Impact of Societal Norms on Safety, Health, and the Environment
Case Studies in Society and Safety Culture
1. Auflage November 2022
672 Seiten, Hardcover
Wiley & Sons Ltd
ISBN:
978-1-119-83002-3
John Wiley & Sons
Weitere Versionen
A compelling exploration of how social norms and commercial culture impact the safety of organizational operations
In Impact of Societal Norms on Safety, Health, and the Environment: Case Studies in Society and Safety Culture, distinguished engineer Dr. Lee T. Ostrom delivers an authoritative treatment of the cultural, social, and human factors of safety cultures and issues in the workplace. The book offers readers compelling discussions of how those factors impact organizational operations and what contributes to making those impacts beneficial or detrimental.
The author provides numerous real-world case studies from North America and Europe that are relevant to a global audience, highlighting the central message of the book: that an organization that views its safety culture as unimportant could be setting itself up for a significant workplace accident.
Readers will also find:
* A thorough introduction to social norms that impact how commercial organizations treat issues of safety and workplace health
* In-depth safety culture case studies from North America and Europe
* Comprehensive explorations of how peoples' perceptions of hazards impact workplace operations and the daily lives of employees
* Fulsome discussions of the effect of societal attitudes on workplace health and safety
Perfect for industrial and safety managers, safety coordinators, and safety representatives, Impact of Societal Norms on Safety, Health, and the Environment will also earn a place in the libraries of industrial hygienists, ergonomic program coordinators, and HR professionals.
Preface xvii
Abbreviations xix
1 Safety Culture Concepts 1
1.0 Introduction 1
1.1 Culture 2
1.2 Safety and Health Pioneers 4
1.3 The Evolution of Accident Causation Models 5
1.4 Safety and Common Sense 13
1.5 Interviews with Safety Professionals 14
1.6 Chapter Summary 59
References 59
2 History of Safety Culture 61
2.1 Life Expectancy and Safety 61
2.2 Consumer Items and Toys 65
2.2.1 Vintage Toys and Other Items 66
2.3 Flawed Cars 69
2.4 Ford Pinto 69
2.5 Off-Highway-Vehicle-Related Fatalities Reported 70
2.6 Work Relationships 71
2.7 Food 75
2.7.1 Food Trends and Culture 78
2.7.1.1 The Tomato 78
2.7.1.2 Fad Diets 78
2.8 Genetically Modified Organisms (GMO) Foods 80
2.8.1 Messenger Ribonucleic Acid (mRNA) Vaccines 82
2.9 Traffic Safety 83
2.10 Public Acceptance of Seatbelts and Masks for Protection from Respiratory Disease 86
2.11 Radiation Hazards and Safety 90
2.11.1 Radiation 91
2.11.2 Measuring Radiation (CDC 2021) 93
2.11.3 Health Effects of Radiation (EPA 2021) 95
2.11.4 Uses of Radiation (NRC 2020) 97
2.11.5 Medical Uses 97
2.11.6 Academic and Scientific Applications 98
2.11.7 Industrial Uses 98
2.11.8 Nuclear Power Plants 100
2.11.9 Misuse of Radiation (EPA 2021) 101
2.11.10 Radium Dial Painters 101
2.11.11 Safety Culture Issues 103
2.12 The Occupational Safety and Health Administration (OSHA) 103
2.12.1 Who Does OSHA Cover 105
2.12.1.1 Private Sector Workers 105
2.12.1.2 State and Local Government Workers 105
2.12.1.3 Federal Government Workers 106
2.12.1.4 Not Covered Under the OSHA Act 106
2.12.2 Voluntary Protection Program 107
2.13 Human Performance Improvement (HPI) 111
2.14 Chapter Summary 112
References 112
3 Chemical Manufacturing 119
3.0 Introduction 119
3.1 Process Safety Management 119
3.1.1 Introduction 119
3.1.2 Process Safety Management 121
3.1.2.1 Process Safety Information 123
3.1.2.2 Process Hazards Analysis 126
3.1.2.3 Operating Procedures 129
3.1.2.4 Mechanical Integrity 131
3.1.2.5 Management of Change 136
3.2 DuPont La Porte, TX, Methyl Mercaptan Release - November 15, 2014 138
3.2.1 Accident Description and Analysis 139
