The Risk Management Tool Box Blog

Stowaway Risk to Shipping

Graham Marshall - Monday, September 01, 2014

Here is a link to a Marine Safety Forum Safety Alert highlighting the risk of stowaway incidents on ships in port.

Dropped Object on Rig

Graham Marshall - Saturday, April 20, 2013

The dangers of dropped objects during rig work is highlighted by this Safety Alert from APPEA.

In the incident, a cheater bar was placed into an open mess-sided cage which allowed the bar to slip out and fall to the drill floor.

Importance of Securing Loads

Graham Marshall - Monday, April 08, 2013

All loads, whether large or small should be adequately secured when being transported by road.

The Origin Energy safety alert shown below highlights how packing crates which are not fit for purpose, or have become unfit for purpose over time can become dangerous in themselves.

The incident shows how a  part of the packing crate disintegrated and was ejected from a moving vehicle on a highway in Queensland Australia.

This high-potential incident could have led to disastrous consequences, but in this instance, luck intervened and no other road users were harmed.

Dropped Valve Actuator

Graham Marshall - Sunday, April 07, 2013

This Woodside safety alert shows how a 200 kg valve actuator was able to fall a distance of 20 metres to the deck below the crane before falling over the side and into the ocean.

The safety alert highlights the need for good risk assessment prior to any lift, the development of an appropriate lift plan for the specific lift in question, and the need for any person directing the lift to be standing in a place of safety.

We would suggest that a lift such as this should also be covered under an appropriately written and specific procedure.

Vacuum Truck Fire Safety Alert

Graham Marshall - Thursday, April 04, 2013
An industrial vacuum truck was vacuuming out a sump in a reagent area of a mineral processing plant when the vacuum pump motor caught fire. 

The fire then ignited gases in the interceptor (the large receiving tank on back of truck) that had built up to explosive levels. 

Material was ejected up to 30 m away.

Investigation showed that the fire was started by a wire leading from the battery to the vacuum pump starter motor. 

The wire was not protected by a fuse and overheated, igniting the wire’s insulation. 

The resulting fire then ignited gas that had built up in the interceptor. 

The gas came from the sludge material that was being cleared up by the truck. 

The sludge included residue and material from the sodium ethyl xanthate tank in the storage bund. 

This material is itself spontaneously combustible, but it can also produce combustible and explosive carbon disulphide gas and ethanol vapors. 

Additionally, the vacuum truck was not fitted with any fire suppression other than a hand-held extinguisher.

Recommendations

1. Identify any sumps that may contain hydrocarbons or other flammable materials before clean up work starts and discuss this information with the workers undertaking the task. 

2. This information must be input to the risk assessment process used for this type of task at your mine.

3. Ensure that suitable electrical protection techniques are used with such diesel pump and motor installations. 

4. Check similar types of equipment and assess whether additional controls, including an appropriate fire suppression system, are needed.


Vehicle Roll Over in Queensland

Graham Marshall - Thursday, January 17, 2013

The Safety Alert shown below highlights the dangers of pulling onto the soft shoulder of narrow rural  bitumen roads when allowing larger vehicles to pass.

In the recent incident in Queensland, two workers narrowly avoided serious injury or a fatality when they lost control of a vehicle, resulting in a high speed roll over.

The vehicle had been driven off the road to accommodate an oncoming truck on a narrow regional road.

The driver lost control of the vehicle on the unsealed road whilst attempting to return to the bitumen.

The Safety Alert illustrates a number of key learning points which are worth sharing with drivers exposed to rural road conditions.

Potential Danger of Working with Pressurized Hoses

Graham Marshall - Monday, January 14, 2013

Enclosed here is an excellent Safety Alert from the Marine Safety Forum which highlights the all-to-common situation in which an experienced work crew is performing a "routine task" and something goes wrong.

In the example shown, an Able-bodied Seaman is struck by a whipping hose which came apart when it was inadvertently pressurized.  Thankfully, the sea farer suffered relatively minor injuries compared to what could have been a very serious incident had he been struck about the head.

The safety alert should prompt all work crews everywhere to not consider "routine" jobs to be low-risk just because they've been performed often and incident free in the past.

Whenever a job involves hazards, there is always the potential for harm if we don't keep our whits about us.

 Perhaps Supervisors could re-inforce this message with a good tool-box talk today!

 

Accident Deaths in the UK

Graham Marshall - Tuesday, January 08, 2013

Falling over at home is now twice has likely to kill people in the UK in relation to being killed in a car crash.

Since the early 1990s, when there were more people killed in car wrecks in the UK, the number of accidental deaths in the home has risen to about 5,000 per year.  But deaths in car accidents have fallen by a third to about 2,000 each year on UK roads.

The report into accidental death in the UK, published by the Royal Society for Prevention of Accidents shows that falls account for most accidental deaths in the home; and accidental poisoning by carbon monoxide is another major killer.

The RSPA noted that road safety improvements have come about because of a systematic road safety strategy led by the Department for Transport, but that accident prevention in the home had been "sidelined" by the National Health Service (NHS) which focused exclusively on treating people rather than preventing harm.

Fundamental Attribution Error in Incident Investigations

Graham Marshall - Friday, January 04, 2013

When examining and explaining the behaviour of other people, there is sometimes a tendency for incident investigators to overestimate the effect of internal "attitudinal" factors, and underestimate the effect of external factors on that behaviour.

In psychology, this problem is known as the Fundamental Attribution Error.

You'll have seen the Fundamental Attribution Error at work when you hear someone say "the person involved in the incident was a bit stupid, or had a poor attitude."

But the problem with adopting a focus on attitudes as a key safety failure mechanism is that it ignores what Psychologists know about mechanisms of the brain.

Many psychological studies have shown that people will experience attention failures, memory lapses, slips of action and mistakes based on incorrect knowledge or experience.

None of these failures can be explained by attitudes alone.

And an attitudes-based focus to incident causation is unlikely to resolve most of these failure mechanisms.

And even deliberate and willful violations of safety rules which do have a strong "attitudinal componant" often occur in response to external pressures rather than just being driven by internal attitudes.

Good incident investigations avoid the fundamental attribution error by recognising the range of failure mechanisms of the brain and the role of external factors in those failures.

And organizations with mature safety culture design error-tolerant work arrangement based on identifying which errors are most likely to occur.

Moreover, mature organizations view incidents as an opportunity to learn something about their systems, assets, or culture, rather than blaming individual workers and their "negative" attitudes.

Finally, they recognise that safety attitudes are most effectively fostered through genuine leadership practices and leading by example at all levels of the organisation, every day.

NOPSEMA Report into Montara Blowout

Graham Marshall - Sunday, December 30, 2012

NOPSEMA has published a report prepared by an independent expert witness in relation to the Montara wellhead platform blowout on 21 August 2009 involving PTTEP AA.

Colin Stuart provided an expert opinion to assist in the investigation of the incident and to support the brief of evidence referred to the Commonwealth Director of Public Prosecutions.

The report provides comprehensive consideration and analysis of the events leading up to, and immediately following, the incident and has been published by NOPSEMA to allow industry to benefit from key lessons learned, in particular improving barrier integrity awareness.

 

The report is available for download in three volumes via the Safety resources web page at NOPSEMA.

 

 


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