What do you do after an accident for those that are impacted by the accident? Linda will talk at the TapRooT® Summit about her medical sentinel event and how people involved need to be supported.
Here’s a video that will provide you some background about Linda and MITSS.
“HILTON HEAD ISLAND, S.C. – The kit-built single-engine plane was gliding quietly as it came down for an emergency landing on a beach. Pharmaceutical salesman Robert Gary Jones, listening to his iPod while jogging, likely never saw or heard it before the aircraft hit him from behind Monday evening and killed him.”
Should we ban headphones from public beaches or post a warning jog with headphones at your own risk?
Megan McArdle wrote an interesting article about the age statistics of the drivers involved in Toyota acceleration accidents. It seems older people (above 60 years old) are much more likely to be involved in an acceleration accident.
She then hypothesizes that this “age discrimination” means that these accidents are driver caused and not “Toyota caused.” Or at least that this is the reason that Toyota did not discover their problems sooner.
“Failure to test a cement casing at an oil well in the Timor Sea was a root cause of a blowout that caused Australia’s worst offshore oil spill, an inquiry has heard.“
It sure seems like there were many more “root causes” to me and that the analysis should have led to root causes that were much more in-depth. And it would be a big help if there was a SnapCharT® to help identify all of the Causal Factors.
This looks like they should have been applying Equifactor® before the accident to handle the equipment reliability problems they were having.
Also, see the lessons learned at the end of the “AccidentRussianHydroPlant.pdf” that is linked to above. Do you think they were based on a through root cause analysis?
Wouldn’t it have been nice to see a real TapRooT® Investigation of this accident…
Imagine a good, complete summer SnapCharT®. And root causes identified for each Causal Factor by using the Root Cause Tree®. And corrective actions developed using the Corrective Action Helper® Module and SMARTER.
How much knowledge is lost because we don’t effectively investigate problems?
Every accident Investigator should be familiar with certain classic accidents that provide lessons across all industries. The capsizing of the ship “herald of Free Enterprise” is one of those accidents. It happened on March 6, 1997.
CNN reported on “giant” waves (26 feet / 9 meters tall) hitting a cruise ship unexpectedly.
Waves 26 feet tall don’t seem “giant” to me. Especially when they were traveling in 45 knot winds.
When I was aboard the USS Arkansas we were steaming at 30+ knots in 15 foot seas off North Carolina when we were hit by a 50+ foot tall rouge wave. It did millions of dollars of damage to the ship but no one was injured.
NTSB reviews of recent airline accidents have found a common thread: flight crews were violating the “sterile cockpit” rule by talking about non-flight related topics when below 10,000 (see article here). The NTSB has recently asked to be allowed to routinely monitor the cockpit voice recorders which are already installed in all commercial aircraft. They want to sample those recordings to see if there is a real problem. http://www.usatoday.com/news/nation/2010-02-23-recorders_N.htm.
Is this a big deal? In the U.S. Navy, the submarine force has the same sterile cockpit rule for their nuclear watchstanders (we said that the maneuvering room had to remain “inviolate”). We were not allowed to talk about non-work related topics for our entire 6-hour watch. This was enforced by having an officer supervising 3 enlisted operators (because, of course, the officer would never violate the rule!), plus we had random checks by senior supervisory personnel to ensure we were all following the rule. Like Rickover said, “Expect what you inspect.”
Is this a reasonable requirement to check on compliance with standards, or is this an unwarranted intrusion into the workplace? Will the new policy make a difference? What unintended consequences can you think of that could occur by instituting this new policy?
The Associated Press reported that Chief Electrician’s Mate John G. Conyers suffered a severe electrical shock and was later pronounced dead at Sharp Coronado Hospital.
The AP reported that the Chief was conducting “routine work” when he was killed.
Normally, Chiefs are supervising, not performing, work. And there is nothing “routine” about working with electricity aboard a ship. Complacency (routine) with electricity on a ship is a deadly combination.
