal of flammable materials at its five U.S. refineries. BP has since pledged to eliminate all the drums and use safer alternatives, such as flare
systems. A properly designed flare system includes an adequately sized vessel for containing liquids and a stack with a flame for safely burning flammable vapors, preventing an uncontrolled fire or explosion near personnel. Flares are the most commonly used disposal system for flammable releases in refineries.

In 1992, the Texas City refinery, then owned by Amoco Corporation, was cited by OSHA for operating an unsafe blowdown drum. However, Amoco succeeded in having the citation and fine withdrawn, asserting that the drum complied with accepted industry standards embodied in API Recommended Practice 521. Today's recommendation from the CSB would strengthen that guidance document so that it would explicitly warn against such unsafe blowdown systems.

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 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. Please visit the CSB website, www.CSB.gov.

For more information, contact Daniel Horowitz at (202) 441-6074 cell (Houston) or Sandy Gilmour at (202) 261-7613 / (202) 251-5496 cell.

This message was transmitted at 10:30 AM Eastern Time (U.S.A.) on October 31, 2006.

Posted by Mark at 02:15 PM | Comments (0)

EXPLOSION ROOT CAUSE ANALYSIS: Comments on the CSB Press Release about the BP Texas City Refinery Explosion and Fire

Yesterday the CSB issued a press release with some new information about the BP Texas City Refinery Explosion. The more I read ... the madder I got.

I thought about not writing this article. Writing it certainly won't win me any friends at BP. But if I can get the attention of just a few people who are in a position to:

• Stand up when bad decisions are being made.
• Tell their boss that a decision is wrong
• Resist budget cuts that erode safety margins.
• Enforce procedure usage and safety rules.

Then I may have helped save a life - or save multiple lives. And the risk I take will be worth it.

Also, remember that I have sympathy for everyone - including management - that was involved in the tragic accident. But the CSB press release posted yesterday in this blog and quoted below has convinced me that the explosion at the BP Texas City Refinery was NOT an accident.

15 people died in a very preventable disaster.

A disaster that management could have and should have prevented. Not an accident ... even though we call it one.

CSB press release statements below are in red. Bold typeface is my emphasis (not the CSB's). My comments are in blue.

The CSB lead investigator said:

"...eight previous instances where flammable hydrocarbon vapors were discharged from the same blowdown drum between 1994 and 2004. In two of these incidents the blowdown system caught on fire. The eight incidents were not properly investigated, and appropriate corrective actions were not implemented. The investigation of a 1994 incident resulted in an action item to analyze the adequacy of the blowdown drum. The area superintendent was responsible for the completion of this item. However, the item was never finished, and management officials did not follow up to assure completion."

MY COMMENT: This quote points to the following root causes:

1. Inadequate incident investigation and root cause analysis from 1994-2004.

2. Inadequate corrective actions from 1994-2004.

3. Inadequate tracking of corrective actions and implementation from 1994 on.

Note that this failure existed for over a DECADE before the explosion at Texas City.

Also, this new information casts doubt on the "independent" Post Accident Process and Operational Audit Report that was recently released by BP. One of that report's findings was that BP investigation process as implemented at Texas City was a "good practice". That's hard to justify if the findings above are true. Or can BP show that there has been a radical change in the incident investigation, root cause analysis, and corrective action processes being used by BP since 2004? And if these "good practices" come from corporate, then what does that say about the rest of the BP refineries and the rest of BP worldwide?

More from the CSB press release (in red) about BP management before the "accident":

"The history of major accidents and fatalities at the plant was summarized in a meeting held in November 2004 by the refinery manager for 100 supervisors. He gave a sobering presentation entitled “Safety Reality” on the 23 deaths at the plant in the previous 30 years; on average, one worker had died every 16 months."

Mr. Holmstrom (the CSB lead investigator) said, “In 2004, BP Texas City had the lowest injury rate in its history, nearly one-third the oil refinery sector average. However, the injury rate does not take account of catastrophic hazards or distinguish between injuries and fatalities. That year, the refinery experienced three major accidents that resulted in a total of three fatalities. One of these accidents was a major process-related fire. In late 2004, following these major accidents and other near misses, the Texas City leadership was attempting to improve the refinery’s safety performance. Several years of audits and reports had identified serious safety system deficiencies. However, the safety initiatives that were undertaken focused largely on improving personnel safety – such as slips, trips and falls – rather than management systems, equipment design, and preventative maintenance programs to help prevent the growing risk of major process accidents.”

“When personnel safety statistics improved, the refinery leadership believed they had turned the corner,” Mr. Holmstrom said. However, existing process safety metrics and the results of a safety culture survey indicated continuing serious problems with safety systems and concerns about another major accident. A Health, Safety, and Environment Business Plan presented on March 15, 2005 – just eight days before the ISOM unit accident – identified as a key risk that the Texas City refinery “kills someone in the next 12-18 months.”

MY COMMENT:

It is hard to read about three fatalities and bad audit findings and understand how management could fool themselves into believing that they have "turned the corner". With those statistics how could they believe that they had greatly improved safety? Maybe they had been living with bad practices for so long that they had no idea what good practices looked like.

Many people mistake the efforts needed to prevent cut fingers with the efforts needed to prevent major disasters. Although there can be some crossover, the proactive efforts needed are not the same. Don't fool yourself. If minor injuries are decreasing, this could be because reporting has been discouraged. Engineering, management knowledge and involvement, adequate budgets, procedure compliance, and continuous improvement are needed to make and keep a hazardous facility safe.

And where was CORPORATE senior management? Is it OK in the BP culture to have three fatalities at one refinery? How many dead bodies are required to get corporate management's attention? At DuPont, one fatality got the PLANT MANAGER replaced.

After reading the CSB press release, I don't think that senior management at BP can seriously claim that they didn't know. If they didn't, it was because they were sticking their head in the sand. Just read the following: (from the CSB press release)

Earlier, a 2003 external BP audit referred to the Texas City refinery’s infrastructure and assets as “poor” and found what it termed a “checkbook mentality.” Budgets were not large enough to manage all the risks, but rather than expanding the budget, expenditures were restricted to the money on hand, in the opinion of the BP auditors.

A 2004 BP Group internal audit of 35 business units including Texas City found significant common gaps, including a lack of leadership competence which pointed to “systematic underlying issues,” widespread tolerance of noncompliance with basic safety rules, and poor implementation and monitoring of safety management systems and processes.

Chairman Merritt (CSB Chairman) stated that stringent budget cuts throughout the BP system caused a progressive deterioration of safety at the Texas City refinery. “BP implemented a 25% cut on fixed costs from 1998 to 2000 that adversely impacted maintenance expenditures and infrastructure at the refinery,” she said. Maintenance spending fell throughout the 1990’s at the then-Amoco refinery, and following the merger with BP further cuts were imposed. “Every successful corporation must contain its costs. But at an aging facility like Texas City, it is not responsible to cut budgets related to safety and maintenance without thoroughly examining the impact on the risk of a catastrophic accident.”

By 2002, an internal BP report had identified the cost reductions as contributing to a decline of infrastructure in Texas City that would require significant investment to correct. These findings were corroborated in a survey of the refinery’s safety culture in 2005 just prior to the accident, known as the Telos study. The survey interview with the Texas City refinery manager identified a history of decapitalization and a culture of “things not getting fixed.”

“The refinery manager was not alone in this candid assessment,” Chairman Merritt said. “Large majorities of the survey respondents reported significant maintenance backlogs that were harming safety. Disturbingly, most employees agreed that ‘production and budget compliance gets recognized and rewarded before anything else at Texas City.’”

Economic pressures were evident in numerous decisions that were causally related to the March 23, 2005, accident.

MY COMMENT:

Management shouldn't try to claim that they didn't know that dramatic and prolonged budget cuts would have a negative impact on safety at a refinery. When they cliam such things, they are either:

a) Proving that they don't know enough to be in their job.

OR

b) Lying.

I know senior managers and they are smart enough to know.

Many (but not all) big oil companies cut expenditures in the refining end of the business when the price of oil and the refining margins were low (the 1990's). But from 1995-2005, the BP/Amoco refineries had more fatalities (22) than all the other US refiners combined (21).(reference) BP managers and others should have known they were taking risks. My belief is that they hoped that the safety margins were large enough that they could delay maintenance and capital projects without experiencing any significant accidents or process outages. But well before 2005 they should have seen that this was not true. The signs were there if they were willing to see.

Since the price of oil and refining margins are now very positive, the same maintenance that was delayed due to lack of funds is now being delayed (at some refineries - but not all) because the units are making so much money that the companies say that they can't afford to shut them down.

ALL REFINERY MANAGERS SHOULD BE AWARE: Skimping on maintenance of hazardous processes will come back to haunt the process owners. Warning signs can only be ignored for so long before an explosion and fire points out the weakest link in the safety chain.

We know - by the results - that BP erred too far toward the side of cost cutting and profit maximazation. The question that others must answer is ... WHAT IS YOUR SAFETY MARGIN? Have other refiners learned from the BP accident?

Are they taking a hard stand against deferring maintenance and engineering upgrades despite the money that the downtime costs?

Are they insisting on insightful root cause analysis and effective corrective actions?

Are they tracking corrective actions to see if they are implemented and validating that the corrective actions were effective?

Are they enforcing procedure usage and positively reinforcing management system standards?

Are they continuously improving performance with the use of best practices that they find inside and outside the refining industry?

I know the BEST are. But here is a message to the REST:

YOU DON"T HAVE TO WAIT FOR A DISASTER TO LEARN TO IMPROVE!

BP had adequate warning prior to the 2005 explosion. The deaths could and should have been prevented.

The whole management chain will have to live with their consciences. They should thank their lucky stars that this refinery wasn't in the UK, or senior management might be facing jail time (which is rare in the US).

Hindsight is too late to prevent the 15 deaths at the BP Texas City Refinery. So the question that YOU need to ask is:

IS YOUR FACILITY LEARNING FROM BP's MISTAKES?

If you are at a refinery or some other hazardous facility ... Are you waiting for your own disaster to provide an opportunity to improve?

Don't be penny wise and pound foolish.

Don't cut corners for short-term profit gains.

Don't put people's lives at risk to look good on the quarterly report.

If you are in senior management, your job is NOT to kill people to maximize shareholder return.

INSTEAD:

You must know what is going on.

You must know enough about the operations of your company to be able to judge the impact of budget cuts.

You must have proactive indicators that tell you if efforts to economize have gone too far. They must be proactive so that you prevent fatalities.

You must insist on tough standards.

You must understand and insist that your facilities use advanced root cause analysis and you must have measures of the effectiveness of the corrective actions they implement.

You must hold yourself accountable for the performance of those who report to you. If they let safety slide, it is YOUR FAULT. You can't make excuses that you didn't know.

The well being of every employee is your responsibility.

If a preventable fatality happens, you have failed.

Many may think these words are harsh. Some may say that I'm being too hard on BP. There were many managers at BP that should have acted from 1994 to 2005 so you can't hold any one manager responsible. Some may say that the managers who just happened to be there when the explosion occurred are nothing more than scapegoats. They may be partially right.

But anyone who takes the big bucks to manage a high hazard facility needs to make sure that under their watch, they run a tight ship. They should be able to stand up and proudly say that they did everything they possibly could to keep people safe and prevent fatalities.

And I'm not speaking from ignorance.

I'm not bragging, but I put my career at risk by standing up to senior management on more than one occasion. So I know what it feels like to be pressured to not speak out. And I know the risk to your career when you do. But I stood in the breach and gambled my future when I saw decisions that could have cost lives. And I sleep well knowing that no one was killed on my watch.

After the damning information provided in the CSB press release quotes above, the senior managers who didn't quit and leave in disgust from the Texas City Refinery from 1994 to 2005 - and by default, their senior corporate management - can't say they did everything they could to safeguard the lives of those who worked for them. They let their workers down.

Why?

They should have known and they should have acted.

The 15 deaths are a result of their inaction (or their ineffective action). That's why I get so mad when I read the CSB information. The billions of dollars of BP profits in 2005 are NOT worth those 15 lives.

Make no mistake. I believe what I wrote in the 2003 article "Stop the Sacrifices". I wrote it for senior managers in the construction industry. But senior managers at BP should have read it. Perhaps the 21st century will be the new age where we stop sacrificing employees to maximize profits. It certainly is time for senior management to stop claiming that they just couldn't see accidents coming. In BP's case, the evidence was there for anyone who cared to look.

If you disagree or if you have an opposing view, please feel free to comment by clicking on the "Comments" link below.

And if you agree, please feel free to let me know by clicking on the "Comments" link below.

But no matter what your opinion of this article, TAKE ACTION to make your improvement program WORLD CLASS. Do everything you can to prevent accidents and save lives at your company. You won't be sorry that you did.

Posted by Mark at 12:01 AM | Comments (5)

October 30, 2006

CSB Investigation of BP Texas City Refinery Disaster Continues as Organizational Issues Are Probed

For more information, go to: BP Investigation Information Page

Washington, DC, October 30, 2006 – In preliminary findings released today, the U.S. Chemical Safety Board (CSB) stated that internal BP documents prepared between 2002 and 2005 revealed knowledge of significant safety problems at the Texas City refinery and at 34 other BP business units around the world – months or years prior to the March 2005 explosion that killed 15 workers, injured 180 others, and was the worst U.S. industrial accident in more than a decade.

CSB Chairman Carolyn W. Merritt said, “The CSB’s investigation shows that BP’s global management was aware of problems with maintenance, spending, and infrastructure well before March 2005. BP did respond with a variety of measures aimed at improving safety. However, the focus of many of these initiatives was on improving procedural compliance and reducing occupational injury rates, while catastrophic safety risks remained. Unsafe and antiquated equipment designs were left in place, and unacceptable deficiencies in preventative maintenance were tolerated.”

