Posted: January 24th, 2023

Accident Investigation

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

Board Question

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Think of a time when you were injured at work or at home. Conduct a “Five Whys” analysis of the accident to reveal root causes and share your findings with the class. Does each one build on the one before it?

Unit Quiz


What are the three types of tree analysis? Briefly describe each. 
Your response should be at least 75 words in length.


Explain the three steps in the fault tree process. What does each level represent? 
Your response should be at least 75 words in length.


What are some of the problems associated with using cause and effect analysis? 
Your response should be at least 75 words in length.


What are the three types of cause and effect analysis? Which one do you think you would choose for an accident involving a forklift striking a worker who was walking across a warehouse? Briefly explain your choice. 
Your response should be at least 75 words in length.

Unit VI Assignment

Fishbone Diagram Project

Read the U.S. Chemical Safety Board 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: ?13741.

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

NOTE: This is the same investigation report used to complete the assignments in Units IV and V. Complete the assignment as detailed below.

Part I: From the information in the report and from the information you developed for the assignments in Unit IV (events and causal factors [ECF] chart) and Unit V (barrier analysis), create a fishbone diagram that illustrates the relationship between the causal factors and the accident. In your diagram, the backbone of the fish should represent the accident, and the big bones should represent the people, procedures, environment, equipment, and policies.

Part II: On a separate page, discuss what new information about the accident is revealed in the chart, and describe how that information might be used to identify potential corrective actions. 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.

Fishbone Diagram





Preventative Maintenance


Work Orders

Spill cleanup








Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.

Overview: Root cause analysis is a structured team process that assists in identifying underlying factors or
causes of an event, such as an adverse event or near –miss. Understanding the contributing factors or causes
of a system failure can help develop actions that sustain corrections.

The Five Whys is a simple problem-solving technique that helps to get to the root of a problem quickly. The
Five Whys strategy involves looking at any problem and drilling down by asking: “Why?” or “What caused this
problem?” While you want clear and concise answers, you want to avoid answers that are too simple and
overlook important details. Typically, the answer to the first “why” should prompt another “why” and the
answer to the second “why” will prompt another and so on; hence the name Five Whys. This technique can
help you to quickly determine the root cause of a problem. It’s simple, and easy to learn and apply.

Directions: The team conducting this root cause analysis does the following:

● Develops the problem statement. (See Step 1 of Guidance for RCA for additional information on
problem statements.) Be clear and specific.

● The team facilitator asks why the problem happened and records the team response. To determine if
the response is the root cause of the problem, the facilitator asks the team to consider “If the most
recent response were corrected, is it likely the problem would recur?” If the answer is yes, it is likely
this is a contributing factor, not a root cause.

● If the answer provided is a contributing factor to the problem, the team keeps asking “Why?” until
there is agreement from the team that the root cause has been identified.

● It often takes three to five whys, but it can take more than five! So keep going until the team agrees
the root cause has been identified.


● Include people with personal knowledge of the processes and systems involved in the problem being

● Note that the Five Whys technique may not always help you to identify the root cause. Another
technique you might consider is the fishbone diagram. The fishbone diagram forces you to think
broadly across various categories that could be causing or contributing to the problem (See How to
Use the Fishbone Tool for Root Cause Analysis tool).

  • Five Whys Tool for Root Cause Analysis
  • Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.


    One sentence description of event or problem






    Root Cause(s) 1.

    To validate root causes, ask the following: If you removed this root cause,
    would this event or problem have been prevented?

    Here is an everyday example of using the Five Whys to determine a root cause:
    Problem statement – your car gets a flat tire on your way to work.

    1. Why did you get a flat tire?
    • You ran over nails in your garage

    2. Why were there nails on the garage floor?
    • The box of nails on the shelf was wet; the box fell apart and nails fell from the box onto the

    3. Why was the box of nails wet?

    • There was a leak in the roof and it rained hard last night. (Root cause=leak in the roof)


      Five Whys Tool for Root Cause Analysis



    &L&”Arial,Bold”&14FAULT TREE CHART – UNIT VI
    Bob slips in water and breaks leg
    No “wet floor” warning
    Water on floor
    Leak in pipe
    Water not cleaned up
    Sam went home without cleaning up the spill
    Basic Event
    No one on day shift aware of spill
    Repair request not submiited
    Resources not available
    Sam chooses to not place warning sign
    Warning sign not available
    Mary calls in to say she will be late
    Tom calls in to say he will be late
    Messages are not passed to another supervisor.
    Messages are not passed to another supervisor.
    Top Event



    Intermediate Fault


    Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.

    Overview: Root cause analysis is a structured team process that assists in identifying underlying factors or
    causes of an adverse event or near-miss. Understanding the contributing factors or causes of a system failure
    can help develop actions that sustain the correction.

    A cause and effect diagram, often called a “fishbone” diagram, can help in brainstorming to identify possible
    causes of a problem and in sorting ideas into useful categories. A fishbone diagram is a visual way to look at
    cause and effect. It is a more structured approach than some other tools available for brainstorming causes
    of a problem (e.g., the Five Whys tool). The problem or effect is displayed at the head or mouth of the fish.
    Possible contributing causes are listed on the smaller “bones” under various cause categories. A fishbone
    diagram can be helpful in identifying possible causes for a problem that might not otherwise be considered
    by directing the team to look at the categories and think of alternative causes. Include team members who
    have personal knowledge of the processes and systems involved in the problem or event to be investigated.

    The team using the fishbone diagram tool should carry out the steps listed below.

    ● Agree on the problem statement (also referred to as the effect). This is written at the mouth of the
    “fish.” Be as clear and specific as you can about the problem. Beware of defining the problem in terms
    of a solution (e.g., we need more of something).

    ● Agree on the major categories of causes of the problem (written as branches from the main arrow).
    Major categories often include: equipment or supply factors, environmental factors,
    rules/policy/procedure factors, and people/staff factors.

    ● Brainstorm all the possible causes of the problem. Ask “Why does this happen?” As each idea is given,
    the facilitator writes the causal factor as a branch from the appropriate category (places it on the
    fishbone diagram). Causes can be written in several places if they relate to several categories.

    ● Again asks “Why does this happen?” about each cause. Write sub-causes branching off the cause

    ● Continues to ask “Why?” and generate deeper levels of causes and continue organizing them under
    related causes or categories. This will help you to identify and then address root causes to prevent
    future problems.


    ● Use the fishbone diagram tool to keep the team focused on the causes of the problem, rather than
    the symptoms.

    ● Consider drawing your fish on a flip chart or large dry erase board.
    ● Make sure to leave enough space between the major categories on the diagram so that you can add

    minor detailed causes later.
    ● When you are brainstorming causes, consider having team members write each cause on sticky notes,

    going around the group asking each person for one cause. Continue going through the rounds, getting
    more causes, until all ideas are exhausted.

  • How to Use the Fishbone Tool for Root Cause Analysis
  • Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.

    ● Encourage each person to participate in the brainstorming activity and to voice their own opinions.
    ● Note that the “five-whys” technique is often used in conjunction with the fishbone diagram – keep

    asking why until you get to the root cause.
    ● To help identify the root causes from all the ideas generated, consider a multi-voting technique such

    as having each team member identify the top three root causes. Ask each team member to place
    three tally marks or colored sticky dots on the fishbone next to what they believe are the root causes
    that could potentially be addressed.


