Sounds like from initial reports that there were no fatalities. If that is true that is good news.
My first reaction when I heard this was: I hope there will be ample time for a thorough investigation before any “knee-jerk” decisions are made to suspend drilling.
Golden Pass LNG Terminal LLC, the owner of the Golden Pass LNG Terminal, is 70 percent owned by an affiliate of Qatar Petroleum, 17.6 percent owned by an affiliate ExxonMobil, and 12.4 percent owned by an affiliate of Conoco Phillips.
Taking the lead before their first shipment of LNG, Golden Pass LNG started the Root Cause Analysis process and training early on. Below are just of few pictures from the first hands-on exercise.
Bloomberg reports that an unreleased internal BP report on the BP Deepwater Horizon accident found that the accident was caused by engineers (commonly called a “company man”) misinterpreting pressure data that indicated a blowout was imminent. The article says that BP plans to release the report in the next 10 days.
Bloomberg says that the report is 200 pages long and details the investigation led by Mark Bly, the head of safety and operations.
CSB Conducting Assessment of Ammonia Release
at Millard Refrigerated Services South of Mobile, Alabama
Washington DC, August 27, 2010 – A three-member assessment team led by Mr. Johnnie Banks from the U.S. Chemical Safety Board (CSB) is deploying to the scene of Monday’s anhydrous ammonia release at the Millard Refrigerated Services, a warehouse and distribution center in Theodore, Alabama, 15 miles south of Mobile.
According to media reports, more than 130 members of the public sought medical attention and four people remain hospitalized as a result of the uncontrolled ammonia release.
CSB Chairperson Rafael Moure-Eraso said, “We are seeing too many ammonia releases in our daily incident reviews. Though many are “small” releases, a high consequence accident that causes multiple injuries to members of the public is a serious one that warrants our examination. Our team will be examining the events that led to the release and ways that the community can be better protected in the future.”
Anhydrous ammonia is one of the most commonly used commercial refrigerants; it is a colorless, flammable, toxic gas. For humans, high exposure levels can result in suffocation as well as severe injuries to eyes, lungs and the digestive system.
Based on the CSB’s monitoring of media reports there were four high consequence incidents involving the release of anhydrous ammonia which led to a total of six fatalities in 2009:
· May 14, 2009: American Cold Storage, Louisville, KY – 2 fatalities
· June 20, 2009: Mountaire Farms, Lumber Bridge, NC – 1 fatality
· July 15, 2009: Tanner Industries, Swansea, SC – 1 fatality
· November 16, 2009: CF Industries, Rosemount, MN – 2 fatalities
Rafael Moure-Eraso, Chairman of the Chemical Safety Board, sent the letter below to Xcel Energy Inc., a utility with its headquarters in Minnesota. I’ve never seen a letter written so strongly from an investigator about the lack of cooperation about an investigation. Have you?
It would certainly be interesting to know more about what happened to cause the lack of cooperation.
CSB Final Report on Xcel Energy Accident Finds
Company and its Contractor Failed to Adequately Prepare
for Hazardous Work Inside Confined Space of Hydroelectric Plant Tunnel;
Xcel Had No Technically Qualified Responders on Duty
Report Urges OSHA, Colorado Public Utilities Commission to
Strengthen Regulations; CSB Finds 45 Confined Space Fatalities
Have Occurred in 53 Incidents Nationwide Since 1993
Denver, Colorado, August 25, 2010—The tragic accident that took the lives of five industrial painting contractors deep inside an Xcel Energy hydroelectric plant tunnel in Georgetown, Colorado, was the result of several vital safety failures, the U.S. Chemical Safety Board (CSB) determined in a final investigation report issued today in Denver.
Nationally, the investigation identified 53 serious flammable atmosphere confined space accidents that occurred from 1993 to April 2010, causing 45 fatalities and 54 injuries, the majority since 2001.
The CSB also released a 15-minute safety video entitled “No Escape: Dangers of Confined Spaces,” which includes a detailed animation depicting the horrible tragedy that unfolded inside the mountain tunnel at Xcel’s Cabin Creek plant on October 2, 2007.
The accident occurred in the water tunnel, or penstock, of the hydroelectric plant, located 45 miles west of Denver. The penstock carries water from an upper reservoir to a lower one, driving power turbines. The painting contractors, from RPI Coating, Inc., were recoating a 1,530-foot steel portion of the 4,300-foot penstock when a flash fire suddenly erupted as the vapor from flammable solvent, used to clean the epoxy spraying wands, ignited, probably from a static spark in the vicinity of the spraying machine. The initial fire quickly grew, igniting additional buckets of the solvent, methyl ethyl ketone (MEK), and other combustible epoxy materials stored nearby.
