The following is a press release from the U.S. Chemical Safety Board, Washington DC.
Changes Urged to National Fire Codes, State Licensing and Inspection Procedures to Improve Safety of Facilities Handling Hazardous Materials
Danvers, Massachusetts, May 13, 2008 - A massive explosion and fire at the CAI/Arnel ink and paint products manufacturing facility in November 2006 occurred because CAI lacked safeguards such as alarms and automatic shutoffs that would have prevented a 10,000-pound mixture of flammable solvents from overheating in the unattended building, investigators from the U.S. Chemical Safety Board (CSB) said in a final draft report made public today.
Steam heat to the mixing tank was most likely inadvertently left on by an operator before he left for the day. As the temperature increased, vapor escaped from the mixing tank, built up in the unventilated building, ignited, and exploded.
The 105-page report is set to be considered by the four-member Board at a public meeting in Danvers this evening, beginning at 6:30 p.m. at the North Shore Ballroom of the Sheraton Ferncroft Hotel, 50 Ferncroft Road. The meeting is free and open to the public. Members of the public are encouraged to attend and comment on the draft report prior to the Board’s consideration. The meeting is expected to conclude at approximately 9:30 p.m.
Following a detailed presentation by the CSB investigators, including a new ten-minute video of the explosion and its impact on the community, local and state officials and a Danversport resident are scheduled to present testimony to the Board describing changes to oversight of manufacturing facilities following the accident.
CSB investigators said that ink manufacturer CAI did not follow regulations or appropriate good practices for the handling of flammable solvents, and the CSB report proposes changes to national fire codes and to state licensing and inspection procedures to improve the safety and oversight of facilities handling hazardous materials.
Investigators said that on the night of the accident, ink base materials - including a volatile mixture of heptane and propyl alcohol - continued to heat and then boil after all the employees left work late in the afternoon. The heating was controlled by a single, manual valve that needed to be closed by an operator to prevent the 3,000-gallon tank from overheating.
The building ventilation system was turned off at the end of the workday - a routine procedure - and vapor coming out of the unsealed tank spread throughout the production area and then ignited from an undetermined source, possibly a spark from an electrical device. The explosion occurred at approximately 2:46 a.m. on November 22, 2006.
The blast ripped through the adjacent Danversport neighborhood, waking sleeping residents as windows were blown into bedrooms and shattered, ceilings fell, and belongings and appliances flew about. The blast wave damaged scores of homes. At least 16 homes and three businesses were damaged beyond repair, and approximately ten residents required hospital treatment for cuts and bruises. The fire department ordered the evacuation of more than 300 residents within a half-mile radius of the facility.
‘The community damage was the worst we have seen in the ten-year history of the Chemical Safety Board,’ said CSB Board Member William Wright, who accompanied the investigative team to the accident site. ‘As others have noted, this explosion had a serious potential for life-threatening injuries and fatalities.’
The facility, shared by ink manufacturer CAI and paint manufacturer Arnel, was completely destroyed by the explosion and ensuing fire and has not been rebuilt. Arnel ceased operations, while CAI continues to produce water-based inks at a facility in Georgetown, Massachusetts.
Mr. Wright said, ‘The immediate cause of the accident was the overheating of a highly flammable mixture for many hours. We found an underlying cause was CAI’s failure to conduct a hazard analysis or other systematic review to ensure flammable liquids were safely handled during the manufacturing process.’
‘The company did not have automated process controls, alarms, or other safeguards in place. The standard practice at the company was to shut off ventilation at night - to retain heat in the building and to allay residential complaints about fan noise,’ Mr. Wright said. ‘When the mixture continued to overheat - absent automatic shutoffs and proper ventilation - the vapor accumulated and filled much of the building over a period of hours. Without safeguards, it is likely that a small but foreseeable human error led to disaster.’
