Help with Board Question (No Word Count), Unit Quiz, and Unit Assignment. APA Format Throughout to Include Reference Page. 

Board Question

Where do you see an organization’s safety manager fitting into the levels of accident accountability? Should safety practitioners be held responsible for accidents? Please explain your views on these topics

Unit Assignment

Events and Causal Factors Chart Project

Read the U.S. Chemical Safety Board (CSB) investigation report of the 2007 propane explosion at the Little General Store in Ghent, WV. The final report can be read/downloaded at the following link: https://www.csb.gov/assets/1/20/csbfinalreportlittlegeneral ?13741

Additional information on the incident, including a video summary, can be found at the following link:

https://www.csb.gov/little-general-store-propane-explosion/

Complete the assignment as detailed below.

Part I: From the information in the report, create a chart listing events and causal factors for the incident in Microsoft Word, Open Office, or a similar word processing software. If you choose to use a program other than Microsoft Word, be sure to save and submit the document as a Microsoft Word document (i.e., , x). The objective of this project is to provide you with an opportunity to use this important and very practical analytical tool. The chart does not have to be infinitely detailed, but the key sequence of events should be charted as should the key conditions surrounding the events. Keep in mind that the purpose of an events and causal factors chart is to aid in identifying which conditions could be causal factors.

Use the charting procedures on pages 72–76 of your textbook to help you with this assignment. In addition, refer to the example events and causal factors (ECF) chart in the Unit IV Lesson for an example of this type of chart.

Part II: On a separate page, discuss the potential causal factors that are revealed in the analysis. How do these causal factors compare to the causal factors found in the CSB’s investigation report? Do you think more analysis is needed? This part of the assignment should be a minimum of one page in length.

Upload Parts I and II as a single document. For Part II of the assignment, you should use academic sources to support your thoughts. Any outside sources used, including the sources mentioned in the assignment, must be cited using APA format and must be included on a references page.

Useful hints: In Microsoft Word, you can use parentheses for events (events), square brackets for conditions [conditions], and brackets for the accident {accident}; you may also use a similar convention, such as color-coded text or the shapes that are available within Microsoft Word. Whatever convention you use, be sure you provide some kind of key.

Unit quiz

QUESTION 1

Which of the following best describes assumed events?

				1.	Events that occurred at the same time
Events that have causal factors
Events that have not yet been verified
Events that are unlikely to have happened

QUESTION 2

At which level of accountability are policies and procedures typically found?

1.

Corporate level

Supervisor level

Management level

Worker level

QUESTION 3

Which analytical approach should be considered first when starting an accident investigation?

1.

Human factors analysis

Barrier analysis

Events and causal factors analysis

Cause and effect analysis

QUESTION 4

What is the next step in an accident investigation once all of the evidence has been gathered?

1.

Determining direct causes

Determining the accident sequence

Contacting Occupational Safety & Health Administration (OSHA)

Determining root causes

QUESTION 5

Which of the following is NOT a benefit of using analytical techniques in the accident investigation process?

1.

It lends consistency to the safety program.

It instills confidence in the investigation process.

Systemic factors are less likely to be missed.

Only lower-level causal factors will be revealed.

Timelineof

Event

s

1/2/16 – 5:33 am Mary leaves message for Tom (supervisor)

1/2/16 – 5:53am Bob found lying in pool of water

1/2/16 – 5:53 am Air horn sounds

1/2/16 – 5:34 am Sam notices leak and wet floor in valve dept.

1/2/16 – 5:41 am Sam leaves note for Mary to mop up wet floor

1/2/16 5:41 am

Sam goes home

1/2/16 – 5:33 am Tom leaves message for Mary

1/2/16 – 6:00 am Ambulance transports Bob to hospital

Key:

Event

Accident

Event

sand

Condition

s

No direct communication to anyone prior to leaving

No one to act on messages

Clean up of floor not done immediately

No “wet floor” signs placed

Leak not repaired for four months

1/2/16 – 5:33 am Mary leaves message for Tom (supervisor)

1/2/16 – 5:53am Bob found lying in pool of water

1/2/16 – 5:53 am Air horn sounds

1/2/16 – 5:34 am Sam notices leak and wet floor in valve dept.

1/2/16 – 5:41 am Sam leaves note for Mary to mop up wet floor

1/2/16 5:41 am

Sam goes home

1/2/16 – 5:33 am Tom leaves message for Mary

Emergency response was good

1/2/16 – 6:00 am Ambulance transports Bob to hospital

Key:

Condition
Event

Accident

1

Course Learning Outcomes for Unit

Upon completion of this unit, students should be able to:

3. Apply accident investigation techniques to realistic case study scenarios.
3.1 Develop an events and causal factors analysis chart.

4. Evaluate analytical processes commonly used in accident investigations.

Reading Assignment

Chapter 6:
The Analytical Process

Chapter 7:
Events and Causal Factors Analysis

Buys, J. R., & Clark, J. L. (1995). Events and causal factors analysis. Retrieved from
https://www.wecc.biz/Administrative/2014%20HPWG%20Workshop%202%20Events%20and%20Ca
usal%20Factors%20Charting

In order to access the resource below, you must first log into the myWaldorf Student Portal and access the
Business Continuity & Disaster Recovery Reference Center database within the Waldorf Online Library.

Kletz, T. (2012). Missed opportunities in accident investigation. Loss Prevention Bulletin, 2012(227), 6-9.

Unit Lesson

Imagine that you are a part of an investigation team that has completed the gathering of evidence related to
an accident. You have witness interviews; photographs and diagrams of the scene; and mountains of paper
that represent policies, procedures, and training. How do you make sense of all of this information? In the
previous unit, we said that accident investigation is a three step process—gain knowledge, analyze the
knowledge, and develop corrective actions. Gathering evidence is a part of the gaining knowledge step,
helping us understand what happened. However, the evidence by itself does not get us very far. We need to
organize it in some fashion so that we can move from what happened to why it happened. An events and
causal factors (ECF) chart is a good first step in making the transition to analysis.

Much like accident investigation itself, creating the ECF chart is a sequential process. The first step is to
define the accident sequence. Once the sequence of events is known, we look for conditions that are related
to each event. At this point, we are not identifying causal factors but, rather, are simply relating conditions to
events. Once all events and conditions are charted, we can use any additional evidence to validate all of the
facts. The sequence can be changed, and conditions can be added or deleted as the evidence is further
examined. Only when the chart is completed and verified can we begin to analyze conditions to determine
causal factors.

Now, it may be helpful to look at an example of an accident sequence. Here is what we know:

On January 2, 2016, at 5:34 a.m., Sam, the night maintenance technician, noticed a leak in the water pipe in
the valve department. The valve had been leaking for four months, but because a maintenance request had
not been submitted, the problem was not fixed. Sam was about to clock out at 5:40 a.m. and decided to leave
a note for Mary, the first shift technician, to mop up the area. At 5:53 a.m., an air horn was sounded for

UNIT STUDY GUIDE

Events and Causal Factors Charting

2

UNIT x STUDY GUIDE

Title

everyone to respond to an area. As workers arrived, they noted that Bob (another employee) was lying in a
pool of water. It was very obvious to everyone that Bob’s leg was broken. An ambulance was called, and, at
6:00 a.m., Bob was transported to the hospital. During the investigation, it was learned that Sam had noted
the water but decided not to clean the area immediately. Sam left a note at the desk at 5:41 a.m. and
departed the area. Mary was supposed to clock in at 5:40 a.m., but she called her supervisor, Tom, at 5:33
a.m.; she was unable to talk to him, so she left a message that she would be arriving at 6:00 a.m. since she
was running late. Tom, the supervisor, also called at 5:33 a.m., and he left a message for Mary, saying that
he was running 15 minutes late. Mary, who arrived at 5:53 a.m., heard the alert horns and responded to the
accident.

First, we chart the known events. Note that the two phone calls are charted as events occurring
simultaneously. We could also chart some events that did not occur, such as Sam not cleaning up the spill
(Oakley, 2012). There could also be assumed events, such as Bob slipping in the water and falling. The level
of detail is up to the investigator, but you may find that more detail results in fewer missed causes.

To see an example of an ECF timeline of events chart for this incident, click here.

The next step is to add conditions that are applicable to the events. Once these are charted, causal factors
begin to emerge. At first glance, we can see that the failure of the night maintenance technician to clean up
the spill was a likely causal factor. It certainly was a factor, and without the chart, we might be tempted
identify it as the sole cause.

To see an example of an ECF events and conditions chart for this incident, click here.

Within a safety program, authority implies control and would reflect the ability to provide direction, apply
discipline, and allocate resources. Responsibility implies that something has been assigned or tasked, and
the expectation is that you will complete it. Accountability is the application of consequences (good or bad) for
actions taken or not taken under the assigned responsibility (Manuele, 2014). It is helpful to think of causal
factors in terms of accountability. According to Oakley (2012), the four levels of accountability are as follows:

 Worker or equipment level: The failure to clean up the spill and not posting a wet floor sign certainly
fall within the responsibility of the night maintenance worker.

 Supervisor level: The communication failures between the supervisor and the other employees
involved deserve more investigation, as do the supervisor’s policies on turnovers from one shift to the
next.

 Management level: Upper management should be held accountable for allowing the leak to remain
uncorrected for four months. Some of this responsibility may be shared with the supervisor.

 Corporate level: The safety culture of an organization that allows leaks to go unrepaired and has not
established clear policies for safety management needs further investigation.

The chart can also reveal good things. The time between the response team being called and the
transportation to the medical facility was only seven minutes. Effective emergency response can be a
significant contributor in reducing the overall severity of an accident (Oakley, 2012).

You can see that our investigation does not end with the completion of the chart since additional avenues to
explore have been identified. Still, we did finally turn the corner from the what to the why. In our example, we
developed the chart after the evidence was gathered, but in a real world investigation, the chart can, and
should, be started as soon as any facts are known about the accident. Expect the ECF chart to change as
new facts and information are uncovered. The order of events may change, as well as the significance of the
conditions. Do not spend all of your time making the chart pretty until the investigation is complete and you
are ready to include it in a final report. Choose substance over style.

An events and causal factors chart is a basic building block of accident analysis. We cannot determine why
something happened until we are certain we know what happened and the sequence in which it happened. In
the next two units, we will examine additional techniques that can be used to identify more of those elusive
why factors.

https://online.waldorf.edu/CSU_Content/Waldorf_Content/ZULU/EmergencyServices/OSH/OSH4601/W15Jc/UnitIV_ECF_Timeline_of_Events x

https://online.waldorf.edu/CSU_Content/Waldorf_Content/ZULU/EmergencyServices/OSH/OSH4601/W15Jc/UnitIV_ECF_Events_and_Conditions x

3

UNIT x STUDY GUIDE
Title

References

Manuele, F. A. (2014). Advanced safety management: Focusing on Z10 and serious injury prevention (2nd
ed.). Hoboken, NJ: Wiley.

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

Suggested Reading

If you are interested in learning more about the events and causal factors analysis, review the PowerPoint at
the link below. It is an in-depth presentation with great information about this subject.

Coffey, M. (n.d.). Events and causal (conditional+) factors analysis [PowerPoint slides]. Retrieved from
http://indico.ictp.it/event/a13209/session/2/contribution/16/material/slides/0

This website discusses events and causal factors charting. This is a skill that we will be using in several unit
assignments, and this may be a helpful resource for more information on the topic.

Occupational Safety & Health Training. (n.d.). Events and causal factor charting. Retrieved from
http://www.oshatrain.org/notes/2hnotes12.html

U

. S . C H E M I C A L S A F E T Y A N D H A Z A R D I N V E S T I G A T I O N B O A R D

INVESTIGATION REPORT

REPORT NO. 2007-04-I-WV

SEPTEMBER 2008

LITTLE GENERAL STORE – PROPANE EXPLOSION
(Four Killed, Six Injured)

Photo courtesy of West Virginia State Fire Marshal

LITTLE GENERAL STORE, INC.
GHENT, WEST VIRGINIA

KEY ISSUES: JANUARY 30, 2007
• EMERGENCY EVACUATION

• HAZARDOUS MATERIALS INCIDENT TRAINING FOR FIREFIGHTERS

• 911 CALL CENTER RESOURCES

• PROPANE COMPANY PROCEDURES

• PROPANE SERVICE TECHNICIAN TRAINING

Little General Store September 2008

ii

Content

s

EXECUTIVE SUMMARY ………………………………………………………………………………………………………….. 1

KEY FINDINGS ………………………………………………………………………………………………………………………… 3

1.0 INTRODUCTION …………………………………………………………………………………………………………… 4

1.1 Summary ……………………………………………………………………………………………………………………….. 4

1.2 Investigative Process ……………………………………………………………………………………………………….. 7

1.3 Little General Store, Inc. ………………………………………………………………………………………………….. 8

1.4 Little General Store Propane Suppliers ………………………………………………………………………………. 8

1.5 West Virginia Emergency Service Organizations ………………………………………………………………… 9

1.6 Professional and Industry Organizations …………………………………………………………………………… 12

2.0 INCIDENT DESCRIPTION …………………………………………………………………………………………… 13

2.1 Events Preceding January 30, 2007 Explosion…………………………………………………………………… 13

2.2 Day of the Incident ………………………………………………………………………………………………………… 14

2.3 Response to the Propane Release …………………………………………………………………………………….. 17

3.0 PROPANE INCIDENT FREQUENCY ……………………………………………………………………………. 20

3.1 United States Hazardous Materials Incidents 2001 – 2006 ………………………………………………….. 20

3.2 Recent Propane Incidents ……………………………………………………………………………………………….. 21

4.0 PROPANE SYSTEM FUNDAMENTALS ………………………………………………………………………. 22

4.1 Propane Properties…………………………………………………………………………………………………………. 22

4.2 System Features…………………………………………………………………………………………………………….. 22

4.3 Propane Standards …………………………………………………………………………………………………………. 24

4.4 Propane Emergency Guidance ………………………………………………………………………………………… 25

5.0 INCIDENT AND EMERGENCY RESPONSE ANALYSIS ………………………………………………. 27

Little General Store September 2008

iii

5.1 Liquid Withdrawal Valve ……………………………………………………………………………………………….. 27

5.2 Propane Tank Placement ………………………………………………………………………………………………… 30

5.3 Propane Service Technician Training and Response ………………………………………………………….. 36

5.4 Fire Department Response ……………………………………………………………………………………………… 41

5.5 911 Emergency Call Center Response ……………………………………………………………………………… 44

6.0 REGULATORY ANALYSIS …………………………………………………………………………………………. 46

6.1 Occupational Safety and Health Administration ………………………………………………………………… 46

6.2 Environmental Protection Agency …………………………………………………………………………………… 46

6.3 West Virginia Fire Commission ………………………………………………………………………………………. 47

7.0 FINDINGS …………………………………………………………………………………………………………………… 51

8.0 CAUSES………………………………………………………………………………………………………………………. 53

9.0 RECOMMENDATIONS ……………………………………………………………………………………………….. 54

Governor and Legislature of the State of West Virginia …………………………………………………………………. 54

West Virginia Fire Commission ………………………………………………………………………………………………….. 54

West Virginia Office of Emergency Medical Services …………………………………………………………………… 54

National Fire Protection Association……………………………………………………………………………………………. 55

Association of Public-Safety Communications Officials ………………………………………………………………… 55

Propane Education and Research Council…………………………………………………………………………………….. 55

National Propane Gas Association ………………………………………………………………………………………………. 56

West Virginia E911 Council ………………………………………………………………………………………………………. 56

Ferrellgas …………………………………………………………………………………………………………………………………. 57

REFERENCES …………………………………………………………………………………………………………………………. 58

APPENDIX A FERRELLGAS INSTALLATION REVIEWS OF THE INCIDENT TANK……………… 60

APPENDIX B 911 CALL AND INITIAL FIRE DEPARTMENT DISPATCH ……………………………….. 63

Little General Store September 2008

iv

APPENDIX C RECENT PROPANE INCIDENTS ………………………………………………………………………. 66

RECENT PROPANE INCIDENTS …………………………………………………………………………………………….. 67

1.0 PROPANE RELEASE INCIDENTS ……………………………………………………………………………….. 67

1.1 Aberdeen, Washington …………………………………………………………………………………………………… 67

1.2 Lynchburg, Virginia ………………………………………………………………………………………………………. 68

1.3 Bristow, Virginia …………………………………………………………………………………………………………… 70

2.0 PROPANE RELEASE AND FIRE INCIDENTS ………………………………………………………………. 72

2.1 Sallis, Mississippi ………………………………………………………………………………………………………….. 72

2.2 Danville, Alabama …………………………………………………………………………………………………………. 73

APPENDIX D TABLE OF STATE REQUIREMENTS FOR PROPANE SERVICE TECHNICIANS . 75

APPENDIX E UNITED STATES EPA – 40 CFR 311 ………………………………………………………………….. 77

Little General Store September 2008

v

List of Figures

Figure 1. Aerial photograph of Little General store and surrounding plot.

