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November 29, 2024 20 mins

The podcast episode focuses on a catastrophic explosion at a food additive manufacturing site in Louisville, Kentucky. The explosion was attributed to the failure of a ventilation system on a cooker, leading to overheating, overpressurization, and a subsequent explosion. The event caused significant community damage, including shattered windows and structural harm, injured 10-12 people, and claimed two lives. Notably, one victim was initially unaccounted for due to a clerical error during the emergency evacuation, raising questions about the company’s emergency management protocols.

The discussion highlights systemic failures in safety leadership and engineering risk management. The organization, already familiar to OSHA, may not have implemented Process Safety Management (PSM) standards, which could have mitigated risks. Questions are raised about preventative maintenance, predictive engineering, and redundancy systems to prevent such incidents. The lack of alarms or fail-safes and the apparent high tolerance for risk are cited as critical oversights.

The podcast emphasizes the importance of proactive leadership in safety culture. It critiques the company’s slow response to the community's concerns and contrasts OSHA compliance with going beyond minimum standards to prioritize worker and community safety. The host reflects on the engineering decisions and leadership deficiencies leading to this tragedy, urging organizations to adopt robust safety practices and foster a culture that values risk management and human dignity.

Ultimately, the incident serves as a stark reminder of the consequences of inadequate safety protocols and the need for comprehensive risk assessment to prevent similar catastrophic events.

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Transcript

Episode Transcript

Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Mark French (00:01):
This week on the podcast, we're talking about an
explosion in Louisville,Kentucky, my home state, that I
want to get deeper into theleadership of how these things
can happen this week on thepodcast, you Mark,

Announcer (00:32):
welcome to the leading and learning through
safety podcast. Your host is DrMark French. Mark's passion is
helping organizations motivatetheir teams. This podcast is
focused on bringing out the bestin leadership through creating
strong values, learningopportunities, teamwork and

(00:54):
safety. Nothing is moreimportant than protecting your
people. Safety creates anenvironment for empathy,
innovation and empowerment.
Together, we'll discover meaningand purpose through shaping our
safety culture. Thanks forjoining us this episode and now
here is Dr Mark French. Youmusic.

Mark French (01:29):
Hello and welcome to this episode of the leading
and learning through safetypodcast. I am so happy that you
can join me for this podcast.
This week, I'm going to attemptto talk about an explosion in
Louisville, Kentucky. I sayattempt because last week I
recorded the podcast, tried toupload it and found that

(01:49):
technology beat me. Itabsolutely defeated me on that
one and it was a corrupted file,so there was no podcast last
week because of that. I am goingto try again this week to talk
about this event. It happened inLouisville, Kentucky a couple of
weeks ago, and it caught myattention one of course, because

(02:13):
it's in my home state. And thosethings capture my attention
because it feels more like yourelate to it. It's easy to put
yourself in that relationshipwhen you find that commonality
of something or someone. Andbeing a Kentuckian that brought
us together for that one. Thesecond one is that the Chemical

(02:35):
Safety Board is going to be onsite conducting investigation.
Now, historically, this ChemicalSafety Board has done a
phenomenal job of reallyunderstanding the root causes of
events like this, and to havethem on site means that there
will be a very in depthinvestigation, and it'll take

(02:55):
some time before we knoweverything, but we will learn
what happened, how it happened,and to better understand the
system's failure that comes withan explosion of this magnitude.
Now, what happened was, this wasa food additive manufacturing
site. They do a lot of differentthings at this site, in

(03:19):
particular, the organizationmakes a food additive that adds
color, and so there's largebasically cookers that are
within the facility. The bestthey understand so far is that
on one of the cookers, theventilation system failed and it
overheated, thus overpressurizing and exploded. It

(03:39):
rocked the neighborhood. Itwindows were shattered, damage
around the community, twopeople, two people did not go
home because of that explosion,and somewhere between 10 and 12
people were injured. Workersthat were injured from that not
and that is not even going intothe community about the broken

(04:01):
glass, the damages to home, thedamages to other items, because
of this explosion. It was verypowerful. It was significant
explosion. And where I see thisis that I won this organization,
when certainly is no stranger toOSHA around the nation. So it's

(04:26):
a nationwide company, and theyare no stranger to OSHA visiting
their sites that was done by asimple search. Also, I must say
up front that I'm reallyimpressed with the local
journalism in Louisville. Theydid a nice job of updating and
being there and making sure thatthe facts that the information