3.2.2 DuPont's Initiation of Process Safety Culture Assessments 160
3.2.3 Summary of Safety Culture Findings 162
3.3 BP Texas City Refinery Explosion - March 23, 2005 163
3.3.1 Introduction 163
3.3.2 Texas City 164
3.3.3 Description of the BP Refinery 165
3.3.4 The Accident 167
3.3.5 Trailer Siting Recommendations 173
3.3.6 Blowdown Drum and Stack Recommendations 174
3.3.7 Additional Recommendations from July 28, 2005, Incident 174
3.3.8 Summary of Safety Culture Issues 174
3.4 T2 Laboratories, Inc. Explosion - December 19, 2007 175
3.4.1 T2 Laboratories, Inc. 175
3.4.2 Event Description 176
3.4.3 Events Leading Up to the Explosion 176
3.4.4 Analysis of the Accident 180
3.4.5 Process Development 183
3.4.6 Manufacturing Process 184
3.4.7 Summary Safety Culture Issues 185
3.5 Final Thoughts for This Chapter 186
References 186
4 Chemical Storage Explosions 189
4.0 Introduction 189
4.1 Port of Lebanon - August 4, 2020 190
4.1.1 PEPCON Explosion - May 4, 1988 191
4.1.2 Lessons Learned 201
4.1.3 Safety Culture Issues 203
4.2 PCA DeRidder Paper Mill Gas System Explosion, DeRidder, Louisiana - February 8, 2017 203
4.2.1 PCA DeRidder Mill 205
4.2.2 The Explosion 205
4.2.3 Safety Culture Summary 210
4.3 West Fertilizer Explosion - April 17, 2013 211
4.3.1 The Fire and Explosion 212
4.3.2 Injuries and Fatalities 215
4.3.3 Safety Culture Summary 215
References 216
5 Dust Explosions and Entertainment Venue Case Studies 219
5.0 Introduction 219
5.1 Dust Explosion Information and Case Studies 221
5.2 AL Solutions December 9, 2010 225
5.2.1 Facility Description 225
5.2.2 Zirconium 228
5.2.3 Description of the Incident 228
5.2.4 The Origin of the Explosion 231
5.2.5 AL Solutions Dust Management Practices 234
5.2.6 Water Deluge System 235
5.2.7 Safety Audits 235
5.2.8 Hydrogen Explosion 237
5.2.9 Previous Fires And Explosions 237
5.2.10 Summary of Safety Culture Findings 239
5.3 Imperial Sugar Company, February 7, 2008 239
5.3.1 Sugar 239
5.3.2 Accident Description 240
5.3.3 Synopsis of Events 240
5.3.4 Detailed Accident Scenario 242
5.3.5 The Chemical Safety Board Investigation 243
5.3.6 South Packing Building 248
5.3.7 Sugar Spillage and Dust Control 249
5.3.8 Force of the Explosion 250
5.3.9 Pre-explosion Sugar Dust Incident History 251
5.3.10 Steel Belt Conveyor Modifications 251
5.3.11 Primary Event Location 252
5.3.12 Primary Event Combustible Dust Source 253
5.3.13 Secondary Dust Explosions 255
5.3.14 Ignition Sources 256
5.3.15 Open Flames and Hot Surfaces 256
5.3.16 Ignition Sources Inside the Steel Belt Enclosure 257
5.3.16.1 Hot Surface Ignition 257
5.3.16.2 Friction Sparks 258
5.3.16.3 Worker Training 258
5.3.17 Evacuation, Fire Alarms, and Fire Suppression 259
5.3.18 Electrical Systems Design 260
5.3.19 Sugar Dust Handling Equipment 261
5.3.20 Housekeeping and Dust Control 262
5.3.21 Imperial Sugar Management and Workers 263
5.3.22 Chemical Safety Board Key Findings 265
5.3.23 Summary of Safety Culture Findings 266
5.4 Entertainment Venue Case Studies 267
5.4.1 Introduction 267
5.4.2 Crowd Surge Events 267
5.4.3 Fires at Bars and Nightclubs 267
5.4.4 The New Taipei Water Park Fire - June 2015 268
5.5 Safety Culture Summary 270
References 270
6 University Laboratory Accident Case Studies 273
6.0 Introduction 273
6.1 My Experience at Aalto University 273
6.2 Texas Tech University October 2008 284
6.2.1 Specifically, the CSB Found 299
6.3 University of California Los Angeles - December 29, 2008 300
6.4 University of Utah - July 2017 302
6.4.1 Utah, Report to the Utah Legislature Number 2019-06 302
6.5 University of Hawaii - March 16, 2016 306
6.5.1 Grounding (OSHA 2021) 307
6.5.1.1 Summary of Grounding Requirements 308
6.5.1.2 Methods of Grounding Equipment 308
6.5.1.3 Event Description 309
6.5.1.4 Summary of Safety Culture Issues 311
References 312
7 Aviation Case Studies 315
7.0 Introduction 315
7.1 Helicopter Accident 337
7.1.1 Liberty Helicopter Crash March 11, 2018 338
7.1.1.1 Overview 338
