Out Of Control Rogue Nuclear Corporation

You see how they are still making good profits at Entergy this quarter but still starving their nuclear plant.

 

The first and second worst plants in the nation are both managed Entergy. Then we got the debacle of Vermont Yankee, Palisades and Pilgrim...

Report: Indian Point plant had most nuclear violations in U.S.

JIM FITZGERALD | AP

WHITE PLAINS, N.Y. (AP) — The Indian Point power plants in the New York suburbs have been cited for more violations than any other nuclear site in the country, although 99 percent were low-risk violations, according to a federal report awaiting release.

The Government Accountability Office report, using figures from the Nuclear Regulatory Commission, said four of the 384 citations between 2000 and 2012 were for "higher-level" violations. Many plants around the nation have more in that category.

But no plant site had more total violations. The closest to Indian Point's total was at the Cooper plant in Brownville, Neb., which had 374 violations. Eleven of those were "higher-level" violations, the report says.

Cooper has just one reactor, while Indian Point has two.

Lower-level violations are those considered to pose very low risk, such as improper upkeep of an electrical transformer.

Entergy Nuclear, owner of Indian Point, issued a statement saying it "has received the most regulatory scrutiny of any plant in the country." It said, "Entergy's commitment to address even minor issues and enhance safety is unrelenting."

1968 Springfield Ma Elevated I-91 Crumbling

1968 Springfield Ma elevated I91 Crumbling

Massachusetts approves study to overhaul Interstate 91 through Springfield

BOSTON — In a step forward for a massive transportation project in Western Massachusetts, the state has chosen a consultant to study possible alternative alignments for Interstate 91 through Springfield, while highway officials proceed with a plan to replace decks on a deteriorating elevated portion of the highway in the city.

The transportation department on late Friday said that it has picked the Cheshire, Conn.-based consulting firm Milone & MacBroom Inc. to evaluate alternatives for a section of Interstate 91 including possibly depressing the highway section to ground level or below ground.

At the same time, the state highway division will be moving forward with a plan to replace decks on the crumbling Interstate 91 viaduct, a spokeswoman said.

"We have an immediate need to replace the decks that are elevated," said Cynthia Roy Gonzalez, the transportation department's assistant secretary for communications, on Tuesday.

She said she could not say when construction would start on the deck replacement, other than to say it would be soon.

She said that Milone & MacBroom would study a section of Interstate 91 south of the most elevated portion of the viaduct near the Naismith Memorial Basketball Hall of Fame in Springfield.

At the same time, the state highway division will develop a plan for replacing the decks of the existing Interstate 91 viaduct, which has raised safety concerns. In April, after a big chunk of concrete fell from the section, Gov. Deval L. Patrick said the state would have "a big, big problem" if the Interstate 91 viaduct falls down.

Chicopee Mayor Michael Bissonnette said it is important to find a solution to the I-91 viaduct. Bissonnette said if it continues to crumble, it might need to be shut down. He said it's the most important transportation priority in Western Massachusetts. "We have to have a plan," he said.

While $400 million is the estimate for replacing the viaduct, the cost could run to $1 billion if part of the highway is depressed to ground level or a tunnel, Bissonnette said.

The upcoming study by Milone & MacBrooms, which has an office in Springfield, is aimed at taking up some longtime concerns that Interstate 91 hurts access to the Connecticut River and to attractions such as the Naismith Memorial Basketball Hall of Fame in Springfield.

The study also comes while MGM Resorts International is planning an $800 million casino in the South End of Springfield that would front Interstate 91 and would draw most of its traffic from the highway. MGM is competing with Mohegan Sun Massachusetts in Palmer for a single state casino license for Western Massachusetts.

Timothy W. Brennan, executive director of the Pioneer Valley Planning Commission, which had a representative on a panel to select the consultant for the study, said the deck replacement needs to happen soon, but it's a good idea to look at future alternatives for aligning the highway.

According to an overview of the study provided by the transportation department, the depression of the highway section to ground level or below ground could be less disruptive to Springfield than the current design. In the long term, it might also be better for the environment and the economy than the existing configuration, the overview said.

Roy Gonzalez said below ground could mean a tunnel or "a boat section," where the road is below grade with retaining walls.

"The study will entail the development and analysis of a full range of alternatives including interchange, highway and non-highway improvements as well as options and design elements that improve access in all modes," said the overview, which was provided at the request of The Republican.