The CSB concluded the causes of the accident included (1) a lack of planning and training for hazardous work by Xcel and its contractor, RPI Coating, Inc., (2) Xcel’s selection of RPI despite its h aving the lowest possible safety rating (zero) among competing contractors, and (3) allowing volatile flammable liquids to be introduced into a permit-required confined space without necessary special precautions.
The CSB report found that the permit-required confined space rule set by the U.S. Occupational Health and Safety Administration (OSHA) does not prohibit entry or work in confined spaces where the concentration of flammable vapor exceeds ten percent of the chemical’s lower explosive limit, or LEL. (The LEL is the concentration of vapor in air below which ignition will not occur.)
OSHA’s rule does state that an atmosphere exceeding ten percent of the LEL creates an atmosphere “immediately dangerous to life and health” and that steps should be taken to define safe entry conditions; however, the rule does not define what those safe entry conditions should be or specifically prohibit entry into such hazardous atmospheres, the report notes. The CSB recommended OSHA establish a fixed maximum percentage of the LEL for entry so that work in potentially flammable atmospheres would be prohibited.
Additionally, the Board made recommendations to the company, the governor of Colorado, the Colorado Public Utilities Commission, trade groups, and other organizations.
CSB Board Member William B. Wark said, “This tragedy should never have happened. The companies did not effectively plan for the dangers of bringing significant amounts of flammable liquids into the tunnel, which was a hazardous confined space. Doing so was an unacceptable deviation from good safety practices.”
There were ten workers in the tunnel and one at the entrance at the time of the fire. Five were unable to get around the fire on the painting platform to get to the only available exit – the improvised tunnel entrance. Five workers on the other side of the platform made it to safety, although three of those workers sustained injuries.
The CSB found that Xcel and RPI failed to have technically-qualified confined space rescue crews immediately standing by at the penstock in case of emergency, as required by regulations. Workers called 911 for help but responders entering the penstock had to retreat in the thick smoke, as did workers who had approached the fire with extinguishers.
The closest confined space technical rescue unit – equipped and trained to enter the smoke-filled tunnel – was approximately one hour and 15 minutes away. The trapped workers died about one hour before this response unit arrived, their escape blocked by a steep vertical section of the tunnel deep inside the mountain.
CSB Investigations Supervisor Don Holmstrom, who led the investigation, said, “The five trapped workers communicated with co-workers and emergency responders using handheld radios for approximately 45 minutes, desperately calling for help, before succumbing to smoke inhalation. Their lives likely could have been saved had qualified, company-provided rescuers been in a position to respond immediately to a fire or other emergency.”
Board Member Mark Griffon, joining Mr. Wark and Mr. Holmstrom at the news conference, said, “Even before the operation began, the stage was set for disaster. Xcel not only did not adequately plan for the operation, but it selected the painting contractor with the lowest possible safety rating among the bidders, and it did so mostly on the basis of cost – it was the lowest bid.”
The investigation found that Xcel hoped to compensate for RPI’s safety record by closely supervising the contract work, but did not do so even when the company learned of safety issues during the initial penstock work.
The CSB investigation found Xcel and RPI managers were aware of the plan to operate the epoxy sprayer in the tunnel and to use flammable solvent to clean the sprayer and other equipment.
Mr. Holmstrom said, “As a result of not performing a hazard evaluation of the work to be done, the companies failed to identify serious safety hazards involving use of flammable liquids within the confined space. Use of safer, nonflammable solvents was not evaluated, continuous air monitoring was not required, and key policies and permit forms did not establish a percentage limit for flammable vapor in the tunnel atmosphere.”
Board Member Wark noted the lack of planning for escape in an emergency. “The penstock had only one egress point – the tunnel entrance,” he said. “Xcel and RPI did actually identify this as a major concern in their planning. But despite this, no plans were made for prompt rescue in an emergency, and no rescuers qualified to enter this confined-space environment were standing by.”
The CSB investigation determined that while companies are required to perform a hazard analysis prior to issuing permits for work in confined spaces, regulatory standards pertaining to the use of flammables within confined spaces are inadequate.
Board Member Griffon stated, “Other OSHA regulations on confined and enclosed spaces – for example in the maritime industry and other sectors – prohibit work in such confined spaces above a specific percentage of the LEL, often ten percent. We are recommending that OSHA adopt such enforceable limits for all industry.”
The CSB recommended that OSHA amend its confined space rule to establish a maximum percentage substantially below the lower explosive limit for any given flammable for safe entry and occupancy while working.
