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A broken valve handle leads to a class B misdemeanor criminal charge
A Delaware corporation with a manufacturing facility in Ohio pleaded guilty in federal court in the Southern District of Ohio to a charge of willfully violating an Occupational Safety and Health Administration (OSHA) rule. The criminal charge is related to an incident where an employee was killed when a pneumatic door closed on his head. The company operates several facilities in the United States,...
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Former Production Manager Pleads Guilty After Releasing Chemical Pollutants into the Cape Fear River (Active Failure vs Latent Organizational Failure)
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.” Also, the DOJ pointed out that...
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Stefan Kühls metaphor_the Safety Theater
Stefan Kühl’s metaphor, the Safety Theater
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 financial bottom line,(4) Meanwhile, someone diligently sweeps...
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Traffic_signal_confusion
Human Factors (error trap) pic of the month
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Safety Thought of the Week... are worker behaviors the problem?
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 I could apologize for my mistakes. It was not until I attended my...
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Wrong Chemical - Wrong Tank (Cl2)
A total of seven people were taken to the hospital after a chlorine gas leak was reported. The cause of the leak was a truck driver who delivered a chemical to a Water Plant and “unintentionally mixed two chemical compounds in a holding tank.” This then released the chlorine gas “from the tank vent.” The chemical reaction released chlorine gas from the tank vent, which drifted with the south wind into...
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csb1
CSB Update on Fatal H2S Release @ TX Refinery
Interesting facts about this event: Safe Work/Line Break Permitting Energy Isolation Verification Emergency Escape Respirators Hydrogen Sulfide Detection (Personal and Area) Contractors 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...
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Figure 1 - Hazardous zone on air castle deck above pilothouse
IMPORTANCE OF HAZARDOUS ZONE MARKINGS AND SAFETY PROTOCOL AWARENESS (USCG)
This United States Coast Guard alert supports my expectation that we must demarcate our HAZLOCs. I usually get pushback as the code does not explicitly require the boundaries of our HAZLOCs to be marked in any way. But in reality, if we want workers to respect the hazards of working inside a HAZLOC, then we need to help them know when they have entered these areas. This alert from the U.S. Coast Guard...
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IMPORTANCE OF ADHERING TO HOT WORK PROCEDURES & IMPLEMENTING ROBUST LOCKOUT/TAGOUT PROGRAMS (USCG)
A recent marine casualty, resulting in a fire and severe injuries to two crewmembers, highlights the risks associated with: Liquified Natural Gas (LNG), Performing hot work in hazardous zones, and the necessity of maintaining a robust lockout/tagout program … HomeRead More »
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Changing our fit-test methods requires an MOC
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 may have a Respiratory...
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Respirator Fit-Testing Facts (NIOSH)
NIOSH research tells us: 10% of subjects failed a fit test after 1 year using the same make, model, and size respirator. Those who have lost more than 20 lbs should prioritize getting fit tested again immediately. Other facial changes requiring fit testing include significant weight gain, extensive dental work, scarring, or cosmetic surgery. Source: https://www.cdc.gov/niosh/npptl/pdfs/Fit-test-10...
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Does changing a chemical supplier require an MOC
Imagine the purchasing manager announcing at a staff meeting that the business is changing the supplier for one of your PSM/RMP-covered chemicals. There is nothing special about this chemical; it is a 100% pure solution/gas, so you think nothing is changing. But this chemical has come under a lot of questions by yours truly, and in fact, a simple change in vendor will impact the Process Safety Information...
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