The state is starting contract negotiations with Milone & MacBroom with a goal of starting work in January, Roy Gonzalez said.

Milone & MacBroom will coordinate with the state highway division as it moves forward with its proposal to replace the decks on the viaduct.

The planned Milone & MacBroom study is another step toward deciding the future of the highway.

Francis DePaola, administrator for the state highway division, has said the decks on the viaduct could be replaced in two years.

At the end of June, Richard A. Davey, secretary and CEO of the transportation department, said the Interstate 91 project is a priority and the state is "very committed" to getting it done. Davey has said that the overhaul of the viaduct could cost $400 million. Davey has said the elevated section is in terrible condition, but it is safe and it is being monitored by the state.

Roy Gonzalez said the transportation department likely will secure funding for the Interstate 91 project if state legislators, as expected, approve a transportation bond bill filed by the governor in March.

Pilgrim Nuclear Plant Severely Uneconomic

Posted: Oct 15, 2013 6:51 PM EDTUpdated: Oct 15, 2013 6:51 PM EDT

JIM FITZGERALD | AP

WHITE PLAINS, N.Y. (AP) — The Indian Point power plants in the New York suburbs have been cited for more violations than any other nuclear site in the country, although 99 percent were low-risk violations, according to a federal report awaiting release.

The Government Accountability Office report, using figures from the Nuclear Regulatory Commission, said four of the 384 citations between 2000 and 2012 were for "higher-level" violations. Many plants around the nation have more in that category.

But no plant site had more total violations. The closest to Indian Point's total was at the Cooper plant in Brownville, Neb., which had 374 violations. Eleven of those were "higher-level" violations, the report says.

Cooper has just one reactor, while Indian Point has two.

Lower-level violations are those considered to pose very low risk, such as improper upkeep of an electrical transformer.

Entergy Nuclear, owner of Indian Point, issued a statement saying it "has received the most regulatory scrutiny of any plant in the country." It said, "Entergy's commitment to address even minor issues and enhance safety is unrelenting."

Phillip Musegaas of the environmental group Riverkeeper, an Indian Point critic, said of the plant's violations, "Even if they're low-level violations, they're still safety violations, and the NRC does not have an effective system for tracking them. ... The people of New York should wonder why Indian Point has twice as many as any other plant in the Northeast."

 

What a dog...this is a widespread collspe with plant reliability. Anybody who watched them last year with repetetive loss of power event in a blizzard last year realized the grid don't have the quality to support a nuclear plant. Entergy, the grid and Nstar have repetedly talked about plant trip after storms never allowing this to happen again...and it keep happening over and over again.

Pilgrim Nuclear Power Station offline again

 

Krux('

HEATHER WYSOCKI

hwysocki@capecodonline.com

October 15, 2013

PLYMOUTH – The Pilgrim Nuclear Power Station is operating on generator power today after one of two power lines went down last night.

At 9:21 p.m. yesterday, the plant automatically shutdown after it lost one of its two 345-KV lines, owned by NStar, which provide offsite power to the plant, according to a statement from Carol Wightman, the spokeswoman for Entergy, the company that owns and operates the Pilgrim plant, said.

Last week, NStar removed the other line from use for planned maintenance, Wightman said. She would not comment on the operating level of the plant while it was under maintenance.

But a spokesman for the federal Nuclear Regulatory Commission told the Times he believed the plant reduced power output to below 50 percent while it flushed organic material off the water condensers for the reactor in a process called “thermal back-washing.”

The plant is now running on its emergency diesel generators, which “immediately started and are safely powering the plant,” Wightman's statement read. There is no impact on the health and safety of employees or the public from the shutdown, she added.

While the plant is shutdown, workers will “take advantage of this time to perform maintenance that cannot be done while the plant is operating,” she said. The plant will return to service after NStar restores offside power and completes maintenance.

Pilgrim has been shut down several times in the past few months for various reasons.

A heat wave in July reduced the plant's output by 15 to 25 percent when water temperatures in Cape Cod Bay, which is used to cool Pilgrim's systems, went over those allowed under the plant's federal license.

Then, starting Aug. 22, there was a monthlong trend of shutdowns and partial power-downs. The plant wasn't restored to full service until Sept. 18.

