Podcast: What Have We Learned From Significant Safety Incidents?

Traci: Oh, good, good. The topic that we have today, we're going to look back at some significant safety incidents from the past. It's certainly not a celebration of momentous anniversaries, rather a look back at what we've learned and how we've adapted to ensure that workers get to go home safely after each shift.

March 23rd marked the 15th anniversary of the tragedy that struck BP's Texas City, Texas, refinery when a cloud of hydrocarbon vapor exploded, killing 15 workers and injuring more than 180 others. Some investigators feel this was entirely avoidable. What are your thoughts? [See: "BP tackles Texas City failings"]

Trish: The simple answer here is yes, I would say that all of the incidents that we see in process safety are entirely avoidable. That doesn't mean it's easy to do. If it was easy to do, then we wouldn't have the 15th anniversary of this tragic incident. On previous webinars, I've actually spoken about hindsight bias. And hindsight bias is a particularly interesting aspect. Because we know what the outcome was, it's very easy to judge what everybody did and what went wrong. And incident investigations do that. They do it very well. They judge exactly who did what, and when it happened, and what went wrong. But the people involved in the incident don't necessarily share the causes before the failure occurred. If they did, I'm sure they wouldn't take those actions because they wouldn't take those actions knowing that was going to cause the incident.

So, one of the challenges is we need to figure out how to learn better so that the learnings can be shared, and understood, and embedded, so we recognize we're going down a wrong path before we get to the catastrophic outcome. So if we look at it, you know, there were things like the blowdown drum on the raffinate splitter had been overfilled before. There was evidence of it having been overfilled before in previous incidents. Well, that was one of the key things that led to the incident occurring here. So, significant negative outcomes hadn't occurred previously so they'd been sort of, like, a near-miss because it hadn't been ignited. But the fact was that we've had an overfill. We could have learnt from that overfill to know that overfills were gonna be bad, and therefore, not to overfill that blowdown drum.

So, you know, any particular process safety incident you could think of, there is actually always a point at which it could have been stopped. In fact, this is in multiple points where it could have been stopped. And it could have been stopped with knowledge that we already have, not new knowledge that we haven't figured out yet. We haven't figured out new ways to have process safety incidents yet. We're still using the same old methods we had. We fundamentally are still dealing with flammable or explosive substances. And they're going to ignite or explode because that's a nature of the substance. So we need to be able to manage those more carefully. So yes, it is possible to avoid these incidents. They don't happen every day, thankfully. But we need to learn better from them so that we can focus on that.

Traci: Now, let's talk about the Texas City disaster that happened April 16, 1947. We're going back on this one. It is the deadliest industrial accident in U.S. history, the fires and resulting explosions killed a total of at least 581 people including all but one member of the Texas City Fire Department. What was learned from this incident?

Trish: That was a really interesting incident. For people that don't know what it was, there was basically two ships moored. They were moored a couple hundred yards from each other at Texas City Port. And one of them contained ammonium nitrate fertilizer grade. And the other one contained ammonium nitrate and some sulfur. And what occurred was there was a fire on the first ship. And that eventually led to a small explosion. That triggered a fire on the second ship. But after the fire on the first ship, everybody came down to the port to watch what was happening because it was all very interesting to see this fire on this ship. And it was a different time, it was 1947.

So, people were lining up on the edges of the port watching this fire. All the fire brigade were in there trying to fight this fire when a second, more violent explosion occurred on the second ship. And so that then was the reason that there were so many fatalities. So we had emergency services going in there, trying to deal with an incident that was an inherently unsafe situation to be in. There were tank farms. I believe there was a refinery on the edge as well. They all suffered significant damage. And so we had massive fire explosion activity in that area that went on for quite some time.

So, some of the things we've learnt, I think, is around how we respond to emergencies. So not just rushing in blindly, although we still have those incidents that occur, and we'll talk about one of those in a moment, where we've rushed in not realizing what else is going on around us and what some of the other consequences could be. The other thing, I think, is trying to keep people back. So we now have shelter-in-place that's used far more often, or even evacuation to try and keep people away from what's going on at the time so that we don't have massive crowds rushing to it.