CSB Lead Investigator John Vorderbrueggen, P.E., said Massachusetts state fire regulations and local enforcement should be improved to better protect communities and employees. He said, ‘The existing Massachusetts fire codes - as well as federal OSHA standards - have requirements for ventilation of flammable vapors to prevent dangerous accumulations inside structures. But Massachusetts has not adopted the most current national fire codes for flammable liquids. Our investigation also found that while the state requires local fire departments to periodically inspect facilities that handle flammable materials, the laws do not specify any inspection frequency or criteria for conducting those inspections.’
The CAI/Arnel facility was last inspected by the fire department in 2002, but the inspection focused on a newly installed fire suppression system and did not identify fire code or permitting violations. In addition to the inadequate ventilation that contributed to the accident, non-causal fire code violations included improper venting of flammable storage containers, use of improper hoses for flammable service, and lack of fire walls.
Under the General Laws of Massachusetts, the CAI/Arnel property was required to have land-use licenses for flammable materials. The only license, first issued to a predecessor company in 1944 and re-registered annually thereafter, initially authorized the presence of 250 gallons of ‘lacquer.’ In 1955, the property owners were granted an amended license by the Danvers Board of Selectmen to store and use 6,000 gallons of ‘miscellaneous’ flammable materials.
By the time of the accident in 2006, the registration record on file with the Town of Danvers referenced a ‘license’ to store and handle up to 11,500 gallons of ‘miscellaneous’ flammable materials. However, the CSB found no record of such a license in the Danvers town files. Therefore, the CSB concluded, the current licensed amount was 6,000 gallons, well below the more than 20,000 gallons of flammable liquid and more than 50,000 pounds of flammable solid, nitrocellulose, stored on site.
The CSB found Massachusetts law to be unclear on the requirements and procedures for towns to approve requests for increasing the amounts of flammables to be stored at industrial sites, including whether or how adjacent property owners should be notified of intended increases. The investigation also pointed out that the state’s licensing and registration forms do not require information on the specific types and quantities of materials stored.
A CSB survey of six Massachusetts municipalities - including Boston, Worcester, Springfield, Danvers, Leominster, and Georgetown - found significant variability in how state licensing and registration laws are applied. Although the six municipalities issued a total of more than 400 flammable materials licenses, only two reported ever having denied a license application.
In addition to a license, Massachusetts regulations require companies to obtain separate permits from the local fire department for the storage of flammable liquids, gases, and solids. However, at the time of the explosion in Danvers, no permits had been obtained by or issued to CAI or Arnel, except an expired permit for underground storage tanks. The lack of permits had not been previously identified by the fire department.
Based on the quantities of flammable materials used, CAI but not Arnel was required to comply with OSHA’s Process Safety Management standard, which would have required the company to conduct a process hazard analysis. Such a review could have identified the need for more sophisticated process control equipment, operator checklists, and continuous building ventilation. The standard also requires the use of written operating procedures, which can reduce the occurrence of human errors.
However, CAI management stated the company was not aware of the Process Safety Management standard’s existence and had not implemented its requirements. OSHA had not inspected the facility prior to the accident.
Finally, the report stated that national model fire codes developed by the National Fire Protection Association (NFPA) and the International Code Council (ICC) do not provide sufficient safeguards for flammable liquids heated inside buildings. The standards - which are voluntary unless specifically adopted by states and localities - contain ambiguous language concerning process vessels and do not explicitly require automatic shutdown or cooling systems to prevent accidental overheating and the uncontrolled release of flammable vapor.
The CSB investigated a similar accident in 2006 at a Chicago-area concrete products company, where a vessel filled with heptane accidentally overheated inside an unventilated building, causing an explosion that killed a driver and caused property damage.
The investigation report makes numerous safety recommendations, which will be considered by the Board. The report calls on the NFPA (based in Quincy, Massachusetts) and the ICC to revise the national fire codes to prohibit the heating of flammable liquids inside buildings in unsealed tanks that do not vent outside and to require automatic safeguards to prevent overheating.
The report calls on the Massachusetts legislature to require companies to certify compliance with state fire codes and safety regulations, to require public input before allowing companies to increase the quantities of licensed flammable materials, and to require the Office of the State Fire Marshal to audit localities’ compliance with licensing and permitting requirements.
