“Sh_t happens” is what I was told when I inquired about a recent training accident at a State Fire Academy. Professional firefighters were running a scenario involving an aircraft prop. What they ended up doing was spaying jet fuel/water mixture onto the fire via an emergency shutdown system and hand lines, causing two minor injuries and currently over $600,000 in damages to equipment and environmental clean up. An independent investigation has learned that the training academy uses an oil/water separator so that the water and fuel can be reused. In 2010, the worker who had operated and maintained this oil/water separator since 1997 retired. Two new workers were hired; however, the report states…
The scope of this investigation did not include what role this change in personnel may have had in the events that occurred in October of 2013 but there appears to be a loss of institutional knowledge after XXXXXXXX left as well as a change in procedures. And this leads me to the learning opportunities.
There are AMPLE learning opportunities in this incident that can be applied to just about ANY hazardous activity. From missed communications to poorly designed emergency shutdown system, we can, AND SHOULD, all learn something from these series of mistakes. Those in process safety should take SPECIAL note to how these failures can find their way into our process safety management systems…