DSS106: CSB Dust Hazard Learning Review - Challenges and Actions

This episode is an overview of the Chemical Safety Board Dust Hazard Learning Review. It’s a project that’s been going on for over two years now, and we will cover it over the next two podcast episodes.

On October 24, 2018, the U.S. Chemical Safety Board issued a Call to Action during the Didion Milling investigation. They released an interim report on Didion Milling and identified some challenges during that investigation. In the Call to Action, they acknowledged other challenges in industries handling combustible dust.

The (at the time) interim executive director at the Chemical Safety Board, Kristen Kulinowski, noted in the Call to Action, “Our dust investigations have identified the understanding of dust hazards and the ability to determine a safe level in the workplace has common challenges. While there’s a shared understanding of the hazards of dust, our investigations have found that efforts to manage those hazards have often failed to prevent catastrophic explosions, to uncover why that is we are initiating the Call to Action, to gather insights and feedback from those most directly involved with combustible dust hazards.”

The Call to Action Goes Out

They sent out a list of 11 questions and collected 57 responses from 14 countries. Respondents ranged from large organizations to health and safety specialists, engineers, consultants, and operators with companies handling combustible dust or potentially combustible dust. After the replies were analyzed and interpreted by Dr. Ivan Pupulidy and Crista Vesel before being used in the report.

Dust Safety Science got involved with the project soon after the Chemical Safety Board did its first outreach. We did a podcast episode on the Call to Action, which was Episode #6: ‘A Call to Action on Combustible Dust from the US Chemical Safety Board – With Cheryl Mackenzie and Dr. Ivan Pupulidy.’ We also sent out a simplified version of the call to action survey to the Dust Safety Science email list and 50 additional people. Once the responses were collected, we sent them to the Chemical Safety Board.

The outcome was a collection of high-level themes and categories, with each category including a discussion of the subject and how the data points and comments fit in. It was an interesting way to get an idea of the overall perceptions of combustible dust.

The high-level themes were:

Barriers to improvement, which include normalization of risk and goal conflicts.
Controls such as the hierarchy of controls, compliance-based approach, dust hazard analysis, dust collection, housekeeping and similar challenges.
Reporting, which includes the challenges of internal reporting within companies.
Language and communication, which can play a strong role in downplaying the risks of combustible dust.
Learning, including learning from near-miss events.
Sharing information within a company or between companies and even between industries and regulators.

Going through the report, we identified six critical challenges:

Awareness of the hazard and risk
Safety as defined as absence of explosions
Having a safe place to share information
Language and communication
Moving from training to learning
Breaking goal conflicts

We talk about the first couple of challenges in this podcast episode and the rest next week.

Awareness of the Hazard and Risk

This is the first challenge that dust safety professionals tend to come across. The Call to Action responses included statements like, “Combustible dust should be a widely recognized hazard just like any other workplace hazard. Most companies visited don’t understand the volatility of their dust problem. If we have enough fear or respect for dust explosions, we will take action using fires as leading indicators. Workers are more aware of dust cloud explosibility from watching ‘MythBusters’ and not internal company training efforts.”

A couple of interesting things came out of this awareness of the hazard and risk of combustible dust. One is normalization of risk. One respondent stated:

“Dust explosions are rare events that lull industrial organizations into a false sense of security while a greater level of recognition of these risks is present in industry than ever before, still far too many dust related incidents occur as a result of ignorance or complacence. Because of the complex variables that must come together to enable a dust explosion, operation personnel are frequently unaware of the true likelihood of these events. While rare, they’re frequently catastrophic when they occur, often the original design of the equipment and safety processes of the operations are initially effective in at least reducing risk.

“However over time, I believe the process of practical drift occurs. Practical drift was first proposed by Scott Snook and his book ‘Friendly Fire.’ He defined it as the slow uncoupling of practice from procedure. His theory is that as people operate in an environment controlled by procedures, they’re constantly acting to reduce effort and improve efficiency based on real-time results. With an infrequent event such as dust explosions, the iterative process can result in many iterations before the explosion occurs, allowing the system to change dramatically before the results of these changes that are made known. I believe this theory is highly applicable to the prevention of combustible dust events.”

Another response was:

“Safety is a nonevent. Think of it as a control loop with a much-delayed feedback signal. Then the control loop starts to drift. Production is tangible and can take priority over safety.” This is really this normalization of risk in action. I think of it like a chess board or a chess game. If you’re playing chess and you’re on a timer every time we have an incident, every time we have an explosion, it resets the clock. Even if we have a really educational push by one group or another, it resets the clock in that industry. But as soon as you make that move and the clock resets, it’s counting down continuously and as nothing happens and you don’t have incidents, then you’re constantly drifting from work as planned.”

When a system is clean and operating correctly when it’s first installed, over time that system can be allowed to drift. If you see a fire every Thursday and no one ever gets hurt, it allows that system to drift even farther off course because now people aren’t using fires as indicators of a problem.

Another, related, concept is constructive paranoia. We don’t want people to be too paranoid and stressed out but there needs to be a sense of vulnerability around combustible dust. That way, the systems are a lot less likely to drift.

Showing an explosion pentagon, although it’s a great way to illustrate control methods, won’t increase the sense of vulnerability. But if you work on a wood chipper and see a video of a dust explosion occurring in one, it is going to be much more effective in increasing a sense of vulnerability.

Safety as Defined as Absence of Explosions

NFPA 652 explicitly states, “The absence of previous incidents shall not be used as the basis for deeming a particulate not to be combustible or explosible or not to perform a dust hazard analysis.”

In other words, safety is not a nonevent. It’s more like a control loop with a much-delayed feedback signal. The control loop starts to drift where production can take priority over safety. Obviously, if you have a loss of life or severe injury from a dust explosion it gets reported. But there are no real drivers to report near misses unless you make that part of your culture in your company or we make it part of our culture as the global combustible dust community to report those issues.

Having a Safe Place to Share Information

This challenge addresses the psychological reasons why people don’t report near misses or even incidents when they happen. It could be a case of time pressure or fear of looking bad in front of your peers or your boss. Safety might just not be a priority: maybe production is a larger priority or there may be competing goal conflicts. There are always psychological reasons why people may not report and share information more broadly and allow for these learning opportunities.

One of the respondents wrote:

“Current data on the number of explosions, fires and near misses due to combustible dust is unreliable and surely under-reported due to the perceived liability by end-users in sharing this information with outside groups.”

This respondent also suggested that the creation of a reliable reporting system, even if it means that the reports are anonymous, would be a huge step in helping industry to fully define the problem and work together on a solution.

Conclusion

The Chemical Safety Board Dust Hazard Learning Review has provided invaluable insights into the concerns and challenges that impact safety in industries handling combustible dust. In the next episode, we’ll review the remaining challenges and explore potential solutions.

If you have questions about the contents of this or any other podcast episode, you can go to our ‘Questions from the Community’ page and submit a text message or video recording. We will then bring someone on to answer these questions in a future episode.