…………………………………………. 4

Figure 2. Site plan of Little General Store. …………………………………………………………………………………….. 6

Figure 3. Liquid withdrawal valve. ……………………………………………………………………………………………… 15

Figure 4. Timeline of initial events ……………………………………………………………………………………………… 17

Figure 5. Timeline of incident response……………………………………………………………………………………….. 19

Figure 6. Typical ASME propane tank. ……………………………………………………………………………………….. 23

Figure 7. Incident valve plug (Telltale circled)………………………………………………………………………………. 27

Figure 8. Crack in valve seal……………………………………………………………………………………………………….. 29

Figure 9. Pre-incident photograph of the Ferrellgas tank. ………………………………………………………………. 30

List of Tables
Table 1. U.S. hazardous materials incidents 2001-2006 …………………………………………………………………. 20

Little General Store September 2008

vi

List of Acronyms and Abbreviations

ASME American Society of Mechanical Engineers

APCO Association of Public-Safety Communications Officials

CETP Certified Employee Training Program

CFR Code of Federal Regulations

CSB

U.S. Chemical Safety and Hazard Investigation Boar

d

DOT U.S. Department of Transportation

EMS Emergency Medical Services

EMT Emergency Medical Technicia

n

EOC Emergency Operations Center

EPA U.S. Environmental Protection Agency

FIR Ferrellgas Installation Review

HAZWOPER Hazardous Waste Operations and Emergency Response

HVAC Heating, Ventilation, and Air Conditioning

IC Incident Commander

LP Gas Liquefied Petroleum Gas

MSDS Material Safety Data Shee

t

NENA National Emergency Number Association

NFIRS National Fire Incident Reporting System

NFPA

National Fire Protection Association

NIMS National Incident Management System

NPGA National Propane Gas Association

OES Raleigh County Office of Emergency Services

OSHA U.S. Occupational Safety and Health Administration

PERC Propane Education and Research Council

RESA Regional Education Service Agency

SCGM Service Center General Manager

STARS Safety and Training Administrative Records System

WVC West Virginia Code

WVCSR West Virginia Code of State Rules

Little General Store September 2008

1

Executive Summary

On January 30, 2007, a propane explosion at the Little General Store in Ghent, West Virginia, killed tw

o

emergency responders and two propane service technicians, and injured six others. The explosion leveled

the store, destroyed a responding ambulance, and damaged other nearby vehicles.

On the day of the incident, a junior propane service technician employed by Appalachian Heating was

preparing to transfer liquid propane from an existing tank, owned by Ferrellgas, to a newly installed

replacement tank. The existing tank was installed in 1994 directly next to the store’s exterior back wall in

violation of West Virginia and U.S. Occupational Safety and Health Administration regulations.

When the technician removed a plug from the existing tank’s liquid withdrawal valve, liquid propane

unexpectedly released. For guidance, he called his supervisor, a lead technician, who was offsite

delivering propane. During this time propane continued releasing, forming a vapor cloud behind the

store. The tank’s placement next to the exterior wall and beneath the open roof overhang provided

a

direct path for the propane to enter the store.

About 15 minutes after the release began, the junior technician called 911. A captain from the Ghent

Volunteer Fire Department subsequently arrived and ordered the business to close. Little General

employees closed the store but remained inside. Additional emergency responders and the lead

technician also arrived at the scene. Witnesses reported seeing two responders and the two technicians in

the area of the tank, likely inside the propane vapor cloud, minutes before the explosion.

Minutes after the emergency responders and lead technician arrived, the propane inside the building

ignited. The resulting explosion killed the propane service technicians and two emergency responders

who were near the tank. The blast also injured four store employees inside the building as well as two

other emergency responders outside the store.

Little General Store September 2008

2

The CSB identified the following causes:

1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard.

Consequently, the tank remained against the building for more than 10 years.

2. Appalachian Heating did not formally train the junior technician, and on the day of incident he was

working alone.

3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid

propane releases.

The CSB makes recommendations to the governor and legislature of the State of West Virginia, the West

Virginia Fire Commission, the West Virginia Office of Emergency Medical Services, the National Fire

Protection Association, the Association of Public-Safety Communications Officials, the Propane

Education and Research Council, the National Propane Gas Association, the West Virginia E911 Council,

and Ferrellgas.

Little General Store September 2008

3

Key Findings

1. The propane service technicians, emergency responders, and store employees did not evacuate the

area as recommended by nationally accepted guidance for propane

emergencies.

2. A defect in the existing tank’s liquid withdrawal valve caused it to malfunction and remain in an open

position.

3. The junior propane service technician who was servicing the tank on the day of the incident had no

formal training and did not recognize the defect in the withdrawal valve. He was also working

unsupervised, even though he had been on the job for only one and a half months.

4. The placement of the 500-gallon propane tank against the building’s exterior back wall provided

releasing propane a direct path into the store’s interior.

5. The Occupational Safety and Health Administration’s and National Fire Protection Association’s

propane standards require training but do not include curricula, practical exercises, or knowledge

evaluation.

6. 911 operators in the United States lack propane emergency guidance to help them collect important

information from callers, offer life-saving advice, and convey relevant information to first responders.

7. Firefighters in West Virginia are required to attend a minimum of four hours of hazardous materials

emergency response training as part of their initial training sequence, but refresher training is not

required. The responding Ghent Volunteer Fire Department captain last attended a hazardous

materials response course in 1998.

8. Propane safety and emergency training is voluntary for fire department personnel in West Virginia.

None of the responders from the Ghent Volunteer Fire Department had specific propane emergency

training.

Little General Store September 2008

4

1.0 Introduction

1.1 Summary

At 10:53 am on January 30, 2007, a propane explosion leveled the Flat Top Little General Store (Little

General) in Ghent, Raleigh County, West Virginia (Figure 1). The explosion killed four and injured six.

The dead included two emergency responders (a fire department captain and an emergency medical

technician, both from the Ghent Volunteer Fire Department) and two Appalachian Heating propane

service technicians. The injured included the four Little General employees who remained inside the

store, and two other Ghent Volunteer Fire Department emergency responders.

Figure 1. Aerial photograph of Little General store and surrounding plot.

Little General Store September 2008

5

The morning of the explosion, a junior propane service technician1 (junior technician) from Appalachian

Heating was preparing to transfer liquid propane from an existing tank owned by Ferrellgas to a newly

installed tank2 owned by Thompson Gas and Electric Services (Thompson). The Ferrellgas propane tank

was installed in 1994 directly against the store’s exterior back wall (Figure 2). At about 10:25 am, the

junior technician, working alone, removed a threaded plug from the liquid withdrawal valve3 on the

Ferrellgas tank and liquid propane began flowing uncontrollably. Liquid propane sprayed upward,

against the roof overhang, and dense propane gas accumulated at ground level around the tank and the

foundation of the building. Over the next 25 minutes, the escaping propane entered the Little General

store through openings in the roof overhang.

Shortly after the release began, the junior technician called the lead technician to report the release and

seek guidance. At 10:40 am, the junior technician called 911 to report the emergency and summon help.

A captain and two emergency medical technicians from the Ghent Volunteer Fire Department were the

first to arrive, followed by the lead technician and two other emergency responders. Shortly after their

arrival, the propane in the store ignited, leveling it and killing two emergency responders (the fire captain

and one of the emergency medical technicians) and the two Appalachian Heating propane service

technicians.

1 The report discusses the activities of two propane service technicians: a junior technician, who had been
performing propane duties for one and a half months, and a lead technician, who had been performing propane
duties for one and a half years. “Junior” and “lead” are used in this report to differentiate the technicians’ relative
experience in propane service.

2 While commonly referred to as tanks, both of these were 500-gallon pressure vessels. The American Society of
Mechanical Engineers (ASME) publishes the Boiler and Pressure Vessel code; generally, stationary propane tanks
are considered unfired pressure vessels and manufactured in accordance with Section VIII of the code.

3 The liquid withdrawal valve was a RegO Chek-Lok valve model number 7572FC, which is no longer
manufactured. Although the RegO name is still used on propane equipment, the company that manufactured this
valve is no longer in business.

Little General Store September 2008

6

Fire departments from the neighboring communities of Beckley, Beaver, and Princeton responded to the

explosion. Later that day a team from the West Virginia Office of the State Fire Marshal arrived to

investigate, assisted by an agent from the U.S. Bureau of Alcohol, Tobacco, Firearms, and Explosives

(ATF).

Figure 2. Site plan of Little General Store.

Little General Store September 2008

7

1.2 Investigative Process

The CSB investigation team arrived at the incident scene on January 31. They joined the Incident

Command structure, in accordance with the National Incident Management System (NIMS),4 and began

on-scene investigation activities. On February 2, 2007, Incident Command demobilized after the State

Fire Marshal concluded that the incident was not a criminal act. The CSB investigation team remained,

and with the help of Little General management, protected and preserved evidence, moving it to a secure

storage locker.

The team interviewed employees of the companies involved, emergency responders, and officials from

the West Virginia Office of the State Fire Marshal; The West Virginia Division of Labor; the Raleigh

County Building Department; Regional Education Service Agency (RESA)5 Region I; the United States

Fire Academy; the ATF; the Beckley and Beaver, West Virginia Fire Departments; the Occupational

Safety and Health Administration (OSHA); the National Fire Protection Association (NFPA); the

National Propane Gas Association (NPGA); and the Propane Education and Research Council (PERC).

In addition, the CSB tested and examined the valve that released the propane from the Ferrellgas tank.

The test protocol included in situ examination and flow testing; removal of the liquid withdrawal valve

assembly (valve, tank nozzle, and dip tube); photography and examination of the valve and dip tube,

including removal of the dip tube; and dismantling and examination of the valve.

4 NIMS is a comprehensive approach to incident response management that provides a consistent, nationwide
template to enable all response entities to work in concert during incidents. Implementation of NIMS is required
by the US Department of Homeland Security in accordance with its authority in Homeland Security Presidential
Directive 5 “Management of Domestic Incidents.” The State Fire Marshal reestablished an incident command
system following the explosion.

5 Enacted by the West Virginia Legislature in 1972, RESA provides educational services to schools, including
technical, professional, operational, and programmatic services. In addition to school-based programs, RESA
coordinates much of West Virginia’s professional firefighter training program.

Little General Store September 2008

8

1.3 Little General Store, Inc.

Little General Store, Inc. operates 48 convenience stores throughout southern and central West Virginia

and western Virginia. The Ghent store was a combination gasoline station and convenience market. At

the time of the incident, the Ghent store and three others included pizzerias, which used propane for

cooking.

1.4 Little General Store Propane Suppliers

1.4.1 Southern Sun

Southern Sun supplied propane to Little General beginning in late 1994. Southern Sun was a family-

owned propane, heating oil, and ice supplier located in south central West Virginia. In 1996 Southern

Sun sold its propane operations to Ferrellgas, which became the supplier to Little General.

1.4.2

Ferrellgas

Ferrellgas, headquartered in Overland Park, Kansas, is the second-largest propane marketer in the United

States, with offices and customers in all 50 states. One of Ferrellgas’ business strategies is to “expand

operations through disciplined acquisitions and internal growth.” Since 1986 Ferrellgas has acquired 166

propane distributors throughout the United States.

Late in 2006, Little General initiated a change in propane suppliers from Ferrellgas to ThompsonGas

Propane Partners.

1.4.3 Thompson Gas and Electric Service, Inc.

Thompson is a privately held company that installs commercial and residential propane systems and

delivers propane in the eastern and southeastern United States.

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1.4.4 Appalachian Heating

Appalachian Heating is a family-owned heating, ventilation, air conditioning (HVAC), and plumbing

company. Appalachian installs appliances, installs and maintains heating and cooling systems, and

installs and repairs plumbing. Appalachian entered into a contract with Thompson in August 2005 to

extend its business to include propane supply.

1.4.5 ThompsonGas Propane Partners, LLC

ThompsonGas Propane Partners is the limited liability company (LLC) formed between Thompson of

Hagerstown, Maryland, and Appalachian Heating of Bradley, West Virginia. Under the agreement

forming ThompsonGas Propane Partners, LLC, Appalachian Heating provides personnel to install

propane systems and deliver propane; Thompson provides equipment, bulk propane, and technical

support. The LLC has no employees.

1.5 West Virginia Emergency Service Organizations

1.5.1 West Virginia State Fire Commission

The West Virginia Fire Prevention and Control Act6 of 1975 established the West Virginia State Fire

Commission and granted the commission authority to promulgate and establish a state fire code.7 The

commission established the National Fire Codes8 as the minimum fire prevention and protection

requirements for the state.

6 West Virginia Code Chapter 29, Article 3 “The Fire Prevention and Control Act.”
7 West Virginia Legislative Rule Title 87, Series 1, “State Fire Code.”
8 NFPA publishes the National Fire Codes annually. The National Fire Codes are a collection of all NFPA’s

standards.

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1.5.2 West Virginia State Fire Marshal

The West Virginia State Fire Marshal’s Office, overseen by the State Fire Commission, has four divisions

providing fire protection and regulatory services: regulation and licensing, public education, fire

investigation, and regional response. The Fire Marshal enforces the rules of the State Fire Commission

throughout West Virginia. Currently, the Fire Marshal’s Office employs 12 code inspectors and 11 fire

investigators.

1.5.3 Raleigh County Emergency Services

An executive group is responsible for emergency services management in Raleigh County, West Virginia.

Group membership includes county commissioners; the district attorney; mayors of municipalities; the

county sheriff; the Office of Emergency Services (OES); and the county public information officer.

Raleigh County emergency services encompass mutual aid management among municipal fire

departments (career and volunteer); police; emergency medical transport services; and community-based

support agencies. Services are coordinated under a unified command system at the Emergency

Operations Center (EOC) located in Beckley.

Local municipalities are responsible primarily for emergency response activities within their areas.

County resources are available from the OES and coordinated through the EOC when emergencies exceed

local response capabilities. The OES develops and maintains the Raleigh County Emergency Plan and

manages the county’s 911 emergency call center.

1.5.4 Ghent

Volunteer Fire Department

The Ghent Volunteer Fire Department was incorporated in 1973 and has 28 members providing fire

fighting, life protection, and ambulance service to residents in the Ghent area. Salaried Emergency

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Medical Technicians (EMTs) are on duty at the fire station 24 hours a day, seven days a week.9 All

Ghent area emergency 911 calls are routed to the Raleigh County EOC where operators dispatch the

appropriate fire or emergency medical service.

1.5.5

West Virginia E911 Council

West Virginia established the E911 Council in 1986 to organize and implement the universal 911

emergency telephone number system. The council promotes, researches, plans, educates, develops

funding streams, and proposes state legislation to ensure reliable 911 call service operations.

Representatives from West Virginia’s 55 counties serve on the council, which meets monthly.

The council works closely with emergency response industry organizations including the National

Emergency Number Association (NENA) and the Association of Public-Safety Communicators Officials

(APCO). In addition, the council is involved in activities to promote and fund 911 systems statewide.

