Heat Exchanger Rupture Incident, Research Paper Example

Accidents are almost always caused by an unsafe surrounding where the conditions are generally or specifically unsafe. Most investigators look at human error because they hold the general principle that unsafe conditions are as a result of unsafe acts. According to CCOHS, most accidents that appear to be straight forward have an array of causes. This principle holds for the explosion at the Goodyear Houston plant.

The accident can be dissected into two main areas. Both direct and indirect systemic and human resource failures led to the explosion. This was the first problematic areas. The second problematic area was the emergency response. Both these events can be considered as one event, however, it is important that they be considered as two separate events to ensure that the direct and indirect causes are identified distinctively.

The Explosion

One of the plant’s anhydrous ammonia heat exchangers experienced an accumulation of steam when undergoing maintenance and cleaning. This was due to one of the block valves closing, therefor insulating the heat exchanger from the pressure control valve. This caused the block valve to fail in expelling the pressure before the pressure reached precarious levels. Owing to the repair procedure carried out on heat exchanger. This repair directly caused the closure of the isolation valve even after the repair procedure. This is the element of human error.

The direct cause of the explosion incident was the accumulation of steam inside one of the anhydrous ammonia heat exchangers. This was also partly due to the closure of two relief valves. Owing to the fact that these direct causes of the explosion were due to a “less than adequate design or operations practices” (Manuele, 2008), they are a small section of the causal chain. They are therefore categorized as task performance causal factors.

The Evacuation

The evacuation procedures implemented by the company were rigged with numerous errors from underlying systemic errors. Owing to the nature colorless and toxic nature of low doses of anhydrous ammonia, the efficiency and effectiveness of both the emergency crew and the employees is essential to the success of the evacuation process. All the procedures employed by Goodyear are grossly below standard.

Most of the employees had no idea of the occurrence of the explosion. This is because the emergency pull boxes were inaccessible due to the water deluge system and the hazard. Information on the explosion was mainly passed on through the radio or word of mouth. This increases the risks on both the employees and the emergency response crew. This is fundamentally a design management category contributing factor (Manuele, 2008).

According to policies employed by Goodyear Management, shelter in place and plant-wide evacuation drills were to be conducted 4 times annually at the least. According to employee reports, these drills were non-existent as far as 4 years before the accident. Most employees have had their emergency training as part of their health and safety training requisite. This type of training is not sufficient in handling real-life emergency situation with a lot at stake. This depicts the lack of a safety culture within the company and the plant in particular.

In conclusion, there are numerous contributing factors that can be identified towards the accident and eventual systemic failures in the emergency response. However, the fundamental and foundational problem to the accident is the distinct lack of a culture of safety with the mission, vision and policies of the company and the plant. There is a clear lack of regardtowards safety as depicted in the manner in which management and the employees slackened on their moralobligation to uphold a safe environment. Management had made the mandatory safety and emergency procedures secondary to the company’s core function.

The little or lack of commitment to safety on the management’s part is the definitive cause of the explosion. This points out to the management’s, and thus overall company’s culture showing the system of expected behavior (Manuele, 2008). Workers would only devoted towards keeping a safe working environment if management is dedicated to the same. Management gives direction to the company, and in this case, management failed to guide the company towards the most profitable path. Management can only remedy this by identifying employees that are dedicated towards ensuring a safe working environment and integrating emergency response training in the event of a plant-wide evacuation. Management can achieve this through the implementation of safety policies.

References

CBS. (2011). Heat Exchanger Rupture and Ammonia Release in Houston, Texas (One Killed, Six Injured). Houston, TX: U.S. Chemical Safety and Hazard Investigation Board.

CCOHS. (2006, April 20). Accident Investigation. Retrieved from Candian Center for Occupational Health and Safety: http://www.ccohs.ca/oshanswers/hsprograms/investig.html#_1_4

Manuele, F. A. (2008). Advanced Safety Management: focusing on Z10 and Serious Injury Prevention. Hoboken: Wiley-Interscience.