The purpose of the presentation/paper is, very simply, to prevent injury at work and home.
The anatomy of this accident and the consequences are something that I encourage Safety Professionals, Safety Teams, or anyone to use as an example to utilize as an accident investigation, Root Cause Analysis, Fault Tree Analysis, etc.
This Incident took place on June 7th of 1984. In this article, I will present information relating to events prior to the accident. The stories of the accident are from the mechanics, operators, frontline supervision, the Rescue Squad, doctors and families' points of view.
We will take a serious look at all the contributing actions that set this accident in motion.
The unsafe attitudes, shortcuts taken, communication breakdowns, production pressures, and pride of quickly completing the job are examples of actions that contribute to this event.
The mill management starts a redesign that moves operation supervision into different areas of the mill. This was an effort to improve working knowledge of the processes.
The mill management continues the redesign by moving maintenance supervision around the mill. New mechanical engineers are placed into several maintenance areas as frontline supervision. Experienced front line supervision is moved into planning positions.
An operator notices a pump leaking fluids from the packing gland. Mechanics are sent and attempt to stop the leak but they can't reduce the flow. They place a piece of felt over the area that is leaking to keep it from spraying on walkways. They report back to their supervisor.
Maintenance and Operations meet to discuss their options. The first option is to do a complete shutdown of this system, which takes this system down for 24 to 36 hours, which reduces production during this entire event. The second option is to secure the closest valve to the leaking pump and change out the pump, which will take the system down for 8 hours and, with storage available, no production will be lost. The second option is chosen, although this procedure has not been an option prior to this event.
The supervisor meets with the crew and tells them that they are going to change out the pump by securing one valve and draining the system. Marion, a mechanic, is assigned to do the job the next day. Marion talks to several experienced mechanics and they tell him this has not been done because of the potential danger. He decides he will lay out the next day.