    Here is an example of the start of a fishbone diagram that shows sample categories to consider, along with
    some sample causes.

    Here is an example of a completed fishbone diagram, showing information entered for each of the four
    categories agreed upon by this team. Note, as each category is explored, teams may not always identify
    problems in each of the categories.

    Facts gathered during preliminary investigation:

    ● Time of fall: change of shift from days to evenings
    ● Location of fall: resident’s bathroom
    ● Witnesses: resident and aide
    ● Background: the plan of care stipulated that the resident was to be transferred with two staff

    members, or with one staff member using a sit-to-stand lift.
    ● Information from interviews: the resident was anxious and needing to use the bathroom urgently. The

    aide was helping the resident transfer from her wheelchair to the toilet, without using a lift, and the
    resident fell, sustaining an injury. The aide stated she did not use the lift because the battery was
    being recharged, and there was no extra battery available. The aide stated she understood that the
    resident could be transferred with assist of one.

    Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.

    With this information, the team proceeded to use the fishbone diagram to better understand the causes of
    the event.

    The value of using the fishbone diagram is to dig deeper, to go beyond the initial incident report, to better
    understand what in the organization’s systems and processes are causing the problem, so they can be

    In this example, the root causes of the fall are:

    ● There is no process in place to ensure that every lift in the building always has a working battery.
    (One battery for the lift on this unit is no longer working, and the other battery was being recharged.)

    ● There is no process in place to ensure timely communication of new care information to the aides.
    (New transfer information had not yet been conveyed to the aide. The aide’s “care card” still indicated
    transfer with assist of one for this resident.)

    The root causes of the event are the underlying process and system problems that allowed the contributing
    factors to culminate in a harmful event. As this example illustrates, there can be more than one root cause.
    Once you have identified root causes and contributing factors, you will then need to address each root cause
    and contributing factor as appropriate. For additional guidance on following up on your fishbone diagram
    findings, see the Guidance for Performing RCA with Performance Improvement Projects tool.

      How to Use the Fishbone Tool for Root Cause Analysis


    Course Learning Outcomes for Unit VI

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

    3. Apply accident investigation techniques to realistic case study scenarios.
    3.1 Develop a cause and effect diagram for an accident investigation.

    4. Evaluate analytical processes commonly used in accident investigations.

    Reading Assignment

    Chapter 10:
    Tree Analysis

    Chapter 11:
    Cause and Effect Analysis

    Chapter 12:
    Specialized and Computerized Techniques

    Access the U.S. Department of Energy resource below, and read the following sections: Cause and Effect
    Relationships (pp. 1-5 to 1-7) and Analyze Accident to Determine “Why” It Happened (pp. 2-76 to 2-86).

    U.S. Department of Energy. (2012). Accident and operational safety analysis: Volume I: Accident analysis
    techniques. Retrieved from

    Centers for Medicare & Medicaid Services. (n.d.). Five whys tool for root cause analysis. Retrieved from

    Centers for Medicare & Medicaid Services. (n.d.). How to use the fishbone tool for root cause analysis
    Retrieved from

    Unit Lesson

    In this unit, we continue with our examination of techniques that can be used to analyze the accident
    sequence and to help determine root causes. You may ask why we need so many techniques. Each
    technique provides a slightly different view, and each can reveal previously unrecognized facts. Each
    technique also helps us determine which facts are not likely to be causal factors.

    In Arthur Conan Doyle’s book, A Study in Scarlet, Sherlock Holmes and Watson are on a camping trip—
    taking a break from the detective business. They had gone to bed and were lying down, while looking up at
    the sky.

    Holmes said, ‘Watson, look up. What do you see?’

    ‘Well, I see thousands of stars.’

    ‘And what does that mean to you?’


    Analytical Techniques II




    ‘Well, I suppose it means that of all the planets and suns and moons in the universe, that we are truly
    the one most blessed with the reason to deduce theorems to make our way in this world of criminal
    enterprises and blind greed. It means that we are truly small in the eyes of God but struggle each day
    to be worthy of the senses and spirit we have been blessed with. And, I suppose, at the very least, in
    the meteorological sense, it means that it is most likely that we will have another nice day tomorrow.
    What does it mean to you, Holmes?’

    ‘To me, it means someone has stolen our tent.’ (as cited in Ewell, 2012, p. 194).

    Like Holmes, an accident investigator needs to be able to identify the facts that are relevant and be capable of
    disregarding those that are interesting but not useful. A good accident investigator also learns how to identify
    causes that go beyond the most obvious (such as human error). Finding the deeper, root causes will lead to
    more effective corrective actions.

    Fault tree analysis is a structured technique that acts as a filter for causal factors. The undesired event is
    listed at the top of the tree. Once the accident is thoroughly investigated, we determine, typically through
    brainstorming, the events necessary to produce the top event. As we continue to ask why something
    happened, the tree branches out, revealing additional paths that could lead to the top event. When there are
    no more events, we have reached a root cause level (Oakley, 2012). A fault tree is an example of deductive
    reasoning, where we start with a specific event and work down to find the facts that support it. Inductive
    reasoning starts with the facts and works upward to find a logical conclusion. We used an inductive approach
    when we developed the events and causal factors chart in Unit IV.

    We often think of Sherlock Holmes as using deductive reasoning to solve crimes, perhaps because of his
    propensity to use the word deduce. Holmes actually used a combination of inductive and deductive reasoning
    (Kincaid, 2015). So, too, in accident investigation, a combination of approaches should be used.

    Recall the accident scenario for Units IV and V where Bob slipped and fell in a pool of water from a leaking
    pipe. Click here to view a fault tree diagram developed from the information in the scenario.

    While much of the information is the same as contained in our earlier change analysis and barrier analysis,
    the fault tree does reveal some new factors that may require further investigation and action. For example, on
    the linked fault tree, one of the possibilities that could have caused Sam not to place a warning sign was that
    there were no warning signs available. A new branch of the tree could be developed from this information,
    and corrective actions could be identified.

    The cause and effect process is another useful tool that, in addition to identifying causal factors, ties the
    factors to relevant categories, which will help in the identification of corrective actions. When conducting a
    cause and effect analysis, it is important to remember that accidents have multiple causes, some more
    evident than others. There is rarely a straight line cause and effect relationship. Just because event B
    happens after event A does not mean that event A caused event B, even if it happens frequently. It is actually
    easier to determine that there is no causal relationship (remove event A, and see if event B still happens with
    the same frequency).

    The “Five Whys” technique and the fishbone (Ishikawa) diagram both use the cause and effect process
    (Oakley, 2012). In the Five Whys, we start with an event and keep asking why until we reach an actionable
    root cause. Returning again to our scenario involving Bob, it might resemble the following:

     Why did Bob fall and break his leg? Because there was water on the floor.

     Why was there water on the floor? Because a valve was leaking.

     Why was the valve leaking? Because no one submitted a repair order.

     Why did no one submit a repair order? Because no one was given the responsibility.

