Tag Archives: fatalities

Worker dies while manually measuring tank

By Kim Smiley

The potential danger of confined spaces is well documented, but nine fatalities have shown that people working near open hydrocarbon storage hatches can also be exposed to dangerous levels of hydrocarbon gases and oxygen-deficient atmospheres.  NPR recently highlighted this issue in an article entitled “Mysterious Death Reveals Risk In Federal Oil Field Rules” that discussed the death of Dustin Bergsing.  His job duties included opening the hatch on a crude oil storage tank to measure the level of the oil and was found dead next to an open hatch.  He was healthy and only 21 years old.

A Cause Map, a visual format for performing a root cause analysis, can be used to help explain what happened to cause his death.  A Cause Map intuitively lays out the cause-and-effect relationships that contributed to an issue and is built by asking “why” questions.  Click on “Download PDF” to view a high level Cause Map of this accident.

So why did his death occur?  An autopsy showed that his death occurred because he had hydrocarbons in his blood.  This occurred because he was exposed to hydrocarbon vapor and he remained in the dangerous environment. (When two causes both contribute to an effect, they are listed vertically on the Cause Map and separated by an “and”.)

When a person is exposed to hydrocarbon vapor, they get disoriented before passing out so it is very difficult for them to get to safety on their own.  Bergsing was working alone at the time of his death and no one was aware that he was in trouble before it was too late.

He was exposed to hydrocarbon gases because he opened a hatch on a crude oil storage tank and the gas had collected at the top of the tank.  He opened the hatch because he planned to manually measure the tank level by dropping a rope inside. Manual tank measurement is a common method to determine level in crude oil storage tanks. Crude oil contains volatile hydrocarbons that can bubble out of the crude oil and collect at the top; the gas will rush out of the tank if a hatch is opened.

Additionally, he wasn’t wearing adequate PPE equipment because it wasn’t required by any regulations and there was limited awareness of this danger.

After his and the other deaths, the industry is starting to become more aware of this issue.  The National Institute for Occupational Safety and Health (NIOSH) and the Occupational Safety and Health Administration (OSHA) issued a hazard alert bulletin that identified health and safety risks to workers who manually gauge or sample fluids on production and flowback tanks from exposure to hydrocarbon gases and vapors and exposure to oxygen-deficient atmospheres. In addition to working to raise awareness of the issue, OSHA and NIOSH made recommendations to improve working safety that include the following:

– Implementing alternate procedures that allow workers to monitor tank levels and sample without opening hatches

– Installing hatch pressure indicators

– Conducting worker exposure assessments

– Providing training on the hazard and posting hazard signage

– Not permitting employees to work alone

Please read the OSHA and NIOSH hazard alert bulletin for more information and a full list of the recommendations. Many of the recommendations would be expensive and time-consuming to implement, but some may be relatively simple ways to reduce risk. Continuing to provide information to workers about the potential hazards might be a good first step to improve their safety.

Track Workers Killed by Train

By ThinkReliability Staff

A derailment and the fatalities of two railroad workers on April 3, 2016 has led to an investigation by the National Transportation Safety Board (NTSB). In this investigation, the NTSB will address the impacts of the accident, determine what caused the accident and will provide recommendations to prevent similar accidents from recurring. While the investigation is still underway, a wealth of information related to the accident is already available to begin the analysis. We will look at what is currently known regarding the accident in a Cause Map, a visual form of root cause analysis.

The first step of the analysis is to define the problem. This includes the what, when, and where of the incident, as well as the impacts to the organizational goals. Capturing the impacts to the goals is particularly important because the recommendations that will result from the analysis aim to reduce these impacts. If we define the problem as simply a “derailment”, recommendations may be limited to those that prevent future derailments. Not only are we looking for recommendations to prevent future derailments, we are looking for recommendations to prevent all the impacted goals. In this case, that includes worker safety: 2 workers died, public safety: 37 passengers were injured, customer service: the train derailed, property: the train and some construction equipment was damaged, and labor: response and investigation are required.