The CSB made recommendations to nine other entities. These included that the governor implement an accredited firefighter certification program for technical rescue with specialty areas including confined space rescue; that the Colorado Public Utilities Commission (PUC) require regulated utilities to adopt provisions for selecting contractors based on safety performance measures and qualifications; and that the PUC require utilities to investigate all incidents resulting in death, serious injury or significant property damage and submit and make public written findings and recommendations within one year of the accident.
Numerous recommendations were made to RPI Coating, particularly aimed at revising its confined space entry program and guidance.
CSB investigators and board members cited difficulties encountered in the investigation resulting from efforts by Xcel Energy and RPI Coating to impede the investigation and prevent the release of the investigation report.
Citing a formal Letter of Admonishment sent to the Xcel chief executive officer earlier in the week, Board Member Wark said, “The lack of cooperation and efforts by Xcel to impede our investigation are unprecedented. Mr. Griffon and I join our chairman in criticizing these actions in the strongest terms.”
The letter, signed by CSB Chairperson Rafael Moure-Eraso, states Xcel Energy did not fully comply with CSB requests for documents or answers to questions in formal interrogatories. This required the CSB to seek assistance from the U.S. Attorney’s office in Denver, resulting in delays to the investigation and additional costs to taxpayers. In May, Xcel took the extraordinary and unprecedented step of going to federal court seeking to block release of the CSB report and the safety video. The court sided with the CSB in favor of release.
Xcel was given an advanced draft copy of the report last April for review for accuracy and for confidential business information in accordance with CSB review protocols. Xcel never responded, but in August 2010, contrary to the conditions of confidentiality attached to their receiving this preliminary copy, released it to a news organization.
The letter from Chairperson Moure to Xcel’s CEO concludes, “In light of this disappointing pattern of corporate conduct, I am writing you directly to ensure that you are personally aware of the actions taken by Xcel to delay the CSB investigation, block publication of the CSB final report, and distort the conclusions of the investigation by releasing an unauthorized draft copy of the CSB report. The CSB will issue a formal recommendation that Xcel shareholders be directly notified by management of the significant findings and recommendations of the CSB report, and of the actions Xcel management intends to take to implement needed safety improvements. In the wake of the corporate responsibility concerns raised by the Big Branch Mine accident in West Virginia and the disaster in the Gulf of Mexico, I strongly urge Xcel to renew its focus on safety and to swiftly implement the CSB’s recommendations.”
The RAIB is carrying out an investigation into a collision that occurred at Sewage Works Lane level crossing, 1.5 miles south of Sudbury in Suffolk, on 17 August 2010.
The accident occurred at around 17:35 hrs when train 2T27, the 17:31 hrs service from Sudbury to Marks Tey, struck the trailer of a loaded articulated tanker lorry on the crossing, causing the leading carriage of the two-car class 156 diesel multiple unit to derail.
There were about 19 passengers on the train and two crew members (driver and conductor). It is reported that all persons on the train received injuries as a consequence of the impact with one passenger sustaining critical injuries.
The impact separated the tractor unit of the lorry from the tank causing a major spillage of the tank’s contents. Some diesel fuel was also released during the accident.
Sewage Works Lane crossing is a ‘user worked crossing’, as is often found at the intersections between the railway and minor (usually private) roads. At all such crossings the road user is required to operate gates or barriers when crossing the railway.
No lights or audible alarms were provided at the crossing to warn of the approach of trains. However, the crossing was provided with telephones to enable the drivers of vehicles to call the signaller to confirm if it was safe to cross.
The RAIB’s investigation is independent of any investigations by the British Transport Police and the safety authority (the Office of Rail Regulation).
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.
I also found it interesting that many of the investigators said that performing a good investigation and seeing people jobs get better (safer) was reward enough.
However, if managers want good investigations, shouldn’t they be rewarding what they want? Isn’t this basic management?
Therefore, one major improvement that management should consider for improving investigations is to start a systematic evaluation of investigations and rewards for good investigations.
WASHINGTON, D.C. – Deepwater Horizon Joint Investigation Co-Chairs J. David Dykes (Bureau of Ocean Energy Management, Regulation and Enforcement) and Captain Hung Nguyen (U.S. Coast Guard) today announced that U.S. District Judge (Ret.) Wayne R. Andersen and U.S. Coast Guard Capt. Mark R. Higgins will be joining the Deepwater Horizon Joint Investigation Team. The addition of Judge Andersen and Capt. Higgins will increase the depth and diversity of the team, drawing on their vast expertise in managing and facilitating complex proceedings.
The public hearings in this matter began on May 11, 2010, and have continued during the weeks of May 26 and July 19. The next hearings are scheduled to take place beginning on August 23, 2010, in Houston, Texas.
