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PRCS Fatality (O2 Defecient Atm - three attempt rescue)
An Oklahoma City employer’s failure to follow federal safety procedures left a 30-year-old worker suffering fatal asphyxiation as they tried to make repairs inside a water tank at a McClain County well site in September 2023. Responding to the report of a fatality in Purcell, OSHA investigators determined the worker had entered a permit-required confined space to fix a leaking bulkhead valve in a production tank and then lost consciousness. Two co-workers entered the tank in a failed rescue attempt and suffered effects from exposure to low atmospheric conditions—neither sustained injuries. OSHA investigators found that the employer failed to evaluate the tank for hazardous conditions – including testing the atmosphere – and did not use protective systems to prevent worker injuries, violating federal regulations. Further investigation determined the remaining water in the tank contained compounds — including ethyl benzene, xylene, trimethylbenzene, isobutane, and other cyclic aliphatic compounds — and atmospheric readings inside showed low oxygen content, volatile organic compounds, and carbon dioxide, all of which can lead to asphyxiation. OSHA issued 16 serious citations. Of these citations, 13 are related to failures that contributed to the worker’s death, including the following:
Membership Content
PRCS fatality due to LOTO failures (Concrete Mixer(s))
We hear it often... "Who would turn the machine on while I'm working on it?" It happens more often than most think.
Employee # 1 and Coworker #1, Coworker #2, and Coworker #3 were cleaning two (2) concrete mixers. Employee #1 was paired with Coworker #1 to clean out a mixer. Employee #1 entered Mixer #1 and began chipping out the concrete build-up while Coworker #1 removed debris from the outside of the machine. Coworker #2 and Coworker #3 were cleaning out Mixer #2 using the same process. Employee #1 had exited Mixer #1 and was leaning over the opening to retrieve a power tool when Coworker#2 exited the mixer and asked Coworker #3 to bump the blades of Mixer #2 to remove inaccessible concrete. Coworker #3 activated Mixer #1 instead of Mixer #2, and Employee #1 was caught between the rotating blades and the machine's body. Employee #1 was pulled into the machine and was killed due to a near decapitation to the back of the skull and neck, a jaw fracture, and fractures to the left elbow. OSHA abatement plans are about making OSHA happy, but do little to improve overall safety
A former client had an amputation accident, and an OSHA inspection followed, with several citations following that. We were hired to help the company digest all that OSHA found wrong, and there was plenty that OSHA found, but there was even more that OSHA did not see or address with its inspection or citations. The client wanted help with the "abatement plans" to close out the OSHA citations and "put this behind us." Still, they had no interest in understanding what needed to be done outside the "abatement plan" to help reduce the likelihood this same accident would happen again. This happens quite often, and it's a serious problem when we play the "compliance game." OSHA assesses the business's "compliance," usually around particular circumstances. This assessment is based solely on compliance with OSHA's MINIMUM standards. They issue citations, and the company has to "abate" those issues. However, those citations usually do not address the "ROOT CAUSE(S)" of those issues. The facility was cited for: How well does management know the "barriers/controls/safeguards"?
When meeting with executive teams, I like to conduct an exercise to gauge the leadership team's level of knowledge and direct involvement in the safety and health of their employees. Before getting deep into the organization's specific barriers/controls/safeguards regarding their top 3 risks (which the team picks), I ask the team to take 10 minutes and identify the barriers/controls/safeguards in today's vehicles and to place them into the three (3) Layers of Safety. They do this as a single team. It is a fun exercise for any group of employees, and it brings to light the stark difference in the role of a barrier/control/safeguard. Some are intended to PREVENT the accident; some are designed to PROTECT the occupants from the consequences of the accident; and some (not necessarily on the vehicle, so this is a trick question) are intended to MITIGATE the event's severity. Who is the idiot?
We see these silly stickers occasionally in our work with clients. Although they are not official company positions, I am curious as to why they aren't removed from company machinery and equipment. Could this be because management/supervisors believe this to be an accurate statement/belief? But let's talk about the message these silly stickers really convey and to do so, I ask the question: Who is the idiot? The worker asked to operate the piece of machinery/equipment or the Management that hired them to operate the piece of machinery/equipment?
The seven C's
The seven C's of being all we can be as safety professionals.
Compassionate
Confident
Collaborative
Contemplative
Civil
Curious, and
Courageous
Let us remember WHY we became safety professionals AND, more importantly, putting those we have the privilege to protect # 1 in our efforts.