Ms. Merritt pointed to earlier CSB findings that the equipment directly involved in the flammable release on March 23 was of an obsolete design already phased out in most refineries and chemical plants, and that key pieces of instrumentation were either known to be not working or known to be unreliable by unit supervisors.

The CSB has scheduled a news conference for Tuesday, October 31, in Houston, Texas, where additional new findings and safety recommendations will be presented.

Due to the complexity of the investigation, Chairman Merritt said that a final CSB report would not likely be issued before March 2007, but it was important for the public and the rest of the industry to remain informed on what the investigation has found.

Chairman Merritt also praised BP’s positive moves in the aftermath of the accident: “Since the tragedy, BP has expressed a strong desire to improve its safety performance globally, has made public its own detailed investigation report on the accident, has cooperated with federal investigators, has made organizational changes to better identify and communicate risks, and has done extensive positive outreach to the rest of the industrial community. BP has also voluntarily funded and supported the work of an independent panel recommended by the CSB to examine BP’s safety culture.” That 11-member expert panel, chaired by former U.S. Secretary of State James A. Baker III, is expected to report its findings on the safety of BP’s five North American refineries in late November.

Today’s preliminary findings were the first significant update in the Board’s investigation since October 27, 2005, when preliminary findings were issued at a public meeting before Texas City employees and residents.

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, causing a series of explosions and fires. Fatalities and injuries occurred in and around work trailers that were placed too near the ISOM unit and were not evacuated prior to the startup. Alarms and gauges that should have warned of the overfilling equipment failed to operate properly on the day of the accident.

After the accident, BP admitted that the placement of the trailers was unsafe and supported an industry-wide move to develop safer siting guidelines, following a CSB urgent recommendation in October 2005.

Don Holmstrom, the CSB supervisory investigator who is heading the inquiry, said that since last October the Board has uncovered additional previous incidents involving the same ISOM unit blowdown drum, which was designed in the 1950’s.

Mr. Holmstrom said that his team has now documented the occurrence of eight previous instances where flammable hydrocarbon vapors were discharged from the same blowdown drum between 1994 and 2004. In two of these incidents the blowdown system caught on fire. The eight incidents were not properly investigated, and appropriate corrective actions were not implemented. The investigation of a 1994 incident resulted in an action item to analyze the adequacy of the blowdown drum. The area superintendent was responsible for the completion of this item. However, the item was never finished, and management officials did not follow up to assure completion.

The explosion on March 23, 2005, was not the only major accident the Texas City refinery had experienced, CSB investigators said. The history of major accidents and fatalities at the plant was summarized in a meeting held in November 2004 by the refinery manager for 100 supervisors. He gave a sobering presentation entitled “Safety Reality” on the 23 deaths at the plant in the previous 30 years; on average, one worker had died every 16 months.

Mr. Holmstrom said, “In 2004, BP Texas City had the lowest injury rate in its history, nearly one-third the oil refinery sector average. However, the injury rate does not take account of catastrophic hazards or distinguish between injuries and fatalities. That year, the refinery experienced three major accidents that resulted in a total of three fatalities. One of these accidents was a major process-related fire. In late 2004, following these major accidents and other near misses, the Texas City leadership was attempting to improve the refinery’s safety performance. Several years of audits and reports had identified serious safety system deficiencies. However, the safety initiatives that were undertaken focused largely on improving personnel safety – such as slips, trips and falls – rather than management systems, equipment design, and preventative maintenance programs to help prevent the growing risk of major process accidents.”

“When personnel safety statistics improved, the refinery leadership believed they had turned the corner,” Mr. Holmstrom said. However, existing process safety metrics and the results of a safety culture survey indicated continuing serious problems with safety systems and concerns about another major accident. A Health, Safety, and Environment Business Plan presented on March 15, 2005 – just eight days before the ISOM unit accident – identified as a key risk that the Texas City refinery “kills someone in the next 12-18 months.”

Earlier, a 2003 external BP audit referred to the Texas City refinery’s infrastructure and assets as “poor” and found what it termed a “checkbook mentality.” Budgets were not large enough to manage all the risks, but rather than expanding the budget, expenditures were restricted to the money on hand, in the opinion of the BP auditors.

A 2004 BP Group internal audit of 35 business units including Texas City found significant common gaps, including a lack of leadership competence which pointed to “systematic underlying issues,” widespread tolerance of noncompliance with basic safety rules, and poor implementation and monitoring of safety management systems and processes.

Chairman Merritt stated that stringent budget cuts throughout the BP system caused a progressive deterioration of safety at the Texas City refinery. “BP implemented a 25% cut on fixed costs from 1998 to 2000 that adversely impacted maintenance expenditures and infrastructure at the refinery,” she said. Maintenance spending fell throughout the 1990’s at the then-Amoco refinery, and following the merger with BP further cuts were imposed. “Every successful corporation must contain its costs. But at an aging facility like Texas City, it is not responsible to cut budgets related to safety and maintenance without thoroughly examining the impact on the risk of a catastrophic accident.”

By 2002, an internal BP report had identified the cost reductions as contributing to a decline of infrastructure in Texas City that would require significant investment to correct. These findings were corroborated in a survey of the refinery’s safety culture in 2005 just prior to the accident, known as the Telos study. The survey interview with the Texas City refinery manager identified a history of decapitalization and a culture of “things not getting fixed.”

“The refinery manager was not alone in this candid assessment,” Chairman Merritt said. “Large majorities of the survey respondents reported significant maintenance backlogs that were harming safety. Disturbingly, most employees agreed that ‘production and budget compliance gets recognized and rewarded before anything else at Texas City.’”

Economic pressures were evident in numerous decisions that were causally related to the March 23, 2005, accident.

For example, in 2002, the refinery undertook an environmental initiative known as Clean Streams, during which plans were made for the elimination of the ISOM unit blowdown drum. Lead Investigator Holmstrom said, “To economize, a decision was made not to replace the blowdown drum with a flare system. The refinery did not conduct federally required safety reviews that likely would have taken into account BP’s own existing policy recommending the elimination of blowdown drums.” The required study of the ISOM unit relief valve system was never completed, though the need was first identified in 1993.

In addition, Texas City’s central training staff was reduced from 30 staff in 1997 to eight in 2004, and the training department budget was cut in half from 1998 to 2004. Trainers were given other duties, so that some spent little time on actual training. For example, the ISOM trainer spent only 5% of his time on training. Control board operator positions were downsized, and workloads were increased. Four open process safety coordinator positions for the ISOM and other area process units were not filled prior to the incident.

Operator fatigue and a lack of effective training and supervision were all cited in earlier CSB preliminary findings describing the causes of the unsafe startup on March 23.

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 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. Please visit our website, www.CSB.gov.

For more information, contact Daniel Horowitz at (202) 441-6074 cell (Houston) or Sandy Gilmour at (202) 261-7613 / (202) 251-5496 cell.

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 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

The CSB investigation of the accident at BP Texas City is the largest, costliest, and most complex in the nine-year history of the agency. To date, more than $2 million has been spent conducting this independent federal investigation.

Posted by Mark at 09:00 AM | Comments (0)

CSB Pursues Investigation of North Carolina Hazardous Waste Fire; Says Likely Origin in Facility’s Oxidizer Section

A Press Release from the Chemical Safety Board:

Washington, DC, October 30, 2006 – The U.S. Chemical Safety Board (CSB) today announced it is pursuing an investigation of the fire that burned from October 5 to 7 at the EQ North Carolina hazardous waste transfer and processing facility and forced the evacuation of thousands of residents from the Raleigh suburb of Apex.

No serious acute injuries occurred, but a number of responders and others were examined for chemical exposure and released.

The CSB investigation, which is expected to take six to 12 months to complete, will lead to a written case study, bulletin, or report that will be released to the public and likely contain new safety recommendations.

CSB Supervising Investigator Robert Hall, PE, said that his team had completed detailed first-round interviews of company employees, community members, and first responders and has begun reviewing documents obtained from EQ. “Credible evidence indicates that the incident likely began in the oxidizer section of the facility, where chemicals such as pool chlorination tablets were stored.”

Mr. Hall said that a chemical cloud was observed rising from the oxidizer storage area before the fire was evident. The facility had multiple storage bays for hazardous wastes such as oxidizers, flammables, acids, and bases. When the first firefighters arrived, they found a small fire approximately the size of two pallets. Within minutes, the fire spread directly into an adjacent bay containing highly flammable solvents. The fire grew out of control and was eventually allowed to burn itself out.

“The emergency response to the fire was appropriate, efficient, and precautionary,” Mr. Hall said, noting that attempting to fight such a fire with water could have led to environmental contamination. “Emergency responders initially sheltered residents in place near the source of the chemical release and evacuated those farther away. Once the chemical plume had dissipated to some extent, the sheltered residents were also evacuated.”

Because of the lack of surviving physical evidence, it is unlikely that the exact source of the chemical cloud will be discovered. However, witness observations are consistent with an incompatible chemical mixture that resulted in an uncontrolled chemical reaction. Such a reaction could have produced flammable vapors and sufficient heat to cause ignition.

Mr. Hall said that normal operations at the plant involved consolidating similar wastes for shipment off-site. “We plan to carefully review the company’s practices for determining the compatibility of waste materials as well as the training provided to workers involved in those operations,” Mr. Hall said. He said workers involved in hazardous waste operations are required by federal regulations to undergo 40 hours of specialized safety training before they begin work.

CSB Chairman Carolyn W. Merritt said, “The fire in Apex raises a number of questions, including whether better fire detection, protection, firewalls, and separation measures could improve the safety of hazardous waste facilities – especially those close to residential neighborhoods. In addition, we must be sure that emergency responders have access to accurate, timely information about the contents of such facilities so they can make the best decisions to protect our communities,” Chairman Merritt added. She said that cooperation between the CSB and local authorities in Apex has been exemplary.

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 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. Please visit the CSB website, www.CSB.gov.

For more information, contact Sandy Gilmour at (202) 261-7613 or (202) 251-5496 cell or Jennifer Jones at (202) 261-3603.

Posted by Mark at 08:53 AM | Comments (0)

Monday Accident & Lessons Learned: More Questions on Heparin Mix-Up

Continued from previous blog note...

Baby's die and people ask: "How different do two bottles need to be to prevent a mix-up?"

Should the nurses have noticed the difference above when they took bottles out of a cabinet that was supposed to have the right bottles in it (but the pharmacy had accidentally stocked the wrong ones)?

In one article by AP, there was following quote from one of the one of the mothers:

Thursday Dawn's mother, Heather Jeffers, said she blamed the nurses at the Indianapolis hospital for the overdose that led to her daughter's death five days after she was born.

I can see how someone who just lost their newborn would blame those who injected the wrong drug.

But blame won't prevent medical errors.

Blame never stops mistakes that are embedded in the system.

Blame is not a root cause.

I know what my friend John Grout would see - an opportunity for mistake proofing to help nurses avoid this problem.

Others say that "The 5 Rights" is the answer. (I've heard "If only they would have used the 5-Rights!")

Still others claim that bar-coding would prevent these issues.

Why can't we find the right answer and stop these tragic deaths?

If you work in the healthcare industry and would like to learn more ways to stop medical errors, there is a conference that I think you should attend:

The TapRooT® Summit

Dr. John Lighter has helped organize a special track for those interested in improving healthcare quality and stopping medical errors. For a complete schedule, click on the Medical Error Reduction button at this link:

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

In addition to the targeted breakout sessions focussed on improving healthcare and stopping mistakes, you will also be able to hear and meet several outstanding keynote speakers:

John Nance - Pilot, Author, ABC News Aviation Safety Consultant, and Healthcare Safety Speaker
Performance Lessons from the Cockpit to the Surgery Suite

Josh Davis - 5 Times Olympic Medalist
Olympic Success Lessons Learned

Judge Andrew Napolitano - NJ Supreme Court Justice and Fox News Consultant
Accident Lessons from the Courtroom

Beverly Chiodo - Award Winning College Professor
Character First!

Richard Hawk - Safety Speaker and Consultant
Creating a Vibrant Safety Culture

The Summit will be held in San Antonio, Texas, on April 25-28, 2007.

For more Summit information see:

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

To see a movie of what previous Summit attendees have to say about their experience see:

http://www.taproot.com/download/07SummitMovie.mov

To download a Summit Brochure, click here.

Posted by Mark at 08:30 AM | Comments (0)

October 24, 2006

10 Most Popular OSHA Violations - And Mark's Comment

The 10 most frequently sited OSHA Violations from October 2005 - September 2006 are:

1. Scaffolding--General Requirements (1926.451) with 7,895 violations
2. Duty to Have Fall Protection (1926.501) with 5,746 violations
3. Hazard Communication (1910.1200) with 5,586 violations
4. Respiratory Protection (1910.134) with 3,410 violations
5. Lockout/Tagout (1910.147) with 3,068 violations
6. Powered Industrial Trucks (1910.178) with 2,582 violations
7. Electrical--Wiring Methods, Components, and Equipment for General Use (1910.305) with 2,396 violations
8. Machine Guarding--General Requirements (1910.212) with 2,296 violations
9. Ladders (1926.1053) with 2,115 violations
10. Electrical--General Requirements (1910.303) with 1,791 violations

Once you review this list you need to step back and try to assess ....

What Does It Mean?

Are these the biggest safety hazards in industry?

Or are these just the safety hazards that OSHA inspectors like to look for?

My belief is that Management and Supervision failing to enforce work standards, policies, and administrative controls is the BIGGEST workplace safety hazard. But I could be wrong. I don't have a statistic for this.

What do I know? I know that all the violations listed on OSHA's top 10 list are violations of standards, policies, and administrative control;s. It is doubtful that all these violations would be occurring if management was enforcing the rules.

