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An intermediate
bulkcontainer(IBC)
was punctured dur-
ing its handling, re-
leasing a refined oil
product onto land
at a l...
24 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
strong safety culture, with prod...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 25Root Cause Analysis of a Minor Spill
logistics, and ...
26 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
(HSE) data demands special atten...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 27Root Cause Analysis of a Minor Spill
environmental c...
28 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
•	 Where a robust analysis of th...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 29Root Cause Analysis of a Minor Spill
Exhibit 2. Pro ...
30 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
•	 The contractor HSE manager,
•...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 31Root Cause Analysis of a Minor Spill
The most common...
32 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
northwest coast of Western Austr...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 33Root Cause Analysis of a Minor Spill
before the proj...
34 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
Exhibit 3. Evaluation of the Pro...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 35Root Cause Analysis of a Minor Spill
Protective syst...
36 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
Exhibit 4. Timeline of Events Re...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 37Root Cause Analysis of a Minor Spill
from pro forma ...
38 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
This author’s research on root c...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 39Root Cause Analysis of a Minor Spill
The root cause ...
40 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
involves asking why, up to five ...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 41Root Cause Analysis of a Minor Spill
thorough RCA ap...
42 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
Exhibit 10. The Results of the R...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 43Root Cause Analysis of a Minor Spill
component contr...
44 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
Exhibit 12. An Estimate of Finan...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 45Root Cause Analysis of a Minor Spill
Exhibit 14. Vie...
46 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
visual inspection by the spotter...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 47Root Cause Analysis of a Minor Spill
quarantine requ...
48 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
sustainable development by reduc...
Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 49Root Cause Analysis of a Minor Spill
a sustainable w...
50 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin
Turlough F. Guerin is a professi...
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An Investigation Into the Root Cause of a Spill From Procuring and Handling of Lubricants in Intermediate Bulk Containers

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An intermediate bulk container (IBC) was punctured during
its handling, releasing a refined oil product onto land
at a large construction site in an environmentally sensitive region of Australia. Understanding and controlling the risks from fuel, oil, and chemical spills on the current project was of critical importance, as part of the project’s overall approval,
and ongoing compliance was dependent upon the project’s commitment to minimize all chemical and petroleum hydrocarbon spills everywhere on the site. The telehandler or forklift did not pierce the plastic of the IBC directly, as was
expected to be the case; rather, one of the tines had caught on the underside of the metal base plate (pallet), despite numerous controls being in place at the time of spill, revealing a previously unreported mechanism for a fluid spill from the
handling of petroleum hydrocarbons and related chemicals.
The investigation
team used a
root cause analysis
(RCA) technique,
based on the fishbone
or Ishikawa
diagram, which was undertaken in a thorough
manner with 12 expert contributors from the
project to identify the underlying cause: an inadequate
inspection process. Applying the safety
controls hierarchy to close out the incident,
given that IBCs could not be eliminated from
the project, and two engineering solutions were
put in place to prevent spills from occurring
from piercing by telehandler tines. Administrative
controls (i.e., those least effective) applied
included the introduction of quality assurance
checks for the verification of IBC condition at
various stages throughout the chain of custody.

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An Investigation Into the Root Cause of a Spill From Procuring and Handling of Lubricants in Intermediate Bulk Containers

  1. 1. An intermediate bulkcontainer(IBC) was punctured dur- ing its handling, re- leasing a refined oil product onto land at a large construction site in an environmentally sensitive region of Australia. Understanding and controlling the risks from fuel, oil, and chemical spills on the current project was of critical impor- tance, as part of the project’s overall approval, and ongoing compliance was dependent upon the project’s commitment to minimize all chemi- cal and petroleum hydrocarbon spills everywhere on the site. The telehandler or forklift did not pierce the plastic of the IBC directly, as was expected to be the case; rather, one of the tines had caught on the underside of the metal base plate (pallet), despite numerous controls being in place at the time of spill, revealing a previously unreported mechanism for a fluid spill from the handling of petroleum hydrocarbons and related chemicals. The investiga- tion team used a root cause analysis (RCA) technique, based on the fish- bone or Ishikawa diagram, which was undertaken in a thorough manner with 12 expert contributors from the project to identify the underlying cause: an in- adequate inspection process. Applying the safety controls hierarchy to close out the incident, given that IBCs could not be eliminated from the project, and two engineering solutions were put in place to prevent spills from occurring from piercing by telehandler tines. Administra- tive controls (i.e., those least effective) applied included the introduction of quality assurance checks for the verification of IBC condition at various stages throughout the chain of custody. These verification checks were not limited to the Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 23 © 2015 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/tqem.21401 An Investigation Into the Root Cause of a Spill From Procuring and Handling of Lubricants in Intermediate Bulk Containers A Case Study on the Practical Application of Root Cause Analysis Turlough F. Guerin
  2. 2. 24 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin strong safety culture, with product spills being no exception. There are numerous federal and state laws in effect in Australia that govern the regulation of chemicals and their subsequent spills from infrastructure, equipment, and plant, and their migration into air, water, and land. Consent conditions, which define the environ- mental guidelines to which construction projects must comply as part of the approval process, also define spills as specific environmental impacts that must be prevented, and if they do occur they must be managed, and there is considerable focus on the management of petroleum-based spills and contamination in the Australian re- sources sector (Altham & Guerin, 2005; Guerin, 2005, 2008; Guerin, Turner, & Tsiklieris, 2004). Based on communication with peer environmen- tal managers in the industry, the author’s own informal research suggests that more than 50% of all construction environmental incidents in Australia involve spills. Therefore, spills can pose a significant challenge in meeting approval con- ditions and ongoing compliance requirements. Safety in the Chemical Supply Chain One of the environmental aims of a facility under construction is to ensure that there is no unintentional loss of containment of oil, refined petroleum products, or other hazardous materials used by earthmoving equipment. The supply of such materials to construction sites presents a risk as it exposes these sites to the potential for loss of product containment. Construction in remote lo- cations requires a flexible, yet secure, logistics sys- tem for the delivery of such fuel, oil, and chemi- cals. IBC units are used to hold various types of liquids, including oils, acids, and concrete ac- celerants (Exhibit 1). IBCs are ideally suited for such applications because of their flexibility for handling and scalability as the construction work front changes. However, despite the industry’s best endeavors, loss of containment may occur, IBC surfaces, but rather included specific checks, using a flashlight, if necessary, for obstructions and deformations particularly in the IBC pallet or belly plate/base. Implications from this investigation are that all projects using IBCs and telehandlers or fork- lifts should assess the risks and manage them to minimize spills and the environmental and safety hazards associated with the interaction between these machines and IBCs, including eliminating, if possible, and minimizing the han- dling of these IBCs. The study also revealed the limitations of the hazard identification (HAZID) process used as part of the approvals prior to the construction project—and prior to procurement of full IBCs onto the site. The HAZID process did not identify the handling of IBCs as a risk. Even though more than 20 controls were identified in the investigation related to the activity associated with and lead- ing to the spill, half of which were in place that could reasonably have been expected to prevent the spill, the incident still occurred with result- ing cost implications. This is the first study of this type to undertake cost accounting for the individual elements of a spill and its subsequent investigation. Introduction Leaks and spills of petroleum hydrocarbon are a major concern in the upstream oil industry, from both a construction and an operational perspective (Altham & Guerin, 2005; Guerin, 2000, 2005, 2006; Ismail & Karim, 2013; Ruffin, 2012; Sánchez-Arias, Remolina, & Alvarez-León, 2013; Stevenson, 2012). The petroleum industry is greatly concerned about safety, and it has a One of the environmental aims of a facility under construction is to ensure that there is no unintentional loss of containment of oil, refined petroleum products, or other hazardous materials used by earthmoving equipment.
