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Senate Committee Webcast about to Begin on CSB Lessons Learned
Washington, DC, July 10, 2007 - U.S. Chemical Safety Board Chairman Carolyn W. Merritt will testify today as the first witness in a Senate hearing entitled, 'Lessons Learned from Chemical Safety Board (CSB) Investigations, Including Texas City, Texas.' The hearing is scheduled to begin at 10:00 a.m. eastern time today, in the Dirksen Senate Building, Room 406. Please visit http://epw.senate.gov to view the hearing webcast. The webcast link will be posted on the committee website once the hearing begins.
The hearing has been convened by the U.S. Senate Committee on Environment and Public Works, Subcommittee on Transportation Safety, Infrastructure Security, and Water Quality, chaired by Senator Frank R. Lautenberg (D-NJ). Senator David Vitter (R-LA) is the ranking member.
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency's board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.
The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.
For more information, please contact Jennifer Jones at (202) 261-3603 or Daniel Horowitz at (202) 261-7613.
Zheng Xiaoyu's execution was confirmed by state television and the official Xinhua News Agency.
"The few corrupt officials of the (State Food and Drug Administration) are the shame of the whole system and their scandals have revealed some very serious problems," SFDA spokeswoman Yan Jiangying said at a news conference held to highlight efforts to improve China's track record on food and drug safety.
"We should seriously reflect and learn lessons from these cases. We should step up our efforts to ensure food and drug safety, which is what we are doing now and what we will do in the future," Yan said about Zheng and a separate case involving Cao Wenzhuang, the administration's former pharmaceutical registration department director.
Is this an effective corrective action to the root causes of a problem?
To read the entire article, click here.
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...
]]>As I learn the Taproot software and become more familiar with it, I will continue the tradition of posting insightful articles to help you maximize the potential of the software. Having a interest in IT Security, I may from time to time also post some general IT security practices that if used, will help minimize the amount of viruses or spyware that get on your machine.
Again, my name is Steve and I look forward to this opportunity and believe that you will continue to find the Tech Support Blog very helpful.
Here are some pictures of the group working hard on the final exercise:
Our summer courses are filling up in Calgary, Dallas, Lake Tahoe, Seattle and more. Don't get stuck on a waitlist . . . check out the course page and register!
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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.
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.
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- improving root cause analysis
- reducing human error
- improving safety & risk management
- stopping sentinel events
- improving your corrective action program
- achieving operational excellence
- improving your lean or six sigma program
- improving uptime and increasing equipment reliability
- becoming a better TapRooT® instructor or software administrator
Then you should be interested in the TapRooT® Summit.
The 2007 Summit was held in San Antonio on April 25-28, 2007. The follwing movies (choose either QuickTime - .mov - or Windows - .wmv - formats) let you see and hear what attendees thought about the 2007 Summit.
Click on the world picture above to play the .mov movie.
Once you see what they have to say, you will be ready to attend the 2008 Summit on June 25-27 in Las Vegas.
Click on the Summit button above for more details (the full Summit site should be up and running by the end of August 2007).