What rules need better enforcement at your facility?

Scaffolding?
Fall Protection?
Lock-out/Tag-out?
Machine Guarding?

What can you do to improve enforcement and save lives?

Perhaps you should consider attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?

What does root cause analysis training have to do with enforcement of the rules?

The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training teaches innovative guidance for positively enforcing the rules (rather than infrequently disciplining people for breaking the rules). A concept that many would benefit from trying.

Just one more reason to attend this excellent, guaranteed, root cause analysis training.

Posted by Mark at 12:31 AM | Comments (2)

October 23, 2006

Monday Accident and Lessons Learned - Fire Picture Info

If you thought the pictures were interesting (and you could use them to teach a lesson), wait until you read the additional information about the accidents and the lessons learned for each of the accidents below.

And if reading about accidents makes you think about preventing them, consider attending a TapRooT® Root Cause Analysis Course and learn to use advanced root cause analysis to reactively investigate problems or to proactively head them off.

Now for the answers to last weeks pictures...

1.
EQ Resource Recovery Fire
near Detroit, MI
Aug. 9, 2005
Investigation: Inconclusive.
David Allison, Fire Chief in Romulus, Michigan, said. "Unfortunately, a lot of the evidence was burned up."
EPA Comments:
http://yosemite.epa.gov/opa/admpress.nsf/7c02ca8c86062a0f85257018004118a6/db0bdabd26e88a38852570bc0073e6b6!OpenDocument

2.
Same fire as picture 1 - different view. (Ha! That's a trick question!)

3.
Valley Solvents & Chemicals
Fort Worth, TX
July 28, 2005
Info:
http://www.infowars.com/articles/us/texas_chem_plant_explosion_injures_4.htm
No final investigation found.

Buncefield Terminal Fire.
Hemel Hempstead, UK
December 11, 2005
For more Information:
http://www.taproot.com/blog/2006/08/monday_accident_lessons_leardn.html
http://www.taproot.com/blog/2006/08/here_are_some_more_pictures_of.html

Great Chicago Fire
October 7, 1871
Info:
http://www.chicagohs.org/fire/intro/gcf-index.html
http://www.prairieghosts.com/great_fire.html

6.
AZF
Toulouse, France
September 21, 2002
Info:
http://www.uneptie.org/pc/apell/disasters/toulouse/home.html
http://pedagogie.ac-toulouse.fr/histgeo/monog/azf/azf.htm

Giant Refinery
Gallup, NM
April 8, 2004
Info:
http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=47

8.
Bombay High Platform
ONGC
India
July 28, 2005
Info:
http://www.mace.manchester.ac.uk/project/research/structures/strucfire/CaseStudy/HistoricFires/Other/default.htm
http://www.hinduonnet.com/fline/fl2217/stories/20050826003602500.htm
http://www.hindu.com/2005/07/28/stories/2005072818230100.htm

West Pharmaceuticals
Kingston, NC
January 29, 2003
Info:
http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=34

Posted by Mark at 12:15 AM | Comments (0)

October 22, 2006

CNN Accident Story

Click here for the story.

Click here for a video.

Posted by Mark at 03:17 PM | Comments (0)

October 20, 2006

Friday Joke - Funny Vehicle Accident Pictures

I know that accidents aren't supposed to be funny. But sometimes you have to laugh when you see what people do.

Vote for the funniest car accident picture by using the comment link.

And don't even try to think about the root causes of these accidents.

10.

11.

12.

Ok - place your vote by clicking on the comment link below and telling me which accident picture (by number) was the funniest.

Posted by Mark at 12:59 AM | Comments (10)

CSB Issues Safety Bulletin on BP Texas City Major Fire: Better Material Identification Needed, Errors During Systems Maintenance Cited; Fire Caused $30 Million in Property Damage

The following is a press release from the Chemical Safety Board (CSB):

Houston, Texas, October 15, 2006

The U.S. Chemical Safety Board (CSB) issued a safety bulletin and new safety recommendations today based on the investigation of the July 28, 2005, hydrogen fire in the resid hydrotreater unit (RHU) at the BP refinery in Texas City, Texas.

The fire occurred four months after the explosion in the refinery's isomerization (ISOM) unit that killed 15 workers and injured 180. The July 28 fire caused $30 million in property damage. Weeks later, this accident was also cited in the CSB's urgent recommendation for BP to examine its safety culture at all its North American refineries.

The fire occurred at about 6:00 p.m. on the evening of July 28 when a piping elbow failed catastrophically and without warning, releasing highly flammable hydrogen gas at high temperature and pressure which immediately ignited. A huge fireball erupted and a fire burned for approximately two hours.

The safety bulletin notes that the piping system for an RHU heat exchanger contained three elbows of identical dimensions and appearance. Two elbows were constructed of alloy steel and were resistant to the effects of high-temperature hydrogen, but the third elbow was made of carbon steel, which is not resistant.

In February 2005, five months prior to the fire, the unit was shut down for routine scheduled maintenance. During the maintenance shut down, the contractor JV Industrial Companies inadvertently switched the positions of the carbon steel elbow with one of the alloy steel elbows, placing a carbon steel elbow on the outlet side of the heat exchanger, where it would be exposed continuously to high-temperature hydrogen. The investigation found that BP had not informed the maintenance contractor that the elbows were not interchangeable.

Lead Investigator John B. Vorderbrueggen, PE, said "Merely disassembling and reassembling piping components during maintenance resulted in an unacceptable hazardous system modification. BP should have required positive materials verification of these pipe elbows using an x-ray fluorescence test device. This would have identified the mistake in the reassembly of the identically appearing elbows before the unit was returned to service. The accident would not have occurred."

The fire resulted in a Level 3 community shelter-in-place alert in Texas City. Level 3 is the second highest emergency classification that applies to an incident where the situation is not under control and protective action may be necessary for the surrounding or offsite area. The Board issued several formal safety recommendations. The BP Texas City Refinery was urged to revise its maintenance program to include materials testing or verification of all alloy steel piping components and to inform work crews of material handling precautions. The Board also recommended that JV Industrial Companies update its piping component installation procedures to require material identification for components removed during maintenance to ensure they are reinstalled in the correct locations.

"There are important safety lessons for oil and chemical companies from this incident," said CSB Chairman Carolyn W. Merritt. "Positive materials verification of the components in piping systems can avoid simple mix-ups that can have devastating consequences." The bulletin also emphasized what is termed "human factors based design" - that is, designing components so that foreseeable human errors are less likely to occur.

The safety bulletin and recommendations were issued at a news conference in Houston on Sunday, October 15, at 11 a.m. The CSB's investigation of the ISOM unit accident remains ongoing with a final report expected in the first part of 2007. CSB lead investigator Don Holmstrom and his team have been continuing to conduct interviews of top BP executives and gathering additional documentary evidence.

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 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. Please visit their website, http://www.CSB.gov.

Posted by Mark at 12:10 AM | Comments (0)

October 16, 2006

Monday Accident & Lessons Learned: Name That Explosion/Fire Picture

It is amazing how many explosions and/or fires happen each year. If you try to make a list of just the industrial fires and explosions, it is long and sad. But pictures of the fires, explosions, and the aftermath can help people understand why safety is important. Why safety rules, procedures, training, and management attention is so important.

Can you name the facilities where the accidents below happened?

Better yet, do you know the root causes of these fires and/or explosions and what you need to do to prevent them at your facility? The answers to these questions can keep your facility safe.

Performance improvement comes from hard work and dedicated people applying industry best practices and advanced root cause analysis. This lesson has been proven over and over again.

10.

For more information on a Summit to learn industry best practices see:

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

For more information about advanced root cause analysis training see:

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

Posted by Mark at 10:25 AM | Comments (1)

October 10, 2006

Fire at Hazardous Waste Plant in Apex, North Carolina

Here is an initial CNN report:

http://www.cnn.com/video/us/2006/10/06/forte.nc.hazardous.fire.news14carolina/content.html

Local news coverage:

http://www.wral.com/news/10012555/detail.html

CNN's report on the end of the evacuation from Associated Press at:

http://www.cnn.com/2006/US/10/07/plant.fire.ap/index.html

The Chemical Safety Board released the following press release:

CSB Deploys Investigators to Site of Chemical Fire and Public Evacuation from North Carolina Hazardous Waste Facility

Washington, DC, October 6, 2006 - The U.S. Chemical Safety Board (CSB) is deploying an investigation team to begin an assessment of the chemical fire, explosions, and large-scale public evacuation in Apex, North Carolina, site of a hazardous waste facility operated by the Environmental Quality Company.

Media reports indicate that a chemical fire began around 9:00 p.m. on Thursday October 5, 2006, causing a series of additional explosions. An estimated 17,000 residents have been evacuated to shelters and several roads have been closed.

The Environmental Quality Co. is a consolidator and processor of hazardous waste that operates approximately 14 facilities in the U.S., including a facility in Romulus, Michigan, that experienced a major fire earlier this year.

The CSB team will be led by investigator Robert Hall, P.E., and will be accompanied by CSB Chairman Carolyn W. Merritt and Board Member William B. Wark, an expert in emergency management. Team members will arrive in Apex this evening and begin their investigative work on Saturday.

The investigators will collect information that will assist the Board in deciding whether to conduct a full investigation of the causes of the incident.

Media contacts: on site, CSB Director of Public Affairs Dr. Daniel Horowitz, (202) 441-6074 (cell); in Washington, DC, Sandy Gilmour (202) 251-5496 (cell) and Jennifer Jones (202) 577-8448 (cell).

This message was transmitted at 12:58 PM Eastern Time (U.S.A.) on October 6, 2006.

Posted by Mark at 12:57 AM | Comments (0)

October 09, 2006

Monday Accident & Lessons Learned: Statistics - Deaths at US Refineries vs Deaths at US Hospitals

I came upon these statistics at the Houston Chronicle web site in a section about deaths at refineries:

http://images.chron.com/content/news/photos/05/05/15/page.html

The stats show that from 1995 through 2005 there were 43 total fatalities with 22 of those (over 50%) at BP Refineries.

These somewhat gruesome statistics makes one stop and think.

But as I pondered these statistics I thought about the reports on medical errors and needless deaths at hospitals. By current estimates in a 10 year period there would be about 900,000 deaths due to errors at hospitals.

The risk at hospitals and refineries can be measured by results. What risk does your facility have?

For those looking to improve performance and stop fatalities, you need to have a comprehensive continuous improvement plan. Plus you need to learn advanced root cause analysis and best practices from your industry and from other industries to help you stop bad things from happening.

For advanced root cause analysis training, see this link:

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

For a place to learn best practices, see this link:

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

But don't wait for a fatality to get started.

Posted by Mark at 09:59 AM | Comments (0)

October 06, 2006

BP Texas City Post Accident Process and Operational Audit Report

For those interested in the BP Texas City Explosion aftermath, there is an interesting audit report that you can download at:

http://www.chron.com/content/chronicle/special/05/blast/stanleyreport.pdf

Also, the Houston Chronicle has a special on-line section at:

http://www.chron.com/content/chronicle/special/05/blast/index.html#

Posted by Mark at 12:00 AM | Comments (2)

October 02, 2006

Monday Accident & Lessons Learned: Medical Mistake: Premature infants receive adult doses of Heparin

(Methodist Hospital in Indianapolis)

Again, medical errors are in the news.

At Methodist Hospital, six premature infants were given the adult dose of a blood thinning medication (Heparin).

What did the news have to say?

CNN:

http://www.cnn.com/2006/US/09/17/premature.infants.ap/index.html

Associated Press:

http://seattlepi.nwsource.com/health/1500AP_Preemie_Deaths.html

USA Today:

http://www.usatoday.com/news/nation/2006-09-20-baby-deaths_x.htm?csp=34

Local TV / Good Morning America:

http://www.theindychannel.com/news/9884927/detail.html

To make things even sadder, the hospital missed the chance to learn from a previous (2001) incident where two infants were given adult doses of Heparine and survived. The hospital had a chance to use advanced root cause analysis and develop effective corrective actions ... but they missed it. What a shame.

I would guess that we aren't too far from seeing such mistakes being treated as criminal negligence. People - nurses and even hospital administrators - could be facing jail time for errors that are preventable. I'm NOT saying this is a GOOD way to prevent future Sentinel Events. But when people get fed up with needless deaths, criminal prosecution may seem to them to be a just result and a way to get the attention of healthcare industry executives.

What are the lessons learned from this tragic event? Here is a link to some ideas from a professional society (the American Society of Health-System Pharmacists):

http://www.ashp.org/emplibrary/Med%20Error%20Member%20Update.pdf

These types of errors are why we plan a special track at the TapRooT® Summit devoted to stopping medical errors. For the schedule for this track at the Summit, click here, and then click on the Medical Error Reduction Best Practices button in the Display Selected Track box on the web page.

We can stop medical errors. These types of errors are preventable.

Root cause analysis of Sentinel Events like this one can contribute to our learning. Every hospital should have several root cause analysis experts trained in TapRooT®.

But it would be even better if hospitals used best practices and proactive improvement methods to stop medical errors BEFORE Sentinel Events happen.

The TapRooT® Summit is an excellent place to learn best practices and proactive tools from the hospital industry and from other industries (nuclear, aerospace, utilities, mining, manufacturing, transportation, ...). If you are responsible for root cause analysis, quality improvement, human performance improvement, or risk management at a hospital, why haven't you attended:

- A TapRooT® Course

- The TapRooT® Summit.

Don't wait for a newsworthy Sentinel Evenet to start learning. You need this information to help you improve your hospital's performance. Get the budget in place and the travel authorized to attend the TapRooT® Summit and a 2-Day TapRooT® Course on On April 22-28, 2007. When you attend both a TapRooT® 2-Day Course and the TapRooT® Summit you will SAVE $200! Click here to register.