  3. 3. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 25Root Cause Analysis of a Minor Spill logistics, and construction projects, which are customers in these supply chains. A recent study by the author analyzing all plant and equipment spills on a large resource construction project in Australia found that four root causes were common to 60% of the spill events reported during the peak period of earth- works (Guerin, 2014). The majority of the spills were of hydraulic fluid, and these occurred pre- dominantly from excavators, loaders, and trucks, and the failed components were typically hydrau- lic hose fittings and their connections. Previous studies, which are relevant to the current spill event because of the similarity of the spilled product, have focused on large oil spills and their causes (Ismail & Karim, 2013), and there are numerous reports on the causes of large oil spills, particularly those occurring in sensitive marine environments (Talley, 1995). The risks of transporting and storing crude oil and its refined products by tankers over large distances primarily concern accidental events. The Oil Spill Intelligence Report, published by Aspen Publishers, provides regular industry updates on major oil spill events and their causes (Anonymous, 2014a). This se- rial has provided insights into root causes for large-scale oil spills, including lack of attention to maintenance of oil lines, poor weather condi- tions, pipe corrosion, rupture of hydraulic hoses, and budget pressures on an oil-field operation. and we need to understand the root causes, con- sequences, and implications of such events. The project’s HAZID did not identify the handling of IBCs as posing a risk to the project. Rather, it agreed to deploy these as an improved approach over other options. Given that there is an underlying requirement in all profession- ally managed construction projects to ensure that the design stage of the project identifies and considers the potential risks (Behm, 2005; Behm & Culvenor, 2011; Behm, Gambates, & Toole, 2014; Fortunato III, Hallowell, Behm, & Dewlaney, 2011; Gambatese, Behm, & Rajendran, 2008), including those from transport and stor- age of chemicals, the current resource construc- tion project decided to use IBCs as an enhanced and preferred method instead of procuring 205 liters (L) or 44 gallon drums strapped to pallets, or to purchase vessels larger than IBCs, such as “ISO” or intermodal containers or other large transportable tanks. Examining Previous Spill Studies Although there have been a large number of spills occurring globally from infrastructure, equipment, and plant failures, many of which have been written about in the literature available in the public domain, relatively little has been published on their root causes or the broader implications of these spills for transportation, Exhibit 1. Examples of Chemicals Commonly Transported to and Stored at Resource Construction and Mining Sites Engine lubricant Grease Brake fluid Gear lubricants Detergents Sealants Coolants Solvents Acetone Sodium hydroxide Hydrochloric acid Bleach Sulfuric acid Dust suppressants Gasoline Flotation reagents Emulsifiers Diesel Herbicides Bitumen emulsion Special fuel mixture Hydraulic fluids Distilled water Other water-soluble chemicals
  4. 4. 26 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin (HSE) data demands special attention from cor- porate leaders and shareholders to control such incidents as an immediate measure, as well as to prevent their recurrence through strategic or operational plans (Restrepo, Simonoff, & Zim- merman, 2009). Furthermore, lessons learned from spill incidents need to be communicated to oil and gas operators and their contractors more broadly across the upstream oil and gas industry to assist in reducing the incidence and severity of these events. Unfortunately, there is evidence that this is not occurring to a sufficient degree on either a national or an international level (Fraser & Ellis, 2008; Fraser, Ellis, & Hussain, 2008). To enable companies to work intelligently toward reducing spills, both across their operations and up and down their supply chains, robust data are required, which, in turn, demand effective and appropriate analytical tools for determining and establishing cause. One of the tools commonly used to investi- gate these losses of containment, RCA, will lead investigators to take both short-term, immediate corrective actions, and to identify the underlying root causes (latent failures) hidden in the way work is done that will help avert similar incidents or spills in the future (Otutu & Agba, 2003). By identifying actions to correct these underlying issues, oil and gas and related construction facili- ties can continuously improve their overall busi- ness, reducing spills and averting injuries from loss of containment of manufactured products (Otutu & Agba, 2003), and minimizing loss of chemicals or product. RCA is a class of problem-solving methods aimed at identifying the underlying (or root) causes of incidents (Anonymous, 2014b; Garg & Gokavarapu, 2012). By directing corrective measures at core or root causes, it is anticipated that the chances of problem recurrence will be minimized. Thus, RCA is frequently considered to be an iterative process, and it is frequently viewed There are, however, relatively few studies published that describe the far larger number of smaller spills and their causal agents, that is, those tentatively set at equal to, or less than, ap- proximately 1,000 L in size. Presumably, these spills are of less interest to researchers and are more in the domain of the commercial interests and practitioners handling the refined products. Such accidents are a cause of major marine transportation spills of oil (Talley, 1995). The upstream and midstream oil sectors take steps to identify potential risks from construction and operational oil and chemical spills, and numer- ous examples of such studies from the Northern Hemisphere have been conducted (Bjørn- bom, Hansen, Engen, & Knudsen, 2012). In the study of Vin- nem, Hestad, Kvaloy, and Skogdalen (2010), there are significant correlations between number of leaks and safety climate indicators, and, interestingly, their very extensive study of the Norwegian oil indus- try showed that leak frequency and equipment age did not show a positive correlation. The study of Ruckart and Burgess (2007) of hazardous ma- terial events in the mining and manufacturing industries has analyzed the key role that human error contributes to spill events. In their study, 11.6% of all events in these industries resulted from human error. Other contributing factors were commonly caused by improper filling, load- ing, or packing. Only 2% of events were a result of forklift puncture, which is of direct relevance to this study. Analysis of Spill Causes The impact of leaks and spills on company or corporate health, safety, and environment Lessons learned from spill incidents need to be communicated to oil and gas operators and their contractors more broadly across the upstream oil and gas industry to assist in reducing the incidence and severity of these events.
  5. 5. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 27Root Cause Analysis of a Minor Spill environmental concerns for end users in their supply chains. Method Description of Operation The contractor company that was operating the IBC-handling equipment when the spill oc- curred was the primary earthworks contractor engaged to supply services to the oil and gas company that had land tenure on the island on which the resources construction project was being built. The contractor organization was operating up to 370 plant items, includ- ing forklifts or tele- handlers, used for handling IBCs. A fully equipped heavy ve- hicle repair workshop was established and operative at the site. The contractor em- ployed approximately 400 personnel (across the entire construction site) at the time of the spill. The contractor’s operation was large compared with other projects underway in the resources sector in Australia at the time, with total revenues from the works estimated in Australian dollars (AUD) at AUD 0.5 billion. As such, it was considered to be representative of operations where there is a large throughput of lubricants, hydraulic fluid, and chemicals. The overall liquid natural gas (LNG) construction project was valued at more than several billion Australian dollars. Site Location The incident occurred at an LNG construc- tion site located offshore from Western Australia on a remote island classified as a Class A Nature Reserve. The site where the spill occurred was as a tool of continuous improvement. RCA, ini- tially, is a reactive method of problem detection and solving. This means that the analysis is done after an incident has occurred. However, by gain- ing proficiency in RCA, it becomes a proactive method. RCA is then able to estimate the pos- sibility of an incident before it occurs. RCA consists of the following steps: • Define the problem; • Analyze the problem; and • Find the solutions for the problem (Garg & Gokavarapu, 2012). These solutions should be both tactical, to address the immediate needs of the operation, and strategic, so as to minimize future occur- rences in the larger organization and industry, and for the same construction operation as well as others. Purpose and Study Rationale This paper has an overall objective to pro- vide a practitioner’s approach to applying RCA to a relatively minor spill event. This study used RCA methodology to investigate the cause(s) and contributing factors that led to an oil spill from a commonly used bulk handling container (IBC) on a large construction project in a remote and environmentally sensitive area. Such contain- ers are now being widely used across numerous industries, largely because of their convenience and low unit cost. The lessons learned and recommendations made from this study have general application for the handling of IBCs internationally, including across the general construction and resource sectors. While this study involves an incident with a relatively small volume spill, there is still a need to determine root causes and contributing factors of such spills, as they can pose serious implications for project costing and budgets, as well as safety and The lessons learned and recommendations made from this study have general application for the handling of IBCs internationally, including across the general construction and resource sectors.
