Impact of Societal Norms on Safety, Health, and the Environment

Lee T. Ostrom, PhD, is the Center Executive Officer at Idaho Falls Center and full Professor in the College of Engineering. He has authored or co-authored four books as well as several book chapters and articles, including Risk Assessment Tools and Techniques and Their Application. He has over 35 years’ experience in the field of workplace safety and health.

• Preface xviiAbbreviations xix1 Safety Culture Concepts 11.0 Introduction 11.1 Culture 21.2 Safety and Health Pioneers 41.3 The Evolution of Accident Causation Models 51.4 Safety and Common Sense 131.5 Interviews with Safety Professionals 141.6 Chapter Summary 59References 592 History of Safety Culture 612.1 Life Expectancy and Safety 612.2 Consumer Items and Toys 652.2.1 Vintage Toys and Other Items 662.3 Flawed Cars 692.4 Ford Pinto 692.5 Off-Highway-Vehicle-Related Fatalities Reported 702.6 Work Relationships 712.7 Food 752.7.1 Food Trends and Culture 782.7.1.1 The Tomato 782.7.1.2 Fad Diets 782.8 Genetically Modified Organisms (GMO) Foods 802.8.1 Messenger Ribonucleic Acid (mRNA) Vaccines 822.9 Traffic Safety 832.10 Public Acceptance of Seatbelts and Masks for Protection from Respiratory Disease 862.11 Radiation Hazards and Safety 902.11.1 Radiation 912.11.2 Measuring Radiation (CDC 2021) 932.11.3 Health Effects of Radiation (EPA 2021) 952.11.4 Uses of Radiation (NRC 2020) 972.11.5 Medical Uses 972.11.6 Academic and Scientific Applications 982.11.7 Industrial Uses 982.11.8 Nuclear Power Plants 1002.11.9 Misuse of Radiation (EPA 2021) 1012.11.10 Radium Dial Painters 1012.11.11 Safety Culture Issues 1032.12 The Occupational Safety and Health Administration (OSHA) 1032.12.1 Who Does OSHA Cover 1052.12.1.1 Private Sector Workers 1052.12.1.2 State and Local Government Workers 1052.12.1.3 Federal Government Workers 1062.12.1.4 Not Covered Under the OSHA Act 1062.12.2 Voluntary Protection Program 1072.13 Human Performance Improvement (HPI) 1112.14 Chapter Summary 112References 1123 Chemical Manufacturing 1193.0 Introduction 1193.1 Process Safety Management 1193.1.1 Introduction 1193.1.2 Process Safety Management 1213.1.2.1 Process Safety Information 1233.1.2.2 Process Hazards Analysis 1263.1.2.3 Operating Procedures 1293.1.2.4 Mechanical Integrity 1313.1.2.5 Management of Change 1363.2 DuPont La Porte, TX, Methyl Mercaptan Release – November 15, 2014 1383.2.1 Accident Description and Analysis 1393.2.2 DuPont’s Initiation of Process Safety Culture Assessments 1603.2.3 Summary of Safety Culture Findings 1623.3 BP Texas City Refinery Explosion – March 23, 2005 1633.3.1 Introduction 1633.3.2 Texas City 1643.3.3 Description of the BP Refinery 1653.3.4 The Accident 1673.3.5 Trailer Siting Recommendations 1733.3.6 Blowdown Drum and Stack Recommendations 1743.3.7 Additional Recommendations from July 28, 2005, Incident 1743.3.8 Summary of Safety Culture Issues 1743.4 T2 Laboratories, Inc. Explosion – December 19, 2007 1753.4.1 T2 Laboratories, Inc. 1753.4.2 Event Description 1763.4.3 Events Leading Up to the Explosion 1763.4.4 Analysis of the Accident 1803.4.5 Process Development 1833.4.6 Manufacturing Process 1843.4.7 Summary Safety Culture Issues 1853.5 Final Thoughts for This Chapter 186References 1864 Chemical Storage Explosions 1894.0 Introduction 1894.1 Port of Lebanon – August 4, 2020 1904.1.1 PEPCON Explosion – May 4, 1988 1914.1.2 Lessons Learned 2014.1.3 Safety Culture Issues 2034.2 PCA DeRidder Paper Mill Gas System Explosion, DeRidder, Louisiana – February 8, 2017 2034.2.1 PCA DeRidder Mill 2054.2.2 The Explosion 2054.2.3 Safety Culture Summary 2104.3 West Fertilizer Explosion – April 17, 2013 