One of my early shipboard jobs in the Navy was being the Electrical Division Officer aboard USS Arkansas (a nuclear powered cruiser). One of the first “performance improvement” programs I ever attempted was to re-instill respect for electricity and get 100% compliance with our lock-out/tag-out program to isolate and check dead all sources of voltage during electrical maintenance work.
People who work with any hazard (for example, electricity), tend to become complacent over time. I’m not sure if this happened on the USS Ronald Reagan, but it certainly is a problem that every manager/supervisor who supervises people who work with a hazard has to confront head-on.
Also, supervisors can frequently be tempted to do work and even take shortcuts to get a job done. This takes them out of their roll to supervise a job and make sure it is done safely and puts them into a dangerous situation where no one is looking over their shoulder to make sure the job is done safely. Once again, I have no evidence that this happened aboard the USS Ronald Reagan, but I’ll be interested in what the eventual accident report has to say.
What can we learn from this fatality BEFORE the investigation is even completed?
First, TapRooT® Users would be getting a complete picture of WHAT happened before they started analyzing WHY it happened. As you can see from my background, there are several problems that I would automatically look for. But, TapRooT® requires the investigator to look at the evidence first before starting the root cause analysis. They have to have a good, complete, accurate, detailed SnapCharT® before they identify the accident’s Causal Factors and find each Causal Factor’s root causes.
Second, TapRooT® Users have a systematic root cause analysis technique, called the Root Cause Tree®, that helps them be sure to check for the many different potential root causes of a problem (Causal Factor). The tree helps guide them to areas they may not have thought of to investigate before. It helps the investigator get beyond blame to find real, fixable root causes that, when fixed, can prevent future accidents.
Third, once the root causes are identified, TapRooT® has a module called the Corrective Action Helper® that helps the investigator develop effective corrective actions. This helps the investigator and management develop corrective actions that might be “outside the box” as far as their experience with corrective actions is concerned.
If you are a TapRooT® User, you have already learned these lessons (but it is good to have them reinforced).
If you are NOT a TapRooT® User, get to a TapRooT® Course NOW! Investigating smaller accidents, incidents, and near misses, as well as using the TapRooT® techniques proactively, can help you avoid major accidents and keep your employees safe.
For more TapRooT® information, including success stories from TapRooT® users, see:
The first trial under the new UK Corporate Manslaughter Act started last Tuesday. But on Friday after hearing legal arguments from both sides, the judge adjourned the trial for 18 weeks while the owner of Cotswold Geotechnical Holdings, Peter Eaton, underwent “urgent and intensive” medical attention.
Peter Eaton faces a life sentence in prison and his company faces an “unlimited” fine if convicted.
The charges stem from a tench collapse that killed Alex Wright. Alex was taking a soil sample at the bottom of a trench when it collapsed and suffocated him.
A TapRooT® user sent me these photos and said that the driver was “lucky.”
I really can’t tell what is holding that truck up there … Maybe that’s why they think the driver is “lucky.” But I can’t help but think if they really were “lucky”, they wouldn’t have had the wreck in the first place! I guess it is all in your perspective…
Here is a statement from Don Holmstrom, Investigations Supervisor, at the US CSB…
Good morning I am CSB Lead Investigator Don Holmstrom; thank you for coming to this CSB news conference. The Chemical Safety Board is an independent federal agency that investigates and reports to the public on the causes of major chemical accidents at industrial sites across the country. The CSB is headed by five board members appointed by the president and confirmed by the Senate. The CSB’s reports and safety recommendations to Congress, federal and state regulators, and industry are widely followed and applied throughout the United States. Our mission is to prevent disastrous accidents of the kind that occurred here less than three weeks ago.
The safety issues raised by this accident are not limited to Connecticut. These issues are larger than any particular company, facility, or individual. The U.S. has embarked an ambitious construction effort for new natural gas power plants. Thousands and thousands of workers across the country will be involved in constructing these plants. The safety of these workers and the nation’s energy independence are at stake as these gas-fired plants are built over the next 20 years.