Other proposed recommendations call on the state’s Office of Public Safety to adopt current national fire codes for handling flammable liquids (NFPA 30) and manufacturing of coatings (NFPA 35), to develop standards and a mandatory frequency for fire department inspections of manufacturing facilities, and to require license and registration forms to specifically list the type and quantity of each hazardous material.
Pending completion of the recommended changes at the state level, the report calls for the Town of Danvers to undertake similar initiatives for certification, licensing, and inspection. Additional, specific safety recommendations were directed to CAI, in the event the company resumes solvent-based processing at another location. The draft report’s findings, statements of cause, and recommendations are all subject to approval by a vote of the Board and are subject to change.
For more information, contact Director of Public Affairs Dr. Daniel Horowitz at (202) 441-6074 (cell), Public Affairs Specialist Hillary Cohen at (202) 446-8094 (cell), or Sandy Gilmour at (202) 251-5496 (cell).
Why do I ask this you may wonder? In today’s world “keyword’s” help internet users find what they need…. sometimes. However, many times “keyword” searches limit your field of opportunities, regardless of what the meaning or purpose of the word may represent. So continuing down this train of thought, would you consider losing a customer an incident?
Oxford’s definition of Incident:
An event or occurrence : several amusing incidents.
• a violent event, such as a fracas or assault : one person was stabbed in the incident.
• a hostile clash between forces of rival countries.
• ( incident of) a case or instance of something happening : a single incident of rudeness does not support a finding of contemptuous conduct.
• the occurrence of dangerous or exciting things : the winter passed without incident.
• a distinct piece of action in a play or a poem.
The TapRooT® definition of Incident:
• The reason the investigation is being conducted and defines the investigation scope
• The incident usually the most serious event that took place
So would losing a customer be a “serious event”? What if you had a customer complaint and still have a chance to keep from losing the customer? I don’t know about you, but I want to keep my customers. By defining the possible loss of a customer as a significant incident what should your next step be? Think TapRooT®, a root cause analysis system and training that helps solve problems both reactively and proactively. The next step is to find out where to learn about TapRooT®:
1. TapRooT® Summit
If you want to learn how others in numerous industries have applied TapRooT® to resolve customer and product issues in oil refining, oil drilling, bio and medical manufacturing, medical care, aviation (service and manufacturing), nuclear regulatory agencies, engineering companies, chemical manufacturing, governmental agencies…. and numerous others, the TapRooT® Summit in June may be your answer. Click on Summit on www.taproot.com to select a topic track that fits your business needs.
2. TapRooT® Public Courses
Meet other industries in a our public courses as you learn the way to perform a solid TapRooT® investigation for any type of incident. Click on Courses on www.taproot.com for a location near you.
3. TapRooT® Onsite Courses
Let us come to your company and train your employees, supervisors, and managers in house. Call us at 865.539.2139 for quotes.
How long does an investigation take? Depends on how many approvals are needed and how long the backlog is. See this note about a Coast Guard investigation of a barge incident:
The Press-Register reported that teams of investigators from OSHA, the state fire marshall, and Louisiana-Pacific were investigating an explosion that injured six workers. Louisiana-Pacific spokeswoman Mary Cohn said:
“They have begun the process of conducting the root cause analysis, but it’s too early to say.”
Cohn said it wasn’t the first such accident at one of the company’s oriented strand board plants.
“We have had some smaller fires in the thermal oil areas, but none of this magnitude,” she said.
My Comment…
Sounds like its time to be more proactive and use advanced root cause analysis to investigate smaller fires and perhaps do proactive audits before there are ANY more fires.
Whenever you have had previous smaller incidents and you then have a major accident, there is something wrong with the response to your previous incidents. The 15 Questions on the front side of the Root Cause Tree® point the investigator toward the MANAGEMENT SYSTEM - Corrective Action Near-Root-Cause Category.
Lesson That You Can Learn
This accident should make you think …
Am I doing all that I can to learn from smaller problems?
