Safety Thought of the Week... A Safety Partnership
A safety partnership is defined as: Leadership, managers, and front-line associates jointly focus on safety and proactively work together in a business entity to minimize the possibility of harm and maximize safety performance. (Cooper, 2016) Creating a genuine safety partnership means management and the workforce jointly working towards achieving common and understood safety goals, with clear and consistent communication, efficient monitoring, reporting, and decisive action to investigate blockages and take the appropriate corrective action as needed. The key drivers for developing and maintaining a safety partnership are straightforward and involve: Read more ...
2018 Bologna Italy LPG Tanker BLEVE
On August 6, 2018, at 1:35 pm, an event occurred at Km 4+300 of the road connection between Motorway A1 and Motorway A14 near Bologna (see picture 1 in Annex 1). The section of the road flows over an elevated structure above the urban road network below. Among the vehicles involved in the accidents, there were two ADR vehicles. A tractor with a semitrailer with an LPG class 2 tank that was traveling in the direction north, for reasons to be clarified, violently hit the column of vehicles stationary in the right lane. The driver of the LPG tank vehicle died immediately due to the impact (see picture 2 in Annex 1). The last vehicle in the row was a vehicle carrying paint solvents - class 3 flammable liquids – which leaked onto the road due to the impact and immediately caught fire (0.5 sec). The fire engulfed the LPG tank quickly, initially only the front and then totally. The flames continued to burn the LPG tank, and about 7 minutes a BLEVE occurred. (see pictures 3,4 in Annex 1). Because of the energy released and the overpressure and heat generated, the road infrastructure collapsed, and the neighboring structures/buildings were strongly affected (see pictures 5, 6, and 7 in Annex 1). In the end, one person died (the driver of the tank vehicle), and 95 persons were injured (all were admitted to the hospitals near the area). Among the injured persons, some police officers and emergency teams rushed to the accident area. Their timely intervention allowed for clearing the area before the explosion, thus reducing damages and saving all the other people present near the scene of the accident. CLICK HERE for the UN Report Most LOTO failures are Latent Organizational Failures - NOT Active Failures
This picture has caused quite the debate in the SAFTENG circle! Many comments in the SAFTENG LI and FB groups point towards the worker(s), which indicates the belief that this is an "Active Failure" of the worker(s) involved. Many of you would NOT believe the tales I could tell about what I have encountered in my travels in 20+ years of consulting. In the vast majority of these situations, where the failure is hard to believe, it is a Latent Organizational Failure that sets the stage for such silliness. The debate we should be having is… Scenario: The sign moves or falls off and exposes the START button, and I come along and push the button, killing/maiming the workers. Am I a killer? Did I violate any procedure/program/training?
Who is “responsible” for this failure? Who is “accountable” for this failure? If this set-up was discovered before or after an accident, what questions would you ask in the investigation and causal analysis? Does the facility have the ability to recognize this failure? Non-Entry rescue mechanical device
OSHA states the following about our non-entry rescue devices... The mechanical device used for emergency rescue must be designed and rated for human use. The standard specifies in paragraph 1910.146(k)(3)(ii) that the retrieval equipment must be designed for personnel. The performance-oriented nature of the standard allows flexibility as to the design specifications of the retrieval equipment itself. OSHA accepts certification by manufacturers as well as listing (as being tested) by Nationally Recognized Testing Laboratory (NRTL). An employer may design, manufacture, test, and certify (for example by a registered professional engineer) mechanical devices used for retrieval of personnel from a vertical space. NASA's Dirty Dozen
The Dirty Dozen highlights the most frequently observed human-related issues discovered during Fiscal Year 2022 agency mishaps and close-call investigations. Throughout the year, these issues contributed to $3,310,298.74 in damage costs and 630 workdays of lost time. NASA's Human Factors Analysis and Classifications System (HFACS)
In Reason’s Swiss Cheese model, there are four “slices "or tiers of human error potential, divided into two sections: an “active” layer and “Latent Factors”: preconditions, Supervision, and Organization. The goal of the Human Factors Analysis and Classification System (HFACS) is to understand human factors throughout the system rather than stopping at the operator. Most mishaps can be connected to human events at NASA, from 2010-2015, human events and conditions totaled 79% of causal factors identified in its mishaps and close calls. Consequently, NASA now requires the participation of a Human Factors Investigator in Type A & B mishaps and High Visibility Close Calls. These are Influences or Factors closely tied to the mishap and described as actions or inactions that result in a mishap. There are four (4) areas in this active layer, and these are: CSB's Accidental Release Reporting (40 CFR 1604)
