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Safety Thought of the Week... James Reason's Human Failure Model: Active and Latent [Organizational] Failures
As safety professionals, we need to understand that we ALL make errors, mistakes, and violations. When we are asked to facilitate a causal analysis, we must keep the team aware of this fact and educate them on the differences between Active and Latent [Organizational] failures. Active failures are “unsafe acts” whose negative consequences are immediately or almost immediately apparent. These are associated with the people at the “sharp end,” that is, the operational personnel who directly see and influence the process in question. Latent failures are decisions or other issues whose adverse consequences may lie dormant within the system for a long time, only becoming evident when they combine with other factors to breach the system’s defenses (Reason, 1990). Some of the factors that serve as “triggers” may be active failures, technical faults, or atypical system states. Latent failures are associated with managers, designers, maintainers, or regulators – people who are generally far removed in time and space from handling incidents and accidents." Incident Commander Training clarifications
Is it OSHA's intent that Incident Commanders be 24-hour HAZWOPER trained irrespective of their actual working location during an incident, e.g., if they are located off-scene, outside of the contaminated area or far from the incident, and are never actually exposed to the site hazards? Membership Content
The myth that a "Culture of Safety" does not exist
I have to chuckle when companies and experts tell me there is no such thing as a culture of safety. That there is only one culture (if even that). I call bullshit on that belief. One way to learn this is the hard way, such as what Boeing is going through. And on an investor call yesterday, CEO Kelly Ortberg told investors: "he plans to prioritize a culture shift to reboot the company's image" The statement came after Boeing announced layoffs and other efforts to downsize this month as its credit rating approaches junk status. Boeing's stock fell 3% in midday trading. Boeing’s growth came back in the 1980s, 1990s, and 2000s. But then it shifted focus to stock price, and EBITA became the dominant metric, overshadowing safety and quality. Safety and quality were no longer viewed as the backbone of the company but as mere obstacles to achieving its financial goals. As the old proverb says… Trust arrives on foot but leaves on horseback. The use of a Lockout Hasp is NOT "group lockout"
The use of a Lockout Hasp, the device shown to the left, is NOT associated with the phrase "group lockout." And yes, I am well aware of how these devices are marketed and sold, and yes, when they are used, they allow multiple people to lockout on an isolation device; however, OSHA's and ANSI's definition of "group lockout" are very clear:
OSHA, 1910.147 states: Safety Thought of the Week (Richard I. Cook, MD)
Complex systems contain changing mixtures of failures latent within them
The complexity of these systems makes it impossible for them to run without multiple flaws being present. Because these are individually insufficient to cause failure they are regarded as minor factors during operations. Eradication of all latent failures is limited primarily by economic cost but also because it is difficult before the fact to see how such failures might contribute to an accident. The failures change constantly because of changing technology, work organization, and efforts to eradicate failures.
Source: How Complex Systems Fail, Richard I. Cook, MD, Cognitive Technologies Laboratory, University of Chicago, 1998 Personal gas meter, its placement, and our "breathing zone"
If we spend enough time in chemical plants, we will encounter a widespread, albeit severe, human failure regarding a "safety-critical instrument." I am referring to the IMPROPER placement of personal gas monitors. Nine times out of 10, where do we find these personal gas monitors on the worker's body? I am betting your experiences are similar to mine and you would answer "back of the worker's hard hat". The problem with this convenient location is that it is NOT in the worker's "breathing zone." What is our "breathing zone"? OSHA and NIOSH DEFINE and QUANTIFY the "breathing zone" as: EPA RMP/EPCRA citations @ food facility (NH3 & $25K w/ $90K SEP)
This case is interesting, as I have always challenged the concept that an engine room (membership required)with large roll-up utility doors and windows and personnel/fire doors that are found propped open more often than not would contain the "catastrophic release of NH3". It seems this EPA inspector was one who attended one of my 5-Day Advanced Process Safety courses, and I was able to convince him/her of this limitation. (LOL) Respondent operated a facility that utilizes anhydrous ammonia for cold storage and freezing peaches, nectarines, plums, and strawberries. On December 19-20, 2018, EPA performed an inspection of the Facility to evaluate compliance with the Comprehensive Environmental Response, Compensation and Liability Act ("CERCLA") Section 103, the Emergency Planning and Community Right-to Know Act ("EPCRA") Sections 304-312, and CAA Section 112(r). Based upon the information gathered during the Inspection and subsequent investigation, EPA determined that Respondent violated specific provisions of the CAA. On May 26, 2023, Respondent reported an incident at the Facility involving two refrigeration employees, which resulted in a 0.57-pound release of anhydrous ammonia. ALLEGED VIOLATIONS CSB releases a new safety video on its investigation into the fatal release of hydrogen chloride
