Was Jenga Risk Management or Infant Mortality to Blame?

When?summarizing my “armchair analysis” of?the January 28 multiple fatality incident at a Foundation Food Group plant in Georgia, I noted that it was a newly installed system that failed. It has been online for only 4-6 weeks.

Many problems can arise with new systems. Most are quite predictable. However, the random failures that happen early in the “life” of a system are referred to as “infant mortality.” They often result from:

• The use of improper servicing materials
• Errors during installation
• Incorrect operating procedures (or not following procedures at all)
• Inadequate knowledge, due to a lack of training, etc.

To figure out what happened in the Foundation Foods system failure, key questions must be asked.

• Was this new system being run according to proper operating procedures?
• Or were old system procedures being used on the new system???
• Did “belt- tightening" play a role?
• Was protective gear outdated or absent?

Layer on the pandemic environment... possibly extended staff hours (fatigue), less staff and spatial distancing and the stage was set for disaster… which quite reliably occurred.

Before the incident, maintainers were performing "unplanned maintenance" as a response to something failing. But “unplanned” means tackling the job without planning what to do or how to do it... which raises a number of questions:

• Did anyone consider the possibility of a?rupture and a leak in advance?
• Did they know how to deal with such a situation???
• Were they prepared for it? In other?words...
• Did they have the right tools?
• Did they have all?the parts and materials they needed?
• Did they have a LOTO* procedure and “safe to work” permits??

When doing unplanned work, maintainers "don’t know what they don’t know" about the problem. This is especially true with?a new system. They are "winging it".?Such work is rarely cost effective or safe. And "winging it" on a cryogenic system ... trying to set something right before it got too out of hand ... clearly led to a deadly outcome.??

Perhaps this was a rare catastrophic failure, never experienced before. But even if it was, those with cryogenic system experience (they are known to be inherently hazardous) would have been aware of the risks and familiar with LOTO* procedures.

Whenever knowledge (or its absence) is a problem, I question the training (if there was any).?This plant’s history of safety infractions and fines indicate they lack a safety culture. Fines would have minimal impact on such a high volume plant. The workers knew about past infractions (and likely more that weren't caught). But like their managers, they tolerated the situation and so it continued.

Now 6 of these workers are dead. A tragic loss of life that could have been predicted and prevented.

The total cost of this failure was massive.?It impacted the entire community; the workers and their families, multiple first responder?agencies, safety and regulatory bodies.?In my next post, I'll sum up the bill for this incident versus what it would have cost to prevent it.

If you were?involved in this?situation, what questions would you want answered?

What sort of reparation or positive change would you want to see?

Have your say in the comments below.

* LOTO is?Lock Out Tag Out, a process used to de-energize a system to make it safe for repair/maintenance work to be carried out.