  6. 6. 28 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin • Where a robust analysis of the root causes and contributing factors are required; and • Where results have to be relied upon before a potentially expensive change to a business process or system is implemented. The RCA method is not commonly used for relatively minor spills such as the one described in this study, so the findings here are important given the reliance that can be placed on the out- put of the method. The steps of this process were: 1. Formation of the investigation team; 2. Collection of incident data including ma- chine handler (operator’s) background; 3. Development of the sequence of events; 4. Undertaking a protective systems analysis; 5. Performing RCA analysis using the cause-­and- effect, fishbone model; and 6. Development of appropriate corrective ­actions. Exhibit 2 lists the pro forma options for possible root causes that were used in the devel- opment of the RCA process. Preselected primary and secondary root causes were provided as drop- down boxes in the documentation to determine the root cause. These preselected options were deployed to facilitate responses and outcomes from all spill events that were as consistent and comparable with each other as far as practical, across all operations of the contractor and opera- tor, thus enabling the comparison of spill causes between operations. Formation of Investigation Team An RCA investigation team was assembled from persons possessing a range of complemen- tary skills. This team comprised 12 members from the contractor company and the oil and gas company. located approximately 2 kilometers (km) from the ocean in the center of the construction works where the LNG plant was being built. The topog- raphy where the spill occurred was flat and well- travelled by project personnel. The IBC involved in the spill was located approximately 20 meters (m) from the main workshop entrance. Management Systems Descriptions The contractor operated under a manage- ment regime comprising an integrated health, safety, quality, and environmental management system. Each component of the system was certi- fied to the relevant International Organisation for Standardisation (ISO) standard, including ISO 9001 and 14001. To ensure alignment of the contractor’s system with that of the oil and gas operator, this in- tegrated system was audited externally by the operator every six months. The incident management compo- nent of the system was fully integrated with the contractor’s business and the operator’s business systems. All contrac- tor and operator personnel were inducted in the use of the incumbent management system at the time that new employees were on-boarded. Overview of Investigation (RCA) Methodology The team conducted the investigation for this incident in accordance with a fishbone, cause- and-effect, or Ishikawa-based RCA process (Anon- ymous, 2014b). The RCA method used in this study is based on the Ishikawa, or so-called fish- bone, method of analysis for determining causes and contributing factors for an event (or more generally, cause-and-effect theory) (Ishikawa, 1990). RCA is typically used in industry: • When a significant injury, death, or major environmental incident has occurred; The RCA method used in this study is based on the Ishikawa, or so-called fishbone, method of analysis for determining causes and contributing factors for an event.
  7. 7. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 29Root Cause Analysis of a Minor Spill Exhibit 2. Pro Forma Root Causes of Fluid Spills Used in Investigations on LNG Construction Sitea Primary root cause Root cause descriptionb Procedures and safe work practices Accepted to deviate from work routine Lack of job oversight Mistake or mental slip None exists or available Not complete or accurate Not enforced, audited, or inspected Not trained on procedure Other priorities conflicted Risk of not following not understood Willful deviation Design Design standards inadequate or not used Did not anticipate the conditions Did not consider human factors Inadequate review Inherent safety design not incorporated Inspection and quality control No inspection Quality control needs improvement Hold point not performed Inspection not required No hold point Foreign material exclusion during work needs improvement Inspection instructions needs improvement Inspection technique needs improvement Training and competency No training Understanding needs improvement Decided not to train Missed required training No learning objective Task not analyzed Continuing training needs improvement Instruction needs improvement Learning objective needs improvement Lesson plan needs improvement Practice/repetition needs improvement Testing needs improvement Misunderstood verbal communication Long message Noisy environment Repeat back not used Standard terminology needs improvement Standard terminology not used
  8. 8. 30 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin • The contractor HSE manager, • The contractor project director, • The contractor’s national construction gen- eral manager, and • The company incident investigation manager. Other administration and support staff were utilized to undertake specific research into the incident and the resultant communications. Team members were: • The company construction director, • The company area construction manager, • Two company environmental coordinators, • The contractor environmental engineer, • The company environmental superintendent, • The telehandler operator, • The health and safety representative (for the telehandler operator), Primary root cause Root cause descriptionb Supervision Preparation Selection of worker Supervision during work Fall protection needs improvement Lock out/tag out needs improvement No preparation Prejob briefing needs improvement Scheduling needs improvement Walk-through needs improvement Work package/permit needs improvement Fatigued Not qualified Substance abuse Team selection needs improvements Upset Inadequate job hazard/safety analysis Risk management Inadequate process hazard analysis Individual snap decision (quick decision made without assessing the risk) Preventive maintenance/repeat failure Equipment parts defective Preventative/predictive maintenance/not preventative mainte- nance for equipment No communication or not timely Preventative/predictive maintenance/preventative maintenance for equipment needs improvement Communication system needs improvement Late communication Turnover needs improvement No standard turnover process Turnover process needs improvement Turnover process not used Turnover less than adequate a All of these root causes were available as drop down options in the spill report forms. Individuals completing the forms were required to use the provided pro forma options, which also included “not applicable” (not listed in this table). b Additional primary root causes with no further or root cause descriptions (to tabulate): contractor safety, communications, human factors, management of change, incident and near-miss investigation, emergency response, natural phenomenon, ­auditing, leadership accountability, and prestart up safety review. Exhibit 2. (Continued)
  9. 9. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 31Root Cause Analysis of a Minor Spill The most common IBC is the one-time use cube (OTC) plastic composite IBC. This unit is a white/translucent plastic container (typically polyethylene) housed within a tubular stainless steel cage that is attached to a pallet. IBCs can be manufactured out of a number of different materials depending upon the needs of the ship- per and the legal requirements that must be met. In addition to the plastic composite IBC, IBCs are also manufactured out of fiberboard, wood, heavy gauge plastic, aluminum, carbon steel, and stainless steel. Heavy gauge plastic IBCs are made of reinforced plastic that requires no steel cage; they have a pallet molded into the bottom so the en- tire unit is manufac- tured as a single piece (Anonymous, 2014a). Communication Processes After project spill events that are considered large by the project’s standards (i.e., >1,000 L; similar to the one described in this study), the contractor and the operator companies prepared projectwide communications that are distributed to all project personnel. These are in the form of an email and a verbal description of the spill events, which is read out to all personnel at a pre- start event (i.e., at the beginning of a shift). “Les- sons learned” or “safety alerts” from spill events are shared at the contractor’s toolbox talks, which are held weekly on the site and provided to all personnel. This also occurred after the investiga- tion report was prepared in the current spill. Results and Discussion Background Information Smaller vessels used for handling refined pe- troleum products on projects such as those in Collection of Incident Data Data collection included one-on-one inter- views, review of project and procedural docu- mentation, employee training records, photo- graphs from the incidents, and procurement manifests and related documents. It also included the goods manifests, discussion with suppliers of the IBC, and licenses. The time of events and activities surrounding the incident were obtained and used to compile a timeline. Identification of Protective Systems in Place Protective systems are defined as software, hardware, or management systems that reduce the potential for having an incident or reduce the consequences of an incident. These include job safety procedures and HAZID documentation. The most commonly used procedures and docu- mentation on Australian construction sites are safe work procedures (SWPs), job hazard analyses (JHAs), and “Step Back 5×5s” (i.e., a quick prejob analysis). The investigation team analyzed all of the protective systems relevant to this event and those relating to it. Description of IBCs An IBC or IBC Tote or Pallet Tank was the type of vessel from which loss of containment occurred in the spill event in this study. An IBC is a single- use container designed for the transport and stor- age of bulk liquid and granulated substances (e.g., oil, chemicals, food ingredients, solvents, pharma- ceuticals). IBCs are stackable containers mounted on pallets that are designed to be moved using a forklift, a pallet jack, or a telehandler. IBCs have a volume range that is situated between drums and tanks, hence the term “intermediate.” The most common sizes are 1,040 L/275 gallons and 1,250 L/330 gallons (the 1,040-L IBCs are often listed as being 1,000 L). Cube-shaped IBCs give a particu- larly good utilization of storage capacity compared with palletized 205 L drums. IBCs can be manufactured out of a number of different materials depending upon the needs of the shipper and the legal requirements that must be met.
