Goodyear is a company which manufactures tires and rubber. Founded in 1898, the company boasts of international operations and long-term experience. The company has its headquarters in Akron, Ohio. The company encountered a fire incidence in its Houston, Texas facility, which shall be the focus of this analysis. The case involves a rapture of a heat exchanger in the synthetic rubber production facility, as well as ammonia release. This caused the death of one worker and injured six more. The case has been investigated by The U.S. Chemical Safety and Hazard Investigation Board and the results of their investigations are used for this analysis.
Production Process and the Hazard at Goodyear
The Houston facility, which produces synthetic rubber was built in 1942 but has been developing in terms of expansion. It contains the production and the finishing section, which are separated. Processing chemicals such as styrene are produced in the reactor vessels installed in the production section. Ammonia is used to control the temperature of the chemicals processed in these vessels. The chemical products from this section are relied to the finishing by means of pipes (U.S. Chemical Safety and Hazard Investigation Board, 2008). Liquid ammonia flows to the 3 heat exchangers from the cooling system, and this ammonia absorbs heat from chemicals being processed. The heat exchanger shell contains boiling ammonia as its temperature rises from the heat absorbed. The ammonia is supposed to be maintained at a pressure of 150 psig while at the heat exchanger. This is facilitated by a relief valve placed in the vapor return line. In between the shell and the relief valve is another isolation valve. After turning to vapor (as a result of heat absorption), the vapor ammonia relies back on the cooling system. It is cooled and liquefied here, for further reliance to the heat exchangers (U.S. Chemical Safety and Hazard Investigation Board, 2008). Heat exchangers are also equipped with a system to protect them from excessive pressure beyond the set limit of 300 psig. This is done through the use of a pressure relief valve which is installed in series with a rapture disk and the two are set at the aforementioned pressure limit. Ammonia vapor is let flow to the atmosphere from this system whenever there is excessive pressure in the heat exchangers.
The heat exchangers use ammonia to cool process chemicals flowing through them. The chemicals pass through the exchangers while in tubes. Operators needed to replace the burst rapture disk on June 11, 2008, which together with a pressure relief valve made sure that there was no excessive pressure in the heat exchangers. To facilitate the replacement, the operators closed the isolation valve (placed between the relief valve and heat exchanger shell) and carried out the replacement. They however, did not reopen the isolation valve. An operator closed a block valve responsible for controlling ammonia pressure, which was closed by an operator so that the operator would clean the piping system using steam. The steam caused the pressure of ammonia to rise as a result of heating. Due to the closing of the isolation valve, the excess ammonia pressure could not flow through the rapture disk and relief valve. In addition, the excess pressure could not be released through the ammonia pressure control valve as the block valve was closed. As a result of the excessive pressure swell, the heat exchanger shell ruptured, causing the debris that did the damage and caused the death of one employee (U.S. Chemical Safety and Hazard Investigation Board, 2008). This employee was walking.
More than five workers were exposed to the released ammonia as a result of the rapture. The injured workers were taken to the hospital as the plant was evacuated. Goodyear used an employee tracking system, but it could not track all workers. It was believed that all employees were removed from the area. However, the heat exchanger surrounding was covered with debris. The body of the worker was recovered below the debris in an area which had not have enough light (U.S. Chemical Safety and Hazard Investigation Board, 2008).
Case Analysis
Research indicates that social and managerial facors are also to blame for disaster occurence, in addition to technical factors. In fact, many disasters like the example of Goodyear,occur as a result of a combination of several factors, including dramatic quality nad emotional factors. Investigations have indicated the problems with the emergency response mechanism installed in Goodyear following this incidence that resulted in death. Although Goodyear had put in place procedures for evacuation, these procedures were ignored. No shelter-in drills and evacuation practices were carried as stipulated in the company regulations. In fact, these were neglected for about four years preceding the accident. This was mentioned by employees during an investigation to the matter (U.S. Chemical Safety and Hazard Investigation Board, 2008). The organization also failed to train all employees regarding some of the aspects of. For instance, some had not been trained on procedures explaining emergency muster points. Although the alarm system was installed, it was not efficient. For instance, as far as this incident is concerned, the alarm which could notify the workers of the specific-position incident at the exchanger was not reachable because of the release of ammonia. In addition, the inaccessibility of the alarm was prevented because the automatic water deluge system released water sprays. In fact, some employees got the information about the accident for the first time, through radio and/or word of mouth.