7.1.1.2 Liberty Helicopter's Safety Program 346
7.1.1.3 Safety Culture Summary 354
7.2 Commercial Aviation 355
7.2.1 Successful Landing of Crippled Commercial Airliners 355
7.2.2 Gimli Glider - Successful Landing of a Crippled Commercial Airliner 1 - July 23, 1983 356
7.2.2.1 Accident Information 356
7.2.2.2 Analysis of the Fuel Problem 362
7.3 Illegal Dispatch Contrary to the MEL: Taking Off With Blank Fuel Gauges 370
7.4 Summary of Safety Culture Issues 373
7.5 Miracle on the Hudson River - Successful Landing of a Crippled Commercial Airliner 2, January 15, 2009 374
7.5.1 Accident Information 374
7.5.2 Flight Crew and Cabin Crew 377
7.5.3 The Captain's 72-Hour History 379
7.5.4 The First Officer 380
7.5.4.1 The First Officer's 72-Hour History 380
7.5.4.2 The Flight Attendants 381
7.5.4.3 Airbus A320-214 381
7.5.4.4 Operational Factors 382
7.5.4.5 Flight Crew Training 384
7.5.4.6 Dual-Engine Failure Training 385
7.5.4.7 Ditching Training 386
7.5.4.8 CRM and TEM Training 387
7.5.4.9 FAA Oversight 388
7.5.4.10 Summary of Safety Culture Issues 389
7.6 737 MAX 389
7.6.1 Introduction 389
7.6.2 737 MAX Design and Manufacture 390
7.6.3 Accidents 391
7.6.4 Design Certification of the 737 MAX 8 and Safety Assessment of the MCAS 393
7.6.5 Assumptions about Pilot Recognition and Response in the Safety Assessment 395
7.7 De Haviland Comet 400
7.8 Summary of Safety Culture Issues 401
References 401
8 Nuclear Energy Case Studies 405
8.0 Introduction 405
8.1 Nuclear Power 405
8.1.1 Sodium Cooled Reactors 409
8.1.1.1 Santa Susana - 1959 410
8.1.1.2 Fission Gas Release 411
8.1.1.3 Fermi 1 - Near Detroit Michigan - 1966 413
8.1.1.4 Safety Culture Summary of Sodium Cooled Reactors 414
8.1.2 The Vladimir Lenin Nuclear Power Plant or Chernobyl Nuclear Power Plant (ChNPP) - April 26, 1986 415
8.1.2.1 Reactivity and Power Control 416
8.1.2.2 Chernobyl Accident 418
8.1.3 Three Mile Island Accident - March 28, 1979 (NRC 2022a) 421
8.1.3.1 Accident 421
8.1.3.2 Summary of Events 422
8.1.3.3 Health Effects 425
8.1.3.4 Impact of the Accident 425
8.1.3.5 Current Status 426
8.1.3.6 Human Factor Engineering Findings (Malone et al. 1980) 427
8.1.3.7 Human Engineering and Human Error 428
8.1.3.8 Procedures 428
8.2 Nuclear Criticality 430
8.2.1 Mayak Production Association, 10 December 1968 (LANL 2000) 430
8.2.1.1 Safety Culture Issues 435
8.2.2 National Reactor Testing Station - January 3, 1961 (LANL 2000) 436
8.2.2.1 Safety Culture Issues 437
8.2.3 JCO Fuel Fabrication Plant - September 30, 1999 (LANL 2000) 438
8.2.3.1 Safety Culture Issues 441
8.3 Medical Misadministration of Radioisotopes Events 442
8.3.1 Loss of Iridium-192 Source at the Indiana Regional Cancer Center (IRCC) - November 1992 444
8.3.1.1 Introduction 444
8.3.1.2 Event Description 444
8.3.1.3 Patient Treatment Plan 444
8.3.2 Greater Pittsburgh Cancer Center Incident 455
8.3.3 Omnitron High Dose Rate (HDR) Remote Afterloader System 456
8.3.3.1 Description of the Afterloader System 456
8.3.3.2 High Dose Rate Afterloader 456
8.3.3.3 Main Console 461
8.3.3.4 Door Status Panel 461
8.3.3.5 Afterloader System Safety Features 462
8.3.3.6 Patient Applicators and Treatment Tubes 462
8.3.3.7 Description of the Source Wire 462
8.3.3.8 Prototype Testing Performed on Nickel-Titanium Source Wire 464
8.3.3.9 Description of the Omnitron 2000 Afterloader System Software 464
8.3.3.10 Equipment Performance 468
8.3.3.11 Failure Analysis Pertaining to the Source Wire 468
8.3.3.12 Possible Failure Areas 468
8.3.3.13 Organization of Oncology Services Corporation 469
8.3.3.14 Management Oversight 469
8.3.3.15 Safety Culture 470
8.3.3.16 Emergency Operating Procedures 474
8.3.3.17 Training 474
8.3.3.18 Radiation Safety Training at the Indiana Regional Cancer Center 475
8.3.3.19 Summary of Safety Culture Issues 476
8.4 Goiania, Brazil Teletherapy Machine Incident (IAEA 1988) 476
8.4.1 Safety Culture Summary 481
References 481
9 Other Transportation Case Studies 485