(04:50):
was shared. They even did deepdives on the facility itself,
the people they have beeninvolved in. Producing good work
to where, when I watch it andread, I get a good picture of
what's happening, and I thinkabout what is real, leadership
and safety. And I've talkedabout this before in giving

(05:13):
examples of those who go, youknow, OSHA is is the minimum and
the maximum, it is the one thatwe hold ourselves to. And once
we hit that mark where we arecompliant legally, we're done.
We're not worried about anythingmore than just basic don't get
me in trouble, avoid big fines,don't go to jail. Compliance,

(05:38):
there are companies out therelike that. Now I am not saying
this company is one of those.
What I am suggesting is thatthere's opportunity to learn
through all the standards whatcan be done and what can be
better in how we interact withour risk. So for instance, my

(06:03):
guess, given that it's a foodadditive manufacturing facility,
I would highly doubt, and givensome of the research not as
thorough as it should be, but Ido not believe they would fall
under process safety management.
Would process safety managementhave helped, I think so. I think
this is one of thoseopportunities where just because

(06:24):
you don't have to doesn't meanyou shouldn't follow some good
practices. And I think the PSMstandard really gives some
performance standards of whatdoes it look like to manage your
risk with opportunities thatcome with this level of risk.
Why did the fan fail? Was therepreventative maintenance? Was

(06:45):
there inspections? Was there anytype of knowing, of predictive
engineering that could have saidthat fan has failed, would fail,
could fail, had been failed,which is probably my larger
concern was, How long had theyknown that that fan may not be
as good as what it was, or whatwas the indicator that it was

(07:08):
getting too hot or overpressurizing? Where was the fail
safe? Where was the redundancy?
Where was the engineering riskassessment? What is really
interesting about engineeringrisk assessments is truly being
able to calculate what are thechances of this event happening,

(07:32):
what are the chances that thiscould occur, and being able to
reduce that systemically throughadding extra pieces of work,
whether it be engineeringredundancies, whether it be spot
checks, whether it be alarms.
What is it that would allowsomething like this to happen

(07:55):
without people knowing that itcould be happening and it could
be coming catastrophic. That iswhere I scratch my head, and I
truly question the leadership ofhow does that happen? To know
that it could fail that bad,like this was a catastrophic,

(08:16):
community changing failure, andit appears that there was very,
potentially very little herethat prevented it, that was in
place to give notification orengineer it, or fix it or

(08:37):
understand it, to even quantifythat that level of risk could
happen, and who said it wasacceptable, or was it truly out
of sight, out of mind? There's alot of questions there, and this
is why I'm happy. I'm sad thatthis happened, of course, but
I'm at least happy that theChemical Safety Board will be

(08:57):
there, looking at historicaldata, looking at what has
happened historically that ledto these critical decision
making steps, the engineering,the work that had to be done
that allowed such a catastrophicevent to happen. Now there's
another piece of this story thatI'm going to get to in the

(09:19):
second half of the podcastcoming up here in just a moment
that allow that gives me furtherindication that there were
significant leadershipdeficiencies. Again, I'm making
an assumption, but when I putthe pieces together and I look
at some of the items that I hearabout, and I learn about and I

(09:39):
hear about from the newsstories. I question what could
have happened there. I questionthe leadership motive. I
question the just the normalcaring, compassion, human
dignity and decency that. Isrequired that some organizations

(10:00):
don't believe in, but should.
Let's talk more about that onthe second half of the leading
and learning through safetypodcast. You

Stinger (10:14):
are listening to the leading and learning through
safety podcast with Dr MarkFrench,

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(10:44):
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Mark French (11:00):
Welcome back to the second half of the leading and
learning through safety podcast.
So I alluded to in the firsthalf that there were more
indicators of this incident inLouisville, Kentucky, where this
vessel exploded a food additive.
Vessel that didn't ventcontinued to heat over,
pressurized and exploded,injuring somewhere around 12

(11:23):
people, killing two in rockingthe neighborhood. Shattered
glass out of windows, damages tobuildings, damages to other
items, significant, catastrophicexplosion, and I mentioned that
there were other items that mademe skeptical, highly skeptical

(11:43):
of the leadership, and I thinkjust the effort to prevention
and this, I still, even thoughI've done this once before,
because I said I've tried torecord this one, I still have
trouble getting The wordstogether of this next piece of
it. And so there was onefatality for sure. They didn't

(12:07):
discover the second fatalityuntil after they were digging
through the rubble. And thereason that they were just kind
of cleaning up to and foundsomeone was that during the
evacuation and head count, theorganization, the company, told
the first responders, emergencyresponders, that everyone was

