EH-9403 Issue 3, March 1994 Occupational Safety Observer
MARCH 1994
Occupational Safety Observer
Industrial Fatality:
WORK PERMIT PROCESS FAILS
In August 1993, four workers at a packaging plant in
Shelbyville, Kentucky, were performing maintenance on a parts
cleaning system when an explosion and fire ripped through the
room. One worker was killed and three others were hospitalized--
two with severe burns. This accident, which was caused by a
failure to follow rudimentary safety precautions, shows how
tragedy can occur when management fails to ensure a safe work
environment.
The accident
The explosion and fire occurred in the parts cleaning room,
where a number of highly flammable and toxic substances--
including methyl-ethyl-ketone (MEK), ethyl acetate, acetone, and
toluene--were used as solvents.
The parts cleaning system was a closed unit that resembled a
large commercial kitchen dishwasher. Solvents were kept in
storage tanks and cycled through the washer where a filter basket
removed foreign substances so the solvents could be reused.
The maintenance operation consisted of removing a pump and
repairing the cover of the filter basket. At the time of the
accident, the pump had been successfully removed and a welder was
preparing to repair the basket cover. The welder was about to
strike an arc when the vapors in the air ignited, causing an
explosion that sent a fireball through the washer and blowing off
its door. The fireball also ignited the buckets of solvents and
other flammable materials located in the room, filling the room
with a high concentration of toxic substances.
The investigation
An investigation confirmed that workers had taken some
precautions before attempting the welding operation. The drain
pit below the washer had been ventilated with compressed air, and
ventilation throughout the room was increased before beginning
the repair of the basket cover. Fire blankets were draped
throughout the room. In addition, the floor and the drain pit
were flooded in an attempt to cover flammable residue left in
those areas.
Nonetheless, numerous hazards remained uncontrolled.
Several 5-gallon buckets containing solvent and residue from the
parts washing process were left in the room. Two soak tanks
containing solvent were not removed, and their lids were
unsealed. The investigators determined that combustible gas
readings were not taken, even though a combustible gas meter was
available.
Plant policies require that a "hot-work" permit be issued
before any welding operation is performed. The purpose of such a
permit is to ensure that welding can be performed safely. An
extensive safety checklist accompanies the permit, and compliance
with the checklist would have precluded conducting welding
operations in an area containing flammable or toxic substances.
Although management believed that a hot-work permit had been
issued in this instance, neither the permit nor any record
related to it has been found.
Another unresolved issue concerns why three people, in
addition to the welder, were in the room when the accident
occurred: only one person was required as a fire guard. A
second person, the individual who was killed, was receiving
on-the-job training as a fire guard. Why the third guard was in
the room has not been explained.
OSHA investigators were baffled by the workers' decision to
conduct a welding operation in an explosive atmosphere and by the
haphazard manner in which safety precautions were undertaken.
Performing the task safely would have required that all
combustible materials be removed from the room and that the area
be properly ventilated.
The company was cited for multiple violations of OSHA and
State regulations, including failure to provide proper oversight,
lack of fire extinguishers, and failure to have a trained
first-aid responder on site. The citation for improper oversight
rightly places much of the blame for this accident on management.
Lessons learned
As this accident demonstrates, welding operations conducted
in a potentially hazardous environment must follow all applicable
safety procedures. For example, the American Welding Society's
"Recommended Safe Practices for the Preparation for Welding and
Cutting of Containers That Have Held Hazardous Substances"
(ANSI/AWS F4.1-88) provides much useful guidance on this subject.
A hot-work permit is required for any welding operation. In
this instance, a hot-work permit apparently was neither requested
nor issued. As a result, the individual responsible for
authorizing the work could not and did not designate the
precautions to be taken. Had a hot-work permit been requested,
it certainly should not have been granted. This accident also
indicates the need for controlling activities in explosive
environments. Although the welder triggered this explosion, any
spark from static or metal-to-metal contact would have had the
same effect.
It should also be noted that incomplete and inappropriate
safety precautions may result in a false sense of security.
Increasing the ventilation, using fire blankets, and flooding the
floor and drain pit may have been appropriate for removing the
pump, but such actions were not adequate for welding. Further,
it should be stressed that only the minimum number of people
required should be allowed in an area where hazardous operations
are under way.
Finally, the safety violations contributing to this accident
could not have occurred if management had placed sufficient
emphasis on safety in the workplace.
Accident Rates Decline:
UMTRA IMPROVES SAFETY PROGRAM
As reported in the December 1992 Observer, a mechanic was
fatally injured in May 1992 at the Uranium Mill Tailings Remedial
Action Project (UMTRA) site near Grand Junction, Colorado. In
the wake of the accident, Project management introduced
comprehensive changes to improve the effectiveness of the overall
safety program. These changes are believed to have contributed
to the recent decline in accident rates at UMTRA.
