Aesica Pharmaceuticals Toxic Chemical IncidentIZABELLA FRYZE, CORRIE BOWES & SHANE CLOHOSEY

Aesica Pharmaceuticals toxic chemical incident

Worker from Tyne and Wear left fighting for life after 7 litres of bromine was sprayed on him as he was removing cables from a valve connected to pipework at Aesica Pharmaceuticals in Cramlington, England.

The worker suffered from severe skin burns, a damaged eye and spent 48 hours in a life-threatening condition after he inhaled the substance.

Some pipework and valves were left suspended on the bellow, it allowed movement in the pipework, but they’re not weight-bearing

The bromine tank failed it’s insurance inspection, but the pipework at one end remained connected for 5 years to fill a adjacent tank with bromine, which made it contaminated. The bellows failed when the worker tried to remove these cables.

The reasons to investigate an incident

Investigating an accident gives us an answer to two important questions.1. How did it happen? 2. Why did it happen?This helps to: Prevent the same accident from happening again in the future Identify the faulty equipment or routine Make workers feel safe, reduce worker compensation costs and injuries Remove hazards from the environment Obtain information for insurers, reports

Useful models

Reason Human Error Taxonomy

Swiss Cheese Model SHELL Human Factor Model

Reason Human Error Taxonomy

Reason’s Human Error Taxonomy and Aesica Pharmaceuticals

Slips: right idea, wrong action- Aesica Pharmaceuticals postponed the replacement of the tank for 5 years after failing the inspection, it could have been replaced after the inspection.

Lapses: forgetting something- Aesica Pharmaceuticals forgetting the bellows aren’t designed to be weight-bearing.

Mistakes: missing information- Aesica Pharmaceuticals left the pipework at one end of the tank connected filling the adjacent tank with bromine and left it contaminated. The bolts on the bellows were corroded and were likely to rupture under stress. Bromine pipework which could possibly become contaminated with bromine were poorly supported. Pipe work hanging on bellows which weren’t weight bearing.

Reasons Human Error Taxonomy and Aesica Pharmaceuticals

Routine violations: intentional. The tank was left working for 5 years after failing the inspection instead of replacing it after the inspection. The bolts on the be

Situational violations: intentional. The insurance inspection required the removal of short sections of pipework. Some pipework and valves were left suspended on the bellows which weren’t designed to lift weight. The inspector didn’t know this and the bellows failed during cable removal.

Swiss cheese model

Swiss Cheese Model and Aesica Pharmaceuticals

SLICES OF CHEESE: THEY REPRESENT THE PROTECTIVE BARRIERS AGAINST HAZARDSHOLES IN THE CHEESE: THEY REPRESENT THE WEAKNESSES AND UNSAFE ACTSALIGNMENT OF THE HOLES: THEY REPRESENT AN OPPORTUNITY FOR A SERIOUS ACCIDENT TO HAPPEN

Ways to fix problems• TEST PROCEDURES• MONITOR CLOSELY • PROPER TRAINING• ADEQUATE SUPERVISION• GOOD MAINTENANCE• BETTER EQUIPMENT

Advantages of Swiss cheese model• SHOWS ALL HUMAN FACTORS.

• SHOWS HOW SMALL ACCIDENTS CAN TURN INTO HIGH IMPACT ACCIDENT.

• SHOWS INDIVIDUAL AND SYSTEM ERRORS

SHELL Model

SOFTWARE: Non-physical Elements for Operation such as policies, rules, procedures HARDWARE: Physical Elements for Operation such as signalling equipment ENVIRONMENT: climate, temperature, socio-political and economic factors LIVEWARE PERIPHERAL: teamwork, communication, leadership LIVEWARE CENTRAL: Human Elements i.e. Skill, Knowledge, Attitude, Culture

SHELL Model Analysis of Aesica Pharmaceutical Incident SOFTWARE: Poor Safety Standards of work. HARDWARE: Equipment was in disrepair, should have been replaced years ago. The bellows were not adequate supports.ENVIRONMENT: Poor working conditions, the tank had failed the insurance inspection so it should have been replaced immediately instead of being left in disrepair. The employee should not have been around the bromine as it is fatal if inhaled.LIVEWARE PERIPHERAL: Pipework at one end of the tank connected filling the adjacent tank with bromine and left it contaminated. The bolts on the bellows were corroded and were likely to rupture under stress. Bromine pipework which could possibly become contaminated with bromine were poorly supported LIVEWARE CENTRAL: Poor attitude towards safety as the contaminated pipes were left for years.

Conclusions and recommendations

The Swiss Cheese Model is efficient as it shows how accidents can happen and how to prevent them from happening.

The Reason’s Human Error Taxonomy shows how intentional or unintentional accidents and incidents happen. It shows what leads to a tragedy step by step. It’s recommended to pay more attention to the safety rules and have a better knowledge of what can be done and what cannot be done with certain parts of the machines. Routines should not be violated and inspections should be taken seriously.

The SHELL Model is effective as it shows how each individual factor can lead to cause or the prevention of an accident.

Finally,

From doing this case study, we have all agreed that each method is excellent in the assessment of risk factors but have decided that in our opinion the most effective is the Reasons Human Taxonomy Error as it shows how intentional or unintentional accidents and incidents happen. It shows what leads to a tragedy step by step. It’s recommended to pay more attention to the safety rules and have a better knowledge of what can be done

Thank You For Listening and Remember to Stay Safe!