I believe I read a statistic somewhere that 25% of Texas' population was injured in this incident. Twenty-five percent of the population of Texas was injured in this incident on top of the 581 or more fatalities that occurred. So, you know, some quite significant things that occurred. And it's often, you know, people don't even remember this one. People often haven't even thought about this one or heard of it. Sometimes, we talk about Texas City, "That's the oil refinery," say, "No, no, Texas City Port in 1947 when it exploded." So it's quite amazing that we don't even remember this one now.

Traci: Is this where shelter-in-place began? Is that what led to our practices now, this incident?

Trish: Well, I can't answer that. I don't know precisely where shelter-in-place eventually evolved from. But one would think that this was probably certainly something that helped it along its way. You know, if there's something going on, then we prefer to have you inside, safe, a distance away than outside watching a spectacular as it unfolded. So, it probably had a fair bit to do with it but I couldn't answer one way or the other definitively on that.

Traci: Well, moving on to yet another ammonium nitrate explosion, April 17th, 2013. There was an explosion that occurred at the West Fertilizer Company storage and distribution facility in West Texas, yet another West Texas. Fifteen people were killed, more than 160 were injured, and more than 150 buildings were damaged or destroyed. This one, though, it was discovered that fire had been deliberately set. Ultimately new regulations were put into effect regarding storage of ammonium nitrate. Can you discuss what we've learned from this tragedy? [See: "Learn from the West Fertilizer Plant Explosion" and "Intentional Fire Caused West Fertilizer Blast"]

Trish: There were certainly a lot of key learnings that came out of this one. And just going back to the March 23rd, 15th anniversary that we talked about earlier where I said, you know, all of it was entirely avoidable, this one was entirely avoidable even though we did learn something out of it. There weren't new learnings, they were reiterating the learnings. So, in terms of some of the tragedy that we learned here, understanding the hazards on the facility, understanding how in this instance the ammonium nitrate was stored. So it was actually stored in timber-constructed bunkers. So we've got a substance that basically oxidizes and is capable of igniting stored in flammable surroundings. That's not typically how we would store ammonium nitrate.

So, making sure you've got appropriate storage, making sure you've dealt with the contamination issue, because if you have contamination in ammonium nitrate, it can actually self-combust, and making sure you've got appropriate separation. So this is where you actually have small bunkers of ammonium nitrate rather than one big enormous stockpile of it. The idea is if you have one small bunker that catches fire, you can contain that fire rather than having one enormous pile that's going to detonate at some point. So, again, reiterating the understanding of the hazards of ammonium nitrate, how it should be stored, what to do with contamination, and how it should be segregated into smaller quantities was really important, and then being able to communicate that information to the emergency responders.

Now, in this tragic incident, the majority of people killed were the emergency responders because they were responding to what they thought was a building fire. They didn't realize it was ammonium nitrate fire. So when it detonated, they had no hope of survival at that point. So, the emergency responders need to know what they're dealing with so they can adequately respond to look after themselves and keep themselves safe. Because if they're hurt or injured, they can't respond on our behalf. And that's what we need them there to do. So similar to what I said in the Texas City disaster, the emergency responders, you know, all but one of the Texas Fire Department was killed because they were all fighting the fire. They didn't really understand the hazards of what they were dealing with at the time.

Couple of other areas came out of this. Land-use planning is a really interesting one. So you'll remember the photos of this incident afterwards. There was a high school that was severely damaged. There was the elderly persons' home that was also quite damaged. Building sensitive populations or locating sensitive populations close to major hazard risks is generally not a good idea because you will have mass casualty events in the event of an incident occurring here. So land-use planning, and whilst that's quite challenging in some areas because there's no laws around what you can build where, it is a really important process to follow because it actually gives you a structured way to try and minimize the risk on the vulnerable populations that we have in our cities and towns. So it's really important to think about that.

And another part to remember that I think this one really highlighted for us again is we've got the Responsible Care program for the chemical companies. And one of the standards, the codes in Responsible Care is a Community Right-to-Know. The community need to know what hazards they've got around them. Just like the fire brigade need to know what hazards they might be fighting. So the community need to know, should they shelter in place or should they evacuate? How do they know what to do? How would they be communicated with and told what to do at the right time? So I think those are some interesting ones that really highlighted themselves out of this particular incident. But again, none of them were actually new learnings. We've learnt them all before. We're just not very good at remembering the learning, I think.