“The addition of Judge Andersen and Capt. Higgins to the Joint Investigation Team will enhance our work and help us to move expeditiously through the proceedings. They will assist us with some of the legal and procedural issues they are experienced, and allow the other members of the team to continue to focus on gathering the facts,” said Dykes. “They are welcome additions to our team.”
“I look forward to welcoming Judge Andersen and Capt. Higgins into the integrated investigative team, which will benefit from their unique skills and experience as we move into a new phase of the proceedings,” said Nguyen.
Andersen is a retired U.S. District Judge for the Northern District of Illinois, where he served from 1991- July 2010. He is currently a mediator and arbitrator for JAMS, a national alternative dispute resolution provider. He previously served as Judge of the Circuit Court of Cook County and Deputy Secretary of State of Illinois. He received his law degree from the University of Illinois College of Law in 1970 and an undergraduate degree in government, cum laude, from Harvard University in 1967. He is donating his time and will not receive compensation for his service on the team.
Higgins is currently serving as the Staff Judge Advocate for the U.S. Coast Guard Atlantic Area. He serves as regional counsel for all legal issues within the Atlantic Area, including operations and international maritime issues involving five Coast Guard Districts and Coast Guard operations in Europe, Africa, and the Middle East. He also serves as a military judge. He received his law degree, cum laude, from the University of Miami in 1989 and an undergraduate degree in civil engineering, with honors, from the U.S. Coast Guard Academy in 1983.
In response to the April 20, 2010, explosion of the Deepwater Horizon, Secretary of the Interior Ken Salazar and Department of Homeland Security Secretary Janet Napolitano directed the Minerals Management Service, now the Bureau of Ocean Energy Management, Regulation and Enforcement (BOEM), and the U.S. Coast Guard to conduct a joint investigation in accordance with a pre-existing Memorandum of Agreement. The facts collected at the hearings, along with the lead investigators’ conclusions and recommendations, will be presented in a final investigative report.
The Joint Investigation Team is comprised of both BOEM and Coast Guard personnel exercising both agencies’ authorities. In addition to the co-chairs, members include: Lt. Robert Butts, Coast Guard; Jason Mathews, BOEM; John McCarroll, BOEM; and Ross Wheatley, Coast Guard.
Press release from the UK Rail Accident Investigation Branch:
The RAIB is carrying out an investigation into the runaway of an engineering train which occurred on the Northern Line of London Underground (LUL) on Friday 13th August 2010.
The train consisted of a self-propelled diesel-powered unit designed for re-profiling worn rails. It had been working between Highgate and Archway stations on the southbound line during the night of 12/13 August. At the end of grinding operations that night, the crew of the unit found that they were unable to restart its engine to travel away from the site of work.
An assisting train, consisting of a six-car train of the 1995 stock used for passenger services on the Northern line, was sent to the rescue of the grinding unit. The assisting train was coupled to the grinding unit by means of an emergency coupling device, and the braking system of the grinding unit was de-activated to allow it to be towed. The combined trains then set out to run to East Finchley station. At about 06:44 hrs, after passing through Highgate station, the coupling device failed and the grinding unit began to run back down the gradient towards central London. The crew of the grinding unit, who had no means of re-applying the brake, jumped off the unit as it passed through Highgate station. It then ran unattended for about four miles, passing through a further six stations, and came to rest near Warren Street station about thirteen minutes later. No-one was hurt.
There was some damage to the grinding unit, and points at Mornington Crescent station were damaged when the unit ran through them.
LUL control room staff took action to clear trains away from the path of the runaway unit. The RAIB’s investigation will seek to identify the position of these trains in relation to the runaway. It will also consider the reasons for the failure of the coupling, and the rules and procedures applicable to the rescue of failed engineering trains.
The RAIB’s preliminary examination has identified no evidence that the condition of the track or the signalling system contributed to the incident.
The RAIB’s investigation 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 Associated Press reported that MSHA cited Massey Energy for failing to report 20 accidents at the Upper Big Branch Mine. These violations were found as part of the investigation into the accident earlier this year that killed 29 workers.
The story also says:
“Separately, MSHA said Tuesday it is fining a Massey Energy subsidiary more than $542,000 for violations that contributed to a fatal accident at a Virginia mine in 2009.
The accident occurred Aug. 20, 2009, when the mine was owned by Cumberland Resources, which Massey acquired in April.”
. . . . .
Once again, finding and fixing the causes of accidents before a major accident happens could have saved lives and big bucks!
$2.4 million is a considerable fine. But one wonders if a fine 3 years after an accident will really help improve safety.
The 2007 accident was a result of poor maintenance and repair activities, says a report by the Pipelines and Hazardous materials Safety Administration. The report took a year to complete and was reported on in part of an article in the Kalamazoo Gazette.