2114.3.1 The Fire and Explosion 2124.3.2 Injuries and Fatalities 2154.3.3 Safety Culture Summary 215References 2165 Dust Explosions and Entertainment Venue Case Studies 2195.0 Introduction 2195.1 Dust Explosion Information and Case Studies 2215.2 AL Solutions December 9, 2010 2255.2.1 Facility Description 2255.2.2 Zirconium 2285.2.3 Description of the Incident 2285.2.4 The Origin of the Explosion 2315.2.5 AL Solutions Dust Management Practices 2345.2.6 Water Deluge System 2355.2.7 Safety Audits 2355.2.8 Hydrogen Explosion 2375.2.9 Previous Fires And Explosions 2375.2.10 Summary of Safety Culture Findings 2395.3 Imperial Sugar Company, February 7, 2008 2395.3.1 Sugar 2395.3.2 Accident Description 2405.3.3 Synopsis of Events 2405.3.4 Detailed Accident Scenario 2425.3.5 The Chemical Safety Board Investigation 2435.3.6 South Packing Building 2485.3.7 Sugar Spillage and Dust Control 2495.3.8 Force of the Explosion 2505.3.9 Pre-explosion Sugar Dust Incident History 2515.3.10 Steel Belt Conveyor Modifications 2515.3.11 Primary Event Location 2525.3.12 Primary Event Combustible Dust Source 2535.3.13 Secondary Dust Explosions 2555.3.14 Ignition Sources 2565.3.15 Open Flames and Hot Surfaces 2565.3.16 Ignition Sources Inside the Steel Belt Enclosure 2575.3.16.1 Hot Surface Ignition 2575.3.16.2 Friction Sparks 2585.3.16.3 Worker Training 2585.3.17 Evacuation, Fire Alarms, and Fire Suppression 2595.3.18 Electrical Systems Design 2605.3.19 Sugar Dust Handling Equipment 2615.3.20 Housekeeping and Dust Control 2625.3.21 Imperial Sugar Management and Workers 2635.3.22 Chemical Safety Board Key Findings 2655.3.23 Summary of Safety Culture Findings 2665.4 Entertainment Venue Case Studies 2675.4.1 Introduction 2675.4.2 Crowd Surge Events 2675.4.3 Fires at Bars and Nightclubs 2675.4.4 The New Taipei Water Park Fire – June 2015 2685.5 Safety Culture Summary 270References 2706 University Laboratory Accident Case Studies 2736.0 Introduction 2736.1 My Experience at Aalto University 2736.2 Texas Tech University October 2008 2846.2.1 Specifically, the CSB Found 2996.3 University of California Los Angeles – December 29, 2008 3006.4 University of Utah – July 2017 3026.4.1 Utah, Report to the Utah Legislature Number 2019-06 3026.5 University of Hawaii – March 16, 2016 3066.5.1 Grounding (OSHA 2021) 3076.5.1.1 Summary of Grounding Requirements 3086.5.1.2 Methods of Grounding Equipment 3086.5.1.3 Event Description 3096.5.1.4 Summary of Safety Culture Issues 311References 3127 Aviation Case Studies 3157.0 Introduction 3157.1 Helicopter Accident 3377.1.1 Liberty Helicopter Crash March 11, 2018 3387.1.1.1 Overview 3387.1.1.2 Liberty Helicopter’s Safety Program 3467.1.1.3 Safety Culture Summary 3547.2 Commercial Aviation 3557.2.1 Successful Landing of Crippled Commercial Airliners 3557.2.2 Gimli Glider – Successful Landing of a Crippled Commercial Airliner 1 – July 23, 1983 3567.2.2.1 Accident Information 3567.2.2.2 Analysis of the Fuel Problem 3627.3 Illegal Dispatch Contrary to the MEL: Taking Off With Blank Fuel Gauges 3707.4 Summary of Safety Culture Issues 3737.5 Miracle on the Hudson River – Successful Landing of a Crippled Commercial Airliner 2, January 15, 2009 3747.5.1 Accident Information 3747.5.2 Flight Crew and Cabin Crew 3777.5.3 The Captain’s 72-Hour History 3797.5.4 The First Officer 3807.5.4.1 The First Officer’s 72-Hour History 3807.5.4.2 The Flight Attendants 3817.5.4.3 Airbus A320-214 3817.5.4.4 Operational Factors 3827.5.4.5 Flight Crew Training 3847.5.4.6 Dual-Engine Failure Training 3857.5.4.7 Ditching Training 3867.5.4.8 CRM and TEM Training 3877.5.4.9 FAA Oversight 3887.5.4.10 Summary of Safety Culture Issues 3897.6 737 MAX 