Traci: And that's the unfortunate part in trying to drive home that point. I mean, that's the $64,000 question, how do you do that?

Trish: Yeah. I think we need to really start to look at how we investigate, and start to try and get to the bottom of it. And we recently did a webinar on this particular topic in understanding why decisions were made more so than the decision itself. We know why it was made, we can actually action dealing with that because a similar person in the same situation will make the same decision. We need to change the context of what's going on around them if we expect to get different decisions and different outcomes.

Traci: And I wanted to go a little bit back on your land-use planning point. What comes first, the chicken or the egg? Some of these factories or facilities are already there and then things are being built around them. Is that what you're talking about in terms of land-use planning and making sure that folks...that people cannot plan those types of facilities around a facility that stores ammonium nitrate or has some other hazardous material?

Trish: Yes. So it actually goes both ways. Though I think it more often goes that we have a facility out in the middle of nowhere that deals with some sort of hazardous substance. And eventually, the community encroaches on it. That's sort of the more common one I see. And so we need to have structures in place to prevent people being allowed to construct apartment complexes, or childcare centers, or old persons' homes, schools, hospitals within a dangerous zone, you know, a hazardous blast curve, for example, around that particular facility. So, we actually need leadership from our local municipalities to say, "No, you can't build that there." And as I said, in some places, the legal structure is not there to allow the municipality to do that. In other places, there's quite rigid structures where they actually said, "No, you can't do that."

So for example, I've seen instances in Melbourne where I live where someone wanted to build an enormous apartment complex right beside a fuel tank farm. That was not allowed to be built. And it ended up going to court to be challenged by the developers that they really wanted to build this. And eventually, it was determined that, actually, that wouldn't be a really smart thing to do to build it right beside a fuel tank farm. Because if that fuel tank farm explodes, there's thousands of people in that building that are at risk of fatality. So, there's that issue of encroachment around the facility. And then sometimes, we do have instances where people build something and they don't necessarily tell the municipality precisely what they're building, and they don't necessarily...they're not honest about what's in their facility. And we eventually have an incident occur at that facility because it's not being managed very well. If it was being managed well, they would be honest about what they've got on site. And we see community outcry because people are injured, or hurt, or impacted in some way. And it's right in the middle of our community. The community lives there, so it does happen both ways.

We've had this similar issue again in Melbourne where we had a waste company that was illegally treating all sorts of contaminated flammable toxic waste. And they were actually just stockpiling it in a factory and no one knew what was in there until it caught fire one day. And they still didn't know what was in there whilst it was burning and it impacted everywhere. The smoke cloud was quite significant. So, it can happen both ways, and either way needs to be adequately dealt with.

Traci: The last one I want to talk about a little bit is this year, obviously, marks the 10th anniversary of the BP Deepwater Horizon oil spill in the Gulf of Mexico, April 20th is actually that anniversary date. It's regarded as one of the largest environmental disasters in American history. The White House commission blamed BP and its partners for a series of cost-cutting decisions, and an inadequate safety system. This resulted in a safety overhaul. Can you give us more insight into what we learned from that? [See: "Look on the Positive Side Of The Oil Spill" and "Deepwater Horizon Prompts Safety Overhaul"].

Trish: So there were a couple of key learnings that really came out of this one for me, I think. And one of them was in decision-making and the decision-making that was taking place. And I've talked about cognitive bias many times. And one of the cognitive biases that was occurring here was confirmation bias. So when they were doing the tests on the cement casing, they were looking for data that suggested the cement casing was good, that it was all done okay, because they thought it was a good cement job to start with. So they were trying to confirm their assumption that it was a good cement job. So that meant they saw the data that suggested the cement job passed the test and didn't actually recognize the data that suggests that it didn't pass the test. Confirmation bias is a really, really difficult one to understand. And it can often be useful, too, in critical situations where decision-making is vital and you've got something going on like determining whether a test has been passed or failed.

