We see this often in our PHAs/HFA and audits… an emergency shutdown procedure would need an Olympic athlete to carry out before the LOPC event begins.  And to top it off, the operators we witness as those who would be expected to carry out this ESD SOP are “senior” operators who tend to be out of shape and look as if they are in a ZZ Top cover band!  Clearly, “human...

The main objective of any safety data collection and analysis system is to make events, hazards, safety trends, and their contributing factors VISIBLE and UNDERSTANDABLE so that the organization can take effective corrective action.  Generally, the same decision-making, communication breakdown, and distraction problems we see in a serious accident will also tend to see in minor incidents and even...

The control of human error requires two (2) different approaches.  First, it is necessary to MINIMIZE THE OCCURRENCE of errors, and the second is to REDUCE THE CONSEQUENCES of the remaining errors by … HomeRead More »

To contain and control human error, one must first understand its nature. There are basic concepts associated with the nature of human error: the origins of errors can be fundamentally different, and the consequences of similar errors can also be significantly different. While some errors are due to carelessness, negligence, or poor judgment, others may be induced by poorly d signed equipment or may...

There is an evil myth regarding LOTO training and Periodic Inspections.  I recently had a lengthy discussion with a Labor Lawyer regarding the FACT that annual LOTO training does NOT satisfy the Annual Periodic Inspection requirements.  An employer is NOT required to perform annual training on LOTO, but they are REQUIRED to conduct a periodic inspection on EACH authorized employee. ...

Maybe you’ve heard about the Fukushima water release plan.  Or maybe you heard something about the drinking water debacle in Flint, MI.  Or maybe you’re an emergency responder and are being bombarded about the Alcohol Film-Forming Foams (AFFF) you were exposed that had the “forever chemicals”. Or maybe you have a home with a basement and learned about Radon and its...

At 3:35 p.m. on December 27, 2022, an employee was knocking gypsum dust off the interior walls of the end saw baghouse hopper. The baghouse was a large steel structure, 40 feet in height, with inward converging walls that led to two screw-augers that moved gypsum dust to the center of the hopper. The dust would then fall through a central rotary valve and be moved back into the facility. The hopper...

At 4:30 a.m. on January 11, 2023, an employee attended a Permit Confined Space Entry Rescue Training. The employee entered the manway and began to descend into a vessel. Approximately halfway into the entry, he realized he could not fit in and began to extract himself. He was distressed and lost consciousness. His coworkers attempted to lift him from the vessel utilizing a rescue hoist attached to...

At 11:00 a.m. on May 23, 2019, an employee removed a regulator from a chlorine gas cylinder to perform yearly maintenance and repacking. When the employee attempted the close the shutoff valve, the valve malfunctioned and stopped turning while still slightly open without the employee’s knowledge. When the employee removed the regulator, chlorine gas escaped. The employee removed himself from...

Two workers were injured on an offshore platform while installing a skillet, the steel circular joining plate inside a section of piping. The incident occurred while the workers were on scaffolding and unbolting a 10-inch flange (Figure 1). After determining the skillet was the wrong size, the supervisor instructed a third worker to join the initial two workers on the scaffolding to take skillet measurements...

Uninterruptible Power Supply (UPS) is a pretty common backup power supply in industrial settings where “power failure” can lead to the loss of control systems, emergencyshutdown systems, and emergency mitigation systems.  But like ALL SAFEGUARDS we take credit for in our Hazard Analyzes, these UPS must be in our mechanical integrity program for testing/validation regularly (e.g., manufacturer’s...

As we have discussed before, all drivers (including all parts of the world) can recognize the universal symbol for STOP.  It is a RED OCTAGON-shaped sign LOCATED on the side of the road at the SAME height in all locations.  Granted, the sign may be on different sides of the road, based on the country you are driving in, as that country may drive on a different side of the road.  But...