October 7th, 2009| by Dr. Saraf |
CSB’s approach to chemical accident investigation is a step further than OSHA’s. CSB gathers background information about the accidents, performs a detailed root cause study, and makes recommendations to appropriate stakeholders. Great approach to a complex issue…but CSB’s strategy following the investigation leaves a lot to be desired.
The hope from CSB’s accident investigations is that the lessons learnt will prevent other manufactures commit similar errors. For CSB’s investigation to be helpful in accident prevention, the recommendations that come out of CSB’s investigations must have following traits:
- Clear and actionable
- Who should take the action
- How the action be implemented
Most of CSB’s recommendations appear to be non-specific and vague.
Non-Specific Recommendations
CSB’s recommendations are not directed to the appropriate stakeholder in many cases and are often too vague.
As an example, below are lessons learnt from CSB’s investigation of explosion at Syntron LLC (2006). I’m only pasting first few lines (pg. 14-15)…you can get the details in the pdf.
- Manufacturers should take a comprehensive approach, and identify and characterize reactive hazards;
- Chemical manufacturers and others with reactive chemistry operations should control changes to batch recipes, including key operating conditions
- Manufacturers with reactive chemistry operations should document the performance requirements and capabilities of process equipment
- Train Personnel on Hazards and Procedures
- Manufacturers should implement an effective emergency plan
All the above statements are basically telling manufactures to “be safe” without giving them any concrete tools to implement the recommendations. Furthermore, these are all known safe-work practices and are covered under current PSM requirements.
CSB’s most recent report on T2 reactive explosion contains TWO recommendations to the American Institute of Chemical Engineers (AIChE) and Accreditation Board for Engineering and Technology (ABET) to introduce a course on reactive chemicals at the engineering bachelor level. OMG…half-a-million dollars or more of investigation for this trivial recommendation!
Communication of Recommendations
Let us say that CSB does have actionable recommendations then further consideration should be given to the message and how it is communicated. Thick reports in “dull” English may not be the optimum way to reach the desired audience. Nowadays creating videos and audio-podcast is not expensive. iPod and YouTube represent a great way to reach audience and capturing their attention; however, the key again is the message. Look at the following YouTube video from CSB about maintaining safety during recession…it is advising you to “be safe” without providing any insights on how to do so.
The issue isn’t just the tools…the issue is depth of the message.
Final Word
CSB has to significantly distill its lessons learned from accident investigations to create practical information valuable to workers and the process industries. Generic recommendations and generic safety messages will not help future accident prevention.
CSB has an incredible opportunity to impact process safety community across the world and a bit of upfront strategic planning will go a long way. Unfortunately, from what I have seen so far the CSB does not have the depth or the vision to make valuable contribution towards worker safety within the process industries.
Posted in Chemical Accidents, Process Safety, Regulations | 2 Comments »