It can be really useful to have that devil's advocate in the room really challenging your biases to make sure that you're not just trying to confirm your own assumption, you're actually taking into account all the right information that's necessary at the time. So I think decision-making was a key critical aspect in this particular area. And who's in charge, who's able to make the decisions, and who's able to speak up and say, "No, I disagree. That's not right. We need to do this differently," how are we empowering people to actually speak up at that point in time. And that's a really critical aspect.

There's a story as well about...years before this actually happened, there was another well in the Gulf of Mexico called Blackbeard West. And most people have never even heard of Blackbeard West. That was because nothing went wrong. And the reason potentially that nothing went wrong was because it was a well being drilled at the time by ExxonMobil. And they were starting to get concerned because the pressures and the temperatures were just not right. The engineers were getting quite concerned about the safety of it all. The drillers wanted to keep going because they were really close to their ultimate depth that they were trying to drill to. And it was potentially going to be a massive find. And the decision ended up going all the way up to the then-chief executive of ExxonMobil. And his response was, "Stop the well. It's only been $170 million." And they didn't drill any further. And they walked away from that well.

And at the time, the markets, you know, panned ExxonMobil for not having the guts. They were not brave enough. They should have been out there just exploring. They were too risk-averse. But someone was willing to say, "This is really not right." And that decision went all the way to the top. So imagine, it kept going through level, after level, after level of, "This decision is not right. We need to stop now." So I'm not comparing one company to another. And I'm not saying one's better than another. But it's an example of, you know, really dig into who has the courage to stand up and say, "This needs to stop. And we need to reassess what we're doing because something is not right," and that is a key learning that I think we can take out of the Deepwater Horizon spill.

A couple of others, you know, verification of your critical devices, making sure your blowout preventer actually functions as it was intended to. And it was found afterwards that the blowout preventer was not functioning adequately. So, you know, your critical equipment, making sure that it actually functions, you do your complete testing on it and you know that it actually works, and monitoring your lead safety metrics. So in this instance, well kicks would have been a metric to have monitored, to have seen what was actually going on with that well as they were drilling it. Other lead metrics would have been...had the maintenance being done to schedule on the BOP before it was installed and tested. Lead process safety metrics are indicators that are absolutely vital. And then we need to really delve in and understand what they're telling us. Just ticking the box and having the number looking pretty on the chart is not what we need. We need the insight behind it. We need to know what it's telling us and what information we can get from that.

Traci: All great lessons learned on all four of these incidents. And I don't want to make it sound like we're just picking on all the Texas City incidents. But for this time period, in April, these are the anniversaries, do you have anything else you'd like to add? I know that we only touched on those four but maybe you have something else that you want to add to this conversation in terms of lessons learned from these incidents?

Trish: I think we need to remember that it's actually easy to judge the past. But rather than judge it, we need to try and understand why things were done and then look at how we can do better, why were the decisions made and how can we change the context of those decisions. So we change the context in our own workplaces so we don't fall into the trap of making similar decisions that result in incidents. And I think that's something that we keep missing the point on. And as I said, it's easy to judge and we jump to judgment very, very quickly. But judgment of what happened doesn't necessarily help us. We need to really unpack why the decisions were made. Then we can try and do something different.

And the other part of that is as we read through the incident reports that have happened in other organizations, we also often hear people say, "Well, that can't happen here." And to me, "That can't happen here," are the four most dangerous words we could ever put together in the English language when we're talking about process safety. Because the moment you say them, you're actually setting yourself up for it to happen because that's complacent. And the complacency will one day lead to the incident. So the better question to ask is, how can that happen here? And what controls do I have in place to prevent that? How can I manage that?

Let me go through my controls and understand whether they really work, are they really delivering the risk reduction that I think they are? That, I think, is the most important part to come out of some of these lessons. And, you know, tragically, April is a significant month. In fact, so with March for other reasons. These incidents have occurred and we need to acknowledge them. And we need to try and figure out how we can apply the learnings, and understand how it can happen in our facility.

Traci: Well, once again, the voice of reason with sage advice. You did allude to the webinar that we did do on Learning from Incidents also great information in that.  [See: "Process Safety Series: Learning from Incidents"]. So, something to be aware of as well. As evidenced by this podcast today, unfortunate events happen all over the world. And we will be here to discuss and learn from them. On behalf of Trish, I'm Traci. And this is "Process Safety with Trish & Traci."

Trish: Stay safe.

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