Tag Archives: Accidents

Risk Assessment

Risk assessment is supposed to be about looking at how likely it is that a person will come to harm, and then putting measures in place to reduce these risks to acceptable levels. As practiced in British Steel and its subsequent incarnations, the risk was assessed by looking at the likelihood of occurrence, the frequency of exposure, the number of people exposed and the degree of possible harm.

What I often found missing, however, was the probability that the maximum harm will occur, thereby leading to a skewing of the level of risk. For instance, at one time I had a frequent discussion with my boss about the holding of hand rails when going up and down stairs. While I don’t argue that holding the hand rail is a good idea whether you’re going up or down the stairs, I could not make my boss see that the level of risk was far greater when going DOWN the stairs, than going UP.

Theoretically it would be possible to state that the risk for both types of action was more or less equivalent if you take likelihood of tripping, the frequency of exposure, the number of people and the maximum level of harm to be the same. However, this line of reasoning ignores the fact that whilst the maximum level of harm, being death or severe disability, is the same for both types of action, the likelihood that you will be killed or severely disabled is far greater when you fall down the stairs than if you tripped going up the stairs.

I don’t know why I could not make my boss that going up and down stairs should be seen as two completely different types of action, each requiring their own risk assessment, rather than aspects of the same action, where the overall assessment of the risk is taken to be the highest of the whole activity.

Presumably this confusion may derive from a “better safe than sorry” approach, but sometimes I wonder whether it also leads to spending too many resources of staying out of trouble as a blanket rather than an activity-specific approach.


Slag Reaction

I’ve seen or heard of the consequences of slag reaction in the BOS vessel firsthand only twice in my life, once at Iscor around 1987, and a second time last year in Port Talbot. The first time there were several fatalities, the second time it was a miracle that no-one got hurt.

First a short explanation of the BOS (Basic Oxygen Steelmaking) process and how it can lead to a slag reaction. In the BOS process, the standard procedure is to charge about 20% scrap and the remainder hot metal (i.e. liquid high-carbon iron) from the blast furnaces, and then blow oxygen through a lance which burns off most of the carbon and other impurities. The carbon is evacuated as a mixture of carbon monoxide and carbon dioxide, whereas the other impurities form a liquid layer of oxides on top of the steel which is called slag.

After the oxygen blow is completed the steel gets tapped into a ladle, followed by a separate tap of the slag into a slag pot. After both taps are completed there is still some slag left in the vessel, and the next charge of scrap and hot metal can be made for the next blow operation. So far so standard. Except that at times (and I don’t know the exact reasons in both instances) the decision can be taken to charge less scrap, and in the two cases I’m aware of, the operation was using a hot metal only charge (i.e. without any scrap charge whatsoever).

The situation in Iscor was as follows: it was a Saturday and visitors were trooping into the pulpit of the steel plant, when a hot metal charge was about to start in the vessel furthest away from them. The hot metal was poured on top of what remained of the slag in the vessel, and the force of the slag reaction forced the hot metal out of the vessel, where it hit the pouring ladle and splashed sideways for a considerable distance. The group of visitors had only partly entered the pulpit and the back of the queue got struck by the spray of liquid metal, causing several of them to be killed. A few days later I passed the site on my way to the morning meeting and could see the remains of the splash against the pulpit wall. The thought occurred to me : “that could have been me.”

The second instance, in Port Talbot, did not involve me to the same extent, but I have been able to find out more of the details that led up to the slag reaction. The new manager director at the time, Mr. Jha, had insisted that Port Talbot try out a practice which he claimed was quite common in India, which is to leave out the scrap charge altogether. Not sure why this was suggested, it may have been cheaper or made better use of raw materials or maybe it’s a faster process. Whatever the case, the previous cast had to have several reblows, meaning that the remaining slag was overoxidised.

It’s not hard to see what would happen if a carbon-rich liquid meets an oxygen rich slag: it’s a bit like throwing water on a hot plate, only far more violent. The instantaneous formation of carbon monoxide gas at the interface between hot metal and slag would want to escape somehow and as such force the hot metal back out. I don’t know the exact circumstances, but presumably Port Talbot was following the practice of clearing the casting platform whenever a hot metal charge was made, and as such there was no-one about to get hurt.

Still, the spray of hot metal caused quite a bit of damage and started some fires, which fortunately were contained before they reached the carbon carbide stores at the desulphurisation station, otherwise that would have caused a massive blow that would have caused fatalities and far more substantial damage.

So why is a hot metal only practice more vulnerable to a slag reaction ? My opinion is that an overoxidised slag is less of a problem when scrap is charged first because (1) the slag is cooled by the scrap; and (2) being solid, the scrap is less likely to be thrown out of the vessel by a slag reaction. I’m not sure if the two were related, but not too long afterwards Mr. Jha was replaced as managing director for Strip Products UK.

Lightning Strike ?

That’s what was reported in all of the media when Port Talbot experienced a works-wide power cut on Thursday the 11th of February 2016. I beg to differ, or at least, I have serious doubts about this scenario.

I happened to be in work at the time (the event happened closer to 7.30am than 8am as reported on the BBC website), and the first thing I noticed was that the lights in the office went off and then came on again. The blip was apparently not severe enough to turn off my computer, but even so, I went to see if anyone else had experienced the same thing in the building. As we were discussing what could have caused the interruption, the lights started to go on and off in a rhythmic pattern and finally stayed off.

Not only was my computer off this time, but also anything electrical and even the landlines. Fortunately a few people had mobile phones on them, and we quickly established that the power cut was far-reaching, and possibly works-wide. We also got reports from cleaners in the AGO (Abbey General Offices) that the substation nearby (which is where all the outside power enters the works) had made the sound of a minor explosion.