1.5.6

West Virginia Office of Emergency Medical Services

The West Virginia Office of Emergency Medical Services (EMS) is a division of the West Virginia State

Trauma and Emergency Care System, administered by the West Virginia Department of Health and

Human Resources. The Office of EMS was legislatively mandated in 1975 and tasked with operating a

comprehensive statewide EMS program. It oversees licensing for EMS agencies and training and

certification for responders.

9 The Ghent fire department comprises trained volunteer firefighters and paid emergency medical technicians.
Many of the emergency medical technicians, including those who responded to the Little General propane release,
also serve as volunteer firefighters.

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1.6 Professional and Industry Organizations

1.6.1 National Fire Protection Association

The NFPA publishes consensus standards applicable to specific industries and activities, including the

propane industry and hazardous materials incident response. These standards, while voluntary unless

incorporated into state laws or regulations, provide safe practice guidelines for operations in the processes

they address. West Virginia adopted the National Fire Codes into the State Fire Code.10

1.6.2

Propane Education and Research Council

Congress created the Propane Education and Research Council (PERC) in the Propane Education and

Research Act of 1996. PERC’s purpose is to promote the safe use of propane energy in the United States.

Each gallon of odorized propane sold in the United States is assessed one-half of one cent to fund PERC.

PERC estimates revenue of $45,300,000 for the 2009 fiscal year.

PERC develops the curriculum for the Certified Employee Training Program (CETP), which is the

propane industry’s primary training method for service technicians, bulk plant operators, delivery truck

drivers, and customer service representatives.

1.6.3

National Propane Gas Association

Founded in 1931, the National Propane Gas Association (NPGA) is the trade association representing all

propane industry segments. It is located in Washington, D.C., and affiliated with 38 state and regional

associations, including the West Virginia Propane Gas Association.

The NPGA administers CETP throughout the United States.

10 The CSB determined that the National Fire Codes were adopted by the West Virginia State Fire Marshal prior to
1967, although the exact date is unknown.

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2.0 Incident Description

2.1 Events Preceding January 30, 2007 Explosion

Significant events preceding the January 30, 2007, explosion at the Ghent Little General Store include

1. 1988 – Southern Sun buys the incident tank and places it in propane service.

2. Late 1994 – Southern Sun relocates the incident tank from its original installation to the Little General

Store in Ghent and installs it against the store’s exterior back wall.11

3. 1996 – Ferrellgas buys the Southern Sun propane business and performs a pre-acquisition review of

the business and operations, including an inspection of some of Southern Sun’s propane systems.

4. 1996 to 2007 – Ferrellgas drivers fill the incident tank about 14 times per year conducting about 140

pre-fill inspections.

5. April and June 2000 – Ferrellgas employees perform two Installation Reviews (Appendix A) on the

propane system at Little General.

6. August 2005 – Thompson Gas and Electric Service, Inc. and Appalachian Heating form the business

ThompsonGas Propane Partners, LLC.

11 At the time of the installation, West Virginia and OSHA required 500-gallon propane tanks to be at least 10 feet
from buildings; however, Raleigh County had no code enforcement mechanism at that time.

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7. September 2006 – Appalachian Heating’s only propane service technician (the lead technician at the

scene of the incident) completes training and becomes fully qualified (in accordance with CETP) to

install propane tank systems.12

8. Fall 2006 – Little General Store, Inc., begins changing propane suppliers from Ferrellgas to

ThompsonGas Propane Partners.

9. December 2006 – Appalachian Heating reassigns an HVAC technician to the propane business (the

junior technician at the scene of the incident).

10. January 2007 – The two propane service technicians from Appalachian Heating began installing a

new Thompson Gas tank and associated equipment at Little General.

2.2 Day of the Incident

On the morning of Tuesday, January 30, the two propane service technicians traveled separately to the

Little General Store. At around 9:15 am, witnesses observed both of their trucks at the store. According

to Appalachian Heating, the day’s work plan was to transfer the propane from the existing Ferrellgas tank

to the newly installed Thompson tank and place the new propane system in service.

By 9:30 am the lead technician had left the store to make a delivery 31 miles northwest of Little General;

the junior technician remained alone at the store. For the next hour, the junior technician worked alone

while he prepared to transfer propane from the Ferrellgas tank to the Thompson tank.

12 Thompson trained the lead technician on sections 1, 2, and 4 of CETP. The lead technician also spent nearly a full
year working with experienced personnel from multiple Thompson offices.

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Around 10:25 am, the junior technician removed a plug13 from the liquid withdrawal valve (Figure 3) on

the Ferrellgas tank. When he removed the plug, liquid propane unexpectedly began spraying from the

valve.

Figure 3. Liquid withdrawal valve.

At 10:28 am, the junior technician called14 the lead technician, who was still offsite, to report the problem.

In response, at 10:31 am, the lead technician called Thompson technical support for guidance. After the

call to technical support, the lead technician called the junior technician twice, most likely to relay the

guidance from technical support and to encourage him to call 911.

13 The valve plug has two functions: to prevent a propane leak if the valve seat leaks and to prevent foreign
materials’ entering the valve mechanism. The withdrawal valve itself is spring-loaded and self-closing and should
not leak; however, if it does, a telltale hole drilled through the threaded portion of the plug sprays a small amount
of propane giving an early warning of a malfunction prior to completely removing the plug.

14 All telephone calls discussed throughout this report were from cellular phones.

Plug

Valve Body

Valve sealing disk and washer

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16

A deliveryman in the store at about 10:30 am told the CSB that he smelled a strong odor and that the store

employees’ eyes were watering. The Little General cashier, concerned about the odor, went outside to

check on the junior technician. The cashier told the CSB that she saw him standing between the tank and

his service truck within a dense vapor cloud,15 but that he told her he was “okay.”

At 10:40 am, the junior technician called 911 to summon help from emergency services (see transcript in

Appendix B). He reported to the 911 operator that he had a leaking propane tank at the Little General in

Ghent and needed the fire department’s assistance to secure the area. The 911 operator collected this

information, clarified the location, and ended the call.

After the 911 call, the junior technician called the lead technician again. The cashier checked on the

junior technician a second time, finding him in the same location between the tank and truck. Figure 4 is

an event timeline prior to the lead technician’s return.

15 Propane is a colorless gas. A liquid release from a tank forms a dense white cloud of visible propane liquid
droplets that then evaporate.

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Figure 4. Timeline of initial events

2.3 Response to the Propane Release

After the junior technician’s call, Raleigh County Emergency Services dispatched the Ghent Volunteer

Fire Department to the Little General (Appendix B).

The first to arrive, at about 10:47 am,16 was a captain from the Ghent Volunteer Fire Department. The

captain assumed the role of incident commander (IC) in accordance with Ghent Volunteer Fire

Department guidelines.17

16 As no record of precisely what time the captain arrived at the scene exists, the CSB estimated it from other known
events.

17 Although functioning in accordance with the Ghent Volunteer Fire Department guidelines, the captain had no
formal incident command training and did not establish command in accordance with NIMS.

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Shortly thereafter, two EMTs arrived in an ambulance. The surviving EMT told investigators that he saw

the IC at the store’s front door when he arrived. According to the Little General store manager, the IC

had ordered the business to close.18

The IC asked the EMTs to follow him behind the building to treat the junior technician for a burn on his

forearm. The EMTs examined the junior technician and determined that the burn was frostbite likely

from the releasing liquid propane.

Following the medical examination, the IC sent the EMTs to the front of the store to ensure that the

business had closed, gasoline was not being pumped, and no one was smoking. One EMT walked to the

store entrance and found it locked; however, he was able to speak to the Little General employees inside

to confirm that the business was closed. The Little General employees had hung a small sign on the door

to inform customers that the store was closed due to a gas leak. The EMT positioned himself in the

parking lot and proceeded to direct traffic and customers away from the property.

Just after 10:50 am, the lead technician returned to the store. He parked in front of the building and

walked to the area of the tanks.

A firefighter arrived in his personal vehicle to assist with the emergency and checked in with the IC. The

firefighter saw the IC and the two technicians working around the leaking tank; he could hear the

escaping propane. The IC ordered him to “make sure everybody’s out, okay?” However, as the

firefighter began walking to the front of the store, the propane ignited and exploded.

18 When ordered to close, the Little General employees turned off the gasoline pumps, locked the doors, and
remained in the building.

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The explosion killed four near the tanks (the two technicians, the IC, and one EMT). The four workers

inside the building and the firefighter survived but sustained serious injuries. The EMT, who was

directing traffic and customers, suffered an arm injury.

The explosion leveled the building, destroyed a Ghent Volunteer Fire Department ambulance (cover

photograph), and damaged many parked vehicles. The force of the blast threw the Ferrellgas tank about

80 feet and the Thompson tank about 50 feet. Figure 5 is an event timeline of the initial emergency

response.

Figure 5. Timeline of incident response.

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3.0 Propane Incident Frequency

3.1 United States Hazardous Materials Incidents 2001 – 2006

The National Fire Incident Reporting System (NFIRS) is the United States Fire Administration’s database

of fire and emergency incidents. The CSB reviewed the NFIRS database for the years 2001 to 2006 to

determine the frequency with which United States fire departments responded to propane incidents.

In this six-year period, the NFIRS database includes 36,744 hazardous materials responses in the United

States.19 Of these responses, 35.3 percent were responses to releases of gasoline, natural gas, or propane.

Incidents involving propane occur nearly once per day.

Table 1. U.S. hazardous materials incidents 2001-2006.

Gasoline
Natural
Gas Propane

Total
hazardous
materials
incidents

2001 658 468 157 4154
2002 817 627 210 4661
2003 1084 830 263 5904
2004 1149 863 234 6307
2005 1423 1151 301 8301
2006 1406 997 317 7417
Total 6537 4936 1482 36,744

19 As not all states require participation in NFIRS data collection, the total number of hazardous materials responses
may not be exhaustive; however, the CSB and the U.S. Fire Administration consider the types of responses
representative of the United States as a whole.

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3.2

Recent Propane Incidents

Since the explosion in Ghent, several similar propane release incidents have occurred in the United States.

The CSB researched five incidents similar to the Little General incident (see Appendix C).

Three incidents involved only propane releases and two involved releases and flash fires. In the three

release-only incidents, both firefighters and propane service technicians responded. A propane service

technician secured one of the incident tanks, and firefighters trained in hazardous materials response

secured the other two. No injuries occurred in these incidents.

The two incidents involving releases and flash fires both occurred at sites where propane service

technicians were involved in tank-to-tank transfers of liquid propane. In these cases, fire departments

responded, and in both incidents destroyed the structures located nearest the propane tanks. One flash fire

injured a person onsite. The other killed one propane service technician and severely injured two others.

Firefighters, propane service technicians, or both regularly respond to propane release incidents. The

successful mitigation of a release depends on the training and experience of both groups.

Additionally, shortly before the Ghent incident, a liquid propane release and explosion occurred at the

Falk Corporation facility in Milwaukee, Wisconsin on December 6, 2006. Employees discovered a pool

of liquid propane near a propane pipeline. Most employees began evacuating; three remained to attempt

to repair the leak. About 10 minutes after the pool of propane had been discovered, it ignited, killing the

three employees and injuring over 40 others. OSHA cited Falk and its piping contractor for failing to

prepare employees for emergencies involving liquid propane.

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4.0 Propane System Fundamentals

4.1 Propane Properties

Propane is used extensively as a fuel for cooking and heating in residential, retail, and commercial

applications.20 It is a gas at ambient temperature and pressure but is transported and stored as a liquid.

Propane-air mixtures can be explosive when the atmospheric concentration of propane is between 2.4 and

9.5 percent by volume. Because propane is odorless and colorless, small quantities of an odorizing

chemical (ethyl mercaptan) are added so leaks can be detected by smell.

Unlike natural gas, propane is heavier than air. Consequently, propane releases tend to accumulate at

ground level or in other low points such as pits and basements.

4.2 System Features

The propane system at Little General consisted of a stationary 500-gallon storage tank (Figure 6) and two

supply regulators to reduce the pressure of the propane for pizza ovens used in the store. The storage tank

had five connections:

1. A fill connection fitted with an internal check valve;

2. A liquid level gage to measure the quantity of propane in the tank;

3. A relief valve (safety device) to prevent over-pressurization of the tank;

4. A service valve to supply gaseous propane to the regulators; and

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5. A liquid withdrawal valve fitted to an internal dip tube for removing liquid propane when necessary.

Figure 6. Typical ASME propane tank.

The liquid withdrawal valve incorporated several safety features:

1. A threaded valve plug to protect the valve from foreign material and provide a secondary seal if the

primary valve were to leak.

2. A telltale in the threaded area on the valve plug. The telltale is exposed before the plug is completely

removed. The telltale releases propane if the primary valve leaks allowing a propane service

technician to check for valve leaks before completely removing the plug.

3. A special connector that, when screwed on, opens the valve.

20 According to PERC, about 17.5 million U.S. households use propane as a heating or cooking fuel, excluding
grills. About 3,500 companies market propane around the country.

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4. An excess flow disk in the valve to limit flow should flow exceed a preset limit, such as during a hose

rupture.

4.3 Propane Standards

4.3.1 Occupational Safety and Health Administration

The OSHA standard Storage and Handling of Liquefied Petroleum Gases21 establishes specific

requirements for most workplaces22 storing and handling liquefied petroleum gases (LP gases)23,

including propane.

The standard’s requirements include, but are not limited to, design, operation, technician training, safety

devices, and tank placement. A 500-gallon tank, like the one at Little General, must be located at least 10

feet from buildings.

4.3.2 NFPA Propane Standards

Two NFPA standards address propane: the National Fuel Gas Code (NFPA 54), which applies to fixed

gas-consuming (including propane) equipment attached to piping, and the Liquefied Petroleum Gas Code

(NFPA 58), which applies to the storage, handling, transportation, and use of LP gas. NFPA 58 Chapter 6

addresses installing LP gas systems, including requirements for tank locations. NFPA 58 also requires a

500-gallon tank to be at least 10 feet from commercial and residential buildings.

21 29 CFR 1910.110.
22 Little General is covered by OSHA’s occupational safety and health standards.
23 Liquefied petroleum gas is the general term for mixtures of hydrocarbon gases liquefied by pressure and used for

cooking, heating, and vehicle fuel. Liquefied petroleum gas can be propane, butane, propylene, butylene or any
mixture of these compounds.

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4.4 Propane Emergency Guidance

4.4.1 Guidance for Consumers

Propane companies (including Ferrellgas and Thompson), NPGA, and PERC distribute literature and

publish information on their websites guiding consumers on actions to take during propane emergencies

such as leaks and releases. If consumers detect a propane leak, this guidance recommends that they:

• Extinguish smoking materials and discontinue the use of lights, appliances, phones, or any electrical or

spark producing device.

• Evacuate the area or building immediately.

• If possible, turn off the gas supply at the tank or cylinder.

• Go to a neighbor’s house and call the propane company or 911.

• Stay out of the area or building where the leak was detected.

4.4.2 Guidance for Emergency Responders

Propane Emergencies, published for the NPGA and PERC, is the primary text for training emergency

responders to handle

propane emergencies.

The textbook outlines a process wherein the IC should

perform a series of actions prior to attempting remediation of the propane emergency. The first step the

textbook specifies is site control; it states that the IC must keep all responders and members of the public

clear of the hazard until the scene and the hazard are fully understood.

The US DOT Emergency Response Guidebook recommends an immediate evacuation to at least 330 feet

in all directions and ½-mile downwind for large spills. Responders are cautioned to keep all members of

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the public away from the area surrounding the point of the release. In addition, the Guidebook states that

propane gas is heavier than air and may settle in low or confined areas.

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5.0 Incident and Emergency Response Analysis

5.1 Liquid Withdrawal Valve

Liquid withdrawal valves are rarely used. Technicians only open them when tanks must be completely

emptied of liquid. The liquid withdrawal valves on most propane tanks may never be used. At Little

General, the day of the incident was either the first or the second time that the plug had been removed

from the liquid withdrawal valve in the tank’s 19 years of propane service.

