昨天台灣各地似乎不少事故
譬如說 桃園某工廠化學原料車加錯 爆炸
瓦斯外洩起火
今午12/31/2010 看 CNN 的 Going Green 節目 其一是韓國的海朝潮發電
青島啤酒廠 如PHILIPS/MOTOROLA等大企業都是中國大污染場
而Nike 公司的許多新產品都採用回收的塑膠料重加工
2010年12月30日 星期四
2010年12月29日 星期三
五十四項的健康知識
很少讀列表 不過列之何妨 (Justing 轉寄來的)
五十四項的健康知識，您做到幾項了呢？
01、聰明地鍛煉
如果你在健身館裡只知道發狠用勁的話，最好不要浪費時間。
一般來講，十個人中只有一個人了解正確的健身方法，
02、多騎自行車
人們應該多騎自行車，以中速騎車，對心肺功能的提高很有幫助，對
03、散步半小時
盡量每週散步四到五次，每次三十到四十分鐘，這對身體非常有益，
無需花費鉅資參加健身俱樂部，只要買一雙舒適的鞋穿就行了。
04、多走樓梯
最好少搭電梯，多走樓梯。爬樓梯是一種非常好的鍛煉形式，對心血
05、保持正確的行走姿勢
保持正確的行走和坐立姿勢，對健康非常有益；
請在行走時放鬆雙肩，保持頸部直立、骨盆肌肉緊張，挺胸收腹，
06、經常伸伸脖子
每天最好輕輕地伸一伸脖子，
07、要吃好早餐
也許在此之前你都不怎麼吃早餐，但現在請不要這樣了。
吃一些麥片粥或牛奶，它們可以緩慢釋放糖分，
08、多吃有機食品
人們應該盡量多吃有機食品，即使是有機的根莖蔬菜也好。
這些食物對身體健康非常有好處，種植方便、成本低，味道也不錯。
09、多吃核桃
大家應該多吃核桃，它的脂肪含量低，是最好的堅果類食品。
最近的研究發現，常吃核桃可延長壽命五到十年。
10、少喝碳酸飲料
牙科醫生警告宣稱，最好少喝碳酸飲料，
果汁中也含有酸性物質和果糖等，因此最好在飲用之前，
11、多吃魚
多吃鯖魚、沙丁魚和鮭魚等深海魚類是最好的，每週以吃兩次為宜。
魚油中發現的Omega3長鏈脂肪酸，似乎是無病不治，對關節炎
12、食用更多的酸酵母
每天早上最好吃一片加乳酪的麵包。
乳酪中富含葉酸，這是一種維生素Ｂ，
考慮懷孕的女性應該多服用葉酸，
13、多吃綠色食品
提高礦物質「硒」的攝取量，
深綠色葉菜和根莖菜中富含硒元素，
大家需要記住一點，食補是最好的進補方式。
14、補充更多的維生素Ｃ
建議大家每天服用一千毫克的維生素Ｃ，
15、為懷孕做好充分準備
如果你計劃今年懷孕生孩子，請馬上開始健康的生活方式，
準媽媽們應該戒酒，並保持均衡的飲食。
16、聽自己的「心聲」
經常聽聽你的「心聲」，看看你的心臟在告訴你什麼信息。
休息時，如果胸部出現短暫疼痛，你可以不用擔心。
但是如果你在正常的活動中，或在步入辦公室的時候，
17、不要壓抑自己
不要刻意控制自己的情緒，不要在意人們說些什麼，哭泣也並不是什
發洩出自己的感情，要比壓抑它們好得多。
18、表達自己
人們應該找到自己富於創造性的一面，
成年人通常不會表達自己的創造性，因為他們害怕失敗，
19、盡情地唱歌
音樂是一種創造性的活動，可以愉悅身心。
有研究證明，唱歌可以促進一種感覺良好的荷爾蒙的產生，
20、記筆記
要經常在身邊放上一個筆記本和一支筆，每當你在睡覺時，
早上醒來時，你可以從一種更為清醒的角度，
21、每天睡八小時
每天保持八小時的睡眠是很重要的，很多人似乎永遠處於欠睡眠狀態
想要早睡的話，最好不要喝酒，這樣才能得到一個真正熟睡的夜晚。
22、關懷雙腳
英國肌肉與骨骼醫學研究所的皮特．斯庫建議說，
這種練習可以提高平衡能力，增強腳弓和腳踝的力量，
冬天的晚上，熱水泡腳，避免手腳冰冷，對於促進循環很有幫助，
23、及時進行身體檢查
男性到了四十五歲以後，都應該定期檢查自己的攝護腺，
如果癌症在及時被發現，還是可以治療的。
男人們不應該像鴕鳥一樣，把自己的頭埋在沙子裡，
24、增強骨骼強度
健身專家提醒，請關注自己的骨骼發育，避免骨質疏鬆症，
園藝、家務和爬樓梯等活動效果都不錯，而抽煙則會導致骨質疏鬆。
25、少用漂白劑
最好扔掉家中的漂白劑和清潔劑等，這些物品中都含有害化學成分。
多花些體力，使用一些檸檬汁或醋，也可達到相同的洗滌效果。
家中的化學物品越少越好，有研究發現：
26、留住耳垢
最好不要用棉花棒清潔內耳的耳垢，
在某些情況下，還可能損害耳鼓。
其實耳朵具有自清能力，耳垢可以在無需外力幫助的情況下，
27、進行掃描檢查
如果你是一名已婚女性的話，趕快去婦科進行一次衣原體（
最好帶上你的那一位，因為他也有可能攜帶病菌。
有４％的成人會感染到這種病菌，但卻毫無症狀。
衣原體病菌很容易治療，但是如果不予理睬的話，
28、善待你的眼睛
結膜炎這種病的交叉感染很普遍，甚至擦一擦眼睛，
請在擦眼或用藥之後清洗雙手，使用專用毛巾，不要與他人共用。
29、躲在陰涼裡
請盡量避免陽光強烈直射。
紫外線能夠破壞皮膚的膠原質和彈性蛋白，加速皮膚老化，
最好享受柔和的陽光，陽光可以幫助人體產生維生素D，
30、扔掉所有垃圾
建議大家扔掉所有多餘、無用的東西，