Source: 7 C's of Compassionate Leaders (Forbes)
Does staffing impact the culture of safety?
I have grown up in safety and emergency response and found that the tools used in both aspects can cross over to the other. For example, I use the National Incident Management System (NIMS) Incident Command on accident investigations to bring structure to the team. In that IC we have a "span of control" of no more than seven (7) people reporting to any one person. This lets people properly manage their team members in a high-stress working environment. And it works. So when we visit a facility/business and see front-line supervision-to-employee ratios of 30:1, we can almost predict what we will find in terms of culture. And this has a dire impact on safety performance and the culture of safety. Looking back to some of the more extreme cases we have encountered, we also remember the "over-the-top" effort by management with their safety banners, safety parties, etc., to overcome their cultural problems. Let's be transparent (and honest): RELATIONSHIPS are a huge part of safety. I have been talking about TRUST and CREDIBILITY in the safety effort as a crucial part of turning around both safety performance numbers and the culture around safety. Both of these are highly dependent on RELATIONSHIPS. Now, I am not talking about supervisors becoming everyone's best friend - it is a tough job, but being fair, honest, and approachable are traits a supervisor MUST have. However, even a great supervisor with these traits can not properly manage 20-30 people AND allow them to build relationships with their team. In a recent project, we interviewed 12 department supervisors, each with over 20 years of experience as a supervisor at the facility. A very stable and dedicated group of professionals. The company had invested in the folks; several had gone on to get degrees in business (paid for by the company), and all had undergone some excellent "supervisor" training throughout their careers. But when asked to name their employees, they could only name 25-30%, and you can probably guess which 25-30% they could name: the great ones and the problem ones. This was also, across the board, the most significant frustration they had. EPA issues RMP citations @ cheese manufacturing plant (NH3, Line Break Accident, & $38K)
This is an unusual case in that it involved a 20-pound release of NH3 during a "line break" on a refrigeration system. There was only a single citation and it came at a price of $38,500. The employee was injured. I have been unable to locate an OSHA investigation regarding this incident, which occurred in TX. This case is also interesting in that the company agreed to implement:
Respondent is the owner and operator of a cheese manufacturing plant. On March 16, 2023, there was an incident at the Facility that resulted in the accidental release of 22 pounds of anhydrous ammonia and the injury of one (1) employee (the “Incident”). On January 11, 2024, the EPA requested documentation and information concerning the Incident and Respondent’s compliance with Section 112(r) of the CAA and 40 C.F.R. Part 68 (the “Investigation”). The process includes fluid milk unloading, cheese manufacturing, cheese packaging and storage, liquid whey processing, whey powder packaging, storage, and shipping. Processing aid substances handled and stored onsite consist of ammonia and sanitation chemicals. The Respondent’s processes meet the definition of “process” and “covered process”, as defined by 40 C.F.R. § 68.3. The Respondent’s RMP Program Level 3 covered process stores or otherwise uses a regulated substance in an amount exceeding the applicable threshold. Anhydrous ammonia is a “regulated substance” pursuant to Section 112(r)(2)(B) of the CAA, and the regulation at 40 C.F.R. § 68.3. The threshold quantity for anhydrous ammonia is 10,000 pounds, as listed in 40 C.F.R. § 68.130. Respondent has greater than a threshold quantity of anhydrous ammonia in a process at the Facility, meeting the definition of “covered process” defined by 40 C.F.R. § 68.3. EPA Findings of Violation A DECON practice challenge
I have been involved with emergency response for over 30 years. During those years, I trained thousands of municipal and private responders, specializing in traditional Hazardous Materials Responses. During all those years, when I received continuing training from the likes of Texas A&M, LSU, NFA, and SERTC, these advanced courses only validated my first HAZWOPER course at Murray State University in 1991. Today, I got my first question, which I could not answer! So, I am turning to the ER and Safety community to see who can provide the "source" of this DECON practice... Inerting a flammable atm is more of a science than art
Not all "simple asphyxiants" are created equal; thus, not all make for good purging or blanketing. Would you believe me if I told you that one very common simple asphyxiant gas should NEVER be used for purging or blanketing flammable atmospheres? Many folks view Nitrogen (N2) and Carbon Dioxide (CO2) as very similar. This is based on how we, as humans, respond to both of these gases. CO2 has been getting a lot of attention lately due to its increasing use in the food and beverage retail industry and industrial refrigeration. It has some great qualities for its intended uses, but it comes with a significantly increased risk to workers who normally do not work around hazardous chemicals. |
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