9.1 Large Marine Vessel Accidents 485
9.1.1 LNG Carrier Collision with Barge 485
9.1.1.1 Accident Description 487
9.1.1.2 Work/Rest of Ships' Crews 499
9.1.1.3 Drug and Alcohol Testing 501
9.1.1.4 Findings 502
9.2 Navy Vessel Collisions 503
9.2.1 USS FITZGERALD Collided with the Motor Vessel ACX Crystal 503
9.2.1.1 Summary of Findings 504
9.2.1.2 Background 505
9.2.1.3 Events Leading to the Collision 506
9.2.1.4 Collision 507
9.2.1.5 Impact to Berthing 2 514
9.2.1.6 Findings 519
9.2.1.7 Training 520
9.2.1.8 Seamanship and Navigation 520
9.2.1.9 Leadership and Culture 520
9.2.1.10 Fatigue 521
9.2.1.11 Timeline of Events 521
9.2.2 Collision of USS JOHN S MCCAIN with Motor Vessel ALNIC MC 524
9.2.2.1 Introduction 524
9.2.2.2 Summary of Findings 525
9.2.2.3 Background 525
9.2.2.4 Events Leading to the Collision 527
9.2.2.5 Results of Collision 530
9.2.2.6 Impact to Berthing 5 533
9.2.2.7 Impact on Berthing 3 536
9.2.2.8 Impact on Berthings 4, 6, and 7 539
9.2.2.9 Findings 542
9.2.2.10 Training 542
9.2.2.11 Seamanship and Navigation 543
9.2.2.12 Leadership and Culture 543
9.2.2.13 Timeline of Events 544
9.2.2.14 Summary of Safety Culture Issues 548
9.3 Stretch Duck 7 July 19, 2018 548
9.3.1 Introduction 548
9.3.2 Accident Description 549
9.3.3 1999 Sinking of Miss Majestic 552
9.3.4 Types of DUKW Amphibious Vessels 553
9.3.5 NTSB Identified Safety Issue No. 1: Providing Reserve Buoyancy 556
9.3.6 Safety Issue No. 2: Removing Canopies and Side Curtains 557
9.3.7 Findings and Conclusions 560
9.3.8 Safety Culture Summary Findings 560
9.3.9 Other Events 560
9.3.9.1 Minnow, Milwaukee Harbor, Lake Michigan, September 18, 2000 560
9.3.9.2 DUKW No. 1, Lake Union, Seattle,Washington, December 8, 2001 561
9.3.9.3 DUKW 34, Delaware River, Philadelphia, Pennsylvania, July 7, 2010 561
9.3.9.4 DUCK 6, Seattle,Washington, September 24, 2015 561
9.4 Recent Railroad Accidents 561
9.4.1 AMTRAK Passenger Train - May 12, 2015 562
9.4.1.1 Accident Scenario 562
9.4.1.2 Amtrak 565
9.4.1.3 Analysis of the Engineer's Actions 566
9.4.1.4 Loss of Situational Awareness 569
9.4.1.5 Two-Person Crews 572
9.4.1.6 Factors Not Contributing to This Accident 572
9.4.1.7 NTSB Probable Cause 574
9.4.1.8 Summary of Safety Culture Issues 574
9.4.2 Transportation Safety Board of Canada (2013a) 574
9.4.2.1 Personnel Information 578
9.4.2.2 Train Brakes 583
9.4.2.3 Locomotives 586
9.4.2.4 Rules and Instructions on Securing Equipment 587
9.4.2.5 Locomotive Event Recorder 590
9.4.2.6 Sense and Braking Unit 592
9.4.2.7 Mandatory Off-Duty Times for Operating Employees 592
9.4.2.8 Securement of Trains (MMA-002) at Nantes 592
9.4.2.9 Securement of Trains (MMA-001) at Vachon 593
9.4.2.10 Recent Runaway Train History at Montreal, Maine, and Atlantic Railway and Previous TSB Investigations 593
9.4.2.11 Training and Requalification of Montreal, Maine, and Atlantic Railway Crews in Farnham 594
9.4.2.12 Training and Requalification of the Locomotive Engineer 595
9.4.2.13 Operational Tests and Inspections at Montreal, Maine, and Atlantic Railway 595
9.4.2.14 Implementation of Single-Person Train Operations 597
9.4.2.15 Canadian Railway Operating Rules (CROR) 599
9.4.2.16 Single-Person Train Operations at Montreal, Maine, and Atlantic Railway 599
9.4.2.17 Review of the Montreal, Maine, and Atlantic Railway Submission and its Relation to the Requirements of Standard CSA Q850 601
9.4.2.18 Research into Single-Person Train Operations 602
9.4.2.19 Safety Culture 603
9.4.2.20 Summary of Safety Culture Issues 604
References 604
10 Assessing Safety Culture 607
10.0 Introduction 607
10.1 Survey Research Principles 608
10.1.1 Developing the Survey Instrument 609
10.1.1.1 Developing the Questions/Statements 609
10.1.1.2 Question/Statement Development 611
10.1.1.3 Sampling 612
10.1.1.4 Demographics 612
10.1.1.5 Survey Delivery 613
10.1.1.6 Analyzing the Results and Reports 613
10.1.1.7 Final Thoughts on Developing and Delivering Surveys 614