  10. 10. 32 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin northwest coast of Western Australia, Australia. Much of the island is covered by spinifex grass- lands, which provide important habitat for a variety of wildlife. While the main feature of the island’s geography is the undulating limestone uplands, the island is surrounded by a mixture of sandy beaches and rocky shores, low cliffs, dunes, salt flats, and reefs. The landscape is arid, and the climate is usually hot and dry. Most of the annual rainfall occurs during the cyclone season between November and April and amounts to approxi- mately 320 millimeters (mm) per year. Because of its high conservation value, the island was declared a public reserve for flora and fauna and has been classified as a “Class A” Nature Reserve for the past 100 years. Using process chemicals, such as petroleum hydrocarbons, on the project in such a sensitive environment is a high-risk activity in relation to potential environmental harm in the event of an uncontrolled release. This sensitivity was of critical importance in the study, as an important part of the project’s overall approval was dependent upon the project, minimizing all chemical and petroleum hydrocarbon spills anywhere on the site (with the exception of within secondary containment). Employee’s (Machine Operator’s) Background The investigation revealed that the telehan- dler operator who was involved in the spill event had more than 10 years of experience in forklift operation, held the relevant high-risk license, including successful completion of the verifica- tion of competency (VOC), and onsite challenge test training. The operator commenced working for the contractor on the project in November 2010, almost two years prior to the spill. The operator conducted various tasks in the course of employment, and carried out this specific task of handling IBCs for the workshop site on previous occasions. There was a JHA for opera- tion of the telehandler, which was signed onto this study include ISO containers and IBCs. The use of IBCs to transport products to construction sites poses its own risks, including those to safety or personnel and potential environmental impact upon rupture. In the current project, up to 50 IBCs per week were entering the site containing lubricants, various chemicals, and hydraulic fluid. Based on estimates from several resource projects in progress, there could be as many as a million such IBCs in circulation in Australia alone. These vessels are vulnerable to damage because of in- tense handling by tined equipment, as their rela- tively flimsy design can allow easy puncture unless very specific controls are in place—as the results of this study later show. It is important to note that there are no previous studies in the scientific literature reporting spills from IBCs, fur- ther highlighting the need to publish the re- sults of this study. IBCs have been used on the project since project commencement to transport various types of bulk fluids as well as for temporary storage on the project site. The chain of custody with IBCs commences from the point of manufacturer to the supplier(s), continuing to contractor and company base supply chains (in accordance with quarantine requirements) prior to arriving on the project site. IBCs are transported to the project in unbunded or bermed sea containers. When they arrive on the project site, the IBCs are kept in the contractor’s secondary containment area when in storage, usually in self-bunded or bermed contain- ers. IBCs are used by the contractor for transport and storage of various chemicals, and they were found to be handled by telehandlers or forklifts. Site Description The construction site was located on a small island located approximately 60 km off the The use of IBCs to transport products to construction sites poses its own risks, including those to safety or personnel and potential environmental impact upon rupture.
  11. 11. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 33Root Cause Analysis of a Minor Spill before the project was started. This finding showed that the HAZID process did not pick up the potential problem of damaging and handling damaged IBCs on the project. This was critical as its absence as a potential risk may have diverted attention away from IBCs as a process safety risk. In his studies on root causes, Hendershot (2007) points out the importance of design engineers considering the impacts of their decisions as early as possible in a construction project and to avoid project designers falling in the mind- set trap of, “it has always been done that way,” when developing the final construction designs. The findings from this study, which describe the risks from IBCs, which were originally deployed because of the perception that the risks from these were very low, will be fed back into the knowledge base for other resource project design engineers in- volved in developing remote projects. As part of the investigation, structural integ- rity issues were found with a range of other IBCs across the project (i.e., with other contractors), with evidence of dents, damage, and obvious accident occurrences with IBCs also used to transport lubricants and chemicals to the project. None of the events that led to this damage was reported on the project, and the events were first discovered and reported as part of the investiga- tion of this study. Sequence of Events Prior to Spill Event A timeline was constructed to summarize ac- tivities before, during, and after the event. These details are presented in Exhibit 4. The timeline revealed that the operator of the telehandler by the operator on the day of the spill. The contractor had a project SWP for telehandler operations, and he had received the procedural VOC training for the task delivered by an expert operator. The operator stated that there were no time pressures associated with the task or any other factors that made the task different on the day of the event. The operator attended the contractor’s return to work session, as this was the operator’s first day of swing after returning to the project site. In summary, the operator was fit for work. Implications of the Assessment of the Protective Systems The investigation team analyzed the protec- tive systems relevant to this event, and the result- ing evaluation is summarized in Exhibit 3. Although there was an extensive array of con- trols for this activity, this was not uncommon for work processes on this project. Analysis showed that there were no inspection requirements in any of the project documentation in relation to IBCs or related items in transport or for storage, particularly inspections to ensure the identi- fication of vessel integrity. Of the 21 controls identified and thought to be relevant to the spill incident and investigation, 10 were deemed to be ineffective, and five critical controls that should have been in place were not in place. Also, of the 21 separate protective systems, processes, and controls in place at the time of the spill, it is noteworthy that only five were categorized as being higher up the safety hier- archy than “Administrative.” The use of IBCs on the project is, in fact, a result of early design considerations that involved substituting pallet- strapped 205-L drums of lubricant, the latter of which were considered to pose an unacceptable risk from a safety and environmental perspec- tive. A HAZID process was used—as is common in industry—and that examined potential risks Structural integrity issues were found with a range of other IBCs across the project (i.e., with other contractors), with evidence of dents, damage, and obvious accident occurrences with IBCs also used to transport lubricants and chemicals to the project.