Posted by Mark at 09:52 AM | Comments (0)

September 29, 2006

Friday Joke: Rescue Gone Awry

Click on the video below ... Should you laugh or should you cry?

If you owned the helicopter, you would cry!

Posted by Mark at 12:11 AM | Comments (0)

September 26, 2006

Send Me Your Safety, Quality, Production, Maintenance, and Environment Incident Pictures (even near misses)

(click on picture to enlarge)

Did you see the one step away from death video and picture that I posted last Tuesday?

I saw an incident (near-miss) and recorded it.

Now others can learn from it and use it in their safety meetings to raise awareness about fall protection and proper work practices.

If you see something that just isn't right ... for example, a:

- quality problem
- safety problem
- near-miss
- production upset
- maintenance issue
- equipment failure
- environmental release
- or any other "event"

Take a picture or a video and send it to me at "info@taproot.com" and I'll post it here to share it with others.

If you want to remain anonymous, just let me know and I won't use your name or your company's name with the posting.

By passing along pictures of problems you can help others save lives, save jobs (by improving quality and preventing operating and maintenance problems), and save the environment (by preventing accidental releases).

And please feel free to use the pictures, videos, and other information from this blog to make performance better at your site.

And if you want to improve your systematic performance improvement attend a TapRooT® Course and the TapRooT® Summit.

Thanks for your help.

Mark

Posted by Mark at 11:16 AM | Comments (3)

September 25, 2006

MONDAY ACCIDENT & LESSONS LEARNED: Alberta Workplace Health & Safety Shares Lessons Learned from 24 Accidents

What can you learn from 24 tragic accidents? Alberta Workplace Health & Safety has posted reports with lessons learned from 24 accidents. See their conclusions at:

http://www.hre.gov.ab.ca/cps/rde/xchg/hre/hs.xsl/123.html

Posted by Mark at 10:30 AM | Comments (0)

September 18, 2006

MONDAY ACCIDENT & LESSONS LEARNED: Workplace Incidents Fatalities Summaries from Alberta 2001-2006 - They Didn't Have to Happen!

What can you learn from the summary of the fatalities of a province? The first thing I saw was that NONE of these deaths had to happen. They all could have been prevented. And some by fairly simple actions. This list would make great topics on hazard awareness for safety meetings.

Click on the yearly links to read more at:

http://www.hre.gov.ab.ca/cps/rde/xchg/hre/hs.xsl/2572.html

Posted by Mark at 12:45 AM | Comments (0)

September 08, 2006

FRIDAY JOKE: An addition to the Bricklayers Accident Report

From many sources on the internet...

This is a bricklayer's accident report that was printed in the newsletter of the English equivalent of the Workers' Compensation Board.

Dear Sir;

I am writing in response to your request for additional information in Block #3 of the accident reporting form. I put "Poor Planning" as the cause of my accident. You asked for a more complete explanation and I trust the following details will be sufficient.

I am a bricklayer by trade. On the day of the accident, I was working alone on the roof of a new six-story building. When I completed my work, I found I had some bricks left over which, when weighed later, were found to weigh 240 lbs. Rather than carry the bricks down by hand, I decided to lower them in a barrel by using a pulley which was attached to the side of the building at the sixth floor.

Securing the rope at ground level, I went up to the roof, swung the barrel out, and loaded the bricks into it. Then I went down and untied the rope, holding it tightly to insure a slow descent of the 240 lbs of bricks. You will note on the accident reporting form that my weight is 135 lbs.

Due to my surprise at being jerked off the ground so suddenly, I lost my presence of mind and forgot to let go of the rope. Needless to say, I proceeded at a rapid rate up the side of the building.

In the vicinity of the third floor, I met the barrel which was now proceeding downward at an equally impressive speed. This explains the fractured skull, minor abrasions, and the broken collarbone, as listed in Section 3, accident reporting form.

Slowed only slightly, I continued my rapid ascent, not stopping until the fingers of my right hand were two knuckles deep into the pulley which I mentioned in Paragraph 2 of this correspondence. Fortunately, by this time I had regained my presence of mind and was able to hold tightly to the rope, in spite of the excruciating pain I was now beginning to experience.

At approximately the same time however, the barrel of bricks hit the ground and the bottom fell out of the barrel. Now devoid of the weight of the bricks, the barrel weighed approximately 50 lbs.

I refer you again to my weight. As you might imagine, I began a rapid descent down the side of the building. In the vicinity of the third floor, I met the barrel coming up. This accounts for the two fractured ankles, broken tooth and severe lacerations of my legs and lower body.

Here my luck began to change slightly. The encounter with the barrel seemed to slow me enough to lessen my injuries when I fell into the pile of bricks and fortunately only three vertebrae were cracked.

I am sorry to report, however, as I lay there on the pile of bricks, in pain, unable to move and watching the empty barrel six stories above me, I again lost my composure and presence of mind and let go of the rope.

- - -

Have you ever heard an incredible story and thought, ... "That can't be true."

Where can you go to debunk Urban Legends?

Try these web sites:

http://www.snopes.com/

http://urbanlegends.about.com/

http://www.truthorfiction.com/

Posted by Mark at 12:45 AM | Comments (0)

September 07, 2006

London Daily Mail Reports: Half a million patients are hit by NHS blunders

I've mentioned needless deaths and injuries at healthcare facilities before in this blog, in our e-Newsletter, and in the Root Cause Network™ Newsletter.

A TapRooT® User forwarded me this link to a story in the London Daily Mail about mistakes and injuries at National Health Service hospitals in the UK:

http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=402499&in_page_id=1770

It looks like their problems are similar to those experienced in the US.

Note that the TapRooT® Summit in San Antonio on April 25-28 has a whole track devoted to stopping medical errors. Perhaps the NHS should be sending an attendee ... or maybe two or more!

Whenever a company or government agency has problems that result in fatalities, action speaks louder than excuses and statistics. The families and loved ones of the 2,159 people that died last year in the UK due to medical errors probably are NOT comforted by the fact that those who died were, according to a UK NHS spokesperson, "... a tiny proportion of the millions of patients who use the NHS each year."

From the spokesperson's insensitive comment, I guess we should thank the NHS for not killing a large fraction of the patients.

Perhaps I am particularly sensitive to this issue because my mother was harmed by a medical error at a hospital in the US. At the time of the mistake, it could have been fatal. The mistake caused significant "loss of function." It wasn't detected until I arrived at the hospital 48 hours later (I was on the road teaching a 5-Day Course). The loss of function eventually contributed to her death a couple of years later.

We never sued anyone but the experience made stopping medical errors much more personal.

Now you may understand why I'm so passionate about improving the quality of care at hospitals. I understand the personal loss that these errors lead to. And I know that dramatic improvement is possible and is cost effective.

So if you are at a medical facility, please don't be offended by my critical analysis of the state of care - and other's articles that highlight errors. Rather, consider attending the Summit because you know it was organized by someone (me) with a personal interest in the success of improvement in the medical industry. Stopping medical errors is a high on my list of priorities as I hope it is for everyone who works in the medical industry around the world.

Posted by Mark at 12:28 AM | Comments (0)

September 06, 2006

CSB PRESS RELEASE: CSB Posts Spanish-Language Version of Agency's Animation of BP Texas City Explosion Events; May Be Downloaded for Training

LINK TO SPANISH VERSION of BP REFINERY EXPLOSION VIDEO

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Posts Spanish-Language Version of Agency's Animation of BP Texas City Explosion Events; May Be Downloaded for Training

Washington, DC, September 5, 2006 - The U.S. Chemical Safety Board (CSB) has posted on its website a Spanish translation of the narrated video of the accident at BP's Texas City refinery which occurred March 23, 2005. This video, as well as eight English-language CSB safety videos, may be viewed online in the Video Room at CSB.gov.

CSB Chairman Carolyn W. Merritt said, 'There are many Spanish-speaking workers in the oil and chemical industry in the United States - and throughout Latin America - and we offer this translated version in hopes that safety managers and others will have an additional tool for training and other safety uses. We thank former CSB Board Member Rixio Medina for providing the translation, which has been recorded by a professional narrator in Spanish.'

The video, which includes a computer-generated animation sequence, illustrates how the refinery's raffinate splitter tower was overfilled, how instruments and alarms failed to indicate the dangerous condition, and how a connected blowdown drum and vent stack released flammable liquid and vapor which exploded. Also shown are still photographs and video illustrating the destruction caused by the accident, which killed 15 workers and injured 170 others. The English-language video is narrated by Don Holmstrom, lead CSB investigator for the BP investigation.

The English version of the video has been widely used by the industry. Since first posted on CSB.gov, this video has been viewed hundreds of thousands of times. Free DVD copies of all English version videos are available by filling out the online request form.

The video has also been translated into German and will soon be available in French.

'This video - in any language - clearly explains the many problems that preceded this event. I believe that prudent managers reviewing this video will ask themselves, 'Could this possibly happen here?' And if they find places where the same problems could exist, we hope they will address them to prevent catastrophic events at their own facilities,' stated Chairman Merritt.

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 Lindsey Heyl, 202-261-3614 / 202-725-2204 (cell), or Sandy Gilmour, 202-261-7614 / 202-251-5496 (cell).

This message was transmitted at 6:14 PM Eastern Time (U.S.A.) on September 5, 2006.

Posted by Mark at 04:16 PM | Comments (0)

September 04, 2006

MONDAY ACCIDENT & LESSONS LEARNED: The BP Texas City Refinery Explosion: Lessons Learned by John Mogford

I've been waiting for the CSB report on the BP Texas City Refinery Explosion to write more about the explosion and investigation, but I thought that this talk given at the 2006 CCPS Process Safety Global Congress might interest readers while their waiting for the CSB to issue their report.

To read a transcript of the talk, click on the link below:

http://www.aiche.org/uploadedFiles/CCPS/John%20Mogford%20Center%20for%20Chemical%20Process%20Safety%20Speech.pdf

Posted by Mark at 12:22 PM | Comments (0)

August 29, 2006

Here are some more pictures of the Buncefield fire & some links ...

A link to video and pictures: http://www.chill3d.f2s.com/

Another site with good pictures: http://www.buncefield-oil-fire-hemel-hempstead.wingedfeet.co.uk/

CCTV footage:

http://buncefield.chill.net/yabbfiles/Attachments/cam09_20051211055927.mpg

http://www.telegraph.co.uk/portal/main.jhtml?xml=/portal/2005/12/17/nfire17.xml

Posted by Mark at 12:24 AM | Comments (1)

August 28, 2006

MONDAY ACCIDENT & LESSONS LEARDNED: Buncefield Investigation

Do you remember the press coverage of an explosion and fire in England just before Christmas of 2005? Smoke could be seen from space.

The UK Government is performing the official investigation of the explosion and fire at the Buncefield petroleum terminal. Below are some links of interest to the official investigation web site:

A safety alert of interest to those who have tank farms with flammable liquids:

http://www.hse.gov.uk/comah/alerts/sa0106.htm

The latest investigation update:

http://www.buncefieldinvestigation.gov.uk/press/b06004.htm

All the press releases about the investigation:

http://www.buncefieldinvestigation.gov.uk/press/index.htm

Here is the Buncefield Explosion forum:

http://www.buncefield.com/

Now what are the lessons learned?

Read the investigation update and see what you think. Make a comment here.

Posted by Mark at 09:00 AM | Comments (0)

August 25, 2006

FRIDAY JOKE: You know it's a bad day when a picture of your new Ferrari makes the rounds of the internet - WRECKED!

What a beautiful car!

To see the rest of the story, click below.

Here is what's left when you hit a pole at over 100 MPH.

The e-mail said:

The car only had 9 miles on the odometer.

The driver only had some bruising (from the seat belt) and 2 small cuts.

Let's here it for Ferrari engineering!

200+ MPH straight out of the crate and a crash protection system that saved an idiot.

By the way, one could define an idiot as anyone who would attempt 200 MPH on a US highway (not even a divided highway...)!

Now for the root cause analysis???

Posted by Mark at 02:31 PM | Comments (1)

August 22, 2006

Good Site for Workplace Safety and Accident Articles

Have a look at this site:

http://www.topix.net/us/osha

Posted by Mark at 11:03 AM | Comments (0)

August 21, 2006

MONDAY ACCIDENT & LESSONS LEARNED: What are the most Hazardous Jobs?

CNN recently published the Bureau of Labor Statistics data on fatalities in the workplace. What was the worst industry to work in? See this link:

http://money.cnn.com/2006/08/16/pf/2005_most_dangerous_jobs/index.htm

To see the BLS stats go to:

http://www.bls.gov/news.release/pdf/cfoi.pdf

and

http://www.bls.gov/iif/oshwc/cfoi/cftb0205.pdf

What are the lessons learned? There is definitely more chance of fatalities in some industries than others. What are the odds in your industry?

No matter the odds in your industry ... even ONE fatality at your site is too many.

What are you doing to prevent fatalities?

Do you analyze the root causes of incidents and near-misses to remove hazards and improve safety at your site?

Do you have a proactive improvement program to stop accidents before they happen?

Posted by Mark at 08:02 AM | Comments (0)

August 19, 2006

CSB Says Kentucky's New Combustible Dust Inspection Program 'Exceeds Recommended Action'

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

Chemical Safety Board Commends the Kentucky Office of Housing, Buildings, and Construction, Says New Combustible Dust Inspection Program 'Exceeds Recommended Action' from Investigation of Fatal 2003 Explosion

Washington, DC, August 16, 2006 - The U.S. Chemical Safety Board (CSB) today formally commended the Kentucky Office of Housing, Buildings, and Construction (HBC) for exceeding the recommended action from the Board's investigation of the fatal 2003 dust explosion at CTA Acoustics in Corbin, Kentucky.