    At this point, we have reached a root cause related to management’s failure to assign responsibility. Note,
    however, that our line of questioning follows a single path, and each question builds from the one above it.
    There could be many other starting points. For example, we could start by asking why the spill was not
    cleaned up. This would reveal the facts about the phone calls and the poor communication. It is not a good



    practice to use the Five Whys as the single analysis technique, but it can be very helpful when brainstorming
    causal factors as a part of a barrier analysis or fault tree analysis.

    A fishbone diagram is a good tool to help an investigation team focus on causes rather than symptoms
    (Centers for Medicare & Medicaid Services, n.d). It is much more structured than the Five Whys and adds an
    additional dimension by sorting ideas into categories. The categories can then be used to group corrective
    actions by area of responsibility. A fishbone diagram is a particularly useful tool for a team investigation
    process because it requires a brainstorming effort, enabling many new ideas to be revealed. Click here for an
    example of a fishbone diagram representing Bob’s injury.

    We are now three-quarters of the way through the course and have yet to discuss corrective actions. A
    mistake often made by accident investigators is to identify corrective actions too soon in the process. It may
    be difficult to convince upper management that the investigation process takes time. They want to be able to
    say they quickly fixed the problem that caused the accident. Too often, corrective actions, such as retraining,
    are taken immediately following an accident, before inadequate training is even established as a causal
    factor. In the words of Sherlock Holmes, “It is a capital mistake to theorize before one has data. Insensibly,
    one begins to twist facts to suit theories, instead of theories to suit facts” (Doyle, 1892, p. 7). In the next unit,
    we finally look at when and how to take specific actions to prevent the accident under investigation from
    happening again.


    Centers for Medicare & Medicaid Services. (n.d.). How to use the fishbone tool for root cause analysis.
    Retrieved from

    Doyle, A. C. (1892). Adventures of Sherlock Holmes. New York, NY: Harper & Brothers.

    Ewell, B. J. (2012). Family treasures: 15 lessons, tips, and tricks for discovering your family history.
    Springville, UT: Cedar Fort.

    Kincaid, D. K. (2015). The Sherlock Holmes conundrum, or the difference between deductive and inductive
    reasoning. Retrieved from

    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

    In order to access the resource below, you must first log into the myWaldorf Student Portal and access the
    Business Source Complete database within the Waldorf Online Library.

    The article below explores safety and safe working practices from two points of view—that of engineers and
    site managers. This analysis will help you to understand safety making processes in organizations.

    Gherardi, S., Nicolini, D., & Odella, F. (1998). What do you mean by safety? Conflicting perspectives on
    accident causation and safety management in a construction firm. Journal Of Contingencies & Crisis
    Management, 6(4), 202-213.

    This article was referenced in the Unit VI Lesson. To read the article in its entirety, click on the link below.

    Kincaid, D. (2015) The Sherlock Holmes conundrum, or the difference between deductive and inductive
    reasoning. Retrieved from
    or-the-difference-between-deductive-and-inductive-reasoning-ec1eb2686112#.tdk40ow74 x



    There are many articles and videos about cause and effect analysis available on the Internet. This one by
    Mind Tools is an example of what you can find.

    Mind Tools. (n.d.). Cause and effect analysis: Identifying the likely causes of problems. Retrieved from

    For a humorous take on the “Five Whys” technique, watch the video below.

    Wright, J. (2011, March 26). Lucky Louie (why) [Video file]. Retrieved from


    Tree Analysis
    Fault Trees and Analytic Trees

    In tree analysis, investigators use a graphic display of information to deductively
    analyze a human, equipment, or environmental system and determine paths
    to failure or success. Tree analysis identifies the interrelationships that led
    to the accident and helps to develop causal factors (Department of Energy
    1999). Trees have been used in industry and government for many years
    in many different capacities. Two basic types of trees are used for accident
    investigations-fault trees and anafytic (developed) trees. Fault trees show the actual
    events of the accident, and they grow as events leading up to the accident
    are discovered. Analytic trees are used to compare the accident situation to a
    tree developed before the accident happened-usually one based on an ideal
    situation. Examples of analytic trees include Management Oversight and Risk
    Tree (MORT), Project Evaluation Tree (PET), and system flowcharts.

    Trees can be used in a variety of ways-as planning tools, in accident
    investigation analysis, in causal analysis, in project evaluation, and in quantitative
    analysis. In all of these applications, trees use deductive reasoning-they start
    witb a general “top” event and continue down to specific causes. (Stephenson
    1991)-Exhibit 10.l illustrates the tree structure.


    ::;rut>£ ‘i:fi CT – z

    Part Ill: Anol;•tzral Tecb111q11es


    Exhibit 10.1



    About Tree Analysis

    Three categories of trees are used to analyze various types of problems:

    • fault (negative) trees

    • positive trees

    • analytic (developed) trees.

    These categories are illustrated in Exhibit 10.2.

    Fault (Negative) Trees
    Fault tree analysis was developed for the U.S. Air Force in 1962. Faulr trees

    ‘ ‘ i•to
    are used qualitatively to determine failures in a system and quanutaave l

    bl I t S)’Srems, for determine failure rates. They are generally used to trou es 100

    h d • . . • · · (St phenson 199!). azar (nsk) analysis, and for accident mvest1gat10ns e

    Positive Trees
    I . formation to

    Positive trees display a system graphically-from genera rn ,s tern;
    • , , I vay to map S) · specific information. Creating an positive tree ts a use u ‘ ‘ . . . ccs cin

    . I · Posrttve lf components or provide information with a quick grap ,re.


    I •

    This is O classic fault tree.1d\ .1 manual alarm clock cou . a,
    in three ways-the clock ,s
    faulty. the owner forgot to
    wind it or the owner forgot to
    set it. II any one of thes1; faults
    occurs, the clock w,11 far/.



    Run a

    This example of a positive tree shows
    that in order for on overoge person to
    run a marathon, he or she must troln
    and be injury-free. Training means
    running long and short runs each
    week; staying Injury-free means
    stretching and eating healthy food,


    less than adequate


    Did not



    This Is an example of a portion of a topic for
    “supervision less than adequate• (LTA),
    Questions are asked to determine whether
    eoc/J circle or rectangle Is LTA. For each
    rectangle, more ques tions are asked, ——————–


    P,,rt Ill: A na/yhral Ttchniq11es


    be developed early in the planning and d •
    es,gn Sta

    an accident occurs, and then used as anal . ges of a S)•
    yuc trees if Stelll

    accident occurs later by comparing the fai!u . and \Vhe • b,r0 r e or acc1d n a fail r,
    (Stephenson 1991). ent to the 1 lire 0, P •nn,d
    Analytic (Developed) Trees

    MORT, PET, and systems flowcharts are ex 1 . amp es of ana] ti

    MORT is a safety system approach devel d y c trees.
    ope by Bil]

    Department of Energy in the 1970s and used . J 0 hns0 , extensive! • n •or th
    1980s. It was developed as a proactive system safe t Y 10 the 1970 ‘ ‘d . . . wn..:i . . ty oolandw I ‘and aca ent tnvesnganon. w ,we 1t 1s still a viabl .d as ater . e acc1 ent in . l!sed;
    tool, there 1s a shortage of individuals who kn h Vest,gati0 n a 0’ ow ow to use . naiys~
    an excellent tool to use after o ther analysis te h . It Proper! , 1 . . c ruques have b ). t IS
    to venfy that all areas have been properly m · . een compJ

    vesugated 0ohn ” ‘

    orce as a
    approach that was simpler to learn and use th MO structured tt

    an RT (Stephenson ,,
    Other types of structured trees such as !JSfe fl h 1991).