31、8歲決定女性生育能力。
此時的激素分泌和黃體酮的水準會對她的一生產生影響，
32、10歲女性青春期萌芽。
40%的骨骼在此時以衝刺的速度形成，
多食用乳製品、多做運動，避免肥胖。
33、17歲智齒發育。
出現口腔疾病，使用漱口水或淡鹽水漱口消炎鎮痛，
34、25歲骨骼發育達到頂點。
要攝入足夠的鈣和維生素D，一般地說，
35、28歲男性開始脫髮。
睾丸激素的水準變化是毛囊萎縮的主要原因，
36、30歲新陳代謝能力下降，開始發胖。每天少攝入200卡路
37、34歲女性最佳生育年齡。
此時生育可以使母嬰都更健康，母親更長壽。
每天服用葉酸對母嬰健康都有好處。
38、35歲白髮開始出現。
這是毛囊中的黑色素細胞不活躍造成的，服用B群維生素可以延緩白
39、40歲男性生育能力下降。
無論母親是否年輕，此時受孕的嬰兒其流產率都會增高。
讓睾丸保持較低的溫度，是提高精子存活率的關鍵。
多攝入富含鋅、硒、維生素C、維生素E的食物能提高精子的活力。
40、41歲骨質疏鬆的跡象開始出現。
加強鍛煉，每週做有氧運動，例如跳舞、跑步等，快走四五次。
41、42歲大腦進入中年期，腦細胞每天流失1萬個。
隨著迴圈能力的下降，腦部供氧減少，記憶力受到影響。
經常讀書、下棋，彈奏樂器都可以幫助我們保持頭腦的敏銳。
42、46歲開始出現老花眼的症狀。
這是眼睛的聚焦能力下降造成的，雖然老花眼不能抗拒，
43、50歲開始出現帕金森症。
多攝入富含維生素E的食物，如橄欖油、瓜子和杏仁。
44、51歲是女性更年期的平均年齡。
改掉喝咖啡的習慣，換成茶或果茶，同時多攝入鈣。
45、59歲容易受到皮膚病的威脅。
避免皮膚在陽光下曝曬，冬天最好也使用低倍數的防曬霜。
46、60歲白內障問題突出。
多吃扁豆、豆芽、捲心菜、萵筍、奇異果、蜜瓜等食物，
47、63歲是女性卵巢癌的平均年齡。
最好多吃花椰菜。十字花科的蔬菜中所含的蛋白質，
48、68歲是關節置換手?N的平均年齡。
控制體重，過重的體重會增加關節負擔，誘發骨關節炎。
49、70歲是英國腸癌的平均年齡。
多吃藍莓，或其他高纖維的食物可防止癌變。
50、75歲大部分人會有高血壓。
高血壓會誘發心臟病和中風，要定期檢查血壓。
51、76歲是英國男性的平均壽命。
降低飯量可以更長壽，還可以減少包括癌症等疾病的發生。
52、81歲是英國女性的平均壽命。
節制飲食，多吃蔬菜和水果，適度吃魚，使用橄欖油，
53、高抬貴腿！
只聽說過高抬貴手，這「高抬貴腿」卻也是有效的健身之道。
據報載，英國女王伊麗莎白年過古稀，
近年來，國外醫學專家也指出，只要每天高抬下肢２～３次，每次５
專家們研究指出，當一個人的雙腿翹起，高於心臟之後，
54、高抬貴手。
當您用心看完本家族信後，
2010年12月28日 星期二
2010年12月27日 星期一
Deepwater Horizon’s Final Hours
Provided to The New York Times
As the fire raged, the Deepwater Horizon buckled. More than 110 people escaped the rig on April 20, but 11 men died. Photographs of the burning rig were provided to The Times by a worker on a nearby boat who asked not to be identified.
By DAVID BARSTOW, DAVID ROHDE and STEPHANIE SAUL
Published: December 25, 2010
The worst of the explosions gutted the Deepwater Horizon stem to stern.
Crew members were cut down by shrapnel, hurled across rooms and buried under smoking wreckage. Some were swallowed by fireballs that raced through the oil rig’s shattered interior. Dazed and battered survivors, half-naked and dripping in highly combustible gas, crawled inch by inch in pitch darkness, willing themselves to the lifeboat deck.
It was no better there.