The analysis is performed by beginning with the impacted goals and developing the cause-and-effect relationships that led to those impacts. Asking “why” questions can help to identify some of the cause-and-effect relationships, but there may be more than one cause that results in an effect. In this case, the worker fatalities occurred because the train struck heavy equipment and the workers were in/on/near the equipment. Both of these causes had to occur for the effect to result. The workers were on the equipment performing routine maintenance. In addition, their watch was ineffective. When capturing causes, it’s important to also include evidence, which validates the cause.

We know the watch was ineffective, because federal regulation requires a watch for incoming trains that gives at least a fifteen second warning. Fifteen seconds should have been sufficient time for the workers to exit the equipment. Because this did not happen, it follows that the watch was ineffective.

The train struck the heavy equipment because the equipment was on track 3, the train was on track 3, and the train was unable to brake in time. It’s unclear why the heavy equipment was on the track; rail safety experts say heavy equipment should never be directly on the track. The train was on track 3 because it was allowed on the track. Work crews are permitted to shut off the current to preclude passage of trains into the work zone, but they did not in this case, for reasons that are still being investigated. Additionally, the dispatcher allowed the train onto the track. Per federal regulations, when workers are on the track, train dispatchers may not allow trains on track until roadway worker gives permission. It appears that in this case the workers either failed to secure permission to work on the track (thus notifying the dispatcher of their presence) or the work notification was improperly cancelled, allowing trains to return to the track, possibly due to a miscommunication between the night and day crews. This is also still under investigation.

While inspection of the cars and maintenance records found no anomalies, the braking system is under investigation to determine whether or not it affected the train’s ability to brake. Also under investigation is the Positive Train Control (PTC), which should have emitted warnings and slowed the train automatically. However, the supplemental shunting device, which alerts the signaling system that the track is occupied, and is required by Amtrak rules, was not in place. Whether this was sufficient to prevent the PTC from stopping the train in time is also under investigation. The conductor placed the train in emergency mode 5 seconds before the collision. As the train was traveling at 106 mph (the speed limit was 110 mph in the area), this did not give adequate time to brake. There should have been a flagman to notify the train that a crew was on the track, but was not. The flagman also carries an air horn, which provides another notification to the track crew that a train is coming.

Says Ashley Halsey III, reporting in The Washington Post, “Basic rules of railroading and federal regulations should have prevented the Amtrak derailment near Philadelphia on Sunday that killed two maintenance workers.” It appears that multiple procedural requirements were not followed, but more thorough investigation is required to determine why and what can be done in the future to improve safety by preventing derailments and worker fatalities.

To view the available information in a Cause Map, please click “Download PDF” above.

Investigators Blame “Human Error” for Train Collision

By Kim Smiley

On February 9, 2016, two commuter trains collided head-on in Upper Bavaria, Germany.  Eleven people were killed and dozens were injured.  Investigators are still working to determine exactly what caused the accident and the train dispatcher is currently under investigation for involuntary manslaughter and could face up to five years in prison if convicted.

Although the investigation is still ongoing, some information has been released about what caused the crash.  The two trains collided head-on because they were both traveling on the same track toward each other in opposite directions.  Running two trains on the same track is common practice in rural regions in Germany and these two trains were scheduled to pass each other at a station with a divided track. The drivers of both trains were unaware of the other train.  The accident occurred on a bend in a wooded area so the drivers could not see the other train until it was too late to prevent the collision.

The dispatcher failed to prevent a situation where two trains were running towards each other on the same track or to inform the drivers about the potential for a collision.  Investigators have stated that the dispatcher sent an incorrect signal to one of the trains due to “human error”.  After realizing the mistake – and that a collision was imminent – the dispatcher issued emergency signals to the trains, but they were too late to prevent the accident.

All rail routes in Germany have automatic braking systems that are intended to stop a train before a collision can occur, but initial reports are that the safety system had been manually turned off by the dispatcher.  German media has reported that the system was overridden to allow the eastbound train to pass because it was running late, but this information has not been confirmed.  Black boxes from both trains have been collected and analyzed.  Technical failure of the trains and signaling equipment have been ruled out as potential causes of the accident.

The information that has been released to the media can be used to build an initial Cause Map, a visual root cause analysis, of this issue.  A Cause Map visually lays out the cause-and-effect relationships and aids in understanding the many causes that contributed to an issue. The Cause Map is built by asking “why” questions. A detailed Cause Map can aid in the development of more effective solutions.