10.1.2 Safety Culture Assessment Methods 614
10.1.2.1 DuPont (DuPont) De Nemours Sustainable Solutions (DSS) 614
10.1.2.2 Department of Energy Assessment of Safety Culture Sustainment Processes 615
10.1.2.3 Institute for Nuclear Power Operations Safety Culture Assessment 617
10.1.2.4 Developing Team Findings 619
10.1.3 United States Air Force Assessment Tool 619
10.2 Assessing Health Care Safety Culture 620
10.3 Seven Steps to Assess Safety Culture 621
10.3.1 A Framework for Assessing Safety Culture 623
10.3.2 Agency for Healthcare Research and Quality 623
10.3.3 Graduate Student Safety Culture Survey 623
10.3.4 Idaho National Engineering Laboratory Survey 626
10.4 Chapter Summary 634
References 634
Index 637
Abbreviations xix
1 Safety Culture Concepts 1
1.0 Introduction 1
1.1 Culture 2
1.2 Safety and Health Pioneers 4
1.3 The Evolution of Accident Causation Models 5
1.4 Safety and Common Sense 13
1.5 Interviews with Safety Professionals 14
1.6 Chapter Summary 59
References 59
2 History of Safety Culture 61
2.1 Life Expectancy and Safety 61
2.2 Consumer Items and Toys 65
2.2.1 Vintage Toys and Other Items 66
2.3 Flawed Cars 69
2.4 Ford Pinto 69
2.5 Off-Highway-Vehicle-Related Fatalities Reported 70
2.6 Work Relationships 71
2.7 Food 75
2.7.1 Food Trends and Culture 78
2.7.1.1 The Tomato 78
2.7.1.2 Fad Diets 78
2.8 Genetically Modified Organisms (GMO) Foods 80
2.8.1 Messenger Ribonucleic Acid (mRNA) Vaccines 82
2.9 Traffic Safety 83
2.10 Public Acceptance of Seatbelts and Masks for Protection from Respiratory Disease 86
2.11 Radiation Hazards and Safety 90
2.11.1 Radiation 91
2.11.2 Measuring Radiation (CDC 2021) 93
2.11.3 Health Effects of Radiation (EPA 2021) 95
2.11.4 Uses of Radiation (NRC 2020) 97
2.11.5 Medical Uses 97
2.11.6 Academic and Scientific Applications 98
2.11.7 Industrial Uses 98
2.11.8 Nuclear Power Plants 100
2.11.9 Misuse of Radiation (EPA 2021) 101
2.11.10 Radium Dial Painters 101
2.11.11 Safety Culture Issues 103
2.12 The Occupational Safety and Health Administration (OSHA) 103
2.12.1 Who Does OSHA Cover 105
2.12.1.1 Private Sector Workers 105
2.12.1.2 State and Local Government Workers 105
2.12.1.3 Federal Government Workers 106
2.12.1.4 Not Covered Under the OSHA Act 106
2.12.2 Voluntary Protection Program 107
2.13 Human Performance Improvement (HPI) 111
2.14 Chapter Summary 112
References 112
3 Chemical Manufacturing 119
3.0 Introduction 119
3.1 Process Safety Management 119
3.1.1 Introduction 119
3.1.2 Process Safety Management 121
3.1.2.1 Process Safety Information 123
3.1.2.2 Process Hazards Analysis 126
3.1.2.3 Operating Procedures 129
3.1.2.4 Mechanical Integrity 131
3.1.2.5 Management of Change 136
3.2 DuPont La Porte, TX, Methyl Mercaptan Release - November 15, 2014 138
3.2.1 Accident Description and Analysis 139
3.2.2 DuPont's Initiation of Process Safety Culture Assessments 160
3.2.3 Summary of Safety Culture Findings 162
3.3 BP Texas City Refinery Explosion - March 23, 2005 163
3.3.1 Introduction 163
3.3.2 Texas City 164
3.3.3 Description of the BP Refinery 165
3.3.4 The Accident 167
3.3.5 Trailer Siting Recommendations 173
3.3.6 Blowdown Drum and Stack Recommendations 174
3.3.7 Additional Recommendations from July 28, 2005, Incident 174
3.3.8 Summary of Safety Culture Issues 174
3.4 T2 Laboratories, Inc. Explosion - December 19, 2007 175
3.4.1 T2 Laboratories, Inc. 175
3.4.2 Event Description 176
3.4.3 Events Leading Up to the Explosion 176
3.4.4 Analysis of the Accident 180
3.4.5 Process Development 183
3.4.6 Manufacturing Process 184
3.4.7 Summary Safety Culture Issues 185
3.5 Final Thoughts for This Chapter 186
References 186
4 Chemical Storage Explosions 189
4.0 Introduction 189
4.1 Port of Lebanon - August 4, 2020 190
4.1.1 PEPCON Explosion - May 4, 1988 191
4.1.2 Lessons Learned 201
4.1.3 Safety Culture Issues 203
4.2 PCA DeRidder Paper Mill Gas System Explosion, DeRidder, Louisiana - February 8, 2017 203