  12. 12. 34 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin Exhibit 3. Evaluation of the Protective Systems and Controls Relevant to the Spill Incident Protective system Type of control based on hierarchy In place? (Y/N) Effective?a (Y/N) Comments IBC: Selection and ­assessment of type, design, and structural integrity Elimination/ substitution N N Other IBC units (from another areas, which are currently or had been in use prior to incident on the project) were identified as damaged during the ­investigation. Self-bunded sea ­container Isolation/engineering N N These containers are not usually used for transport. These containers are typically used for chemical storage on the project. Spotter Isolation N N JHA referenced use of spotter if ­required (when handling IBCs with tined equipment). Operator assessed spotter was not required. Note: The use of spotter may have ­influenced the outcome. Work method ­statement Administrative N N Not developed for this particular task. Plant acceptance HSE checklist Administrative N N No document was available for the ­investigation. SWP Administrative Y N SWP for forklift operations is not ­specific on when a spotter is required. SWP did not identify potential hazard of obstructions on underside of IBC. JHA Administrative Y N Operator signed onto JHA. JHA did not specify when a spotter is required. JHA did not identify potential hazard of obstructions on underside of IBC. Communication of ­similar incidents Administrative Y N Operator not aware of previous related incidents associated with IBC holding an acid (hydrochloric acid spill of similar magnitude, incident on project site on March 19, 2011). IBC inspection— Prior to lift Administrative Y N General area around IBC inspected, inspection did not include underside of IBC and metal plate. Sea container ­stacking/ filling Isolation Y Y Correct use of strapping. “Step back 5×5” (i.e., prework risk analysis conducted by all em- ployees on project site) Administrative Y Y Four step back 5×5s were completed by the operator throughout the day of the incident. Telehandler prestart check Administrative Y Y Prestart check was conducted; no issues identified with telehandler. Inspection of area (sea container) prior to lift Administrative Y Y Inspection took place, did not include underside of IBC; according to the JHA there was no requirement to do so. Supervision Administrative Y Y Supervisor on call and involved in step back 5×5s; supervisor not required to be present for each lift. Communication Administrative Y Y Communication between operator and workshop superintendent in planning the move of the IBCs and the incident response.
  13. 13. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 35Root Cause Analysis of a Minor Spill Protective system Type of control based on hierarchy In place? (Y/N) Effective?a (Y/N) Comments Training: JHA, hazard identification, RTWc Administrative Y Y Personnel developing JHAs receive feedback from HSE advisors. Hazard identification toolbox April 18, 2012. Half-day HAZID course.b RTW training. Training: Spill response Administrative Y Y Occurs on a six-month basis for all site personnel. Random drug and alco- hol testing Administrative Y Y Process in place and effective Control of spill Administrative/ protective equipment Y Y Swift and effective control. Containment Administrative/ protective equipment Y Y Earthen bund quickly constructed. Cleanup Administrative/ protective equipment Y Y Cleanup required inspection after soil excavation a The investigation team made an assessment as to whether the control was effective. b HAZID is a hazard identification process involving a cross-section of stakeholders identifying potential hazards prior to project initiation. c RTW, return to work. Exhibit 3. (Continued) tines before extending the telescopic boom. The operator then returned to the telehandler and commenced extending the telescopic boom into the IBC pocket (i.e., pallet base/belly) to engage the lift. (Note that this function is achieved by the operator holding in the button to extend the telescopic boom.) The operator commenced extending the boom and then heard a “popping” noise and observed the IBC collapse immediately. The operator witnessed oil spilling onto the ground. The IBC had not been lifted off the ground at this stage. The operator immediately exited the telehandler and went to the workshop where he notified the workshop superintendent of the spill. The workshop superintendent and the op- erator returned to the location immediately with two large spill kits. The workshop superintendent directed the operator to tilt the IBC upward to prevent any further spilling (the tines were still placed within the pockets of the IBC). The IBC was propped by wooden chocks, and telehandler was removed and parked close by. was not negatively impacted prior to the inci- dent. Furthermore, there were no other adverse ­conditions impinging on the activity of moving the IBC in question. Outcomes From the Incident On the day of the incident, the operator had undertaken various tasks associated with the use of a telehandler on the construction site. At ap- proximately 14:45 hours (h), the operator was called on the ultra high frequency radio to go to the workshop to unload a sea container. Upon arrival, the operator went to the workshop of- fice and obtained direction as to where the items from the sea container were to be positioned. The operator removed the first two pallets of heavy vehicle parts from the sea container and placed them at the southern end of the workshop. The operator returned to commence removal of IBCs from the sea container. The operator commenced the activity by placing the tines partially into the pockets of the IBC and then exited the machine to check the alignment/position of the fork
  14. 14. 36 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin Exhibit 4. Timeline of Events Related to the Oil Spilla Timeb Description of events 6:20 Operator returns to work, first day of swing 6:30 Operator attends prestart meeting 7:00 Operator return to work meeting (normal meeting that occurs when personnel returning to project site) 7:45 Assigned task to operate telehandler 7:50 Operator signs onto JHA for activity 7:55 Operator completes Step Back 5×5 for first assigned task 7:55–8:00 Prestart conducted on telehandler by operator 8:00–10:00 Operator moved pallets for plumbers 10:00 Work break 10:45 Operator completes postwork break Step Back 5×5 10:45–12:00 Operator continues performing various lifts with telehandler 12:00 Lunch break 14:15 Operator completes postlunch Step Back 5×5 completed 14:45 Operator was called on radio and directed to unload sea container at workshop 14:50–15:00 Operator assessed contents of sea container and task 15:00 Operator completes Step Back 5×5 at workshop, for unloading the sea container 15:00–15:15 Operator contacted workshop office to ascertain where pallets were to be positioned once ­removed 15:15 Operator moved two pallets of spare parts from the sea container in front of IBC, and placed in nominated area workshop 15:15–15:25 Operator released straps securing IBCs within sea container Operator positioned tines of telehandler into pockets of IBC (approximately 20–100 mm in pocket) Operator exited telehandler to check positioning of tines Operator reentered telehandler to commence extending boom and tines into IBC pocket 15:25 Operator heard a “popping” sound, saw IBC collapse quickly and witnessed oil spilling onto the ground 15:25–15:30 Operator exited telehandler and immediately notified workshop superintendent of spill Workshop superintendent and operator immediately returned to location with spill kits to ­commence control IBC repositioned by operator using the telehandler as instructed from workshop superintendent to eliminate any further leaking of oil from IBC 15:30 Workshop superintendent notified contractor’s environmental engineer of spill 15:30–15:40 Loader available in the area commences construction of an earthen bund to contain spill 15:40 Contractor’s environmental engineer arrives at the area, reviews and completes spill report 16:15 Company environmental coordinator arrives on scene, earthen bund is in place 16:30 Pooled oil pumped out of low point in earthen bund. This was then disposed of as hazardous waste 17:40 Contractor submitted spill report to company. Spill report contained all factual details of the spill 18:00 Soil placed over area affected by oil spill to assist in containing the spill. All of the impacted soil was excavated and disposed of the following day 18:30 Incident entered into company database and added to other HSE data from the project 19:00 Investigation commenced a Documentation was collated on the operator’s training attainment dates, other incidents that operator was involved in, and other incidents involving IBCs from prior to the day of the incident. b Time on the date of incident.