One of the general Cause Mapping rules of thumb is that an investigation should not stop at “human error”.  Human error is too general and vague to be helpful in developing effective solutions. It is important to ask “why” the error was made and really work to understand what factors lead to the mistake.  Should the safety system be able to be manually overridden?  Is the training for dispatchers adequate?  Does there need to be a second check on decisions by dispatchers?  Should two trains traveling in opposite directions be sharing tracks?  I don’t know the answers, but these questions should be asked during the investigation.  Charging the dispatcher with involuntary manslaughter may prevent HIM from making the same mistake again, but it won’t necessarily reduce the risk of a similar accident occurring again in the future.  To really reduce risk, investigators need to dig into the details of why the error was made.

Landslide of construction debris buries town, kills dozens

By ThinkReliability Staff

Shenzhen, China has been growing fast. After a dump site closed in 2013, construction debris from the rapid expansion was being dumped everywhere. In an effort to contain the waste, a former rock quarry was converted to a dump site. Waste at the site reached 100 meters high, despite environmental assessments warning about the potential for erosion. On December 20, 2015, the worries of residents, construction workers and truckers came true when the debris slipped from the quarry, covering 380,000 square meters (or about 60 football fields) with thick soil as much as 4 stories high.

A Cause Map can be built to analyze this issue. One of the steps in the Cause Mapping process is to determine how the issue impacted the overall goals. In this case, the landslide severely impacted multiple goals. Primarily, the safety goal was impacted due to a significant number of deaths. 58 have been confirmed dead, and at least 25 are missing. The environmental goal and customer service goal were impacted due to the significant area covered by construction waste. The regulatory goal is impacted because 11 have been detained as part of an ongoing criminal investigation. The property goal is impacted by the 33 buildings that were destroyed. The labor goal is also impacted, as are more than 10,600 people participating in the rescue effort.

The Cause Map is built by visually laying out the cause-and-effect relationships that contributed to the landslide. Beginning with the impacted goals and asking “Why” questions develops the cause-and-effect relationships. The deaths and missing persons resulted from being buried in construction waste. Additionally, the confusion over the number of missing results from the many unregistered migrants in the rapidly growing area. The area was buried in construction waste when waste spread over a significant area, due to the landslide.

The landslide resulted from soil and debris that was piled 100 meters high, and unstable ground in a quarry. The quarry was repurposed as a waste dump in order to corral waste, which had previously been dumped anywhere after the closure of another dump. Waste and debris was piled so high because of the significant construction debris in the area. There was heavy construction in the area because of the rapid growth, resulting in a lot of debris. Incentives (dumpsite operators make money on each load dumped) encourage a high amount of waste dumping. Illegal dumping also adds to the total.

While an environmental impact report warned of potential erosion, and the workers and truck drivers at the dump registered concerns about the volume of waste, these warnings weren’t heeded. Experts point to multiple recent industrial accidents in China (such as the warehouse fire/ explosion in Tianjin in August, the subject of a previous blog) as evidence of the generally lax enforcement of regulations. Heavy rains contributed to ground instability, as did the height of the debris, and the use of the site as a quarry prior to being a waste dump.

Actions taken in other cities in similar circumstances include charging more for dumping debris in an effort to encourage the reuse of materials and monitoring dump trucks with GPS to minimize illegal dumping. These actions weren’t implemented in Shenzhen prior to the landslide, but this accident may prompt their implementation in the future. Before any of that can happen, Shenzhen has a long way to go cleaning up the construction debris covering the city.

Component Failure & Crew Response, Not Weather, Brought Down AirAsia Flight QZ8501

By Staff

Immediately following the December 28, 2014 crash of AirAsia flight QZ8501, severe weather in the area was believed to have been the cause of the loss of control of the plane. (See our previous blog on the crash.) However, recovery of the “black box” and a subsequent investigation determined that it was a component failure and the crew’s response to the upset condition that resulted in the crash and that weather was not responsible. This is an example of the importance of gathering evidence to support conclusions within an investigation.