    , – , ms owe arts, can be us
    a syseem s structure graphically. For accident • . . ed to sho,,

    mvesugauons an i .
    uses the tree to trace back through the system d find ‘ nvesngaror

    an faults .

    The Fault Tree Approach

    The fuse seep in constructing a fault tree is to determ· h
    . . _ . 1ne t e top evem.

    For acadent mvesnganons, the top event is the accident · · d , tnJury, or amage
    that occurred (Hammer 1993) . Events that had to happen in order for the
    accident to happen are listed on the next tier of the tree. Causal factors-
    fixable siruations or correctable areas-are on the bottom tier of the tree.
    The corrective actions the accident investigator recommends will be geared
    to fixing these problems.

    Symbols and gates are part of the fault-tree diagram. The mosr common
    tree symbols and gates are illustrated in Exhibit 10.3. Since the purpose of
    this chapter is to describe how trees can be used in accident investigations co

    Chapter 10: Tree A nalysis

    fault tree analysis methodologies and symbols that
    al factors, di d . e ,nos, _ – vestigation are not scusse .

    t1ettf111u1 ‘ to ncCident 1Il . –
    0, ,ppl) . ediate” events m fault-tree termmology. Failures Jo fl re “1nterm . .

    ,vents a . all diagramed under tntermediate events. Under each
    fop are logic, Y . . .

    ,,esses h e may be other intermediate events (intermediate J- . ~mt~ …
    11edcace . be discovered as the mvesngauon goes on), basic iitrt’fl conunue to .
    cs n1’Y that stop the chatn), undeveloped events (events that ,.-en al factors . .

    . 0cs (caus .al bout which not enough 1s known to conunue the tree), ,,t enn or a
    ;0coosequ ( nts that are normally expected to occur). For example aJt _ 1 events eve ,

    ,0,1er<1"' din a hole and broke his leg, the broken leg is the top o 1 yee steppe ;rane01P0 , 5

    next tier of events includes the intermediate events “hole
    ‘fhe rree . · “G · c __ L ereoc. ” d “employee not paying attenuon. omg a step uu mer leads

    [10,guarded an the answers to questions like “Why was the employee not
    b ic ” ‘eots– d d,” Th · · co as • ;, Why was the hole not guar e . e mvestrgator must
    . attenuon.

    p,png f the accident scenarios in order to structure an accurate, fully
    ,oaly1e all 0
    dereloped analytical tree. . ..

    · a fault tree are logically directed through gates (see Exhibit 10.3). Alleveots 10
    d” means that all outputs must occur. For example, if the top event lee “an gate

    ‘. ding an e-mail, then to make that top event occur, the computer must be
    ‘: 00 AND it must be connected to a phone line. Other things may have to
    cum fth dfircil An”” th 1,,ppen as well, but both o ese must e te y occur. or gate means at
    if anv one of the events on the second tier happens, the top event will happen.
    Foe ~,ample, if the top event is making a million dollars, then to make it occur
    )1lU could be a professional athlete OR win the lottery.

    Once you determine the top event, the next step is to start tree construction.
    The uee construction steps for an accident are:

    I. Define the top event (accident, injury, or damage).

    2 Investigate the accident. (Learn about the system, the management
    structure, the accident, etc.)

    3. Construct the tree. (Work from the top down asking why the top event

    l. Develop causal factors. (The basic events-the boetom tier of the tree-
    are causal factors.)

    Pa11 Ill: A•alJliral T«bRiqm

    The Analytic Tree Process
    (Using MORT for Validation)

    It is probably better to use MORT as a method of valid .
    . . . . th . . •ling •noth

    im·esnganon techruque an to use It as your pnmary techni ue er t}’Pe of
    to ensure that you did not nuss an area that should have b! ·. It can help
    and that the proper causal factors were determined If yo n 1nvestiga1’1J . . u consult th ‘ chart and find that some areas were nussed, the investigati e »!OR1 . . . . on can con . your invesnganon has been thorough, It will not take you Ion t tlnue. lf
    the MORT chart. g o cornple,,

    Example Scenario

    Once again using the forklift-ladder accident, part of a tree that
    al thi .d . ill d . could be used to an yze s aca. ent 1s . ustrate m Exhibit 10.7. The top event

    is the warehouse supervtsor falling off the ladder. The next level is the
    forklift hitting the ladder, and the next is three ways that a forklift could hit
    a Ladder. The investigator asks questions about these three reasons to arri,..c
    at the bonom tier-basic events or causal factors: “Why did the warehouse
    supenisor not communicate what he was about to do to the supervisor of
    the night shift? Was his failure to communicate a training issue, or did he
    just decide to disregard the procedures? Why was the forklift traveling ,ith
    an obstructed view?” If the accident investigator docs not know the answers
    to these questions, he or she must interview witnesses, obtain documents, or
    perform tests to find the answers.


    Chapter 1 O: Tree Analysis


    Part l/l: A nalytical Ttchniq11es


    Many techniques are used in tree analysis . Each techni que works b
    for some rypes of investigation than for others, and some tech . etter

    . r f . . . mques ar
    inappropnate ,or some rypes o mvest1gat1ons. The ma1·or b fi e ene u of us·
    tree analysis is that trees are, for the most part, structured eas t mg . , Y o create and
    easy to understand. You will be able to use one or more of thes h .’ e tee mques
    to investigate almost every accident you encounter. (Please see th A . e ppenclix
    for a sample Analyncal Tree Flowcharr.)


    1. Which type of gate requires that all outputs must occur?

    2. What are the three categories of tree analysis? Briefly describe each.

    3. What Is MORT?

    4. What are the steps of tree construction?
    s. Continue the analytic tree process for the example scenario (Exhibit 10.7),



    . 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


    REPORT NO. 2007-04-I-WV

    SEPTEMBER 2008

    (Four Killed, Six Injured)

    Photo courtesy of West Virginia State Fire Marshal


    KEY ISSUES: JANUARY 30, 2007





    Little General Store September 2008




    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


    Little General Store September 2008


    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



    Little General Store September 2008


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

    Little General Store September 2008


    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


    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


    U.S. Chemical Safety and Hazard Investigation Boar


    DOT U.S. Department of Transportation

    EMS Emergency Medical Services

    EMT Emergency Medical Technicia


    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


    NENA National Emergency Number Association

    NFIRS National Fire Incident Reporting System


    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


    Executive Summary

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


    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


    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


    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


    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


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


    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


    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


    Little General Store September 2008


    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


    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


    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


    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


    Figure 2. Site plan of Little General Store.

    Little General Store September 2008


    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


    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


    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.



    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.

    Little General Store September 2008


    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


    Little General Store September 2008


    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


    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

    Little General Store September 2008


    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.


    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.


    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.

    Little General Store September 2008


    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


    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.


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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


    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.


    Valve Body

    Valve sealing disk and washer

    Little General Store September 2008


    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.

    Little General Store September 2008


    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

    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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


    Figure 5. Timeline of incident response.