3897.6.1 Introduction 3897.6.2 737 MAX Design and Manufacture 3907.6.3 Accidents 3917.6.4 Design Certification of the 737 MAX 8 and Safety Assessment of the MCAS 3937.6.5 Assumptions about Pilot Recognition and Response in the Safety Assessment 3957.7 De Haviland Comet 4007.8 Summary of Safety Culture Issues 401References 4018 Nuclear Energy Case Studies 4058.0 Introduction 4058.1 Nuclear Power 4058.1.1 Sodium Cooled Reactors 4098.1.1.1 Santa Susana – 1959 4108.1.1.2 Fission Gas Release 4118.1.1.3 Fermi 1 – Near Detroit Michigan – 1966 4138.1.1.4 Safety Culture Summary of Sodium Cooled Reactors 4148.1.2 The Vladimir Lenin Nuclear Power Plant or Chernobyl Nuclear Power Plant (ChNPP) – April 26, 1986 4158.1.2.1 Reactivity and Power Control 4168.1.2.2 Chernobyl Accident 4188.1.3 Three Mile Island Accident – March 28, 1979 (NRC 2022a) 4218.1.3.1 Accident 4218.1.3.2 Summary of Events 4228.1.3.3 Health Effects 4258.1.3.4 Impact of the Accident 4258.1.3.5 Current Status 4268.1.3.6 Human Factor Engineering Findings (Malone et al. 1980) 4278.1.3.7 Human Engineering and Human Error 4288.1.3.8 Procedures 4288.2 Nuclear Criticality 4308.2.1 Mayak Production Association, 10 December 1968 (LANL 2000) 4308.2.1.1 Safety Culture Issues 4358.2.2 National Reactor Testing Station – January 3, 1961 (LANL 2000) 4368.2.2.1 Safety Culture Issues 4378.2.3 JCO Fuel Fabrication Plant – September 30, 1999 (LANL 2000) 4388.2.3.1 Safety Culture Issues 4418.3 Medical Misadministration of Radioisotopes Events 4428.3.1 Loss of Iridium-192 Source at the Indiana Regional Cancer Center (IRCC) – November 1992 4448.3.1.1 Introduction 4448.3.1.2 Event Description 4448.3.1.3 Patient Treatment Plan 4448.3.2 Greater Pittsburgh Cancer Center Incident 4558.3.3 Omnitron High Dose Rate (HDR) Remote Afterloader System 4568.3.3.1 Description of the Afterloader System 4568.3.3.2 High Dose Rate Afterloader 4568.3.3.3 Main Console 4618.3.3.4 Door Status Panel 4618.3.3.5 Afterloader System Safety Features 4628.3.3.6 Patient Applicators and Treatment Tubes 4628.3.3.7 Description of the Source Wire 4628.3.3.8 Prototype Testing Performed on Nickel–Titanium Source Wire 4648.3.3.9 Description of the Omnitron 2000 Afterloader System Software 4648.3.3.10 Equipment Performance 4688.3.3.11 Failure Analysis Pertaining to the Source Wire 4688.3.3.12 Possible Failure Areas 4688.3.3.13 Organization of Oncology Services Corporation 4698.3.3.14 Management Oversight 4698.3.3.15 Safety Culture 4708.3.3.16 Emergency Operating Procedures 4748.3.3.17 Training 4748.3.3.18 Radiation Safety Training at the Indiana Regional Cancer Center 4758.3.3.19 Summary of Safety Culture Issues 4768.4 Goiania, Brazil Teletherapy Machine Incident (IAEA 1988) 4768.4.1 Safety Culture Summary 481References 4819 Other Transportation Case Studies 4859.1 Large Marine Vessel Accidents 4859.1.1 LNG Carrier Collision with Barge 4859.1.1.1 Accident Description 4879.1.1.2 Work/Rest of Ships’ Crews 4999.1.1.3 Drug and Alcohol Testing 5019.1.1.4 Findings 5029.2 Navy Vessel Collisions 5039.2.1 USS FITZGERALD Collided with the Motor Vessel ACX Crystal 5039.2.1.1 Summary of Findings 5049.2.1.2 Background 5059.2.1.3 Events Leading to the Collision 5069.2.1.4 Collision 5079.2.1.5 Impact to Berthing 2 5149.2.1.6 Findings 5199.2.1.7 Training 5209.2.1.8 Seamanship and Navigation 5209.2.1.9 Leadership and Culture 5209.2.1.10 Fatigue 5219.2.1.11 Timeline of Events 5219.2.2 Collision of USS JOHN S MCCAIN with Motor Vessel ALNIC MC 5249.2.2.1 Introduction 5249.2.2.2 Summary of Findings 5259.2.2.3 Background 5259.2.2.4 Events Leading to the Collision 5279.2.2.5 Results of Collision 5309.2.2.6 Impact to Berthing 5 5339.2.2.7 