The article said:
“In addition to the $2,405,000 fine, Enbridge must also revise and implement certain pipeline maintenance and repair procedures, as well as train and re-qualify its employees.”
The fine comes after a accident in Michigan that happened on July 26 that resulted in more than 1 million gallons of oil spilling into the Kalamazoo River. Enbridge has released estimates of the cost of the cleanup of that spill: $300 to $400 million. Some of those costs will be covered by insurance. After insurance, Enbridge expects the costs to be $35-45 million.
. . . . . .
Wow! The fine is a pittance compared to the accident costs of the recent spill. It seems as if a great deal of money could be saved by implementing proactive maintenance programs to improve pipeline/equipment reliability. Perhaps Enbridge should be looking into using Equifactor® and attend the Heinz Bloch session at the TapRooT® Summit to learn the latest ideas for equipment reliability improvement.
Sometimes we take equipment reliability for granted. But equipment failures can cause serious accident.
In this case, no one was hurt when the boiler exploded. But considerable damage was done to the hotel. The root cause analysis of the failure will be interesting.
How do you ensure your equipment is reliable?
How do you troubleshoot equipment problems?
Do you find the root causes of your equipment problems and fix them to prevent future accidents?
A man operating a loader accidentally crushed another worker. He was prosecuted for breaches of the Australian Mining and Quarring Safety and Heath Act 1999.
He was found guilty and given a sentence of 8 months in prison (suspended) and a fine of $13,437.70 to pay for investigation and court costs. The article said that, “Neither the SSE nor the Operator nor Contractor were charged.”
Here are the “key messages” from the lawyer in Australia that wrote the article:
“Ensure you have a robust health and safety management system, regardless of your industry. It needs to be documented and it needs to be followed through, so the reality of what you do matches what’s contained in the documents.”
“Employers need to be able to demonstrate that employees are trained in and understand the system. If employers can show that and something goes wrong, they are in a defendable position. It also minimises the possibility of things going wrong.”
“Take swift action when employees do the wrong thing. If an employee breaches the safety system, do not hesitate to take severe action against them. In other words, employers should be considering discipline and termination. Courts view such breaches very seriously, and so should employers.”
What do you think?
Were the root causes discovered?
Were all the lessons learned that should have been learned?
Would you be sure that this accident won’t happen again?
How would you approach this accident?
Leave a comment here about your approach to this accident. And then think about …
Would you be ready for a fatality investigation at your facility?
Would you know how to handle all the aspects (including police issues) of a fatality investigation?
Perhaps you should consider attending the pre-Summit Course:
UK TapRooT® Instructors Alan Smith and Mhorvan Sherret, the Directors of Matrix Risk Control (UK) Ltd, and former senior Detectives, provide a course that will help you prepare for the worst by participating in realistic police interviews and investigation scenarios. It’s a great chance to get prepared just in case something bad ever does happen.
This course is only offered in the US just prior to the Summit and attendance is limited, so sign up today.
The EHS & Safety News America reported that a safety manager was indicted for one count of involuntary manslaughter after a fatality at a facility in Ohio.
For an individual. involuntary manslaughter carries a maximum penalty of up to five years in jail and a $10,000 fine.
Two TapRooT® trained former detectives will share information you need to know about dealing with the aftermath of a fatality.
After the course (October 25-26 in San Antonio), consider attending the TapRooT® Summit to learn best practices to prevent fatalities at your facilities. For more Summit information, see:
USA Today published an article about the recent crash that killed ex-Senator Ted Stevens and the hazards of flying to remote locations in Alaska.
The story mentioned several reasons for improving safety in Alaska but missed one. What is the one they missed? TapRooT®.
Back in 2002 we licensed The Medallion Foundation to teachTapRooT® and use it to investigate aviation accident in Alaska.
Then in 2003, we licensed the FAA in Alaska to use TapRooT® for accident investigations.
Now they cooperate in their investigative efforts to improve aviation safety in Alaska.
How has TapRooT® Helped improve Alaska aviation safety? Attend the TapRooT® Summit and find out. Dennis Ward, Executive Director of the Medallion Foundation and a certified TapRooT® Instructor, will present “Improving Performance by Analyzing Multiple Aviation Accidents for Common Causes” in the Investigation, Troubleshooting, and Root Cause Analysis Track. His talk explains the use of TapRooT® to find deeper meaning from the analysis of multiple accidents.
This is part of The Medallion Foundation’s efforts to improve the safety culture of the aviation industry in Alaska. Their web site has the following information:
“The Medallion Foundation is a non-profit organization promoting aviation safety through systems enhancements by providing management resources, training, and support to the aviation community. Our mission of reducing aviation accidents is fostered by research, analysis, education, auditing, and advocacy of Safety Management Systems and higher flight-training standards.”
