A firefighter battling a blaze at a California refinery bashed a pipe trying to get to the fire below. This caused a small leak that made matters worse. Clearly, the firefighter failed to understand the risk. I reckon the firefighter wasn’t informed of the situation or wasn’t trained to deal with it. However, blaming inadequate training, while easy, often masks the real cause. Here, like in many other situations, poor decision-making really is the culprit.
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Don’t dismiss such errors as resulting from the tension of the moment. Consider this gem from Trevor Kletz’s book “What Went Wrong?: Case Histories of Process Plant Disasters and How They Could Have Been Avoided,” 4th ed., p. 316, about a liquefied petroleum gas (LPG) tank truck sent for repair. Laboratory staff were asked to analyze the atmosphere in the tanker. They regularly checked for oxygen and so reported “none detected” — not realizing hydrocarbons were the issue. The operator failed to ask what was being checked and the safety manager hadn’t established clear procedures. Fortunately, the repair shop had its own check procedure — which showed more than a ton of LPG was still present. Miscommunication nearly resulted in a massive catastrophe.
At facilities I’ve worked at, everyone involved in a chemical operation generally must get annual safety training. Typically, this involves looking at a series of memos and videos, perhaps followed by a test. Does this really prepare us to take proper action when needed?
Now, imagine you’re a welder, electrician or engineer visiting a facility. Your “safety orientation” is even more abbreviated than the annual training employees get. Even well-run chemical facilities that regularly drill staff in safety procedures usually spend little time on safety training for people temporarily on site.
This unfamiliarity can be fatal: e.g., three contractors were killed (and seven others injured) in a hot permit accident at the Packaging Corporation of America (PCA) plant in DeRidder, La., on February 8, 2017. (See: https://bit.ly/36w1hrl.)
So, how can we reduce the risk? Giving craftspeople stacks of memos and playing videos won’t help them (or many of your own staff, by the way). These are hands-on people. You must approach them differently.
Write a clear procedure — this is for your benefit not theirs! This will help you prepare for what’s next. Say, you’re going to open a pipe that contains a highly corrosive, toxic, hot liquid to do some welding. First, note the need for a flush procedure because you can’t weld on a contaminated surface; then, state that a drying process, usually with air, or nitrogen if the liquid is flammable, must follow. While normally not involved in these steps, the welder should know they must take place to check that operations did its job.
Next, the pipe must get pressure bled off and, then, isolated. Here, the welder may take part — and certainly will have to know that the pipe is isolated securely.
Then, there’s the cutting and welding. Don’t get lost in the permitting process; focus on what the welder will do. Testing (pressure, equipment) follows this. Finally, there’s cleanup (including inside the pipe) and handoff to maintenance or operation. You’ll want debris flushed out of the pipe or vacuumed out if the line is short.
So, now that you’ve written the procedure (replete with marked-up photos), review it one last time. Now, you’re ready for the last step.
Call together the people doing the work — at the job site. Also, invite someone involved in writing the permits and the handoff to sit in. Walk them through your procedure. Wait for questions — and be prepared to re-write the procedure if necessary.
Once you’re done with the walk-down, meet in a conference room to go over everything. This may lead to changes to the procedure. Maintenance might not like how you or they are approaching the job, so take that into account.
Here’s one more thing: do this walk-down at least twice — before the job is bid and the day before the work is to begin. Also, ensure all those involved in the work go through the walk-down. If someone new is added to the job, tutor that person through it. Maybe, by remembering that craftspeople are hands-on, we can avoid the type of accident that happened at PCA.