Says Richard Quest, CNN’s aviation correspondent, “It’s a series of technical failures, but it’s the pilot response that leads to the plane crashing.” Because, as in common in these investigations, there is a combination of causes that resulted in the crash, it can help to lay out the cause-and-effect relationships. We will do this in a Cause Map, a visual form of root cause analysis. The Cause Map is built by beginning with an impact to the goals, such as the safety goal, and asking why questions.

The 162 deaths (all on board) resulted from the plane’s rapid (20,000 feet per minute) plunge into the sea. According to the investigation, the crash resulted from an upset/ stall condition AND the crew’s inability to recover from that condition. Because both of these causes contributed to the crash, they are both connected to the effect (crash) and separated with an “AND”.

More detail can be added to each “leg” of the Cause Map by continuing to ask “why” questions. The prolonged stall/ upset condition resulted from the aircraft being pushed beyond its limits. (It climbed 5,400 feet in about 30 seconds.) This occurred because of manual handling and because of the failure of the rudder travel limiter system, which is designed to restrict rudder movement to a safe range. The system failed due to a loss of electrical continuity from a cracked solder joint on a circuit board. Although maintenance records showed 23 complaints with the system in the year prior to the crash, it was not repaired. A former pilot and member of the investigation team stated it was considered “minor damage” and was “not a concern”.

The plane was being manually controlled because the autopilot and autothrust were disengaged. These systems were disengaged when a circuit breaker was reset (removed and replaced) to attempt to reset the system after a computer system failure (indicated by four alarms that sounded in the cockpit). While this is sometimes done on the ground, it shouldn’t be done in the air because it disengages the autopilot and autothrust systems. However, the crew had inadequate upset recovery training. According to the manual from the manufacturer the aircraft is designed to prevent it from becoming upset and therefore training is not necessary. The decision to manually place the plane in a steep climb is believed to have been an attempt to get out of the poor weather. Just prior to the crash, the less experienced co-pilot was at the controls.

The lack of crew training on upset conditions is also believed to have caused the crash. In addition, for at least some time prior to the crash, the pilot and co-pilot were working against each other by pushing their control sticks in opposite directions. The pilot was heard on the voice recorder calling for them to “pull down”, although “pulling” is used to bring the plane up.

The only recommendation that has so far been released is for commercial pilots to undergo flight simulator training for this type of emergency situation. AirAsia has already done so. The company, as well as the aviation industry as a whole, will hopefully look at the conclusions of the investigation report with a very critical eye towards improving safety.

Interim Recommendations After Fatal Chemical Release

By ThinkReliability Staff

After a fatal chemical release on November 15, 2014 (see our previous blog for an initial analysis), the Chemical Safety Board (CSB) immediately sent an investigative team. The team spent seven months on-site. Prior to the release of the final report, the CSB has approved and released interim recommendations that will be addressed by the site as part of its restart.

Additional detail related to the causes of the incident was also released. As more information is obtained, the root cause analysis can be updated. The Cause Map, or visual root cause analysis, begins with the impacts to the organization’s goals. While multiple goals were impacted, in this update we’ll focus on the safety goal, which was impacted due to four fatalities.

Four workers died due to chemical asphyxiation. This occurred when methyl mercaptan was released and concentrated within a building. Two workers were in the building and were unable to get out. One of these workers made a distress call, to which four other workers responded. Two of the responding workers were also killed. (Details on the attempted rescue process, including personal protective equipment used, have not yet been released.) Although multiple gas detectors alarmed in the days prior to the incident, the building was not evacuated. The investigation found that the alarms were set above permissible exposure limits and did not provide effective warning to workers.

Methyl mercaptan was used at the facility to manufacture pesticide. Prior to the incident, water accessed the piping system. In the cold weather, the water and methyl mercaptan formed a solid, blocking the pipes. Just prior to the release, the blockage had been cleared. However, different workers, who were unaware the blockage had been cleared, opened valves in the system as previously instructed to deal with a pressure problem. Investigators found that the pressure relief system did not vent to a “safe” location but rather into the enclosed building. The CSB has recommended performing a site-wide pressure relief study to ensure compliance with codes and standards.