That same explosion had ignited a firestorm that enveloped the rig’s derrick. Searing heat baked the lifeboat deck. Crew members, certain they were about to be cooked alive, scrambled into enclosed lifeboats for shelter, only to find them like smoke-filled ovens.
Men admired for their toughness wept. Several said their prayers and jumped into the oily seas 60 feet below. An overwhelmed young crew member, Andrea Fleytas, finally screamed what so many were thinking:
“We’re going to die!”
It has been eight months since the Macondo well erupted below the Deepwater Horizon, creating one of the worst environmental catastrophes in United States history. With government inquiries under way and billions of dollars in environmental fines at stake, most of the attention has focused on what caused the blowout. Investigators have dissected BP’s well design and Halliburton’s cementing work, uncovering problem after problem.
But this was a disaster with two distinct parts — first a blowout, then the destruction of the Horizon. The second part, which killed 11 people and injured dozens, has escaped intense scrutiny, as if it were an inevitable casualty of the blowout.
It was not.
Nearly 400 feet long, the Horizon had formidable and redundant defenses against even the worst blowout. It was equipped to divert surging oil and gas safely away from the rig. It had devices to quickly seal off a well blowout or to break free from it. It had systems to prevent gas from exploding and sophisticated alarms that would quickly warn the crew at the slightest trace of gas. The crew itself routinely practiced responding to alarms, fires and blowouts, and it was blessed with experienced leaders who clearly cared about safety.
On paper, experts and investigators agree, the Deepwater Horizon should have weathered this blowout.
This is the story of how and why it didn’t.
It is based on interviews with 21 Horizon crew members and on sworn testimony and written statements from nearly all of the other 94 people who escaped the rig. Their accounts, along with thousands of documents obtained by The New York Times describing the rig’s maintenance and operations, make it possible to finally piece together the Horizon’s last hours.
