“If at any time [federal] inspectors identify something that needs to be addressed, our team does so immediately.” — Elizabeth Ward, company spokesperson for Boar’s Head Provision Co.
I was once a Scoutmaster. One of the most coveted items that my younger Scouts could earn was the Totin’ Chip, which granted them the right to carry and use a pocketknife, a camp saw, and an ax. A lesson that they each had to learn was that a sharp, clean knife is safer than a dull one; a dull knife is more likely to slip under misapplied force and draw blood. In other words, a Scout with a Totin’ Chip had to learn how important proper maintenance is to safety.
A couple of recent incidents in the national news highlight just how important proper maintenance is to safety.
The Wreck of the MV Dali
On Tuesday, March 26, 2024, at 1:29 am, the MV Dali collided with the Key Bridge as it made its way out of the Port of Baltimore. There were no serious injuries to the crew and traffic had cleared the bridge, but six construction workers repairing the bridge died when the collapsing bridge tossed them into the water below. On Wednesday, September 18, 2024, the U.S. Department of Justice filed civil charges against the owner of the Dali, Grace Ocean Private Limited, and its operator, Synergy Marine Pte. Ltd. in an effort to recover the combined $100,000,000 that U.S. federal agencies spent cleaning up the wreckage of the bridge and in reopening the Port of Baltimore. The Port is open, but not the bridge. Construction to rebuild is planned to begin in 2025 and be complete in 2028, finally reconnecting the I-695 Baltimore Beltway.
In their filing, the DoJ listed a series of maintenance failures that led to the wreck. The day before the wreck, there were two electrical failures aboard the ship—near misses—that could have acted as a warning but did not. As is often the case with near misses, we only recognize their significance after the actual disaster occurs.
When the Dali was underway, Transformer 1 tripped and the ship lost power. Obviously, equipment fails. This was not a normal failure, though. The transformer had deteriorated as a result of its exposure to excessive vibration. A longstanding problem on the ship, the problem had never been appropriately addressed and eventually it caught up with them.
On the failure of Transformer 1, the ship should have switched automatically to its installed spare, Transformer 2. However, the switching function was disabled, meaning that the first layer of protection was not in service and failed on demand.
Simultaneously, a separate emergency generator should have started automatically. Regulations require that the generator starts within 45 seconds. It took over a minute. On the open seas, the difference between 45 seconds and 90 seconds probably wouldn’t matter, but in the close quarters of a harbor, it proved disastrous. The second layer of protection failed to perform as intended.
At some point in the ship’s past, a fuel pump had been replaced with a flushing pump—not a replacement-in-kind. Unlike the original fuel pump, the flushing pump was not designed to recover automatically from a loss of power. The third layer of protection failed.
Given this series of failures, the pilot ordered that the crew drop the port-side anchor so that its drag would help turn the ship. However, it was not ready for immediate release, as required by regulations. The fourth layer of protection failed.
As a last resort, then, the pilot ordered the crew to put full power to the ship’s bow thruster, a propeller that assists in steering the ship. It didn’t start and the crew reported that it was “unavailable”. The fifth layer of protection failed.
Five layers of protection and they all failed. The common cause of their failures? Poor maintenance.
The Boar’s Head Listeria Outbreak
On July 19, 2024, the Center for Disease Control reported that they were investigating a multi-state Listeria outbreak that had already killed two people. They eventually traced it back to the liverwurst production line at the Boar’s Head facility in Jarratt, Virginia.
CBS News used the Freedom of Information Act to obtain USDA inspection records for the Jarratt plant during the past year. Instead of an isolated incident, the records showed a pattern of neglect and poor maintenance. While many of the non-compliance reports were for paperwork issues, inspectors repeatedly noted mold and mildew growth on the facility surfaces, including stainless steel vessels used to contain product. There was mold on holding coolers for product. Inspectors also noted leaking and pooling water, some with algal growth, as well as condensation dripping on product.
While the pools of blood on the floor and the insects in and around deli meats may have been the result of momentary lapses, it is hard to imagine that mold, mildew, and algae growth were sudden and spontaneous occurrences. And it appears that the practice at the plant was to respond to inspector complaints, rather than to properly maintain the facility in the first place.
By the end of August, the death toll from the Boar’s Head Listeria outbreak had climbed to nine, in states all across the United States. The Boar’s Head Provision Company closed the Jarratt, Virgina plant indefinitely on Friday, September 13, 2024, putting over 500 employees out of work.
If It’s Broke, Fix It!
When it comes to process safety, many of us are covered by OSHA’s Process Safety Management (PSM) standard, 29 CFR 1910.119, and most of us follow its principles, even if not covered. One of the elements of PSM is mechanical integrity. While most of the section on mechanical integrity addresses testing and inspection, it is not enough to know that equipment is deficient. Deficiencies must be addressed. Paragraph (j)(5) has this to say:
Equipment deficiencies. The employer shall correct deficiencies in equipment that are outside acceptable limits (defined by the process safety information in paragraph (d) of this section) before further use or in a safe and timely manner when necessary means are taken to assure safe operation.
In other words, if it’s broke, fix it. And until you fix it – that is, restore it to proper operating condition – don’t use it. To be clear, proper operating condition WILL NOT involve the use of duct tape or baling wire.
Maintenance is Essential
To this day, I believe that the most important thing to operating a process safely is to properly maintain that process. The department that contributes most to the safety of a process—to the safety of an entire facility—is the maintenance department. A facility that is in good working order is far easier to operate safely than one that merely works.
Poor maintenance led directly to the deaths of six construction workers performing repairs on the Key Bridge in Baltimore. Poor maintenance led directly to the deaths of 9 consumers who were exposed to Listeria-contaminated liverwurst from the Boar’s Head plant in Jarratt, Virginia. Undoubtedly, those deaths will prompt intense scrutiny in narrow areas of transportation safety and food safety. Let’s not wait for more deaths to prompt closer scrutiny in process safety.
Maintenance is essential to safety. As safety professionals, make sure you are doing what must be done to assure that proper maintenance is being performed and that your maintenance department has the staff and the resources it needs to do the job it must. Lives depend on it.
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