Impact of Societal Norms on Safety, Health, and the Environment: Case Studies in Society and Safety Culture

Cover
Title Page
Copyright
Contents
Preface
Abbreviations
Chapter 1 Safety Culture Concepts
	1.0 Introduction
	1.1 Culture
	1.2 Safety and Health Pioneers
	1.3 The Evolution of Accident Causation Models
	1.4 Safety and Common Sense
	1.5 Interviews with Safety Professionals
	1.6 Chapter Summary
	References
Chapter 2 History of Safety Culture
	2.1 Life Expectancy and Safety
	2.2 Consumer Items and Toys
		2.2.1 Vintage Toys and Other Items
	2.3 Flawed Cars
	2.4 Ford Pinto
	2.5 Off‐Highway‐Vehicle‐Related Fatalities Reported
	2.6 Work Relationships
	2.7 Food
		2.7.1 Food Trends and Culture
			2.7.1.1 The Tomato
			2.7.1.2 Fad Diets
	2.8 Genetically Modified Organisms (GMO) Foods
		2.8.1 Messenger Ribonucleic Acid (mRNA) Vaccines
	2.9 Traffic Safety
	2.10 Public Acceptance of Seatbelts and Masks for Protection from Respiratory Disease
	2.11 Radiation Hazards and Safety
		2.11.1 Radiation
		2.11.2 Measuring Radiation (CDC )
		2.11.3 Health Effects of Radiation (EPA )
		2.11.4 Uses of Radiation (NRC )
		2.11.5 Medical Uses
		2.11.6 Academic and Scientific Applications
		2.11.7 Industrial Uses
		2.11.8 Nuclear Power Plants
		2.11.9 Misuse of Radiation (EPA )
		2.11.10 Radium Dial Painters
		2.11.11 Safety Culture Issues
	2.12 The Occupational Safety and Health Administration (OSHA)
		2.12.1 Who Does OSHA Cover
			2.12.1.1 Private Sector Workers
			2.12.1.2 State and Local Government Workers
			2.12.1.3 Federal Government Workers
			2.12.1.4 Not Covered Under the OSHA Act
		2.12.2 Voluntary Protection Program
	2.13 Human Performance Improvement (HPI)
	2.14 Chapter Summary
	References
Chapter 3 Chemical Manufacturing
	3.0 Introduction
	3.1 Process Safety Management
		3.1.1 Introduction
		3.1.2 Process Safety Management
			3.1.2.1 Process Safety Information
			3.1.2.2 Process Hazards Analysis
			3.1.2.3 Operating Procedures
			3.1.2.4 Mechanical Integrity
			3.1.2.5 Management of Change
	3.2 DuPont La Porte, TX, Methyl Mercaptan Release – November 15, 2014
		3.2.1 Accident Description and Analysis
		3.2.2 DuPont's Initiation of Process Safety Culture Assessments
		3.2.3 Summary of Safety Culture Findings
	3.3 BP Texas City Refinery Explosion – March 23, 2005
		3.3.1 Introduction
		3.3.2 Texas City
		3.3.3 Description of the BP Refinery
		3.3.4 The Accident
		3.3.5 Trailer Siting Recommendations
		3.3.6 Blowdown Drum and Stack Recommendations
		3.3.7 Additional Recommendations from July 28, 2005, Incident
		3.3.8 Summary of Safety Culture Issues
	3.4 T2 Laboratories, Inc. Explosion – December 19, 2007
		3.4.1 T2 Laboratories, Inc.
		3.4.2 Event Description
		3.4.3 Events Leading Up to the Explosion
		3.4.4 Analysis of the Accident
		3.4.5 Process Development
		3.4.6 Manufacturing Process
		3.4.7 Summary Safety Culture Issues
	3.5 Final Thoughts for This Chapter
	References
Chapter 4 Chemical Storage Explosions
	4.0 Introduction
	4.1 Port of Lebanon – August 4, 2020
		4.1.1 PEPCON Explosion – May 4, 1988
		4.1.2 Lessons Learned
		4.1.3 Safety Culture Issues
	4.2 PCA DeRidder Paper Mill Gas System Explosion, DeRidder, Louisiana – February 8, 2017
		4.2.1 PCA DeRidder Mill
		4.2.2 The Explosion
		4.2.3 Safety Culture Summary
	4.3 West Fertilizer Explosion – April 17, 2013
		4.3.1 The Fire and Explosion
		4.3.2 Injuries and Fatalities
		4.3.3 Safety Culture Summary
	References
Chapter 5 Dust Explosions and Entertainment Venue Case Studies
	5.0 Introduction
	5.1 Dust Explosion Information and Case Studies
