Episode 167 - Going Beyond

The podcast episode focuses on a catastrophic explosion at a food additive manufacturing site in Louisville, Kentucky. The explosion was attributed to the failure of a ventilation system on a cooker, leading to overheating, overpressurization, and a subsequent explosion. The event caused significant community damage, including shattered windows and structural harm, injured 10-12 people, and claimed two lives. Notably, one victim was initially unaccounted for due to a clerical error during the emergency evacuation, raising questions about the company’s emergency management protocols.

The discussion highlights systemic failures in safety leadership and engineering risk management. The organization, already familiar to OSHA, may not have implemented Process Safety Management (PSM) standards, which could have mitigated risks. Questions are raised about preventative maintenance, predictive engineering, and redundancy systems to prevent such incidents. The lack of alarms or fail-safes and the apparent high tolerance for risk are cited as critical oversights.

The podcast emphasizes the importance of proactive leadership in safety culture. It critiques the company’s slow response to the community's concerns and contrasts OSHA compliance with going beyond minimum standards to prioritize worker and community safety. The host reflects on the engineering decisions and leadership deficiencies leading to this tragedy, urging organizations to adopt robust safety practices and foster a culture that values risk management and human dignity.

Ultimately, the incident serves as a stark reminder of the consequences of inadequate safety protocols and the need for comprehensive risk assessment to prevent similar catastrophic events.

Transcript

Mark French: 0:01

This week on the podcast, we're talking about an explosion in Louisville, Kentucky, my home state, that I want to get deeper into the leadership of how these things can happen this week on the podcast, you Mark,

Announcer: 0:32

welcome to the leading and learning through safety podcast. Your host is Dr Mark French. Mark's 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. You music.

Mark French: 1:29

Hello and welcome to this episode of the leading and learning through safety podcast. I am so happy that you can join me for this podcast. This week, I'm going to attempt to talk about an explosion in Louisville, Kentucky. I say attempt because last week I recorded the podcast, tried to upload it and found that technology beat me. It absolutely defeated me on that one and it was a corrupted file, so there was no podcast last week because of that. I am going to try again this week to talk about this event. It happened in Louisville, Kentucky a couple of weeks ago, and it caught my attention one of course, because it's in my home state. And those things capture my attention because it feels more like you relate to it. It's easy to put yourself in that relationship when you find that commonality of something or someone. And being a Kentuckian that brought us together for that one. The second one is that the Chemical Safety Board is going to be on site conducting investigation. Now, historically, this Chemical Safety Board has done a phenomenal job of really understanding the root causes of events like this, and to have them on site means that there will be a very in depth investigation, and it'll take some time before we know everything, but we will learn what happened, how it happened, and to better understand the system's failure that comes with an explosion of this magnitude. Now, what happened was, this was a food additive manufacturing site. They do a lot of different things at this site, in particular, the organization makes a food additive that adds color, and so there's large basically cookers that are within the facility. The best they understand so far is that on one of the cookers, the ventilation system failed and it overheated, thus over pressurizing and exploded. It rocked the neighborhood. It windows were shattered, damage around the community, two people, two people did not go home because of that explosion, and somewhere between 10 and 12 people were injured. Workers that were injured from that not and that is not even going into the community about the broken glass, the damages to home, the damages to other items, because of this explosion. It was very powerful. It was significant explosion. And where I see this is that I won this organization, when certainly is no stranger to OSHA around the nation. So it's a nationwide company, and they are no stranger to OSHA visiting their sites that was done by a simple search. Also, I must say up front that I'm really impressed with the local journalism in Louisville. They did a nice job of updating and being there and making sure that the facts that the information was shared. They even did deep dives on the facility itself, the people they have been involved in. Producing good work to where, when I watch it and read, I get a good picture of what's happening, and I think about what is real, leadership and safety. And I've talked about this before in giving examples of those who go, you know, OSHA is is the minimum and the maximum, it is the one that we hold ourselves to. And once we hit that mark where we are compliant legally, we're done. We're not worried about anything more than just basic don't get me in trouble, avoid big fines, don't go to jail. Compliance, there are companies out there like that. Now I am not saying this company is one of those. What I am suggesting is that there's opportunity to learn through all the standards what can be done and what can be better in how we interact with our risk. So for instance, my guess, given that it's a food additive manufacturing facility, I would highly doubt, and given some of the research not as thorough as it should be, but I do not believe they would fall under process safety management. Would process safety management have helped, I think so. I think this is one of those opportunities where just because you don't have to doesn't mean you shouldn't follow some good practices. And I think the PSM standard really gives some performance standards of what does it look like to manage your risk with opportunities that come with this level of risk. Why did the fan fail? Was there preventative maintenance? Was there inspections? Was there any type of knowing, of predictive engineering that could have said that fan has failed, would fail, could fail, had been failed, which is probably my larger concern was, How long had they known that that fan may not be as good as what it was, or what was the indicator that it was getting too hot or over pressurizing? Where was the fail safe? Where was the redundancy? Where was the engineering risk assessment? What is really interesting about engineering risk assessments is truly being able to calculate what are the chances of this event happening, what are the chances that this could occur, and being able to reduce that systemically through adding extra pieces of work, whether it be engineering redundancies, whether it be spot checks, whether it be alarms. What is it that would allow something like this to happen without people knowing that it could be happening and it could be coming catastrophic. That is where I scratch my head, and I truly question the leadership of how does that happen? To know that it could fail that bad, like this was a catastrophic, community changing failure, and it appears that there was very, potentially very little here that prevented it, that was in place to give notification or engineer it, or fix it or understand it, to even quantify that that level of risk could happen, and who said it was acceptable, or was it truly out of sight, out of mind? There's a lot of questions there, and this is why I'm happy. I'm sad that this happened, of course, but I'm at least happy that the Chemical Safety Board will be there, looking at historical data, looking at what has happened historically that led to these critical decision making steps, the engineering, the work that had to be done that allowed such a catastrophic event to happen. Now there's another piece of this story that I'm going to get to in the second half of the podcast coming up here in just a moment that allow that gives me further indication that there were significant leadership deficiencies. Again, I'm making an assumption, but when I put the pieces together and I look at some of the items that I hear about, and I learn about and I hear about from the news stories. I question what could have happened there. I question the leadership motive. I question the just the normal caring, compassion, human dignity and decency that. Is required that some organizations don't believe in, but should. Let's talk more about that on the second half of the leading and learning through safety podcast. You