(12:28):
accounted for. They said thatthey had a clerical error that
allowed them to forget thatthere was still someone, another
individual in the building. Theyleft someone in the building
after the explosion. I don'tknow. I have not heard like was
this an instantaneous How longwere they alive? But they told

(12:52):
the first responders, we haveeveryone accounted for. And yet,
one person was left in therubble and was not discovered
until during the cleanup phase.
So when I look at catastrophicengineering failure, no nothing,
alarm to tell them it washappening, it continued to

(13:13):
happen. No fail safe. And then Igo to the emergency management
piece of it again, all of thiswould have been covered under
PSM if they were a PSM facilityor or if they'd had the
leadership to just follow theguide and to write their own
internal policy stating theywould do things like, I don't.
Maybe they have it. I would. I'mskeptical, highly skeptical

(13:39):
there, but Emergency Managementhaving a robust system to assure
the most important partaccounting for your team. Where
are they? Can we find them? Dowe know where they are? And
there was a video of one of thenews stories where they were

(14:00):
showing there was a communitycenter where people were talking
to the city officials, some ofthe company officials, and the
son of that employee spoke, andHis quote just struck me as very
truthful, very honest. And sohis son said, I have never seen

(14:24):
a man lead by example and workas hard as my father did. I just
never thought his commitment towork would lead to his final
days. Yeah, he gets it real. Andthat gets no more real than
that. Not only did it happen,the explosion, the lack of

(14:49):
whatever happened that led tothat that wasn't working. And
then to tell people that we haveeveryone accounted for. Right,
and one person was left behind.
The attorney for the family saidanother very truthful statement

(15:10):
and very blunt, a vessel likethat just does not explode,
correct? Because if that was thecase, vessels all over the
country would be just exploding.
They're not built for that. Theengineering and the systems that
are in place are there to helpmake sure it does not explode,
because when it does, it ishuge, it is catastrophic. The

(15:33):
risk was way too high, theacceptance of risk by the
leadership team, by theleadership, and it may be, I'll
say even the corporateleadership, was unbelievable to
accept that catastrophic riskand go, we had to be okay. Not

(15:55):
sure where the decision makingcomes from. There's some really
interesting research by theKraus Bell group on decision
making and catastrophic eventsor significant incident
fatalities, in how far back thedecisions go and how they lead
to these things. And now, Ithink in those terms, where did

(16:16):
the decisions happen that led tothis event, short term and long
term, especially with investmentin engineering and evaluation of
risk. Where is it? What was it?
Definitely it was not thecorrect level. And that's truly

(16:37):
evident by what happened thatyou can see when it happens that
it's too late for worrying aboutthat, but the level of risk
acceptance was way too high, andthat begins the first journey of
where is the tolerance for riskand what is the worst case
outcome of that risk. In thiscase, it was catastrophic, and

(16:59):
I've said that so many times,it's hard for me to wrap my mind
around how much, if you look atthe pictures, if you do some
research and research thisexplosion, the damage was it's
unbelievable how much damage wasdone and how big the explosion
was, and how poorly it wasreacted To, because some of the

(17:21):
community concerns that came outwas that the the company didn't
do enough of the community fastenough that their response was
slow, that when they came out toinvestigate it, it was too slow,
that the whole response was justkind of slow, that it was
evidently indicative of how theywere treating safety, as it's

(17:45):
important, but how important isthere something else that may be
a little bit more important? Anddid that show in this event, how
it happened? Yeah, you see it.
You see the pieces. And itbecomes, to me, it feels very
clear, and again, that's myopinion of just all the items
that should have been donedifferent. Thanks for joining me

(18:09):
on this episode of the leadingand learning through safety
podcast. Again. As we close outthis episode, what it comes down
to is we look at the minimumthat's required, but we look at
other standards that areavailable, and we say, Should we
adopt them? Can we be betterthan the basic? And in this

(18:30):
case, there was opportunity, andwe have to look at that as how
where do we control the risk?
Where do we help our peoplethrough strong safety
leadership. I hope you'veenjoyed this episode, and until
next time we chat, stay safe.

Announcer (19:01):
Thank you for listening to the leading and
learning through safety podcast.
More content is available onlineat www dot tsda consulting.com
all the opinions expressed onthe podcast are solely
attributed to the individual andnot affiliated with any business
entity. This podcast is forinformational and entertainment

(19:26):
purposes. It is not a substitutefor proper policy, appropriate
training or legal advice.
You This has been the leadingand learning through safety

(19:57):
podcast. You.
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