It Bears Repeating
It's Friday afternoon, and the week is winding down. I'm starting to think about packing it in. This ought to be the time to post something funny for "Out of Control" or more good news to follow up on Walt's last post.
Unfortunately, that's not what I'm going to do. This morning in my Twitter feed I found two links from Mike Boudreaux over at Emerson. They take one to a video of what went wrong at Bayer Cropscience in 2008 and to the summary of the final report from the Chemical Safety Board about the same incident.
The depressing thing about them is that much of what is in the two reports isn't news. The CSB says it found "multiple deficiencies" during a start-up process--as in
"the startup was begun prematurely, a result of pressures to resume production of the pesticides methomyl and Larvin, and took place before valve lineups, equipment checkouts, a pre-startup safety review, and computer calibration were complete. CSB investigators also found the company failed to perform a thorough Process Hazard Analysis, or PHA, as required by regulation.
This resulted in numerous critical omissions, including an overly complex Standard Operating Procedure (SOP) that was not reviewed and approved, incomplete operator training on a new computer control system, and inadequate control of process safeguards. A principal cause of the accident, the report states, was the intentional overriding of an interlock system that was designed to prevent adding methomyl process residue into the residue treater vessel before filling the vessel with clean solvent and heating it to the minimum safe operating temperature.
Furthermore, the investigation found that critical operating equipment and instruments were not installed before the restart, and were discovered to be missing after the startup began. Bayer’s Methomyl-Larvin unit MIC gas monitoring system was not in service as the startup ensued, yet Bayer emergency personnel presumed it was functioning and claimed no MIC was release."
Come on, people. We do know better. The folks at Bayer Cropscience knew better. How many of these incidents is it going to take before we remember that faster and cheaper in some circumstances also can mean deadly?
Guess whether we want to or not, we're just going to have to keep saying it over and over again.