Interesting Review of a CSB Final Report
On May 21, 2021, the U.S. Chemical Safety Board (CSB) released its final report and associated materials into the October 2019 hydrogen sulfide release at the Aghorn Operating waterflood station in Odessa, Texas. This incident resulted in two fatalities, one was a worker and one was the spouse of the worker. There was potential for two more fatalities. The news release can be viewed here.
This incident, while resulting in a double fatality, was totally preventable, based upon the investigation of the CSB and presented in their report.
The CSB investigation file for this incident includes:
- Video of Board Meeting
- Staff presentations, to include overview of incident and outcomes.
- Chairman Opening and Closing Statements
- Final Report
The reviewing of this incident report and associated items in the investigation file was enlightening to this Safety Professional as to the investigation process of the CSB. I have always used various CSB videos in training classes by only viewing the video and scanning the CSB report on some of the videos I used in training classes.
What was the most interesting in this specific release of investigation materials was that the video and animations have not yet been developed and released. It was very interesting to watch the video of the Board Meeting which is over 2 hours and 45 minutes long and included the opening remarks by the Chairperson, then the presentation of the incident and the investigation findings by the lead investigator which included pictures and diagrams accumulated during the investigation. Then other members of the investigation team listed then explained the CSB-determined Probable Cause specifically detailing the six issues associated with the Probable Cause. After the presentation on the Probable Cause and associated issues, the Chairperson asked questions of the investigation team to clarify their findings in the report. The report was approved with further clarifications to be incorporated then the Chairperson made closing comments.
Watching the video of the CSB Board Meeting was interesting because it gave a glimpse into the process that the CSB used during this investigation which took about a little less that 18 months to complete (assuming some delays due to the pandemic). It gives a glimpse into the thinking of the investigators as to their findings and why they came to the conclusions to which they agreed.
I found myself Monday-morning quarterbacking after watching the video and reading the final report wondering why they did not ask “that” question or how could they not have gotten “that” piece of information or determined if this happened or that happened and why did they list the issues in the order they did. As Safety Professionals, we are always trying to improve our own processes and the “second-guessing” of the CSB process and report that I was doing was just part of that process of continual learning and always trying to improve by learning from others. There were items that I thought, initially, were not important points to cover and then later in the report understood why that question was important to ask and how it tied into the overall report, Probable Cause, Issues, and the recommendations made by the CSB to the company involved, OSHA, and the Texas Railroad Commission.
I reviewed this specific incident in preparation for a webinar I am presenting for Industrial Safety & Hygiene News (ISHN) on July 29, 2021. I invite you to register for the webinar here at ISHN.
For more information and/or assistance, contact:
Wayne Vanderhoof CSP, CIT
RJR Safety Inc.