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Mark French: 11:00

Welcome back to the second half of the leading and learning through safety podcast. So I alluded to in the first half that there were more indicators of this incident in Louisville, Kentucky, where this vessel exploded a food additive. Vessel that didn't vent continued to heat over, pressurized and exploded, injuring somewhere around 12 people, killing two in rocking the neighborhood. Shattered glass out of windows, damages to buildings, damages to other items, significant, catastrophic explosion, and I mentioned that there were other items that made me skeptical, highly skeptical of the leadership, and I think just the effort to prevention and this, I still, even though I've done this once before, because I said I've tried to record this one, I still have trouble getting The words together of this next piece of it. And so there was one fatality for sure. They didn't discover the second fatality until after they were digging through the rubble. And the reason that they were just kind of cleaning up to and found someone was that during the evacuation and head count, the organization, the company, told the first responders, emergency responders, that everyone was accounted for. They said that they had a clerical error that allowed them to forget that there was still someone, another individual in the building. They left someone in the building after the explosion. I don't know. I have not heard like was this an instantaneous How long were they alive? But they told the first responders, we have everyone accounted for. And yet, one person was left in the rubble and was not discovered until during the cleanup phase. So when I look at catastrophic engineering failure, no nothing, alarm to tell them it was happening, it continued to happen. No fail safe. And then I go to the emergency management piece of it again, all of this would have been covered under PSM if they were a PSM facility or or if they'd had the leadership to just follow the guide and to write their own internal policy stating they would do things like, I don't. Maybe they have it. I would. I'm skeptical, highly skeptical there, but Emergency Management having a robust system to assure the most important part accounting for your team. Where are they? Can we find them? Do we know where they are? And there was a video of one of the news stories where they were showing there was a community center where people were talking to the city officials, some of the company officials, and the son of that employee spoke, and His quote just struck me as very truthful, very honest. And so his son said, I have never seen a man lead by example and work as hard as my father did. I just never thought his commitment to work would lead to his final days. Yeah, he gets it real. And that gets no more real than that. Not only did it happen, the explosion, the lack of whatever happened that led to that that wasn't working. And then to tell people that we have everyone accounted for. Right, and one person was left behind. The attorney for the family said another very truthful statement and very blunt, a vessel like that just does not explode, correct? Because if that was the case, vessels all over the country would be just exploding. They're not built for that. The engineering and the systems that are in place are there to help make sure it does not explode, because when it does, it is huge, it is catastrophic. The risk was way too high, the acceptance of risk by the leadership team, by the leadership, and it may be, I'll say even the corporate leadership, was unbelievable to accept that catastrophic risk and go, we had to be okay. Not sure where the decision making comes from. There's some really interesting research by the Kraus Bell group on decision making and catastrophic events or significant incident fatalities, in how far back the decisions go and how they lead to these things. And now, I think in those terms, where did the decisions happen that led to this event, short term and long term, especially with investment in engineering and evaluation of risk. Where is it? What was it? Definitely it was not the correct level. And that's truly evident by what happened that you can see when it happens that it's too late for worrying about that, but the level of risk acceptance was way too high, and that begins the first journey of where is the tolerance for risk and what is the worst case outcome of that risk. In this case, it was catastrophic, and I've said that so many times, it's hard for me to wrap my mind around how much, if you look at the pictures, if you do some research and research this explosion, the damage was it's unbelievable how much damage was done and how big the explosion was, and how poorly it was reacted To, because some of the community concerns that came out was that the the company didn't do enough of the community fast enough that their response was slow, that when they came out to investigate it, it was too slow, that the whole response was just kind of slow, that it was evidently indicative of how they were treating safety, as it's important, but how important is there something else that may be a little bit more important? And did that show in this event, how it happened? Yeah, you see it. You see the pieces. And it becomes, to me, it feels very clear, and again, that's my opinion of just all the items that should have been done different. Thanks for joining me on this episode of the leading and learning through safety podcast. Again. As we close out this episode, what it comes down to is we look at the minimum that's required, but we look at other standards that are available, and we say, Should we adopt them? Can we be better than the basic? And in this case, there was opportunity, and we have to look at that as how where do we control the risk? Where do we help our people through strong safety leadership. I hope you've enjoyed this episode, and until next time we chat, stay safe.

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