Category Archives: Incidents

Pencil-Whipping can Kill

What is it? Pencil-whipping is when you complete a form, record, or document without having performed the implied work or without supporting data or evidence. Here are some common examples in NH3 refrigeration: Completing “word orders” without conducting the work … Continue reading

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Militarized Incompetence or Unintentional Sabotage

  In 1944, near the end of WW2, the Office of Strategic Services (the forerunner to the CIA) released a field guide called the “Simple Sabotage Field Manual.” The purpose of the suggestions in the manual was “to present suggestions … Continue reading

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APR’s aren’t Magic

When I see people writing “Have a Full-Face APR (Air Purifying Respirator) nearby, within arm’s reach” in their Line/Equipment Opening (aka Line Break) procedures, my blood-pressure shoots through the roof. Yes, I know I am a rather excitable guy by … Continue reading

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What the Ammonia refrigeration industry can learn from West, TX

Last night I attended the CSB Public Meeting in Waco, TX concerning the 2013 West, TX Ammonia Nitrate explosion. The purpose of the meeting was to release their report on the incident. The explosion resulted in 15 fatalities and 260 … Continue reading

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Shock to the system

The CSB just released a video on the August 23, 2010 Alabama ammonia release. While not perfect, it is a worthwhile video to watch as it might just make you question how you should deal with the type of power-failure issues … Continue reading

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Lessons Shared #2 – “That policy is for other people…”

This post is part of a series on Lessons Shared… This incident is about a common problem in PSM plants: Some people don’t think the rules apply to them. This story is from a friend who works as a refrigeration … Continue reading

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$205,000 fine for dumping 40 pounds of ammonia

Kodiak fish processor North Pacific Seafoods pleaded guilty Tuesday in federal court to illegally dumping ammonia into the Kodiak city sewer, while the processor’s chief engineer faces charges of his own. District Court Judge Ralph Beistline imposed $205,000 in criminal … Continue reading

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Lessons Shared #1 – “The Graveyards are full of Heroes”

I had to fight back tears the first time I read this NIOSH report. Having lived on a family farm for a short period, it was very easy for me to imagine the reaction of the people involved… A 43-year-old … Continue reading

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The “PSM Lessons Shared” project

Recently, during a PSM class, I had a student with an all-too-common issue: How do I change the incident reporting culture at my facility? As a new PSM coordinator he was struggling because he couldn’t get his operators to report … Continue reading

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CSB Releases Safety Video on 2009 Fatal Blast at NDK Crystal – Animation Depicts Stress Corrosion Cracking; Vessels Were Not Inspected or Tested

Today the CSB issued a report on a 2009 vessel failure that it blamed on Stress Corrosion Cracking. There are some interesting lessons to be learned about incident investigation in this report since the mechanism that led to the vessel’s … Continue reading

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