What emerges is a stark and singular fact: crew members died and suffered terrible injuries because every one of the Horizon’s defenses failed on April 20. Some were deployed but did not work. Some were activated too late, after they had almost certainly been damaged by fire or explosions. Some were never deployed at all.
At critical moments that night, members of the crew hesitated and did not take the decisive steps needed. Communications fell apart, warning signs were missed and crew members in critical areas failed to coordinate a response.
The result, the interviews and records show, was paralysis. For nine long minutes, as the drilling crew battled the blowout and gas alarms eventually sounded on the bridge, no warning was given to the rest of the crew. For many, the first hint of crisis came in the form of a blast wave.
The paralysis had two main sources, the examination by The Times shows. The first was a failure to train for the worst. The Horizon was like a Gulf Coast town that regularly rehearsed for Category 1 hurricanes but never contemplated the hundred-year storm. The crew members, though expert in responding to the usual range of well problems, were unprepared for a major blowout followed by explosions, fires and a total loss of power.
They were also frozen by the sheer complexity of the Horizon’s defenses, and by the policies that explained when they were to be deployed. One emergency system alone was controlled by 30 buttons.
The Horizon’s owner, Transocean, the world’s largest operator of offshore oil rigs, had provided the crew with a detailed handbook on how to respond to signs of a blowout. Yet its emergency protocols often urged rapid action while also warning against overreaction. Fred Bartlit, chief counsel for the presidential commission that is looking into the Horizon disaster, said Transocean’s handbook was “a safety expert’s dream,” and yet after reading it cover to cover he struggled to answer a basic question:
“How do you know it’s bad enough to act fast?”
Transocean has defended the Horizon’s crew. “They acted appropriately based on the information they had at the time,” the company said in a statement, adding, “This world-class crew — some of whom lost their lives — battled to the end to gain control of the well.”
In the end, though, after the Horizon’s elaborate defenses had failed, many lives were saved by simple acts of bravery, the interviews and records show. All over the rig, in the most hellish of circumstances, men and women helped one another find a way to live.
Morning, April 20
Caleb Holloway, a lanky 28-year-old floorhand, headed up to the Horizon’s vast main deck just after 11 a.m. It had always been a breathtaking sight.
The deck, nearly as big as a football field, was dominated by a 25-story derrick flanked by two cranes. Below deck were two more floors, including quarters for up to 146 people. Each room had its own bathroom and satellite television. There was a gym, a sauna and a movie theater. Housekeepers cleaned the crew members’ rooms and did their laundry. “A floating Hilton,” they called it.
Before joining the Horizon in 2007, Mr. Holloway had worked on a rusty little jack-up rig just off the Gulf Coast. But this place — a space-age behemoth packed with up to 5,000 pieces of sophisticated drilling equipment — practically gleamed. “Everything on Horizon, it’s like, pretty,” he said.
Mr. Holloway gathered with the rest of his drilling crew, about a dozen men in all, to discuss the day ahead with their bosses, Wyman Wheeler, the toolpusher, and the driller, Dewey Revette. They were a tight-knit bunch, working in close quarters 12 hours a day, day after day, over a 21-day hitch. They knew one another’s moods and quirks. They all knew Mr. Revette was a nut for Jeeps, and that Steve Curtis, an assistant driller, could do a turkey call that was so convincing you half expected a turkey to land on the rig. Everyone had a nickname — Mr. Holloway was “Hollywood” — and their bond went beyond work. Some hunted and fished together, others worked out together, and a few studied the Good Book together.
“It was family,” Mr. Holloway said.
It was also a family with some swagger.
Drilling is a competitive business, and it was an article of faith that the Horizon’s crew members were among the best. Just last year, the Horizon drilled the deepest oil well on earth, at 35,055 feet.
They shared something else — a clear-eyed realization that they held one of the last great blue-collar jobs, where someone with a high school diploma could easily make six figures a year.
The Horizon was not just a job; it was a path to a life otherwise out of reach.