During the investigation, the CSB found that the Kentucky state fire marshal's office, which is part of the HBC, did not regularly inspect industrial facilities for fire safety and had not inspected the CTA facility since it was constructed in 1972. On February 15, 2005, the Board voted at a public meeting in London, Kentucky, to recommend that the HBC 'identify sites that handle combustible dusts when facilities apply for new or modified construction permits, and use this information to help prioritize establishments that will be inspected by the fire marshal.'

The HBC fulfilled the recommendation by modifying its building code review process to identify all new or modified facilities that can generate large quantities of combustible dust and adding those facilities to the state fire marshal's annual inspection list.

The HBC also went above and beyond the CSB safety recommendation by: (1) generating a list of existing facilities at risk for combustible dust explosions; (2) successfully seeking additional funding from the Kentucky state legislature to hire more inspectors; (3) prioritizing its 2006 inspection schedule to concentrate on facilities with combustible dust hazards; and (4) actively working with inspected facilities to generate cleaning plans. On the basis of these additional actions, which will reduce future dust explosion risks, the Board voted to designate the recommendation as 'closed - exceeds recommended action.'

The explosion on February 20, 2003, at CTA Acoustics killed seven workers, injured 37 others, and essentially destroyed the facility which produced automotive insulation. The Board's investigation found that the facility lacked effective firewalls and blast-resistant construction designs and had extensive accumulations of combustible phenolic resin powder, which fueled the explosion.

The incident was one of three fatal combustible dust explosions that occurred in 2003 and were investigated by the CSB. In 2004, the Board began a national study of combustible dust hazards, which has so far identified 281 industrial dust explosions in the U.S. over a 25-year period; those incidents resulted in a total of 119 deaths and 718 injuries.

CSB Chairman Carolyn W. Merritt said, 'The Kentucky state government has demonstrated a strong commitment to making industrial facilities safer from deadly dust explosions. The new program is helping to identify workplaces at risk and promote changes. The Kentucky program is a model for other states to study and follow. Kentucky's actions will help prevent future tragedies like the one that claimed seven workers' lives in 2003.'

The Board votes to assign a status to each of its safety recommendations based on a staff analysis of documents and other information provided by recipients. The Board may designate a recipient's actions as 'acceptable' or 'unacceptable' based on whether the actions meet the intention of the Board's safety recommendation. The 'exceeds recommended action' designation has been used only six times among the 178 formal safety recommendations that the Board has voted to close since 1998.

For more information, contact Dr. Daniel Horowitz, Director of Public Affairs, (202) 261-7613 or (202) 441-6074 cell or Sandy Gilmour, (202) 261-7614 or (202) 251-5496 cell.

________________________________________________________

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

Posted by Mark at 12:56 PM | Comments (0)

August 18, 2006

FRIDAY JOKE: PICTURES ... A bad day for the pilot!

If your a pilot, you know it's a bad day when...

Click on pictures to enlarge ...

Click below for more ...

So here's to having a GOOD DAY!

Posted by Mark at 12:35 AM | Comments (0)

August 14, 2006

MONDAY ACCIDENT & LESSONS LEARNED: BP Pipeline Corrosion

I don't have any inside information. I don't know any more than is available in press reports 1), 2), and 3).

What do I know???

I know there is a lesson that all senior executives should learn.

And I know the pipeline leak is costing BP much more than they ever imagined.

Let's look at some estimates of the cost...

The most obvious is the lost production. The hit to BP's bottom line. If they loose 200,000 barrels of production (1/2 the field) for 20 days, that equals 4,000,000 barrels of oil that will not be sold. At a price of $70 per barrel, that is $280,000,000. That's a sizable hit in a quarters earnings. But that is just the tip of the iceberg of costs.

Perhaps the biggest loss to BP is that this spill could provide the bad publicity that keeps drilling in the Arctic National Wildlife Refuge from happening. If it is assumed that BP would lead that effort, an estimate of the loss is 1,000,000 barrels per day of production over a decade or more. A quick calculation ...

1,000,000 barrels per day X 365 days per year X 10 years X $40 per barrel = $146 Billion.

But there is even a bigger loss to the US and world economy. The loss of the ANWR oil supply impacts the economy. Oil prices went up 3% on the news of a loss of production of 400,000 barrels per day. If the loss of 1,000,000 per day is figured into the price of oil, that's a 7.5% increase in the price of oil over a 10 year period. I'm not an economist, but I can make an attempt estimating the impact on the average family...

If I assume $3 per gallon gas and the price is passed through to consumers, that's a 22.5¢/gallon price increase over 10 years. If families in the US fill up twice a week at 15 gallons per fill up, that's over $300 per year per family. That might sound small. But would BP reimburse all of us? All they would have to do is make a car payment once a year for every family in the US. Or maybe they should buy a new car for 10% of the families every year. I think that would make BP a bigger auto supplier than GM or Toyota. Got the idea ... big impact!

Of course there is also a more personal side to this story. Within BP a big impact like this won't go unnoticed. Somebody's career - or maybe several careers - will be ruined.

And what about BP's corporate reputation for protecting the environment? Didn't they pay for a bunch of commercials about how environmentally friendly BP is? Kiss that PR champaign goodbye. I've already seen pictures of workers cleaning up oil from the pristine tundra. This probably won't be as bad - PR wise - as Exxon's Valdez oil spill (the North Slope is more remote and there aren't very many cute animals), but it will be a big black eye.

So what should senior management (CEO's, COO's, CFO's, ...) be learning?

Give me your opinions as comments by clicking on the comment link below...

Posted by Mark at 08:45 AM | Comments (7)

August 10, 2006

Bloomberg Provides More Info on BP Pipeline Problems

Click on this link for more info on BP's pipeline closure.

Posted by Mark at 12:34 AM | Comments (0)

August 07, 2006

Monday Accident & Lessons Learned: Fall Protection - NOT

Photo from the
Naval Safety Center web site

http://www.safetycenter.navy.mil/photo/archive/archive_101-150/photo143.htm

At a recent course one of the students brought an example for an exercise that reminded me of this picture. There were only three differences:

1. The employee used the scissor lift to tighten a bolt. (The bolt was beyond his reach so he climbed up on the railing.)
2. He was wearing fall protection but he didn't hook up. (The job would just take a second.)
3. He slipped, fell, and was killed.

Getting people to work safely at heights requires managers' and supervisors' attention.

Yes, people should be careful.

Yes, people should follow the rules.

Yes, people are responsible for their own safety.

But we know that people take shortcuts to save time and effort.

We know that people react to real and perceived pressure to "Get 'er done!"

We know that if management and supervision don't show their concern by consistent enforcement (both positive and negative enforcement) of the rules, people will start to ignore them.

Thus management must insist that the rules are followed and develop a program to make sure that they are followed.

If your company has people working at heights, ask yourself:

HOW DO YOU ENSURE THAT
PEOPLE ARE FOLLOWING THE RULES
ABOUT WORKING AT HEIGHTS?

Good, proactive enforcement of the rules can prevent accidents. You won't have to analyze the root causes of a fatality if you prevent it by enforcing the rules!

Posted by Mark at 01:37 PM | Comments (0)

July 31, 2006

Monday Accident and Lessons Learned - The Bhopal Investigation

I found an outstanding description of the difficulties encountered conducting a major investigation - the chemical release at Bhopal. The paper is entitled:

Investigation of Large-Magnitude Incidents: Bhopal as a Case Study
by Ashok S. Kalelkar and presented at the AICHE Conference on Preventing Major Accidents in May of 1988.

Download a copy at:

http://www.bhopal.com/pdfs/casestdy.pdf

What will you learn? The challenges of a highly political, legally contentious investigation.

Posted by Mark at 12:14 AM | Comments (0)

July 24, 2006

MONDAY ACCIDENT & LESSONS LEARNED • ACTIONS WITHOUT THOUGHT ... WHAT IS THE ROOT CAUSE???

ACTIONS WITHOUT THOUGHT ... WHAT IS THE ROOT CAUSE???

Here is a question from a new TapRooT® user who attended a course and sent me this question...

From: Michael Baer

Just a quick follow up from the training class last week - I talked to Ken a little bit about this there & he suggested following up by email. We were discussing routine actions without thought; one of the things that comes through from the video 'Remember Charlie' that we use for our safety training. If I recall correctly, CCPS defines this as one of their possible immediate causes - I wasn't clear about how (or if) this would fit in under the TapRooT® Root Cause Tree®.

After looking at the Root Cause Tree® & the dictionary again, I'm still not clear on the subject & would be grateful for your input. I would think that it would fall out under the 1st one of the 15 questions - but I'm not seeing something similar in the dictionary under Human Engineering or Work Direction. Did I miss something?
Thanks

Mike

Here was my reply:

From: Mark Paradies
To: Michael Baer

Mike:

Thanks for the question.

These types of errors are sometimes categorized as "slips" and sometimes even as "mistakes" under James Reason's classification system. Another psychological term for this type of error is "Situational Awareness". However, these classifications don't help much when developing corrective actions.

Routine actions without thought could be listed as a causal factor of "Bubba just goofed up".

These types of errors are hard to analyze because people often take the easy way out - they just tell Bubba ... "Be more careful next time!"

But there are root causes. The analysis requires the investigator to open their eyes to causes they may not have previously considered. I'll should you how the Root Cause Tree® works to make this happen...

When this general type of causal factor is taken through the Root Cause Tree®, there are several of the 15 questions that should be considered (and I will bold the most applicable part of the questions):

1. Was the person excessively fatigued, impaired, upset, bored, distracted?

2. Should the person have had and used a written procedure but did not?

3. Was a mistake made while using a procedure?

4. Were alarms or displays to recognize or respond to a condition unavailable or misunderstood.

5. Were displays, alarms, controls, tools, or equipment identified or operated improperly?

6. Was work performed in an adverse environment (such as hot, humid, dark, cramped, or hazardous)?

7. Was task performed in a hurry or a shortcut used?

8. Were policies, administrative controls, or procedures, not used, missing, or in need of improvement?

As you can see when you look at your tree, there are lots of places that this type of mistake can lead including the following Near-Root-Cause Categories:

Procedure - Not Use/Not Followed
Procedures - Followed Incorrectly
Management System - SPAC Not Used
Human Engineering - Human-Machine Interface
Human Engineering - Work Environment
Human Engineering - Non-Fault Tolerant System
Work Direction - Preparation
Work Direction - Selection of Worker

From these Near-Root-Cause Categories, the root causes that I think are most likely to be found by my experience are:

Procedures - Not Used/Not Followed - (no root cause)
Management System - SPAC Not Used - Enforcement NI (related to Procedure usage)
Human Engineering - Human-Machine Interface - monitoring alertness NI
Human Engineering - Human-Machine Interface - controls NI
Human Engineering - Work Environment - ... could be almost any of the categories
Human Engineering - Non-Fault Tolerant System - errors not recoverable
Work Direction - Preparation - scheduling (see Dictionary for ideas)
Work Direction - Selection of Worker - ... either fatigued, upset, or substance abuse

What I usually find is that people have not done the analysis to be able to say if any of the root causes above were applicable to the mistake.

For example, how do they investigate fatigue?

Another example, are they using procedures to improve human reliability?

Another example, are the controls prone to simple errors (controls NI)?

Once one uses the full power of the Root Cause Tree® in their investigations, they can find that simple errors like "Routine actions without thought" usually have causes that just have not been investigated. A very small percentage (perhaps less than 5%) are actually errors that we can't explain (understand?) or fix.

I see that you've been to a 2-Day TapRooT® Course. These topics are covered much more thouroughly in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course that has several sections on the causes of human error - causes that often seem to be simple, but are in fact fairly complex.

Hope this helps.

Mark

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

July 20, 2006

CSB Issues Press Release about Formosa Plastics Point Comfort, Texas, Fire and Explosions and a Video About The Accident

(CSB Picture of initial accident site from CSB Accident Report)

To get more information about the investigation, root causes, and recommendations see:

http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=304

View the PDF format investigation report at:

http://www.csb.gov/completed_investigations/docs/Formosa_TX_Case_Study_07-14-06.pdf

To watch the video go to:

http://www.csb.gov/index.cfm?folder=video_archive&page=index#launch

Posted by Mark at 03:00 PM | Comments (0)

July 19, 2006

Failed Rudder - Hard Turn - Injured Passengers - Ship Back to Port - Root Cause???

Some initial reports indicate that a mechanical failure of the rudder may have been the cause of an accident aboard the Crowne Princess (operated by Princess Cruise Lines).

How do they troubleshoot equipment failures?

How do they analyze root causes?

I would bet there were previous near-misses that weren't thoroughly investigated. I would also bet that if these near-misses' root causes had been corrected, the cruise line could have prevented these injuries and this public relations fiasco.

For a more detailed initial report see:

http://www.cnn.com/2006/US/07/18/cruise.return/index.html

Posted by Mark at 02:52 PM | Comments (0)

July 18, 2006

German Translation of CSB Animation of the Explosion at BP Refinery, Texas City, Texas, Now Available from CSB Web Site

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

German Translation of CSB Animation of the Explosion at BP Refinery, Texas City, Texas, Now Available

Washington, DC, July 17, 2006 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today posted on the agency's website a German translation of the narrated video of the accident at BP's Texas City refinery which occurred March 2005. This video, as well as the eight English language CSB Safety Videos, may be viewed online at the Video Room on http://www.csb.gov/index.cfm?folder=video_archive&page=index.

