Liquid Nitrogen Dewars Near-miss Report
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1 Purpose To share lessons learned gained from incident investigations through a small group discussion method format. To understand lessons learned through a Systems of Safety viewpoint. This material was produced by the Labor Institute and the United Steelworkers International Union under grant number 46DO-HT11 Susan Harwood Training Grant Program, for the Occupational Safety and Health Administration, U.S. Department of Labor. It does not necessarily reflect the views or policies of the U.S. Department of Labor, nor does mention of trade names, commercial product or organizations imply endorsement by the U. S. Government. Volume 07, Issue The Labor Institute 1
2 Background Information Before beginning this, please review this and the next page which contain information that will introduce the concepts of and Systems of Safety. Creating a safe and healthy workplace requires a never ending search for hazards that sometimes are not obvious to us. These hazards exist in every workplace and can be found by using various methods. are just as the name suggests: learning from incidents to prevent the same or similar incidents from happening again. Systems Are Not Created Equal: Not equal in protection and not equal in prevention. Using our Systems Focus to uncover system flaws or root causes is only one part of controlling hazards. We also need to look at the systems involved to decide on the best way to deal with the problem. The most effective way to control a hazard is close to its source. The least effective is usually at the level of the person being exposed. The system of safety in which the flaw is identified is not necessarily the system in which you would attempt to correct the flaw. 2
3 Liquid Nitrogen Dewars Near-miss Report Major Safety System Level of Prevention Design & Engineering Highest the first line of defense Maintenance & Inspection Mitigation Devices Warning Devices Middle the second line of defense Training & Procedures Personal Protective Factors Lowest the last line of defense Effectiveness Most Effective Least Effective Goal To eliminate hazards To further minimize and control hazards EXAMPLES OF SAFETY SUB- SYSTEMS** Technical Design and Engineering of Equipment, Processes and Software Management of Change (MOC)** Chemical Selection and Substitution Safe Siting Work Environment HF Organizational (must address a root cause) Staffing HF Skills and Qualifications HF Inspection and Testing Maintenance Quality Control Turnarounds and Overhauls Mechanical Integrity Enclosures, Barriers Dikes and Containment Relief and Check Valves Shutdown and Isolation Devices Fire and Chemical Suppression Devices Machine Guarding Monitors Process Alarms Facility Alarms Community Alarms Emergency Notification Systems Operating Manuals and Procedures Process Safety Information Process, Job and Other Types of Hazard Assessment and Analysis Permit Programs Emergency Preparedness and Response Training Refresher Training Information Resources Communications Investigations and To protect when higher level systems fail Personal Decisionmaking and Actions HF Personal Protective Equipment and Devices HF Stop Work Authority Management of Personnel Change (MOPC) Work Organization and Scheduling HF Work Load Maintenance Procedures Pre-Startup Safety Review Allocation of Resources Buddy System Codes, Standards, and Policies** HF - Indicates that this sub-system is often included in a category called Human Factors. * There may be additional subsystems that are not included in this chart. Also, in the workplace many subsystems are interrelated. It may not always be clear that an issue belongs to one sybsystem rather than another. ** The Codes, Standards and Policies and Management of Change sub-systems listed here are related to Design and Engineering. These subsystems may also be relevant to other systems; for example, Mitigation Devices. When these sub-systems relate to systems other than Design and Engineering, they should be considered as part of those other system, not Design and Engineering. Revised October
4 Title: Liquid Nitrogen Dewars Near-miss Report Identifier: Volume 07, Issue 34 Date Issued: March 1, 2007 Statement: Using the Systems of Safety approach will identify root causes and the systems fixes to prevent this type of incident. A well-designed loading dock would be an application in the Design and Engineering System of Safety. Application of the Maintenance and Inspection System of Safety would ensure loading docks are inspected and maintained to prevent load shifts that could potentially cause incidents. 4
