A point has been reached in the development of technology where the greatest dangers stem not so much from the breakdown of a major component or from isolated operator errors, as from the insidious accumulation of delayed-action human failures occurring primarily within the organizational and managerial sectors. These residual problems do not belong exclusively to either the machine or the human domains....

On October 17, 2007, a wiring employee came to a press brake to get more pieces from Employee #1, a press operator. Employee #1 turned and put down a piece, collapsed to the floor, and experienced convulsions. The wiring employee panicked and asked the laser operator for help. The laser operator cleared the area. As he stood from the kneeled position, he also became lightheaded and lost consciousness...

On February 7, 2017, an employee, 50, was making preparations to replace the relief valve of a 1,000-gallon ammonia (NH3) tank. The incident investigation reported that the tank was empty of liquid NH3. However, it contained approximately 80 psi of vapor pressure. The employee set up a 30-gallon drum that contained water and affixed it to the nurse tank by way of a hose. He then turned the relief valve...

At 8:30 a.m. on May 24, 2018, Employee #1, 45, set up a booth representing the control laboratory for a safety day event at the plant, which involved approximately 1,000 employees, visitors, and vendors. Employee #1 wanted a fog effect at the booth to attract visitors. Employee #1 made plans to have coworker #1 get dry ice for the effect. When coworker #1 could not get dry ice, coworker #1 asked coworker...

I talk a lot about “safe locations” when we discuss Pressure Relief Device (PRD) discharge. The phrase “safe location” is used in just about every PRD RAGAGEP; however, none of them DEFINE or QUANTIFY the phrase, leaving it open to some poor designs. Here is a case where two workers were doing work 30′ under a Rupture Disc discharge. On January 15, 2022, Employee #1 and...

We have discussed this many times: far too many employees fail to recognize the proper application of “pounds per square inch” (PSI). In my LOTO training, I spend 15 minutes explaining that even 1.0 PSI can be lethal. This case was brought about by poor planning and a LOTO failure, but it shows that even low PSI can be lethal. On March 25, 2003, two employees were instructed to remove a...

On July 14, 2009, Employees #1 and #2 were performing a pneumatic test to verify leak tightness of a new pipeline meter station. The test medium was nitrogen gas, and the system being tested included piping and two (2) pressure vessels. Numerous leaks were found in the system during the test. The system reached the required test pressure of 2225 psig at approximately 3:25 p.m., and Employee #1 observed...

At 3:00 a.m. on February 19, 2020, Employee #1, 30, was using a torch to “dry” his shirt after spilling isopropanol on it. The employee’s shirt caught on fire, and the employee picked up the shirt in an attempt to extinguish the flames. The employee started to spin the shirt in his left hand and, in the process, caught the back of his pants on fire. The employee was doing this action...

On July 23, 2020, an employee, 30, was looking into a vessel being filled with chemicals, including Isopropyl alcohol, to ensure the level of the mixture was above the blades before turning on the mixers. The access port was mounted with one bolt so the employee could rotate the cover to look in. The employee turned on a small flashlight and was looking into the access port when a chemical explosion...

On July 12, 2024, an employee, 74, at a campground resort was attempting to add sodium hypochlorite to a bulk supply container to recharge the swimming pool. The employee added sodium hypochlorite to a container of sulfuric acid and was overcome by the vapors generated by the mixture. The employee was killed due to the inhalation of chlorine gas vapor generated by the mixture. … HomeRead More...

On July 13, 2024, Employee #1, 41, entered a manhole to tape piping in preparation for pouring concrete inverts. Shortly after entry, a coworker stationed topside observed that Employee #1 appeared pale and profusely sweating. When asked, Employee #1 indicated difficulty breathing. As Employee #1 attempted to climb the steps to exit the manhole, he experienced a medical incident, lost consciousness,...