Site-specific improvements implemented under the revised
program include (1) better daily, weekly, and monthly
surveillances by management and (2) better tracking and closure
systems for safety deficiencies. These changes have helped
workers and managers to improve their performance in crucial
environment, safety, and health (ES&H) areas.
The role of management
As part of the management response to enhance worker safety,
the Project Office established the Safety Advancement Field
Effort (SAFE) (1) to review plans and procedures and (2) to
provide increased safety awareness in the field.
A separate group, the ES&H Committee, was reestablished to
review policies and procedures. Made up of representatives from
DOE, contractor, and subcontractor organizations, the committee's
objective was to improve personnel awareness and performance by
focusing on programmatic ES&H issues.
In addition, a multidisciplinary steering committee
undertook responsibility for interpreting safety requirements and
developing selected safety programs for UMTRA operations. The
Project Office also prepared a requirements identification
document (RID) to identify minimum institutional and regulatory
requirements for safe remedial action at the Grand Junction site.
This document establishes a baseline for developing customized,
site-specific RIDs and operating envelopes for the other UMTRA
sites. As a result, formal policies and procedures have been
appropriately modified, documented, and distributed to Project
personnel.
Before restart of operations at the Grand Junction site
could proceed, an operational readiness review was conducted by
the contractor to evaluate the facility's state of readiness.
The review included an evaluation of personnel qualifications,
the condition of equipment, the adequacy of training procedures,
and emergency response capabilities. DOE then conducted an
operational readiness evaluation to verify the contractor review.
This process is repeated at each UMTRA site that undergoes either
startup or restart activities.
Increased audit support
To strengthen safety and health audits at all UMTRA sites,
contractor management has expanded its audit support capability
by hiring a construction safety specialist and by instituting
environmental audits. The services of a transportation safety
specialist and a trainer coordinator have also been acquired, and
ES&H managers have been assigned to all active UMTRA sites.
By assuming responsibility for reporting accidents and
incidents at UMTRA sites, the Project Office has been able to
incorporate its occurrence reports into an existing program used
for tracking and trending audit findings and developing lessons
learned.
Finally, the creation of the Regulatory Oversight and
Compliance Support group has provided the Project Office with
three important capabilities: (1) tracking and reviewing
appropriate regulations and Orders; (2) maintaining a data base
for the UMTRA operating envelope; and (3) providing assistance to
DOE for internal programmatic appraisals, planning, and guidance
documents.
Followup:
MANAGEMENT INDICTED IN MINING ACCIDENT
In April 1993, the Observer reported on a mine explosion
that killed eight workers. The explosion occurred on December 7,
1992, when a cigarette lighter ignited built-up methane gas. An
investigation into the cause of the accident found evidence of
the systematic violation of safety standards. In November 1993,
we printed a followup article reporting that the Mine Safety and
Health Administration had fined the company and was considering
criminal charges against management. A Federal grand jury
recently indicted the mining company and two of its officials on
charges related to 6 felonies and 11 misdemeanors. If convicted,
the company faces up to $8.5 million in criminal penalties, in
addition to the $439,172 in fines already levied by OSHA.
One of the indicted officials, a mine superintendent, faces
a maximum sentence of 26 years in prison and a $2.5-million fine.
He is charged with authorizing, ordering, and implementing unsafe
work practices, all of which are classified as misdemeanors. The
superintendent also faces charges on four felony counts of
falsifying records.
The other official, a foreman, was indicted on three
misdemeanor counts related to safety and one felony count for
falsifying records. Prosecutors allege that the foreman failed
to conduct an adequate pre-shift examination of the mine, then
falsified records to indicate otherwise. He faces a maximum
sentence of 8 years in prison and a $1-million fine.
When the Observer first reported this accident, we noted
that management attitudes toward safety may have been a
contributing factor. Information contained in the indictment
continues to call into question the actions of both the
supervisor and foreman, as well as the role of the mine's owners.
A company spokesman unequivocally denies that the law was
violated in any way. Although the exact extent of the blame is
not yet known, it is clear that a deficient safety culture at the
mine had tragic consequences.
Thanks for the Feedback:
RESULTS OF READER SURVEY
The November 1993 issue of the Observer included a reader
survey. About 4 percent of our 4,000 readers responded. The
Observer staff would like to take this opportunity to thank these
readers, and we would like to share some of the survey results.
Reader characteristics
The Observer is read by workers and managers in a variety of
job classifications. Most Observer subscribers are DOE
contractors (68 percent), 17 percent work for DOE, and 7 percent
are subcontractors. (Incidentally, we would like to increase our
circulation among subcontractors. If you know a subcontractor
who would like to receive the Observer, please contact our
circulation department at 206-528-3246 or fax the name, address,
and telephone number to John Everett at 206-528-3552.)
