Incidents Continue to Happen
Washington DC, August 15, 2016 - An investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that injured seven workers – including three critically – that occurred Friday August 12 at the Sunoco Logistics Partners, a terminal facility in Nederland, Texas. According to initial inquiries the incident involved a flash fire during welding – also referred to as hot work - activities at the facility. Hot work is defined as burning, welding, or similar spark-producing operations that can ignite fires or explosions. Media reports state that all of the injured were contractors engaged in work activities on a crude oil pipeline connection.
–– US Chemical Safety Board
"We typically hear about hot work accidents weekly. It has become one of the most significant types of incidents the CSB investigates, in terms of deaths, in terms of frequency."
–– CSB Investigations Supervisor Donald Holmstrom, 2010
“The CSB has identified over 60 fatalities since 1990 due to explosions and fires from hot work activities on tanks. Hot work is defined as “work involving burning, welding, or a similar opera-tion that is capable of initiating fires or explosions.” Hot work also includes other activities with the potential to create a source of ignition such as cutting, brazing, grinding, and soldering. Workers are potentially at risk not only in the oil and gas industry, where flammables are handled regularly, but also in many other sectors within general industry, such as food production, paper, and wastewater treatment.”
–– Seven Key Lessons to Prevent Worker Deaths During Hot Work In and Around Tanks, CSB 2009
“According to insurance industry statistics, hot work operations are one of the largest causes of fire loss in the workplace.”
–– EMC Insurance Company
“Hot work operations conducted outside of a designated hot work area (a weld shop for exam-ple) are a major cause of fires. Between 2005 and 2009, the United States averaged 3,165 fires, $145 million in property damage, 8 deaths, and 116 civilian injuries per year relating to torch, soldering, and burner equipment.”
–– National Fire Protection Association (NFPA), March 2011
Maintain a Sense of Vulnerability
A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future! Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
- Do you require consistency in practice from everyone in the organization?
- Do you have systems in place to determine if inconsistencies exist?
- Do people believe that “yes, it can happen here”?
- Do people believe that “yes, we have similar vulnerabilities”?
- Have you experienced similar incidents but without consequences (i.e., near misses)?
- Do you combat organizational overconfidence that can be stimulated by past good performance?
- Do discussions on potential vulnerabilities take place between operations and senior leadership?
Prevent Normalization of Deviation
Normalization of deviation is defined as…
“The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.”
–– Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)
“A gradual erosion of standards of performance as a result of increased tolerance of nonconformance.”
–– CCPS Glossary (iPhone Application)
Signs of Normalization of Deviations – Does this describe your organization?
- If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
- Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
- Are the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
- Do you allow operations outside established safe operating limits without a detailed risk assessment?
- Are willful, conscious, violations of established procedures tolerated without investiga-tion or without consequences for the persons involved?
- Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
- Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago? For example:
- Do you allow hot work to start/progress with an LEL reading greater than 2%?
- Are all employees empowered to stop work for any situation deemed unsafe?
Evaluate Your Program
Do you audit your Hot Work program to ensure the program is yielding the intended results?
Do you review the following items:
- Written Hot Work procedure?
- Hot Work permits?
- Roles and responsibilities of persons involved in Hot Work activities?
- Training and competency provided to persons involved in Hot Work activities?
- Hazard assessments performed before Hot Work activities are conducted?
- Job observations performed on Hot Work activities?
Have you audited your Hot Work permits and discussed the results of the audits?
Was there evidence that:
- Permits were not completely filled out (i.e., no LEL reading)?
- Permits were not signed?
- Permits showed evidence that the Fire Watch failed to remain on site after job comple-tion?
- The permit writer was not trained?
- The fire watch not trained?
- Permit conditions were not communicated within the subject work team?
- Work was not coordinated between work groups (permit writing group vs. group(s) that perform the work?
- Work extended beyond the authorized period of time?
- The work area covered by the permit was too large?
- Certain technical provisions of the permit were not followed?
- Gas detection was not performed properly or continuously?
Have you evaluated your Hot Work audit program?
- To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
- To ensure the competency levels of the auditors?
- Does your Hot Work procedure reflect the desired intent and is this intent adequately detailed in procedural instruction?
- Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
- Does the execution of the procedure yield the intended results? Are you evaluating your program for:
- Procedural Compliance – are actions and tasks in compliance with procedural requirements? (Paper Control), and
- Program Health – is your system providing the intended results? (Actual Execution)
- Do you know of any site or company incidents related to Hot Work?
- Have you discussed the results and causes within your organization?
- Do you know of any site or company near misses related to Hot Work?
- Have you discussed the results and causes within your organization?
Continually Improve Your Program
Are you considering improvements to prevent future incidents? Here are some ideas you may want to consider:
- How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?
- How frequently and what methods are used to calibrate the LEL meters?
- Do you have sufficient LEL meters to support all hot work?
- Do you track specific hot work-related metrics that can be used to determine program effectiveness and improve performance?
- Have you benchmarked your program against other programs in your industry?
- How often do your senior managers visit the field to watch hot work in action?
- Do you have a requirement to periodically update your program?
- Do your workers (those closest to the work), have an easy method to suggest improvements to your program?
Organizational Culture
A successful Hot Work program depends on the actions of individuals within the organization. Do the values and behaviors of your organization determine the manner in which your Hot Work program is managed and executed?
- Does management and supervision reinforce desired behaviors to ensure they be-come integrated into the group’s values?
- Are high standards of Hot Work performance clearly established?
- Is open and effective communication encouraged and supported?
- Has management established safety as a core value?
- Does management and supervision provide strong leadership?
- Has management formalized the safety culture emphasis and approach?
- Does management work to ensure employees maintain a sense of vulnerability?
- Are individuals empowered to successfully fulfill their safety responsibilities?
- Does management ensure open and effective communication exists?
- Does management support and foster mutual trust?
- Does management establish and enforce high standards of performance?
- Does management defer to expertise?
- Has management established a questioning/learning environment?
- Does management require timely responses provided to safety issues and concerns?
- Does management provide continuous monitoring of performance?