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GCI TECH NOTES©
Volume 8, Number 1 A Gossman Consulting, Inc. Publication January 2003
Caused
by Multiple
Failures of Elements Within a Safety Management System
by
Dave Constans,
Gossman Consulting, Inc.
There
have been some rather spectacular catastrophic accidents at hazardous
waste
management facilities during the last few years. The explosion of a
rail car at
a hazardous waste fuels facility near Logansport, Indiana in February
of 1999
probably being the most spectacular.
Rarely are such incidents the result of a single event. While a
specific
event does immediately precede such a catastrophic accident, this event
alone
will not in-and-of-itself cause the accident to happen.
An
examination of the multiple elements needed to result in a fire is an
example of
this. To have a fire, whether it is to warm your house or to burn a
forest,
requires three things; fuel, oxygen and an ignition source. Remove any
one of
them and a fire cannot occur. This same principle may be applied to
devising
safety systems for industrial facilities and can be extended to prevent
a wide
range of potential accidents.
Regulatory
Requirements Will Never be Adequate The EPA mandates a number of requirements in
its regulations;
requirements regarding the prevention of accidents, personnel training
and
contingency planning to name a few. Clearly the regulations can never
enumerate
all of the necessary considerations that facility management must
address to
ensure the safe operation of the facility to secure the protection of
human
health and the environment. Nor would the hazardous waste management
industry
survive such an enumeration and subsequent bureaucratization of endless
regulatory requirements. Indeed the EPA has an entire program dedicated
to
raising our awareness of accident prevention (http://yosemite.epa.gov/oswer/ceppoweb.nsf/content/index.html.)
In one document, a case study of an explosion at a fuel blending
facility in
Oklahoma, the EPA stated in the introductory paragraph: “Major chemical
accidents can not be prevented solely through command and control
regulatory
requirements; understanding the root causes of accidents, widely
disseminating
these lessons learned into safe operations are also required.” (EPA
550-F00-001, April 2000, http://yosemite.epa.gov/oswer/ceppoweb.nsf/vwResourcesByFilename/chiefinl.pdf/$File/chiefinl.pdf.) Let us repeat
that: “Major chemical accidents
can not be prevented solely through command and control regulatory
requirements…” an amazing admission from one of the government’s
most
regulation prolific agencies. The
EPA
is right, but be warned! The fact that
the EPA is making an effort to raise industries’ awareness of accident
prevention will not preclude them from adding additional regulations
particularly if industry does not respond. Herein lies the purpose of
this
TechNotes.
Safety
Management Systems
The
management of hazardous waste is inherently complex. Unlike a chemical
production facility, which handles tons of the same 10 or 15 chemicals
year
after year, a hazardous waste facility handles tons of maybe 100, 200
or more
chemicals each year and often at a receipt frequency that lulls
management into
a routine that has not addressed all of the variabilities that each
waste
receipt presents. Hazardous waste after all, is a waste not a
specification
product. This is what is left over (or mistakenly produced) during the
production of a product or the completion of a service. It is safe to
say that
every receipt should be approached as if it were a “surprise” no matter
how
often similar material has been received or how consistent the
generator has
been. Yet, exhibiting safe practices beginning at time of receipt is
starting
way too late. The safe management of hazardous wastes has to start when
the
facility is first planned and the people first hired and must be
systematically
unrelenting there after. This may seem boringly obvious and our
emphasis of it
overly dramatic, but multiple failures of elements of a safe hazardous
waste
management program are the cause of catastrophic accidents, not that
last fatal
act by an unaware operator.
Examination
of One Accident Points out Many System Failures
In
the case study noted above, the story is quite simple. About 200
gallons of
waste solvent was mixed with about 2 gallons of dry oxidizers; a
mixture of
chlorates, perchlorates and nitrates. In less than a minute this
exploded out
of the mixer fatally engulfing one man and starting a large fire in a
building
storing flammable liquids. Clearly, mixing flammable liquids with
oxidizing
chemicals is an unbelievably stupid thing to do - but it happened. It
happened
because the full nature of the chemical characteristics was not
investigated
and understood, so that a plan of action could be proposed, that
proposal
evaluated for safety and the approved plan presented as a standard
operating
procedure (SOP) and the operators trained to safely execute the SOP. It
may be
that there was no safe way of doing this, but in that case the initial
investigation would have made that determination.
In
the end the preventative steps drawn from an examination of this one
simple
incident are the same ones GCI has advocated after every accident we
have
investigated and prior to operation of every facility we have set up. Quoting directly from the case study, those
preventive steps are:
·
The chemicals and
reaction mechanisms associated with the substances
mixed or blended must be well understood and documented. Facilities need to conduct
the necessary information searches or laboratory tests to ensure that
all
reaction mechanisms are known and documented, especially those that may
trigger
fires or explosions as a result of abnormal situations or changes in
chemicals
mixed.
·
Chemical and process
hazards must be understood and addressed. Once the reaction
mechanisms are well understood, facilities need to ensure that process
equipment, controls, and procedures are designed, installed, and
maintained to
safely operate the process. A formal hazard review using techniques
like
‘What-If’ or ‘Hazop’ can help identify opportunities for failure (e.g.,
human
error, mechanical failure) and layers of protection to minimize the
consequences
of such failures, based on established codes and standards, industry
practices,
regulations (federal or state) and common sense.
·
All employees need to
understand the chemical and process hazards. All personnel should
openly communicate information about hazards and process conditions and
understand the consequences of deviations and unusual situations.
Facilities
should establish mechanisms for documenting and sharing such
information.
·
Standard Operating
Procedures (SOPs) are essential to safe operations. Facilities should
establish a system to develop and maintain written SOPs and ensure that
they
are understood and followed at all times. The SOPs must address all
phases of
operation, safe limits for operation, consequences of deviation, and
identification of corrective measures during emergency situations.
·
Before starting a
process or procedure that has been changed or
modified, the chemical and process hazards must be evaluated. Abnormal or non-routine
circumstances are a leading factor in chemical accidents. Facilities
should
make use of management of change (MOC) and pre-startup safety review
techniques
to ensure that modified processes or procedures will function as
intended
without unanticipated impacts on other operations.
·
Employees must be
properly trained in the processes they work on using
the SOPs for that process or job tasks. Training must include potential hazards,
reduction
of those hazards, safety consequences if procedures are not followed,
and
proper emergency response to abnormal situations. Training should
contain clear
and concise objectives that can be easily evaluated for operator
competence.
In
some of the more spectacular incidences that GCI has examined every
one
of these steps were either ignored or truncated.