The survey indicated that many readers share their copies of
the Observer with others. In fact, on average, each copy is read
by 16 people. Readers indicate that information from the
Observer is often quoted during safety meetings. One reader uses
the Observer to "open the eyes of management" to the importance
of safety. Another includes excerpts from Observer articles in
an employee newsletter, a practice we encourage--as long as the
Observer is given credit for the material.
In general, the survey indicates that upper level management
uses the Observer as a source of information for developing
policy and programs. Safety personnel use its articles to
improve their programs, training, and inspection techniques.
First-line managers use the newsletter to alert workers about
hazards related to specific tasks. Finally, the workers
themselves respond to the Observer as a source of information
about how actual accidents have affected other workers.
Useful feedback
The survey also solicited feedback regarding what readers
liked about the Observer and what they would like to see changed.
Overall, the responses were very positive. There were many
suggestions for improving the Observer, and we'll try to
incorporate them as we continue to fine-tune this publication to
meet the needs of our audience.
One reader suggested that we set up an e-mail address for
comments, which we have done (Internet address:
observer@battelle.org). Many readers suggested articles on
specific topics, such as construction safety or fire protection.
We will try to include articles on these topics in the near
future. Others suggested that we keep articles in the Observer
as timely as possible by focusing on "hot" topics and by
communicating information quickly.
The Observer staff and the Office of Safety and Quality
Assurance are committed to providing our readers with information
that will support continuous improvement of safety in the
workplace. We can best accomplish that goal by enhancing our
ability to respond to your concerns. If you have comments about
an Observer article, an idea for an article, or any other
suggestions, please contact the coordinating editor at the number
listed on page 2 of each issue. This month, the coordinating
editor's number is (301) 903-2033.
Do We Have Your Current Address?
If you've moved, or would like to add your name to the
Observer subscription list, please contact our subscription
department by phone at (206) 528-3264, by fax at (206) 528-3552,
or on Internet at observer@battelle.org.
How Safe is Your Chair?
DANGER IN THE OFFICE
On-the-job accidents can occur anywhere, including the
office. The two accidents described in this article indicate
that the common office chair can present a significant workplace
hazard. The victims of both accidents required hospitalization.
The incidents
On April 19, 1993, a worker at Los Alamos National
Laboratory was injured while attempting to dust a bookcase. The
worker knelt on a swivel chair to reach the top of the bookcase,
and she fell when the chair moved. When the worker was
hospitalized for x-rays, her injuries were diagnosed as two
broken ribs, bruised kidneys, and a bruised liver. She was
admitted for overnight observation and subsequently missed 5 days
of work.
On September 9, 1992, a supervisor at the Savannah River
Operations Office was injured when his office chair broke,
causing him to fall backwards and strike his head on a carpeted
concrete floor. He sustained a head injury and was hospitalized
for 2 days. An investigation into this incident determined that
the chair was broken at the point where the seat and back were
attached to the base. The chair showed evidence of a fatigued
weld. Management then conducted a sitewide inspection, which
identified a second chair with a similar defect.
Lessons learned
OSHA regulations do not specifically address using chairs as
ladders; however, it should be noted that chairs do not meet the
requirements OSHA imposes on ladders and other working surfaces.
The accident at Los Alamos could have been prevented if a step
stool had been used to reach the bookcase.
Management should ensure that workers are aware of the
dangers associated with the misuse of office furniture and should
provide step stools and ladders where necessary. This issue also
provides management with an excellent opportunity to lead by
example. The manager who consistently emphasizes--and follows--
such basic rules of safety can effectively prevent accidents.
The accident at Savannah River, on the other hand,
demonstrates the difficulty of guarding against unexpected
equipment failures. DOE sites might consider holding periodic
inspections of office furniture to identify potential hazards.
For example, older chairs could be inspected to determine whether
they are safe. Faulty chairs could then be removed from service
to be repaired or discarded.
References
ALO-LA-LANL-ADOADMIN-1993-0002
SR--USRC-SEPGEN-1992-0006
FEATURE ARTICLE
Preventing Recurrence of Accidents:
ACCIDENT INVESTIGATIONS AS LEARNING TOOLS
Occupational safety programs are implemented to minimize or
eliminate work-related accidents and hazards that can result in
injuries or fatalities. Those accidents that do occur, however,
provide opportunities for learning how similar situations can be
successfully avoided. A properly conducted accident
investigation and a clearly written, well-supported investigation
report are key elements of this learning process. As part of an
ongoing project for the Office of Safety and Quality Assurance,
DOE contractors reviewed accident investigations performed by
DOE, other Federal agencies, and private industry. The review
process included an evaluation of more than 40 DOE accident
investigation reports dating back to 1990, interviews with former
DOE accident investigators, and analysis of accident
investigation programs operated by other organizations.