It also says:
“The Medallion Foundation provides specific training classes, one-on-one company mentoring, and auditing in conjunction with and supplemental to the Five-Star / Shield programs. Courses such as System Safety, Safety Officer, Flight Risk Management, and TapRooT® Root Cause Analysis are offered as prerequisites for the Star Programs.”
OK … I added the emphasis on TapRooT®. But hearing how Dennis used TapRooT® to find significant Generic Causes of accidents from their root cause analysis, will help you understand why I put emphasis on using TapRooT® as a fundamental part of any improvement program.
The National Transportation Safety Board has launched
a Go Team to investigate last night’s airplane crash near
Dillingham, Alaska.
At about 8:00 p.m. Alaska Daylight Time, a DeHavilland
DHC-3T (N455A) crashed 10 miles northwest of Aleknagik,
Alaska. Reports are that 5 of the 9 persons on board died
in the accident.
Senior air safety investigator Clint Johnson, from the
NTSB’s Anchorage regional office, will serve as
Investigator-in-Charge. He will be assisted by
investigators from the Alaska office and from NTSB
headquarters in Washington, D.C.
NTSB Chairman Deborah A.P. Hersman is accompanying
the team and will serve as spokesperson for the on-scene
investigation. Terry Williams is the NTSB press officer
traveling with the team. The full team is expected to
arrive in Dillingham around mid-day today.
Contact information for the team will be released when
it is available.
- 30 -
NTSB Press Contact: (In Washington)
Keith Holloway
keith.holloway@ntsb.gov
202-314-6100
The National Transportation Safety Board today released the following photographs of the pipeline that ruptured and spilled oil into a river last week in Marshall, Michigan.
On the evening of Sunday, July 25th, a 30-inch crude oil pipeline, operated by Enbridge Energy Partners/Pipeline, experienced multiple low pressure alarms near the Marshall City Pump station during a planned shutdown. By 11:45am (EDT) the following morning Enbridge employees confirmed an oil leak extending into nearby Talmadge creek, a tributary to the Kalamazoo River.
Two sections of the pipe, 23 feet, 4-inches and another 26 feet, 10-inches, have arrived at the NTSB for further examination.
The photographs show the length of the fracture which extends approximately 6 1/2 feet longitudinally with the widest portion of the opening measuring 4 1/2-inches. The fracture was located approximately 25 feet from the upstream joint in a 40 foot section of 30-inch pipe.
The photographs may be viewed by clicking on the following link http://ntsb.gov/Pressrel/2010/100807.html
This track maintenance related derailment was investigated by the UK Rail Accident Investigation Branch. See the following report for the causes of the accident and the UK RAIB recommendations:
New research suggests that King Tut was killed by a chariot accident.
What if the ancient Egyptians had used TapRooT®? They could have found the root causes of previous incidents and near-misses and King Tut’s death might have been prevented.
CSB to Investigate Accident that Killed
Two Workers at Horsehead Holding Company
Washington, DC, August 3, 2010 – The U.S. Chemical Safety Board announced today that it will be conducting a full investigation into the July 22, 2010, explosion and fire that killed two workers at the Horsehead Holding Company zinc recycling facility located in Monaca, PA.
On July 25, the CSB deployed a three-person assessment team to the accident site. Investigators interviewed company personnel and documented the scene. The facility, which recycles and purifies zinc through a high temperature distillation process, is located approximately 35 miles north of Pittsburgh. Preliminary interviews indicate there was a loss of containment from the lower section of one of the distillation columns.
CSB Chairman Rafael Moure-Eraso said, “I am very concerned about the safety of this type of production process for the workers and the community. There may be other facilities across the country that are using a similar metal distillation process; the CSB will be examining how to increase the safety of this type of operation.”
Below is a PowerPoint presentation about an accident that occurred near Townsville, Australia. Christopher Cochran sent it to me because he thought people could learn from the fatality at another facility. I pass it along on this blog with the same thought in mind.
In his e-mail to me, Chris pointed out the presentation highlights:
• The required Task Risk Assessment/Job Safety Analysis was not carried out
• The mandatory job start meeting was not completed
• There was a failure to adequately manage change i.e.. failure to “stop the task” when changes occurred to re-assess the risks
• There was a lack of field operators that caused a Manager/Supervisor to undertake the work.
• Fellow employees failed to challenge/question a senior colleague as to their work practices and “stop the task”
• There was a lack of appropriate equipment to safely complete the task
• Short cuts were taken to get the task done
Chris also provided these questions for people to think about:
• Do you actively encourage people to raise safety issues with you, including issue relating to your own behavior?