When the junior technician removed the plug from the liquid withdrawal valve, liquid propane released

uncontrollably. The plug, though, has a telltale drilled through the threaded portion (Figure 7) which

should have released a small stream of propane once the plug was partially backed out. This should have

alerted the technician that the valve was leaking.

Figure 7. Incident valve plug (Telltale circled).

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The CSB determined that the junior technician likely was unaware of the existence and function of the

telltale due to inexperience and lack of training and removed the plug completely. Although the CSB

determined that it is highly unlikely the telltale hole was obstructed at the time of the incident, CETP

training could have made the junior technician aware of and prepared for the possibility of an obstruction

of the telltale. The CETP section on liquid withdrawal valves states:

In some cases, a damaged seat may allow an excessive amount of liquid to be discharged when

the closing cap [plug]24 is loosened. A bleed hole [telltale] in the closing cap has been provided

to vent the liquid before the cap is completely unscrewed. If a significant amount of liquid

continues to be blown from under the closing cap for more than 30 seconds, it can be assumed

that the internal seat will not prevent a dangerous amount of gas from escaping. IF IN DOUBT,

DO NOT REMOVE THE CLOSING CAP. [CETP 2.2.13]

In addition to the information on the valve above, the CETP procedure for transferring liquid propane

from a tank to a truck states:25

While removing the plug, if an excessive volume of propane leaks from the valve, reinstall the

plug and follow manufacturer’s instructions. [CETP 2.2.13]

The CSB initially tested and examined the tank and valve in its “as-found” condition. The CSB

determined that the liquid withdrawal valve leaked when the tank was pressurized.26 Following this

examination and test, the CSB removed the valve from the tank, performed additional examinations and

24 Plug (external threads) closures are no longer used with liquid withdrawal valves; therefore CETP refers only to
cap (internal threads) closures.

25 CETP contains step-by-step procedures for liquid propane transfer from a stationary tank to a tank truck. Liquid
propane transfer from a stationary tank to a second stationary tank is not described in CETP.

26 Nitrogen was used to pressurize the tank since it is inert and allowed this test to be conducted safely.

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tests, and partially disassembled the valve. The CSB found the valve jammed, likely because of a

manufacturing defect,27 and the valve seal cracked (Figure 8). With the valve jammed in an open

position, only the plug stopped the liquid propane from escaping. When the junior technician removed

the plug, propane began uncontrollably releasing. Cracks in the seal material likely prevented the excess

flow feature from limiting the release.

Figure 8. Crack in valve seal.

27 A hole bored through the center of the lower guide through which the valve stem moves was determined to be too
small for the valve stem to move freely.

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5.2 Propane Tank Placement

In 1994, Southern Sun installed the 500-gallon propane tank directly against the Little General store’s

exterior back wall. The tank remained in this position and in operation until the day of the incident. The

position of the tank was contrary to both the West Virginia Fire Code and the OSHA LP gas standard.

Figure 9 shows a 2003 photograph of the building with the propane tank visible behind a wooden fence.

Photo courtesy of Little General Store, Inc.

Figure 9. Pre-incident photograph of the Ferrellgas tank.

Multiple witnesses told the CSB that Southern Sun placed the tank against the back wall. Paint patterns

on the tank corroborate this: the outward facing side of the tank was painted with the Ferrellgas color and

logo, while the side of the tank facing the building was painted with the Southern Sun name and logo

(Figure 10). This suggests that Ferrellgas painted only the side of the tank that was accessible.

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Figure 10. Incident tank side facing building.

During the release, witnesses described seeing billowing white clouds striking the building and roof

overhang and cascading toward the ground, which is consistent with the known behavior of propane

vapor following a liquid release. The peaked roof of the store overhung the exterior walls. The overhang

was open to allow ventilation in the store’s attic space; restroom exhaust ducts terminated inside the

overhang directly above the incident tank. The open overhang and restroom exhaust ducts provided a

direct pathway for propane to enter the building. The CSB found that if the tank were placed at least 10

feet from the store, propane likely would not have entered the store in large quantities.

5.2.1 Southern Sun Acquisition

Ferrellgas’ acquisition of Southern Sun included a pre-acquisition review of Southern Sun’s business and

operations, which included inspections of propane systems at select Southern Sun customer locations. In

addition, Ferrellgas was allowed to identify and request correction of any deficiencies discovered in the

year following the acquisition. According to Southern Sun, only two propane tanks were returned, both

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because of illegible or missing tank nameplates. Ferrellgas first filled the tank at the Little General soon

after the acquisition, and did not identify the tank placement as deficient.28

5.2.2 Ferrellgas Inspection and Quality Review Program

5.2.2.1 Ferrellgas Inspections

The Ferrellgas inspection program for propane systems at customer locations consists of two separate

activities: the driver’s pre-fill inspection, where delivery personnel visually inspect the system and the

Ferrellgas Installation Review (FIR), where an experienced service technician visually inspects the

system and records the findings.

1) Drivers’ Pre-Fill Inspection

Drivers perform pre-fill inspections prior to each propane delivery at a customer location. This visual

inspection includes the tank, visible piping, regulators, and the area around the tank. Ferrellgas trains

drivers to inspect the installation for potential deficiencies such as tank damage or corrosion,

accumulations of combustible materials near the tank, fitness of piping and regulators, tank placement and

new structures near the tank, and tank labeling. The driver does not record the results of the pre-fill

inspection, but does have the authority to remove the system from service upon finding unsafe conditions.

The driver must also report unsafe conditions to management so that a service technician can fix any

noted problems. Ferrellgas training materials for delivery drivers discuss tank placement and clearly state

that 500-gallon propane tanks must be at least 10 feet from buildings.

28 The week prior to the incident, Appalachian Heating had also replaced another Ferrellgas tank that was placed less
than 10 feet from a different Little General Store location.

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Ferrellgas filled the tank at Little General Store about 14 times per year; in the 10 years that Ferrellgas

owned the tank, drivers would have performed more than 100 pre-fill inspections. The CSB interviewed

several drivers who filled the Little General tank and performed the required inspections. All drivers

stated that they believed the tank was permitted to be directly against the building’s exterior back wall

either because it was “grandfathered,”29 the installer had received a variance from local authorities,30 or

there was no other place to install the tank.

2) Ferrellgas Installation Review

The Ferrellgas Installation Review (FIR)31 is a visual inspection of the installation at a customer’s site.

The FIR includes the same topics as the driver’s pre-fill inspection; however, the inspector records the

results either on a form or handheld computer. The service center receives the results of the FIR, records

deficiencies, and dispatches service technicians to repair noted problems.

Ferrellgas performed two FIRs on the Little General Store installation in 2000, four years after acquiring

the tank (Appendix A). These inspections were two months apart; neither inspector noted the placement

of the tank on the form.32 Both inspectors told CSB that they could remember neither the inspections nor

the reasons for not reporting the tank’s placement in the FIR.

29 They believed that the tank installation predated the 10-foot clearance requirement, and was permitted to remain
next to the building under some previous set of rules.

30 Local authorities issue formal waivers from code requirements such as the tank placement distances, which are
known as variances. Ferrellgas training materials reference the possibility of obtaining a variance from local
authorities; however, a variance was not issued for the placement of the tank at Little General.

31 Ferrellgas called this inspection program the FIR during the time it owned the incident tank. The review has been
renamed and is now called the Product Installation Review. The methodology for inspection has not changed.

32 Checking the location of an installed tank is step one in the FIR procedures, which states that tanks that do not
meet the 10-foot placement requirement must have a written variance from local authorities.

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5.2.2.2 Ferrellgas Quality Review Program

Ferrellgas’s Quality Review program33 comprises two annual internal audits; each reviews safety and

quality at a Ferrellgas service center location. Each service center’s general manager (SCGM) conducts

one audit (the SCGM audit), and a regional technical analyst conducts the other (the regional technical

analyst audit).

1. Service Center General Manager’s Audit

Since 2005, Ferrellgas has required its SCGM to perform quarterly audits of his service center. Each

SCGM uses a standard checklist-based procedure to audit specific segments of the business according to

the following schedule:

• First Quarter: Administration, including delivery, installation, and training documentation, operating

procedures, and inspection results;

• Second Quarter: Plant operations, including piping, tanks, system and container integrity, and operator

proficiency;

• Third Quarter: Delivery operations, including delivery trucks’ integrity and roadworthiness, and driver

proficiency; and

• Fourth Quarter: Customer installations, including inspection of 10 old and 10 new systems.34

33 The Quality Review program is independent of the FIR and the driver’s pre-fill inspection. Neither audit is
scheduled to coincide with a system installation or propane delivery.

34 New installations might be placed by Ferrellgas during the year or be acquired by buying other preexisting
propane systems.

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The CSB requested all SCGM audits from the Princeton and Beckley, West Virginia, service centers for

the 10 years preceding the incident. Ferrellgas provided SCGM audits from 2005 and 2006 but provided

no documentation of any customer installation audits.

2. Regional Technical Analyst Audit

At least once annually, regional technical analysts (known as operations managers prior to 2005) conduct

compliance and safety audits at Ferrellgas service centers in their respective regions. The audit is similar

to the SCGM quarterly audit in that the technical analyst examines delivery operations, administration,

plant operations, and customer installations, using a checklist to guide the audit and record the results.

The only apparent difference is that the technical analyst performs all four segments of the audit within

one to two days and the SCGM examines one segment per quarter.

5.2.3 Ferrellgas Inspection and Quality Review Program Analysis

At least six Ferrellgas delivery drivers and service technicians were in a position to identify and report the

incorrect placement of the tank behind Little General; none did. Although Ferrellgas training materials

discuss correct tank placement and list tank placement as an inspection criterion for which drivers and

technicians may remove tanks from service, the employees who filled and inspected the tank believed that

its location was approved.35

The SCGM customer installation audits for the Beckley and Princeton offices were likely not conducted.36

Had managers performed these audits, it is still possible that because of the sampling methods used they

35 All Ferrellgas drivers and technicians reported to the CSB that they had received training in accordance with
Ferrellgas procedures.

36 Ferrellgas was unable to provide any documentation of customer installation audits for the ten years preceding the
incident.

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would not have detected the improper installation at Little General. Ferrellgas’ instructions on

conducting audits merely recommend SCGMs inspect customer installations that were filled on the day

prior to the review or inspect those that the manager is driving past. These methods of sampling provide

no way to systematically review all installations over time.

SCGMs’ and regional technical analysts’ audits focus primarily on identifying and correcting deficiencies

at facilities and customer locations. Only those installations that are spot-checked during the quality

review are corrected; therefore broader systemic problems may remain undetected. In contrast, generally

recognized and accepted practices for auditing safety management systems focus on assessing and

verifying system effectiveness.37 These practices include using statistical sampling, trend analysis,

management system review, and corrective action to detect systemic problems and ensure ongoing hazard

control throughout the organization.38

5.3 Propane Service Technician Training and Response

5.3.1 Propane Service Technician Training

5.3.1.1 Federal and State Training Requirements

The United States Department of Transportation (DOT) and OSHA regulations have limited propane

service technician training requirements. DOT requires training only for propane personnel who engage

in transportation activities. OSHA requires training for propane service technicians but does not elaborate

on this requirement (Section 6.1).

37 Standard safety texts describe audits as systematic, independent reviews that determine conformance to company
and industry standards whereas inspections are physical inspection of installations and facilities.

38 CCPS, 1993; Petersen, D., 1996; Weinstein, M.B., 1997

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Some form of state-mandated training and/or testing requirement for propane service technicians exists in

14 states, and 10 of those have specific training requirements; however, the depth of training required

varies broadly. No states require emergency response training for propane service technicians.

Three states require licensing for propane service technicians. States use licensing to establish and

enforce minimum competency standards for technicians; collect funds for inspection, compliance, and

training programs; and communicate technician qualifications to consumers. In the states that license

propane service technicians, CETP is an accepted training program. Additionally, at least 10 states have

licensing programs applicable to propane and natural gas appliance installers. Recurrent licensing

requirements, based on state-established standards of training, testing, and/or experience, aim to ensure

that only qualified personnel work on indoor propane and natural gas systems.

West Virginia does not require propane service technicians to be trained, certified, or licensed. Appendix

D contains a table of the state requirements.39

5.3.1.2 NFPA 58 Training Recommendations

NFPA 58 recommends training for propane industry employees who perform activities within its scope,

which includes those who transport and transfer LP gas. The standard states that these employees “shall

be trained in proper handling procedures. Refresher training must occur at least every 3 years. The

training shall be documented.”40 An appendix note states that refresher training may be less intensive

than original training. However, NFPA 58 does not elaborate on what constitutes initial training. It

includes no guidance suggesting a scope, timeframe, or testing component for facilitating an enforceable

training standard for states that have adopted NFPA 58, including West Virginia.

39 Information on state training requirements was provided to the CSB by PERC.
40 NFPA 58 – 2008 Section 4.4 “Qualifications of Personnel.”

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5.3.1.3 Propane Industry Training Program

PERC and the NPGA developed its comprehensive training curriculum for propane industry employees,

CETP, in 1988. Although CETP is voluntary in most states, many employers in the propane industry use

it to train and certify employees. PERC offers the task-based modular curriculum both in instructor-led

settings and as a computerized self-teaching program, and sells course materials to employers for in-

house training and preparation for CETP certification tests.

CETP consists of eight modules. Applicable training modules include

• Propane “basics,” including properties of propane, industry standards and organizations, bulk

plant and delivery vehicle identification, safe work practices, and reacting to interruptions of

customer gas service;

• Propane delivery, including equipment and operating procedures, loading and unloading,

inspecting delivery trucks and installed propane systems, responding to customer calls, and

evacuating propane tanks; and

• Propane vapor distribution system installation, including transporting tanks and cylinders,

installing aboveground and underground tanks, installing regulators and piping, performing leak

checks, documenting installations, and communicating safety information to customers.

Employers may select topics as appropriate to address job tasks for individual employees, who may then

take certification exams in those areas for which they have completed training. For example, customer

service representatives often complete the propane basics module, and delivery drivers complete the

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propane basics and propane delivery modules. Companies may also augment the curriculum to include

company-specific policies and information.41

An important part of the CETP curriculum is its skills testing component. The training program itemizes

basic propane procedures; within 12 months of passing the CETP certification exam, certification

candidates must demonstrate these procedures and be evaluated. The CETP curriculum includes skills

assessment forms; a trainer or other supervisor with sufficient experience must observe a certification

candidate perform or simulate procedures correctly, document performance evaluations for each set of

procedures, and forward the documentation to PERC before the candidate is certified to work alone.

The junior technician at Little General was preparing for a tank-to-tank transfer of liquid propane.

Although a CETP module provides step-by-step procedures for liquid transfers to and from bulk delivery

trucks, such procedures do not exist for tank-to-tank transfers. While some propane companies may

develop their own instructions for this task, the junior technician had no written procedure for his

activities on the day of the incident.

5.3.1.4 Propane Service Technician Emergency Response Training

A propane incident involving fire department response occurs nearly once per day in the United States

(see Table 1). The CSB found that propane service technicians routinely respond to these emergencies.

When the lead technician returned to the Little General store in response to the emergency, he was

functioning as a specialist responder, with expertise in propane and propane systems. By the time he

arrived, a hazardous materials release had been underway for at least 20 minutes. However, his training

had not included an emergency response component.

41 PERC offers the Safety and Training Administrative Records System (STARS), a computer-based program for
record keeping and training management, which also allows employers to add their own policies to modules.

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The CSB found a number of other incidents in which propane service technicians assisted first responders

in emergencies involving their companies’ equipment and product. First responders consider propane

service technicians to be “product and container specialists” who have more experience dealing with

propane and its systems than firefighters, police, paramedics, and EMTs.42 Although propane service

technicians are not trained to take action to mitigate a hazardous materials emergency without specific

training,43 emergency responders often seek their advice and assistance.

PERC and the NPGA provide a Propane Emergencies training curriculum for first responders that

addresses the role of propane service technicians in the incident command structure (see Section 5.3).

However, CETP only briefly addresses emergencies at bulk plants and traffic accidents involving delivery

vehicles. No CETP module specifically addresses the potential emergencies service technicians

encounter or the basics of hazardous materials incident response.