Will my responses effectively solve the root causes of problems so that big problems will be prevented?
Are my corrective actions fixing symptoms or the real root causes of the problems?
If you don’t have good answers to the questions above, perhaps now is the time to attend a TapRooT® Root Cause Analysis Course BEFORE you have a major accident at your facility.
I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:
Is the Healthcare Industry Ready to Change?
I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.
What’s in the Medical Error Reduction Best Practices Track? Here’s a list:
Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2
The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies
MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center
Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group
Measuring Performance - Dr. Joel Haight, Professor, Penn State
Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2
TapRooT® User Success Stories from Industry & Healthcare - Linda Unger
“Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada
Also, participants will hear from five very interesting and motivating Keynote Speakers:
Nikki Stone - Olympic Champion
Lt. Col. Ralph Hayles - Gulf War I Veteran
Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board
Ed Frederick - Operator during the Accident at Three Mile Island
Marcia Wieder - America’s Dream Coach
In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.
The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:
Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.
The Air Force Link reports that Col. Richard Haddan will chair an investigation board looking into a recent crash of a T-38 training jet. The crash killed Maj. Brad Funk and his student, 2nd Lt. Alec Littler.
No other information will be released prior to the completion of the board’s investigation.
I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.
Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!
(Spare time maintenance.)
SOMETHING FOR NOTHING
Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:
- Poor investigations & corrective actions
- Repeat incidents
- Increased risk of big accidents
- Risk of regulatory action after a big accident or because of repeat incidents
- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents
- Overworked, disheartened investigators
- Investigators trying to dodge investigation assignments
- Disenchanted employees who look at investigations as a waste of time
- Inaccurate investigation statistics
- Loss of management’s faith in root cause analysis
That’s quite a list.
Perhaps economizing on investigations isn’t a good idea.
(Climb the ladder to work on the roof. A reasonable assignment?)
REASONABLE ASSIGNMENTS
If investigating incidents in your spare time is bad, what is a good practice?
A measured response with a wise allocation of resources.
Let’s look at three examples.
Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.
Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.
In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.
HOW MUCH WORK?
For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.
Management needs to keep asking, “Is there any help that you need?”
(Benchmarking at the Summit.)
BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES
Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!
Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.
A subway accident is scary. On Sunday, the derailment of one wheel on two cars of a subway train required 449 passengers to be evacuated on a “rescue train.”
The accident caused Monday commuter service to be disrupted.
72 people have died after an accident in east China. The corrective action that has made headlines is the firing of officials. So far, eight have been fired. For a story with more information, see:
Washington, DC, April 30, 2008 - The U.S. Chemical Safety Board (CSB) announced that it will convene a public meeting on Tuesday, May 13, 2008, in Danvers, Massachusetts, to review the final CSB investigation report on the causes of the November 2006 explosion at the CAI/Arnel ink and paint manufacturing plant.
The report examines company work practices, state and local licensing and permitting procedures, and state and national fire codes for the safe handling and processing of flammable liquids.
The meeting will begin at 6:30 p.m. at the Sheraton Ferncroft Hotel, North Shore Ballroom, located at 50 Ferncroft Road in Danvers. The meeting is free and open to the public. Members of the public are encouraged to attend and comment on the draft report prior to the Board’s consideration. The meeting is expected to conclude at approximately 9 p.m.
On the night of November 22, 2006, a CAI mixing tank containing flammable heptane and alcohol solvents overheated, releasing vapor that filled the building and then ignited at about 2:45 a.m. The resulting explosion and fire destroyed the facility and created a blast wave that damaged or destroyed dozens of nearby homes and businesses in the Danversport neighborhood. As CSB investigators noted at a May 2007 public meeting in Danvers, the building’s ventilation system was routinely turned off at night, contributing to the accumulation of the flammable vapor.
The meeting will include a detailed presentation by the CSB investigative team of the findings and conclusions from the agency’s investigation. In preparing the final report, investigators examined the accident site; interviewed numerous company personnel, neighbors, and officials; conducted blast modeling and laboratory testing; and examined relevant federal, state, and local regulations and standards.