9/9/13: Basically I told neil, why is their so many different reports on the goings on at the Pilgrim Plant post outage.

Why can’t the agency write or force Entergy to write a concise report of these events. Why no event report? I know the rules.

I think the object is the NRC and Entergy give incomeplete information...they want the media to make mistake in reporting issues with nuclear power. That way, the editors will ask for perfect information, thereby mismizing reports in the media. It is a stratory to disrupt communication.

And the NRC has the power to make news...you have to call in to the public relation office. Thus the media owes a favor to the NRC for a free story.

They agency is playing the media becuase they don't have the independant skills and knowledge to understand the complex terms of nuclear power...

Region I says it is a leaking feed water heater and generally it is in restricted and isolated area. Certainly because of the high radiation around the heaters...people pass this area quickly. And stay times are limited.

It is absolute disgrace...they don't clearly tell us why they shutdown. All these tricky words. Now it is a safety relief valve...

Did they use it during the feed pump scram...

Monday morning around 5:25 a.m. the Pilgrim nuclear power plant in Plymouth was shut down again to investigate a minor leak on one of the plant’s four safety relief valves.

You get it, they are still don't fully understand what happened to the power supplying those feed pumps...there is nothing more reckless than you don't know what is going on in your systems and starting up...

Sept 10: They don’t say where the leak comes from…the worst nuclear power plant accident in the USA comes from the Surry nuclear plant...which scalded to death 4 workers and severely injured two more in 1985...

You get that don't you, it hot water water under very high pressure...it is only steam when it is released to the air.
 
A big pipe at 400 degrees broke apart…

Mechanical Malfunction

By BY CHRISTINE LEGERE
clegere@capecodonline.com

September 09, 2013 10:25 PM

PLYMOUTH – A series of mechanical difficulties at the Pilgrim Nuclear Power Station has kept the plant from operating at peak for more than two weeks.

Currently Pilgrim is completely off the electric grid, shut down Sunday evening because of a steam leak in a pipe supplying hot water to the nuclear reactor.

Spokesmen for both the plant and the Nuclear Regulatory Commission stressed the problem did not pose a safety risk for the public, but Pilgrim opponents say such ongoing mechanical problems show the time has come to shutter the 41-year-old plant.

Diane Turco, a Harwich resident and founder of the Cape Downwinders, said recent events at Pilgrim make it the perfect time to deliver to the Statehouse a citizens advisory calling for Pilgrim's closure. The advisory was penned by the Downwinders and approved by town meeting or ballot votes in 14 Cape towns last spring.

“It calls on Gov. Patrick to request the NRC uphold their mandate and close the Pilgrim nuclear plant because the public safety cannot be assured,” Turco said. “We're supposed to be given a time and date to meet with the governor on Wednesday.”

Both Gov. Deval Patrick and Attorney General Martha Coakley opposed the relicensing of the plant in June 2012. The NRC subsequently renewed the license for another 20 years.
The governor's office did not return a request for comment on an upcoming meeting with the Downwinders.

Dave Lochbaum, director of the Nuclear Safety Project for the Union of Concerned Scientists, tracks nuclear plant shutdowns in the U.S.

Pilgrim has had “more than its share,” leading with seven shutdowns between January and June 30, Lochman said.

“Overall there have been 94 shutdowns at U.S. nuclear power reactors in 2013 through June,” Lochbaum said. “With roughly 100 reactors, that's an average of less than one shutdown per reactor. Pilgrim has had seven times that.”

Neil Sheehan, spokesman for the Nuclear Regulatory Commission, said his agency categorizes shutdowns into unplanned forced shutdowns and controlled shutdowns to make needed repairs. Since January, Pilgrim has logged four forced shutdowns, according to NRC records.

One of those occurred on Aug. 22. Workers forced a rapid shutdown when an electrical malfunction caused a loss of power to the three massive pumps that supply water to the reactor.

When the plant was being powered back up four days later, the motor on one of the three main water pumps failed. The plant stayed at 76 percent power while Entergy, the owner-operator of the power plant, secured a replacement motor. The replacement was installed last weekend, but the plant never made it back to full power.

Plant operators had been keeping an eye on a small leak in a steam pipe joint, according to Carol Wightman, spokeswoman for Entergy. On Sunday, workers noticed the leak was getting worse, and they decided to systematically shut down the reactor and address the problem.