	5.2 AL Solutions December 9, 2010
		5.2.1 Facility Description
		5.2.2 Zirconium
		5.2.3 Description of the Incident
		5.2.4 The Origin of the Explosion
		5.2.5 AL Solutions Dust Management Practices
		5.2.6 Water Deluge System
		5.2.7 Safety Audits
		5.2.8 Hydrogen Explosion
		5.2.9 Previous Fires And Explosions
		5.2.10 Summary of Safety Culture Findings
	5.3 Imperial Sugar Company, February 7, 2008
		5.3.1 Sugar
		5.3.2 Accident Description
		5.3.3 Synopsis of Events
		5.3.4 Detailed Accident Scenario
		5.3.5 The Chemical Safety Board Investigation
		5.3.6 South Packing Building
		5.3.7 Sugar Spillage and Dust Control
		5.3.8 Force of the Explosion
		5.3.9 Pre‐explosion Sugar Dust Incident History
		5.3.10 Steel Belt Conveyor Modifications
		5.3.11 Primary Event Location
		5.3.12 Primary Event Combustible Dust Source
		5.3.13 Secondary Dust Explosions
		5.3.14 Ignition Sources
		5.3.15 Open Flames and Hot Surfaces
		5.3.16 Ignition Sources Inside the Steel Belt Enclosure
			5.3.16.1 Hot Surface Ignition
			5.3.16.2 Friction Sparks
			5.3.16.3 Worker Training
		5.3.17 Evacuation, Fire Alarms, and Fire Suppression
		5.3.18 Electrical Systems Design
		5.3.19 Sugar Dust Handling Equipment
		5.3.20 Housekeeping and Dust Control
		5.3.21 Imperial Sugar Management and Workers
		5.3.22 Chemical Safety Board Key Findings
		5.3.23 Summary of Safety Culture Findings
	5.4 Entertainment Venue Case Studies
		5.4.1 Introduction
		5.4.2 Crowd Surge Events
		5.4.3 Fires at Bars and Nightclubs
		5.4.4 The New Taipei Water Park Fire – June 2015
	5.5 Safety Culture Summary
	References
Chapter 6 University Laboratory Accident Case Studies
	6.0 Introduction
	6.1 My Experience at Aalto University
	6.2 Texas Tech University October 2008
		6.2.1 Specifically, the CSB Found
	6.3 University of California Los Angeles – December 29, 2008
	6.4 University of Utah – July 2017
		6.4.1 Utah, Report to the Utah Legislature Number 2019‐06
	6.5 University of Hawaii – March 16, 2016
		6.5.1 Grounding (OSHA )
			6.5.1.1 Summary of Grounding Requirements
			6.5.1.2 Methods of Grounding Equipment
			6.5.1.3 Event Description
			6.5.1.4 Summary of Safety Culture Issues
	References
Chapter 7 Aviation Case Studies
	7.0 Introduction
	7.1 Helicopter Accident
		7.1.1 Liberty Helicopter Crash March 11, 2018
			7.1.1.1 Overview
			7.1.1.2 Liberty Helicopter's Safety Program
			7.1.1.3 Safety Culture Summary
	7.2 Commercial Aviation
		7.2.1 Successful Landing of Crippled Commercial Airliners
		7.2.2 Gimli Glider – Successful Landing of a Crippled Commercial Airliner 1 – July 23, 1983
			7.2.2.1 Accident Information
			7.2.2.2 Analysis of the Fuel Problem
	7.3 Illegal Dispatch Contrary to the MEL: Taking Off With Blank Fuel Gauges
	7.4 Summary of Safety Culture Issues
	7.5 Miracle on the Hudson River – Successful Landing of a Crippled Commercial Airliner 2, January 15, 2009
		7.5.1 Accident Information
		7.5.2 Flight Crew and Cabin Crew
		7.5.3 The Captain's 72‐Hour History
		7.5.4 The First Officer
			7.5.4.1 The First Officer's 72‐Hour History
			7.5.4.2 The Flight Attendants
			7.5.4.3 Airbus A320‐214
			7.5.4.4 Operational Factors
			7.5.4.5 Flight Crew Training
			7.5.4.6 Dual‐Engine Failure Training
			7.5.4.7 Ditching Training
			7.5.4.8 CRM and TEM Training
			7.5.4.9 FAA Oversight
			7.5.4.10 Summary of Safety Culture Issues
	7.6 737 MAX
		7.6.1 Introduction
		7.6.2 737 MAX Design and Manufacture
		7.6.3 Accidents
		7.6.4 Design Certification of the 737 MAX 8 and Safety Assessment of the MCAS