Research indicates that organizations need to assess their internal and external environments to reduce the likelihood of occurence of disasters. In fact, the case at Goodyear is an example of a man-made disaster model, because of the combination of the various factors that caused the accidents. Wrong assumptions were made regarding the error of lack of training and carrying out drills. There was also the occurrence of dangerous pre-conditions in the system, which went unnoticed.
Goodyear had a computerized system that would help supervisors account for their employees. The system (badge-in/badge-out) generated a master list to facilitate this. However, the supervisors could not generate these lists during this accident, as a result of a malfunction in the system. The supervisors were forced to use contractor lists and lists generated by handwriting as employees gathered. Comparison was done by the Emergency Operations Command, between these lists and computer records to account for personnel present at the production section. In addition, the company had made no effort to inform all employees that they would be exposed to carrying such an accountability procedure as part of their job in an emergency, since it was found that not all employees and emergency response members were aware of this. In addition, not all were trained on this. The response team did not consider it unusual that one of the employees was missing from the muster point because she was from the emergency response team (U.S. Chemical Safety and Hazard Investigation Board, 2008).
Studies show that it is possible to shape the behaviors of individuals in an organization through socialization. In addition, organizations should put into place instrumental and terminal values, which shape employee goals and instill positive behaviors. Individual and group behaviors, as well as their values and attitudes such as the psychological contracts, affect safety culture in an organization (Hughes & Ferrett, 2009).
It is the breach of such a contract that may lead to the occurence of an accident as employees get to agree and withdrawal. A weak safety culture also results from a poor safety management system (Hurst, 1998). Negative attitudes and behaviors such as negligence of safety rules can be eliminated through health and safety training programs. These can be used to foster positive behavior, such as making workers feel responsible for their actions. It can be seen that a problem also occurred when the isolation valve was never reopened after the replacement of the rapture disk. This may have been caused by a negative employee behavior or attitude such as negligence for safety rules, anti-social, dysfunctional and workplace defiance behavior. The organization needs to determine whether the minimal observanceof safety rules at Goodyear are intentional or pervasive in nature. Again, lack of adherance to organizational rules may indicate the incompetence of the organization’s safety culture, which makes sure that the workers identified and rectified the defect (Hughes & Ferrett, 2009). Employee behaviors are also affected by the culture adopted by other employees regarding the culture of health and safety (Hurst, 1998). The maintenance staff did not observe the work order procedures according to a CBS investigation, and this would have helped identify the problem. If the isolation valve was opened again after the repair of the disk, excessive pressure would have been controlled, even if the block valve was closed. The second error occurred when the cleaning operator closed the block valve without making sure that the other valve (isolation valve) was working well and opened. He might have just assumed that it is working and open. Another problem was that of neglect. The maintenance team failed to counter-check that the system was well after the replacement of the rapture disk. This would have helped them to identify that they had not reopened the isolation valve. According to the U.S. Chemical Safety and Hazard Investigation Board (2008), employees in Goodyear were being trained in emergency preparedness. This element was included in employee training for health and safety. The latter was computer-based. In addition, the company run and had an emergency response team. The fact that the employees were trained yet the accident occurred due to neglect, emphasizes the need for a safety culture than has been established in Goodyear Company.
Negative behaviors make employees neglect safety rules, and a long-term result is that a culture that neglects safety rules is formed. Although training was done to have procedures explained in the work order and lockout/Tagout for repair and maintenance of the rapture disk, the investigation found out that they were breached. Workers were required to obtain signature verification before and after carrying out the maintenance job as per the work order system. There was no documentation of the maintenance status and a handwritten note was the only tool that contained the information that the isolation valve was still closed. No signed copy of the work order for the maintenance job was produced, yet the signing out was a requirement of the work order system after repairs are done. This had a significant contribution to the accident.