Impact on Berthing 3 5369.2.2.8 Impact on Berthings 4, 6, and 7 5399.2.2.9 Findings 5429.2.2.10 Training 5429.2.2.11 Seamanship and Navigation 5439.2.2.12 Leadership and Culture 5439.2.2.13 Timeline of Events 5449.2.2.14 Summary of Safety Culture Issues 5489.3 Stretch Duck 7 July 19, 2018 5489.3.1 Introduction 5489.3.2 Accident Description 5499.3.3 1999 Sinking of Miss Majestic 5529.3.4 Types of DUKW Amphibious Vessels 5539.3.5 NTSB Identified Safety Issue No. 1: Providing Reserve Buoyancy 5569.3.6 Safety Issue No. 2: Removing Canopies and Side Curtains 5579.3.7 Findings and Conclusions 5609.3.8 Safety Culture Summary Findings 5609.3.9 Other Events 5609.3.9.1 Minnow, Milwaukee Harbor, Lake Michigan, September 18, 2000 5609.3.9.2 DUKW No. 1, Lake Union, Seattle,Washington, December 8, 2001 5619.3.9.3 DUKW 34, Delaware River, Philadelphia, Pennsylvania, July 7, 2010 5619.3.9.4 DUCK 6, Seattle,Washington, September 24, 2015 5619.4 Recent Railroad Accidents 5619.4.1 AMTRAK Passenger Train – May 12, 2015 5629.4.1.1 Accident Scenario 5629.4.1.2 Amtrak 5659.4.1.3 Analysis of the Engineer’s Actions 5669.4.1.4 Loss of Situational Awareness 5699.4.1.5 Two-Person Crews 5729.4.1.6 Factors Not Contributing to This Accident 5729.4.1.7 NTSB Probable Cause 5749.4.1.8 Summary of Safety Culture Issues 5749.4.2 Transportation Safety Board of Canada (2013a) 5749.4.2.1 Personnel Information 5789.4.2.2 Train Brakes 5839.4.2.3 Locomotives 5869.4.2.4 Rules and Instructions on Securing Equipment 5879.4.2.5 Locomotive Event Recorder 5909.4.2.6 Sense and Braking Unit 5929.4.2.7 Mandatory Off-Duty Times for Operating Employees 5929.4.2.8 Securement of Trains (MMA-002) at Nantes 5929.4.2.9 Securement of Trains (MMA-001) at Vachon 5939.4.2.10 Recent Runaway Train History at Montreal, Maine, and Atlantic Railway and Previous TSB Investigations 5939.4.2.11 Training and Requalification of Montreal, Maine, and Atlantic Railway Crews in Farnham 5949.4.2.12 Training and Requalification of the Locomotive Engineer 5959.4.2.13 Operational Tests and Inspections at Montreal, Maine, and Atlantic Railway 5959.4.2.14 Implementation of Single-Person Train Operations 5979.4.2.15 Canadian Railway Operating Rules (CROR) 5999.4.2.16 Single-Person Train Operations at Montreal, Maine, and Atlantic Railway 5999.4.2.17 Review of the Montreal, Maine, and Atlantic Railway Submission and its Relation to the Requirements of Standard CSA Q850 6019.4.2.18 Research into Single-Person Train Operations 6029.4.2.19 Safety Culture 6039.4.2.20 Summary of Safety Culture Issues 604References 60410 Assessing Safety Culture 60710.0 Introduction 60710.1 Survey Research Principles 60810.1.1 Developing the Survey Instrument 60910.1.1.1 Developing the Questions/Statements 60910.1.1.2 Question/Statement Development 61110.1.1.3 Sampling 61210.1.1.4 Demographics 61210.1.1.5 Survey Delivery 61310.1.1.6 Analyzing the Results and Reports 61310.1.1.7 Final Thoughts on Developing and Delivering Surveys 61410.1.2 Safety Culture Assessment Methods 61410.1.2.1 DuPont (DuPont) De Nemours Sustainable Solutions (DSS) 61410.1.2.2 Department of Energy Assessment of Safety Culture Sustainment Processes 61510.1.2.3 Institute for Nuclear Power Operations Safety Culture Assessment 61710.1.2.4 Developing Team Findings 61910.1.3 United States Air Force Assessment Tool 61910.2 Assessing Health Care Safety Culture 62010.3 Seven Steps to Assess Safety Culture 62110.3.1 A Framework for Assessing Safety Culture 62310.3.2 Agency for Healthcare Research and Quality 62310.3.3 Graduate Student Safety Culture Survey 62310.3.4 Idaho National Engineering Laboratory Survey 62610.4 Chapter Summary 634References 634Index 637