This is a reminder that if your ERP or Environmental Management System (EMS) has not been updated to reflect these "NEWER" CSB reporting requirements, the facility should consider updating these programs/processes and including the reporting requirements in EHS training. Also, line 9.8 of your RMP should list 40 CFR 1604 - Accidental Release Reporting. The U.S. Chemical Safety and Hazard Investigation Board (CSB) has launched investigations into toxic chemical releases at two facilities in Louisiana during 2023: the release of hydrogen fluoride (HF) and chlorine at a facility in Geismar, LA, in January 2023 and the release of ethylene oxide (EtO) at the a facility in Plaquemine, LA in July 2023. Both incidents were reported to the CSB in accordance with the agency’s Accidental Release Reporting Rule (40 CFR Part 1604). Changes to Chlorine - 2024 ERG Table 3
This is just an FYI to my Cl2 clients. Although the changes are NOT significant (0.1 - 0.3 miles), they are indeed changes to the Downwind Protective Action Distances. If you have used the 2020 ERG Distances in your Pre-Plans, which you or I did for your Emergency Response Plan (ERP), it may be beneficial to update them. REDUCED distances are highlighted Changes to Anhydrous Ammonia - 2024 ERG Table 3
This is just an FYI to my NH3 clients. Although the changes are NOT significant (0.1 - 0.2 miles), they are indeed changes to the Downwind Protective Action Distances. If you have used the 2020 ERG Distances in your Pre-Plans that you or I did for your Emergency Response Plan (ERP), it may be beneficial to update these pre-plans/ERP. REDUCED distances are highlighted 2024 ERG - CONSIDERATIONS FOR LITHIUM BATTERY AND ELECTRIC VEHICLE (EV) FIRES FIRE CONTROL
One of the many changes to the 2024 ERG, includes considerations for lithium battery and electric vehicle (EV) fires fire control. NOTE: the print editions are NOT yet available, but we can download the app (CLICK HERE) Water spray cools batteries and helps suppress and slow the release of toxic gases but does not stop the chemical reaction (thermal runaway). Other extinguishing agents (CO2, dry chemical, etc.) can trap heat instead of removing it and could result in false (lower temperature) readings. During an electric vehicle (EV) fire, consult the manufacturer's specific emergency response guide for help with identifying high voltage and medium voltage cabling. DO NOT CUT THESE CABLES. EPA RMP citations @ refrigerated distribution center and warehouse (NH3 & $161K)
The Respondent formerly operated an ammonia refrigeration process at a distribution center and warehouse, which maintained a maximum inventory of the regulated toxic substance anhydrous ammonia at the Facility, which exceeds the threshold quantity of 10,000 pounds of anhydrous ammonia as set forth in Table 1 at 40 C.F.R. § 68.130 and, therefore, has had a regulated substance present in more than a threshold quantity as determined under § 68.115, since at least 1999. At the Facility, the respondent operated a process, as defined in 40 C.F.R. § 68.3, that includes the use, storage, handling, and on-site movement of anhydrous ammonia, a regulated substance. The Covered Process at the Facility consists of seven compressors, three storage vessels, one high-pressure storage vessel, three condensers, 27 ammonia detection sensors, piping, and 100 evaporators (Covered Process). The Facility is subject to Program 3 because the Covered Process does not meet the Program 1 eligibility requirements at 40 C.F.R. § 68.10(g), and it is subject to the OSHA process safety management standard, 29 C.F.R. § 1910.119, in accordance with 40 C.F.R. § 68.10(i). On September 16, 2021, EPA conducted an announced inspection of the Facility. Prior to and during the September 2021 inspection, one business owned and the respondent operated the ammonia refrigeration system at the Facility. After the September 2021 inspection, the owner took over operations. During the September 2021 inspection, EPA inspectors reviewed documents relating to the RMP that the operator provided (RMP Documents). The RMP Documents included aspects of the Facility’s RMP involving the management system, process safety information, process hazard analysis, operating procedures, training, mechanical integrity, management of change, pre-startup safety review, compliance audits, hot work permits, employee participation, and contractors. |
Partner Organizations
I am proud to announce that The Chlorine Institute and SAFTENG have extended our"Partners in Safety" agreement for another year (2024) CI Members, send me an e-mail to request your FREE SAFTENG membership
Member Associations
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