CSB Chairman Carolyn W. Merritt said, 'The CSB thanks Bayernoil Raffineriegesellschaft mbH, Ingolstadt, Germany, for producing and sharing this German-language translation of the CSB's BP Texas City animation video. This video has learning potential in any country with industrial chemical processes. We hope this video will have further impact on non-English speakers in the worldwide community, in order to help prevent this type of accident from ever happening again.'

The video, which includes a computer-generated animation sequence, illustrates how the refinery's raffinate splitter tower was overfilled, how instruments and alarms failed to indicate the dangerous condition, and how a connected blowdown drum and vent stack released flammable liquid and vapor which exploded. Also shown are still photographs and video illustrating the destruction caused by the accident, which killed 15 workers and injured 170. The English language video is narrated by Don Holmstrom, lead CSB investigator for the BP investigation.

The English-language version of the video has been widely used by the industry. Since first posted on CSB.gov, this video has been viewed almost 350,000 times. Free DVD copies of all English version videos are available by filling out the online request form.

'This video clearly explains the many problems that preceded this event. I believe that prudent managers reviewing this video will ask themselves, 'Could this possibly happen here?' and if they find places where the same problems could exist, they will address them to prevent catastrophic events at their own facilities,' stated Chairman Merritt.

This message was transmitted at 2:38 PM Eastern Time (U.S.A.) on July 17, 2006.

________________________________________________________

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

Posted by Mark at 12:24 AM | Comments (0)

July 17, 2006

Monday Accident and Lessons Learned - Nosocomial Infections

Every day there are infections passed from one patient to another at hospitals. Each of these infections is a small incident. If the infection is difficult to control and the patient dies, it is a major accident.

The sad part of these infections is that they are almost 100% preventable by simple techniques. Most could be prevents by doctors and nurses properly washing their hands. For an example program see:

http://www.henrythehand.com/pages/content/infection_control.html

Will Sawyer, M.D, is the creator of this program and I've asked him to discuss it - and the issue of changing doctor behavior - more extensively at the Medical Error Reduction Best Practices Track at the TapRooT(R) Summit (April 25-28, 2007, in San Antonio).

Sometimes the lessons learned from a fatality can be a simple change for the better.

Posted by Mark at 10:23 AM | Comments (0)

July 14, 2006

Friday Joke - Just Doing What the Sign Said

(Click on picture to enlarge.)

Posted by Mark at 11:56 AM | Comments (0)

July 07, 2006

Friday Joke - Don't Worry - It Couldn't Happen Twice in the Same Place!

(Click on picture to enlarge.)

Posted by Mark at 07:22 AM | Comments (0)

June 30, 2006

What Happened to the Office Trailers During the BP Texas City Explosion? CSB Releases Data...

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Releases Trailer Blast Damage Information from BP Texas City Accident

Washington, DC, June 30, 2006 - The U.S. Chemical Safety Board (CSB) announced it is releasing detailed trailer blast damage information developed during the ongoing investigation of the March 23, 2005, explosions at the BP refinery in Texas City, Texas. The information was posted to the agency's website, CSB.gov, and also provided to the American Petroleum Institute (API), the trade organization that is working to develop new guidance on the safe placement of trailers and similar temporary structures used in the oil and chemical industry.

The accident at BP killed 15 workers and injured about 180 others when flammable liquid and vapor overfilled a blowdown drum during the startup of the refinery's isomerization unit. All of the fatalities and many of the injuries occurred in and around trailers that had been positioned near the isomerization unit to support maintenance activities on adjacent refinery units.

The data released today include details of the injuries and structural damage that occurred among some 44 different trailers that were located in the vicinity of the isomerization unit. The fifteen fatalities occurred in or near two trailers that were located 121 to 136 feet from the blowdown drum. Occupants were injured in trailers as far away as 479 feet from the drum. Damage was noted in trailers almost 1000 feet away.

On October 25, 2005, the CSB issued an urgent recommendation to the API to develop new industry guidance 'to ensure the safe placement of occupied trailers and similar temporary structures away from hazardous areas of process plants.' The API announced it would begin work on the new guidance and convened a committee of industry representatives that has since met several times.

The Board's urgent safety recommendation called on the industry to establish minimum safe distances for trailers away from hazardous process areas. The CSB noted that, for reasons of convenience, trailers are often placed close to refinery units during maintenance activities. Unlike permanent structures such as control rooms, trailers can easily be relocated to safer positions.

'The information we made public today underscores just how vulnerable trailers are to serious blast damage. Placing trailers where there is a risk of explosion poses an unacceptable risk to occupants,' said Board Member John S. Bresland. 'At a distance of 597 feet from the source of the flammable vapor, the roof of one trailer collapsed and its walls were heavily damaged. Modest explosion overpressures that would cause no significant harm to a modern blast-resistant refinery control room can devastate a trailer.'

'We are providing our findings to the American Petroleum Institute to help expedite the development of new guidance that is based on the best available science and provides adequate protection for industry workers,' Mr. Bresland stated.

Following the tragic accident in March 2005, BP developed a new corporate trailer siting policy that provides exclusion zones for areas where explosions are possible. The BP policy states that all occupied trailers should be located outside of vulnerable areas even if this means a location outside the site boundary. A large number of Texas City personnel were relocated to a permanent building away from the refinery.

Board investigators issued preliminary findings about the accident at a public meeting in Texas City on October 27, 2005. The Board's final report on the root causes of the accident at BP is expected to be released before the end of the year.

The U.S. Chemical Safety Board is an independent federal agency charged with investigating industrial chemical accidents. 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.

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 safety management systems, regulations, and industry standards. Visit our website www.csb.gov.

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

This message was transmitted at 12:05 PM Eastern Time (U.S.A.) on June 30, 2006.

________________________________________________________

For more information see the CSB web site at:

http://www.csb.gov

Posted by Mark at 02:26 PM | Comments (0)

June 28, 2006

CSB to Investigate the Root Causes of a Fatal Explosion and Fire at Universal Form Clamp Co. in Bellwood, Illinois

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

Chicago, Illinois, June 28, 2006 - The U.S. Chemical Safety Board (CSB) today announced it will pursue an investigation of the fatal explosion and fire at Universal Form Clamp Company in Bellwood, Illinois, a Chicago suburb.

Shortly after 9:00 a.m. on Wednesday, June 14, 2006, an explosion and fire occurred in a mixing room at the facility, causing one fatality and five injuries.

The incident occurred while workers were heating and mixing flammable solvents in an open tank. At the time of the incident there were approximately 11,000 pounds of a mixture of heptane and mineral spirits in the open-top tank. Heptane is a highly flammable and volatile liquid that is a component of gasoline.

During the heating process there was a sudden evolution of flammable vapors from the tank. The vapors ignited, causing an explosion and fire. Combustible chemicals stored nearby also caught fire and burned for two hours until the blaze was extinguished by local firefighters.

CSB investigators arrived at the facility on Thursday, June 15, 2006, to assess the incident, interview witnesses and employees, and examine the site.

According to eyewitness interviews, the injured workers were not in the mixing room, but in adjacent work areas. CSB interviews indicate that the fatally injured worker was a delivery driver who was not employed by Universal Form Clamp Company.

Universal Form Clamp Co. is a manufacturer and supplier of construction products and chemicals. The facility changed ownership about six weeks prior to the incident. The company has been cooperating fully with the investigation.

CSB Board Member John Bresland said, 'The Board is concerned about the practice of mixing and heating flammable liquids in open tanks without appropriate safeguards. Our investigation will examine facility procedures as well as the adequacy of fire codes, standards, and local permitting and enforcement.'

For more information, contact: In Chicago, Public Affairs Specialist Kara Wenzel, 202-577-8448 (cell), or Jennifer Jones 202-329-5335 (cell). In Washington, DC, contact Daniel Horowitz at 202-261-7613.

This message was transmitted at 2:08 PM Eastern Time (U.S.A.) on June 28, 2006.

________________________________________________________

The CSB's web site, at http://www.csb.gov, has more information about investigations and recommendation to improve chemical safety.
--

Posted by Mark at 02:29 PM | Comments (0)

June 26, 2006

Monday Accident & Lessons Learned - CSB Recommendations

(CSB Chairman Carolyn Merritt testifies
about agency recommendations on
community emergency response
procedures. - from CSB web site)

The US Chemical Safety Board has issues 28 reports with recommendations to improve safety. These recommendations are based on the CSB's root cause analysis of major chemical accidents (almost all involving fatalities).

Do you know what those recommendations are?

Do they include lessons learned that should be applied at your facility?

And what if you aren't in the chemical industry ... Could you learn generic lessons that could still be applied at your facility?

To see the reports' recommendations go to:

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

If you would like to see the CSB's statistics on the response to their recommendations, see:

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

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

June 24, 2006

Helo Crash Video

Bad day for the pilot. And everyone else didn't have much fun.

Whenever I see a video of a crash I wonder ... Did they find the root causes?

(Click on box to play video)

Posted by Mark at 06:50 PM | Comments (0)

June 23, 2006

Friday Joke: Fire Protection Needs Improvement

I thought the bucket brigade was obsolete until Ken Reed, one of our TapRooT(R) Instructors, sent me this picture.

(Click on picture to expand.)

Seems to me that evacuation would be the best idea....

Posted by Mark at 03:11 PM | Comments (0)

June 19, 2006

Monday Accident & Lessons Learned - SMARTER Corrective Actions and Reviews for Unintended Consequences

"I believe the up-armoring has caused more deaths than it has saved," said Scott Badenoch, a former Delphi Corp. vehicle dynamics expert told the Dayton Daily News for Sunday editions.

That's the quote from a CNN story on troop deaths in Humvees in Iraq.

Sometimes corrective actions can cause more problems than they cure. The story doesn't say for sure that adding armor was a mistake - but it suggests that it might be.

The last R on SMARTER (a technique that we teach in our courses that helps people develop better corrective actions) stands for REVIEWED.

Part of reviewing a corrective actions is to have someone independent of the corrective action development team review the corrective action for unintended consequences.

Perhaps an independent review of the added rollover risk posed by armoring Humvees might have caught this problem before personnel were killed in increasing numbers of roll-over accidents and tens of millions of dollars were spent on armor that might actually increase the numbers of fatalities.

This is also an example of how reacting to a safety problem can cause unintended problems that might make safety worse.

It certainly makes one think that developing corrective actions to address problems is harder that one might think!

One more interesting point in the story...

Army spokesman John Boyce Jr. told The Associated Press on Sunday that the military takes the issue seriously and continues to provide soldiers with added training on the armored Humvee.

The Army also made safety upgrades to the vehicle, including improved seat restraint belts and a fire suppression system for the crew, he said.

Notice that the Army's first response to a problem is ...

TRAINING!

The corrective actions may or may not address the root causes of the roll-over problem. They certainly don't address the potential problem that the Army may have made matters worse by adding armor in the first place. (How should the Army do better root cause analysis and corrective action development?)

If you would like to learn more about advanced root cause analysis and developing SMARTER corrective actions, I would suggest a 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course. For more information see:

http://www.taproot.com/courses.php?d=2

Posted by Mark at 12:00 AM | Comments (0)

June 16, 2006

Friday Joke - For Those Who Don't Read Signs

(click on picture to enlarge)

Posted by Mark at 12:58 AM | Comments (2)

June 15, 2006

One Year after Gas Cylinder Fire and Explosions at Praxair St. Louis, CSB Issues Safety Bulletin Focusing on Pressure-Relief Valve Standards and Good Safety Practices

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

Washington, DC, June 15, 2006 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today issued a safety bulletin following the agency's investigation into the June 24, 2005, fire and explosions that swept through the Praxair Distribution, Inc., gas cylinder filling and distribution center in St. Louis, Missouri. The accident occurred when gas released by a pressure relief valve on a propylene cylinder ignited.

The Safety Bulletin, entitled "Dangers of Propylene Cylinders in High Temperatures: Fire at Praxair St. Louis," includes key findings, best practices for cylinder storage, and safety recommendations.

In addition, the CSB has released a Safety Video on the incident, which includes a computer animation depicting the gas release, as well as video of the initial release and fire taken by a Praxair security camera. The video features comments by CSB investigators and Chairman Carolyn W. Merritt. This safety video may be viewed and obtained by filling out an online form of request at www.csb.gov.

The bulletin notes that as a result of the fire, dozens of exploding cylinders were launched into the surrounding community and struck nearby homes, buildings, and cars, causing extensive damage and several small fires. Workers and customers quickly evacuated the facility after a worker sounded the alarm at the plant. Fortunately, residents escaped injury from the falling fragments.

CSB investigators noted the accident occurred on a hot summer day with a high temperature of 97 degrees F in St. Louis. At Praxair, cylinders were stored in the open on asphalt, which radiated heat from the direct sunlight, raising the temperatures and pressure of the gas inside the cylinders. At approximately 3:20 p.m., a propylene cylinder pressure relief valve began venting. CSB investigators believe static electricity, created by escaping vapor and liquid, most likely ignited the leaking propylene.

Praxair security camera video shows the initial fire spreading quickly to other cylinders. Exploding cylinders - mostly acetylene - flew up to 800 feet away, damaged property, and started fires in the community. The fire could not be extinguished until most of the flammable gas cylinders were expended. An estimated 8,000 cylinders were destroyed in the fire, which took five hours to control.

The investigation determined that the pressure relief set points, specified in industry standards, are too low for propylene and may allow the gas to begin venting during hot weather - well below the pressures that could damage the cylinders. Not only are the specified set points too low for propylene, the CSB found some valves begin releasing gas even before the pressure reaches the set point. Each time a pressure relief valve opens, its performance deteriorates - making it more likely to vent gas at too low a pressure in the future.

CSB lead investigator Robert Hall said, "The key lesson learned in our investigation is that the combination of high ambient temperatures and relief valves that open at too low a pressure increase the risk of catastrophic fires at these facilities."