4.2.1 PCA DeRidder Mill 205
4.2.2 The Explosion 205
4.2.3 Safety Culture Summary 210
4.3 West Fertilizer Explosion - April 17, 2013 211
4.3.1 The Fire and Explosion 212
4.3.2 Injuries and Fatalities 215
4.3.3 Safety Culture Summary 215
References 216
5 Dust Explosions and Entertainment Venue Case Studies 219
5.0 Introduction 219
5.1 Dust Explosion Information and Case Studies 221
5.2 AL Solutions December 9, 2010 225
5.2.1 Facility Description 225
5.2.2 Zirconium 228
5.2.3 Description of the Incident 228
5.2.4 The Origin of the Explosion 231
5.2.5 AL Solutions Dust Management Practices 234
5.2.6 Water Deluge System 235
5.2.7 Safety Audits 235
5.2.8 Hydrogen Explosion 237
5.2.9 Previous Fires And Explosions 237
5.2.10 Summary of Safety Culture Findings 239
5.3 Imperial Sugar Company, February 7, 2008 239
5.3.1 Sugar 239
5.3.2 Accident Description 240
5.3.3 Synopsis of Events 240
5.3.4 Detailed Accident Scenario 242
5.3.5 The Chemical Safety Board Investigation 243
5.3.6 South Packing Building 248
5.3.7 Sugar Spillage and Dust Control 249
5.3.8 Force of the Explosion 250
5.3.9 Pre-explosion Sugar Dust Incident History 251
5.3.10 Steel Belt Conveyor Modifications 251
5.3.11 Primary Event Location 252
5.3.12 Primary Event Combustible Dust Source 253
5.3.13 Secondary Dust Explosions 255
5.3.14 Ignition Sources 256
5.3.15 Open Flames and Hot Surfaces 256
5.3.16 Ignition Sources Inside the Steel Belt Enclosure 257
5.3.16.1 Hot Surface Ignition 257
5.3.16.2 Friction Sparks 258
5.3.16.3 Worker Training 258
5.3.17 Evacuation, Fire Alarms, and Fire Suppression 259
5.3.18 Electrical Systems Design 260
5.3.19 Sugar Dust Handling Equipment 261
5.3.20 Housekeeping and Dust Control 262
5.3.21 Imperial Sugar Management and Workers 263
5.3.22 Chemical Safety Board Key Findings 265
5.3.23 Summary of Safety Culture Findings 266
5.4 Entertainment Venue Case Studies 267
5.4.1 Introduction 267
5.4.2 Crowd Surge Events 267
5.4.3 Fires at Bars and Nightclubs 267
5.4.4 The New Taipei Water Park Fire - June 2015 268
5.5 Safety Culture Summary 270
References 270
6 University Laboratory Accident Case Studies 273
6.0 Introduction 273
6.1 My Experience at Aalto University 273
6.2 Texas Tech University October 2008 284
6.2.1 Specifically, the CSB Found 299
6.3 University of California Los Angeles - December 29, 2008 300
6.4 University of Utah - July 2017 302
6.4.1 Utah, Report to the Utah Legislature Number 2019-06 302
6.5 University of Hawaii - March 16, 2016 306
6.5.1 Grounding (OSHA 2021) 307
6.5.1.1 Summary of Grounding Requirements 308
6.5.1.2 Methods of Grounding Equipment 308
6.5.1.3 Event Description 309
6.5.1.4 Summary of Safety Culture Issues 311
References 312
7 Aviation Case Studies 315
7.0 Introduction 315
7.1 Helicopter Accident 337
7.1.1 Liberty Helicopter Crash March 11, 2018 338
7.1.1.1 Overview 338
7.1.1.2 Liberty Helicopter's Safety Program 346
7.1.1.3 Safety Culture Summary 354
7.2 Commercial Aviation 355
7.2.1 Successful Landing of Crippled Commercial Airliners 355
7.2.2 Gimli Glider - Successful Landing of a Crippled Commercial Airliner 1 - July 23, 1983 356
7.2.2.1 Accident Information 356
7.2.2.2 Analysis of the Fuel Problem 362
7.3 Illegal Dispatch Contrary to the MEL: Taking Off With Blank Fuel Gauges 370
7.4 Summary of Safety Culture Issues 373
7.5 Miracle on the Hudson River - Successful Landing of a Crippled Commercial Airliner 2, January 15, 2009 374
7.5.1 Accident Information 374
7.5.2 Flight Crew and Cabin Crew 377
7.5.3 The Captain's 72-Hour History 379
7.5.4 The First Officer 380
7.5.4.1 The First Officer's 72-Hour History 380
7.5.4.2 The Flight Attendants 381
7.5.4.3 Airbus A320-214 381
7.5.4.4 Operational Factors 382
7.5.4.5 Flight Crew Training 384
7.5.4.6 Dual-Engine Failure Training 385
7.5.4.7 Ditching Training 386
7.5.4.8 CRM and TEM Training 387
7.5.4.9 FAA Oversight 388
7.5.4.10 Summary of Safety Culture Issues 389
7.6 737 MAX 389
7.6.1 Introduction 389