5 Liquid Nitrogen Dewars Near-miss Report Discussion: Five full liquid nitrogen Dewars nearly tipped over on employees; resulting in a near-miss incident. Two warehouse employees were transferring full liquid nitrogen Dewars from the dry air plant filling station to the cylinder transport pan on their fork truck. The 6 x 6 x 12 bumper block mounted on the face of the dock is used as a guide to level the cylinder pan with the dock, allowing ease of loading/unloading Dewars from the station. The pans, which weigh approximately 700 lbs. each, resulted in 4,000 4,500 lbs. of weight on the bumper block. The bumper block was mounted to the concrete dock with six anchor bolts approximately six inches in length and spaced approximately two feet apart. The anchor bolts only penetrated the concrete dock face approximately 1.5 inches. A chunk of concrete was missing at each anchor bolt location indicating that their shallow depth did not provide sufficient holding strength. While the pan was resting on the bumper block during the loading of the liquid nitrogen Dewars, the bumper block broke free from the dock. This allowed the cylinder pan to tilt forward, causing the nitrogen Dewars to roll and tip forward. The warehouse employees were able to stop the movement of the Dewars and prevent any further incident or injury. When the Dewars were stabilized, one employee was able to operate the fork truck and level the cylinder transport pan. The incident was then reported to their supervisor. 5
6 Analysis The Logic Tree is a pictorial representation of a logical process that maps an incident from its occurrence, the event, to facts of the incident and the incident s root causes. Event Nitrogen Dewars tilted Dewar carrying pan tilted Workers moving Dewars Bumper block broke loose Lip of pan resting on bumper block No SOS Failure Approximately 4,000 lbs. of load on pan Insufficient anchor bolt depth (Root Cause) No added support for bumper block (Root Cause) Created level surface for cylinder transition Weight of lifting plate and five full Dewars SOS Failure Maintenance and Inspection (Mechanical Integrity) SOS Failure Design and Engineering No SOS Failure No SOS Failure 6
7 Liquid Nitrogen Dewars Near-miss Report Recommended Actions 1. Engineering redesign the 6 x 6 x 12 load-bearing surface. 2. Consult warehouse personnel before replacing the 6 x 6 bumper block to accommodate their needs. 3. Ensure all other bumper blocks on the plant site meet their design parameters. 4. Provide additional support to the bumper block to bear the weight to be applied. 5. When attaching bumper blocks, ensure adequate anchor bolt depth is achieved into the concrete. 7
8 Education Exercise Working in your groups and using the Statement, Discussion, Analysis and Recommended Actions, answer the two questions below. Your facilitator will give each group an opportunity to share answers with the large group. 1. Give examples of ways to apply the Statement at your workplace. 2. Of the examples you generated from Question 1, which will you pursue in your workplace? (Note: When we say something you may pursue, we mean a joint labor-management activity or a union activity rather than an activity carried out by you as an individual.) 8
9 Liquid Nitrogen Dewars Near-miss Report Trainer s Success Inventory Following a (LL) session, the trainer who led the LL should complete this form. This information will: 1) Help you reflect on the successes and challenges of the session; 2) Help USW with new curriculum development; and 3) Help USW as a whole better understand how the LL Program is supporting their workers. By reviewing LL from different sites or from other areas of their workplaces, workers are able to analyze the information and apply these lessons to their own workplaces in order to make their workplaces healthier and safer. 1. Site name (if there are participants from ore than one site, please list all). 2. Date of LL training 3. LL number used in today s Training 4. Your name 5. Summary of Education Question 1: Please summarize participants examples of ways to apply this LL Statement to their workplace. Please continue on reverse side. 9
10 6. Summary of Education Question 2: Please summarize which actions or recommendations participants discussed pursuing at their workplace(s). Thank you for completing this form. 10
11 Liquid Nitrogen Dewars Near-miss Report EVALUATION : Liquid Nitrogen Dewars Near-miss Report Please answer the two questions below: 1. How important is this lessons learned to you and your workplace? (Circle one.) Rate on a scale of 1 to 5, with 5 being the most important What suggestions would you make to improve this? 11
12 End of Training Trainer s Instructions Please complete the information below. Trainer s Name (Please Print) Date of training: No. of Participants: Total Hourly Management Location of Training: USW Local # Send: 1. This page; 2. The Education Exercise (page 8); 3. The Trainer s LL Success Inventory form (pages 9 and 10); 4. The evaluation for each participant (page 11); and 5. The Sign-in sheet (page 13) to: Doug Stephens United Steelworkers International Union 3340 Perimeter Hill Drive Nashville TN Thank you for facilitating the sharing of this Lesson Learned with your coworkers. 12
13 Liquid Nitrogen Dewars Near-miss Report Sign-in Sheet Name of Class Date of Class Instructors: Please Check One* H M Print Name Signature *H = Hourly Worker M = Management or Salaried Worker 13
14 14
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