The CSB has a team of ten here investigating at the Kleen Energy accident site. On behalf of all of us at the CSB, we extend our deepest condolences to the families of Ronald Crabb, Peter Chepulis, Raymond Dobratz, Kenneth Haskell, Christopher Walters and Roy Rushton. The goal of the CSB investigation is that terrible accidents like this will not happen again and that no families will suffer such tremendous losses in the future.
The CSB team arrived at the site on February 8th. Since that time, the CSB team has conducted a large number of interviews, reviewed documents, and closely examined the accident site on numerous occasions. We appreciate the outstanding cooperation from the workers at this facility, who despite living through such a horrible ordeal have provided valuable information to CSB investigators.
This accident occurred during a planned work activity to clean debris from natural gas pipes at the plant. To remove the debris, workers used natural gas at a high pressure of approximately 650 pounds per square inch. The high velocity of the natural gas flow was intended to remove any debris in the new piping. At pre-determined locations, this gas was vented to the atmosphere through open pipe ends which were located less than 20 feet off the ground. These vents were adjacent to the main power generation building and along the south wall. The open pipe ends are visible here in the photographs.
You can actually see the high-pressure gas venting out of one of these open pipe ends in this photograph taken a short time before the accident on February 7.
This cleaning practice is known within the natural gas power industry as a “gas blow.” Industry personnel have indicated to CSB investigators that gas blows are a common practice during the commissioning of new or modified gas pipes at their facilities.
CSB investigators have reviewed gas utility records for the morning of the accident. These records together with written pipe cleaning procedures and witness testimony confirm that the gas blows occurred intermittently over the course of the morning. At the same time that gas blows were underway, there were potential ignition sources present in the surrounding area, including inside the power plant building. There were many construction-related activities underway inside the building.
Determining the exact ignition source is not a major focus of our investigation at this point. In most industrial worksites, ignition sources are abundant and efforts at accident prevention focus first and foremost on avoiding or controlling the release of flammable gas or vapor.
Initial calculations by CSB investigators reveal that approximately 400,000 standard cubic feet of gas were released to the atmosphere near the building in the final ten minutes before the blast.
That is enough natural gas to fill the entire volume of a pro-basketball arena with an explosive natural gas-air mixture, from the floor to the ceiling.
This gas was released into a congested area next to the power block building. This congested area likely slowed the dispersion of the gas. The gas built up above the lower explosive limit of approximately 4% in air and was ignited by an undetermined ignition source.
In the days since the accident, companies and safety regulators from around the world have contacted the CSB asking about the circumstances of this devastating accident. Some companies, including a power plant here in the region, indicated that they themselves have been planning similar gas blows as part of commissioning pipes in the very near future.
A major focus of the CSB investigation is to determine what regulations, codes, and good practices might apply to these gas blows. To this point, no specific codes have been identified, but we are continuing our research.
In the meantime, we strongly caution natural gas power plants and other industries against the venting of high-pressure natural gas in or near work sites. This practice, although common, is inherently unsafe.
The CSB is investigating possible alternatives to this practice, including the use of air, steam, nitrogen, or water or the use of combustion devices to safely destroy the gas. Combustion devices like flares can safely burn up flammable gas or vapor, preventing the possibility of an explosion.
Recommending safer alternatives will be a primary focus of the CSB investigation as we move forward.
Just three days prior to this tragic accident, the Chemical Safety Board recommended changes to the National Fuel Gas Code to prevent disastrous explosions involving gas purging. We note with great appreciation that just yesterday, at a meeting in San Francisco, the NFPA panel responsible for the fuel gas code voted to move forward with the CSB’s recommendations to make purging practices safer at work sites across America. These provisions will apply at hundreds of thousands of facilities, once fully adopted.
The type of purging described in that code is different from the gas blows used in the power industry, and power plants remain exempt from the national fuel gas code. However, gas purging as defined in the code has certain similarities to gas blows, in that gas is applied at one end of a pipe and gas is intentionally vented at the other end to the atmosphere.
