January 15, 2009 | Dave Janney

Equipment Failures, Making Things Worse after an Accident, and Corrective Actions

Here is a report about 85 gallons of radioactive waste that was spilled at a DOE site in Washington:


Here are some excerpts:

“The Documented Safety Analysis for Tank Farms provides technical safety requirements that, if properly implemented, would preclude an overpressure situation in the dilution line.”

“Of particular concern is the failure of tank farm management to properly consider the potential for chemical vapor exposure in the initial response to the accident or in the initial medical actions.  The potential chemical vapor exposures were not adequately addressed until site management received reports of symptoms among workers following the accident management.”

This is an interesting read, and there are multiple things that should have been done better.  However, just a few comments:

How often do we consider equipment failures just that and not dig deeper to find that human performance problems actually were the reason the equipment failed?  In this case, it was a very serious event, and I’m glad they got to the bottom of it; however, what if a plant does not have a serious event but a series of smaller incidents such as downtime for repairs?  These types of events disrupt the business and over time can cost millions of dollars in repairs, wasted time, and lost production.  Our Equifactor® module in TapRooT® can help you troubleshoot equipment issues so you can find the root causes of equipment failures and the underlying human performance issues that caused them.  For more information on Equifactor®, see http://www.taproot.com/courses.php?d=3

Next comment – in this case, the initial response to the incident left employees in harms way.  They did have an Emergency Response Plan; however, the plan was in need of improvement.  Again, an organization such as the DOE with a site this hazardous has to have a plan; however, how many worksites in general industry do not have a robust plan for responding to emergencies?  The time to develop a plan is not during an event!

Last point – I know this is a long report to read but I want to call your attention to the matrix on page 19 that shows corrective actions from a previous NOV (Notice of Violation) were not addressed. Would you say this is common?  Whether it is a regulatory response, an audit finding, or an investigation corrective action, my opinion is this is where we many times drop the ball.  If you want a problem fixed, follow-up has to happen, or all of the work done prior to that is for naught.  The corrective action techniques learned in a TapRooT® course include the requirements for verification (was it completed) and validation (did it work as intended).  To learn more, attend a course today – here is the schedule:


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