Episode 155: Repeat Issues

In this episode of the "Leading and Learning Through Safety" podcast, hosted by Dr. Mark French, the focus is on systemic and normalizing incidents as part of a safety culture. Dr. French emphasizes the importance of learning from safety incidents to improve organizational practices. He highlights a recent report from the US Chemical Safety and Hazard Investigation Board (CSB) regarding a fatal release and fire at the BP Husky Toledo refinery in September 2022. This incident underscores the recurring safety issues within BP, such as failure in liquid overflow prevention, poor abnormal situation management, and alarm flooding. Dr. French criticizes BP for not learning from past incidents and stresses the need for organizations to systematize their learnings to prevent future incidents. He concludes by emphasizing the importance of documenting and addressing risks systematically to improve safety culture.

Transcript

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systemic and normalizing incidents as part of a safety culture. That's what we're going to talk about this week on the leading and learning through safety podcast. Welcome to the leading and learning through safety podcast. Your host is Dr. Mark French marks passion is helping organizations motivate their teams. This podcast is focused on bringing out the best in leadership through creating strong values, learning opportunities, teamwork, and safety. Nothing is more important than protecting your people. Safety creates an environment for empathy, innovation, and empowerment. Together, we'll discover meaning and purpose through shaping our safety culture. Thanks for joining us this episode. And now here is Dr. Mark French. Welcome to the leading and learning through safety podcast. Hi, I am your host, Dr. Mark French. And I am so happy that you have joined me for this episode. This week, my focus is going to be on a US Chemical Safety and Hazard Investigation Board. So the CSP, one of my I do appreciate everything the Chemical Safety Board does. Generally underfunded in my opinion, but they do some amazing investigations. Their investigations are they don't have penalties associated with them. But they're so detailed in some helping other industries learn. And you may be asking like what can I learn from a Chemical Safety Board report if you're not in the chemical industry? And my answer to that is, you can learn a whole lot. There's a lot there that comes from reading through these incidents. This one struck me as in they released them as frequently as they can after lots of writing and research and going through the investigation. But there's a lot to learn from a system standpoint, a process standpoint, just because these mistakes happened in a chemical plant, they were significant. Because of that. It doesn't mean that the same conditions cannot exist in other any industry. And that's what I want to talk about. So this was published just last month. It's very new. And it's in regards to the fatal release and fire at the BP Husky Toledo refinery in September of 2022. So, almost two years later, the report from the Chemical Safety Board is released. And it has a lot to say. And I would say that it's disappointing from a lot of reasons and not disappointing from the report disappointing from looking at the condition that this industry has been left in BP. Unfortunately, and I hate calling names. I don't but this one here has to be said because it's just know what this was. They continue to have issues whether it be polluting significantly from a pipe break to every few years having some kind of explosion that kills people. It's unbelievable that they repeat the same thing, the same issues over and over and over again. It's scary. It's disappointing. It's infuriating that you can make billions and be fined millions. And that's huge numbers. I can't even fathom the kind of numbers. But profits continue to soar. People continue to die. The environment continues to be polluted, and they learn they appear to learn nothing from it. And that's what drew my attention to this report was just how clear the US Chemical Safety Board wrote about their failures to learn. So the key safety issues that come from the report, I will post a link to the report if you're interested in reading this 170 Page beast of a report. I will post a link to it so you can see and add on my LinkedIn and Facebook pages. So it will be there attached to the podcast if you want to see more, the critical safety issues, liquid overflow prevention. While so many times these towers get filled, and this is what leads so many times that leads to the explosion as the towers overfill Ignite and explode, rather than being prevented from overflowing and you would think overflow technology is not new. You're right. Just think about everything that you fill up that has overflow technology that works. filling up your gas tank on your car, I have a dehumidifier that fills up with water. And as soon as spilling water all over the floor, it turns off overflow prevention, even though it's I am simplifying to an nth degree when I talk about the difference between the chemical plant and our normal everyday processes. But what I want to get across is that you would think that a more complex and more sophisticated process, such as this would have enough redundancies in enough engineering to work instead of consistently having the same issue. Moving on abnormal situation management, alarm flooding. And then the final bullet point learning from incidents they failed to learn from their incidents. That is the most frustrating part is that so let me read the executive summary at least I'll give you the high level of it. On September 2022. It was almost seven o'clock in the evening, a vapor cloud ignited causing a flash fire at this BP refining and or Oregon, Ohio. The vapor cloud formed when two of the products would release flammable liquid from a pressurized vehicle vessel as a result of fire to BP employees who were brothers were fatally injured. In addition, they had about five, almost $600 million worth of property damage, estimated over 23,000 pounds of chemical was released. And to date, this is the largest fatal incident at a BP operated petroleum refinery. Since they had their other explosion in 2005, which was 15 workers and 180 people injured 15 workers died 180 people injured. All ultimately there was a series of events that led to this incident that were repeatable. So even though so let me move through there, if you just look at their synopsis of what happened. It's unbelievable. What was allowed to happen. And ultimately, it was one, the liquid overflow prevention, they had a PHA but didn't really follow it didn't really learn from it didn't really do anything with it. They had abnormal situation management. So there there are some very good guidance documents out there in the world from the from process safety to chemical safety to international standards that had been written that talk about how do you handle abnormal processes. So whenever something unexpected happens at a highly hazardous location, like a chemical plant, there should be certain amount of training or a certain amount of allowances for human performance. Because at the time that something happens, it's an abnormal situation. We have to be able to react. And that's why we do drills. This is why do we do incident emergency drills so that we don't panic. If something happens, the goal is to always prevent the if something happening. If we if something happens, we want to be prepared to be able to