Organizational style also relates to the safety culture in the organization as it does to the behaviors of the individuals (Hurst, 1998). The organization has a responsibility to foster positive safety climate among employees by defining and assessing what is required of them as far as health and safety of facilities and humans in the factory is concerned (Byrom and Corbridge, 1997). HR departments must be made accountable for the development of safety cultures (Marquez, 2007). In addition, the leadership should involve the necessary stakeholders (Marquez, 2007) and employees. HR departments must identify future needs for the health and safety of workers such as employee training and safety management systems (, 2003). They must recognize that safety demands are changing from time to time. The character of an organization comes from a combination and interaction of behaviors, values and attitudes by individuals and leadership (Hurst, 1998). The character includes how the organization handles ideas and beliefs about risks (Hurst, 1998). The leadership should lead in establishing a healthy Health and Safety culture and policy and ensure and monitor its implementation. The organization on its part had breached the American Society of Mechanical Engineers Boiler and Pressure Vessel Code, which required that a pressure vessel be continuously monitored if there is temporal blockage of the pressure release device and over-pressurization was a possibility (U.S. Chemical Safety and Hazard Investigation Board, 2008). The company did not have any means to address this, neither did it provide that a worker be posted to check the status of the isolation valve incase over-pressurization was occurring (U.S. Chemical Safety and Hazard Investigation Board, 2008).
Organizational learning avails organizations with the opportunity to continually reflect upon their safety practice. There is a need for Goodyear to have rules that arerealistic and acheivable regarding organizational safety. A good safety program must establish a linkage between environmental and cognitive factors. It appears that Goodyear has moved from using a traditional approach to safety management, which is based on safety and health rules and regulations which employees are supposed to observe. However, the investigation found out that the safety management system was not complete, which contributed to the accident. Although effort has been made to introduce working operations such as emergency rescue operations which are necessary for safety of workers during accidents, it appears that the organization has a weak safety culture, which mainly focuses on the development of positive safety behaviors of employees. The company had put in place training mechanisms on safety, but they are yet to yield benefits, such as modeling employee positive safety culture which is necessary to avoid accidents such as the one reported (Giovanis, 2010). It is recommended here that the organization should foster on developing a stronger safety culture by intense training of all employees. It has already been mentioned that not all employees were trained on safety procedures established in the safety regulations and code of practice of the company. Intense and continuous training ensures that employees always mind safety and remind to observe safety regulations. Accident in Goodyear is partly blamed on employee negligence of observing safety codes such as the work order guidelines and the lockout/tagout procedures. A strong safety culture means the employees don’t need to be reminded to observe safety regulations, but that the latter is part of an employees’ daily duty. This can be fostered through inclusionary, hierachical and functional techniqes of socialization. There was need for leadership to foster this culture and exemplify it by taking concern about safety rules and procedures, such as ensuring that they follow emergence operations guidelines. For instance, Goodyear leadership should have shown commitment to observance of safety guidelines to all workers by ensuring that they schedule shelter-in-place drills and implement the procedures.
Another recommendation is that the company should put in place a mechanism to measure safety systems on a regular basis. Safety performance evaluation (Giovanis, 2010) techniques would have helped the top management to discover the neglected safety operations such as the need to carry out of the shelter-in-place drills and evacuations four times in a year. These performance evaluation strategies should have helped the company to link the administrative process with the health and safety conditions in both the production and finishing sections at Goodyear (Giovanis, 2010). The organization need to put in place personal assessment of hazard, which helps avoid exposure to danger from a personal level. Personal assessment of hazards is an important aspect of safety which needs to be included in the whole safety practice and concern (Powell, 1998). The performance evaluation for safety must include safety performance indicators such as goals for safety (Grimaldi and Simmonds, 1989), macro measures (what organization has put in place to take care of workplace safety- for example getting the opinion of the employee and use of surveys), micro measures (individual performance towards safety) (Petersen, 1998). Review of job analysis in the organization to focus on long term reduction of occurence of accidentts may focus on introducing opportunity for behavior modelling while at the job, employee satisfaction, and reduce job autonomy for maintenance tasks. Instrumental values are supposed to be employed to shape positive behaviors of employees,necessary to reducing occurences of disasters. This can be achieved by having a clear vision statement which features employee safety values. Leadership can also analyze employee characteristics, wmotional intelligence and traits in order to determine behavior and pattern of response to safety regulations. This is beneficial for the purpose of recruitment aimed at improving employee safety, introduction of training programs focusing on safety and job scehduling according to the safety requirements of each particular job in the production and finishing unit. Such training should help to establish linkage between organizational safety goals and emplyee attitudes, personalities and values. Appropriate personality,attitudes and goals should be fostered through training, in order to adopt a proper safety culture.
References
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