Sheehan indicated issues with the electrical power to the water pump may not yet be fully resolved. “Troubleshooting activities are continuing.” Sheehan said in an email. “Further investigation involving the electrical supply system for the motor are ongoing.”

Meanwhile Plymouth officials, who recently signed a three-year agreement for $28.75 million in lieu of taxes from Entergy, are also closely watching power plant operations.

“It's very concerning,” said Selectman Belinda Brewster. “There seems to be an increase in the number of shutdowns over the last year.”

Plymouth Selectman John Mahoney, who also serves on the Plymouth Nuclear Matters Committee, said, “With a plant entering its fifth decade of operation, these problems are bound to happen.”

“The only thing we can do is keep pressure on with the NRC and our federal officials,” Mahoney said.

It sounds like they been watching the leak for days and they screwed up big time by not fixing it when they were shutdown for the feedpump trip.

"She said plant personnel had been monitoring the leak while they decided whether it needed an immediate repair. The plant was taken offline when the amount of the leak increased Sunday."

Sept 9: What in the hell is Pilgrim in the NRC status report at 0% power today...the NRC says they are shutdown last night... 

Originally posted 9/7

May 9, 2013

Entergy-Fitzpatrick Is Beginning To Be Unreliable?

First published on Sept 5

Believe me, Neal Sheehan gets it...I talk to him first and then the so called "foes" come in to clean up after me. Least it gives him time to gather the agency's information. Neal was kinda nice to me.

What was clear to me talking to Neal...I couldn't get a answer when was the first indication they were having troubles with the feed pump. Was it during the trip or did if fail during the startup....or weeks before? Did it have a intermittant or small ground for many days...then it failed.

Everyone including the NRC is pissing their pants wondering if Pilgrim will be next?

Pilgrim plant foes cry foul

By CHRISTINE LEGERE 

clegere@capecodonline.com

September 07, 2013

PLYMOUTH, Sep 07, 2013 (Menafn - Cape Cod Times - McClatchy-Tribune Information Services via COMTEX) --Two weeks after an electrical malfunction caused the shutdown of the Pilgrim Nuclear Power Station's reactor, the plant is still not at full power.

Representatives from Entergy, which owns and operates the plant, initially attributed the delayed return to standard procedure. Shutdowns provide opportunities to address items on a reactor's "to do" list, they said.

But federal nuclear energy officials confirmed Tuesday that a failed motor in one of three massive pumps that supply water to the reactor was keeping the plant from operating at peak.

The burned-out motor, within days of the wiring problem, had nuclear watchdogs talking.

Diane Turco, a Harwich resident and founder of the Cape Downwinders, compared the 41-year-old plant to an old Volkswagen Beetle. "You keep repairing it bit by bit until the front wheels fall off," Turco said. "This is a far too serious situation to keep having problems. They need to close the reactor."

Mary Lampert, founder of Pilgrim Watch, called the two plant problems "an example of one thing after another."

"It's indicative they're not spending the money to make sure the equipment is in operable condition," Lampert said. A replacement motor was in stock at the plant, but it had last been refurbished in about 2007. Plant officials decided to send it out for an inspection before installing it.

The motor was checked and is now awaiting installation.

"It's fair to say any power plant has operational conditions that need to be managed, and we're doing a good job of responding and getting the plant back to full power," said James Sinclair, spokesman for Entergy.

Lampert said the Nuclear Regulatory Commission should be demanding better performance from Pilgrim. "The NRC doesn't seem capable of developing a backbone and making sure they're doing what they should be doing," Lampert said.

NRC spokesman Neil Sheehan said feed-water pumps are a production issue, not a safety issue. They provide water for the nuclear reaction process. "Still we are certainly going to monitor the work," Sheehan said of the motor installation.

On Aug. 22, a breaker had tripped due to a faulty electric cable in the junction box, causing the three large feed-water pumps to shut down. Workers immediately halted the nuclear reaction process.

Pilgrim was at zero power from Aug. 23 to 25, then very slowly powered up over the next three days to 20 percent. On Aug. 29, power reached 74 percent and now hovers at about 76 percent.

While the lower production rate would seemingly result in lost revenue, Sinclair said Entergy does not comment on production-related issues for business reasons.

In its mid-year performance review released Wednesday, the NRC appeared satisfied with the Plymouth plant. "Pilgrim operated in a manner that preserved public health and safety and met all cornerstone objectives," the review letter said.