As people were starting to trickle into the office for their normal start of the day we received tales of massive flames coming from the coke ovens. Now this had been interpreted by the outside world as “the steel plant is on fire”. Not so. It is actually a safety feature of the coke ovens that the exhaust valves open up in the case of a power failure, otherwise the pressure build-up would destroy the batteries. However, the gas formed in the coke ovens is rich in carbon monoxide, and on contact with the atmosphere the hot gas turned to massive flames.

I’m fairly confident that the fire service only made sure that the fire didn’t spread to surrounding buildings and equipment, because there was no point extinguishing the flames until the power was turned back on, which happened within one to two hours from the power failure. From that moment on the extraction system could operate again and the valves could be shut again.

But was there a lightning strike at the time of the power cut, as widely reported in the media ? I didn’t hear any thunder following the alleged lightning – after all, we were about a mile away from the substation, and a lightning strike that close would surely have been both visible and audible. I later heard from someone at Occupational Health that a nurse was just passing the substation when there was an explosion there – but not a word about lightning striking.

My opinion is that the management team did not contradict the media’s lightning story, or may even have suggested it as a possibility because it was a rather convenient piece of fiction. After all, lightning is an act of god, and does require no intervention by the Health & Safety inspectorate. Whereas if the actual cause was a malfunction in the substation, then that WOULD have to be investigated as an incident. I wonder what was decided in the end – there definitely was no follow-up bulletin clarifying what had happened.

Seeing Someone Die

In all my life I’ve only seen one person die in front of my eyes. Even when my parents died, I was elsewhere, and although I could make it to the funeral, I wasn’t there in the hospital when either my mum or dad died.

Likewise at work : although fatalities did happen during my time at Iscor and British Steel / Corus / Tata Steel, it was always something that you heard of or read about, but not something you witnessed.

The one exception was when I was working for a 2-week stint as a summer student at a company where they stored and handled frozen fish in Ostend. At one stage we were going to defrost one of the freezers, and one person, Victor de Man, was going to shut off the cooling system, and then we were supposed to get the ice off the pipes using metal rods.

My cousin Frank and I were standing there waiting for Victor to do his part of the job when his wrench key fell to the floor. I thought he just let it slip and was about to pick it up, when i heard my cousin shout : “What’s happening now ?!?”. He had been looking up and had seen how Victor had stumbled backwards and collapsed.

What I saw was how Victor fell backwards, without uttering a sound, arms spread out like the wings of an airplane, and fell head first to the ground. I can still hear the sound when his head hit the concrete floor, like when someone squashes an empty can. Then he fell on his belly with a sound of a wet fish being thrown onto the counter. I knew for certain that I had just seen someone die right in front of my eyes.

Frank ran straight away for help, I followed him in a daze. When questioned I couldn’t say anything more that Victor had fallen. A co-worker had gone to see what happened, then came sprinting out calling for a doctor or an ambulance. When I took another glance, I saw him lie there, not moving an inch, with his head in a pool of blood. If I had had breakfast that morning I definitely would have thrown up.

I didn’t need to hear the verdict of the paramedics when they arrived a few moments later, because I knew for a fact that there was no hope.

It’s funny how certain memories stay with you for the rest of your life, even if you would have given money to forget about it. It’s still not hard to recall the vision in front of my eyes or the sound of that fatal crash. It’s not something you want to witness too many times.

Middle Age and Accidents

I have not been involved in any incidents where my life was in danger during my time in any part of the steel industry. But unfortunately, accidents and fatalities do happen, and the strange thing is that in my time with Corus and Tata Steel over the last 10 years all of the fatalities have involved middle-aged men.

You could argue that working on the shop floor is always hazardous, and that middle-aged men may be over-represented in comparison with the population at large, but it is undeniable that the last few fatalities were all men in their late 40s and 50s.

  • Hywel Thomas – aged 52 – Pontardulais – crushed by coil
  • Bryan Robbins – aged 53 – Port Talbot – crushed by locomotive
  • Kevin Downey – aged 49 – Port Talbot – burnt in molten slag channel
  • Robert Gillard – aged 46 – Port Talbot – crushed by tipper truck
  • Michael Down – aged 64 – Port Talbot – dragged into milling machine

I sometimes wonder whether there’s a number of factors in common here. All of these people had been working in their respective jobs for a long time, and should have known their jobs inside out. All of them would have been fully aware of the hazards around them, and at least one of them (Hywel Thomas) was a safety representative. But I just wonder whether being in a job for a long time makes you slightly complacent because you become habituated to the risks of the job and feel that you can handle them because you’ve already done so for 20 years or more.

And then there’s the factor that the older you get you may think you’re still the same person as you were in your twenties, but maybe your reactions are a little slower, and maybe the likelihood of a senior moment becomes greater.

From personal experience, I had a moment like that, not in work, but whilst parking my car on the drive of our house. This drive slopes slightly towards the garage. I was a bit in a hurry because we were going to go to the movies and I was late getting home. Not sure exactly what happened, but I walked from my car to the front door and as I was about to use my key to open it, the car crashed into the garage door. For the same money I could have been crushed by my own car, and all because of a senior moment at the wrong time.

I just wonder how many of the accidents I listed above could have involved such an “oh shit” moment. I have no answer of what you can do to avoid this type of thing from happening; you can and try to eliminate risk as much as possible, but in a hazardous environment risk will always be there, and human frailty can become an additional factor, and possibly one that looms larger as you get older.