		7.6.5 Assumptions about Pilot Recognition and Response in the Safety Assessment
	7.7 De Haviland Comet
	7.8 Summary of Safety Culture Issues
	References
Chapter 8 Nuclear Energy Case Studies
	8.0 Introduction
	8.1 Nuclear Power
		8.1.1 Sodium Cooled Reactors
			8.1.1.1 Santa Susana – 1959
			8.1.1.2 Fission Gas Release
			8.1.1.3 Fermi 1 – Near Detroit Michigan – 1966
			8.1.1.4 Safety Culture Summary of Sodium Cooled Reactors
		8.1.2 The Vladimir Lenin Nuclear Power Plant or Chernobyl Nuclear Power Plant (ChNPP) – April 26, 1986
			8.1.2.1 Reactivity and Power Control
			8.1.2.2 Chernobyl Accident
		8.1.3 Three Mile Island Accident – March 28, 1979 (NRC 2022a)
			8.1.3.1 Accident
			8.1.3.2 Summary of Events
			8.1.3.3 Health Effects
			8.1.3.4 Impact of the Accident
			8.1.3.5 Current Status
			8.1.3.6 Human Factor Engineering Findings (Malone et al. )
			8.1.3.7 Human Engineering and Human Error
			8.1.3.8 Procedures
	8.2 Nuclear Criticality
		8.2.1 Mayak Production Association, 10 December 1968 (LANL )
			8.2.1.1 Safety Culture Issues
		8.2.2 National Reactor Testing Station – January 3, 1961 (LANL )
			8.2.2.1 Safety Culture Issues
		8.2.3 JCO Fuel Fabrication Plant – September 30, 1999 (LANL )
			8.2.3.1 Safety Culture Issues
	8.3 Medical Misadministration of Radioisotopes Events
		8.3.1 Loss of Iridium‐192 Source at the Indiana Regional Cancer Center (IRCC) – November 1992
			8.3.1.1 Introduction
			8.3.1.2 Event Description
			8.3.1.3 Patient Treatment Plan
		8.3.2 Greater Pittsburgh Cancer Center Incident
		8.3.3 Omnitron High Dose Rate (HDR) Remote Afterloader System
			8.3.3.1 Description of the Afterloader System
			8.3.3.2 High Dose Rate Afterloader
			8.3.3.3 Main Console
			8.3.3.4 Door Status Panel
			8.3.3.5 Afterloader System Safety Features
			8.3.3.6 Patient Applicators and Treatment Tubes
			8.3.3.7 Description of the Source Wire
			8.3.3.8 Prototype Testing Performed on Nickel–Titanium Source Wire
			8.3.3.9 Description of the Omnitron 2000 Afterloader System Software
			8.3.3.10 Equipment Performance
			8.3.3.11 Failure Analysis Pertaining to the Source Wire
			8.3.3.12 Possible Failure Areas
			8.3.3.13 Organization of Oncology Services Corporation
			8.3.3.14 Management Oversight
			8.3.3.15 Safety Culture
			8.3.3.16 Emergency Operating Procedures
			8.3.3.17 Training
			8.3.3.18 Radiation Safety Training at the Indiana Regional Cancer Center
			8.3.3.19 Summary of Safety Culture Issues
	8.4 Goiania, Brazil Teletherapy Machine Incident (IAEA 1988)
		8.4.1 Safety Culture Summary
	References
Chapter 9 Other Transportation Case Studies
	9.1 Large Marine Vessel Accidents
		9.1.1 LNG Carrier Collision with Barge
			9.1.1.1 Accident Description
			9.1.1.2 Work/Rest of Ships' Crews
			9.1.1.3 Drug and Alcohol Testing
			9.1.1.4 Findings
	9.2 Navy Vessel Collisions
		9.2.1 USS FITZGERALD Collided with the Motor Vessel ACX Crystal
			9.2.1.1 Summary of Findings
			9.2.1.2 Background
			9.2.1.3 Events Leading to the Collision
			9.2.1.4 Collision
			9.2.1.5 Impact to Berthing 2
			9.2.1.6 Findings
			9.2.1.7 Training
			9.2.1.8 Seamanship and Navigation
			9.2.1.9 Leadership and Culture
			9.2.1.10 Fatigue
			9.2.1.11 Timeline of Events
		9.2.2 Collision of USS JOHN S MCCAIN with Motor Vessel ALNIC MC
			9.2.2.1 Introduction
			9.2.2.2 Summary of Findings
			9.2.2.3 Background
			9.2.2.4 Events Leading to the Collision
			9.2.2.5 Results of Collision
			9.2.2.6 Impact to Berthing 5
			9.2.2.7 Impact on Berthing 3
			9.2.2.8 Impact on Berthings 4, 6, and 7
			9.2.2.9 Findings
			9.2.2.10 Training
