Fact Sheet: 2011 Combustible Dust Related Incidents, NFIRS Analysis from Combustible Dust Policy Institute
Near Misses in Non-medical Domains
A Combustible Dust Policy Institute (CDPI) preliminary
analysis of 2011 National Fire Incident Reporting System (NFIRS) incident data provided
by the National Fire Data Center of the U.S. Fire Administration indicated over
500 combustible dust related incidents in manufacturing facilities where dust
was the item first ignited. Near misses include incidents that did not result
in any harm to personnel, the facility, process, or product. Analysis did not include
the grain sector or coal-fired energy plants.
Additionally, the CDPI analysis does not include many
incidents that were not reported by fire departments to the National Fire
Data Center.
As a result there are many more combustible dust related incidents that cannot
be evaluated in determining whether the incident was a near miss or not.
Special thanks to the nation's Fire Departments, NFIC State Program Managers,
and the National Fire Data Center at the U.S. Fire Administration in
sharing this valuable Information.
Casual Pathways Between Near Misses and Catastrophic Events
Excellent article by Carsten Busch from Norway, highlighting Common Cause Hypothesis (CCH) which also
pertains to near misses and catastrophic combustible dust related
incidents. In the current OSHA ComDust rulemaking process and recently
reintroduced proposed combustible dust bill H.R. 691, incidents
resulting in property/content loss (30% NFIRS analysis) yet no
casualties (approximately 95%) are considered near misses. Yet the
casual pathways (ignition sources, dust management strategies, etc.) for
the consequences of all combustible dust related incidents are all the
same.
The true definition of a "near miss" is an incident not resulting
in any harm to personnel, the facility, process, or product. So why are near misses ignored in accounting for combustible dust
related fire and explosion hazards in protection of the workplace in the OSHA ComDust rulemaking process and recently
reintroduced proposed combustible dust bill H.R. 691?
Report on preliminary findings of a study of incident reporting systems
for near misses in nonmedical domains.
This can also apply to combustible dust related incidents/accidents
where NFIRS data provides a multitude of information in developing
barriers for the prevention of future accidents.
Near Misses in Non-medical Domains
"Consequently, the same patterns of causes of failure and their relations precede both adverse events and near misses." Sounds familiar with ComDust
related incidents at facilities whether it was flash fire, dust
explosion, or layer fire? They all have casual pathways of improperly
managed ignition sources and fuel sources. A written fire prevention plan (FPP) addresses these casual pathways initially at the
organizational level. The next step would be implementation at the
technical and operational level.
"We defined a near miss as any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome." Note: National Fire Incident Reporting System (NFIRS) was not included in the report of near misses in nonmedical domains.
"We defined a near miss as any event that could have had adverse consequences but did not and was indistinguishable from fully fledged adverse events in all but outcome." Note: National Fire Incident Reporting System (NFIRS) was not included in the report of near misses in nonmedical domains.
U.S. Chemical Safety Board (CSB): Near Misses.
Dust Explosion Hazard Awareness / Imperial Sugar Management and Workers
(Page 54 .pdf) "The CSB concluded that the small events and “near-misses” caused company management, and the managers and workers at both the Port Wentworth, Georgia, and Gramercy, Louisiana, facilities to lose sight of the ongoing and significant hazards posed by accumulated sugar dust in the packing buildings."
CSB Key Findings: Imperial Sugar Refinery
Page 48 .pdf) # 4 "Company management and the managers and workers at both the Port Wentworth, Georgia, and Gramercy, Louisiana, refineries did not recognize the significant hazard posed by sugar dust, despite the continuing history of “near-misses’”
Hoeganaes
(Page 14 ,pdf) "Operators and mechanics reported being involved in multiple flash fires during their employment at the Gallatin facility. At the time of the incidents, many were aware that the iron dust could burn or smolder. However, they were not trained to understand the potentially severe hazard when accumulated dust is dispersed in air. Rarely would operators report the minor flash fires and “near-misses” that periodically occurred."
(page 27 .pdf) CSB Recommendations to Hoeganaes 2011-4-I-TN-R9
"Develop and implement a “near-miss” reporting and investigation policy that includes the following at a minimum:"
• Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
• Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corp.
• Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
• Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).
Dust Explosion Hazard Awareness / Imperial Sugar Management and Workers
(Page 54 .pdf) "The CSB concluded that the small events and “near-misses” caused company management, and the managers and workers at both the Port Wentworth, Georgia, and Gramercy, Louisiana, facilities to lose sight of the ongoing and significant hazards posed by accumulated sugar dust in the packing buildings."
CSB Key Findings: Imperial Sugar Refinery
Page 48 .pdf) # 4 "Company management and the managers and workers at both the Port Wentworth, Georgia, and Gramercy, Louisiana, refineries did not recognize the significant hazard posed by sugar dust, despite the continuing history of “near-misses’”
Hoeganaes
(Page 14 ,pdf) "Operators and mechanics reported being involved in multiple flash fires during their employment at the Gallatin facility. At the time of the incidents, many were aware that the iron dust could burn or smolder. However, they were not trained to understand the potentially severe hazard when accumulated dust is dispersed in air. Rarely would operators report the minor flash fires and “near-misses” that periodically occurred."
(page 27 .pdf) CSB Recommendations to Hoeganaes 2011-4-I-TN-R9
"Develop and implement a “near-miss” reporting and investigation policy that includes the following at a minimum:"
• Ensure facility-wide worker participation in reporting all near-miss events and operational disruptions (such as significant iron powder accumulations, smoldering fires, or unsafe conditions or practices) that could result in worker injury.
• Ensure that the near-miss reporting program requires prompt investigations, as appropriate, and that results are promptly circulated throughout the Hoeganaes Corp.
• Establish roles and responsibilities for the management, execution, and resolution of all recommendations from near-miss investigations
• Ensure the near-miss program is operational at all times (e.g. nights, weekends, holiday shifts).
Conclusion
Near misses can no longer be ignored. It's very distressing that OSHA in the combustible dust rulemaking process in conjunction with the legislators in the reintroduction of the proposed combustible dust bill H.R. 691 have chosen to ignore 95% of combustible dust related incidents in manufacturing facilities, which do not result in personnel casualties. Yet these very same incidents, as history illustrates are precursors to catastrophe.
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