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 »

The CSB promulgated its Accidental Release Reporting Rule to help the CSB decide when to initiate an investigation into an accidental release, including whether to deploy a team of investigators to the site to do “all things necessary and proper” to initiate an investigation and obtain critical information about the incident. Upon arriving at the site of an accidental release, CSB investigators, on...

 

This post contains a series of questions, that members of an organization might use – from the boardroom to the shop floor – to help them consider their personal contributions to safety culture. The questions are not intended to be exhaustive. We encourage operating organizations to use these questions as a basis for discussion and to consider developing them further as “prompts”...

In this post, I am using two recognized and widely used models to assess the “culture” of a facility.  To be honest, as far as I know, these two models were never intended to be used next to each other.  But the fit is amazing.  I am calling these: Path of Progress and Path of Decline If we take these two models and set them beside each other, one is a path of progress, and...

The best birthday present a process safety engineer could ask for; especially on a birthday when a client is dealing with a tragedy.  OSHA has “officially” announced the potential changes to the scope of the current PSM standard it is considering: … HomeRead More »

As my year comes to a close on the railroad, I recently has a discussion with a senior manager about ALARP, a new acronym for the RR.  The manager wanted to know more about using the Hierarchy of Controls to reduce risks; more specifically, how we would reduce the SEVERITY of the consequence of an event.  So I used the scenario of… … HomeRead More »

The process of planning and controlling work activities is implemented to maintain safety. Work management is a deliberate process in which work is identified, selected, planned, scheduled, executed, closed, and critiqued.  The entire organization is involved in and fully supports the process.   Attributes:   Work Management: The organization implements a process of planning, controlling,...

A Safety-Conscious Work Environment (SCWE) is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination. The Service Unit creates, maintains, and evaluates policies and processes that allow personnel to raise concerns freely.   Attributes: SCWE Policy: The organization effectively implements a policy that supports individuals’...