The investigation team will present new safety recommendations to prevent future accidents for consideration by the Board.
Following the presentation of the CSB report and recommendations, a panel of outside witnesses will describe changes in state and local oversight of chemical facilities that have been proposed or implemented since the explosion. Officials from the state government and the Massachusetts fire services have been invited to testify, along with a community representative.
For more information, please contact Public Affairs Specialist Hillary J. Cohen at (202) 261-3601.
If you think that some root causes were missed, what is your evidence?
Here’s a tip.
Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.
What Causal Factors led to this fatality?
Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.
One final question…
How do you assess the thoroughness of investigations at your facility?
For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).
The UK Rail Accident Investigation Branch (UK RAIB) has released a report on a collision between a train and a tractor near Limavady Junction, Northern Ireland, on August 2, 2007. The RAIB has made six recommendations. For the complete report see:
The second is an investigation into a runaway engineering wagon and its subsequent collision with a road-rail vehicle at Armathwaite, Cumbria, on 28 January 2007. See:
The father of a 12-year-old boy who was crushed to death by a tractor has been fined £1000 for letting his son drive the machinery while underage.
Sam Stanbridge was towing a roller on 25 March 2007 at the family farm at Kibworth Harcourt, Leicestershire, magistrates in Leicester heard on 28 February. There were no witnesses to the incident, but his mother found him unconscious while out riding. He had sustained a fatal injury to the head, having apparently been crushed by a two-and-a-half-tonne roller attached to the tractor he was driving. The tractor fell into a nearby canal. Sam was pronounced dead at Leicester Royal Infirmary.
A coroner’s inquest into his death concluded that Sam either slipped, tripped, or fell out of the cab; while getting in and out of the cab; or while already out of the cab. He had undertaken the same activity the day before the incident, and during the previous year, despite the law banning children under 13 years of age from driving or riding on agricultural machinery.
There was no evidence that the tractor had been driven recklessly, nor could any horseplay on Sam’s part be attributed to the cause of the incident.
In court, the boy’s father, Mark Stanbridge, pleaded guilty to breaching reg. 4 of the Prevention of Accidents to Children in Agriculture Regulations 1998, in that he allowed Sam to drive a tractor while carrying out agricultural work, which culminated in his death. He was fined £1000 and ordered to pay costs of £1500. http://www.shponline.co.uk/article.asp?pagename=incourt&article_id=7308
How much punishment is enough?
Do you think the father needs to be fined £1000 to prevent future accidents?
Sometimes I wonder about courts and enforcement of regulations.
The Ontario Workplace Safety and Insurance Board created a set of fairly gruesome commercials that dramatically show the results of “accidents.” The message is that there are no accidents. Accidents are caused.
Here’s the video:
These are also available at the WSIB web site for download:
The real question I have about these videos is the focus on blaming the worker, the supervisor, and management. We see the accident happen, but do we know what set the accident up?
To me, the video also shows the difficulties of finding and fixing the real root causes of an accident when our culture first looks to blame.
Washington, D.C. - The National Transportation Safety Board today released preliminary aviation accident statistics for 2007.
“The U.S. aviation industry has produced an admirable safety record in recent years,” said NTSB Chairman Mark V. Rosenker. “However, we must not become complacent. We must continue to take the lessons learned from our investigations and use them to create even safer skies for all aircraft operators and their passengers.”
The Safety Board’s aviation accident statistics show that in 2007, there were 24 nonfatal accidents involving Part 121 airlines (aircraft with 10 or more seats). One fatality occurred involving a nonscheduled Part 121 aircraft when a mechanic was fatally injured while working on a Boeing 737 in Tunica, Mississippi.
No fatalities occurred among Part 135 commuter operators (fewer than 10 seats). However, on-demand (charters, air taxis, air tours and medical services when a patient is on board) Part 135 operations reported 43 fatalities (62 accidents, 14 fatal accidents), up from the 16 fatalities that occurred in 2006.
