Category Archives: Incidents

What can we learn from the Fernie Ammonia fatalities?

The October 17th, 2017 Ammonia release in Fernie, BC resulted in three fatalities: On October 16, 2017, the curling brine chiller at the Fernie Memorial Arena was put back into operation after a seasonal shutdown. During the shutdown and seasonal … Continue reading

Posted in Community Involvement, General Duty, Incidents | Tagged , , , , , , , | Comments Off on What can we learn from the Fernie Ammonia fatalities?

Learning from Failure

“Failure is only opportunity to begin again. Only this time, more wisely.” –Henry Ford We often push PSM practitioners to perform Incident Investigations for fairly minor events in the hopes that the lessons learned from those minor incidents will stop … Continue reading

Posted in Culture, General Information, Good Engineering Practices, Incidents, OSHA, System Optimization | Tagged , , , , , | Comments Off on Learning from Failure

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

Posted in Compliance, Culture, General Information, Incidents, Inspections, Mechanical Integrity, Operator Training, System Optimization | Tagged , , , , | Comments Off on Pencil-Whipping can Kill

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

Posted in Culture, Incidents, Oddities, Training | Tagged , , , | Comments Off on Militarized Incompetence or Unintentional Sabotage

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

Posted in Culture, Incidents, Operator Training, Training | Tagged , , | Comments Off on APR’s aren’t Magic

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

Posted in Community Involvement, Compliance, CSB, Culture, Good Engineering Practices, Incidents | Tagged , , , | Comments Off on What the Ammonia refrigeration industry can learn from West, TX

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

Posted in Community Involvement, Compliance, CSB, Good Engineering Practices, Incidents | Tagged , , , , | Comments Off on Shock to the system

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

Posted in Compliance, Culture, Incidents | Tagged , , | Comments Off on Lessons Shared #2 – “That policy is for other people…”

$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

Posted in Community Involvement, Compliance, EPA, Incidents | Tagged , , | Comments Off on $205,000 fine for dumping 40 pounds of ammonia

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

Posted in Culture, Incidents, Operator Training, Training | Tagged , , | Comments Off on Lessons Shared #1 – “The Graveyards are full of Heroes”