  15. 15. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 37Root Cause Analysis of a Minor Spill from pro forma root cause descriptions that the company had developed over several decades (refer to Exhibit 2). The rational for this was that there was a defect with the IBC, which caused the path of the fork tines to be obstructed, leading to tearing of the base plate and subsequent punctur- ing of the IBC. Furthermore, there was no specific inspection process during the chain of custody for personnel to inspect the undersides of IBCs for faults or deformities in the metal base plate in which the fork tines could be caught on. A gen- eral inspection only around the body of the IBC and around the base was undertaken, and this was not sufficient to identify the internal damage to the IBC pallet base plate. There were two contributing factors to the cause of the incident: 1. The design of the IBC cage did not anticipate condi- tions on the project. The IBC is designed to be moved a limited number of times. This was confirmed by a lubricant supplier, who informed the author that IBCs are often referred to as “one-trip cubes,” hence the petroleum industry term OTCs; and 2. The use of a spotter may have prevented the outcome, as the spotter may have been able to identify the deformity in the pallet base plate. The rigor of the inspection required to have picked up such a deformity in the base plate of the pallet would have required the use of a flashlight, and the inspector would have had to have leaned down and looked into the pal- let slot and known what to have looked for. Exhibit 6 illustrates the configuration of the impacted IBC at the time of the spill. From the close inspection of the IBC base, deformed An earthen bund or berm was quickly con- structed to contain the spill, and pooled oil was vacuumed out of a low point from the soil surface using a truck with the capability of vacuuming a spilled agent. Cleanup of the affected area was in progress at this time (i.e., 15:30–15:40 h). The investigation team inspected the area and observed that the ground condition around the sea container was flat, and there were no vis- ible obstructions, which could have affected the alignment of the tines with the IBC pallet. An in situ inspection of the telehandler confirmed that the tines were not skewed or misaligned. The data summarized in Exhibit 3 were ob- tained as part of the investigation process. Imme- diately following the incident, the operator, work- shop superintendent, and environmental engineer inspected the site. This team proceeded to gather evidence for the purpose of the investigation. Of critical importance in the incident inves- tigation was the finding that the fork tines had not pierced the plastic bladder of the IBC directly. The investigation determined that the fork tines had caught on the underside of the metal base plate. The base plate was subsequently distorted and pushed inward as the telescopic boom of the telehandler was extended. The distorted metal of the base plate punctured the IBC causing it to im- mediately discharge its contents—and causing the “popping” sound recorded by the operator. The evidence supported this conclusion (see ­Exhibit 5) and is discussed in the following section. Findings From the RCA This section reports the detailed and thorough findings from the RCA, a result of the extensive collaboration achieved through 12 experts from the project contributing their efforts to finding a root cause. The primary root cause of the spill was determined to be “Inspection/Quality Con- trol—Inspection and Acceptance Process is Not in Place or Adequate.” This root cause was selected Of critical importance in the incident investigation was the finding that the fork tines had not pierced the plastic bladder of the IBC directly.
  16. 16. 38 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin This author’s research on root causes of fluid spills from plant and equipment has shown that the underlying reasons for the majority of fluid spills is the failure of hydraulic systems, par- ticularly hoses and their fittings (Guerin, 2014). Other researchers have reported on the causes of spills that occur during the operation of oil and gas facilities (Al-Mansouri & Alam, 2008), although such research is not directly related to IBCs or small-sized vessels. These researchers came to the conclusion that the majority (more metal had caught on the IBC bladder to cause the spillage. This finding was established only after the damaged IBC was inverted and closely inspected. The investigation also revealed that the tines of the telehandler had sufficient clear- ance to enter the base of the impacted IBC under normal conditions where no such metal deforma- tion is expected (Exhibits 7–9). Through an in- verted fishbone or Ishikawa diagram, Exhibit 10 graphically describes the outcome from the RCA used during the incident investigation process. Exhibit 5. Data Collected to Verify the Cause of the Oil Spill Incident Data description Comments Authority to operate/inspect/maintain for operator for the telehandler Manitou MT 1440 dated May 16, 2011 and stating one-year experience with the machine Discussed by investigation team Operator’s license to perform high-risk work issued on October 6, 2010 expires on October 6, 2015 Discussed by investigation team VOC for operator May 10, 2011 Discussed by investigation team Step Back 5×5—7:45 am May 3, 2012 for “operating telehandler” Conducted by operator Step Back 5×5—10:45 am May 3, 2012 for “loading of truck with roof sheeting and steel…” Conducted by operator Step Back 5×5—14:15 pm May 3, 2012 for “driving forklift” Conducted by operator Step Back 5×5—15:00 pm May 3, 2012 for “unloading sea container” Conducted by operator OEM’s health and safety procedure “manual forklift trucks and powered pallet movers” Note Prestart on telehandler machine Discussed by investigation team Contractor’s SWP for forklift operations Note JHA for telehandler April 20, 2012 Signed onto by operator on May 3, 2012 Inspection of pierced IBC Workshop superintendent stated that new IBCs are requested from the supplier Witness statement of telehandler operator Formal statement obtained Witness statement of crane supervisor Formal statement obtained Witness statement of workshop superintendent Formal statement obtained Witness statement of mechanical supervisor Formal statement obtained Photographs taken one to two hours following the incident Viewed and discussed by investigation team Additional photographs taken of incident area and other used IBC units Refer to Exhibits 6 to 15 in this text Multimodal dangerous goods form, completed for the sea container May 2, 2012, supply base Confirms that “the goods have been packed/loaded into sea container in ­accordance with the applicable provisions” Photographs taken of IBC immediately after it was loaded into the sea ­container at supply base prior to shipment to quarantine checking Shows that IBC was handled at supply base as part of quarantine requirements Logistics notification request DG standard, sea freight May 2, 2012 Note Contractor quarantine inspection checklist—packaging May 2, 2012 Quarantine-specific checks only, does not include inspection of integrity/condition of IBCs Sea container manifest Reviewed by investigation team members
  17. 17. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 39Root Cause Analysis of a Minor Spill The root cause in this study of “inspection in- adequate” is similar to ineffective quality control (described in “vi” above). No other studies have specifically detailed causes of spills from han- dling of the types of chemical containers (IBCs) described in this study. Comparing the RCA Method With the “5 Why” Analysis The RCA method using the fishbone, cause- and-effect, or Ishikawa diagram, is used in the literature for analyzing large spills because the underlying causes of such incidents can be than 90%) of these leaks and spills are due to one or a combination of potential root causes such as: (i) Aging facilities, (ii) Equipment failure, (iii) Construction defect, (iv) Accidental damage, (v) Defeat/bypassing of protective system, (vi) Ineffective quality control, (vii) Operational deviation, (viii) Design fault, (ix) Blow out of oil well, and (x) Human error. Exhibit 6. Views of Damaged IBC Note: Top left: Timber and tines of the telehandler used to hold punctured IBC in tilted position (note bladder has collapsed or on itself). Top right: Underside of IBC showing impact of damaged metal (belly) plate and location in which the tines are inserted. Bottom left: Underside of IBC showing point of puncture/tear on IBC bladder. Bottom right: Undamaged IBC behind damaged IBC (in sea container) for comparison and spill absorbent material in front.
  18. 18. 40 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin involves asking why, up to five (or even more) times, a particular event occurred in the series of events that led to an incident. In simple terms, once asking the “Why” question yields no fur- ther reasons for the cause(s) of an incident, then the root cause is determined and communicated. This is why, on many commercial construction and resource projects, the shorter and less in- volved process of the “5 Why” method is com- monly used instead of an RCA. The advantage of the “5 Why” method is that it can be done using limited resources (usually by an individual or small team). However, it does rely on profes- sional judgment or practical experience to ensure that the line of questioning is appropriate for the event under investigation. A qualitative com- parison of these two types of root cause assess- ments is given in Exhibit 11. In the majority of cases, this depth of analysis is “fit for purpose,” enabling the business to learn quickly and keep determined with a high degree of confidence. The results from these analyses are more likely to be trusted (though not always) for implementa- tion, and, therefore, they are more likely to be considered to help prevent recurrences of such incidents in other sites or settings. However, as in this study, the thoroughness required by the RCA method means that a relatively large num- ber of people with a range of in-depth skills must be brought in on the investigation. Typically, several experts may be required for several hours. One of the problems with the application of RCA methodology is that it is often only applied to relatively large or major spills. Commercially, RCA approaches are marketed under various trade names, such as ICAMM, Taproot, and the like, and require several days of training to gain proficiency in the detailed methodology. A shortened version of the RCA is called the “5 Why” method (Pojasek, 2000). This method Exhibit 7. Views of Work Site at Location at the Time of Spill Note: Top left: Punctured IBC in location at the time of spill with telehandler in proximate location. Top right: Tines of telehandler involved in the spill. Bottom left and right: Dimensions of tines of telehandler indicating that there was sufficient clearance for insertion of tines into IBC base without any damage expected. Distal end on bottom left and load end on bottom right.
