Investigations of accidents in a number of hazardous domains suggest that a cluster of organizational pathologies—the “vulnerable system syndrome” (VSS)—render some systems more liable to adverse events. This syndrome has three (3) interacting and self-perpetuating elements: Blaming front-line individuals, Denying the existence of systemic error provoking weaknesses and Blinkered pursuit...

productThis week I have been helping a client/friend understand what a true non-entry rescue system looks like and how it functions.  Back in July 2011, I wrote an article titled “CS Rescue… Tripods and Winches and a false sense of security” to help facilities understand the vast limitations of the traditional tripod and winch setup.  Namely, that setup works ONLY when you...

The respondent operates a water chlorination process. On July 27, 2021, EPA conducted an announced inspection of the Facility. The Facility maintains a maximum inventory of 14,000 pounds of chlorine, a regulated substance, as a liquified compressed gas in 1-ton cylinders. Here are the findings from the inspection: … HomeRead More »

I found another ppt from years ago, dusted it off, and updated it for a client.  This is based on many of the HOP/HPI/Resiliency talks we hear these days.  But know this, without trust, NOTHING will work in our effort to improve the worker’s safety.  My favorite saying on trust is from Dr. Clive Lloyd: “Unless the mistrust of the workforce can be overcome, then even the most...

After the month I have witnessed, this image came to me this weekend as I reflected on the state of safety in the USA.  I have mentioned before, has the compliance model done more harm than good?  I mean, OSHA has made a huge impact on workplace safety. Still, once a business achieves “compliance” (and very few achieve total compliance), we see a significant pushback regarding...

  Light hydrocarbon was released through a pinhole breach of an insulated process pipe.  A plant operator detected an abnormal hydrocarbon odor and immediately responded as per site emergency protocol. A localized possible breach was identified, and the processing unit was safely shut down for further investigation. A 3-inch insulated pipe connecting process piping to a pressure safety...

If you have not yet read Clive Lloyd’s “Compliance to Care”, it is a must-read.  Here are my five (5) favorite points he makes: … HomeRead More »

I enjoy the engineering side of safety more than the cultural piece, but both play a critical role in achieving world-class performance.  After spending 18 years consulting and do more technical consulting than cultural, it has been fun working with a single client on culture this year.  It allowed me to dust off a lot of materials.  This is an oldie but goodie… it is from 2008...

The systems approach provides a framework for the analysis of errors and efforts to improve safety. Many specific techniques can be used to analyze errors, including retrospective methods such as root cause analysis and prospective methods such as failure modes effect analysis. Failure modes effect analysis (FMEA) attempts to prospectively identify error-prone situations, or failure modes, within specific...

Respondent operates a food manufacturing process involving ammonia refrigeration with more than 10,000 pounds of anhydrous ammonia on site.  Respondent has an RMProgram level 3 covered process, which stores or otherwise uses anhydrous ammonia in an amount exceeding its applicable threshold of 10,000 pounds.  On February 27, 2020, the EPA conducted an on-site inspection of the RMProgram related...

At 9:45 a.m. on February 22, 2021, an employee was working for a general, long-distance freight trucking company. He washed vehicles and cleaned equipment for the company. He was cleaning a tanker trailer that had contained ALFOL 16 (tradename for 1-Hexadecanol). The employer stated that the employee was inspecting the tank for materials. The atmosphere in the tanker had been charged with nitrogen....

At 5:00 p.m. on January 30, 2022, an employee was loosening powdered limestone from inside silo #7 with a weight. The employee entered the silo to recover the tool being used. The employee walked on top of the powdered limestone inside the silo (confined space) and was engulfed in the material and was killed as he sank into the material. … HomeRead More »