While the overall number of general aviation accidents rose from 1,518 in 2006 to 1,631 in 2007, the number of fatalities in 2007 was down from 703 to 491 (a 30 percent decrease), making it the lowest annual total in more than 40 years.
Foreign registered aircraft accounted for 11 accidents in the U.S. in 2007, with 3 fatalities from a single fatal accident. Of the 14 accidents involving unregistered aircraft, 6 were fatal and resulted in 7 fatalities.
The BBC reported that an accident in Scotland caused by a 30-ton digger falling off a truck while being moved and hitting car (killing a passenger) would have been prevented if the truck driver had been properly trained.
“I express surprise and some concern at the absence of any requirement for compulsory training for drivers of heavy goods vehicles in relation to loading and securing of loads.”
“It seems to me that if such training had existed prior to July 5 in 2006 then there is at least the possibility that the accident which occurred might not have taken place.”
Training always seems like a potential solution after an accident with 20/20 hindsight. Without additional details of the sequence of events, the causal factors, and a thorough root cause analysis, the actual root causes may never be known.
A press release from the US Chemical Safety Board (CSB):
Apex, North Carolina, April 16, 2008 - In a case study report released today on the October 2006 hazardous waste fire at the Environmental Quality Company (EQ), the U.S. Chemical Safety Board (CSB) called for a new national fire code for hazardous waste facilities and for improving the information provided to community emergency planners about the chemicals those facilities store and handle.
The fire occurred on the night of October 5, 2006, at the EQ hazardous waste transfer facility on Investment Boulevard in Apex, a suburb of Raleigh, North Carolina. The facility was not staffed or monitored after hours, and no EQ employees were present at the time of the fire. Emergency responders did not have access to specific information on the hazardous chemicals stored at the site and ordered the precautionary evacuation of thousands of Apex residents. The evacuation order remained in place for two days, until the fire had subsided.
The CSB also today released a new 16-minute CSB safety video, entitled ‘Emergency in Apex - Hazardous Waste Fire and Community Evacuation,’ available on free DVDs and on the agency’s video website, Safetyvideos.gov.
The CSB investigation found that a small fire originated in the facility’s oxidizer storage bay, one of six storage bays where different wastes were consolidated, stored, and prepared for transfer off-site to treatment and disposal facilities. Within the oxidizer bay were a number of chemical oxygen generators, which had earlier been removed from aircraft during routine maintenance at a facility in Mobile, Alabama. However, they had not been safely activated and discharged before entering the waste stream. Solid chlorine-based pool chemicals were stacked on top of the box containing still functional oxygen generators.
Apex firefighters initially responded to a 911 emergency call from a resident driving past the facility, who reported observing a haze with a ’strong chlorine smell.’ When firefighters arrived, they discovered what was still a small ’sofa-size’ fire. But that fire spread quickly, most likely as the aircraft oxygen generators discharged and accelerated the blaze.
‘The only fire control equipment on-site consisted of portable, manually operated fire extinguishers,’ said CSB Supervisory Investigator Rob Hall, P.E., who led the investigation. ‘The facility lacked fire walls and automatic fire suppression systems. As a result, the fire spread quickly into other bays where flammables, corrosives, laboratory wastes, paints, and pesticides were stored.’ The bays were separated by six-inch-high curbs only designed to contain liquid spills.
The facility was destroyed in the ensuing fire and explosions, which sent fireballs hundreds of feet into the air. About 30 people, including one firefighter and 12 police officers, required medical evaluation at local hospitals for respiratory distress and other symptoms that occurred as a plume from the fire drifted across the area.
Hazardous waste facilities like EQ’s are regulated under the federal Resource Conservation and Recovery Act (RCRA). The investigation noted that RCRA regulations developed by the Environmental Protection Agency (EPA) require facilities to have ‘fire control equipment’ but do not specify what equipment and systems should be in place. In addition, there is no national fire code to define good fire protection practices for hazardous waste facilities.