• How do you (and will you) verify that people are complying? How do you know if people are complying with company policy/procedures or not complying?
His closing thoughts were:
• We must ask questions when you are unsure about the task, about how the crew will control hazards, and how we will comply with all policies and procedures
• We need to be mindful and aware at all times of potential hazards. We must never get complacent and think “…it can’t happen to me”
Here is the presentation and a Safety First work statement that Chris sent with his e-mail…
Toward the end of the PowerPoint presentation, the presenter asked this “unanswered question”:
“Why did a highly experienced, trained person who was heavily involved in the planning of the job and with all the authority to make decisions regarding the job, make a conscious decision not to comply with well established rules and procedures to undertake this job safely?”
Alright, TapRooT® Users, what do you think? How would you tackle this question in a TapRooT® investigation???
FACTS is an online diagnostic expert system to help investigators and companies readily determine if human fatigue may have been a causal factor in an accident/incident.
ABOUT CIRCADIAN®
CIRCADIAN® provides Fatigue Risk Management Systems, Shift Schedules, Software, and Training & Publications to solve the challenges of the 24/7 workforce.
FACTS is a web-based investigatory tool that helps users determine if human fatigue may have been a causal factor in an accident/incident. Developed by the world’s leading experts in sleep, fatigue, and circadian rhythms, FACTS generates results that correlate well (r = .91) with conclusions reached by experts who investigated NTSB and other industrial accidents.
Fatigue is one of the most pervasive yet under-reported causes of human error-related accidents, incidents, and injuries in both the industrial and transportation sectors.
Because fatigue is difficult to detect (i.e., no blood, urine or breathalyzer test exists to identify it) companies have a difficult time quantifying the true impact and cost of fatigue in their operations.
To bridge this gap, CIRCADIAN® created an online diagnostic expert system to help investigators and companies readily determine (by standardizing criteria and with high probability) if human fatigue may have been a causal factor in an accident/incident.
- – - END OF ANNOUNCEMENT
One additional note …
One of the developers of FACT will be at the TapRooT® Summit to share information about the technique and how to use it.
This presentation is in the Changing Behavior and Stopping Human Error track from 10:40-12 on Thursday, October 28.
Of course, major accidents have bad outcomes. Now, many CEO’s should feel less secure after the recent BP Deepwater Horizon accident outcomes.
What and I talking about? Tony Hayward is “Standing Down” and accepting retirement after his leadership was questioned (see the BBC report at http://www.bbc.co.uk/news/business-10434908).
Previous BP CEO, Lord Browne, also “stood down” after the BP Texas City accident and a lawsuit over court testimony (personal in nature and not related to his BP work).
There are heated debates in many quarters about the criminal and personal liability that CEO’s should have for accidents at their companies, these developments should make CEO’s think about the risks that their employees face and their efforts to improve safety and environmental performance.
We already know that the BP Deepwater Horizon and BP Texas City accidents were preventable. We already know how to set up a world class performance improvement program. We already know how to apply advanced root cause analysis to analyze small problems and prevent big ones.
A CEO should make sure that his/her company is applying these improvement techniques and stopping major accidents before they happen.
What if they don’t?
They risk following in the footsteps of Lord Browne and Tony Hayward.
German prosecutors are investigating the causes of a crowd control failure that lead to the deaths of 19 at the Love Parade techno music festival in Duisburg, Germany.
A Canadian Health Unit report said that a doctor’s cataracts are partly to blame for incorrect pathology reports that led to an unnecessary colostomy, two mastectomies, and at least four other cases of “serious concern.”
The story was reported by healthzone.ca. See the whole story at:
The UK RAIB’s report had three “Learning Points”:
1. Repeated occurrences of the same or closely related faults are likely to be a symptom of an underlying problem. Systems should be in place to identify repeated faults and to implement effective remedial action.
2. Maintenance requirements, particularly those applying to equipment connected with safety (such as the maintenance of gate stops (paragraph 13)), should not be left to local interpretation but should be determined by a competent person and recorded in a maintenance document.
3. It is important that signallers and crossing keepers at crossings of this type are given an unobstructed view of the gates, where it is practicable to do so.
The New York Times wrote an article titled “Workers on Doomed Rig Voiced Concern About Safety” that questioned the maintenance practices of Transocean aboard the Deepwater Horizon. Quotes from the article include:
“Some workers also voiced concerns about poor equipment reliability, ‘which they believed was as a result of drilling priorities taking precedence over planned maintenance,’ according to the survey.”
“’I’m petrified of dropping anything from heights not because I’m afraid of hurting anyone (the area is barriered off), but because I’m afraid of getting fired,’ one worker wrote.”
