Overfill of vapor recovery units (UK's HSE Alert)
A Health and Safety Executive (HSE) investigation into a gasoline overfill of a carbon adsorption vapor recovery unit (VRU) revealed concerns with the VRU's design. The overfill prevention system was NOT INDEPENDENT of the basic process control system (BPCS). When the BPCS failed, the overfill prevention system also failed. This resulted in loss of containment, and risked a significant fire and explosion, as well as extensive environmental damage. Membership Content
If we feel the need to discipline for a behavior, remember this…
We discipline for the behavior - NOT for the result/outcome of that behavior. This is never more true in safety-related events. When we discipline a worker for an injury for not wearing their PPE. We just set the standard for NOT WEARING PPE! So the next time a worker fails to wear their prescribed PPE, regardless of whether they were injured, the discipline is the same for the worker who was injured. Do we want to set a standard of discipline in the journey to safety excellence? Accountability is a necessary element in establishing a culture of safety; however, too much emphasis on holding those closest to the risk more accountable for their ACTIVE FAILURES than those farther away from the risks and their LATENT ORGANIZATIONAL FAILURES is no way to build trust and credibility in the safety efforts. For example: Helping others understand RISKS may be our biggest obstacle
I believe the most significant challenge we (safety professionals) face is those outside (and even some inside) our profession and their lack of understanding of RISKS. I am confident that any safety pro reading this has endured the old and tired argument... "We have been doing ________ that way for __________ years, and it has not hurt anyone, but now you want us to do ____________?!?!?" Recently, while participating in a serious accident investigation, there was an honest discussion of how the LOTO program and all the effort to implement it caused the accident. Yep, several members of senior management and front-line supervision pointed out that since the facility had implemented its LOTO practice, there had been several injuries and none before the LOTO program. They were serious, albeit somewhat ignorantly, blaming the LOTO program and the effort to implement it for the serious accident in which the 2-year-old LOTO program was NOT followed and cost a worker their arm. Sadly, I was not shocked as I had heard this argument many times over my career. In fact, in this accident, several witnesses were part of the LOTO discussion, and the supervisor decided that LOTO was not necessary for the task that would be performed. He stated this task would fall under "minor servicing," which had become a cancer within the LOTO practice at this facility. Essentially, if the LOTO would take too long or have too large of an impact on production, it was sidestepped under the guise of "minor servicing" even though the written program and training clearly DEFINED AND QUANTIFIED "minor servicing" and provided the framework to assess the task(s) as "minor servicing" and prescribed the additional/alternative safeguarding that would be required for the "minor servicing" tasks. None of these were being followed by management. Minor Servicing had become the rule, and LOTO had become the exception! This is still happening at far too many facilities in 2024. OSHA cited the company for 2 willful and 24 serious PRCS violations (1 H2S death & $171,680)
Federal investigators determined a truck washing company failed to protect workers from hydrogen sulfide gas as they entered over-the-road tanker trailers to clean them out, causing one worker’s fatal injuries and hospitalizing two co-workers. OSHA responded to a report of the Sept. 1, 2023, incident and found the business failed to evaluate the tanker trailers for hazardous conditions – including testing the atmosphere – and did not train workers on potential hazards before letting them enter the confined spaces, both violations of OSHA regulations. Inspectors found multiple violations of OSHA’s confined space regulations. They noted the employer lacked both respiratory and hearing protection programs and exposed workers to fall hazards of up to nine feet while cleaning the trailers. Line Break gone bad (Flare and Knock-Out Drum)
A boiler maker, 36, suffered fatal burns after an explosion occurred at a refinery. A contractor employed the victim and two injured co-workers at the facility. The three employees were hospitalized as a result of the explosion. The victim died four days later from burns over approximately 90% of his body. The events occurred in the area of the South Flare and Knock-Out Drum (KO Drum). A 36-inch pipe delivers hydrocarbons from the refinery production area and collects them in the KO Drum. Another 36-inch pipe exits the top of the KO Drum and delivers vapors to be burned at the South Flare to relieve pressure from the production area. The process leading up to the fatality began when, during a turnaround (shut down for maintenance), an environmental project was begun to capture flare gas and re-use it as fuel or feedstock rather than burn the gas in the flare. The 36-inch pipe between the KO Drum and the South Flare would be altered by installing a bypass allowing the South Flare to remain in service while work was performed at the KO Drum and the Flare Gas Recovery System. To begin the recovery project, the KO Drum and Flare Gas Recovery System had to be isolated from the South Flare and piping to the flare. Three contractor employees climbed onto the catwalk above the South Flare KO Drum at the 36-inch diameter outlet pipe. Their job was to open the pipe flange, insert a pipe blind, and close the flange. Safety Thought of the Week - dismissal of people and their behavior concerning risk as idiotic
The dismissal of people and their behavior concerning risk as idiotic really doesn’t help much How good is your HAZCOM program management?