Types of investigations
The purpose of an investigation is to determine why the
accident occurred and to identify the actions necessary to
prevent or minimize the chance of a recurrence. Depending on the
severity and nature of a given accident, DOE conducts a Type A,
Type B, or Type C investigation at the affected site.
DOE 5484.1, "Environmental Protection, Safety, and Health
Protection Information Reporting Requirements," establishes the
criteria for determining the investigation type. For example, a
Type A accident investigation is conducted by DOE personnel in
the event of an accident resulting in a fatality or damages in
excess of $250,000. A Type B investigation is conducted by DOE
or contractor personnel, as appointed by the affected DOE field
organization, in the event of a relatively less severe accident
(resulting either in serious injury or $50,000 to $250,000 in
damages). Type C accident investigations address the least
severe accidents and are conducted by DOE contractor personnel
whenever their operations are involved.
Key lessons learned
The DOE-sponsored review of accident investigation programs
identified a number of findings, which in turn were developed
into lessons learned that can be used to maximize the
effectiveness of the investigation process. A brief overview of
these lessons is provided below.
--Scope-- Two lessons related to the scope of an investigation
are particularly important. First, a broad scope will enhance
the investigation board's ability to identify and address the
root causes of an accident: a good investigator will not allow
initial impressions to narrow the focus of the investigation,
even when the accident seems relatively easy to explain. The
board must also strive to maintain an independent perspective
that avoids outside pressures and conflicts of interest. Second,
the investigation board should thoroughly examine the role of
management systems when determining the cause of an accident.
Inadequate or ineffective management systems often lie at the
heart of an accident scenario.
--Board composition and resources-- Board composition and the
availability of resources were identified as crucial factors
affecting the success of an investigation. Except for Type C
investigations, at least one board member must be a trained
investigator. All board members should have knowledge of the
accident investigation process, and some should have expertise in
technical areas related to the accident and should be familiar
with analytic tools. Advisors with specific technical skills can
also provide valuable assistance. In addition, the availability
of administrative personnel dedicated to support functions can
free board members to focus on the investigation. Finally,
experience has shown that the assistance of a professional editor
can significantly improve the quality of an accident
investigation report.
--Logic of the investigation-- Collecting and documenting
evidence provides the basis of any investigation. Without an
accurate and complete set of facts, the investigation's analysis
and conclusions will be inadequate. Hence, a conscious effort
must be made to ensure that the evidence collected is as complete
as possible, and investigators must remain open-minded about what
is relevant.
Many investigation board members consider analyzing evidence
to be the most difficult part of their task. Analysis provides
the basis of the board's conclusions and "judgments of need" for
corrective action. The DOE-sponsored review of accident
investigation programs indicates that many substantive problems
occur in this area. As the review confirmed, analysis must be
conducted in a formal manner and must be thoroughly documented in
a well-written report. Otherwise, no matter how sensible the
board's conclusions may seem, they cannot be formally
substantiated. Using the analytic tools available, board members
must constantly look beyond the direct cause of an accident to
determine the root cause. They must keep asking "how" in an
effort to determine "why."
The conclusions--including findings, probable causes, and
judgments of need--should flow clearly from an analysis of the
evidence gathered, and this process must be fully documented in
the report prepared by the investigation board. A board may
conduct a thorough investigation, yet fail to provide adequate
documentation of the links between its facts, analysis, and
conclusions. Hence, the importance of producing a solid
investigation report cannot be overemphasized.
--Corrective actions-- Although the DOE-sponsored review of
accident investigation programs did not specifically examine the
activities that follow a completed investigation, it is important
to emphasize that corrective actions based on the investigation's
judgments of need be developed and implemented in a timely
manner. The key to avoiding the recurrence of accidents is to
learn from past mistakes by acting quickly and intelligently to
correct them.
Resources
Specific guidance related to the DOE accident investigation
process is provided in (1) DOE 5484.1, which establishes
parameters for conducting a DOE accident investigation and
documenting the results, and (2) the DOE Accident Investigation
Manual (DOE/SSDC 76-45/27), which provides detailed direction
about the process itself.
In addition, Practical Guidance for Accident Investigation
and Reporting, a concise, user-friendly handbook, is available
through the Office of Safety and Quality Assurance. This
handbook should be used in conjunction with DOE 5484.1 and the
Accident Investigation Manual.
If you're interested in receiving a free copy of Practical
Guidance for Accident Investigation and Reporting, please contact
Towanda O'Brien, at (206) 528-3552 (fax), or (206) 528-3237
(voice).