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Maintenance and the Safety Envelope

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Throughout our travels, we are impressed by the knowledge, skill, and dedication of these industrial teams and their leaders. Yet, as we continue to hear stories and study reports of accidents and near misses, we are now even more convinced of the need to instill the disciplined habits of systematic operations and maintenance to all elements of the workforce; for, in nearly every case we review, the events could have been easily prevented through application of a few simple techniques (Vital Operating Skills) as discussed in The Industrial Operator's Handbook.

For that reason, we have begun a new stage in our mission to provide insight and instruction to the supporting elements of industrial teams regarding application of the principles and skills essential to safe and effective performance. In that vein, we have set out to produce a series of supplemental resources focusing on specific topics and dedicated to specific work groups. Maintenance and the Safety Envelope is the first in that series. It is dedicated to the maintenance teams whose efforts provide safe and reliable machinery and processes that function as intended by design. Without properly performed maintenance, neither objective (safety and reliability) is possible.

This book begins with a review of accident causes and practices that prevent accidents with particular emphasis on their application to maintenance.

It continues with a detailed discussion of the Safety Envelope and its specific relevance to the maintenance function.

Four maintenance-related case studies are reviewed and discussed in depth to illustrate these principles, again focusing on the role of maintenance in providing a safe and efficient industrial environment.

Although Maintenance and the Safety Envelope is extremely useful as a stand-alone text, it is particularly effective when used as a supplement in conjunction with The Industrial Operator's Handbook.


Chapter 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction and Review 
The Causes of Accidents . . . . . . . . . . . . . . . . . . . . . . . . . 2
Practices That Prevent Accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Application to Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
  
Chapter 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Maintenance and the Safety Envelope 
Maintenance Terms and Definitions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
The Safety Envelope. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Hard and Soft Barriers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Defense In-Depth. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
The Most Important Barrier? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Keeping the Fabric Intact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Think About It . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
  
Chapter 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Even Small Errors Have Major Effects 
Eastern Airlines Flight 855, May 1983. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Damage to the Aircraft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Cause of the Occurrence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Failed Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Learning from Flight 855. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Case Study References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
  
Chapter 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Integrity of the Envelope 
Bright Field Freighter Allision, December 1996. . . . . . . . . 31
Troubled Voyage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Arrival in U.S. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Returning to Sea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Freighter Out of Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Striking the Wharf . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
The Cost . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Causes and Contributing Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Deficient Engine Maintenance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Contaminated Lube Oil. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Deficient Maintenance Support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Factors Affecting Command and Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Learning from Bright Field . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Case Study References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
  
Chapter 5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
In Accordance With Approved Procedures 
Gannon Station Explosion, April 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Preparing for Outage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
The Accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Causes and Contributing Factors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Failure to Follow Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Ineffective Lockout/Tagout . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Inadequate Job Briefing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
A Broken Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Learning from Gannon Station . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Case Study References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
  
Chapter 6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Last Line of Defense 
Railroad Grade Crossing Collision, September 1999 . . 76
Description of the Grade Crossing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Pre-Accident Maintenance Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Maintenance Requirements Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Accident Response and Investigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Questions of Integrity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Findings and Underlying Cause. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Learning from the Crossing Accident . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Case Study References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
  
Chapter 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
It All Depends on You! 
Recounting the Lessons. . . . . . . . . . . . . . . . . . . . . . . . . . 87
Competence and Character . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
It All Depends On You!. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Preface

Since publication of the first edition of The Industrial Operator's Handbook in October, 1995,we have been overwhelmed with the response of industry to the concepts presented in the book.Thousands of readers have consulted the text for application in their industries and thousands more-operators, maintenance technicians, laboratory analysts, engineers, and managers of all levels-have participated in the seminars we have presented across the United States,Canada, and other countries. Our travels have taken us to a myriad of North American electrical generators powered by nuclear, coal, gas, and oil fuels as they provide the electrical needs of their communities.We have visited Department of Energy sites throughout the U.S. whose teams engage daily in sampling, characterizing, processing, packaging, shipping, and storing radiological contaminants and other hazardous waste. And we have evaluated the activities and taught the staffs of oil refineries and chemical production plants in places as far-ranging as Trinidad.

Nearly always, we are impressed by the knowledge, skill, and dedication of these teams and their leaders. At the same time, we are amazed at what they are able to accomplish in accident prevention as cutbacks in the sizes of workforces and resources have swept each industry. Clearly, "doing more with less" is a challenge to the best teams as they try to balance mission accomplishment with reasonable safety.

Yet, as we hear the stories and study the reports of our clients' accidents and near misses (and those of industry at large), we are now even more convinced of the need to instill disciplined habits of systematic operations and maintenance to all elements of the workforce-for, in nearly every case we review, the events could have been easily prevented through application of a few of the simple techniques discussed in Section III (Vital Operating Skills) of The industrial Operator's Handbook, 2nd Edition.

For that reason, we have begun a new stage in our mission to provide insight and instruction to the supporting elements of industrial teams (elements such as maintenance and engineering) regarding application of the principles and skills presented in the main work. In that vein, we have set out to produce a series of supplemental resources focusing on specific topics (and dedicated to specific work groups).

This book is the first in that series. It is dedicated to the maintenance teams whose efforts provide to the operating crews equipment which functions as intended by design-machinery and processes which are safe and reliable. Without properly performed maintenance, neither objective is possible. We hope you enjoy your journey!

 


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