The NRC will continue to oversee Pilgrim at the level used for plants that meet performance standards.

Sheehan said the August shutdown, the plant's fifth unplanned shutdown in the last 15 months, wasn't factored into the mid-year review, but will be considered as part of the NRC's third quarter report later this fall.

"We are still evaluating whether there will be any changes in oversight due to the number of unplanned shutdowns," Sheehan wrote in an email.

Sept 5: Pilgrim Nuclear Plant Severely Uneconomic

I mean, last cycle with all their shutdowns and power reduction associated with the defective "new" safety relief valves…now for the last five days the plant has been restricted to 75%. How can these guys be economically healthy?

As I said, I think Entergy has lost the capability to effectively and cost effective….to keep up with maintenance and upkeep. They aren't getting a big enough bang for their maintenance buck.

They have lost the capability to maintain increasing members of their nuclear fleet...to keep up at a economic high capacity factor.

One thing you can say about Vermont Yankee…they stayed out of the media’s eyes and have maintain very high capacity factor post AOG leak…

Right, Pilgrim now is on a special NRC watch because of all the shutdown issues?

...I mean, from the startup on Aug 27...they never exceeded 76% power. That is ten days at 75% power?

How has Fitzpatrick been doing?

Are we talking about the next 18 months at 76%?

Then the Palisades boondoggle with their refueling and their injection water tanks…

...Hmm, and Fitz has been at 90% since Aug 25...

...And the media and antis have been asleep about this since start-up.

...So region ii says they busted a main feed pump...they are staging the job now.

So Entergy-Pilgrim recently tripped by a botched maintenance job done during the the last outage... that shorted the pump cooling water power instrumention tripping all feed pumps. They were coming out of that screwup 10 days ago...when they discovered the bum feed pump. The moter is bad..

Don't drop the stator...

Nuclear Regulatory Commission website

Nuclear Regulatory Commission website

Adams is still up...

Due to the lapse in government funding, the NRC's website was last updated on October 9, 2013, and will not be updated until further notice. Normal business activities (including public meetings) are suspended. We sincerely regret this inconvenience.

According to the NRC's shutdown plan, approved by the Office of Management and Budget, the agency will retain about 300 of its current 3,900 employees for "excepted functions" during a lapse of appropriations. Of that number, roughly half are resident inspectors assigned to reactor and fuel facilities. The rest are staff necessary to respond to emergency situations at NRC-licensed facilities. For updates on the status of the NRC, please go to the agency blog. For information about the status of the

 

 

 

Note To My lawyer: "Build New Bridge" Sign Littering Charge

( under law You can't break what is already broken...)

"The allegation is that he struck the rear portion hatchback window, which has a gaping hole already in it; it's already destroyed," Arlia told reporters. "Under the law, it's a fatal flaw. You can't break what's already broken."

Look at all this littering...like, how small a group do I belong too on being charged with littering in Island Park.

This was the area I was protesting in for years...

Why was I charged with it and all these people got away with it?

Mike Mulligan Arrested For littering With "Need New Bridge" Sign

Reed said the volunteers found "everything from couches to bedding to clothes to empty food cans and lots of toys. So that means lots of people have their children out there." There were also two love seats, a tire and large piece of sheet metal in addition to 40 bags of garbage and 28 bags of recyclables.

Keeping the river clean

Volunteers remove debris from underneath bridge during 17th Annual Source to Sea Cleanup

By DOMENIC POLI / Reformer Staff

BRATTLEBORO -- As the president of the National Honor Society at Hinsdale (N.H.) High School, Abigail Haskins had already registered all her mandatory volunteer hours before last weekend, but thought tidying up under the Anna Hunt Marsh Bridge would be worthwhile.

So she, and about 25 other students from both her school and Brattleboro Union High School, decided to join a local group of volunteers sacrificing their time for the 17th Annual Source to Sea Cleanup on Friday and Saturday. The cleanup, organized by the Connecticut River Watershed Council (CRWC), is an annual event for trash pickup along the Connecticut River and its tributaries in the four states that touch the watershed - Vermont, New Hampshire, Massachusetts and Connecticut.

Groups of volunteers clean up sections of the Connecticut River, thus preventing trash and debris from flowing down to the Long Island Sound and into the Atlantic Ocean.

