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1July 18, 2012
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High Reliability: Enabling Motivated Organizations to transition from theory to practice
The Role of the Chemical Safety Board
5/21/2012
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DisclaimerThe PowerPoint presentation given by Mark Griffon, Board
Member, United States Chemical Safety & Hazard Investigation Board is for general informational purposes only. The presentation represents his individual views and all references, conclusions, or other statements regarding current on going CSB investigations are preliminary in nature and do not represent a formal adopted product of the full Board. Users of this presentation should also note the contents were compiled solely for this presentation. For specific and accurate information on completed investigations, please refer to the final printed version by going to the CSB website at www.csb.gov.
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WHAT IS THE CSB?• An independent U.S. federal agency
– investigating chemical accidents– promoting prevention – public knowledge
• Authorized by Congress in 1990
• Five Board Members; approx 45 staff
• Modeled after NTSB
• Intent of CSB investigations are to get to root cause(s) and make recommendations toward prevention
• Not regulatory; no enforcement authority
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CSB Investigation Approach• Formal analysis to identify underlying technical,
human factor, management system, organizational and regulatory causes of the incident.– Beyond immediate technical events and individual
actions – Focus is on improving safety NOT assigning blame
• Addressing the immediate cause ONLY prevents that exact accident from occurring again.
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Investigative Approach• Analysis of Safety Systems
– Not just how they are set up but how the systems work in real life (interviewing employees at all levels within organization)
• More emphasis on Organizational and Social Causes– Safety culture– Organizational Structure– Cost Pressures– Regulatory Gaps and ineffective enforcement– Performance Agreements or bonus structure
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Causal Analysis
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Societal Risk Tolerance; Econonmics
Government and Regulatory Regulatory gaps; enforcement
Industry Group Best Practices; Audit function
Company Organizational structure; decision making; communicatoins
Technical and Operational Management Safety Management Systems; Performance Metrics; monitoring and feedback loop
Physical Processes and Employeeactivities
Technical process and the human interaction with the systems
Equipment Designed for safety, maintenance
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Deepwater Horizon (DWH) Incident• April 20th, 2010
• 11 deaths
• 17 serious Injuries
• ~5 million barrels of oil
spilled in Gulf
• Tremendous Economic
Impact
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Safety Culture Findings / Recommendations
• “Transform the industry safety culture” (Presidential Commission)– question data, raise concerns, double check– Greater attention to even minor anomalies
• Develop and Maintain Industrial and Governmental HROs (DWH Study Group)
– Organizations with core Systems Safety Cultures
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CSB Investigation• Examine specifics of organizational factors
– Staffing and organizational structure (changes)– Safety Metrics– Awards and Bonuses– Cost and Performance Pressures (cost and production
goals)– Organizational Learning
• Human factors analysis of how mistakes occurred– Reliance on human intervention– Evidence / Explanations for “inexplicable” decisions
leading up to the incident– Control / display panels
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Examination of consideration of Risks• High Hazard Risks
– Examining BPs approach for assessing the risk• Safety risk was considered to be low; low level review• Regulator review
• Personal Safety vs. Process Safety– Safety professionals focused on personal safety
• Commercial Risk vs. Safety Risk– Exploration Division : Big Risk – Big Reward– Examining decisions leading up to the event
• Decisions made to save time and money
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Blow Out PreventerBOP and LMRP are stacked (BOP pictured here)
57 feet 400 tons
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Other Investigations• Hoeganaes
– 3 Combustible Dusts Incidents over 6 months
• Texas Tech University– University Lab Safety
• DuPont (WV and NY incidents)– WV Belle facility, 3 incidents in 33 hours– NY Yerkes facility, planning leading up to hot work
incident
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Challenges• Response to incidents often is to ‘fix the
component that failed’, ‘fix (make more rigorous) the procedure’ or ‘fix the worker’ (training)
• Safety Culture– Many definitions / misinterpretation– Questions on how to measure / assess– No regulatory requirements
• Great focus on personal safety as an indicator for safe process– No regulatory requirements for process safety
indicators
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CSB Challenges• Management must walk the talk
– Incentives must be consistent with higher level safety mission
• Chemical Process Safety is dynamic– Cost and production pressures can drive a system
toward accidents• Complacency
– Underestimate of risk, not planning for high consequence / low probability events, ignoring warning signs
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Contact the CSB
• Web site: www.csb.gov
• Mark Griffon
July 18, 2012