    Little General Store September 2008


    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.

    Gas Propane


    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.

    Little General Store September 2008



    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.

    Little General Store September 2008


    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

    Little General Store September 2008


    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.

    Little General Store September 2008


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


    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.

    Little General Store September 2008


    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

    Little General Store September 2008


    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.

    Little General Store September 2008


    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).

    Little General Store September 2008


    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,


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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

    Little General Store September 2008


    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 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.

    Little General Store September 2008


    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.

    Little General Store September 2008

    34 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


    • 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.

    Little General Store September 2008


    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

    Little General Store September 2008


    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 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

    Little General Store September 2008


    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 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.”

    Little General Store September 2008

    38 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

    Little General Store September 2008


    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. 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.

    Little General Store September 2008


    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).

    Little General Store September 2008


    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.

    Little General Store September 2008


    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,

    Little General Store September 2008


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    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.


    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.

    Little General Store September 2008


    • 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.

    Little General Store September 2008


    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


    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

    Little General Store September 2008


    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.

    Little General Store September 2008


    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


    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


    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.

    Little General Store September 2008


    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


    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.

    Little General Store September 2008


    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.

    Little General Store September 2008


    9.0 Recommendations

    Governor and Legislature of the State of West Virginia


    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


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

    training for all firefighters in West Virginia.


    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


    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.

    Little General Store September 2008


    National Fire Protection Association


    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


    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


    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.


    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.

    Little General Store September 2008


    National Propane Gas Association


    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.


    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


    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.

    Little General Store September 2008




    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.

    Little General Store September 2008


    By the

    U.S. Chemical Safety and Hazard Investigation Board

    John S. Bresland


    Gary Visscher


    William Wark


    William Wright


    Date of Board Approval

    Little General Store September 2008



    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


    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


    Appendix A

    Ferrellgas Installation Reviews of the Incident Tank

    Little General Store September 2008


    Little General Store September 2008


    Little General Store September 2008


    Appendix B

    911 Call and Initial Fire Department Dispatch

    Little General Store September 2008


    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


    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


    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


    Appendix C

    Recent Propane Incidents

    Little General Store September 2008


    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


    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


    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


    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


    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


    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


    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


    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


    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


    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


    Appendix D

    Table of State Training, Testing, and Licensing Requirements
    for Propane Service Technicians

    Little General Store September 2008


    For Propane Service

    Technicians, this state







































    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


    Appendix E

    United States EPA – 40 CFR 311

    Little General Store September 2008


    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


    Cause and Effect Analysis

    The cause and effect analysis is a structured approach to determine th


    causes and effects of events, which lead to the accident. There are many types
    of cause and effect analysis used in accident investigations, and this book
    will focus on the Apollo method (cause and effect process) and the Ishikawa
    Fishbone analysis ( developed by Kaoru Ishikawa) that the best way to view the
    causes and effects was to draw it out like a fish skeleton, with the problem at
    the head of the fish and the bones representing the causes. Another view of
    a cause and effect analysis is the “5 Whys” or “Questions to the Void.” The
    5 Whys approach is to analyze the event to five levels (give or take a couple)
    until it is clear that the root cause is found.

    The cause and effect approach is a structured approach, and examining
    the Apollo Method is based on (1) defining the problem; (2) developing a
    causal understanding of why the problem occurred (cause and effect chart);
    (3) identifying solutions; and ( 4) implementing and monitoring effectiveness
    of the best solutions (Gano 2007). For accident investigations, the problem
    has been identified, so for this approach, the only part discussed will be the
    cause and effect approach and the cause and effect chart.


    P11rt Ill: Anab•timl Trchniquu

    11 8

    Cause and Effect Approach

    The cause and effect analysis is best performed as a charc .
    events and causal factors analysis or tree analysis. The k s1Illilar to h

    . . ey to the t e
    effect analysts 1s che thought process of developing the effe caus, •nd
    and repeating that sequence. The process is the sam h cts of cau

    . . e w ether . ses Apollo Cause and Effect, Ishikawa F1shbone, or the 5 Wh using the ·th h ·d d ys analy · approach is to start WI t e aca ent an analyze until • sis. ‘l-1
    1t reache th ‘n,

    factors . The approoch to this an alysis can be perfo d s e caus,i
    rme on c software (Apollo 2011 ) or done on a sheet of paper h . 0 rnputer

    . , w lteboard using adhesive nores. The benefit of a thorough cau , or bi·
    . . se and effe . keep analyzing unnl all causal fac tors are found includin ct IS to

    h · th · . g any sysr . causes, althoug many runes . e 1nvesugato r will stop at th enuc
    causes. e superficial

    The approach to these three cause and effect analyses .
    . are very Similar

    Exlubit 11.1 displays the charnng structure for the three approaches. ·

    The Apollo Method is a software-based m ethod that leads th • .
    e tnvesngator

    through the approach with an effect followed by at least two causes. Each
    effect is “’caused by” a conditional cause and an action cause. According
    ro the Apollo method, “every time we ask ‘why,’ we should find at leasr
    ru-o causes and for each of these causes we should find at least two more
    causes resulting in four causes, and so on” (Gano 2008). Normally the
    chan is developed from left to right.

    The fishbone diagram has been used for many years in business and as a
    quality rool for manufacturing. The diagram resembles the skeleton of a
    fish and focuses on the causes rather than the symptoms of a problem.
    The problem statement is the head of the fish along the fish’s backbone.
    The ne..u step is the brainstorming or in case of an accident investigation, the
    facrs and analysis are analyzed to structure the big bones of the fish that
    are connected to the backbone (Ishikawa 1968). What areas of the acciden< investigation are the major types of causes? Some investigators _use the same major big bones such as people, policies, procedures, eqwpmem, and measurement, materials, and/ or environme nt. Others change each

    Chapter 11: Cause and Effect Anafysis

    es of causes for the accident, such as lockout
    the relevant typ . h Thi

    ” “””n ID . . procedure and management overstg t. s wa5•- dure uammg, ‘ . h
    .,gou• proc~ ‘m different and more specific to the accident; owever,
    -,kes each agra_ ti ier to start the process. Most fish bone diagrams
    1…- , is a lit e eas . k
    ,)le firS t wa) d ent on the right of the page and will actually wor

    .th the hea or ev h th fi h’ ,..,. wt 1 f . however it really doesn’t matter whic way e s s bacJ.,,ar

    he< 15

    . thod of solving a problem or finding the causes of
    5 Whys IS a me . • The t dly asking-at least five tunes-why the problem, ·dent by repea e

    an ,co .d t occurred and then why that cause occurred to explore
    . oracoen . . h

    esenr, d effect relationship and discover the causal factors (Haig t
    the cause an . f th h thi .

    X’h,ile this is not a precise techruque as many o e ot ers, s IS an
    2008). ·ct · · · h the effective technique if the investigator or acct ent mvest:1gatton ~earn as
    . th faces and analyses of the accident. This is not a technique you use

    l'”rt Ill· . A 11aly1fr,,/ T , .


    Fishbone Diagram

    ~eople J
    ~ _l!kof

    1~–~ // Equipment ] [ Policies J



    Why? Bad

    Chapter 11: Ca11st and Ejftd Ana!Jsis

    cause and Effect Process

    · to deterrnine the effect (event, accident, problem). In an
    · ·· Thi . .

