In this video, we can see BOTH operators fail to vent the gasoline vapors BACK into the truck. Instead, they vent them to the atmosphere at ground level. Gasoline vapors are 2X the weight of air, so they travel along the ground until they find an adequate ignition source (<1 mJ) and accumulate to their LEL (<2%).
We can see a lot of items that should be discussed in the incident investigation causal analysis.
- Civilian sitting at the unloading area and in direct line of the venting gasoline vapors (some suspect he/she was the ignition source)
- Driver on his mobile device during the unloading tasks
It is clear from watching the entire video that these workers had their vent hoses, they just failed to use them. So it would be easy for us to declare this accident is the result of an “unsafe act/behavior” and hold these two men accountable for their actions.
But how many of you believe that this was the first and only time drivers at this company have committed this act?
Do we believe this act was committed in a vacuum? These are the only two drivers in the company that perform this task in this manner.
Would it be helpful to identify WHY these two (2) men did not use the vent hoses? Maybe that is how they were trained months earlier.
Does the business have an audit process for this high-risk task (unloading a flammable liquid) that verifies this task is done per the SOP? Is there even a written SOP? Is there refresher training or a frequency in which the drivers must demonstrate they know how to perform this task properly?
We can see from the video that they did not use the hoses they were provided – but we must identify the WHY they chose not to use them and address those factors as they played a role in the decision-making of these men.