7.6.2 737 MAX Design and Manufacture 390
7.6.3 Accidents 391
7.6.4 Design Certification of the 737 MAX 8 and Safety Assessment of the MCAS 393
7.6.5 Assumptions about Pilot Recognition and Response in the Safety Assessment 395
7.7 De Haviland Comet 400
7.8 Summary of Safety Culture Issues 401
References 401
8 Nuclear Energy Case Studies 405
8.0 Introduction 405
8.1 Nuclear Power 405
8.1.1 Sodium Cooled Reactors 409
8.1.1.1 Santa Susana - 1959 410
8.1.1.2 Fission Gas Release 411
8.1.1.3 Fermi 1 - Near Detroit Michigan - 1966 413
8.1.1.4 Safety Culture Summary of Sodium Cooled Reactors 414
8.1.2 The Vladimir Lenin Nuclear Power Plant or Chernobyl Nuclear Power Plant (ChNPP) - April 26, 1986 415
8.1.2.1 Reactivity and Power Control 416
8.1.2.2 Chernobyl Accident 418
8.1.3 Three Mile Island Accident - March 28, 1979 (NRC 2022a) 421
8.1.3.1 Accident 421
8.1.3.2 Summary of Events 422
8.1.3.3 Health Effects 425
8.1.3.4 Impact of the Accident 425
8.1.3.5 Current Status 426
8.1.3.6 Human Factor Engineering Findings (Malone et al. 1980) 427
8.1.3.7 Human Engineering and Human Error 428
8.1.3.8 Procedures 428
8.2 Nuclear Criticality 430
8.2.1 Mayak Production Association, 10 December 1968 (LANL 2000) 430
8.2.1.1 Safety Culture Issues 435
8.2.2 National Reactor Testing Station - January 3, 1961 (LANL 2000) 436
8.2.2.1 Safety Culture Issues 437
8.2.3 JCO Fuel Fabrication Plant - September 30, 1999 (LANL 2000) 438
8.2.3.1 Safety Culture Issues 441
8.3 Medical Misadministration of Radioisotopes Events 442
8.3.1 Loss of Iridium-192 Source at the Indiana Regional Cancer Center (IRCC) - November 1992 444
8.3.1.1 Introduction 444
8.3.1.2 Event Description 444
8.3.1.3 Patient Treatment Plan 444
8.3.2 Greater Pittsburgh Cancer Center Incident 455
8.3.3 Omnitron High Dose Rate (HDR) Remote Afterloader System 456
8.3.3.1 Description of the Afterloader System 456
8.3.3.2 High Dose Rate Afterloader 456
8.3.3.3 Main Console 461
8.3.3.4 Door Status Panel 461
8.3.3.5 Afterloader System Safety Features 462
8.3.3.6 Patient Applicators and Treatment Tubes 462
8.3.3.7 Description of the Source Wire 462
8.3.3.8 Prototype Testing Performed on Nickel-Titanium Source Wire 464
8.3.3.9 Description of the Omnitron 2000 Afterloader System Software 464
8.3.3.10 Equipment Performance 468
8.3.3.11 Failure Analysis Pertaining to the Source Wire 468
8.3.3.12 Possible Failure Areas 468
8.3.3.13 Organization of Oncology Services Corporation 469
8.3.3.14 Management Oversight 469
8.3.3.15 Safety Culture 470
8.3.3.16 Emergency Operating Procedures 474
8.3.3.17 Training 474
8.3.3.18 Radiation Safety Training at the Indiana Regional Cancer Center 475
8.3.3.19 Summary of Safety Culture Issues 476
8.4 Goiania, Brazil Teletherapy Machine Incident (IAEA 1988) 476
8.4.1 Safety Culture Summary 481
References 481
9 Other Transportation Case Studies 485
9.1 Large Marine Vessel Accidents 485
9.1.1 LNG Carrier Collision with Barge 485
9.1.1.1 Accident Description 487
9.1.1.2 Work/Rest of Ships' Crews 499
9.1.1.3 Drug and Alcohol Testing 501
9.1.1.4 Findings 502
9.2 Navy Vessel Collisions 503
9.2.1 USS FITZGERALD Collided with the Motor Vessel ACX Crystal 503
9.2.1.1 Summary of Findings 504
9.2.1.2 Background 505
9.2.1.3 Events Leading to the Collision 506
9.2.1.4 Collision 507
9.2.1.5 Impact to Berthing 2 514
9.2.1.6 Findings 519
9.2.1.7 Training 520
9.2.1.8 Seamanship and Navigation 520
9.2.1.9 Leadership and Culture 520
9.2.1.10 Fatigue 521
9.2.1.11 Timeline of Events 521
9.2.2 Collision of USS JOHN S MCCAIN with Motor Vessel ALNIC MC 524
9.2.2.1 Introduction 524
9.2.2.2 Summary of Findings 525
9.2.2.3 Background 525
9.2.2.4 Events Leading to the Collision 527
9.2.2.5 Results of Collision 530
9.2.2.6 Impact to Berthing 5 533
9.2.2.7 Impact on Berthing 3 536
9.2.2.8 Impact on Berthings 4, 6, and 7 539
9.2.2.9 Findings 542
9.2.2.10 Training 542
9.2.2.11 Seamanship and Navigation 543
9.2.2.12 Leadership and Culture 543