    1n’ . ·gacion the effect is the ace1dent, UlJury, or damage. s 1s
    •dent lflvesu , . ‘”‘ f’ er that effect is then analyzed by asking: •’Why?”; •’What was this

    ,hefirSte ,e ‘ , • · ., b ,, … or ”\VhY did this happen?’ to get to the next level. This 1s then
    ted until the causal factors are found. One of the issues with any causal

    c,,11SCU } · ‘
    ::~ analysis is knowing when to stop. If there is lack of investigating or
    1:n,wledge of the facts and analysis of the accident, then these techniques
    ,ill not lead to the causal factors but will stop short and lead to symptoms
    of problems instead. Tbere are many types of problems that can occur with
    the cause and effect analysis, as listed in Exhibit 11.2.

    Exhibit 11.2

    • Stopping too soon (stopping at th
    supert1c1al causes) e

    • The need to place blame

    • Not having enou h of the accident o;st~~owledge (facts)
    analysis too soon ,ng the

    • Not looking at all issues
    (management pol’
    supervision, t/aini~cy’
    human factors des~g• ‘ n, etc.)

    Exarnpl S Tu, e cenario
    example scenarj



    )~cal techr,j nt investiga . ould be f . l e other techni
    ques to find th Uons there is b’ airy straightfo ques

    e causal facto a tg benefit of _rward. This
    rs. If using the 5 ~sing multiple

    ys techni que,


    Parl II/: Analytital I,,bniqueJ


    the accident would be laid out similar to the tree analy ·
    . s15 and WouJd shape. For purposes of usrng the technique, let’s do take that

    a couple of . . of the 5 Whys. The top event would be the individual fallin ueranons
    \Vhy did the individual fall off the ladder> Exhibit l l 3 di off th• ladder.
    th 5 Wh h . w n.. . thi . sp ays the s••-e ys tee ruque. w uen usrng s technique, you will h ~, of
    many iterations to get all of the causal factors . ave to per/onn

    Exhibit 11.3

    Event Falling off

    Why? Ladder hit

    by forklift

    Why? Failure to

    barricade aisle


    There are three types of cause and effect analysis: Apollo Method, fishbone
    diagram, and the 5 Whys. Each of these techniques is a structured approachw
    stan with the accident and analyze it until it reaches the causal factors. While
    there are problems with this technique, if it is used by experienced trruned
    ~ ve5rigators, these techniques are very effective at reaching causal factors,
    mcluding systemic causes.


    Chapter 11: Couse a11d Ejftrl A11olysis

    d effect analysis?

    es of cause an . ,
    ethe three !’/P and effect analysts .

    1.wttatar . three types of cause
    he differences tn the

    iWhatare t ctured approach?
    J. wt,at is the Apallo method stru . fusing a cause and effect analysis

    blems orfatlures o
    4 W,,ataresome of the pro

    . such as the 5 Whys? . does the investigator
    d ffect what questions

    5. When analyzing a cause an e ‘

    continually ask? A llo method and the
    I the example scenario with the po 6. Continue to ana yze

    fishbo ne diagram.

    I ••r

    Specialized and

    Computerized Techniques

    So far this book has discussed five major types of analytical techniques:
    events and causal factors analysis, change analysis, barrier analysis, tree analysis,
    and cause and effect analysis. Many other specialized analytical techniques can
    be used in accident investigations, and each has a role in certain situations.
    (NOTE: 1n some types of accidents, these specialized techniques may yield so
    much information and so many possible causes that the investigator cannot
    deal with them. The process becomes too confusing and frustrating. The
    mvestigator must learn to use the appropriate technique for each type of

    Some of the newest analytical techniques for accident investigation involve
    ~-~oo d . all . . mputers an software. Some programs s!Illply ow investigators
    to portray a ·a · ·d cc, ents graphically, but others actually help to analyze acc1 ents.

    h ” . d . e tee ruques range from computerized trees to fully an!Illate
    accident re . construction programs.


    Part lll: At1u!) t1l”al Trrhm


    Specialized Techniques

    Time Loss Analysis

    Time loss_ analysis ,~•as developed for the National Tran
    Board. It 1s a graphical analysis tool that investigators casportation Sifett
    ro ~nderstand, de~’elop, an~ evaluate interventions and em: use proacti\”e:\;.
    ~coons, ~nd r~acav~ly co give credit to good emergenc , re tgency responst
    1mervent10ns 1n accident situations. ) sponse effons or

    Time loss analysis helps the investigator to evaluate how the _ .
    em~ncy response or loss control actions affected the loss cau llnung of
    ac~dent and to analyze _the losses that occurred as the events lea . sed hr the
    acadeot progressed. It 1s useful in determining how 1 up to the oss control mterv .
    changed (or could have changed) the amount of loss a d h . . enao~

    n owumeincrcasea
    ~r decre~sed lo~ses ~r costs. It provides a way to analyze the interventions
    l.Il an acadent s1 ruat1on and determine how they changed the course of the
    accident sequence (SSDC 1987) .

    To use this technique, investigators follow these seeps:

    Discover and analyze all interventions that took place leading up to
    and during the accident.

    Determine whether these interventions increased, decreased, or had
    no effect on the outcome (the accident sequence). Forexample,ini
    car crash with an injury, what is the effect o f the vehicle having anti-lock
    brakes? D o the brakes allow the car to sto p any sooner or in a shorter
    distance? What about airbags? What about crumple zones?

    Assign a time value to each intervention. The time value can be an acrw.l
    number or a relative positio n on the chart. For example, the brakes stan

    to act as soon as the driver senses danger and applies them. The anti-Jock
    brake mechanism activates when the wheels begin to lock. The air b~
    activate at the moment of impact. The crumple zones crumple after che

    . . h damage to che
    initial impact as the car continues to m ove, increasmg t e
    car but distributing energy away from the passengers.


    . f-,,ed and Computen’z.rd Tedmiqurs
    Chapter 12: p,na1,

    k d in dollars or units of
    The loss axis is usually mar e b er of people injured ,

    e the loss- d d or gas leaked, num
    ‘ p,.,i112.t ount of water £loo e
    •• (iJll f . hides damaged). . c the simple car crash

    I# o ,e al •sts chart ior .
    n1,l!ll . wires a time loss an ) . fall three intervenoo ns-
    £.tlubit 12.1 l~ lowest amount ofloss occurs t ed. Even if all three


    ,h(·lflo-lOC ill be some damage; however,
    ¢ therew

    i,’t , ,ill be much greater.