Doug Crawford of Mount Olive, Miss., had hit a dead end in the poultry industry. Patrick Morgan of McCool, Miss., saw the writing on the wall when his Georgia-Pacific plant began downsizing. Six years ago, Mr. Holloway was pouring concrete foundations and wondering if he would ever get a paid vacation. Now he and his wife owned an Infiniti and a sprawling brick home.
Leo Lindner, a former college English teacher who discovered that he could make far more money handling drilling fluids on the Horizon, was not fooled by the rig’s collection of good old boys. “Sometimes maybe a little rough,” he said, “but a very intelligent crew.”
On this day, the main task was finishing off the “well from hell.” The Macondo had been behind schedule nearly from the get-go, and the Horizon had been sent to get it back on track. At first the Horizon drilled rapidly, welcome news for a crew whose bonuses were tied to meeting schedules.
But drilling quickly adds risk. For all of the Horizon’s engineering wizardry, it was tangling with powerful and unpredictable geological forces. And pushing rapidly into a highly pressurized, three-mile-deep reservoir of oil and gas can be particularly problematic in the Gulf of Mexico’s unstable and porous formations.
Sure enough, the Horizon hit trouble. Heavy drilling fluid, called mud, kept disappearing into formation cracks. Less mud meant less weight bearing down on the oil and gas that were surging up. This set off violent “kicks” of gas and oil that sent the Horizon’s drilling teams scrambling to control the well. March 8 had been especially bad. A nasty kick had left millions of dollars worth of drilling tools jammed in the well. Operations were halted for nine maddening days. There was still so much gas filtering up that cookouts were suspended on the deck.
For the crew, the sooner they left the Macondo the better, so the team quickly got down to business. Mr. Holloway worked the drilling floor with Adam Weise and Dan Barron, the team’s newest member. Before long, Mr. Holloway received a call over his radio from Mr. Revette: “Mr. Jimmy needs to see you down in his office.”
Jimmy Harrell, 54, had started off as a floorhand just like Mr. Holloway. Now, after three decades with Transocean, he was the boss of the Deepwater Horizon. He was revered by his crew, regarded as approachable, competent and to the point. Mr. Holloway found most of the rig’s leaders waiting in Mr. Harrell’s office, including Curt Kuchta, the captain, and Randy Ezell, the senior toolpusher, who supervised drilling operations.
“All right,” Mr. Harrell began. “Close the door.”
Mr. Harrell handed him a box. Inside was a handsome silver watch — a reward for spotting a worn bolt on the derrick. “You did a really good derrick inspection,” Mr. Harrell said.
The gesture was typical of the potent safety culture on the Horizon, where before every job, no matter how routine, crew members were required to write out a plan identifying all potential hazards. Despite the long hours and harsh conditions, injuries were remarkably rare. So rare that two BP executives and two senior Transocean officials had flown out earlier in the day to praise the crew’s safety performance.
But the V.I.P.’s were also there to discuss the Horizon’s crowded schedule. Along with finishing the Macondo, the rig had to complete several repairs before beginning two other high-priority projects for BP. The executives were keen to keep the Horizon on track. In e-mails, BP managers — whose bonuses were heavily based on saving money and beating deadlines — kept asking when the well would be finished.
Mr. Holloway returned to work, and he and the other floorhands got busy cleaning the drilling floor. They avoided the drill shack, though. Lately, there had been too much stress there.
Mr. Holloway could tell when the BP “company men” got on Mr. Revette’s nerves: he would rub his head a certain way. This had happened a lot on the Macondo job. The Horizon might have been Transocean’s rig, but it was BP’s well, and it was obvious that the guys in the shack felt that the BP men were breathing down their necks. “You could just tell,” Mr. Holloway said.
BP has denied pressuring the Horizon’s crew to cut corners, but its plans for completing the well kept changing, often in ways that saved time but increased risk. “It’s a new deal every time we get up,” Jason Anderson, a 35-year-old toolpusher, complained to his father.
By early evening, there was one crucial test remaining before the Horizon could plug the Macondo and move on. To make sure the well was not leaking, the crew would withdraw heavy mud from it and replace it with lighter seawater. Then they would shut in the well to see if pressure built up inside. If it did, that could mean hydrocarbons — oil and gas — were seeping into the well.