know that we will react in some way we have some process ingrained in us to refer back to that tells us how we will go forward. This was one of the problems. They didn't have that in the 24 hours leading up to the incident they experienced a number of abnormal situations in ultimately this led to them trying things that may not have been normally approved or normally accepted or even should have been even recognized as let's not do it that way. Let's do something else. Let's shut it off. But there's a fear there. A fear to shut things down. Because what if we lose production? What if we lose the what if we lose money for the company? We can't do that. In that is infuriating. And that abnormal situation was compounded by the fact that there were a bunch of them. Let's talk about that on the second half of the leading and learning through safety problems. Podcast, you are listening to the leading a learning through safety podcast with Dr. Mark French. D is da consulting, learn you lead others, the Myers Briggs Type Indicator is an amazing tool. The problem is that it can be easily misinterpreted. Dr. Mark French is MBTI certified and ready to help you discover your inner strengths. The MBTI assessment can help with team building stress management, communication, conflict management, and so much more. Individual and group sessions are available to help you discover what makes you great. For more information, visit us on the web at T SDA consulting.com. And welcome back to the second half of the leading and learning through safety podcast. This week, we're talking about the Chemical Safety Board released a report last month, so just a few weeks ago, about the 2022 incident with BP. Part of the problem was their liquid overflow prevention process. The next part was not having a great way for their system, their overall safety system to cope with abnormal situations. The third main issue which ties in extremely well, or actually compounded to a to a bad issue. And this can happen. And that's why I say when these two items immediate each other, you have an immediate situation for danger. And that's when an abnormal situation is compounded by a whole bunch of abnormal situations. Board operators were receiving far more than 10 alarms in 10 minutes, on average. So when like a 12 hour period, they recorded 3712 alarms. How does someone keep up with that? So in a chemical plant, the board operators, those who are managing the process, keeping up with it, watching it, have to acknowledge and do something with alarms. 3012. So if you're working in let's say we're working 12 hour shift, which could be very common in these industries, I have seen that normal as part of it. 3000 alarms in a 12 hour shift? Unbelievable. How do you even keep up? How do you know which way is up? How do you know which one is the most important? How do you know where to go? How do you know which way to direct it? Why is it not being fixed so that you don't have 3000 alarms almost 4000 Coming at you if they hadn't been so overwhelmed with these abnormal situations, if all these alarms going off, it is there is a great chance they would have seen what was going on and prevented it from happening. So we go back, and we look at what have they been doing like this seems to be a continual problem. In 2007, there was a panel report called The baker panel report that was written and saying that BP should use the lessons from all of their tragedies, to learn and to prevent things, whether it be from 2005, whether it'd be when following a 2019 incident up to a 22 that ultimately the the report that was published, said you need to start learning from what you're doing wrong. You can't continue to make the same mistakes because there are commonalities in what you're doing there. There's high commonalities that we are seeing and are predictable, seen. And statistically reliable saying that you should learn from these, you should be able to see this, learn from it and fix it. So there was a report published telling BP telling them independent report, telling them to learn from their mistakes, to be better to just see what they're doing and somehow make it a systemic and well known way to put event the issue. And basically, the Chemical Safety Board sites that and say says you didn't, there, there wasn't any learnings here, the learnings were not effective. The learnings were not spread, the learnings were not systemized or put into place. That's not easy. I'm not saying that that's an easy process. But it appears from the report that it wasn't even attempted that a good faith effort, or even a good effort of any form, was even attempted to do that, in that scary. And I'm not saying that anyone who works there is bad because a lot of times there's defensiveness, when it comes to saying, Well, this this organization or this had issues, yeah. But there's a lot of good people, who are they there to try to make it better? Probably. It's not where you are, it's where you're going. And what's unfortunate here is there wasn't that there wasn't that movement, to try to learn from what was going on, in how they were adapting to it. Same same issues, same process safety, in why I say that this is something we should learn from I ask the question, are you capturing the information? Do you in your system, in your life in your world? Do you know why you're doing what you can do? Are you forgetting like, you know, I started doing that because I had an issue back, whenever. And I'll give you a perfect example. I have some dietary restrictions that make me exceptionally uncomfortable if I break them. And after enough time, I will forget just how bad it feels to break that dietary restriction. And so I will knowingly eat something I shouldn't eat because I just gotta have it. And then when I have to pay the consequences, I'm like, Oh, my God, how did I forget how bad this was, we lose that severity. If we do not quantify it, if we do not take time to say it was this bad. And I did it. And we have to correct it. Organizations are the same way, except significantly more complex, because there's a lot more people having to learn from that incident, to capture that information, to make it systemic, to say we have this rule in place that goes above and beyond. Or we have this process this very specific process in place, because we had this happen. And we need to avoid and reduce significant risk to our organization. Therefore, we have this process in place, or we put this piece of equipment in place, or this guard always needs to be in place because we had this issue. It's so important that we're able to capture that and that's where we all learn from this. To see that are we capturing the reasons why we've done what we've done to reduce risk. I feel like I'm not done with this topic. So I have I have a guest that will probably talk about this again next week. We'll continue this chat about documenting the consequences documenting the risk preventing that risk. So until next week, I really appreciate you chatting with me joining me for the leading and learning through safety podcast. And until next time we chat stay safe. Thank you for listening to the leading and learning through safety podcast. More content is available online@www.ts da consulting.com. All the opinions expressed on the podcast are solely attributed to the individual and not affiliated with any business entity. This podcast is for informational and entertainment purposes. It is not a substitute for proper policy, appropriate training or legal advice. This has been the leading and learning through safety podcast