The building, which contained the methyl mercaptan piping, was enclosed and inadequately ventilated. The building had two ventilation fans, which were not operating.   Even though these fans were designed PSM critical equipment (meaning their failure could result in high consequence event), an urgent work order written the month prior had not been fulfilled. Even with both fans operating, preliminary calculations performed as part of the investigation determined the ventilation would still not have been adequate. The CSB has recommended an evaluation of the building design and ventilation system.

Although the designs for processes involving methyl isocyanate were updated after the Bhopal incident, the processes involving methyl mercaptan were not. The investigation has found that there was a general issue with control of hazards, specifically because non-routine operations were not considered as part of hazard analyses. The CSB has recommended conducting and implementing a “comprehensive, inherently safer design review” as well as developing an expedited schedule for other “robust, more detailed” process hazard analyses (PHAs).

Other recommendations may follow in the CSB’s final report, but these interim recommendations are expected to be implemented prior to the site’s restart, in order to ensure that workers are protected from future similar events.

To view an updated Cause Map of the event, including the CSB’s interim recommendations, click “Download PDF” above. Click here to view information on the CSB’s ongoing investigation.

5 killed and dozens injured when duck tour boat collides with bus

By Kim Smiley

Five people were killed and dozens more injured when an amphibious Ride the Ducks tour boat collided with a charter bus in Seattle on September 24, 2015.  The circumstances of the accident were particularly unfortunate because two large vehicles carrying tour groups across a busy bridge were involved.  Traffic was mangled for hours as emergency responders worked to treat the high number of victims, investigate the accident and clear the roadway.

The National Transportation Safety Board (NTSB) is investigating the accident to determine exactly what led to the collision and if there are lessons learned that could help reduce the risk of a similar crash in the future.  Potential issues with the duck boat are some of the early focuses of the investigation.  In case you are unfamiliar, duck boats are amphibious landing craft that were used by the U.S. Army during World War II that have been refurbished for use as tour vehicles that can travel on both water and land to give visitors a unique way to experience a city.  Their military designation DUKW was changed to the more user-friendly duck boat moniker that is used by many tour companies throughout the world.

Eyewitnesses of the accident have reported that the duck boat unexpectedly swerved while crossing the bridge, slamming into the driver’s side of the tour bus.  Reports are that the left front wheel of the duck boat locked up and the driver lost control of the vehicle.  NTSB investigators have stated that the duck boat didn’t have a recommended axle repair done that was recommended in 2013 and that they are working to determine whether or not this played a role in the accident.

Investigators are also looking into whether or not Seattle Ride the Ducks was notified of the repair.  Photos of the wrecked duck boat show that the front axle sheared and the left wheel popped off the vehicle, but it hasn’t been conclusively determined whether the damage was the cause of the accident or occurred during the accident.  The issues with the axle certainly seem like a smoking gun, but a thorough investigation still needs to be performed and the process will take up to a year.  If there was a mechanical failure on the duck boat unrelated to the already identified axle issue, that will need to be identified and reviewed to see if it applies to other duck tour vehicles.

This severity of this accident is raising concerns about the overall safety of duck tours.  The duck boat involved in this accident underwent regular annual inspections and was found to meet federal standards.  If a mechanical failure was in fact involved, hard questions about the adequacy of standards and inspections will need to be asked.  The issue of the recommended repair that was not done also raises questions about how the recommendations are passed along to companies running duck boat tours as well as incorporated into inspection standards.

Click on “Download PDF” above to see an outline and Cause Map of this issue.

Explosions raise concern over hazardous material storage

By ThinkReliability Staff

On August 12, a fire began at a storage warehouse in Tianjin, China. More than a thousand firefighters were sent in to fight the fire. About an hour after the firefighters went in, two huge explosions registered on the earthquake measurement scale (2.3 and 2.9, respectively). Follow-on explosions continued and at least 114 firefighters, workers and area residents have been reported dead so far, with 57 still missing (at this point, most are presumed dead).

Little is known for sure about what caused the initial fire and continuing explosions. What is known is that the fire, explosions and release of hazardous chemicals that were stored on site have caused significant impacts to the surrounding population and rescuers. These impacts can be used to develop cause-and-effect relationships to determine the causes that contributed to an event. It’s particularly important in an issue like this – where so many were adversely affected – to find effective solutions to reduce the risk of a similar incident recurring in the future.