There is an underlying common theme among the tragic accidents at Kleen Energy, the ConAgra Slim Jim plant in North Carolina, the Ford River Rouge power plant in Michigan, the Hilton Hotel in San Diego, and many other purging-related accidents. Companies must ensure that flammable gases are not vented into close proximity with ignition sources and workers. That is a vital safety message from all these tragedies.
We encourage the gas power industry to closely study the very positive actions recommended by the NFPA and the American Gas Association committees yesterday. The CSB investigation will focus on determining what permanent changes in standards or practices are needed to prevent future accidents involving gas blows.
Thank you for attending this morning and we will be happy to answer questions from members of the media. Please state your name and affiliation with your questions.
The Mercury News reported that Cal-Osha fined the Department of Water Resources $140,000 after an accident caused by failing to replace an energy dispersion ring in a valve (the report said that they didn’t have time to replace the ring because of the upcoming season) and failure to inspect/maintain a steel wall for 40 years.
Does your facility have standards for maintenance and repairs?
What happens when a part related to safety isn’t available?
Who makes the decision what to do?
Has becoming “Lean” created spare parts shortages?
What old equipment needs safety inspections to make sure that wear or corrosion hasn’t made it unsafe?
I saw an interesting article at nuclearmatters.co.uk about a speech given by Judith Hackitt discussing the potential to have process safety accidents with multiple fatalities because of short-term business pressures. I thought it was a good speech that the article was based on, but that there were a couple of inaccurate impressions that needed to be corrected. So I left this comment:
I like Judith’s statement but there two slightly incorrect facts in her comments …
1) Judith said: “… lack of injuries and near misses is no guide whatsoever that all is well in process safety terms…”
BP Texas City DID NOT have a good safety record.
They were killing people almost every year. They may have kidded themselves into believing that they were improving safety (a little under-reporting can go a long ways) but they had an unacceptable rate of fatalities. These fatalities were proof that something was wrong.
Also, they had previous process safety incidents and near-misses on the very process that exploded that indicated problems and that were not corrected.
Thus, at least for BP Texas City, they should have seen this accident coming and prevented it. They had warnings. All they had to do was listen, find the root causes, and act.
2) Judith said: “Short-term business pressures drove BP to cut capital expenditure at its Texas City plant by deferring projects and failing to monitor the subsequent impact of this. This had a dramatic impact on the repair and maintenance programme at the site and was a significant factor in the catastrophic explosion in 2005.”
The cost cutting at the Texas City refinery was not short term.
It started before BP bought the refinery. BP should have known that they would have to INCREASE spending to make up for cuts prior to the Amoco sale to BP. Instead, BP continued to cut spending right up until the accident. That makes it five, six, or perhaps even seven years or more of underfunding safety and maintenance.
The Texas City refinery under Amoco/BP had backlogged safety corrective actions that were a decade past due when the accident occurred. Therefore, this was not just a one or two year budget cut problem. It was historical underfunding of a high risk process. Short-term business pressures may have caused this underfunding in any one year but the impact was long-term and establish a culture of shortcuts and a “make it work” mentality.
Reasonable management should have been able to see that this game of process safety Russian roulette can’t go on forever. Eventually, someone has to “pay the piper.”
The fact that management can get away with underfunding safety and maintenance for several years without an accident is what makes taking shortcuts so tempting. This is especially true when managers are quickly promoted so that they don’t stick around to see the impact of their business decisions on performance at a complex facility (like the Texas City refinery). The wrong lessons (we can cut costs without noticeable impact) are reinforced as the market (and benchmarking surveys) rewards those with the highest production and the lowest costs. Management is not required to understand or face the long-term impact of their decisions.
Therefore, I still believe that many executives have not learned the lessons that:
1) You must work diligently to learn from your experience (they think Texas City was a surprise when it should not have been a surprise).
2) There is a point below which you should not cut the budget on a high-risk enterprise.