			9.2.2.11 Seamanship and Navigation
			9.2.2.12 Leadership and Culture
			9.2.2.13 Timeline of Events
			9.2.2.14 Summary of Safety Culture Issues
	9.3 Stretch Duck 7 July 19, 2018
		9.3.1 Introduction
		9.3.2 Accident Description
		9.3.3 1999 Sinking of Miss Majestic
		9.3.4 Types of DUKW Amphibious Vessels
		9.3.5 NTSB Identified Safety Issue No. 1: Providing Reserve Buoyancy
		9.3.6 Safety Issue No. 2: Removing Canopies and Side Curtains
		9.3.7 Findings and Conclusions
		9.3.8 Safety Culture Summary Findings
		9.3.9 Other Events
			9.3.9.1 Minnow, Milwaukee Harbor, Lake Michigan, September 18, 2000
			9.3.9.2 DUKW No. 1, Lake Union, Seattle, Washington, December 8, 2001
			9.3.9.3 DUKW 34, Delaware River, Philadelphia, Pennsylvania, July 7, 2010
			9.3.9.4 DUCK 6, Seattle, Washington, September 24, 2015
	9.4 Recent Railroad Accidents
		9.4.1 AMTRAK Passenger Train – May 12, 2015
			9.4.1.1 Accident Scenario
			9.4.1.2 Amtrak
			9.4.1.3 Analysis of the Engineer's Actions
			9.4.1.4 Loss of Situational Awareness
			9.4.1.5 Two‐Person Crews
			9.4.1.6 Factors Not Contributing to This Accident
			9.4.1.7 NTSB Probable Cause
			9.4.1.8 Summary of Safety Culture Issues
		9.4.2 Transportation Safety Board of Canada (2013a)
			9.4.2.1 Personnel Information
			9.4.2.2 Train Brakes
			9.4.2.3 Locomotives
			9.4.2.4 Rules and Instructions on Securing Equipment
			9.4.2.5 Locomotive Event Recorder
			9.4.2.6 Sense and Braking Unit
			9.4.2.7 Mandatory Off‐Duty Times for Operating Employees
			9.4.2.8 Securement of Trains (MMA‐002) at Nantes
			9.4.2.9 Securement of Trains (MMA‐001) at Vachon
			9.4.2.10 Recent Runaway Train History at Montreal, Maine, and Atlantic Railway and Previous TSB Investigations
			9.4.2.11 Training and Requalification of Montreal, Maine, and Atlantic Railway Crews in Farnham
			9.4.2.12 Training and Requalification of the Locomotive Engineer
			9.4.2.13 Operational Tests and Inspections at Montreal, Maine, and Atlantic Railway
			9.4.2.14 Implementation of Single‐Person Train Operations
			9.4.2.15 Canadian Railway Operating Rules (CROR)
			9.4.2.16 Single‐Person Train Operations at Montreal, Maine, and Atlantic Railway
			9.4.2.17 Review of the Montreal, Maine, and Atlantic Railway Submission and its Relation to the Requirements of Standard CSA Q850
			9.4.2.18 Research into Single‐Person Train Operations
			9.4.2.19 Safety Culture
			9.4.2.20 Summary of Safety Culture Issues
	References
Chapter 10 Assessing Safety Culture
	10.0 Introduction
	10.1 Survey Research Principles
		10.1.1 Developing the Survey Instrument
			10.1.1.1 Developing the Questions/Statements
			10.1.1.2 Question/Statement Development
			10.1.1.3 Sampling
			10.1.1.4 Demographics
			10.1.1.5 Survey Delivery
			10.1.1.6 Analyzing the Results and Reports
			10.1.1.7 Final Thoughts on Developing and Delivering Surveys
		10.1.2 Safety Culture Assessment Methods
			10.1.2.1 DuPont (DuPont) De Nemours Sustainable Solutions (DSS)
			10.1.2.2 Department of Energy Assessment of Safety Culture Sustainment Processes
			10.1.2.3 Institute for Nuclear Power Operations Safety Culture Assessment
			10.1.2.4 Developing Team Findings
		10.1.3 United States Air Force Assessment Tool
	10.2 Assessing Health Care Safety Culture
	10.3 Seven Steps to Assess Safety Culture
		10.3.1 A Framework for Assessing Safety Culture
		10.3.2 Agency for Healthcare Research and Quality
		10.3.3 Graduate Student Safety Culture Survey
		10.3.4 Idaho National Engineering Laboratory Survey
	10.4 Chapter Summary
	References
Index
EULA