"I have all my volunteer hours already but I just really thought it was a good cause and my teacher was involved and I thought it'd be pretty cool," said Haskins, 17. "I've never done it before but I'd love to do it again.

"We got a lot of stuff. It was hard to get all the stuff out but I think we did a really good job," she continued. "We pulled together a lot more than I thought we would. I got to know some more students in a different way and we worked together. It was really good."

Dinah Reed, of the Windham Regional Commission, said this was the first year of the volunteer group known as the Wantastiquet Hellgrammites. She explained that a hellgrammite is used as fish bait and serves as an indicator of fresh water wherever it lives.

"(The cleanup) went really well. And more people came than I expected," she said, after she and the students worked tirelessly from 9:30 a.m. to 12:15 p.m. She said the volunteers found a lot of remnants from homeless camps under the Anna Hunt Marsh Bridge, one of the two linking Brattleboro to Hinsdale, N.H.

Reed said the volunteers found "everything from couches to bedding to clothes to empty food cans and lots of toys. So that means lots of people have their children out there." There were also two love seats, a tire and large piece of sheet metal in addition to 40 bags of garbage and 28 bags of recyclables.

Mike Auerbach, the faculty advisor for the Preserve our Planet group at BUHS, said it is great to see so many young people volunteer their time to help the community and it is proof that not all high school students get into mischief or trouble on the weekends.

"This was the best turnout we've ever had," he said. "When you read the negative things about kids, it's nice to know there is just as large a percentage here or twice as many as you read about in the roundup [police log]."

Angela Mrozinski, the CRWC's outreach and events director, told the Reformer last week there were 80 registered groups made up of 2,000 people who volunteered from northern Vermont and New Hampshire down the river's roughly 410 miles to the Long Island Sound. She said 70 percent of the water in the Long Island Sound comes from the Connecticut River - the longest in New England - and any trash or debris picked up by volunteers is guaranteed not to get washed downstream and into the sound, the Atlantic Ocean and the large floating garbage patches around the world.

According to a statement from the CRWC, trash pollution of rivers is a major problem for human and wildlife communities and about 806 tons of trash have been removed from the river as part of Source to Sea Cleanups to date.
Domenic Poli can be reached at dpoli@reformer.com; or 802-254-2311, ext. 277. You can follow Domenic on Twitter @dpoli_reformer.

Why Unattached Boards On The Charles Dana Bridge Matters

Do you know what the job of a whistleblower is? We are consequence minimizers and occurrence disruptors. We illuminate or bring to light the true behaviors and defects of the organization before the accident happens...before we then all have to spend big bucks on a accident.

We all play the whistleblower role many times in our lives...we are all whistleblowers! 

I will give you an idea of what I am talking about. We drive drunk 100 to 300 times on average before we get caught by the police.

"The Anna Hunt Marsh Bridge connects Brattleboro to Hinsdale Island, which is connected to Hinsdale by the Charles Dana Bridge. JB Mack, the principal planner for the Southwest Region Planning Commission, previously told the Reformer federal highway standards dictate the bridges are too narrow and have insufficient weight limits and vertical clearance. "

 

This is the pdr of the below...easier to read. 

 

The Firebird Forum

THE OCCURRENCE PYRAMID

The Nature of High Hazard Industries

We read about the highly consequential events, but the near misses, compromises, and deviations/infractions seldom get much ink. Thus, the data we encounter can mislead the unwary.

However, we are generally not surprised at the results of detailed government inspections of organizations that have had newsworthy consequential events. These inspections nearly always report that there were near misses, compromises, and deviations/infractions before the consequential event.

The nature of occurrences in high hazard industries, and, perhaps, of life generally, is illustrated by The Occurrence Pyramid in the first column.

Often a regulator, a journalist, or an editorial writer bemoans the failure of the organization to attend to the non- consequentials before the consequential occurred.

Recent consequentials in the news include:

The Occurrence Pyramid

Consequentials and near misses

Compromises

Deviations/ Infractions

Suggestion for root cause instructors

e
The Newsletter of Event Investigation Organizational Learning Developments Volume 16 • Number 10 October 2013

The West Delta 32 Platform Explosions

Links to more information on those consequentials is readily available by internet searching

 

How about "Near Misses"?

A "near miss" is generally thought of as an occurrence that could have resulted in one or more of the d-words given below, but did not because of only one non-robust mitigating factor2.