You must have strict standards that can’t be compromised and you have to say, “No - We won’t continue to operate without support for these safety initiatives.”
If management (especially senior management and corporate boards of directors) fails to learn these lessons and continues to operate high risk facilities as if they were any standard manufacturing plant, we (society) are doomed to see accidents with causes like those that caused the explosion at Texas City again.
Lest one thinks that this is only a problem for refineries and chemical and oil industry facilities, look no further than the Davis-Besse reactor vessel hole for a near-miss that was only prevented by the regulator saying “No” to a utility request to cut inspection requirements again.
No high hazard industry is immune to the temptation to get buy with less and the failure to listen to the warnings of operating experience.
Best Regards,
Mark Paradies
What do you think?
Has management learned the budget and operating experience lessons from Texas City?
Have they established strict standards and drawn a funding line that can’t be crossed?
Are they interested and actively promoting analysis of operating experience, advanced root cause analysis, and prompt implementation of corrective actions?
Or have things gone back to business as usual?
After all, the five year anniversary of the Texas City refinery explosion is just around the corner.
These don’t have to happen. We know how to stop these fatalities. No new science needs to be invented. Each trench collapse fatality is a needless loss of life.
Here’s a video demonstrating a collapse…
And here’s a trench cave in that occurred while an Oregon OSHA Inspector was filming…
Luckily the man “in-the-hole” was not killed in the second example. But many are not as lucky.
Back in 2003, I wrote an article called “Stop the Sacrifices.” It was an emotional appeal to the construction industry to stop these needless deaths. It caused a lot of controversy.
Perhaps the construction industry has improved since them. I know that some companies have. But others continue to put peoples’ lives at risk by promoting shortcuts (or at least turning a blind-eye to their workers’ taking shortcuts) and not promoting best practices to keep people safe.
If you are responsible for construction work and trenching, take a moment to review what you are doing to keep workers safe. A new sewer line or a broken water pipe isn’t worth someone’s life.
If you would like to learn more about best practices to improve safety, consider attending the 2010 TapRooT® Summit. The Safety & Risk Management Track has these Best Practice Sessions that will give you ideas to improve performance:
From the “facts” in the story, on a dark, rainy night, a person crossed against the light and stepped in front of a car that was not speeding and had a green light. The driver’s lawyer says the driver was not texting at the time of the accident.
However, the Gwinnett police disagree and say that the outcome of the “accident” could have been different is the driver had not been texting. They say her use of the cell phone was a contributing factor and have charged Lori Reineke, the driver, with vehicular homicide.
(Police photo of Lori Reineke)
What do you think? Are we going too far in criminalizing accidents?
More information on the sudden acceleration problems. The article starts with this paragraph:
“Complaints of deaths connected to sudden acceleration in Toyota vehicles have surged in recent weeks, with the alleged death toll reaching 34 since 2000, according to new consumer data gathered by the government.”
Whenever accident get this much press, you know that lawsuits will follow. That’s a “lesson learned” that shouldn’t be forgotten. If Toyota had found the root causes of these accidents and fixed them two years ago, they wouldn’t be facing these serious lawsuits.
One more thing. How serious are these lawsuits? I saw one blog posting saying that he wouldn’t be surprised if Toyota declared bankruptcy because of the lawsuits. I don’t think that’s possible … how many suits would it take to make Toyota go bankrupt? But the fact that somebody might suggest it makes one think twice about what the final cost of this quality/safety issue will be.
By the way, here’s the picture in case the footage above gets taken down again…
The steel post that he hit is about 1 meter to the right of the wall you can see him going over.
This is the last turn and in the video, you can see him drop down from the curve and hit the inside wall, fly off his sled, go over the short wall. and hit a steel post head first.
The fixes to the “safe” course were to raise the wall all along the section where you can see it and to move the start line down the run to reduce speeds (which were higher than in any previous Olympic luge event.)
The steel post that he hit is about 1 meter to the right of the wall you can see him going over.