9.2.2.13 Timeline of Events 544
9.2.2.14 Summary of Safety Culture Issues 548
9.3 Stretch Duck 7 July 19, 2018 548
9.3.1 Introduction 548
9.3.2 Accident Description 549
9.3.3 1999 Sinking of Miss Majestic 552
9.3.4 Types of DUKW Amphibious Vessels 553
9.3.5 NTSB Identified Safety Issue No. 1: Providing Reserve Buoyancy 556
9.3.6 Safety Issue No. 2: Removing Canopies and Side Curtains 557
9.3.7 Findings and Conclusions 560
9.3.8 Safety Culture Summary Findings 560
9.3.9 Other Events 560
9.3.9.1 Minnow, Milwaukee Harbor, Lake Michigan, September 18, 2000 560
9.3.9.2 DUKW No. 1, Lake Union, Seattle,Washington, December 8, 2001 561
9.3.9.3 DUKW 34, Delaware River, Philadelphia, Pennsylvania, July 7, 2010 561
9.3.9.4 DUCK 6, Seattle,Washington, September 24, 2015 561
9.4 Recent Railroad Accidents 561
9.4.1 AMTRAK Passenger Train - May 12, 2015 562
9.4.1.1 Accident Scenario 562
9.4.1.2 Amtrak 565
9.4.1.3 Analysis of the Engineer's Actions 566
9.4.1.4 Loss of Situational Awareness 569
9.4.1.5 Two-Person Crews 572
9.4.1.6 Factors Not Contributing to This Accident 572
9.4.1.7 NTSB Probable Cause 574
9.4.1.8 Summary of Safety Culture Issues 574
9.4.2 Transportation Safety Board of Canada (2013a) 574
9.4.2.1 Personnel Information 578
9.4.2.2 Train Brakes 583
9.4.2.3 Locomotives 586
9.4.2.4 Rules and Instructions on Securing Equipment 587
9.4.2.5 Locomotive Event Recorder 590
9.4.2.6 Sense and Braking Unit 592
9.4.2.7 Mandatory Off-Duty Times for Operating Employees 592
9.4.2.8 Securement of Trains (MMA-002) at Nantes 592
9.4.2.9 Securement of Trains (MMA-001) at Vachon 593
9.4.2.10 Recent Runaway Train History at Montreal, Maine, and Atlantic Railway and Previous TSB Investigations 593
9.4.2.11 Training and Requalification of Montreal, Maine, and Atlantic Railway Crews in Farnham 594
9.4.2.12 Training and Requalification of the Locomotive Engineer 595
9.4.2.13 Operational Tests and Inspections at Montreal, Maine, and Atlantic Railway 595
9.4.2.14 Implementation of Single-Person Train Operations 597
9.4.2.15 Canadian Railway Operating Rules (CROR) 599
9.4.2.16 Single-Person Train Operations at Montreal, Maine, and Atlantic Railway 599
9.4.2.17 Review of the Montreal, Maine, and Atlantic Railway Submission and its Relation to the Requirements of Standard CSA Q850 601
9.4.2.18 Research into Single-Person Train Operations 602
9.4.2.19 Safety Culture 603
9.4.2.20 Summary of Safety Culture Issues 604
References 604
10 Assessing Safety Culture 607
10.0 Introduction 607
10.1 Survey Research Principles 608
10.1.1 Developing the Survey Instrument 609
10.1.1.1 Developing the Questions/Statements 609
10.1.1.2 Question/Statement Development 611
10.1.1.3 Sampling 612
10.1.1.4 Demographics 612
10.1.1.5 Survey Delivery 613
10.1.1.6 Analyzing the Results and Reports 613
10.1.1.7 Final Thoughts on Developing and Delivering Surveys 614
10.1.2 Safety Culture Assessment Methods 614
10.1.2.1 DuPont (DuPont) De Nemours Sustainable Solutions (DSS) 614
10.1.2.2 Department of Energy Assessment of Safety Culture Sustainment Processes 615
10.1.2.3 Institute for Nuclear Power Operations Safety Culture Assessment 617
10.1.2.4 Developing Team Findings 619
10.1.3 United States Air Force Assessment Tool 619
10.2 Assessing Health Care Safety Culture 620
10.3 Seven Steps to Assess Safety Culture 621
10.3.1 A Framework for Assessing Safety Culture 623
10.3.2 Agency for Healthcare Research and Quality 623
10.3.3 Graduate Student Safety Culture Survey 623
10.3.4 Idaho National Engineering Laboratory Survey 626
10.4 Chapter Summary 634
References 634
Index 637
Lee T. Ostrom, PhD, is the Center Executive Officer at Idaho Falls Center and full Professor in the College of Engineering. He has authored or co-authored four books as well as several book chapters and articles, including Risk Assessment Tools and Techniques and Their Application. He has over 35 years' experience in the field of workplace safety and health.
