An investigation into the cause of loss of containment from the supply of mini-bulk lubricants |
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| Affiliation: | 1. School of Information Science and Engineering, Hunan University, Changsha 410082, China;2. School of Computer and Communication Engineering, Changsha University of Science and Technology, Changsha 410114, China;3. School of Information and Control Engineering, China University of Mining and Technology, Xuzhou 221116, China;4. School of Computer and Software, Nanjing University of Information Science and Technology, Nangjing 210044, China;1. Department of Engineering and Architecture, University of Trieste, Via A. Valerio 10, 34127, Trieste, Italy;2. NAPA Ltd, PO Box 470, FI-00181 Helsinki, Finland;3. National Technical University of Athens, School of Naval Architecture and Marine Engineering, 9 Heroon Politechniou St., 15773, Athens, Greece;1. Department of Automation, University of Science and Technology of China, Hefei, China;2. Institute of Energy Technology, ETH Zurich, Switzerland;3. Department of Systems Engineering & Engineering Management, City University of Hong Kong, China;1. Department of Safety Technology and Management, China University of Mining & Technology, Beijing, 100083, China;2. Institute of Environmental Engineering (IfU), ETH Zürich, Zürich, CH-8093, Switzerland;1. Functional Safety Center, Instrumentation Technology and Economy Institute, Beijing, PR China;1. Department of Nuclear Engineering, Kyung Hee University, 1732 Deogyeong-daero, Giheung, Yongin, Kyounggi 446-701, Republic of Korea;2. Nuclear Material Safety Research Division, Korea Atomic Energy Research Institute, 989-111 Daedeok-daero, Yuseong, Daejeon 305-353, Republic of Korea |
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| Abstract: | An Intermediate Bulk Container (IBC) was punctured during its handling, releasing oil onto soil at an environmentally-sensitive region of Australia. The telehandler did not pierce the plastic of the IBC directly (as was expected) but rather one of the tynes had caught on the underside of the metal base plate, despite numerous controls being in place at time of spill, revealing a previously unreported mechanism for a fluid spill from handling of petroleum hydrocarbons. The diverse investigation team used a root cause analysis (RCA) technique to identify the underlying cause: the inspection process was inadequate with contributing factors of not using a spotter and design of IBC did not anticipate conditions. Engineering controls were put in place as part of the change management process to help prevent spills from occurring from piercing from telehandler tynes on the current project site. |
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| Keywords: | Root cause Spill Process Change management Forklift |
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