Even with so much information unavailable, an initial root cause analysis can identify many issues that led to an adverse event. In this case, the cause of the initial fire is still unknown, but the site was licensed to handle calcium carbide, which releases flammable gases when exposed to water. If the chemical was present on site, the fire would have continued to spread when firefighters attempted to fight it using water. Contract firefighters, who are described as being young and inexperienced, have said that they weren’t adequately trained for the hazards they faced. Once the fire started, it likely ignited explosive chemicals, including the 800 tons of ammonium nitrate and 500 tons of potassium nitrate stored on site.

Damage to the site released those and other hazardous chemicals. More than 700 tons of sodium cyanide were reported to be stored at the site, though it was only permitted 10 tons at a time. Sodium cyanide is a particular problem for human safety. Says David Leggett, a chemical risk consultant, “Sodium cyanide is a very toxic chemical. It would take about a quarter of teaspoon to kill you. Another problem with sodium cyanide is that it can change into prussic acid, which is even more deadly.”

But cleaning up the mess is necessary, especially because there are residents living within 2,000 ft. of the site, despite regulations that hazardous sites are a minimum of 3,200 ft. away from residential areas. Developers who built an apartment building within the exclusion zone say they were told the site stored only common goods. Rain could make the situation worse, both by spreading the chemicals and because of the potential that the released chemicals will react with water.

The military has taken over the response and cleanup. Major General Shi Luze, chief of the general staff of the military region, said, “After on-site inspection, we have found several hundred tons of cyanide material at two locations. If the blasts have ripped the barrels open, we neutralize it with hydrogen peroxide or other even better methods. If a large quantity is already mixed with other debris, which may be dangerous, we have built 1-meter-high walls around it to contain the material — in case of chemical reactions if it rains. If we find barrels that remain intact, we collect them and have police transport them to the owners.”

In addition to sending in a team of hazardous materials experts to neutralize and/or contain the chemicals and limiting the public from the area in hopes to limit further impact to public safety, the state media had said they were trying to prevent rain from falling, presumably using the same strategies developed to ensure clear skies for the 2008 Summer Olympics. Whether it worked or not hasn’t been said, but it did rain on August 18, nearly a week after the blast, leaving white foam that residents have said creates a burning or itchy sensation with contact.

View an initial Cause Map of the incident by clicking on “Download PDF” above.

Legionnaires’ Disease Outbreak Blamed on Contaminated Cooling Towers

By ThinkReliability Staff

An outbreak of Legionnaires’ disease has affected at least 115 and killed 12 in the South Bronx area of New York City. While Legionnaires’, a respiratory disease caused by breathing in vaporized Legionella bacteria, has struck the New York City area before, the magnitude of the current outbreak is catching the area by surprise. (Because the vaporization is required, drinking water is safe, as is home air conditioning.) It’s also galvanizing a call for actions to better regulate the causes of the outbreak.

It’s important when dealing with an outbreak that affects public health to fully analyze an issue to determine all the causes that contributed to the problem. In the case of the current Legionnaires’ outbreak, our analysis will be performed in the form of a Cause Map, or visual root cause analysis. We begin by capturing the basic information (what, when and where) about the issue in a problem outline. Because the issue unfolded over months, we will reference the timeline (to view the analysis including the timeline, click on “Download PDF”) to describe when the incident occurred. Some important differences to note – people with underlying medical conditions and smokers are at a higher risk from Legionnaires’, and Legionella bacteria are resistant to chlorine. Infection results from breathing in contaminated mist, which has been determined to have come from South Bronx area cooling towers (which is part of the air conditioning and heating systems of some large buildings).

Next we capture the impact to the goals. The safety goal is impacted due to the 12 deaths, and 115 who have been infected. The customer service goal is impacted by the outbreak of Legionnaires’. The environmental and property goals are impacted because at least eleven cooling towers in the area have been found to be contaminated with Legionella. The issue is resulting in increased regulation, an impact to the regulatory goal, and testing and disinfection, which is being performed by at least 350 workers and is an impact to the labor goal.

