Tag Archives: Incidents

What can we learn from the Fernie Ammonia fatalities?

Posted on July 30, 2018 by Brian Chapin

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 →

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Learning from Failure

Posted on May 17, 2018 by Brian Chapin

“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 →

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How to get Willful OSHA Citations & Fines

Posted on February 16, 2017 by Brian Chapin

The incident we are discussing today is from a recent ruling in the United States Court of Appeals, Seventh Circuit where they recently denied a petition for review in the case of “DANA CONTAINER, INC. v. SECRETARY OF LABOR.” While this … Continue reading →

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Pencil-Whipping can Kill

Posted on December 15, 2016 by Brian Chapin

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

Posted on October 23, 2016 by Brian Chapin

  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

Posted on October 14, 2016 by Brian Chapin

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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When does a Car-Seal program make sense for Industrial Ammonia Refrigeration systems?

Posted on September 9, 2016 by Brian Chapin

First off: What is a Car-Seal program and what does it do?  A Car-Seal program is designed, implemented and managed to ensure that safety-critical valves within the covered process are maintained in their safety-critical position / setting during normal system … Continue reading →

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What the Ammonia refrigeration industry can learn from West, TX

Posted on January 29, 2016 by Brian Chapin

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

Posted on March 27, 2015 by Brian Chapin

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…”

Posted on May 6, 2014 by Brian Chapin

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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