5.3.2 Thompson Gas/Appalachian Heating Employee Training

Thompson Gas Propane Partners, LLC required all propane service technicians to be CETP-trained to the

appropriate level for their jobs. The 2005 contract with Appalachian Heating defines responsibilities,

including employee training: Appalachian is responsible for ensuring that all employees working with

propane are qualified “as defined in NFPA 54 and 58” and CETP-trained for their particular jobs. The

specific requirements include completion of CETP 1.0, Basic Principles and Practices, within 30 calendar

days of first working for Appalachian/Thompson, and completion of other applicable modules within one

year. Additionally, Appalachian Heating must maintain all training records and certifications, provide

ongoing training, and update the staff list for Thompson Gas before any new employees begin working.

42 Propane Emergencies, PERC and NPGA, 3rd edition, page 44.
43 HAZWOPER Standard, 29 CFR 1910.120(q).

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Thompson provided CETP training for Appalachian’s lead technician in 2006, including the basic

principles, delivery, and vapor distribution system installation modules. Experienced Thompson trainers

directly supervised his performance of propane service and delivery tasks for nearly a year. This was

combined with the CETP classroom training to ensure that he was able to demonstrate proficiency and

pass certification examinations prior to working unsupervised.

The junior technician began working in the propane business in mid-December, about 45 days prior to the

incident. However, Appalachian did not inform Thompson of the new employee. At the time of the

incident the junior technician had not trained with CETP and had not received any other formal propane

service training.

Had Appalachian Heating implemented the training procedures required by the contract, the junior

technician would have, via CETP, become familiar with a range of procedures and situations that might

occur in the course of working with propane including operation of the liquid withdrawal valve.

5.4 Fire Department Response

The IC arrived at the Little General store shortly after the initial dispatch call. In the approximately five

minutes from his arrival until the explosion at 10:53 am, the IC took several actions. He:

• Assessed the frostbite injury to the junior technician;

• Ordered the business to close;

• Directed the EMTs to the rear of the building to treat the junior technician’s frostbite;

• Ordered the EMTs to ensure that the business was closed, that no one was smoking, and that no

gasoline was being pumped; and

• Ordered the firefighter to ensure that everyone was out of the building.

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Guidance for emergency responders in hazardous materials emergencies recommends evacuating and

evaluating the situation from a safe distance as the first task. However, the IC’s final direction, to ensure

that everyone was out of the building, came too late. Within about 30 seconds of the order, the propane

ignited and the building exploded.

Based on witness statements and the IC’s known actions, the CSB determined that the IC allowed the

propane service technician to try to correct the propane release while the IC managed the scene.

However, the IC was likely unaware of two critical facts:

• The junior technician, upon whom the IC was relying to correct the release, was neither trained

nor experienced in propane transfer operations and propane emergencies (Section 5.3).

• The building was filling with a flammable mixture of propane and air. While the IC was

concerned with ignition sources outside such as cigarettes and vehicles, ignition sources inside

the building remained uncontrolled during the release.

Without knowledge of these facts, the IC was likely unable to fully understand the severity of the

emergency at Little General, even though he was fully trained in accordance with the rules of the West

Virginia Fire Commission.

5.4.1 Hazardous Materials Incident Training for Firefighters

West Virginia requires all firefighters to receive basic training in hazardous materials incident response.

This training is required prior to working as a firefighter and therefore is generally conducted only once,

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early in a firefighter’s career. In contrast, chemical facilities and refineries in the United States that

maintain hazardous materials response teams are required to train team members annually.44

The required hazardous materials incident response training teaches firefighters to identify hazardous

materials and incidents involving hazardous materials, use DOT’s Emergency Response Guidebook, and

recognize when additional resources are necessary. The training instructs firefighters to take only

defensive actions when encountering a hazardous materials incident; it does not give firefighters the

knowledge or skills to enter the area of the release and attempt to stop the release. This action is reserved

for organized hazardous materials response teams.

The IC at Little General attended a hazardous materials incident response course in 1998. This was a

higher-level course than required (see Section 6.3 for requirements), and included topics such as incident

risk assessment, selection of personal protective equipment, and control techniques, and a practical

exercise. However, this training occurred nine years before the Little General incident, and the CSB

found no documentation that the IC had attended refresher training or practical exercises. Unrehearsed

knowledge decays over time; hazardous materials incident response skills acquired in training are more

difficult to retain without regular refresher training or practice.45

5.4.2 Propane Industry Training for Emergency Responders

The Propane Emergencies training program offered by PERC and the NPGA is free to fire departments

around the United States. The program trains first responders to recognize the specific hazards of a

44 29 CFR 1910.120 requires industrial hazardous materials incident responders to attend eight hours of refresher
training annually.

45 For a full discussion of skill loss, see Arthur Jr., W., Bennett Jr., W., Stanush, P., & McNelly, T. (1998). “Factors
That Influence Skill Decay and Retention: A Quantitative Review and Analysis,” Human Performance, Vol. 11,
pp. 57-101.

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propane release and treat it as a hazardous materials incident. It emphasizes the importance of evacuating

the incident area and evaluating the hazards from a safe distance prior to taking other actions.

Additionally, it addresses incident command structure implementation and the advisory role of propane

service technicians. None of the Ghent Volunteer Firefighters had participated in this program.

5.5 911 Emergency Call Center Response

At many 911 call centers around the United States, operators use quick-reference guide cards to help them

evaluate caller emergencies, gather pertinent incident details, and convey life-saving information to

callers. Several organizations in the United States produce pre-written guide cards for 911 centers to

purchase.46 These guide cards provide easy-to-access information for operators, including questions

relevant to the emergency and instructions to be given to the caller prior to emergency services’ arrival.

Specific sets of guide cards exist for health and injury, fire service, and police response emergencies.

Raleigh County 911 uses guide cards for health emergencies and injuries only.

At 10:40 am on the day of the incident, the propane service technician called Raleigh County 911 to

report the release and summon emergency services. The operator who received the call did not have a

guide card or protocol to help evaluate the situation, collect pertinent information, and provide guidance

to the caller.

46 Guide cards are available as printed or electronic references and kept at each operator’s station.

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The propane industry developed a model questionnaire and script to use in situations where customers

report propane emergencies such as leaks or releases. The questionnaire prompts personnel answering

calls to ask questions such as

• Where is the leak?

• Do you hear gas escaping?

• Is the leak near any building?

• Is there an odor of gas in the building?

An affirmative answer to these and other questions prompts the gas company operator to read a script that

instructs the caller to eliminate ignition sources, evacuate the building to a safe distance, and wait for gas

professionals or fire service personnel.

Equipping 911 operators with such a prewritten guide can potentially improve safety by initiating

important first response actions such as evacuation.

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6.0 Regulatory Analysis

6.1 Occupational Safety and Health Administration

The OSHA standard regulating propane systems requires that all personnel “performing installation,

removal, operation, and maintenance of propane equipment shall be properly trained in such function.”47

However, neither the standard, its preamble, nor letters of interpretation define or interpret “properly

trained,” nor does it provide for specific training standards, requirements for recurrent training, written

testing, or skills testing. OSHA only requires employers to develop training programs they deem

appropriate without providing any performance criteria such as those under the industry’s program.

Additionally, the OSHA standard requires that owners of propane tank(s) be notified prior to work being

done on their tank(s) by others.48 Although Appalachian Heating employees removed the liquid

withdrawal valve plug from the Ferrellgas tank, Appalachian Heating did not notify Ferrellgas.

6.2 Environmental Protection Agency

Firefighters and emergency medical personnel are typically the first responders to hazardous materials

spills and releases, like the incident at Little General. However, in 26 states (including West Virginia),

state and municipal employees are not covered by the OSHA health and safety regulations that require

first responder hazardous materials training.49 In an attempt to close the gap, the U.S. Environmental

Protection Agency (EPA) promulgated the Worker Protection standard (Appendix E)50 for municipal and

state emergency responders.

47 29 CFR 1910.110(b)(16).
48 29 CFR 1910.110(b)(14)(ii).
49 See CSB Report No. 2006-03-I-FL “Bethune Point Wastewater Treatment Plant” for a full discussion.
5040 CFR 311.

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The Worker Protection standard requires states and municipalities to prepare employees for hazardous

materials emergencies in accordance with OSHA’s Hazardous Waste Operations and Emergency

Response standard.51 The standard’s requirements apply to career and volunteer fire companies, and

public emergency medical response agencies. The United States Fire Administration and PERC52 both

cite the Worker Protection standard in their incident response training courses for firefighters. The rules

for firefighters and emergency medical personnel in West Virginia, however, do not specifically

incorporate the EPA requirements under the Worker Protection standard.

6.3

West Virginia Fire Commission

The primary role of the Fire Commission in West Virginia is the promulgation of the state fire code and

certification requirements for fire departments.

6.3.1 Requirements for Fire Departments53

The West Virginia Fire Commission certifies fire departments every five years based on

• location, size and boundaries of the fire protection district;

• number of active and available personnel and their level of training;

• quantity and type of equipment;

• administrative procedures and policies including chain-of-command;

51 29 CFR 1910.120 – Hazardous Waste Operations and Emergency Response generally requires employers to
develop emergency response and health and safety plans that address worker training, preparedness, and health
monitoring. The regulation applies to both long-term hazardous waste clean-up operations in addition to
emergency response for incidents involving any hazardous material (not limited to hazardous wastes). The
standard requires initial training and annual refresher training.

52 Propane Emergencies, 3rd ed., p. 41.
53WVC 29-3-2.

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• 911 service and mutual aid agreements for the area served;

• the department’s record of response to emergency calls; and

• recordkeeping and NFIRS reporting.54

On April 1, 2005, the Fire Commission published an administrative policy to assist it in its evaluation of

fire departments.55 The policy addresses certifying and training active personnel in fire departments,

requiring them to attend Firefighter Level I, first aid, cardio-pulmonary resuscitation (CPR), and

hazardous materials response training.

The Fire Commission’s policy specifically requires the following for hazardous materials response:

Fire department members and officers shall be trained in NFPA Standard No. 472, Professional

Competence of Responders to Hazardous Materials Incidents.56 All Fire Department personnel

shall be certified at the Awareness level. Fire Department personnel that operate at hazardous

materials incidents must minimally meet U.S. Environmental Protection Agency and U.S.

Occupational Safety and Health Administration requirements for response at the Operations level.

Additional training should be at the discretion of the fire chief based on possible involvement

with hazardous materials incidents unless otherwise directed by federal or state statutes, rules

and/or regulations. [WVC 29-3-9(i)]

Unlike requirements for industrial hazardous materials incident responders, this Fire Commission

requirement does not specifically address recurrent training. All active industrial hazardous materials

54 The criteria are located in WVR 87-6-5.
55 The administrative policy is found at WVC 29-3-9(i).
56 NFPA 472 was renamed the Standard for Competence of Responders to Hazardous Materials/Weapons of Mass

Destruction Incidents in the 2008 revision.

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responders in the United States are required to undergo an annual refresher course. Yet firefighters, who

are likely to respond to many incidents involving gasoline, natural gas, or propane—all hazardous

materials—in any given year, are not specifically required by the West Virginia Code to complete an

annual refresher course or perform regular response drills. As discussed in Section 5.4, the IC in the

Ghent incident had not trained for or practiced hazardous materials emergency response in almost 10

years.

6.3.2 West Virginia Fire Code

West Virginia has a comprehensive statewide fire code.57 The fire code incorporates, by reference, the

majority of the NFPA’s standards and guides. Incorporated standards include NFPA 472, which addresses

response to hazardous materials incidents. NFPA 472 defines the levels of response to hazardous

materials incidents—awareness, operations, technician, incident commander, and specialist employee—

and outlines basic expectations for responders at each level.

The NFPA’s definition of awareness level personnel is consistent with OSHA’s definition:58 awareness

level personnel are those who, during the course of their normal job functions, could encounter

emergencies involving hazardous materials. These persons must be able to recognize hazardous materials

emergencies, protect themselves, call for trained assistance, and secure the area.59 Awareness level would

apply to propane service technicians like the junior technician at Little General when the release began,

since they may encounter propane emergencies during the course of their duties.

Operations level personnel respond to already-discovered hazardous materials incidents, taking actions to

protect people, the environment, and property from the effects of the release. They are qualified to take

57 West Virginia Rule Title 87 Series 1 Fire Code.
58 29 CFR 1910.120
59 NFPA 472 Chapter 4

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defensive actions to mitigate the damage caused by a hazardous materials incident, but not to actively

handle or attempt to contain the hazardous material(s). This type of action might include assessing the

scene and planning a response, establishing evacuation perimeters, setting up communications, and

initiating the incident command system. The operations level designation applies to anyone arriving at

the scene in response to a hazardous materials emergency; in Ghent, the lead technician, the EMTs, and

the fire department personnel acted at an operations level by arriving at the Little General in response to

the junior technician’s phone call.

Hazardous materials technicians, in contrast, are those qualified to take defensive and offensive actions in

response to an incident. Offensive actions entail entering the incident “hot zone” to attempt to control a

release, and require additional training beyond the operations level.60 Additionally, hazardous materials

responders may seek the help of specialists: industry employees familiar with and trained in the hazards

and systems of a given material, like propane. Specialist employees must also meet specific NFPA 472

competencies to be qualified to perform release control actions. Propane service employees who assist

emergency responders physically secure releases must meet at least these competencies. Although the

evidence and witness statements indicate that the Appalachian Heating employees and Ghent Volunteer

Fire Department personnel were standing in the vapor cloud and attempting stop the release, none were

trained to the technician or specialist level.

60 Technician level training corresponds to 29 CFR 1910.120 40-hour HAZWOPER training.

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7.0 Findings

1. The propane service technicians, emergency responders, and store employees did not evacuate the

area as recommended by nationally accepted guidance for propane emergencies. In fact, emergency

responders and the propane service technicians were observed standing in the propane vapor cloud.

2. Propane companies, the National Propane Gas Association, and the U.S. Department of

Transportation recommend evacuation to a safe distance as the first action in response to a propane

release.

3. The fire department captain, the propane service technicians, and the Little General Store employees

were unaware of the dangerous propane accumulation inside the building.

4. A defect in the existing tank’s liquid withdrawal valve caused it to malfunction and remain in an open

position.

5. About 25 minutes elapsed from the time the release began until the explosion.

6. Both the U.S. Occupational Safety and Health Administration’s and the West Virginia Fire

Commission’s propane standards require a distance of at least 10 feet between 500-gallon propane

tanks and buildings such as the Little General Store. However, when the Southern Sun propane

company installed the propane tank in 1994 it was placed directly against the Little General Store’s

exterior back wall.

7. Ferrellgas, which acquired Southern Sun in 1996, allowed the tank to remain against the building’s

exterior wall for more than 10 years.

8. The placement of the 500-gallon propane tank against the building’s exterior wall provided propane a

direct pathway into the store’s interior during the release.

9. Ferrellgas management’s quality review program functions as a basic safety inspection rather than a

management systems audit.

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10. The junior propane service technician who was servicing to the tank on the day of the incident had no

formal training and did not recognize the defect in the withdrawal valve. He was also working alone

even though he had been on the job for only one and a half months.

11. Propane service technicians commonly do not receive emergency response training.

12. The propane industry’s primary training curriculum (the Certified Employee Training Program)

consists of procedures and materials for performing routine (non-emergency) tasks only.

13. The Occupational Safety and Health Administration’s and National Fire Protection Association’s

propane standards require training but do not include curricula, practical exercises, emergency

actions, or knowledge evaluation tools.

14. A propane emergency significant enough for fire department response is reported nearly everyday in

the United States. Only gasoline and natural gas are involved in more hazardous materials

emergencies.

15. 911 operators in the United States lack propane emergency guidance to help them collect important

information from callers, offer life-saving advice, and convey relevant information to first responders.

16. Minimal information on the nature of the incident was exchanged between the propane service

technician and the 911 operator. Therefore, the only information the 911 operator provided the Ghent

Volunteer Fire Department responders was the incident location and the “report of a propane leak.”