The analysis begins by asking “why” questions from one of the impacted goals. In this case, the deaths resulted from an outbreak of Legionnaires’ disease. The outbreak results from exposure to mist from one of the contaminated cooling towers. The design of some cooling towers allows exposure to the mist produced. It is common for water sources to contain Legionella (which again, is resistant to chlorine) but certain conditions allow the bacteria to “take root”: the damp warm environment found in cooling towers and insufficient cleaning/ disinfection. The cost of cleaning is believed to be an issue – studies have found that, like this outbreak, impoverished areas are more prone to these types of outbreaks. Additionally, there are insufficient regulations regarding cooling towers. The city does not regularly inspect cooling towers. According to the mayor and the city’s deputy commissioner for disease control, there just hasn’t been enough evidence to indicate that cooling towers are a potential source of Legionnaires’ outbreaks.

Evidence would indicate otherwise, however. A study that researched risk factors for Legionnaires’ in New York City from 2002-2011 specifically indicated that proximity to cooling towers was an environmental risk. A 2010 hearing on indoor air quality discussed Legionella after a failed resolution in 2000 to reduce outbreaks at area hospitals. New York City is no stranger to Legionnaires’; the first outbreak occurred in 1977, just after Legionnaires’ was identified. There have been two previous outbreaks of Legionnaires’ this year. Had there been a look at other outbreaks, such as the 2012 outbreak in Quebec City, cooling towers would have been identified as a definite risk factor.

For now, though the outbreak appears to be waning (no new cases have been reported since August 3), the city is playing catch-up. Though they are requiring all cooling towers to be disinfected by August 20 and plan increase inspections, right now there isn’t even a list of all the cooling towers in the city. Echoing the frustrations of many, Bill Pearson, member of the committee that wrote standards to address the risk of legionella in cooling towers, says “Hindsight is 20-20, but it’s not a new disease. And it’s not like we haven’t known about the risk of cooling towers, and it’s not like people in New York haven’t died of Legionnaires’ before.”

Ruben Diaz Jr., Bronx borough president, brings up a good point for the cities that may have Legionella risks from cooling towers, “Why, instead of doing a good job responding, don’t we do a good job proactively inspecting?” Let’s hope this outbreak will be a call for others to learn from these tragic deaths, and take a proactive approach to protecting their citizens from Legionnaire’s disease.

Deadly balcony collapse in Berkeley

By Kim Smiley

A 21st birthday celebration quickly turned into a nightmare when a fifth-story apartment balcony collapsed in Berkeley, California on June 16, 2015, killing 6 and injuring 7.  The apartment building was less than 10 years old and there were no obvious signs to the untrained eye that the balcony was unsafe prior to the accident.

The balcony was a cantilevered design attached to the building on only one side by support beams.  A report by Berkeley’s Building and Safety Division stated that dry rot had deteriorated the support beams significantly, causing the balcony to catastrophically fail under the weight of 13 bodies.

Dry rot is decay caused by fungus and occurs when wood is exposed to water, especially in spaces that are not well-ventilated. The building in question was built in 2007 and the extensive damage to the support beam indicates that there were likely problems with the water-proofing done during construction of the balcony.  Initial speculation is that the wood was not caulked and sealed properly when the balcony was built, which allowed the wood to be exposed to moisture and led to significant dry rot. However, the initial report by the Building and Safety Division did not identify any construction code violations, which raises obvious questions about whether the codes are adequate as written.

As a short-term solution to address potential safety concerns, the other balconies in the building were inspected to identify if they were at risk of a similar collapse so they could be repaired. As a potential longer-term solution to help reduce the risk of future balcony collapses in Berkeley as a whole, officials proposed new inspection and construction rules this week.  Among other things, the proposed changes would require balconies to include better ventilation and require building owners to perform more frequent inspections.  Only time will tell if proposed code changes will be approved by the Berkeley City Council, but something should be changed to help ensure public safety.

Finding a reasonable long-term solution to this problem is needed because balconies and porches are susceptible to rot because they are naturally exposed to weather.  Deaths from balcony failures are not common, but there have been thousands of injuries.  Since 2003, only 29 deaths from collapsing balconies and porches have been reported in the United States (including this accident), but an estimated 6,500 people have been injured.

Click on “Download PDF” above to see a Cause Map, a visual format of root cause analysis, of this accident.  A Cause Map lays out all the causes that contributed to an issue to show the cause-and-effect relationships.