    Analysis 11uman Factors al . and a human factors or
    ri f h an factors an ysts,
    1’1..- ire man}’ methods o um al ‘ The basis of human factors
    .. ~- h uld erform the an l ses. .
    ..oonomics expert s o p chin / w· orunent interaction and to detemune .,- . tify human/ ma e en f
    ~’Sisis to1den : h d an effect on the accident. There is som e type o
    ~ticther the intw.cnon a f cident The key is to determine the

    involvement in all aspects o an ac . . ~= involvement and the human capabilities to perform the task.
    Exhibit 12.1





    TO – Driver senses danger

    I _______ T 1 -Driver applies brakes \ I T 2 -Anti-lock brakes deploy T 3 – Airbags deploy I, T 4 -Crumple zones crumple
    \~~ Natural : : : : , course of

    : \ \ \ \ \ accident
    9 : \ : Courseof

    \ : ; \ l ~i~~d=l~t
    : \ interventions

    -~ ineffect
    To T, T2 T3 T4



    To ~ nduct n human/ machine / environment analysis
    c.,-pc:.n tollm.vs these steps: of an accid

    •n~ th
    Analyze ho·w the human interacted with th ‘

    e rnachin environment, etc. e, eqUiPrnen
    Llst the bad interactions in the accident t,
    – – sequence l
    mter.1cao ns that do not favor the capabilities of the h · hese are th
    capabilities include physical interactions (stre h umf! a~ body. I-I1.1rn ‘

    . . . . ngt , ex,bi]j an
    m~a~ n, eyesight, ~eann~, men~al tnteractions (knowled e ~• ra~ge of
    tr.11n1Ilg), and emononal mteracnons (morale mon· . g • lrltelligence

    , vanon, attitud •
    Other types of human factors analysis analyze anthropome . e).
    rk h · I cl · d · · try, btomechani ,vo – p ysio ogy, s ecnon an traU11ng of personnel, job tasks and w ts,

    In this of analysis, the focus i~ on the work environme~t that orkloads.
    bad beha”‘,or. The safety professional tries to eliminat th b Produces
    . . eeadbeh · instead of focusing on human error (Oakley and Smith 2000). avior

    Integrated Accident Event Matrix

    An integrated accident event matrb. includes a list of all individuals who
    were at the scene of an accident and a time-based chart that shows their
    interactions (DOE 1999). This matrix allows an investigator to analyze what
    each individual was doing at the time of the accident. Although the chan can
    include any amount of time before the accident, it usually only covers the ten
    co twenty minutes before the accident occurred. This type of matrix is helpful
    for many types of accident investigations and is very simple to perform. It is
    a low-tech method of accident reconstruction.

    To perform an integrated accid ent event matrix, the investigator follows
    these steps:

    List all of the individuals who may hav e been involved in the accident in
    the left column of the matrix.

    . d · h ‘ activities under Mark the next columns with umes, an write eac person s ed
    the appropriate time. Exhibit 12.2 illustrates an example of an integrat
    accident event matrix. ft shows that there was no interaction ben~een the

    . U d at the p1pefiner pipefitter and the mechanic and that the supervisor ye e .
    to get the job done as soon as possible, interrupting him. Creaong an

    Chapter 12: SperialiZJd and Co111puterized Tedmiqtm

    . . a simple technique that can be used to
    ed accident event macnx is

    ji11ef1′ . ns between people.
    dis(O”er wceracno

    odes and Effects Analysis .
    failure M al . . sually used as a proacave safety tool d effects an ys1s ts u
    ,,_:1,,re rnodes an . al al how failures can affect systems. The
    r,.,i- – r rofesston s an yze . . d .
    .,, help safe[) P d actively for accident invesogaaons an 1s ,., also be use re .d
    ttChnique can I if the accident was caused by a system failure. In acc1 ent
    rs~ y.usefu all failure modes should be analyzed to determine whether

    Note: This technique is very helpful in fata l acciden~s

    or other situations where some viewpoints are not available.

    PEOPLE 10:01 10:02 10:03 10:04

    Usf all people Record what
    whocouldgive each worker
    infomlotion was doing at
    aboutinter- each time in
    ocrionsand the sequence.
    lttlp toanalyze
    rht ocddent.

    Pipefitter Walked to job Turned to talk Went to Walked to
    site with super- electrical box equipment;

    visor and turned on found
    breaker mechanic in

    Supervisor Talked with Yelled at Finished Finished

    vendor pipefitter paperwork for paperwork

    Mechanic Worked on Worked on Talked on Received equipment equipment cell phone electrical
    – shock

    Part TT!: A 11a!Jtiral Terh11iq11es


    Other Specialized Techniques

    Expert Techniques

    Some techniques that can be useful in accident investiga,-;
    . uOnare b by e.,–pe.rts. E.,;:amples include: est Perfottned

    Sofa,,ar, ha-:z.ard ana!Jrsis. Helps investigators to analyze f
    so tware fail find causal fuctors in computer systems. llres ‘-nd

    Common Cal/St faihm ana!Jsis. Used to find system failures th
    . . . at led to accide

    • Sneak amal ana!Jn.s. Looks at sneaks (failures) in a s nts.
    ystem or circuit.

    Failure Analysis and Structural Analysis

    Failure analysis and structural analysis can be used for aca·d · .
    ent mvesuga · ro determine types of failures and structural flaws that led t . llons
    o an acadent.

    Sdentific Modeling

    ]Vlany types of modeling can be used to describe possible accident scenarios or
    ro sample data to reconstruct scenarios. These types of analysis are performed
    by experts who understand data collection and analysis processes. Most of
    these types of analysis are performed in a laboratory setting.

    Acddent Reconstruction

    Accident reconstructions may be simulated or computer-generated. To
    reconstruct an accident, the investigator finds out how each step in the accident
    sequence occurred. Once this sequence is determined, the reconstruction
    will help ro analyze the effects or potential effects of the each event in the

    Computerized Techniques

    Graphical Programs
    . . Mi soft VisioTM and

    lnvesogators can use graphical programs such as cro h alytical
    h rts grap an CorelDRAWTM ro create events and causal factors c a ‘ d effects

    d ture cause an trees, draw barrier analysis summary charts, an strUC

    Chapter 12: Specialized a11d Computerized Tech11iq11es

    s such as Microsoft PowerPoint™ and Corel ration program . .
    , .. ….ens-Presen d t draw simple charts and analyocal trees. While
    ill’5′- rM can be use o . . . .

    sent:1cions . all di play the results of the accident mvesogaaon, p~ ms graphic y s . .

    d not actu Y tb

    . al Programs
    ,\Jlalyuc t ized programs however, can help accident b ed of compu er , .
    A new re . blem solving, investigation, and analysis. These programs

    ·”‘tors with pro . . b al ~res0o·· nl find causal facrors and correcave acoons, ut so to be used not o y to
    c,J\ al ses into written reports.
    – ~m y . .

    rograms have been designed for accident analysis,
    Many custom p . 1 . U .

    d 1 factors charting and analysis, and tree ana ys1s. smg – m= . .. 1· am does not take the place of mvesogaong, ana yzmg, ,computer progr . . .
    thi ki however. Four accident invesogaoon and problem solvmg ,nd n ng,

    programs are:
    , REASON® Root Cause Analysis by Decision Systems, Inc.

    , Apollo Root Cause Analysis and RealityCharting™ by Apollo Associated

    , TapRooT® System with SnapCharT® Software and Root Cause Tree®
    Software by System Improvements, Inc.

    ‘ RootCause LEADER™ Software by ABS Consulting, Inc.

    The following short descriptions of the capabilities of each program were
    obtained from the companies’ web sites. Web site addresses are listed in the
    bibliography at the end of the book.