The CSB investigation identified 22 other hazardous waste fires, explosions, and releases that have occurred at U.S. hazardous waste facilities in past five years. More than a third had adverse community impacts, such as evacuations, orders to shelter, and transportation disruptions.
Federal RCRA regulations require operators to ‘familiarize’ local responders in advance concerning facility hazards, but do not describe what specific information must be shared about stored chemicals, or define the frequency of communications. Similarly, EPA regulations under the 1986 Emergency Planning and Community Right-to-Know Act do not require facilities to share information about hazardous wastes with local agencies, since those wastes are generally exempt from Occupational Safety and Health Administration (OSHA) rules requiring preparation of material safety data sheets (MSDSs).
In fact, the investigation found that EQ had had limited contact with the Apex Fire Department prior to the October 2006 fire.
‘Specific, accurate, up-to-date information on chemical hazards is essential to emergency response planning,’ said CSB Board Member William Wark, who accompanied the investigative team to Apex in October 2006. ‘Communities have a fundamental right to know about stored hazardous chemicals that may affect their health and well-being. For first responders, having prompt access to such information is a matter of basic life safety.’
The CSB report recommended the EPA require that permitted hazardous waste facilities periodically provide specific, written information to state and local response officials on the type, approximate quantities, and location of hazardous materials.
The Board called on the Environmental Technology Council, a trade association representing about 80% of the U.S. hazardous waste industry, to develop standardized guidance on waste handling and storage to prevent releases and fires. The CSB also recommended that the Council petition the National Fire Protection Association (NFPA) - an organization that authors national fire codes - to develop a specific fire protection standard for the hazardous waste industry. The new standard should address fire prevention, detection, control, and suppression. Similar NFPA standards already exist for other industries, such as wastewater treatment.
Earlier, in June 2007, the CSB issued a safety advisory and urgent recommendations designed to ensure that chemical oxygen generators are safely activated and discharged prior to transportation and disposal. The advisory cited findings of the National Transportation Safety Board (NTSB) following the 1996 ValuJet crash in Florida, which was caused when generators activated and ignited in the plane’s cargo bay.
For more information, in Apex contact Dr. Daniel Horowitz at (202) 441-6074. In Washington, DC, contact Mr. Sandy Gilmour at (202) 261-7614 / (202) 251-5496 or Ms. Hillary Cohen at (202) 261-3601 / (202) 446-8094.
A press release from the UK Rail Accident Investigation Board:
The RAIB is carrying out an investigation into a derailment of a Docklands Light Railway train near Deptford Bridge station on 4 April 2008.
At 05:27 hrs on 4 April the 05:19 hrs service from Lewisham had just left Deptford Bridge station, and was traveling towards Greenwich, when it struck an object on the track and was derailed by the second axle of the first bogie. The front of the train came to a rest 88 meters after hitting the object. There were no injuries to the 59 persons on board the train and all were evacuated safely back to Deptford Bridge station.
The train, which was the first train of the day from Lewisham, was under automatic operation. The object on the track was found to be a steel drilling template that had been in use during engineering activities the previous night.
The RAIB’s investigation into the derailment is independent of any investigations by the safety authority.
The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website:
The Chief Inspector for the UK RAIB is Carolyn Griffiths. She is one of the Keynote Speakers at the TapRooT® Summit being Held on June 25-27 in Las Vegas, Nevada. For more information about the Summit and for registration, see:
The RAIB is carrying out an investigation into an accident when a road coach moved as a shuttle train departed from the UK terminal on 4 April 2008.
At 17:08 hrs a tourist shuttle train was departing from the UK terminal when a road coach moved backwards relative to the shuttle train, trapping the coach’s driver against the internal fire barrier door. Another passenger activated the emergency alarm to alert the train crew. As the train stopped the coach moved forward releasing the coach driver. The coach driver received injuries that required him to be admitted to hospital for treatment.
The RAIB’s investigation into the incident is proceeding independently of any parallel investigations by the safety authority, but the RAIB will share technical evidence as appropriate, subject to legal exclusions such as the identity and statements of witnesses.