17. Firefighters in West Virginia are required to attend a minimum of four hours of hazardous materials

emergency response training as part of their initial training sequence but refresher training is not

required. The responding Ghent Volunteer Fire Department captain last attended a hazardous
materials response course in 1998.

18. Propane safety and emergency training is voluntary for fire department personnel in West Virginia.

None of the responders from the Ghent Volunteer Fire Department had specific training relating to

propane emergencies.

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8.0 Causes

1. The Ferrellgas inspection and audit program did not identify the tank location as a hazard.

Consequently, the tank remained against the building for more than 10 years.

2. Appalachian Heating did not formally train the junior technician, and on the day of the incident he

was working alone.

3. Emergency responders were not trained to recognize the need for immediate evacuation during liquid
propane releases.

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9.0 Recommendations

Governor and Legislature of the State of West Virginia

2007-04-I-WV-R1

Require training and qualification of individuals who operate bulk propane plants, dispense and deliver

propane, install and service propane systems, and install propane appliances. The training and

qualification requirements should be comparable to those of existing propane industry programs such as

the Certified Employee Training Program.

West Virginia Fire Commission

2007-04-I-WV-R2

Revise the Fire Commission rules and codes to require annual hazardous materials response refresher

training for all firefighters in West Virginia.

2007-04-I-WV-R3

Revise the Fire Commission rules and codes to require that all West Virginia fire departments perform at

least one hazardous material response drill annually.

West Virginia Office of Emergency Medical Services

2007-04-I-WV-R4

Revise the Office of Emergency Medical Services rules and codes to require annual hazardous materials

response refresher training for all emergency medical personnel in West Virginia.

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National Fire Protection Association

2007-04-I-WV-R5

In the Liquefied Petroleum Gas Code (NFPA 58) “Qualifications for Personnel” section, specify training

requirements (including supervised on-the-job training), training curricula, competencies, and testing

through written examination and performance evaluation, or reference a nationally recognized curriculum

for these requirements.

Association of Public-Safety Communications Officials

2007-04-I-WV-R6

Develop a guide card for propane emergencies to assist 911 operators in the collection of pertinent

information on propane emergencies. The questionnaire in Section 1.9.1 in the Propane Education and

Research Council’s Certified Employee Training Program may be used as a model.

Propane Education and Research Council

2007-04-I-WV-R7

Revise the Certified Employee Training Program to include

• Procedures for transfer of liquid propane from tank to tank, or

• The prohibition of the transfer of liquid propane from tank to tank.

2007-04-I-WV-R8

Revise the Certified Employee Training Program to include emergency response guidance for propane

service technicians who respond to propane emergencies similar to guidance provided to emergency

responders in the Propane Emergencies program.

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National Propane Gas Association

2007-04-I-WV-R9

Submit a request to the United States Occupational Safety and Health Administration for a letter of

interpretation to determine if the Certified Employee Training Program curriculum meets the training

requirements in 29 CFR 1910.110.

2007-04-I-WV-R10

Work with the West Virginia E911 Council with development of propane emergency guidance by

providing the Council with the customer leak questionnaire located in Section 1.9.1 of the Certified

Employee Training Program and technical assistance.

West Virginia E911 Council

2007-04-I-WV-R11

Work with the National Propane Gas Association to develop and distribute propane emergency guidance

for use by all county and municipal 911 communication centers in West Virginia.

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Ferrellgas

2007-04-I-WV-R12

Establish and implement a comprehensive safety management system that includes at a minimum:

• An auditing program developed in accordance with generally accepted methodologies to

monitor the performance and effectiveness of safety management systems and personnel

at all levels,

• An inspection program that uses NFPA 58 as a guide to systematically inspect all

customer propane systems and identify all deficiencies,

• A means of tracking audits and inspections and identified deficiencies,

• A means of tracking corrective actions,

• A means of collecting and using audit and inspection data for trend analysis and

organizational learning,

• A means of periodically reporting audit and inspection trends to the Board of Directors

and Managing Board, and

• A provision for periodic safety management system audits conducted by a third party

competent in the requirements of NFPA 58.

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By the

U.S. Chemical Safety and Hazard Investigation Board

John S. Bresland

Chair

Gary Visscher

Member

William Wark

Member

William Wright

Member

Date of Board Approval

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References

Center for Chemical Process Safety (CCPS), 1993. Guidelines for Auditing Process Safety Management

Systems, American Institute of Chemical Engineers (AIChE).

Ferrellgas Partners, L.P., 2006. US SEC Form 10-K – Annual Report Pursuant to Section 13 or 15(d) of

the Securities Exchange Act of 1934.

Hildebrand, M.S., and G. G. Noll, 2007. Propane Emergencies,3rd ed., National Propane Gas Association

(NPGA) and Propane Education & Research Council (PERC).

Lemoff, T. C., ed., 1998. LP-Gas Code Handbook (5th edition), National Fire Protection Association

(NFPA).

National Fire Protection Association (NFPA), 2008a. Liquefied Petroleum Gas Code, NFPA 58.

NFPA, 2008b. National Fuel Gas Code, NFPA 54.

NFPA, 2008c. Standard for Competence of Responders to Hazardous Materials/Weapons of Mass

Destruction Incidents, NFPA 472.

Occupational Safety and Health Administration (OSHA), 2007. Storage and Handling of Liquefied

Petroleum Gases, 29 CFR 1910.110, OSHA.

Petersen, D., 1996. Analyzing Safety System Effectiveness, Third Edition, John Wiley & Sons, Inc.

Raleigh County Emergency Services Agency, 2006. Raleigh County Emergency Operations Plan (EOP).

West Virginia Fire Commission, 2004. State Fire Code, Title 87 Series 1 (87CSR1), West Virginia

Legislative Rules.

Weinstein, M.B., 1997. Total Quality Safety Management and Auditing, Lewis Publishers.

West Virginia Legislature, 2007. Fire Prevention and Control Act, Chapter 29 Article 3 (WVR 29-3),

West Virginia Code.

Little General Store September 2008

60

Appendix A

Ferrellgas Installation Reviews of the Incident Tank

Little General Store September 2008

61

Little General Store September 2008

62

Little General Store September 2008

63

Appendix B

911 Call and Initial Fire Department Dispatch

Little General Store September 2008

64

Emergency 911 Call – Report of Release

AUTOMATED VOICE: Conversation recorded on January 30th, 2007, at 10:40, on Channel 7.

DISPATCHER: 9-1-1, where is your emergency?

CALLER: Yes, ma’am. I need to — I need a fire department down at the Little General Store in Ghent. I

need a — I got a propane leak — I need their help to secure the area.

DISPATCHER: A propane leak?

CALLER: Yes, ma’am.

DISPATCHER: What’s the address? Is that the one on Odd Road?

CALLER: No, ma’am. It’s the one actually on, uh — the one going towards Shady Springs. With the

Godfather’s Pizza.

DISPATCHER: Do you know the address?

CALLER: No, I don’t, ma’am. Right in front of Flat Top Lake.

DISPATCHER: Flat Top Lake.

CALLER: Yes, ma’am.

DISPATCHER: And this is Little General, right?

CALLER: Yes, ma’am.

DISPATCHER: And this is a propane leak? What is your name?

Little General Store September 2008

65

CALLER: XXXXXXXXXXXXX;1 I work for Appalachian Heating; we’ve had a dysfunction in the

tanks, and I have a leaky tank.

DISPATCHER: Okay. All right, I’ll get the fire department out there for you.

CALLER: Thank you. Bye-bye.

DISPATCHER: Thank you.

Emergency Dispatch – Initial Dispatch Notification to Ghent

Volunteer Fire Department

AUTOMATED VOICE: Conversation recorded on January 30th, 2007, at 10:43, on Channel 21. (Fire

tones.)

DISPATCHER: Raleigh Control, Station 110 — Station 110 — you need to respond to Flat Top Road in

Ghent, the Little General, across from Flat Top Lake; report of a propane leak. Repeating, Station 110,

need units to respond to Flat Top Road at the Little General, report of a propane leak. WGC808, 10:44.

1 Name removed.

Little General Store September 2008

66

Appendix C

Recent Propane Incidents

Little General Store September 2008

67

Recent Propane Incidents

CSB identified the following incidents for further research based on their similarity to the Little General

incident. The CSB interviewed the propane companies, emergency responders, and local investigators

involved in these incidents to collect relevant information. The CSB did not conduct an independent

investigation.

1.0 Propane Release Incidents

1.1 Aberdeen, Washington

1.1.1 Incident Description

On October 23, 2007, the Southshore Mall in Aberdeen, Washington, was evacuated due to a vapor

release from a 1,150-gallon propane tank. The tank was located in a utility yard approximately 25 feet

from the mall restaurants for which it supplied heat and fuel. Shortly after 2:00 pm, a mall employee

heard a “pop” and, upon going outside to investigate, discovered the leaking tank. The fire department

responded, evacuated the mall, and isolated the scene.

The fire department called the propane company that owned the tank for incident support. The company

sent one service technician to assist the fire department. The responding technician found the release was

from the tank’s fill valve, which had become stuck partially open. The technician installed a double-

check valve on the leaking fill valve to stop the release. The fire department lifted the evacuation order

by 2:45 pm.

1.1.2 Incident Responders

The propane company involved in this incident reported having a preexisting working relationship with

the fire department. All the propane company’s employees train on job procedures with CETP and

Little General Store September 2008

68

practice emergency response scenarios. The service technician who was sent to assist the fire department

had both CETP training on all propane service and delivery procedures and on-the-job experience as a

service technician and a delivery driver.

In emergency response cases like this one, the fire department is in charge of the scene, with the gas

company employees on the scene to assist and advise the fire department as necessary. Occasionally,

propane service technicians responding at the request of a fire department take offensive steps to stop a

release—in this case, by installing a valve. The fire department’s decision to allow the propane service

technician to repair the tank was different from the Ghent incident in several important ways:

• The fire department had evacuated and secured the scene prior to the technician’s entry.

• The vapor release from the leaking fill valve was much less severe than the liquid propane release

in Ghent, requiring only a small repair for the tank to remain in service safely.

• The technician was CETP-certified and experienced, had drilled on emergency response

scenarios, and had previously worked with the fire department on propane incidents.

When emergency responders and service technicians have clearly established and rehearsed roles in an

incident command structure, both groups are better equipped to implement their training.

1.2 Lynchburg, Virginia

1.2.1 Incident Description

At about 1:00 pm on November 26, 2007, a traffic accident caused a vehicle to crash into a 1,000-gallon

propane tank used for filling cylinders, located outside of a True Value Hardware store in Lynchburg,

Virginia. When the vehicle struck the tank, the inch-and-a-half liquid line connecting a pump and the

tank was severed. The tank settled on top of the severed pipe, which in turn prevented the excess-flow

valve from seating, resulting in a liquid propane release. Hardware store employees called 911 and the

Little General Store September 2008

69

propane company that owned the tank. Although the 911 operator dispatched the hazardous materials

response team to the incident as a gas leak, a citizen driving past called the team to clarify that it was a

propane release.

The team arrived and secured the area, evacuating shoppers from the rear of the hardware store on foot.

Since the valve could not be repaired, the response team used water spray to disperse the vapor cloud

formed by the liquid release, while keeping the area evacuated. Once most of the propane in the tank had

been released, the response team approached the tank and used a strap to completely seal it. They then

loaded the sealed tank onto a truck for removal from the area. The release lasted two hours.

Propane service technicians from the company that owned the tank also responded. They arrived after the

hazardous materials response team, and attempted to approach the tank. Response team members

removed the technicians to the incident command post, outside of the release area.

1.2.2 Incident Responders

The responding hazardous materials team is an all-career unit, with all members trained to technician

level (40-hour) training, which qualifies them to take offensive action in response to releases. According

to responders, propane incidents occur frequently in the area; although most involve residential propane

cylinders, the hazmat team has responded to several major incidents. As a result of the prevalence of

propane in the area, its hazards are a focus in training sessions. With this training, responders were able

to quickly assess the uncontrolled release and evacuate the area.

All propane service technicians at the company that owned the tank, a small locally owned business,

receive CETP training. Additionally, the company has trained with the fire department in CETP

procedures to help emergency responders understand propane systems. However, the CETP program has

no emergency response component, and propane service technicians do not train with responders the

incident command system or other aspects of hazmat response. As in Ghent, propane service technicians

Little General Store September 2008

70

attempted to take an active role in release mitigation without hazardous materials or emergency response

training. However, unlike Ghent, fire department responders in this incident were trained and

experienced in the hazards of propane releases, and evacuated everyone, including technicians, from the

area.

1.3 Bristow, Virginia

1.3.1 Incident Description

On May 19, 2008, the Linton Hall School in Bristow, Virginia, was evacuated due to a vapor release from

a 500-gallon propane tank. The tank was located 15 to 20 feet from the school, near the cafeteria kitchen.

At about 11:20 am, a trash truck backed into a chain connecting the tank to a light pole,

1 overturning the tank and shearing off its service valve, causing a propane vapor release. School

administrators called 911 and the propane company that owned the tank, and evacuated the 205 students

and 30 faculty members according to routine fire drill procedures.

The 911 operator who received the call dispatched the county fire department to the incident as an outside

gas leak. The first responding fire engine company arrived on scene, assessed the situation, and revised

the call to an inside gas leak due to the tank’s proximity to the school kitchen and water heater,

dispatching the hazardous materials response team.2 When the team arrived, it sprayed water in a fog

pattern to push released vapor down and away from the school, then used a wooden dowel and a towel to

plug the leak. Propane service technicians from the company that owns the tank arrived after the team

had secured the release and moved the tank to a large open parking lot away from the school to repair the

1 A “No Parking” sign hung from the chain.
2 The dispatching system in this county requires the hazardous materials unit to respond to all interior gas leaks.

Little General Store September 2008

71

valve. No one was injured. Students remained at a church across the street until parents arrived to take

them home.

1.3.2 Incident Responders

The hazardous materials team involved in this incident has responded to several propane incidents in the

last year, all of which have been vapor releases. They receive technical information from propane service

technicians, but take release mitigation actions themselves. To protect propane service technicians from

entering the release area, the team uses methods including

• taking digital photographs of tank damage so that technicians can see and assess the damage on a

remote laptop computer,

• bringing similar tanks or other equipment to the scene so that technicians can point out features

the team will find on the incident tank, and

• escorting technicians to the edge of the secured release area to point out potential leak sources for

team members.

Additionally, the hazardous materials response team trains local 911 operators to use follow-up questions

to elicit needed information from callers reporting hazardous materials incidents. In this incident, as in

Ghent, the 911 operator conveyed little information to the fire department. However, unlike Ghent

responders, the first fire engine company to arrive immediately recognized the danger posed by the

release’s proximity to a building and called for hazardous materials backup.

The propane service technicians responding to this incident were branch employees of a national propane

company that uses CETP. In the event of a propane emergency, whichever technicians are working

nearest the incident stop work immediately and respond. Since these responders are all trained with

CETP, they are familiar with what types of incidents they can mitigate using normal propane procedures.

Little General Store September 2008

72

In this case, propane service technicians attempted to repair the tank only after the fire department had

secured it and removed it from nearby buildings.

2.0 Propane Release and Fire Incidents

2.1 Sallis, Mississippi

2.1.1 Incident Description

On May 13, 2007, a propane explosion occurred at the Longhorn’s Steak House in Sallis, Mississippi,

while the restaurant was closed and two propane service technicians were transferring propane from an

old 500-gallon tank into a new 500-gallon tank behind the building. The transfer procedure had been

completed and the new tank was leak-tested and placed in service. The technicians next planned to

remove the old tank (which still contained some propane) from the premises, but were unable to load it

onto the service truck. They left and returned later in the day with a trailer. As the technicians were

loading the old tank onto the trailer, it slid to one side, severing a valve at the bottom of the tank. The

technicians heard a loud noise and saw liquid propane releasing from the bottom of the tank and forming

a vapor cloud along the ground. They immediately ran toward the front of the building; the propane

reached an unknown ignition source and a flash fire occurred seconds later. Another person who was

near the front door of the restaurant at the time was badly burned in the flash fire. The building and a

pickup truck parked in front were destroyed. Local volunteer fire departments responded, and the

Mississippi State Fire Marshal’s office investigated.