    REASON® Root Cause Analysis

    The latest version of this root cause analysis software from Decision Systems,
    Inc. is called REASON@ 7.2. REASON® believes root cause analysis should
    be a validated and consistent process that discovers the root cause of a
    Ptoblem so th b · – f h at usiness pracoces can be used to prevent recurrence o t e

    _blem. One of the key features of REASON® is that it gives the user a

    thrailroad track to get you to the correct root cause.” In other words, it gives
    e user th l

    e too s to find the failure. The program leads the user to ask the


    Parl III: A 11t1()’hcal Terlmiqu,s


    right questions, and thus arrive at the e d . n pomt (
    an e.,perc sys tem software tha t guides yo root cause) “t> . u to uncov · ,,ea
    your operaoons problems, enable you to er the r00 50n is . manage and t cau
    acoon plans and communicates the lesson learned track Your c ses of
    activities” (Decision Systems Inc. 2011) from Y0 ur probl orrective ernso[ · software is used not only for accide · . V!ng . nt mvest::tgations
    of problem so! or process improvement. A vali . , but for an

    c…. ti · · . dat::ton ste . Y type son ,vare; us gives consistency to the root ca al . Pis built in

    use an ys1s pro to the
    oes nor attempt to funnel the user into a sel cess. REAsoN

    . . ect number of root ca r t
    Other unportant funcnons are a correctiv . Uses. . . e act::ton datab

    correcove acoons and a searchable query for hin ase that track searc g previ s
    issues, root causes, and corrective actions. The ftw ous accidents so are also h ‘
    report editor. This program can be used for both . as a powerful
    . . . . reacove and .

    s1tuanons and combrnes rntegrated root cause anal . _proacuve
    . ys1s, corrective ac .

    tracking, and lessons learned. (Decision Systems Inc. 20l l) Uon

    Apollo Root Cause Analysis

    When Apollo Associated Services first started out it introduc d . . ‘ e an approach
    to basic problem solvrng that also works well for accident investigation. A llo
    has developed a very effective training program and cause-and-effect pr!:ss.
    The cause-and-effect process can be performed either on a computer or
    on paper. The process and a particular method of analysis is Apollo’s real
    product. As the computer has grown to be a more important tool in accident
    investigation, Apollo has developed a variety of computerized charting
    programs. The newest is RealityCharting™.

    RealityCharting™ is a graphical program that facilitates the cause-and·
    effect charting process. One of its features is the ability to drag and drop
    causes to any location on the chart. The software also provides:

    • embedded Apollo Root Cause Analysis methodology

    • detailed problem definition helps you understand sigiuficance

    • graphic representation of interrelated causes and causal paths

    • effective solution generation

    • comprehensive reporting features


    . ,. ed and Co/Jlputerized Techniques
    Chapter t 2: pee1a,1z

    . nal user through the rules of the
    ,,,,ides the new or occas10 Jetion of a RealityChart (Apollo

    0ndoW b- th rn roward comp if!I’ d leads e
    ,\ ~tz ethod llfl ,,,,uo m . s 2011)-~, . red service
    -~-o0a . .

    o0’f® . two computerized accident invesngat1on
    f1pB T®Systern consists of T e® These products are

    Roo d R ot Cause re · d
    ,i,, fap SnapChar’f® an o . dhesive notes to chart events an

    grams, t over using a h d pro irnprovernen . al gram that draws c arts an
    Jefini1ely an Char’f® is a graphic pro . li

    ., factors. Snap .fi . The result is a presentation-qua ty
    ~us~ modi 1cat1ons. d h
    . ,.,ms and allows easy . h I investigators understan w at

    ,lii5•- Ch ‘f® diagram e ps “The Snap ar d h ,, (Systems Improvement
    ch•rt- 1 . what happene to ot ers. happened and exp am
    J 2011) ff
    nc. ot Cause Tree® software picks up where SnapCharT® leaves o • ‘In~:~® detemunes what happened, and Root Cause Tree® finds root

    lnap ard develops corrective actions. software features a Root Cause
    ~m C Tree®diccionary and a Corrective Action Helper® module. The Root ause
    Tre~includes a Human Performance Troubleshooting Guide that helps
    investigators ask the right questions to solve human performance problems.
    A built-in reporting feature and integrated databases ensure that corrective
    ,ctions are tracked (Systems Improvement Inc. 2011 ).

    RaotCause LEADER™ Software
    RootCause LEADER™ allows accident investigators to investigate and track
    my l}pe of incident, event, or nushap. It can also perform data trending and
    ana!ys15, generate report forms, and include a detailed background/ description
    for each causal fact d >-rL: ftw . . . . or an root cause. , ms so are can 1dent1fy root causes of
    madents events · d • . . .

    . • , acc1 ents, near nusses, reliability problems, quality impacts,

    or Ustness losses.

    RootCause LEADER™ h . . . usino R C as five key features: identifying consequences
    -.,, OOt ause Ma TM hin ‘

    recornrn d . P ‘ attac g photo files and other documents, tracking
    en auons and tr d. Th Roo1ca M ‘ en ing. e consequence categories and ABS’s use apTM ar £ £

    investigator identi e eatures or customizing the database and helping the
    fy root causes (ABS Consulting Inc. 2011 ) .


    Part [] I: A nalytical T echnique,


    Many specialized and
    . . cornputeriz d


    accident 1nvestigatio I e anaJyticaJ
    h . n. n Order to technj

    tee 111que, it rnust be c receive th que,

    1 . y y an expe ,, S!tuatton ,, on fro u sed for accident analysis b . rt. <>1any syste~ . “‘any re,, .. ~•
    . . , ut cauaon h … safety “‘ll’!lrti gamed 1s useful. These anaJys . s 0 uJd be used t ana.Jys,

    , , _

    th es rnay identify O ensu, ..,. be at rnay not be practical for th .d . an overwhel-, e that th, ,. al . e ace, ent tn . “‘ung “‘ll an ys1s and problem-so[v;~g p vesttgati

    . u, rograrns b •nenew to tnvestigators. are ecorning i . c

    1. What does time loss analysis try to analyze?

    2. Which techniques must be performed b

    ncreastngl , .
    l rn,Po”‘n,

    y an expert?
    3. What does a failure modes and effects analysis look for?

    4. What is the difference between a design criteria analysisand h
    c angeanalysisl

    5. How can computerized techniques be helpful in accident investigations?

    Part IV
    < z



    D · d hich is the ultimate f, how to prevent future ace, ents, w . art: :;~:~::cnting accident investigations. Determining the accident
    purpo d the causal factors prepares the accident investigator to deterrrune
    stljUence an · · hould
    corrective actions that will prevent similar accidents. Correcuve acuons s
    be initiated, documented, and followed up (audited) to ensure that they are
    perfonning as intended.

    Writing an accident report or filling out an accident form is not simply an
    exercise in paperwork. The report should document that the facts and analysis
    are correct, the accident sequence has been determined, and corrective actions
    have been developed to avoid recurrence of the accident.

    Learning from accidents is one of the important aspects for conducting
    an accident investigation. Communicating the lessons learned, preventing
    systemic problems, and improving the safety programs are key components
    of learning from the accident. No accident should be repeated.

    Objectives for Part IV:



    and the purpose of corrective actions and be able to develop
    effecuve corrective actions and recommendations for accidents.
    Understand th I · hi

    . e re auons ps among facts, analysis causes and correcu·ve , ,

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