Boom Factory! #pauto #manufacturing #safety #SIS

This has not been a good week for refineries in the United States. On August 2, the diesel hydrotreater of the Holly-Frontier Tulsa East refinery blew up, causing the unit to be shut down, possibly for months. You can read about it here: http://www.tulsaworld.com/business/article.aspx?subjectid=49&articleid=20120808_49_0_Lastwe902577 . No one appears to have been injured, and no cause for the accident has been announced.

On Monday, August 6, the crude unit at the Chevron Martinez refinery sprang a leak. It was a little bitty leak, "a couple of drops," one bystander said. Suddenly that leak became a really big leak and the crude unit was destroyed. You can read about THAT one here:
http://www.sfgate.com/bayarea/article/Small-refinery-leak-leads-to-big-disaster-3770451.php#page-2. According to the San Francisco Chronicle's article, operators and maintenance personnel were standing around discussing what to do when the leak suddenly became much larger and caught fire.

According to the ASM (Abnormal Situation Management) Consortium, whose incident newsfeed we reproduce at ControlGlobal.com by permission, (http://www.controlglobal.com/articles/2010/asm_news.html) there have been 21 incidents worldwide since August 1.

In the San Francisco Chronicle article on the Chevron fire, the reporters noted that according to a report published recently by the American Fuel and Petrochemical Manufacturers Association (formerly NPRA), the rate of incidents has not declined since 2005.

In fact, in the article, Charlie Drevna, president of AFPMA, noted ""As an industry, we were able to bring it down to a level. When you compare us to other industries we are doing OK." He said that he felt that wasn't enough, that AFPMA is dedicated to eliminating incidents.

Read more: http://www.sfgate.com/bayarea/article/Small-refinery-leak-leads-to-big-disaster-3770451.php#ixzz22zVf1uaK

So, if Chevron has a safety culture, and AFPMA (jeez, NPRA was simpler to write, folks) is dedicated to eradicating incidents, and everybody has a safety culture, why are incidents NOT GOING DOWN for at least 6 years now?

Something is not right here.

I don't think we can just blame it on profit before safety. I don't think we can blame it on poor training and even worse situational awareness...

It may be some of all of those things.

It may actually be inherent in primate biology. I've talked before about Dr. John Lambshead, professor emeritus of evolutionary biology at London's Museum of Natural History. John's opinion is that what he calls "the leopard in the grass" is hardwired into primate (not just human) behavior. The chimpanzee troop are out on the savannah and the grass rustles and a leopard leaps out. All the rest of the chimpanzees run for their lives, and one becomes leopard lunch. As time passes, though, and the leopard doesn't leap out every time the grass rustles, the chimpanzees relax their watchful behavior-and then, of course, it happens again.

This would argue for exactly what we're seeing. After every major accident, we see some movement toward more safety...but after a while without a major incident, everybody relaxes, and then the cycle repeats.

Sad, isn't it?