Events, Conditions, and Accident Chart

Unit IV Assignment

BOS 4601 Accident Investigation

Columbia Southern University

Events, Conditions, and Accident Chart

January 30, 2007

Tank Location

Too Close to Building

Events, Conditions, and Accident

This paper will provide an analysis of some of the potential causal factors identified following the January 30, 2007 propane explosion at the Little General Store in Ghent, West Virginia wherein four (4) persons were killed and six (6) were injured. This is not whatsoever to be considered a complete analysis of all causal factors that may or may not have existed prior to this accident and is merely a theoretical piece for educational purposes only. This paper will discuss the potential causal factors revealed in the analysis and the chart on page two (2) of this paper. Analysis of the events and conditions begin when charts like the attached are finished completely (Oakley, 2012).

The first condition noted was the physical location of the tank. Upon later review by the CSB, it was found that this location was too close to the store and should not have been allowed to remain there for the past ten (10) years (CSB, 2008). The next condition was the junior technician not being briefed that the senior technician would be leaving at some point during the day. This condition led to the event identified at 0915 hours wherein the two arrive at the store for work and no opportunity is presented for the junior technician to ask any needed questions. The following condition occurs about fifteen (15) minutes later when the senior technician in fact leaves the junior technician alone as he runs an errand. This event is memorialized at about 0930 hours with the important issue being that the senior technician did not leave any emergency instruction with his junior counterpart.

During the course of his employment, the junior technician was tasked with moving liquid propane from one tank to a new tank. In doing so, the next condition occurred when he removed a threaded plug from the tank’s withdrawal valve. This valve was later determined to contain a defect which allowed the uncontrolled flow of propane from the tank (CSB, 2008). The resulting event at 1028 hours was this uncontrolled release of propane. Not having the appropriate training, nor being briefed as to how he should respond in this type of scenario, the junior technician then caused the next condition by calling the senior technician rather than starting an emergency response and/or evacuating the area. This led to the event wherein people were allowed to stay in the area as propane flowed uncontrollably for about ten (10) minutes. At about 1040 hours, the junior technician calls 911 and initiates an emergency response.

Another condition is created by the untrained local emergency responders who arrive following the 911 call. At about 1047 hours, they order the store to close, but do not identify that evacuation is needed, creating an event. The senior technician has now returned and with EMS, goes to examine the tank while people are allowed to remain in the area, albeit not inside the store. At 1051 hours, a local firefighter checks the front of the store and ensures the store is in-fact closed.

The accident occurs at about 1053 hours when an explosion occurs. Six (6) are injured and four (4) are killed as a result. At about 1056 hours, a mutual aid call goes out and additional first responders and firefighters respond to assist.

Casual factors are events or conditions that contribute to an accident (Oakley, 2012). The casual factors found on this chart are consistent with those found in the CSB report. This accident was completely avoidable and should not have occurred. As a result, the CSB submitted recommendations and corrective actions following their report (CSB, 2008).

References

CSB Report. 2008. Investigation Report. Little General Store Propane Explosion. Retrieved from:  https://www.csb.gov/assets/1/20/csbfinalreportlittlegeneral.pdf?13741

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications (2nd ed.). Des Plaines, IL: American Society of Safety Engineers.