2.1.2 Incident Responders

The propane service technicians were from a local propane company. Although they had already

completed a tank-to-tank transfer without incident, they immediately realized the danger of a liquid

propane release from the damaged tank. Since the propane reached an ignition source only seconds after

Little General Store September 2008

73

the release began, the technicians were unable to evacuate the person in front of the restaurant before the

flash fire. Both reported to investigators that they had attempted to do so.

Local firefighters responded and reported the incident as a structure fire. The county sheriff’s department

informed the State Fire Marshal’s Office that propane was involved, and LP Gas Division investigators

completed the state’s report.

2.2 Danville, Alabama

2.2.1 Incident Description

On May 20, 2008, three propane service technicians were attempting to perform a tank-to-tank transfer of

liquid propane at a farm in Danville, Alabama, when a propane vapor release caused a flash fire. A

1,000-gallon propane tank at a chicken house was reported by property owners to be leaking around the

pressure relief valve. Technicians were to replace the half-full tank with a new tank and transfer the

remaining propane.

The technicians removed the leaking tank from its installed location and placed it to the side, then set the

new tank in its place. Employees next used the service truck boom to suspend the leaking tank upside

down and at an angle, near the new tank. They planned to use the filler valve to evacuate the old tank,

hooking it to a hose with a filler valve adaptor. However, damage to the filler valve caused it to stick in

an open position and release propane vapor. The vapor reached the service truck, idling near the transfer

location, and ignited setting fire to the chicken house.

The town’s volunteer fire department was dispatched to a structure fire. When firefighters arrived, they

discovered that the fire was due to a propane release. The firefighters then moved the three injured

technicians away from the fire, used water to cool the propane tank, and approached the tank in full

protective equipment to attempt to close the valve. They discovered that the valve had been sheared off

entirely and withdrew, continuing to contain the fire to prevent it from reaching other propane tanks

Little General Store September 2008

74

located 25 to 30 feet away. The firefighters called for the nearest hazardous materials response team to

assist them in using thermal imaging to determine how much propane remained in the tanks. The incident

tank was empty; no other tanks released. The chicken house was destroyed. All three propane service

technicians were severely burned; one died in hospital.

2.2.2 Incident Responders

The volunteer firefighters in Danville are all trained using the Propane Emergencies curriculum, which is

offered through the state fire college as a two-day program. The fire chief requires that they complete the

program twice before responding to propane incidents. This training includes practice on controlled

propane releases and fires, and allows the fire department to mitigate propane emergencies without

relying on propane companies. If firefighters cannot contain a release, they may let propane service

technicians work on the tank, but only if no fire is involved and the area has been secured.

Little General Store September 2008

75

Appendix D

Table of State Training, Testing, and Licensing Requirements
for Propane Service Technicians

Little General Store September 2008

76

For Propane Service

Technicians, this state

A
rk

an
sa

s

A
la

ba
m

a

C
ol

or
ad

o

Fl
or

id
a

Io
w

a

M
ai

ne

M
ar

yl
an

d

M
ic

hi
ga

n

M
is

so
ur

i

N
eb

ra
sk

a

N
ew

J
er

se
y

O
kl

ah
om

a

T
ex

as

V
er

m
on

t

Requires training x x x x x x x x x x

Requires testing x x x x x x x x x

Requires recurrent

training x* x x x x x* x

Accepts CETP x x x x x x x

Requires CETP† x† x x† x x x

Requires License x x x

* Only safety training required on a recurrent basis

† CETP or equivalent training required

Little General Store September 2008

77

Appendix E

United States EPA – 40 CFR 311

Little General Store September 2008

78

311.1 Scope and application.

The substantive provisions found at 29 CFR 1910.120 on and after March 6, 1990, and before March 6,

1990, found at 54 FR 9317 (March 6, 1989), apply to State and local government employees engaged in

hazardous waste operations, as defined in 29 CFR 1910.120(a), in States that do not have a State plan

approved under section 18 of the Occupational Safety and Health Act of 1970.

311.2 Definition of employee.

Employee in Sec. 311.1 is defined as a compensated or noncompensated worker who is controlled

directly by a State or local government, as contrasted to an independent contractor.

• copy for updated table of contents
• draft for pages through 6
• copy for pages 7 through 12
• copy for pages 13 through end
• copy for pages appendix headings

CHAPTER6

The Analytical Process

An accident investigation is the process of breaking down information
into pieces until the investigator understands what happened; then he or
she can analyze the pieces to determine ways to prevent the accident from
recurring. Asking “why” is a crucial first step in discovering the causal factors
of an accident.

Causal

Analysis

Once the evidence from an accident is gathered, you must discover the
accident sequence, an

d

once you know the sequence, causal analysis-the
process of determining the causal factors-can begin. (Senecal and Burke
1994) . The goal of causal analysis is to find all of the causes including the
systernic causes-not just the immediate or superficial causes. If only the
superficial causes are found and dealt with, the same accident could happen
again with a different employee.

One of the problems accident investigators sometimes have is knowing
~hen to stop searching for causes. Many accident investigators have used the
5

Whys” technique to find causes. This is simply asking ”Why?” five times
to get to the root of a problem. Fo r example, suppose John was working

59

rQU
Part JI: Organizing the Investigation

60

d
..nring pipes from one location to another ‘”h out oors ca …… ,– ,, . . vv en a .

c Here are five “Why? questions the investigator c ul Ptpe feU
1oot. · O d a k O!) l·

. d er into the cause of the accident: s Joh •ijs
going eep n, each

Investigator: John, why did the pipe fall on your foot?

John: I dropped it.

Investigator: Why did you drop it?

John: It slipped out of my hand.

Investigator: Why did it slip?

John: It was wet.
Investigator: Why was it wet?

John: The pipes were sitting in a pool of water.

Investigator: Why were they sitting in water?

John: It rained earlier today.

(Obviously, the questioning process in this case has only begun.)

Causal analysis is a process in which an investigator analyzes, probes
discovers, ponders, and uses scenarios, facts, tests, and assumptions t~
determine what caused an accident. Causes and causal factors can exist at
many levels-worker, equipment (failure or hazard), supervisor, management,
management systems (policies and procedures), and even corporate culture,
philosophy, and style. Lower-level causes are usually more specific to one
particular accident, but they are still important to list and fix. In fact, problems
at the lowest level can lead to worthwhile engineering and equipment
corrections that solve a problem or eliminate a hazard. Upper-level causal
factors are more difficult to fix, but doing so will affect a broader range of

1 d
. . f ·d t (DOE 1999). peop e an s1tuat1ons and help to prevent uture acc1 en s . .

Exhibit 6.1 displays the levels of accountability for accident inve5t1gat1ons.

Causal Analysis Example . ,1
. /. piece~

An accident occurred when a worker did not use a lock and tag to ,so ate
11

equipment and keep the electricity out.

Exhibit 6.1

1• workeror
equipment level

2. Supervisor level

3. Management
level

4. Corporate level

Chapter 6 : The A na!Jtical Process

LEVELS OF ACCOUNTABILITY

This is the lowest level of accountability. At the worker
level work is performed and equipment operates.
Causal factors in this area include equipment failures,
inadequate training, inexperience, and what many
consider human error (which would include training,
experience, etc.).

People at this level describe how work is to be done.
Causal factors often include inadequate handling of
job safety analyses, communication, or scheduling,
and lack of proper supervision.

Management level dictates policies and proce-
dures. Causal factors at this level are usually related
to budget issues, communication, and policies/
procedures.
This highest level dictates the culture, philosophy,
and style of the company. If problems are found
and corrected at this level, many accidents can be
prevented.

A lower-level causal factor is that the worker failed to use the proper lockout/
tagout procedure to isolate the energy. A higher-level factor could be that
management did not enforce or have a policy on lockout/ tagout. If the lower-
level problem is fixed-the worker is trained on lockout/ tagout procedures
and given a lock and tag-that worker probably will not have another accident.
However, if management develops a policy of training al/workers in lockout/
tagout procedures, many similar accidents can be prevented.

With this type of accident, a causal factor may also exist at the corporate
level if upper management failed to audit the plant’s procedures and
therefore did not find out that the plant lacked lockout/tagout policies. If
up~er management started performing policy audits, many more types of
accidents d b c • cause y 1ailure to follow policy or procedure-not just electrical
andlocko t/ . u tagout acc1dents–could be avoided.

61

Part IT: Organi~ng the Investigation

62

This example demonstrates the importance of an 1 . . . a YZJ.ng a
all levels. If you mvest1gate only at the lower levels you tn . n accident

th . . ay nuss s at causal factors-and thus e correcttve acttons-at the hi h 0 rne of th
. . g er level e

changes at higher levels 1s more complex than making th s. Makin
, em at lo g

It is difficult to change a company s culture, philosophy \Ver levels:
. . . . ‘ or style ‘Thi

not mean that you should av01d mvesttgattng high-level causal · s does
bili. . . b factors level of accounta ty 1s important- ut everyone should be a –each

only corrective action that is effective is one that is initiated a ware that the
by the appropriate decision-makers. nd supported

Hazards vs. Failures

As you investigate accidents, it is important to distinguish between hazards
and failures. A hazard is something that has the potential to cause injury, and
hazards are correctable. Examples of hazards are a sharp table edge or a pool
of grease on the floor.

A failure is something that goes wrong with personnel, equipment, or the
environment (Ferry 1981). A failure may or may not have the potential to
cause injury. If it does, it is also considered a hazard. A dead battery in an
automobile is an example of a failure that is not a hazard; ordinarily it would
not cause an accident. However, an automobile tire that fails and blows out
while someone is driving is considered a hazard as well as a failure, because
the failure could cause an accident.

d fi . d te maintenance, Failures are usually caused by faulty design, a e ect, ma equa
limits that were exceeded, or environmental effects.

Analytical Techniques
safety . d from systeW

Many accident investigation techniques were derive . f •iures and
· t design al techniques that were developed to analyze equipmen f Defense
h D artment o hazards. These types of techniques are used by t e ep

and Department of Energy (Vincoli 1994).

d

Chapter 6: The A11a!Jtical Process

There are five main accident investigation techniques. They are introduced
here and will be examined in depth in the next part of this book:

, events and causal factors analysis

, change analysis

, barrier analysis

, analytical trees

, cause and effect analysis

Each technique analyzes a different type of problem, and each has strengths
and weaknesses. The techniques are broad enough in scope to handle small
incidents as well as major catastrophes. Using several techniques in an
investigation ensures accuracy, consistency, and validity and helps investigators
to obtain more information about the accident sequence, be more accurate
and precise, and share investigative responsibilities with others. It is also
possible for the results of different techniques to validate each other. These
techniques must not be used mechanically or without consideration of the
accident sequence and circumstances (DOE 1999).

A flowchart of analytical techniques is illustrated in Exhibit 6.2.

Benefits of Using Analytical Techniques

• If you do not use analytical techniques, it is very easy to find only lower-
level causal factors and miss the systemic factors.

• Using analytical techniques for every accident investigation lends consistency
to your safety program.

• Analytical techniques will help you to make a smooth and consistent
transition from facts to causal factors.

• The thoroughness of the analytical techniques will give you confidence
that your investigation determined what really happened and that your
recommendations will prevent future accidents.

63

Pt111 II: Ort,t1//izf”g tbe [// vestigt1tio//

Exhibit 6.2

Has there been a
change in the process?

Is the task recurring?
Has it been done
accident-free?

Change Analysis

Is there a need to
evaluate the loss
control efforts or

emergency
response1

Time Loss
Analysis

Is there a failure of a
system or hardware?
Could a systematic.
evaluation of failure

modes be useful?

Type of Accident

Is there an accident
sequence?

Events and Causal
Factors Analysis

Has there been a
failure of an

engineered or
administrative barrier?

Barrier Analysis

Is there an event
sequence (event,

problem, or accident)?

Cause and Effect
Analysis

Specialized Analytical
Techniques

Did a human/machine/
environment interface

or interaction affect
the accident?

Human Factors
Analysis

Has there been a
deviation from the

requirements? Can a
review of the codes
requirements, and’

standards be useful?

;-r-~~~

. ~.”‘@~
.. ~ .

Has there been a
failure of a system?

Can a deductive
approach be useful?

Analytical Trees

Is there a need for a
time-based matrix of
all personnel at the

accident scene?

Integrated Acc!dent
Event Matrix

Is there still a void in
the information? can a

specific tes~ or . 7
technique fill thlS void,

“‘

Failure Modes and
Effects Analysis

————————~ Adapted from osHA ins
Design Criteria

Analysis

64

Chapter 6: T he A na/ytica/ Process

Summary

The events or circumstances that contribute to an accident are called causal
factors. Correction of these causal factors at whatever level they may occur
is what ensures that a particular incident will not recur. When using analytical
techniques, investigators must be able to distinguish between hazards
and failures . Using causal analysis and analytical techniques will make the
investigation more effective.

b

REVIEW QUESTIONS
1. What is a causal factor?

2. Describe the four levels of accountability.

3. What is the d ifference between a hazard and a failure?

4. Why is it advisa ble to use more than one an a lytica l technique to investigate
an accident ?

65

Part III

ANALYTICAL TECHNIQUES

Pm III focuses on how to analyze an accident and detennine what happened.
It explains events and causal factors analysis, change analysis, barrier analysis,
analytical trees, and cause and effect analysis as well as some other accident
investigation tools and techniques.

Part III also introduces a fictional accident scenario that will be used
to demonstrate techniques throughout the rest of the book, with each
demonstration building on the ones before it. The scenario is not intended
to fully analyze an accident but simply to demonstrate accident investigation
techniques.

I,yury:

When:

Where:

ACCIDENT SCENARIO

Employee fell off a ladder and suffered a broken arm
and a concussion.

7:45 A.M., February 5, 2011

Warehouse

Accident Description: Bill, a recently hired warehouse supervisor,
was hanging up a new exit sign to comply with NFP A Life Safety
Code requirements. During a recent warehouse expansion, new
rows had been added, and the fire inspector, during his visit the

67

Purl /[[: A 11ab’tical Tech11iqJ1eS

68

. d had noted that new exit signs needed to be install d
previous ay, . . . e .

ill d to
correct the violation as soon as possible

B wante ·
He arrived at work before his shift beg~-while the night shift
was still stocking shelves-to hang the signs. He placed a ladder
at the end of an aisle between two rows and climbed the ladder to
hang the sign. A forklift driver coming down the next aisle turned
the corner and hit the ladder. Bill fell and landed on his arm and
head. The forklift driver was not injured. She immediately alerted
her supervisor and the proper medical personnel were called.

Other Jnjo17!1ation: This was a non-recurring task. There were no
written job procedures for this exact task; however there were
procedures for changing light bulbs, a similar task. There were
also procedures for working on ladders and procedures for work-
ing in the aisles of the warehouse. There was no discussion or
review of potential hazards associated with this task. Bill’s shift
started at 8:00 A.M. Night shift personnel were taking their last
load to the warehouse before taking the forklifts to the recharging
area. Communication between the shifts and within management
had always been a problem. Bill was new to supervision; he had
just completed supervisor training the week before. The forklift

driver was properly trained.

Objectives for Part III:

• Understand the analytical techniques used for accident investigations.

• Be able to perform an events and causal factors analysis, change analysis,
barrier anal · al · · c accident. ysis, an yttcal tree, and cause and effect analysis 1or any

• Have a ge al kin d puterized ner wor g knowledge of other specialized an com
techniques.

>

CHAPTER 7

Events and Causal Factors Analysis

One of the most important steps in performing a comprehensive accident
investigation is documenting the accident sequence, and one of the best ways
to do this is to use events and causal factors ana/ysis. This technique has two
parts—creating an events and causal factors chart and using the chart to ana!Jze
the accident. The events and causal factors analysis will help you to determine
the accident sequence, analyze the sequence, and find the causal factors of

the accident.