I will use one of the last tests when a facility has hit home runs in managing its Hazardous Communications program. They are great with their container labeling, pipe labeling, training, etc. They even could provide an SDS for all their significant chemicals; however, only a tiny percentage of these facilities can do this... NTSB Animation – Overview of the collapse of the Fern Hollow Bridge
On Friday, January 28, 2022, at about 6:37 a.m. eastern standard time, the Fern Hollow Bridge, which carried Forbes Avenue over the north side of Frick Park in Pittsburgh, Allegheny County, Pennsylvania, experienced a structural failure. As a result, the 447-foot-long bridge fell about 100 feet into the park below. The collapse began when the transverse tie plate on the southwest bridge leg failed due to extensive corrosion and section loss. The corrosion and section loss resulted from clogged drains that caused water to run down bridge legs and accumulate along with debris at the bottom of the legs, which prevented the development of a protective rust layer or patina. Although repeated maintenance and repair recommendations were documented in many inspection reports, the City of Pittsburgh failed to act on them, leading to the deterioration of the fracture-critical transverse tie plate and the structural failure of the bridge. At the time of the collapse, a 2013 New Flyer articulated transit bus, operated by the Port Authority of Allegheny County, and four passenger vehicles were on the bridge. A fifth passenger vehicle drove off the east bridge abutment after the collapse began and came to rest on its roof on the ground below. As a result of the collapse, the bus driver sustained minor injuries and two bus occupants were uninjured. Of the six passenger vehicle occupants, two sustained serious injuries, one sustained a minor injury, two were uninjured, and the injury status of one was unknown.
Are we interior decorators or safety professionals?
This one is bound to offend some folks in the safety profession, but it was some very wise advice a dear friend and former boss gave me after I submitted my first Corrective Action Plan (CAP) to him after a corporate audit. Just 12 years into my career, I was taught the hard way how CAPs get written and managed to closure. But his analogy of what he expected of me stuck with me to this day. Our one-on-one discussion went something like this... NOTE: This former boss is one of my best friends today and was a client for 20 years after we parted ways in 2003; he is a former CSP and began his career as a safety engineer inside the company where we met) Bryan, do you want to be a world-class safety engineer, or did you miss your calling as an interior decorator? Management's Safety Dilemma (Reason's "Safety Space")
A mature Safety Management System (SMS) will contain a Hazard Identification Element that identifies hazards that adversely affect safety. These HAZARD ID processes also provide practical and objective mechanisms to assess the risk presented by those identified hazards and implement ways to eliminate or mitigate the associated risks those hazards may pose to the worker, environment, and business. The result of this SMS Element is achieving an acceptable level of safety while balancing the allocation of resources between production and protection. From a resource allocation perspective, the concept of a "safety space" is instrumental in describing how this balance is achieved. What is the "Safety Space?" HAZMAT Response - TX Style (Safety Satire Video)
The source is unknown, but this is hilarious. The supporting actor gets my vote for an Oscar. |
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