Professional Documents
Culture Documents
Purpose
This material was produced by the Labor Institute and the United Steelworkers
International Union under grant number 46DO-HT11 Susan Harwood Training Grant
Program, for the Occupational Safety and Health Administration, U.S. Department of
Labor. It does not necessarily reflect the views or policies of the U.S. Department of
Labor, nor does mention of trade names, commercial product or organizations imply
endorsement by the U. S. Government.
Lessons Learned
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Air Compressor Electrical Fire Lessons Learned
Background Information
Before beginning this Lessons Learned, please review this and the next
page which contain information that will introduce the concepts of
Lessons Learned and Systems of Safety.
Using our Systems Focus to uncover system flaws or root causes is only
one part of controlling hazards. We also need to look at the systems
involved to decide on the best way to deal with the problem. The most
effective way to control a hazard is close to its source. The least
effective is usually at the level of the person being exposed. The
system of safety in which the flaw is identified is not necessarily the
system in which you would attempt to correct the flaw.
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Lessons Learned Air Compressor Electrical Fire
Major Personal
Design & Maintenance Mitigation Warning Training &
Safety Protective
Engineering & Inspection Devices Devices Procedures
System Factors
Level of Highest—the first Middle—the second line of defense Lowest—the
Prevention line of defense last line of
defense
To protect when
Goal To eliminate hazards To further minimize and control hazards higher level
systems fail
Technical
Inspection and Enclosures, Barriers Monitors Operating Manuals Personal Decision-
Design and Testing Dikes and and Procedures making and Actions
Engineering of Containment Process Alarms HF
Equipment, Processes Maintenance Process Safety
and Software Relief and Check Facility Alarms Information Personal Protective
Quality Control Valves Equipment and
Management of Community Alarms Process, Job and Devices HF
Change (MOC)** Turnarounds and Shutdown and Other Types of
Overhauls Isolation Devices Emergency Hazard Assessment
Chemical Selection and Stop Work Authority
Notification Systems and Analysis
Substitution Mechanical Integrity Fire and Chemical
Suppression Permit Programs
EXAMPLES OF Safe Siting Devices
SAFETY SUB- Emergency
SYSTEMS** Work Environment HF Machine Guarding Preparedness and
Response Training
Organizational
Refresher Training
(must address a
root cause) Information
Resources
Staffing HF
Communications
Skills and
Investigations and
Qualifications HF Lessons Learned
Management of Maintenance
Personnel Change Procedures
(MOPC)
Pre-Startup Safety
Work Organization and Review
SchedulingHF
Work Load
Allocation of
Resources
Buddy System
HF - Indicates that this sub-system is often included in a category called Human Factors.
* There may be additional subsystems that are not included in this chart. Also, in the workplace many subsystems are interrelated. It may not always
be clear that an issue belongs to one sybsystem rather than another.
** The Codes, Standards and Policies and Management of Change sub-systems listed here are related to Design and Engineering. These
subsystems may also be relevant to other systems; for example, Mitigation Devices. When these sub-systems relate to systems other than Design
and Engineering, they should be considered as part of those other system, not Design and Engineering.
Revised October 2006
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Air Compressor Electrical Fire Lessons Learned
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Lessons Learned Air Compressor Electrical Fire
Discussion:
The overloads and contacts of an air compressor failed, causing a fire in
the electrical compartment of the compressor. A substantial contributor
to the fire was the sound-proof insulation that had become oil-soaked
during normal operation of the compressor. As the oil soaked insulation
burned, the internal compressor oil used to run the compressor during
normal operation heated to a flash point of 450°F. This caused the
compressor oil to boil off and further contribute to the fire; approximately
28 gallons of oil were consumed by the fire.
The operator had just conducted a walk-around and noticed nothing out
of the ordinary. Shortly afterwards, an operator noticed a large drop in
air pressure. About this same time a shift supervisor saw smoke coming
from the boiler area. The supervisor activated a fire alarm and an ERT
(Emergency Response Team) was notified. The ERT attempted to cool
the building in which the compressor was housed using water, being
careful not to make contact with the still energized compressor. At the
time the ERT could not confirm the exact status of the energized state
of the compressor. When the PTO (power take off) on the plant’s fire
truck failed, the local fire department was called in for assistance.
Attempts were made to further extinguish the fire by utilizing fire extin-
guishers; but the fire persisted until electrical power was shut down to
the compressor.
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Air Compressor Electrical Fire Lessons Learned
Analysis
The Logic Tree is a pictorial representation of a logical process that
maps an incident from its occurrence, “the event,” to facts of the
incident and the incident’s root causes.
Event
Air Compressor
Electrical Fire
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Lessons Learned Air Compressor Electrical Fire
Recommended Actions
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Air Compressor Electrical Fire Lessons Learned
Education Exercise
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Lessons Learned Air Compressor Electrical Fire
1 2 3 4 5
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Air Compressor Electrical Fire Lessons Learned
Send this page plus the Education Exercise and Evaluation for each
participant and the Sign-in sheet to:
Doug Stephens
United Steelworkers International Union
3340 Perimeter Hill Drive
Nashville TN 37211
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Lessons Learned Air Compressor Electrical Fire
Sign-In Sheet
Name of Class_______________________________ Date of Class____________
Instructors: _________________________________________________________
Please
Check One* Print Name Signature
H M
*H = Hourly Worker
M = Management or Salaried Worker
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Air Compressor Electrical Fire Lessons Learned
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