About Events and Causal Factors Analysis
The concept of events and causal factors analysis has been around for more
than thirty years under a variety of names. The National Transportation
Safety Board used a similar technique called Multilinear Event Sequences
to document the events of an accident (Benner 1975) (Ferry 1981). The
?epartment of Energy incorporated events and causal factors charting into
tts 1:0RT system. In System Sefery 2000, Joe Stephenson introduced the idea
of VIS aliz’ · . u 1ng and analyzing the chart to find causes and develop corrective
acnons. He called this process causal factors ana/ysis (Stephenson 199

1

). The
refinements made through the years are incorporated into the description of
events and causal factors analysis discussed in this chapter.

69

Q
/>(llt JI/: A 11″1J•timl Tech11iq11es

70

The Events and Causal Factor
Analysis Approach s

As an accident investigation progresses, more and more info .
. d rtnatton is I

about the accident. Events an causal factors analysis pro •d earned
. v1 es a tool

events and causal factors chart-for chronologically arranging this in£ :–the
create a timeline of the accident. As facts are uncovered th orrnatJ.on to , e correspo din
events and conditions are incorporated into the chart. The inve . n g Stlgator an ,,,
the chart to find the causal factors of the accident only after al/ of a;,ze,
have been discovered. Figure 7-1 illustrates the events and ca

th
1 fe facts . . . usa actors

analysis t1meline approach.

Events and Causal Factors Charting

Some of the functions of the events and causal factors analysis chart are
listed and discussed below (OSHA Institute 1995) (Department of Energy
1999):

• Graphic portrayal of the accident sequence

• Recording of events and conditions

• Validation and verification of facts

Exhibit 7.1
EVENTS AND CAUSAL FACTORS ANALYSIS TIMELINE APPROACH

FACT FACT FACT

C:’.:’.Tl:’:’.:M’.:E======================”-
V ——

>
Chapter 7: Events and Ca11sal Factors Ana!Jsis

. ery of holes in the accident sequence
, D1scov
, Identification of multiple causes
, Elimination of memorization as a means of documentation

, Aid in report writing
, Determination of causal factors (in the analysis part of the technique)

Graphic Portrayal of the Accident Sequence
Start constructing the chart as soon as you obtain facts about the accident.
Many investigators find it convenient to write information on removable
adhesive notes and place them in chronological order on a wall or table .
Notecards also work, but they must be taped in place. Computer programs
can print an events and causal factors chart, but it is best to use them after
the wall or table chart is completed.

Recording of Events and

Conditions

Three types of information are recorded on an events and causal factors
chart: events (occurrences with time and date), conditions (what was going on
during the events), and the accident itself. At the top of the adhesive note for
each event, write the event as a sentence with a subject and an action verb
to describe the event (example: “Bill dropped the hammer.”). At the bottom
of the note write the time and date the event happened and the source of
the information. On separate notes write conditions that existed at the time
of the event. See “Documentation Procedures” later in this chapter for more
information on recording events and conditions.

Validation and Verification of Facts
You may encounter conflicting information as you examine evidence and
lnterview people. If you write on each event or condition, note where you
obtained the information-witness statement, interview of foreman, lockout/
tag_out log, plant procedures, etc.-you will have a way to decide which piece
ofmfio · · rmatton ts valid.

71

/’rut /II: A 11al}tiral T,cb11iq11es

72

. of }-{oles in the Accident Sequence
Discovery

. • the eve nts and causal factors chart is an excellent w
Exarn101 ng . . . . . . ay to find

h I
. our invest1″”t10n. Swee the chart 1s 1n chronological time d o es in Y ,,,- . . . . . . or er, it

. t cell whether information 1s nusswg. It 1s unportant to find all f
1s easy o . o the

ail hie
information and facts about the accident before you start anal .

wa
the accident sequence.

Identification of Multiple Causes
As you document the facts of the accident on the events and causal factors
chart, che chart actually becomes the accident sequence, and it can be used
co identify multiple causes as well as a single cause.

Elimination of Memorization as a Means of Documentation

As you start investig:iting an accident, you may rely on memory rather than a
chart to keep track of the information you discover. However, it is extremely
difficult to memorize the events and conditions for complex accidents-there
is just coo much information to keep track of mentally. The events and causal
factors chart is a concrete way to document the facts so that you do not

depend on memorization.

Aid in Report Writing
\’v’hen you write an accident investig:ition report, an events and causal factors
chart will provide an excellent outline of the accident.

Charting Procedures
MoSt investigators construct charts in a secure controlled location using
removable adhesive notes or notecards taped t~ a wall or cable. After_ tbe
chart is complete, some investig:itors transfer the information to a specialized
computer program. (See “Computerized Charts” later in this chapter.)

….. ,ng Various Types of Events
Cha•=·

Chapter 7: Events and Causal Factors Ana!Jsis

events
Record each event, along with the date and time it occurred and the information
source, on a separate note and place the note in chronological order in the
chart- Events should be written with a subject (noun) and a verb.

Assumed Events
‘Ibese are events that you know must have happened but have not yet been
verified. Write them on notes of a different color from those used for verified
events. This will remind you that more investigation is needed.

Non-events-Events That Did Not Occur
If a worker did not place a lock and tag on an electrical panel, this is a non-
event. Non-events can be important in determining causal factors. Some
accident investigators do not include non-events on their charts, while others
include them until all of the other information is received. Information about
non-events should be captured somehow, and the chart is a good place to
document it. Although they are not events, they may be cited as conditions
or causal factors when the chart is analyzed.

Events That Occur Simultaneously
It is possible for two events to occur at the same time. In this case, place the
second set of events and conditions directly below the first to signify that they
occurred at the same time. Exhibit 7.2 displays a secondary event sequence.

Charting Conditions
Conditions are situations related to an event, such as what caused the event
to happen, what was happening during the event, or even non-events. For
example, suppose that the event is that a worker turned off an electrical panel
Ill Room A. Conditions associated with this event might be that the worker
was about t .

ll
. 0 service a machine (what caused the event); Room A was not

we -lit bee Ii and h didause a ghtwas burned out (what was happening during the event);
th he not place a lock and tag on the electrical panel (non-event). On

e c art, use different color notes for events and conditions.

73

1’11rl // /: A 1111b•tiral Terhniq1,es

74

Exhibit 7.2 EVENT SEQUENCE

ACCIDENT

Charting the Accident
The last cype of information to chart is the accident itself. Place a note on
the chart (in a different color from those used for events and conditions)
describing the accident along with a time and date. It is possible for events
to occur both before and after an accident; usually the ones after the accident
will be emergency response actions. When you look at the chart, it will be
obvious where the accident falls in relation to the events and conditions

leading up to and following it.

Computerized Charts
If you transfer your chart to a computer, it is customary to place events in
rectangles, conditions in ovals, and accidents in diamonds. For assumed events
and conditions, dashed rectangles and ovals are used. There are computer
programs specifically designed to create events and causal factors charts;
however, many other programs-such as PowerPoint™, Visiou.i, and CAD

or graphic programs–<:an be used as well.

Exhibit 7.3 illustrates a typical event, condition, and the accident.

How Much Should You Include on the Chart?
The chart’s ft · . . · eluded . e ecuveness 1s linked to the amount of informauon Ul .11
on 11. You must · f thr . d place””

f h
. si t ough all of the information you receive an ,j]]

o t e 1mporca t mple
11

ill n events and conditions on the chart. A short exa
ustrate an eve d nts an causal factors chart.

Chapter 7: Events and Causal Factors Ana/ysis

An office worker noticed that a light bulb in the break room was
burned out and decided to change the bulb himself. He found a
new light bulb and a step ladder. He had one of his lunch partners
hold the ladder as he climbed to the top rung. As he reached to
screw in the light bulb, he fell off the ladder and broke his arm.

Exhibit 7.4 depicts an events and causal factors chart for this simple
example. Note that each event note contains a sentence describing the

Exhibit 7.3
liliili~””‘–..;;;E…;.VE_N_TS, CONDITIONS, AND THE ACCIDENT __ _

Subject + Action Verb

——1———-T——-
: Source of:

Date : infor- : Time
: mation :

&
I

[Note: This information can be written
on the back of the paper to ensure
confidentiality. This is important if
conflicts develop.]

Situation related to the
event or circumstance

[Note: Including the source of the
information can be useful

if conflicts develop.]

ACCIDENT

Date and
time

EVENTS

Media for
posting events:

• removable
adhesive notes

• notecards
•computer

CONDITIONS

ACCIDENT

Worker turned off
electrical panel in

Room A
[Note: The event should be as
specific as possible. There should
be only one noun and verb; record
one event at a time.]
——–r——-~——–

‘ Shift I
12/14/11 : log- : 10:41 AM

: book ‘
I

No approval received
from building supervisor

OR
Did not use LOTO

procedure

Worker
received electric

shock
12/14/11
10:42 AM

75

Parl Ill: Ana/ytical Techniques

76

event and the date and time of the event. The sour
. . . . ce of the.

in this case the miured worker, ls Offiltted in this lnfottti. .
. . exaniple b atton

written on the back of the note. Conditions associat d . Ut could ‘
e With th be

written on notes placed above each event note st ki e events
. , ac ng th ate

if there are several. As with event notes, source inc . em V-etticau
. . iorniauo y

written on each condition note. n should be

Exhibit 7.4

Very dark in
one comer
of lunch
room.

Worker
noticed a

light out in
lunchroom.
1/9/2011

11 :20

Did not
notify

mainte-
nance

depart-
ment

Worker
found new
light bulb.
1/9/2011

11 :21

EXAMPLE CHART

Not
normal job
duty-no
training

Violated
safety rule

Used top
rung of
ladder

Worker
climbed
ladder to

replace bulb.
1/9/2011

11:24

Worker fell
off ladder.
1/9/2011

11 :25

Co-worker
called

ambulance
1/9/2011

11:26

Chapter 1: Events and Causal Factors Ana/ysis

Charting Tips

• Fill your chart with information. Do not be too concerned with charting
style and correctness-just include as much information as you can.

• Make room for your chart. Charts for complex accidents grow from day
to day as new information is received. Place adhesive event and condition
notes on a wall or large table, depending on the size of the investigation.
For larger investigations the notes may wrap around an entire room!

• Keep the notes sticky. Especially in humid offices, do not depend on
adhesive notes to keep sticking as they are moved to make room for
others-use additional tape.

• Leave some expansion room. Leave some breaks in the chart for
expansion to avoid having to move all of the notes every time you insert a
new one. Put space between events when you think additional information
will be received.

• Mark time breaks. For complex accidents, tape day, hour, and possibly
minute markers to the wall so you can find and place notes easily.

• Be thorough, but be aware that being thorough takes time. For
complex accidents, creating events and causal factors charts is extremely
time-consuming, but the more time you take, the more thoroughly you will
have investigated the accident. If all pertinent information is not included
in your chart, your analysis is not representative of the entire accident
sequence, and you may not discover the true causal factors of the accident.

• Archive the chart. Once the chart is finished and the causal factors have
been analyzed, it can be taken down and the information entered into a
computer. When you take the chart down, disassemble it carefully, keeping
the event notes in order and the condition notes behind their corresponding
event notes. If you need to revisit the chart, you will be able to reconstruct
it easily. Store chart notes and computer printouts in a protected area.

• Use the chart as the basis of a report.You may wish to include a summary
of the chart in your accident investigation report. Pick ten to fifteen events
th

at summarize the accident sequence. The events you choose should include
all of the events that were identified as causal factors. A chart like this tells

77

78

Part Ill: A nalytical Techniques

the story of the accident-it gives the reader the eve
. . nts, conditi

causal factors m an easily understood chronological pictur S ons, and
e. urnrnary are also very effective as management tools (Stephenson
1991

). charts

Events and Causal Factors Analysis

Analysis of the events and <;onditions-a qualitative approach to visua!izin the accident-begins when the chart is finished. Exhibit 7.5 portrays this p~ of the process . You must evaluate each event to determine its significance to the accident, asking, "What occurred? How did it occur? Why did it occur? What is its relevance? What are the circumstances surrounding it?" As you answer these questions, you will discover the accident's causal factors. It is usually best to start with the first event and proceed until you reach the

Exhibit 7.5

C EVENTS AND CAUSAL FACTORS ‘.~ NALYSIS f

Causal
Factors

V

3. Analyze to see if a causal
factor or relationship
involved in the accident,
if corrected, would have
prevented the accident.

Conditions

iJ
Events

1. Analyze each
event to
determine
significance.

2. Analyze each
condition related to
the event and ask:
What caused this
event? .
What wa~ happ~~,ng
during this even .
Why did this event
occur?

1

Chapter 7: Events and Causal Factors Ana!Jsis

. Do not skip events-sometimes the more obscure ones turn out cc1dent. . .
a ry important. When you have firushed the analysis, you may wish to to be ve

. . h the events that were causal factors with a color code or symbol dist:IDgu1S
h as a hexagon. sue

Example Scenario

In the forklift-hitting-the-ladder example given in the introduction to Part
III, two accidents may be identified-the forklift hitting the ladder and the
supervisor falling off the ladder. While investigating either should yield the
same causal factors, the one in which injury or damage is involved-in this
case the supervisor falling off the ladder-is usually identified as the primary
accident.

Exhibit 7.6 illustrates the first stage of the events and causal factors chart.
All of the facts and information related to this accident are not included in this
chart; other analysis methods discussed later in the book will add information
and the chart will continue to grow until it includes all of the information
necessary for analysis.

79

Part III: Ana!Jtical Techniques

80

Exhibit 7.6
EVEN_T,…S .,.A,..ND~ CAUSAL ANAL YSI —-

Bill received
promotion to

New wing of
warehouse

finished.
1/6/2011

1—-; warehouse t—–
supervisor.

Bill arrived at
work.

2/5/2011
7:35

1/23/2011

Bill retrieved
a ladder.
2/5/2011

7:41

Fire
inspection

found
violations in
warehouse.
2/4/2011

Bill walked
with ladder to

end of row.
2/5/2011

7:43

Chapter l: Events and Causal Factors Ana/ysis

s·AND ,AUSAL ANALYSIS OF EXAMPLE SCENARIO continued EVENT ·· ‘

Bill climbed
ladder to

install sign.
2/5/2011

7:44

No
barricades

Forklift hit
ladder.

2/5/2011

7:45

Difficult

thed
driv

Forklift driver
loaded last
load of the

day.
2/5/2011

7:44

Forklift driver
turned corner

~—1 of aisle.
2/5/2011

7:45

Bill fell off
ladder.

2/5/2011
7:45

Forklift driver
immediately

notified
medical.
2/5/2011

7:46.

81

82

Port III: Ano!Jticol Techniques

Summary

Events and causal factors analysis is a comprehensive accid .
. ent Investj . tool that develops the accident sequence as well as determinin gation

. . g causal fac The accident sequence is separated lilto events and condition Th tors.
· li f h ·d Af s. e event illustrate a time ne o t e acci ent. ter a complete chart · d s

. is evelo d from the facts of the accident, the events and conditions are a al pe
n yzed and causal factors are determined. Many hours of work are needed to p d

ro uce an effective events and causal factors analysis; however, the result is that .d
. acc1 ent investigators understand the accident sequence and are confident that the

causal factors of the accident have been found. This technique ensures that
an adequate investigation is performed and a documented accident sequence
is developed. This technique answers the ultimate question for accident
investigators: “Why did this accident occur?”

REVIEW QUESTIONS
1. What are the advantages of using an events and causal factors analysis to

investigate an accident?

2. What analysis errors might be caused by an incorrect timeline?

3. Why is it important to document the source of each item of information?

4. When should an events and causal factors chart be started?

. e7 5. How do you display two events that occurred at the same t,m ·

6. How do you perform the analysis portion of the event an d causal factors
analysis?

. . . d causal 7- How do you make a summary chart from a completed events an
factors chart?

. le scenario
B. Continue the events c1nd causal factors chart for the examp

(Exhibit 7.6).