Why is that we do not seem to learn lessons from incidents? One of the root causes of the 2005 BP Texas refinery incident was attributed to operator fatigue and overload. In many cases lack of training and troubleshooting skills are also mentioned. Do not neglect such warnings. An article mentions the following about the San Bruno gas pipeline accident:
"The San Bruno natural gas explosion has underscored a growing concern about the capabilities of utility employees who watch over the nation's pipelines and whose errors have been linked to a number of mishaps, some of them catastrophic.
The National Transportation and Safety Board has said among the questions it is investigating is whether workers at a PG&E pipeline-monitoring terminal in Milpitas were fatigued or poorly trained. And just eight days after the Sept. 9 blast, the federal Pipeline and Hazardous Materials Safety Administration moved to speed up adoption of a rule to insure that workers doing similar jobs at companies across the country are well-trained and rested -- especially since many of those workers put in 12-hour shifts".
"A 2005 NTSB study that scrutinized 13 pipeline mishaps involving various liquids from 1992 to 2004 found that "in ten of these accidents, some aspect of the SCADA system contributed to the severity of the accident." In many cases, the problems were aggravated when workers monitoring the systems failed to quickly recognize and respond to leaks. Among the accidents cited:
# An April 7, 1992, fire in Brenham, Texas, that caused three deaths and 21 injuries after a poorly trained worker failed to notice the changing pressure in a pipe, in part because the system didn't display data in a way the worker could easily interpret.
# On June 10, 1999, a worker failed to realize that a gasoline pipeline had ruptured and burst into flames in Bellingham, Wash., because the malfunctioning control system was providing erroneous data. As a result, it took more than an hour to shut the pipe's valves. Three people died and eight were injured.
# On Oct. 27, 2004, after a pipeline containing the caustic and potentially deadly chemical anhydrous ammonia ruptured in Kingman, Kansas, a worker misinterpreted alarms generated by a control system and mistakenly increased the flow of ammonia into the line. No one was killed or injured, but 204,000 gallons of the liquid flowed into a creek, killing more than 25,000 fish, including some threatened species.
"From 1990 to 2009, gas-line operator errors caused a little more than 5 percent of all the significant accidents nationwide, resulting in 8 fatalities, 150 injuries and $16.2 million in property damage, according to data kept by the Pipeline and Hazardous Materials Safety Administration. During the same period, operator error caused 11.5 percent of "serious incidents," which involve a fatality or an injury requiring hospitalization".
Read more of the article in this link.
A good post.But nowadays managements are also facing acute shortage of skilled manpower across all functions. So, the need of the hour is to develop and implement longterm specific process safety training modules to enhance their employees troubleshooting skills which will eventually reduce near misses and incidents in near future.
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