The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website:
Spaceflight Now says that $150 million will be paid by an insurance company after a DISH Network satellite failed to reach its required orbit. The failure was caused by a rocket shutting down prematurely.
The article also said that a Russian Board is looking into the failure of the Proton’s Breeze M upper stage engine and is “close to determining the failure’s root cause.”
The FBI concluded that the crash of Senator Joe Lieberman’s web site WAS NOT a dirty trick from the opposing camp (Ned Lamont).
According to the FBI the data logging indicates a simple overload of the site combined with a misconfiguration of the server by the administrator. The FBI concludes that:
“The system administrator misinterpreted the root cause…”
For the complete story see The New York Times article:
Aviation is often mentioned as an example of a high-reliability industry. Yet accidents continue to occur.
There is much to be learned - good and bad - from the many investigation processes and reports published around the world. So this posting will review some of the web links that investigators may review.
First, there is the international aviation accident investigation standard: ICAO Annex 13 - Aircraft accident and incident investigation. You can find about 1/4 of it on-line at:
Another aviation accident investigation manual that is available on-line is the NTSB’s Aviation Investigation Manual for Major Team Investigations. See: http://www.iprr.org/manuals/ntsbaviationman.pdf
Many countries have their equivalent of the NTSB. A list of national aviation investigation boards with links to their web sites can be found at:
I previously wrote a blog entry about the wrong kidney being removed from a cancer patient.
Yesterday, I read an AP article with the following quotes:
“Twenty-four wrong-site surgeries were reported to the Minnesota Department of Health between October 2006 and October 2007. Two were at Methodist, but Carlson said they were relatively minor compared with last week’s error: a needle biopsy on the wrong lung, and a diagnostic exam of the wrong bronchial tube.”
“Kathleen Harder, a University of Minnesota researcher, said medical errors of this magnitude are rare but do happen.”
“Medical errors” certainly are NOT rare. The question is: “How rare are high consequence medical errors?”
The answer is: “No one knows.”
Why?
Because their is no national law that requires the reporting of high consequence medical errors to a central reporting agency.
Thus all statistics are a guess.
On top of that, to avoid liability errors may disguised as normal deaths. I read a sad story about a family being told that “every possible had been done” to save the life of their grandmother. They chose not to have an autopsy performed. Later, they found out that she had been administered large doses of blood thinner that may have contributed to, or caused, a fatal hemorrhage in her brain. The death would have been a natural death in the statistics. It would have gone unreported. Yet, the family now believes it was a covered up medical error that was detected by a nurse (a family member) reviewing the medical records.
I’m not a person that favors large government regulatory initiatives. And I’ve seen many government programs go astray. But unless the healthcare industry can come together to establish effective reporting and improvement programs, a large government lead regulatory initiative will surely be the eventual result.
If you are interested in efforts to reduce medical errors, you should participate in the TapRooT® Summit in Las Vegas on June 25-27. There is a Best Practice Track dedicated to medical error reduction. And you can network with experts inside the medical field and from a large variety of other industries. The cross industry networking may be the only hope for accelerated improvement in the healthcare industry. After all, as Sam Levenson quipped:
“You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.“
If you are in the medical industry leading an improvement effort, don’t miss this once a year chance to learn from others.
The results of thousands of “lost” bags are called a “Luggage Mountain.”
They have had to fly jumbo jets loaded with just bags across the ocean to try to unite travelers with their luggage.
And news outlets say the problem could get WORSE!
The cost of this “incident” is more than just the immediate costs to the airlines and travelers. Some say it has caused damage to the whole British reputation.
What is the “cause?” Everyone has an opinion. Most are looking for someone to blame.
But instead of looking for someone to blame, they should try advanced root cause analysis.
TapRooT® has been applied by many major airlines. Alaska Airlines even used it to analyze delayed flights and improve on-time departure statistics.
Perhaps British Air should try TapRooT® to stop the baggage meltdown and improve customer service?
And next time they should use root cause analysis as a PROACTIVE tool to improve performance BEFORE they open a new terminal and thus avoid a major quality of service incident.