  19. 19. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 41Root Cause Analysis of a Minor Spill thorough RCA approach was used, ensuring that the needed resources would be employed to generate sufficient confidence in the result of the analysis to enable the needed changes to be made on the project (see the following section on Development of Corrective Actions). Cost Implications Although the cost of safety model has been prevalent in the mainstream safety literature for the past decade or more (Behm, Veltri, & Kleinsorge, 2004), corporations have not widely adopted the approach, nor is any form of finan- cial analysis of safety or spill incidents commonly going, business as usual, plus locking in the re- quired prevention strategies. However, when the “5 Why” method is used to determine underlying causes, this means that full analysis and understanding of the root causes and contributing factors are not always thoroughly determined. This, in turn, means that changes that are made as a result of the findings of a “5 Why” analysis might not provide ad- equate prevention measures. As a consequence, the actual root causes are not necessarily properly identified and communicated as widely as would be desired to reduce fluid spills. For this reason, it was important in this study that the more Exhibit 8. A Side View of the Base of the IBC; Pallet Showing Dimensions Relevant to the Telehandler Interaction Exhibit 9. Location of IBC Relative to Rest of the Sea Container Contents and the Telehandler in the Delivered Container
  20. 20. 42 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin Exhibit 10. The Results of the RCA “Why Tree” for the Oil Spill Incident
  21. 21. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 43Root Cause Analysis of a Minor Spill component contributing to the spill). Given that on this project, the same contractor had three- to-four incidents of such magnitude (at the time the data were collected for this study), total costs from spill events are estimated conservatively at AUD 1–2 million when all project contractors— up to 20 additional and separate entities—are considered. Development of Corrective Actions Based on the findings of the study, numerous corrective actions were identified and were rec- ommended to be implemented by the contractor and the company. The hierarchy of controls was applied to the corrective actions, and the actions were numbered from one to six. While effort was directed at elimination of risks, substitution, and engineering, the majority of the implemented controls to control risks from spillages of bulk lubricants and chemicals were administrative in nature. As previously mentioned, the deci- sion to use IBCs stemmed from the early design stages, where the risks perceived from using 205 L drums strapped to pallets were considered to be too high. practiced. As a result, companies have tended either to underinvest in preventive and detection efforts, or to overspend, putting controls in place that outweigh the risks from failure. No compa- rable cost breakdown data were available from the literature for assessing the current incident. An estimate was compiled for the break- down of the costs of the current spill and the subsequent investigation, and these are given in Exhibit 12. The cleanup of the contaminated soil and the commitment of time by the contrac- tor’s environmental engineer were the single larg- est cost items from the spill incident. The cleanup involved the rapid deployment of earthmoving equipment away from other construction jobs on the project, containment of oil using earthen bunds (see Exhibit 13), and then removal, and disposal of the contaminated soil. This was fol- lowed by reporting of the incident and replace- ment of the lost product. This cursory analysis illustrates that the immediate knock-on effects of such a spill can have a material impact on a proj- ect’s budget. The analysis also does not attempt to quantify the lost productivity from equipment and machinery downtime (impacted by the failed Exhibit 11. A Qualitative Comparison of the “Why Tree” (RCA) and “5-Why” Process for Determining Root Causesa RCA “5-Why” Detailed, time consuming Requires extensive training for personnel to lead investigation (several days) High-level, rapid Short course (one to two hours) required Thorough, extensive collaboration in decision making, ­involving a broad range of experts from diverse backgrounds Brief, with minimum of consultation/collaboration to decide on the causes, designed to be conducted by individuals or small teams Requires significant level of resources (requires a team of at least five to six) Can be done using limited resources (can be done by an individual or small team) Provides a robust analysis of the root causes and ­contributing factors Relies on professional judgment to ensure the line of questioning is appropriate for the event Results can be relied upon to change business process or systems Limited reliance can put on the results of a single analysis Is applied in commercial contexts where a significant ­injury, death, or major environmental incident has occurred Is applied in commercial contexts as a common method for RCA where an incident investigation is required a This comparison has been developed for practitioners and is based on the author’s experience and professional judgment (Ishikawa, 1990).
  22. 22. 44 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin Exhibit 12. An Estimate of Financial Costs of the Spilla Cost element Description Value (AUD) Loss of product 1,000 L of high-quality lubricant 5,000 Time commitment of ­environmental engineer 60 hours of time committed to remediation, ­investigation, and close out 9,600 Soil cleanup Operation of a wheel loader (one to two hour) and supervision/disposal of 10 t contaminated soilb 11,000 RCA Preparation, delivery, and review 3,000 Interviews Meeting with all stakeholders involved 640 Engagement of suppliers Discussions regarding IBC and its history 240 Reporting Preparation of entire investigation report and ­presentation to operator 6,500 Administration Collection of all required documentation, ­communication of findings 2,000 Total 37,980c a Conservative estimates based on pay rates of approximately AUD 160 per hour for an engineer. b The cost of disposal of contaminated soil on the project site was approximately $ AUD 1000 per ton. c It excludes downtime or lost opportunities for the contractor. Exhibit 13. View of Spill and Cleanup Note: Top left: Spilled oil migrated out of unbunded sea container to soil around the front of container. Top right: Floor of container showing the absence of internal bunding. Bottom left: Rear of container. Bottom right: Side of container showing earthen bund erected to limit flow of oil, minimizing safety and environmental impacts. All contaminated soil and contaminated absorbent materials were removed and disposed of as contaminated material within 24 h of the spill event occurring.
  23. 23. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 45Root Cause Analysis of a Minor Spill Exhibit 14. View of Engineering Controls Note: Top left: Engineering control, that is, IBC cage, put in place as a result of the spill investigation by contractor at the point of receival of IBCs onto project at the supply base. Top right: The second engineered control, a base plate manufactured on site to minimize impacts of tines on IBCs. Middle left: Other IBCs identified on the project site, that is, in the jurisdictions of other contractors, after the investigation, showing damage to top of IBC other IBCs identified on the project site. Middle right: after the investigation showing damage to base. Bottom left: Other IBCs with extensive damage to base. Bottom right: Damage to the side of another IBC from the project.
