In today’s episode of the Dust Safety Science podcast, Paul von Norden, Global ATEX expert for FrieslandCampina in the Netherlands, reviews the differences between incident investigation for dust explosions compared to gas explosions. This is Paul’s second appearance on the podcast: last week, he spoke about how to become a global expert in explosion safety and protection.
In this episode, Paul answers the following questions:
- What is the Tripod B approach?
- What are the different elements used in investigating explosions?
- What about near misses?
What is the Tripod B Approach?
Paul explained that Tripod B is an incident investigation method called Tripod Beta. The ‘tripod’ reference comes from the fact that it deals with the three elements that cause an incident.
“The first element is the energy or the danger, and we can compare it with a tiger. The second point is the target or the object: for example, the person in the zoo. An incident is the third point of the tripod. Thus, these three are connected. If you are familiar with the bow tie, then you might recognize the Tripod Beta incident investigation as a collapsed bow tie.”
Using the example of a tiger in a cage at a zoo, Paul said that incidents occur if a barrier fails. With the tiger, this could be the cage door being open or someone climbing into the cage. Using Tripod B, one tries to understand what barriers did not work before looking for the immediate cause, such as the zookeeper leaving the cage open.
“Tripod B also looks a little bit further. What were the error-enhancing circumstances? For example, the person was tired or the keys were lost, or whatever. Tripod B also looks to the secondary causes or the latent failures, as they call it. For example, the guard or the carer was not trained well. That’s what I like so much about the Tripod B method – it doesn’t look only at the direct cause. It’s easy to say, ‘Oh, stupid man! He shouldn’t have left the door of the cage open.’ There are always organizational aspects. Why could it happen that he left the door open? And so also with explosion incident investigations, there’s always a why.”
Paul admitted that Tripod B is not the only incident investigation method, but he likes it because it addresses deeper problems, such as issues in an organization that can allow an explosion incident to happen in the first place.
What are the Different Elements Used in Investigating Explosions?
Paul said that when an incident happens, preserving evidence is critical.
“During gas investigations, we always try to find facts when we arrive at the scene of an incident. As an industry, we have a tendency to quickly repair equipment and get things running again. By doing so, we risk losing the evidence. For example, the memory inside suppression control equipment is quite short. Therefore, we need to remember what happened the second before a suppression system ignited – to store that memory and to keep it. In addition, sensors that were involved in the incident should not be cleaned, but kept as they were. During incident investigations, it is crucial to leave the site as it is till the investigators arrive. So never clean the place after the incident.”
The next step is to analyze the evidence. Paul said that in his opinion, the biggest mistake in incident investigation is jumping to conclusions. It is important to think in terms of all possible scenarios, even when management is pushing for a quick conclusion.
“Always think in scenarios. And if (there is) room for more than one scenario, never be content if you can come up with only one scenario.”
What About Near Misses?
He emphasized the importance of investigating and understanding near-misses. When a disaster doesn’t actually happen, management simply consider themselves lucky and carry on, as near-miss investigations take time. However, these incidents are opportunities to learn how to prevent a disaster.
“It should be in the culture of the organization to learn from the near-misses. But in fact, the approach is more or less the same with incident investigation. But with a near miss, a barrier did not fail. Otherwise, the incident should have happened. But it almost failed or the danger was almost created. But still, if you look at the iceberg theory, you know, a lot of near-misses will cause a serious incident, and so we should learn from it.”
He warned against pointing toward an operator as an immediate cause.
“Yes, someone made the immediate cause of the incident, but there is always a reason behind it. It’s caused by the organization or even by the management, and we should have the guts to search deeper.”
He recalled one incident at a factory that used gas transported by trucks. One day, after the gas truck came and the gas was put in the system of the factory, there was an issue with an earthing cable with a rusted clamp.
“The rusting must have existed for many years and nobody had observed it. It had probably become a normal practice to have this clamp rusted. So the truck with the gas was not earthed well anymore, but nobody knew it. This kind of deviation must always be avoided. But sometimes you don’t see it anymore because it has become too, too normal.”
Conclusion
Paul concluded the interview by saying, “Let me stress that incidents may give the impression that everything is wrong in the organization, but it’s the way around. Many things are good in our company and in many other companies. But it’s just a little thing which we don’t observe anymore that can cause an incident.”
If you would like to discuss further, leave your thoughts in the comments section below. You can also reach Paul Van Norden directly:
Email: [email protected]
LinkedIn: https://www.linkedin.com/in/paulvannorden/
Website: https://www.frieslandcampina.com/
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.
Resources mentioned
Dust Safety Science
Combustible Dust Incident Database
Dust Safety Science Podcast
Questions from the Community
Dust Safety Academy
Dust Safety Professionals
Dust Safety Share
Companies
FrieslandCampina
Organizations
IECEx
Directives
ATEX
Previous Episodes
DSS199: How To Become A Global Expert In Explosion Safety & Protection with Paul van Norden
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