The CSB bulletin lists three similar fires at gas repackaging facilities that were reported to be caused by leaking propylene containers since 1997. Fires occurred at another Praxair facility in Fresno, California just a month after the St. Louis accident; an Airgas facility in Tulsa, Oklahoma; and an Air Liquide facility in Phoenix, Arizona.

Board Chairman Carolyn W. Merritt said, "The fire at Praxair was serious and not the only one that has occurred at compressed gas facilities. The accidents show the need for companies to follow best practices for outdoor cylinder storage and fire protection. We hope the industry takes notice with the coming of summer and high ambient temperatures in cylinder storage yards."

The CSB Safety Bulletin lists several best practices for cylinder storage at gas repackaging facilities, including fire protection systems to cool cylinders and limit the spreading of fires, adding barriers to contain exploding propylene cylinders within the facility, and gas detection systems that can sound alarms and activate fire mitigation systems.

The Board recommended that the Compressed Gas Association (CGA) revise its standards for propylene relief valves to provide a greater margin of safety and improved reliability.
________________________________________________________

To see other CSB accident investigations and recommendations, go to:

http://www.csb.gov

Posted by Mark at 05:28 PM | Comments (0)

June 14, 2006

CSB to Conduct Full Investigation of Fatal Oilfield Incident at Partridge-Raleigh Oilfield in Raleigh, Mississippi

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

Washington, DC, June 14, 2006 - The U.S. Chemical Safety Board (CSB) today announced it will pursue an investigation into the June 5, 2006, fatal oilfield incident at Partridge-Raleigh Oilfield in Raleigh, Mississippi, sixty miles southeast of Jackson.

Around 8:30 a.m. on Monday, June 5, 2006, three workers died and one worker suffered broken bones while attempting to install new piping to connect two 400-barrel capacity oil production tanks and one salt water tank to a 500-barrel capacity power oil tank. All four workers were employed by Stringer Oilfield Services.

CSB investigators arrived at the oilfield on Tuesday, June 6, 2006 to conduct an assessment of the incident site. They conducted interviews with eyewitnesses, who describe the four workers standing on top of the production tanks, preparing for the new piping installation just before the incident occurred. As one worker lit a welding tool, explosive vapors in two of the tanks likely ignited, causing two rapid explosions that threw one worker over twenty-five feet from the tank and scattered debris as far as 130 feet away. Emergency responders found the welder, the sole survivor of the blast, hanging from one of the oil tanks. He used fall protection equipment prior to starting his work.

The CSB has investigated similar incidents involving flammable vapors in aboveground storage tanks and welding tool use at a wastewater disposal facility in Daytona Beach, Florida, where two workers died earlier this year, and in 2001 at an oil refinery in Delaware City, Delaware, where one worker died. The agency also assessed an incident in Palestine, Texas, in 2003, in which three teenagers were killed while standing on top of an oil tank that exploded. They were using a cigarette lighter to see inside an oil tank filled with flammable oil distillate.

The agency has also investigated incidents involving explosions and fires at oilfields in Louisiana in 1998, which resulted in four worker fatalities, and Texas in 2003, which resulted in three worker fatalities. In each case, a lack of hazard recognition played a role in the worker deaths.

Failure to recognize the hazards posed by use of welding tools in a flammable vapor environment likely contributed to the incident at Partridge-Raleigh. Failure to manage those hazards with well-established, safe work practices could have also contributed to the incident. During initial interviews with CSB investigators, Stringer and Partridge-Raleigh employees stated that they regularly tested for flammability in oil tanks by lighting and inserting torches into open hatches on tanks prior to welding. The CSB investigation of this incident will discuss appropriate flammability
testing equipment and procedures.

CSB Chairman Carolyn W. Merritt said, "The Board believes this explosion emphasizes the serious need for thorough written safety procedures and worker training at oil fields and all facilities where flammable vapors and welding activities may coexist. To ensure worker safety, companies must be vigilant about using safe testing procedures and equipment."

The oil and gas industry experiences one of the highest fatality rates of all major industries, according to a March 2005 paper (Upstream Oil and Gas Fatalities: A Review of OSHA's Database and Strategic Direction for Reducing Fatal Incidents) authored by government and industry authorities and presented at a Society of Petroleum Engineers conference.

In 2004, the oil and gas industry experienced 43.9 fatalities for every 100,000 workers. This equates to approximately one fatality every four days. This rate is over eight and a half times higher than the average fatality rate for all industries in the United States. In comparison, the coal mining industry had a fatality rate of 29.9 fatalities for every 100,000 workers in 2004.

For more information, contact: In Jackson, Public Affairs Specialist Kara Wenzel, 202-577-8448 (cell), or Jennifer Jones 202-329-5335 (cell).

This message was transmitted at 11:00 AM Eastern Time (U.S.A.) on June 14, 2006.

________________________________________________________

For more information about CSB accident investigations see:

http://www.csb.gov

Posted by Mark at 05:47 PM | Comments (0)

June 12, 2006

Monday Accident and Lessons Learned - Nosocomial Infections

The sad part of these infections is that they are almost 100% preventable by simple techniques. Most could be prevents by doctors and nurses properly washing their hands. For an example program see:

http://www.henrythehand.com/pages/content/infection_control.html

Sometimes the lessons learned from a fatality can be a simple change for the better.

Posted by Mark at 06:46 PM | Comments (0)

Monday Accidents & Lessons Learned - Crane Accidents

Want to see a web site with lots of pictures of crane accidents?

See: http://www.craneaccidents.com/

Plenty of lessons learned as well...

(click on picture to enlarge)

How do you investigate crane accidents to find their root causes?

If you haven't had any root cause analysis training, you need to get some!

Attend a TapRooT(R) Course to learn advanced root cause analysis techniques.

Posted by Mark at 11:27 AM | Comments (0)

June 05, 2006

Monday Accident and Lessons Learned - Draw a SnapCharT(R) of this Sentinel Event

http://www.thenewstribune.com/news/local/story/5774982p-5162905c.html

To start leearning about what happened, the first step is to draw a SnapCharT(R). So try it with the information in the article above and see what you learn.

Then post a comment with what you've learned.

Posted by Mark at 11:03 PM | Comments (0)

June 02, 2006

Friday Joke - Two for the Price of One

Sent to me by Linda Unger, VP at System Improvements:

Was this a two for one sale or just common courtesy in New York (note that they both have New York plates)? I think the root cause was that they wanted to become the Friday Joke!

Posted by Mark at 09:39 AM | Comments (0)

May 29, 2006

Monday Accidents & Lessons Learned - Fatigue as a Cause of Accidents, Incidents, Near-Misses - How Do You Evaluate Fatigue?

Sleepy controllers contributed to near-misses, NTSB says

That's the headline at the CNN web site.

What can we learn from the NTSB investigation? First, fatigue can cause human performance to be degraded. Second? You need some formal analysis to ask about fatigue as a part of your root cause analysis process.

So ... How do you evaluate fatigue as a part of your accident, incident, quality, or near-miss investigations and root cause analysis?

The TapRooT(R) System has questions that ask investigators to look for fatigue. But we are trying to do even more. We are working with Circadian Technologies, a world leader in fatigue research and work scheduling, to develop a fatigue evaluation tool to be used in conjunction with the TapRooT(R).

Would you like to participate in a test of this new fatigue evaluation tool? If yes, drop me a note by clicking here or by sending a comment by clicking on the comments link below.

Posted by Mark at 12:47 AM | Comments (1)

May 24, 2006

CSB Completes Assessment of Valero St. Charles Refinery Fire; Agency Plans No Additional Investigation

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Finishes Assessment of Valero St. Charles Refinery Fire; Agency Plans No Additional Investigation

Norco, Louisiana, May 24, 2006 - Investigators from the U.S. Chemical Safety Board (CSB) completed their two-day assessment of the May 20 fire at the Valero St. Charles refinery here and are returning today to Washington, DC. No further CSB investigation of the incident is planned.

At approximately 11:30 p.m. on Saturday evening, a 12-inch overhead pipe ruptured in the refinery's Distillate Hydrotreater, a unit that uses hydrogen to remove sulfur from a hydrocarbon feedstock. The pipe normally operates at a pressure of approximately 600 pounds per square inch. The rupture of the pipe caused a loud report and began releasing flammable gaseous hydrocarbons at a temperature high enough to cause spontaneous ignition. No personnel were present in the unit when the pipe rupture occurred.

The Valero fire brigade extinguished the ensuing fire at around 1:30 a.m. No employees or emergency responders were injured. Air monitoring at the perimeter of the refinery did not detect elevated concentrations of any hazardous chemicals.

The CSB investigative team examined the Distillate Hydrotreater unit and the fire-damaged equipment, which was confined to an approximately 100-foot square section of the unit. Two fan-type heat exchangers were destroyed by the fire along with an approximately 50-foot section of piping; electrical conduit was also damaged by radiant heat. No blast damage was observed.

Valero personnel cooperated fully with the CSB team. CSB Lead Investigator John Vorderbrueggen said: 'Valero has assembled an incident investigation team to identify the proximate causes and, more importantly, any management system deficiencies that contributed to the incident. Valero management has committed to sharing the recommended corrective actions and program improvements throughout the company's global refining operations.'

While cautioning that the cause of the pipe rupture at Valero has not been determined, CSB Board Member Gary Visscher noted there have been a number of past instances of corrosion-related failures in refinery hydrotreater units. Mr. Visscher said: 'While this incident fortunately caused no injuries, it is important to carefully maintain the integrity of piping that contains hazardous substances through rigorous inspection and testing.'

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

This message was transmitted at 1:40 PM Eastern Time (U.S.A.) on May 24, 2006.

________________________________________________________

To see additional information about the CSB or other investigations see: http://www.csb.gov

Posted by Mark at 01:28 PM | Comments (0)

May 23, 2006

When is a Fine Too Big? Hatfield Rail Crash, BP Refinery Explosion, and Davis-Besse Reactor Vessel Head "Hole" Test Increased Fines

I've already reported about the BP Refinery Explosion Fine ($21 Million US), the fine for a follow up inspection at other BP facilities ($2.4 Million US) , and the fine for the Davis-Besse reactor vessel "hole" incident ($28 million US).

Now the UK Courts have imposed a £10m fine on the engineering firm Balfour Beatty over the cracked rail that caused the Hatfield rail crash.

The engineering firm - although pleading guilty and providing a public apology - is appealing the fine because they think the fine is excessive. (For details see the BBC report.)

So what is an excessive fine?

Do fines really improve safety behavior by companies?

Or are large fines just another tax on the consumers of the services provided (gas, electricity, or rail service) and the shareholders of the companies because they will eventually be passed along by the companies or taken out of dividends or money for future growth (a penalty for future employees)?

Interesting ... What do you think?

CSB Starts Preliminary Investigation of Valero St. Charles Refinery Explosion

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Investigation Team Heads to Valero St. Charles Refinery Explosion Site

Washington, DC, May 22, 2006 - A team of investigators from the U.S. Chemical Safety Board (CSB) has begun an assessment of the May 20 explosion and fire at the Valero St. Charles refinery in Norco, Louisiana, 15 miles from New Orleans.

The explosion late Saturday reportedly involved the refinery's diesel hydrotreater unit and caused no injuries. Large portions of the 250,000 barrel-per-day refinery remain shut down.

CSB investigator John Vorderbrueggen will lead a team of four who will assess the circumstances of the explosion and recommend whether a further CSB investigation is warranted. Investigators began their work at the site on Monday afternoon.

CSB investigations of the root causes of accidents typically take 6 to 18 months to complete. The CSB is currently investigating a nitrogen asphyxiation incident at Valero's Delaware City (DE) refinery which killed two workers in November 2005.

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.

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

This message was transmitted at 4:57 PM Eastern Time (U.S.A.) on May 22, 2006.

For more information about the Chemical safety Board and other investigations see:

http://www.csb.gov

Posted by Mark at 09:15 AM | Comments (0)

May 22, 2006

Miners Trapped Two Week Underground Then Freed - CNN Report...

See this link for more information ...

http://www.cnn.com/2006/WORLD/asiapcf/05/21/australia.miners.ap/index.html

Posted by Mark at 09:30 AM | Comments (0)

Monday Accident & Lessons Learned - Even Test Pilots Need SPAC (Standards, Policies, and Administrative Controls)

A TapRooT(R) User, Rick Brower of Occidental Petroleum, sent me this video. He said it is old (1992) but still applicable.

Click on the video below to play...

Here is the note that was attached to the e-mail that he forwarded to me:

If this is true...This is why we have Pre-Flight Checklists not to mention WALK AROUNDS!

Not doing a solid preflight is a real goof on top of the control lock goof. Yikes.

This happened just north of Winnipeg, and the aircraft was the first version with PT-6-67 Turboprops.

The Canadian DOT concluded that the control locks were still locked when the aircraft took off.

You who have flown the Caribou wonder how that could have happened But this aircraft was being modified (still restricted category) and the throttle quadrant was not properly rigged to accommodate the throttle levers for the turbine engines.

Three persons were on board; two test pilots and an engineer.

The Lesson Learned seems to obvious to mention. SPAC Not Used leads to accidents.

Hope that you can use this to drive the point home.

Posted by Mark at 12:24 AM | Comments (0)

May 15, 2006

Monday Accidents & Lessons Learned - Common Tasks That Could Have Benefited from Proactive Safeguards Analysis

Watch the following accidents unfold and think ...

What was the HAZARD???

What was the TARGET???

And what were the SAFEGUARDS that the users had planned???

So many times I see:

alertness of the operator
carefulness of the user, or
luck of the target.

As the final (or only) Safeguard that is preventing an accident.

Could have the accident activities above benefited from even a simple Safeguards Analysis befopre they started? You bet!

That is this weeks lesson learned.