  24. 24. 46 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin visual inspection by the spotter, the spotter will notify the area supervisor to assess and determine the need for the contents of the IBC to be decanted into another IBC unit in good order prior to lifting or moving the damaged IBC. IBC units that are identified as damaged were tagged out to prevent the use of a forklift/telehandler to pick them up. Several such damaged IBCs were identified across the project site (Exhibit 14). The im- plications of this change to the inspection regime are that it may expose the inspection personnel (or spotters) to the added risk of back injury/strain resulting from repetitious leaning down to inspect pallets, and this risk will need to be monitored on the project. 4. Numerous other administrative controls were upgraded on the project as a result of the investigation. All relevant JHAs and SWPs within contractor, subcontractors, and con- tractor offsite and supply bases were updated to include: • Mandatory use of spotter for the transfer of hydrocarbons or hazardous materials; • Specific reference to detailed inspection of the bases of IBCs, including the use of a flashlight to enhance visual inspection of underside of The corrective actions are: 1. Design, construct, and use of a protection plate (an engineering control) was employed to prevent fork tines from puncturing IBC units as they are handled, particularly on major projects where there are numerous points of handling of these vessels. The design and construction of such a plate are provided in Exhibits 14 and 15. In addi- tion, as a result of the incident, the contrac- tor began trialing the use of a metal cage for storing IBCs during shipment and transport (Exhibit 14). A series of such plates were manufactured on the project site and have been deployed across the contractor’s opera- tions wherever IBCs are being handled. 2. Undertake chain-of-custody inspections of IBCs containing lubricants and other chemi- cals to identify and reject any damaged IBCs with metal base frame deformities from the supplier’s to the contractor’s supply base. 3. Undertake inspections of all IBCs that are re- quired to be moved onsite (across the project) by telehandlers to identify any other potential metal base frame deformities. When an IBC is identified as damaged underneath from the Exhibit 15. Design of Plywood Protection Board (or Base Plate) for Handling IBCs Notes: 1. Height of the fork lift tine slots not to exceed the height of the IBC frame/skid slots 2. Cut outs for hand holds 3. Tine spacing thickness 400–500 mm
  25. 25. Environmental Quality Management / DOI 10.1002/tqem / Summer 2015 / 47Root Cause Analysis of a Minor Spill quarantine requirements), it would appear that their construction is not likely to be suitable for multiple lifts with a forklift or telehandler. There are four points of entry in which the fork tines can be entered into the base of IBCs. Two of these entry points create potential obstruc- tions from the protruding support strut under the metal base plate on which the fork tines can be caught. It is necessary to check and/ or reject IBC units with damage during chain of custody, paying particular attention to the underside/metal base to ensure that there are no obstructions. Therefore, it is recommended that quality assurance checks for verifica- tion of IBC condition at the various stages throughout the chain of custody should be implemented. There is no protec- tion plate on these IBC frames to eliminate fork tines from making contact/puncturing IBC units (bladders containing product). Also, this particular type of IBC unit has no self-bunding to capture spilled product. Other damaged IBCs around the construction site were identified and marked as potentially unsafe so as to avoid similar incidents. It is also recommended that the use of a spotter be implemented to further minimize the risk of future spills. It should not be assumed by the handlers of these vessels that their lifts will be restricted to a certain “low” number. Rather, damage to these IBCs should be expected and looked for as they arrive into the areas under the handler’s operational control. Given that the RCA process can be predictive, this knowledge of the vulnerability of commonly used IBCs can be used by IBC handlers to help eliminate the type of spill reported in this study. IBC units in sea containers for possible dam- age to metal base plate; • Use of a protection plate to prevent tines from puncturing the IBC unit; • Prior to lifting or moving IBCs what are iden- tified as damaged underneath from the visual inspection by the spotter, the spotter will no- tify the particular area supervisor to assess and determine the need for the contents of the IBC to be decanted into another IBC unit; and • Identified damaged IBC units will be tagged out to prevent forklifts/telehandlers from in- teracting with damaged IBCs. These changes were incorporated into the contractor’s HSE systems and wider business. 5. Developed a toolbox talk package for rele- vant teams within the contractor’s workforce and communicated the lessons learned from the incident, including new requirements, which were added to inspect the underside of IBCs, and amendments to updated JHAs and SWPs. 6. Communications were prepared after the completion of the investigation, and a site- and project-wide alert was prepared and dis- tributed. While these recommendations are specific to the project site of this study, the implications for other sites and projects are much broader, given the popularity of the use of the 1,000-L IBC for supplying and distribution of lubricants, chemicals, and other hazardous materials across resource construction projects. Conclusions General In designing an IBC that is fit for pur- pose (i.e., of lightweight nature and will meet In designing an IBC which is fit for purpose (i.e., of lightweight nature and will meet quarantine requirements), it would appear that their construction is not likely to be suitable for multiple lifts with a forklift or telehandler.
  26. 26. 48 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin sustainable development by reducing environ- mental impact (Guerin, 2009). Engagement with plant and equipment and chemical suppliers by oil and gas companies and/or their civil contrac- tors would be a productive next step. There is also scope for greater involvement of broader cross-company (or site) personnel to collaborate in such investigations. Similarly, there is an opportunity for compa- nies to have their HAZID processes or assessments reviewed by external parties to ensure that these assessments are not compromised by limited (or inwardly focused) thought patterns by company personnel. More broadly, there are opportunities to reeval- uate the role of RCA in commercial applications to undertake spill investigations. In addition, there are opportunities for industry to consider adopting improvements to the RCA process to make it less complicated and more streamlined without losing its ability to derive actual underlying causes of incidents, as other safety professionals (Ferjencik, 2014) suggest from their extensive work done on the improvement of RCA methodology. References Al-Mansouri, F. A. A., Alam, M. A. (2008). Sources of hy- drocarbon leaks spills in upstream oil industries—Its potential reasons preventive measures. In Proceedings of the 9th International Conference on Health, Safety and Environment in Oil and Gas Exploration and Production 2008—“In Search of Sustainable Excellence (Document ID SPE=111725-MS).” Nice, France: Society of Petroleum Engineers. Altham, J., Guerin, T. F. (2005). Cleaner production. In V. Rajaram, S. Dutta, K. Parameswaran (Eds.), Sustainable min- ing practices (pp. 93–120). London, UK: A.A. Balkema (Taylor Francis Group Plc.). Anonymous. (2014a). Intermediate bulk container. Re- trieved from http://en.wikipedia.org/wiki/Intermediate_bulk_ container Anonymous. (2014b). Root cause analysis. Retrieved from http://en.wikipedia.org/wiki/Root_cause_analysis Behm, M. (2005). Linking construction fatalities to the design for construction safety concept. Safety Science, 43(8), 589–611. Behm, M., Culvenor, J. (2011). Safe design in construction: Perceptions of engineers in Western Australia. Journal of Health and Safety Research and Practice, 3(1), 9–23. A cursory examination of the costs arising from the spill suggests that such events are likely to have a material impact on the costs for the project. As such, ongoing attention will need to be given to ensuring controls are kept effective and communicated to all contractors across the project. Insights and innovation in this project were derived from the application of rigorous and di- verse thinking and viewpoints during the inves- tigation—even though the event was a relatively minor spill in relation to large industry spills. By conducting the RCA, the “unusual” (or unex- pected) root cause was identified (i.e., the inter- action of a forked tine with deformed pallet base plate), which would most likely have been over- looked unless a high level of rigor was applied to the investigation. This finding subsequently drove change in the project such that a more thorough inspection process is now used to check the underside of IBC pallets (belly/base plates). The greater level of investment in this particular spill incident investigation, compared with the commonly used “5 Why” method, has enabled reduced spill incidents from damaged IBCs and the subsequent (negative) multiplier effect such spills have on operational costs. Further Research As with all innovations or change in envi- ronmental management, adoption depends on, among other things, communication to the in- fluential stakeholders (Guerin, 2001). Commu- nicating the findings of this study to vendors of the equipment assessed in the study to determine the merit of integrating design changes to allevi- ate spills from new equipment or other supplied items could provide an opportunity for further research. The author has previously described the critical role that petroleum hydrocarbon suppliers to the resource industry can play in enabling the resource sector to achieve its goals for
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  28. 28. 50 / Summer 2015 / Environmental Quality Management / DOI 10.1002/tqem Turlough F. Guerin Turlough F. Guerin is a professional environmental manager currently managing the approvals and compliance programs for First Solar’s EPC business in Australia, overseeing the construction of several solar PV power stations in Australia. His career has spanned soil and groundwater assessment and remediation for Rio Tinto and Shell, contractor compliance and assurance management for Chevron, managing the sustainability portfolio for Australia’s largest telecommunications company, Telstra, and consulting to Levine-Fricke-Recon, ICF Kaiser Engineers, and Motorola. He received his bachelor’s degree in agriculture and undertook postgraduate studies and research into the degradation of chlorinated pesticides in farming soils, sediments, and waterways.

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