Safety Info Posts

Former Production Manager Pleads Guilty After Releasing Chemical Pollutants into the Cape Fear River (Active Failure vs Latent Organizational Failure)

/ Free, Hazardous Materials, Human Factors Engineering / / , , ,

This case is a classic example of how Latent Organizational Failures INFLUENCE the decision-making of workers (and middle managers). At the end of this press release, the DOJ admits that “Company management had informed some of its employees that if operations came to a halt, the company would suffer serious financial harm, potentially including dissolution.” […]

Stefan Kühl’s metaphor, the Safety Theater

/ Free, Safety Management System /

Inspired by Stefan Kühl’s metaphor, the Safety Theater is a stage where people in an organization play their parts. From left to right:(1) A worker in full PPE flashes a big smile for the audit,(2) A corporate safety manager holds up a script labeled “Zero Harm”,(3) Backstage, a couple of managers whisper warnings about the

Safety Thought of the Week… are worker behaviors the problem?

/ Free, Safety Thought of the Week / / , , ,

I know I made these mistakes in my early years. In the early 1990’s “Behavior Based Safety” was all the rage, and it had me “hook, line, and sinker.” Sometimes, I wish I was still in contact with some operators/maintenance tech who got the raw end of our (mostly mine) investigations and causal analysis so

CSB Update on Fatal H2S Release @ TX Refinery

/ Chemical Process Safety (PSM/RMP), Free / / , , , , , ,

Interesting facts about this event: On October 10, 2024, at 4:23 p.m., approximately 27,000 pounds of hydrogen sulfide gas were released during maintenance at the Refinery in Deer Park, Texas. The release fatally injured two (2) contract workers. Background Information The facility is a petroleum refinery located in Deer Park, Texas and is a Limited

Changing our fit-test methods requires an MOC

/ Emergency Response, Free, Respiratory Protection / / , ,

For decades, businesses have used the TSI Porta-Count QNFT method to fit test tight-fitting respirators. Today, new variations of this NIOSH-approved method (e.g., Condensation Nuclei Counter(CNC) are faster, and we have seen many organizations adopt these new methods. However, changing our Fit-Testing method may require an MOC. I say “may” as not all PSM processes

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