For every consequential occurrence you should expect to see roughly ten near misses. A "consequential" is an occurrence that resulted in one or more of the d-words: death, damage, dollars of loss, disruption of service, delays in work, disgrace to the organization, defection of customers, or the like.

1 https://en.wikipedia.org/wiki/Lac- M%C3%A9gantic_derailment 2 For a fascinating near miss asphyxiation see https://app.box.com/s/3r4111e5qm9hbsrgi778

Thought of the month

Quotation of the month

Back Issues

The Arkansas Nuclear One Stator Drop

The Crystal River Containment Failure

The San Onofre Steam Generator Failures

The Lac-Megantic Rail Car Explosions

Challenger launch could be regarded as near misses because they had O-rings similar to those of the Challenger, but happened to have been launched at a higher temperature. Sometimes near misses are easy to recognize and sometimes they are not.

Almost everyone would recognize a dropped object event involving penetration of a hard hat3 as a near miss injury.

Most people would recognize a load drop within a few feet of a work area as a near miss. Some people would not. I knew of one organization that did not recognize repeated diesel generator exhaust system fires as near misses.

At another organization an electrician involved in a near miss electrocution did not recognize it, but his foreman did- fortunately. It may well be that near misses are the most difficult level of event to recognize, at least by some people. Thus it is worthwhile to have unfamiliar people review the occurrence database from time to time to see if their calls are the same as yours.

Perhaps like dead men in the old pirate saying4, near misses tell no tales.

How about "Compromises"?

A "compromise" is a situation in which a required safety or quality barrier has been omitted, breached, or degraded. For example, conducting a load lift within a short distance of work would be a compromise.

 

Similarly, driving without a seat belt or driving with air bags disarmed would be a compromise.

The inoperable blowout preventer on the Macondo Rig was a compromise in that important protection was missing5.

The power operated relief valve failures to close that preceded the Three Mile Island Unit 2 fuel damage event were compromises in that they represented a situation in which a required safety or quality barrier was breached, or degraded.

Noticing that one is in the wrong unit of a multi-unit plant is a recognized compromise. But many compromises are unrecognized until after the consequential that they were precursors to.

http://www.marinesafetyforum.org/upload- files/safetyalerts/msf-safety-flash.06-08.pdf#! 4

 

See the last few seconds of the clip at

 

http://youtu.be/aLSJNTr-k9o 5

 

For the whole report see: http://ccrm.berkeley.edu/pdfs_papers/bea_pdfs/dhsgfinalreport -march2011-tag.pdf

More commonly, compromises consist of omissions such as failures to invoke appropriate quality program requirements, failures to reinstall foreign material barriers, failing to close security doors, failures to replace protective covers, failure to recharge fire extinguishers after discharge, and the like. .

We should expect to see about ten compromises for every near miss.

How about "Deviations/ Infractions"?

A "deviation" or an "infraction" is a situation in which a quality or safety requirement that supports required barriers has been inadvertently or deliberately overlooked. For example, if a load lift were conducted without walking down the lift path a deviation or infraction would have occurred.

All non-consequential self-check and peer check errors are deviations or infractions.

These are somewhat harder to detect than consequentials, near misses, or compromises. It takes knowledge of requirements to recognize deviations and infractions and many organizations do not provide effective training in what the requirements are.

You should expect to see roughly ten deviations/infractions for every compromise. This is shown in The Occurrence Pyramid. The base of the Occurrence Pyramid suggests a thousand or so deviations/infractions preceding every consequential.

All deviations/infractions are noncompliances with requirements. This creates a link between compliance and safety.

But what good does this do me?

If you buy into this model you can use it in at least two ways.

You can use it to test the integrity of your occurrence database and you can use it to gain support for certain safety improvement measures.

Occurrence Database Integrity

Often the occurrence database is a reflection of what is going on in people’s minds rather than what is going on in the facility.

An occurrence database will reflect what gets into it. It will reflect The Occurrence Pyramid if the database "holds water", i.e., has integrity. Otherwise it will not.

If, for example, you see about the same number of compromises as near misses, you might hypothesize that the compromises are not being reported faithfully.

You might want to explore what it is about your organization that results in its recorded experience not being typical of high hazard industries. Is there something that is suppressing compromises relative to near misses?