In effect, they were daring the well to blow out. Designing and interpreting this test — a “negative pressure” test — requires a blend of art and engineering expertise. There are no industry standards or government rules. Designing the test was BP’s job, yet the oil company’s instructions, e-mailed to the rig that morning, were all of 24 words long.
It fell to the BP company men and the drilling crew to work out the details, but it did not go well. There was strong disagreement over the test results. Pressure had built up, exactly what they did not want, and Mr. Wheeler, the team’s toolpusher, was worried. A BP company man said he thought the test went fine. Other rig managers, including Mr. Anderson, joined the discussion, and they debated whether to repeat the test.
By 8 p.m., after redoing the test, they all agreed that the Macondo was stable. In a few hours, the drilling crew’s 21-day hitch would be done. They were working unusually fast. In seven years on the Horizon, Joseph Keith had never seen so much activity while sealing a well, and it made him uncomfortable. His job included monitoring gauges that detect blowouts. But all the jobs going on at once — transferring mud to a supply vessel, cleaning mud pits, repairing a pump — could throw off his instruments. Mr. Keith did not tell anyone that he was worried about his ability to monitor the well. “I guess I just didn’t think of it at the time,” he later testified.
Mr. Holloway and Mr. Weise were filling out paperwork when Mr. Revette called on the radio again. He needed a floorhand in the pump room below. “I’ll see you at 11:30, buddy,” Mr. Weise said, heading down. Mr. Holloway walked to the drill shack to drop off the papers.
By then, oil and gas had probably begun seeping into the well.
Investigators believe that the influx began about 8:50 p.m. Preparing to plug the well, the drilling crew was pumping mud from it, reducing the weight bearing down on the hydrocarbons. Investigators agree that the Macondo had in fact failed its crucial final test. They have pointed to BP’s cursory instructions and questioned whether the Horizon’s crew had the skills to correctly interpret the results. They also believe that monitors should have allowed Mr. Revette’s team to spot the signs of leaking within the first 20 minutes.
But Mr. Holloway detected no concern in the drill shack. Whether the team was distracted by other tasks or rushing to get done or simply complacent may never be known.
“The question is why these experienced men out on that rig talked themselves into believing that this was a good test,” said Sean Grimsley, a lawyer for a presidential commission investigating the disaster.
“None of these men out on that rig want to die.”
Mr. Ezell, the senior toolpusher, was in his office below deck. He had been up nearly 18 hours, but a little before 9:30 he decided to check in one last time with Mr. Anderson, who had relieved Mr. Wheeler. Mr. Ezell and Mr. Anderson had been born in the same Texas hospital, and though they were 20 years apart, Mr. Ezell considered Mr. Anderson to be “just like a brother.” He knew Mr. Anderson would give it to him straight on whether there were lingering doubts about the final tests.
Mr. Anderson assured him everything was good.
“Get your ass to bed,” he said.
Blowout
By now, investigators agree, hundreds of barrels of oil and gas were moving up the well, gathering force and speed as the gases expanded.
At 9:38, well data indicates, the first hydrocarbons passed through the Horizon’s five-story blowout preventer. Resting on the seabed, the blowout preventer was an elaborate fail-safe device that gave the drilling crew several ways to seal the well. But once the oil and gas got past the blowout preventer, there was nothing to stop them from racing up the Horizon’s riser pipe, the 5,000-foot umbilical cord to the rig.
Mr. Holloway and Mr. Barron were working on the main deck when Mr. Holloway happened to glance up at the drilling floor. He could not believe it. Drilling mud was gushing up from the well, just like a water fountain.
It would be nine minutes before the first explosion, well data shows.
Nine precious minutes.
The drilling crew had trained for blowouts. Floorhands like Mr. Holloway were the crucial first responders. A driller would call “Blowout!” and time their response. This usually involved quickly installing a special valve on the drill pipe to end the imagined blowout.
But confronted with the real thing for the first time, Mr. Holloway realized there were no floorhands on the drilling floor to respond.