Regardless of what CSB highlights in this video... TORQUE VALUES MATTER and having your Emergency Escape Respirator on your person all played a role in this accident! Also, SIMOPS is a term discussed the video. CLICK HERE to see a great, and FREE, safety document explaining SIMOPS from our friends at the CCPS. I also implore you to read my 87 articles on "Line Breaking", several of which I discuss how the risks increase based on where the break/opening is occurring and how this may require increased levels of PPE. TWO means of egress, opposite ends of the elevated platform, are needed. A fixed ladder, used for emergency egress only, could have changed the tragic outcomes. Although the video states there is a lack of guidance on this topic, yet we can apply OSHA's 1910.36 requirements (as I do in my PHA's)
The U.S. Chemical Safety and Hazard Investigation Board (CSB) released a new safety video on its investigation into the fatal release of hydrogen chloride at the Wacker Polysilicon North America facility in Charleston, Tennessee, on November 13, 2020. One contract worker was killed - and two others were seriously injured - when attempting to escape the release. The CSB's new safety video, “No Way Down: Chemical Release at Wacker Polysilicon,” includes an animation of the events leading to the incident. The CSB’s investigation found that at the time of the incident there were multiple contract workers present on the fifth floor of an equipment access platform at the facility. The contract workers were from two different firms, conducting different work, and were wearing different levels of Personal Protective Equipment. One of the workers applied excessive torque to flange bolts on a heat exchanger outlet pipe containing hydrogen chloride, causing the pipe to crack and release the hazardous chemical in the vicinity of the workers. There was only one way to exit the platform – via a staircase. As the white cloud of hydrogen chloride expanded, the workers on the platform were not able to see their surroundings or access the staircase. Three of the workers who were not wearing full-body chemical resistant suits began climbing down the side of the structure to escape the hazardous cloud. All three workers fell approximately 70 feet during their attempt to escape. One of the workers died from the fall, and the other two sustained serious injuries. Inspection Guidance for Animal Slaughtering and Processing Establishments
October 15, 2024
This memorandum establishes guidance for inspections conducted in all animal slaughtering and processing establishments, North American Industry Classification System (NAICS) 3116, Animal Slaughtering and Processing.1 This memorandum updates and supersedes OSHA's previous inspection guidance specific to a subset of this NAICS, poultry slaughtering and processing establishments (NAICS 311615), OSHA Memorandum, October 28, 2015. This expansion into the broader Animal Slaughtering and Processing industry (NAICS 3116) is based on OSHA's determination that this industry has a high Bureau of Labor Statistics (BLS) days away, restricted, or transfer (DART) rate (i.e., above the 1.7 private industry national average). The goal of this initiative is to significantly reduce injuries and illnesses resulting from occupational hazards, through a combination of enforcement, compliance assistance, and outreach. Under this new memorandum, all programmed and unprogrammed inspections in NAICS 3116 shall cover the focus hazards associated with the list below, in accordance with the FOM:
These focus hazards shall be assessed in addition to other hazards that may be the subject of the inspection or based on information gathered by the compliance safety and health officer (CSHO) during the inspection. Additionally, the Department of Labor's Wage and Hour Division (WHD) protects workers from unlawful wage and hour practices and child labor violations. Therefore, OSHA offices should initiate referrals and exchange appropriate information relating to complaints, inspections, or investigations and related matters, to support the enforcement activities of the agencies. If OSHA discovers information relating a possible violation of the laws and regulations enforced by WHD, OSHA offices are to provide timely information to WHD by making a referral, per the Memorandum of Understanding between WHD and OSHA, dated May 4, 2023. All workers, regardless of their socioeconomic backgrounds or immigration status, have the right to a workplace that is free of known safety and health hazards and to report hazards to OSHA without fear of retaliation. OSHA shall also make referrals to whistleblower staff when indicated. Scope: This guidance applies to all Federal OSHA inspections, programmed and unprogrammed, conducted in: 1998 H2S incident (same contractor; wrong place-wrong time)
Looking at the contractor involved with the refinery H2S incident last week, I came across another refinery accident involving H2S where this contractor had their employees exposed. I have no special info on this latest incident, and I will let the media release the name of the contractor, but this 1998 incident was being in the wrong place at the wrong time. Another contractor company had its team exposed to this H2S event. Employees #1 through #10 worked at a crude oil refinery where nearby process units (crude oil and gas oil treater) were undergoing a planned turnaround. The units had staggered shutdown and startup schedules and shared some product transfer piping leading to storage. When the product flow was rerouted by operations prematurely, sour naphtha liquid was released into the crude unit from an OPEN connection installed on a NEW 6 in. piping section that served as an exchanger bypass line. The low-pressure release lasted for several minutes and allowed clouds of toxic hydrogen sulfide (H2S) gas to accumulate in and around the nearby control room and through nearby process units. |
Partner Organizations I am proud to announce that The Chlorine Institute and SAFTENG have extended our"Partners in Safety" agreement for another year (2025) CI Members, send me an e-mail to request your FREE SAFTENG membership
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I will probably catch a lot of flack for repeating this (as I have this debate at least annually), as very few agree with me, but it needs to be repeated! 
