Health and Safety Presentation

1. Aesica Pharmaceuticals
Toxic Chemical Incident
IZABELLA FRYZE, CORRIE BOWES & SHANE CLOHOSEY

2. 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.

3. 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

4. Useful models
 Reason Human Error Taxonomy
 Swiss Cheese Model
 SHELL Human Factor Model

5. Reason Human Error Taxonomy

6. 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.

7. 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.

8. Swiss cheese model

9. Swiss Cheese Model and
Aesica Pharmaceuticals
SLICES OF CHEESE: THEY REPRESENT THE PROTECTIVE BARRIERS AGAINST
HAZARDS
HOLES IN THE CHEESE: THEY REPRESENT THE WEAKNESSES AND UNSAFE
ACTS
ALIGNMENT OF THE HOLES: THEY REPRESENT AN OPPORTUNITY FOR A
SERIOUS ACCIDENT TO HAPPEN

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

11. Advantages of Swiss
cheese model
• SHOWS ALL HUMAN FACTORS.
• SHOWS HOW SMALL ACCIDENTS CAN TURN INTO HIGH IMPACT
ACCIDENT.
• SHOWS INDIVIDUAL AND SYSTEM ERRORS

12. 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

13. 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.

14. 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.

15. 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

16. Thank You For Listening and
Remember to Stay Safe!