““The company is always using fear tactics,” another worker said. ‘All these games and your mind gets tired.‘”
“The two Transocean-commissioned reports obtained by The Times echo the findings of a maintenance audit conducted by BP in September 2009. But the Transocean-commissioned reports indicate that maintenance concerns existed just days before the explosion and the rig owner was aware of them. The 2009 BP audit found that Transocean had left 390 maintenance jobs undone, requiring more than 3,500 hours of work. The BP audit also referred to the amount of deferred work as ‘excessive.‘”
Washington DC, July 21, 2010 – A U.S. Chemical Safety Board (CSB) case study released today on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio, calls on the industry to improve safety standards covering hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous operating areas.
The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured – was less than 30 feet from the waste recycling processing area where the flammable vapor was released.
CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”
The Board issued a recommendation to the National Fire Protection Association (NFPA), which develops codes and standards for industry, urging NFPA to require companies to perform engineering analyses to determine safe separation distances between buildings occupied by administrative and other personnel not essential to process operations, and buildings housing the potentially hazardous process equipment.
The Board also revised a previous recommendation to the Environmental Technology Council, a hazardous waste industry trade group, to petition the NFPA to develop a standard specific to hazardous waste treatment, storage and disposal facilities. This would include guidance on reducing the likelihood of fires, explosions, and releases of hazardous waste.
Dr. Moure noted, “The Environmental Technology Council did not respond adequately to our 2007 recommendation, which we issued following an explosion and massive fire at the Environmental Quality hazardous waste facility in Apex, North Carolina, to work for more stringent standards in the hazardous waste industry. I strongly urge the industry to act now. These facilities, by their nature, contain wide varieties of flammable and toxic materials that can cause significant injury to workers and threaten the well being of nearby communities. Facility owners and operators need stricter technical requirements to improve the safety of life and property.”
The report notes that after a normal run of the tetrahydrafuran (THF) solvent recovery process at the Veolia facility, the unit operator began a routine shutdown. Completing the process required blowing nitrogen back through the circulation piping to clean it, prior to closing valves.
CSB lead investigator Johnnie Banks said, “At the time of the shutdown, witnesses reported hearing the sound of a sudden, loud vapor release and smelling a very strong odor of THF solvent which knocked several employees to their knees. It was a matter of just a couple of minutes until the highly flammable vapor ignited.”
The vapor drifted to the laboratory and operations building and found an ignition source inside the building. A worker in the control room reported being enveloped in a fireball that went through the building. The first explosion knocked over a bank of lockers, severely injuring an employee and pinning him underneath.
Because of the extensive fire damage, the CSB was unable to conclusively determine the exact initiating event for the vapor release, concluding one of two possible scenarios likely occurred. In the first scenario, air may have been drawn into a tank containing THF residue and peroxides, causing increased pressure in the tank and forcing flammable vapor from the tank to escape through a manway cover or a vacuum breaker.
In the second possible scenario, CSB investigators believe a line hose, intended to send pressurized nitrogen into a different tank, may have instead been connected to a tank containing unprocessed, flammable liquid. When the nitrogen was applied, it forced flammable vapor out through the tank vent. In either scenario, the vapor drifted to the operations building and ignited, causing the injuries.
In addition to issuing recommendations to NFPA and the hazardous waste industry, the Board also issued recommendations to Veolia, which is rebuilding the plant. The CSB called on the company to restrict occupancy in buildings in close proximity to the operating plant to personnel trained in the safe operation and orderly shutdown of the plant. The Board also called on the Center for Chemical Process Safety, a division of the American Institute of Chemical Engineers, to revise control room siting guidelines to address the characteristics of all Class 1B flammable liquids.
For more information, contact Public Affairs Specialist Hillary Cohen, 202-261-3601, or Sandy Gilmour, 202-261-7614, cell 202-251-5496
Every once in a while, investigators discover something unexpected. This seems to be the case in the Massy Energy Company mine explosion in West Virginia.
Early investigation guesses focussed on Massey’s history of safety violations. This new information may show that past safety violations had nothing to do with this accident.
“The FAA safety order affects 138 planes registered in the United States out of a global fleet of 314 planes. Aviation officials in other countries usually follow the FAA’s lead on safety of U.S.-manufactured planes.”
“The order only applies to 767s that have the original pylon design. Boeing changed the design after the problem first became known…. FAA issued a safety order for these planes in 2005 requiring inspections for cracks every 1,500 flights. The new order accelerates that schedule to every 400 flights or every 90 days, whichever is later.”
read more here:http://news.yahoo.com/s/ap/20100721/ap_on_bi_ge/us_boeing_safety_order
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