Or are the compromises being concealed? Or do people just not bother to report compromises?

Gaining Support for Safety Improvements

Given your belief in The Occurrence Pyramid a strategy for reducing the consequentials and the near misses is to correct the conditions, behaviors, actions, and inactions that result in deviations/infractions and in compromises.

The same conditions, behaviors, actions, and inactions that result in deviations/infractions and in compromises will, under different conditions, result in consequentials or near misses.

By use of The Occurrence Pyramid you may be able to convince some people in your organization that it is in their best interests to understand and correct the b conditions, behaviors, actions, and inactions involved in compromises and in deviations/ infractions.

A reliable way to reduce the size of The Occurrence Pyramid in your organization is to reduce the size of the base. What we are talking about is finding out what conditions, behaviors, actions, and inactions cause the compromises and deviations/ infractions and correcting them.

Unfortunately, many organizations ignore the compromises and deviations/ infractions or simply record them without finding the behaviors and conditions that cause them. Even some regulatory agencies downplay non-consequential pathogenic occurrences by giving them dismissive names.

We are not suggesting that a Root Cause Analysis be done on all such minor occurrences, but we are suggesting that an intelligent sampling scheme might surface the dominant behaviors and conditions that need to be corrected for safety and business reasons.

But what about precursors?

A “precursor” is a situation that has some, but usually not all, of the ingredients of a certain type of consequential occurrence, e.g., there are precursors to plant scrams, precursors to large environmental releases, electrocution precursors, etc.

Seen in this way, all occurrences in the pyramid are precursors, even the consequentials. For example, an electrocution of one worker is a precursor of an electrocution of multiple workers if there is a possibility of doing the same job with a larger work team. Most electrocutions are also precursors of serious fires.

Thus it is generally not useful to single out certain events as precursors and exclude others. Any harmful event, condition, behavior, action, or inaction worth discussing is a precursor to something consequential, otherwise it is not very significant.

Precursors come in exactly three types by their potential involvement in the consequential that has not yet happened. These are facilitators, initiators, and exacerbators. A facilitator precursor is a condition, behavior, action, or inaction that sets the stage for a certain specified type of consequential.

An accumulation of transient combustible material could be a facilitator precursor to a hot work induced fire. An accumulation of combustible gas could be a facilitator precursor to a hot work induced explosion.

An initiator is a condition, behavior, action, or inaction that could have initiated a consequential (but didn't because other ingredients were missing). For example, creating a spark in an area known to occasionally contain combustible gas would be an initiator precursor to a detonation.

An exacerbator precursor is a condition, behavior, action, or inaction that couldn't facilitate a consequential or initiate one, but could make the consequences of an event worse, should it be initiated.

For example, a defective piece of fire fighting equipment could be an exacerbator type of precursor of a consequential fire.

The failures of the reactor shutdown systems at Salem and Browns Ferry were exacerbator precursors.

Before the chemical release at Bhopal the inoperability of some safety systems6 was an exacerbating precursor, even though it was not recognized as such.

Summary Table

The Summary Table below shows the relationship of The Occurrence Pyramid levels to the normal types of precursors. These relationships are not always as shown, but this table is a good rule of thumb. Like all rules of thumb apparent and legitimate exceptions are not unusually difficult to find.

6 https://en.wikipedia.org/wiki/Bhopal_disaster

 

Occurrences

Level

Precursor Type Facilitator Initiator Exacerbator Conseq-

Not uential

Normally

Not Normally Near Miss

Yes

Not Normally

Yes Yes

Compro- mise

Yes

Not Normally

Yes

Deviation Infraction

Yes Yes Yes

Suggestions for root cause instructors

Discuss The Occurrence Pyramid. Indicate how the behaviors that result in pyramid base occurrences can also result in pyramid peak occurrences.

Thought of the Month

The consequential occurrences are the tip of the iceberg. They are supported by the whole pyramid of near misses, compromises, and deviations/ infractions. In order to understand the culture you must understand the whole pyramid and the management behaviors that sustain it.

Quotation of the Month

Geiger's Principle: "If you only investigate consequentials you will soon have consequentials to investigate."

Firebird Forum Staff

William R. Corcoran, Ph.D., P.E. 21 Broadleaf Circle Windsor, CT 06095-1634 Tel: 860-285-8779 e-mail: firebird.one@alum.mit.edu

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