Posted by Mark at 02:53 AM | Comments (0)

May 09, 2006

Why wear seat belts? Watch these crash dummy videos!

Need some material (videos) for a safety presentation on wearing seat belts?

See the National Highway Trafic Safety Web Site and go to their Multi-Media page:

http://www.nhtsa.dot.gov/portal/site/nhtsa/menuitem.7908a78a98232a8d304a4c4446108a0c/

Hope this helps!

Posted by Mark at 04:06 AM | Comments (0)

May 08, 2006

Monday Accident and Lessons Learned - Bad Day at the Refinery - Vessel is Launched

This PowerPoint was forwarded to me by a TapRooT(R) User who couldn't vouch for its authenticity. Let's just call it ... A test gone wrong ...

Or at least that's what the PowerPoint says.

Have a look and see what lessons you can learn.

Pneumatic Test in Piping Incident.pps

Posted by Mark at 12:12 AM | Comments (1)

May 07, 2006

WHAT "SEVERITY SCALE" DO YOU USE???

I subscribe to many e-mail discussion sessions and I came across an e-mail that I thought might interest people reading this blog. The e-mail described a rating system based on a severity of falls at a hospital. They rated the severity in the following way:

0 = No injury ……No injuries resulting from the event
1 = Minor………...Drsg,ice OTC med,sore/abrased/red,observation
2 = Moderate ……Suture.steri strip/glue,splint,add’l care/monitor
3 = Major…………Surgery,cast,consult,+ diag. tests,ext. stay,ED
4 = Catastrophic…Permanent,severe injury;increased morbidity
5 = Death…………Pt. dies as a result of the injury
6 = Misc.…………Just in case it does not fall into the others

The TapRooT(R) Book also shows a scale built into the sample investigation policy in Appendix A of the book that has safety, environmental, production loss, and quality scales for rating incidents and deciding what level of investigation is needed for the consequences of the incident.

So the e-mail rating scale above got me thinking. It would be really interesting to see the different severity scales that people use in different industries.

So I have made this entry and people can respond with their severity/rating scale for incidents.

Simply add your rating system by posting a comment. I think this will develop into a very interesting list.

Posted by Mark at 04:51 AM | Comments (4)

May 01, 2006

CSB Team to Assess Propylene Explosion at Huntsman Olefins Facility

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington, D.C.

CSB Team to Assess Propylene Explosion at Huntsman Olefins Facility

Washington, DC, May 1, 2006 - A team of investigators from the U.S. Chemical Safety Board (CSB) is deploying to the site of Saturday morning's explosion at a propylene refrigeration unit at the Huntsman Corporation olefins plant in Port Arthur, Texas. No injuries were reported, but the plant has been shut down and fires continued to burn on Monday.

Investigator John Vorderbrueggen will lead a team of four that will arrive at the facility on Tuesday morning. In 2004, the CSB investigated a peroxide explosion at the Huntsman facility in Port Neches, Texas, and issued a related safety bulletin entitled "Removal of Hazardous Material from Piping Systems." The CSB is currently investigating a propylene leak and fire that occurred at the Formosa Plastics facility in Point Comfort, Texas, in
October 2005.

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

This message was transmitted at 1:30 PM Eastern Time (U.S.A.) on May 1, 2006.

Visit the CSB web site at http://www.csb.gov

Posted by Mark at 03:25 PM | Comments (0)

Monday Accident & Lessons Learned - Aviation Equipment Failures - Another Example of a Mechanical Failure Starting an Even Larger Failure

Attached (click on the continuation link below) is a report from an aviation failure on a small plane (not a jet).

This is another example of a small mechanical failure (a generator failure) that could have led to a larger failure (loss of the plane and loss of life of the crew and passengers).

What is the lesson I think you should learn?

That equipment reliability is a key part of system performance and SAFETY.

Safety professionals should help maintenance and equipment reliability folks find the root causes of equipment problems by using TapRooT(R). That's why safety folks (in addition to equipment reliability and maintenance professionals) should attend Equifactor(R) Training.

For general Equifactor(R) information see:

http://www.equifactor.com/

For 3-Day TapRooT(R)/Equifactor Equipment Troubleshooting and Root Cause Failure Analysis Training see:

http://www.taproot.com/courses.php?d=3

LEARN FROM THE EXPERIENCES OF OTHERS.... BEECH 100

Incident: Multiple Electrical Systems Failures

1. En-route from --- to --- (First Officer Flying Pilot) at 9000 ft msl, about 30 Miles north of ---. The Left Gen tripped off line, and momentarily came back on. The Volt Ammeter showed the Left Gen accepting a load. Then the process repeated, with the Left coming back on-line. For a third time, the Left Gen tripped and this time did not reset itself, nor would it reset manually.
2. During the next few minutes, the following were noted: a right Gen load of approximately .45, a left Gen load of zero, no ability to reset the left Gen, a red light in the gear handle, failure of the pressurization system, failure of the left fuel gauge, failure of the number one Comm radio, failure of the transponder’s mode C, a red “Computer” flag on the left ADI, failure of the #1 inverter, the inability to lower the flaps, and gear. Failure of the Primary Pitch trim. ATC (APP) was notified of the initial Communications Radio problems, and informed us of the Transponder Mode C failure. No assistance was requested at that time.
3. About 30 miles out of --- a call was made to the Company requesting the assistance of Maintenance. Due to the limitations of one Comm radio, numerous changes back and forth were required.
4. The aircraft was slowed to about 130 KIAS in the vicinity of ---, and the gear selected down. Nothing happened.
5. The Emergency Gear extension procedure checklist was reviewed. Then followed. During this period approximately sixty strokes of the (emergency) gear handle were applied. Seeing no green gear lights, and realizing that the electrical failure may have affected those lights, they were tested and failed to illuminate. We concluded they would not illuminate. This meant we could not stop pumping at the normal indication (three green) as taught in Ground School.
6. Flaps Approach were selected. The flaps did not move as observed from the cockpit.
7. The gear position was uncertain. Given that, and the multiple systems failures, an Emergency was declared with Tower.
8. A fly by of the tower was conducted. An aircraft at the runway hold line for Rwy 35. A regional airliner at the hold line suggested the gear looked normal. The Tower reported a “bowed appearance”. We proceeded to the East of the Airport and Called Company for about the fourth time.
9. The passengers received a preliminary briefing of the difficulties, and were told we were working closely with maintenance and ATC.
10. The emergency gear handle was pumped about twelve (12) more strokes, and resistance was met. Pumping ceased.
11. Another low pass down the runway was made. Tower reported gear appeared down. Company called again for further consultation with MX Personnel.
12. The passengers were briefed again. Brace positions were reviewed, and coats were passed forward to act as a cushion for passenger seated on the couch adjacent to the bulkhead.
13. An audible signal for assuming the brace position was agreed upon (the tone generated by cycling of the FSB sign).
14. Multiple systems were secured (lights – which had failed anyway, Bleed Air, and the checklist for an aborted landing with inability to stop on the runway was reviewed for action items. The F/O was briefed as to his actions, and as to those the Captain would accomplish.
15. A power on, zero flap landing with a Ref speed of 110 KIAS was made. The gear appeared normal, and the aircraft exited Rwy 35 at Delta Taxiway were it was shut down, and the passengers deplaned to a safe location at the edge of the taxiway.
#1 Generator bearing failure followed by 325 amp current limiter failure.

This would have been a challenging failure: 1) in low IFR, 2) at night, 3) in icing conditions, or 4) at altitude as oxygen masks are not connected when the depressurization starts, and the emergency descent calls for gear down (not possible) creating a longer time lapse in getting down.

Posted by Mark at 01:35 AM | Comments (0)

April 26, 2006

BP Texas City Explosion Follow Up ... CNN Reports on OSHA Inspection at Other BP Refineries and $2.4 Million Fine

Here is the article from CNN:

http://money.cnn.com/2006/04/25/news/companies/bp_fine/index.htm

Some thoughts ...

The refining industry has been run hard (at maximum capacity) for a number of years. Are other accidents waiting to happen at other refineries? Does this inspection show that BP has an overall safety problem or is the problem more widespread?

These are the kinds of questions one must answer when they are looking to go from specific root causes of problems to generic causes. If one does a good job of asking questions and finding answers about generic root causes, one can eliminate whole classes of accidents rather than addressing accidents one at a time.

Of course company wide (or industry wide) corrective actions are usually much more expensive. So justifying these corrective actions takes evidence that takes time and effort to collect. (For example, the result of the OSHA Audit at other BP Refineries was just released ... over a year after the original explosion at the BP Texas City Refinery).

Posted by Mark at 08:13 AM | Comments (0)

April 25, 2006

Thinking Differently - Air Bag in a Jacket - Another Safeguard for Motorcycle Riders

We've had a couple of articles about motorcycle safety and I thought I would pass along this idea...

Sometimes people just can't see another answer when they are developing corrective actions. The link below goes to a CNN article that explains how one Japanese inventor saw a different way to protect motorcycle riders.

http://money.cnn.com/2006/04/24/magazines/business2/softeningcrashlanding/index.htm

The sad thing is that, according to the article, US liability laws have kept this safety technology out of the US.

Posted by Mark at 10:46 AM | Comments (0)

April 24, 2006

Monday Accident & Lessons Learned: CNN Reports: Multitasking Triples Car Crash Risk

Interesting report from CNN:

http://www.cnn.com/2006/US/04/20/driving.study/index.html

Here is MSNBC's take on the same report:

Study: Driver drowsiness big safety problem
Tired drivers are four times more likely to crash than rested motorists

http://msnbc.msn.com/id/12405053/

Hmmm... little different take.

Here's what the NHTSA said in their press release:

Breakthrough Research on Real-World Driver Behavior Released

http://nhtsa.gov/portal/site/nhtsa/template.MAXIMIZE/menuitem.416f74e8613992381601031046108a0c/?javax.portlet.tpst=4427b997caacf504a8bdba101891ef9a_ws_MX&javax.portlet.prp_4427b997caacf504a8bdba101891ef9a_viewID=detail_view&javax.portlet.begCacheTok=token&javax.portlet.endCacheTok=token&itemID=71052f9b8559a010VgnVCM1000002c567798RCRD&viewType=standard

I thought that this quote was important:

"Drivers who engage frequently in distracting activities are more likely to be involved in an inattention-related crash or near-crash. However, drivers are often unable to predict when it is safe to look away from the road to multi-task because the situation can change abruptly leaving the driver no time to react even when looking away from the forward roadway for only a brief time."

Here is the link to the university report about the study:

http://www-nrd.nhtsa.dot.gov/departments/nrd-13/driver-distraction/PDF/DriverInattention.pdf

What lessons can we learn from all this accident data?

FIRST, sometimes you have to install monitoring devices or you won't get real data about human performance in accidents.

SECOND, people may not be a good judge of when it is safe to multi-task. This may apply to situations other than driving cars.

THIRD, drowsiness increased the crash risk by 4-6 times but that being drowsy during accidents was probably under-reported in actual accidents (without monitoring).

Finally, imagine ... These people drove while distracted and drowsy even though they knew that they were being monitored. Do you think the general population (unmonitored drivers) is even worse? Or did these drivers get so used to be monitored that they accurately reflect the general driving public?

Posted by Mark at 09:03 AM | Comments (3)

April 17, 2006

Monday Accident & Lessons Learned - Surprise at the Gas Pump

(click on picture to play video)

Last year in the e-Newsletter we discussed cell phones starting gas tank fires. The web site below says they have NEVER seen a fire caused by a cell phone. But when I saw this video, I just had to pass it along. Why? Because you don't want this to happen to you or anyone you know.

Watch the scary video above and then visit this web site:

http://www.pei.org/static/index.htm

The info from this web site and the video above should make an excellent on-the-job or off-the-job refueling safety presentation.

LESSON LEARNED

1) Don't get back in the car while refueling and

2) Ground yourself by touching metal on the car away from the nozzle before you grab the nozzle.

And pass this information on to everyone you know!

Posted by Mark at 12:23 AM | Comments (0)

April 16, 2006

Bad Day for Ship's Captain ... root cause?

Chris Christine, one of out TapRooT(R) Instructors, passed these photos of a shipboard fire. The ship (Hyundai Fortune) was (assumed sunk by now) an express from Asia to Europe.

What was the root cause of the fire? Unless the shipping company's crew is trained in root cause analysis, we probably will never know.

(click on the pictures to enlarge)

TapRooT® Blog Category Archive

July 10, 2007

Senate Committee Webcast about to Begin on CSB Lessons Learned

July 03, 2007

Root Cause Analysis of Strange Incidents

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

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

June 19, 2007

How Far Will Someone Go To Complete a Job?

June 18, 2007

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

June 16, 2007

New CEO aims to help BP overcome deadly past

June 14, 2007

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

June 11, 2007

Deadly Construction Accident in Indianapolis

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

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

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

CSB to Conduct Full Investigation of Valero McKee Refinery Fire

March 10, 2007

BP Annual Report Reveals Subpoenas for BP Texas City Refinery Blast and Bonus Cuts for Execs - More Reasons to Proactively Improve Performance by Using Advanced Root Cause Analysis

March 07, 2007

CSB To Release Root Cause Analysis of BP Texas City Refinery Explosion at Public Meeting on March 20

February 28, 2007

CSB Final Report on Chlorine Release at DPC Enterprises in Glendale, Arizona

February 27, 2007

Bus Crash near Uppsala, Sweden - The cause of the crash was not immediately clear...

February 26, 2007

UK Train Wreck Interim Report by RAIB

Monday Accident & Lessons Learned - Pipeline Safety Incidents

February 24, 2007

More on the Friday Train Derailment in the UK

What will the Courts Say About Testimony of BP CEO?

February 23, 2007