This posting is a spin-off of information presented in the white paper from the UK’s Chartered Institute of Ergonomics and Human Factors. That paper focused on concerns with treating human factors in Bowtie’s analysis. I have modified their wording to make their valid points reflect all recognized PHA methodologies. The paper mentions eight (8) concerns…...
That would have been my headline as a safety professional with over 30 years of experience investigating serious accidents. I am always amazed at how society sees failures like organizations do. If the DOJ truly believes what they claim to have found in the 2-year investigation of the MPD, then why did they prosecute the…...
The pandemic is chocked full of LEARNING opportunities that we can translate into our effort to improve safety at our facilities. The one that screams at me the most is one of how our elected leaders (and I use that term loosely) behaved. I said back in the middle of the pandemic that we needed…...
Imagine a room of 100 adults, and I am teaching these adults basic math for the first time. I write on my whiteboard that 2+2 = 4. And I repeat this over and over. Out of these 100 adults, there will be 10% that believe me because I am the teacher, and they understand they…...
The recent release of a report regarding the catastrophic collapse of Champlain Towers South is a “storybook” of how Latent Organizational failures set the stage for an accident. And like all the bad accidents before this one, everyone from the government to the media is looking for someone or some people to blame (i.e., Active…...
PTFE-lined piping, such as the equipment installed in the HCl regeneration unit, requires a retorquing of flange bolts to minimize leakage from bolt relaxation. The retorquing involves bringing the processing unit to operating temperature, allowing it to cool to ambient temperatures, and retorquing to the set value. As the original equipment manufacturer (OEM) describes: A…...
At 1:00 p.m. on December 16, 2022, an employee monitored the start-up and operations of a high-pressure Water Tube Generator Boiler in preparation for an anticipated winter storm. A threaded plug on the boiler wall failed during the boiler’s start-up as system pressure was building, allowing the release of high-temperature and high-pressure steam. The steam…...
This happens more often than most think: At 6:30 a.m. on December 7, 2022, an employee was removing wood bark from a de-barker machine at the CHANGE OF NIGHT SHIFT WHEN A DAY SHIFT COWORKER STARTED THE DE- BARKER. The employee was crushed and killed due to internal injuries. Had the worker performing the “cleaning”…...
EPA recently issued two citations to a juice processing facility for failing to comply with the amended requirements in 40 C.F.R. § 68.93(a) & (c). On March 21, 2022, an incident at the ammonia refrigeration facility resulted in an accidental release (the “Incident “). Pursuant to Section 114 of the CAA, 42 U.S.C. § 7414,…...
Respondent has a refining process meeting the definition of “process”, as defined by 40 C.F.R. § 68.3. Methane, ethane, propane, pentane, propylene, hydrogen, butane, hydrogen sulfide, and ammonia are each a “regulated substance” pursuant to 40 C.F.R. § 68.3. The threshold quantity for methane, ethane, propane, pentane, propylene, hydrogen, butane, hydrogen · sulfide, and ammonia…...
Several organizational characteristics can feed organizational silence: Managerial illusions: managers can believe that the situation is under control simply because of the number of procedures. They can also believe that failure to follow a procedure is the only possible mechanism that can produce accidents. This discourages feedback about situations where procedures are difficult, time-consuming, or…...
It is commonly admitted that the great majority of industrial accidents are caused directly by specific unsafe acts of persons or exposure to specific mechanical or physical hazards. It is agreed that these causes and the accidents that they create interfere seriously with the quality, volume, and cost of production and are of a preventable…...
