AIChE: ‘That Can’t Happen Again’

Wednesday, May 2, 2018 @ 04:05 PM gHale

By Gregory Hale
A near miss and a tragic incident have totally different results, but for Kenneth Tague they both have incredible – and lasting – learning experiences that should be shared with everyone.

Tague mentioned one incident, a near miss, will stay with him forever. “The feeling of I’m not going home today I remember vividly to this day,” he said. “I knew this thing was going to explode and there was nothing we can do about it.”

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Tague, process safety manager at Archer Daniels Midland, gave a riveting talk last week entitled, “That Can’t Happen,” at the 14th Global Congress on Process Safety during the 2018 AIChE Spring Meeting in Orlando, FL.

In the near miss, Tague talked about an incident in the 1990s involving a PVC reactor gasket.

“We were having lunch and we heard a noise we never heard before,” he said.

At one point Tague thought there was going to be a huge incident, but after some smart thinking by those on the scene, a crisis was averted – barely.

“Luck isn’t a strategy; you must learn and share near misses. Luck runs out and we got lucky that day,” he said. “We ended up transferring to another vessel and that was something we had never done before. We had this extra provision to transfer. It was a last line of defense.”

Afterward, in talking about the near miss scenario Tague said a supervisor told him, this “near miss didn’t turn into a catastrophic loss, but you understand that can’t happen again.”

Here is what Tague learned during the investigation:
• Some gasket materials can flow
• Torque doesn’t necessarily mean tight
• B7 vs. grade 8 bolts
• Bolts can stretch
• There is a proper way to do everything. Even using antiseize compounds

“You don’t realize there is a lot of science behind everything. You have to minimize the consequences. Just because it didn’t happen, don’t minimize the risk,” he said. “There are a lot of things to know. It is OK to say ‘I don’t know, but I will find out.’”

“I then got a call saying ‘your plant just blew up.’ That is a feeling I don’t want anyone to feel.”
— Kenneth Tague

That near miss incident led Tague to talk about an event that happened April 23, 2004.

“I heard a muffled boom. I thought it was an explosion or my daughter falling out of bed. I thought it couldn’t be my plant, it was 27 miles away – the whole house shook,” he said.

“I then got a call saying ‘your plant just blew up.’ That is a feeling I don’t want anyone to feel,” Tague said. “It wasn’t like if there was one person killed, it was how many.”

Five people died in that explosion.

The Occupational Safety and Health Administration (OSHA) and the Chemical Safety Board (CSB) came in to investigate.

Lessons Tague said he learned from that incident included:
• Assessing operator behavior regarding risk management requires careful considerations
• Focus on is it possible, not is it credible
• Managing organizational change is crucial for risk management
• 37 years has taught me don’t miss the opportunity to learn from luck
• There are technical details to everything around process safety
• Management of change is critical for managing risk
• Human error can’t be allowed to result in a catastrophic event



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