Mr. Holloway cursed and sprinted for the stairs. Mr. Barron was right behind him. A waterfall of mud was pouring off the drilling floor to the main deck. Then, in a split second, mud and water exploded up inside the derrick.
When they reached the drilling floor, Mr. Holloway and Mr. Barron paused. They would have to pass through a watertight door to get to the drilling floor. Yet they could not be sure what they would find on the other side.
Mr. Holloway cracked open the door. All he could see was mud and water bouncing off the derrick in every direction with incredible force. He and Mr. Barron went through anyway.
Twenty feet from the blowout’s full fury, it sounded like a jet engine, a shrill whining howl. Mr. Holloway was instantly soaked, his protective glasses coated in mud. Objects were crashing around him, some “loud enough to make you jump.”
He told Mr. Barron to take shelter in the heavy tool room just behind them.
Their training sessions contemplated a blowout coming up through only the drilling pipe. This one, it seemed, was erupting from the whole well opening. “I had no idea it could do what it did,” Mr. Holloway said.
He considered making a dash for the drill shack to find out what his bosses wanted to do, but he would risk being torn apart by the blowout.
He reached for his radio and called Mr. Revette.
“Dewey!” he shouted. “What do I do?” He didn’t hear an answer. He took his earplugs out and tried again.
“Dewey. Dewey. What do we need to do?”
Again, no response.
‘Something Ain’t Right’
High above the rig floor, from his perch in a crane cab, Micah Joseph Sandell had a clear view of the blowout.
When the mud subsided for a moment, he thought the drilling crew had it under control. But then it erupted again, he said, so loudly that it was like “putting an air hose to your ear.”
Even more unnerving was the smoky haze of gas coming from a pipe opening positioned like a large shower head high up on the derrick. The Horizon had two ways to defend against oil and gas surging to the rig. The drilling crew could turn a valve and divert the blowout out to sea. Or it could try to contain it on the rig by funneling it into a device called a mud gas separator.
The separator was much preferred for smaller kicks because it avoided any cleanup and investigation required by a spill. Drilling crews rarely even rehearse diverting blowouts into the ocean, and Transocean’s handbook seemed to offer contradictory advice. It said either method could be used if hydrocarbons entered the riser.
The gas Mr. Sandell saw floating down from the derrick indicated that Mr. Revette’s team had chosen the mud gas separator, only to see it quickly overwhelmed.
The gas cloud spreading over the aft deck was a grave threat.
The Horizon’s six main diesel engines, spanning the rig’s back end, were fed by air intakes above the deck. If the engines began taking in air suffused with gas, they might speed up to the point of breaking apart.
Doug Brown, a chief mechanic, was doing paperwork in the engine control room, which was sandwiched in the middle of the six main engines. Three of his men were with him. Suddenly, a computer console began chirping, warning that sensors had detected gas somewhere on the rig. “Something ain’t right,” Mr. Brown said.
Up on the bridge, the crew was busy showing off the Horizon’s impressive capabilities to the V.I.P.’s.
Andrea Fleytas, one of the bridge officers, felt a jolt. Curt Kuchta, the 34-year-old captain, also sensed something wrong. There was a high-pitched hissing. On a closed-circuit television, they could see mud flying into the sea.
Suddenly, gas alarms began lighting up Ms. Fleytas’s computer console. The lights showed gas spreading over the rig, from the drilling floor to the main deck. There were so many alarms it was hard to keep track of where gas was being detected. More frightening still, the lights were all magenta, signaling extremely high levels of combustible gas.
The phone rang. It was the crew in the drill shack. They said they were having a well-control situation and hung up. A second call came — the engine control room asking what was going on. “We have a well-control situation,” Ms. Fleytas replied.
She said nothing about the erupting mud or the gas alarms.
The alarm system relied on dozens of sensors strategically placed all over the Horizon. When a sensor detected fire or gas, a corresponding alarm lighted up on computer consoles — not just on the bridge, but also in the two other crucial parts of the rig, the drill shack and the engine control room. In theory, this meant anyone in the three critical locations could respond swiftly to the first sign of trouble.
As originally designed, this system would also automatically trigger the general master alarm — the shrill warning that signaled evacuation of the rig — if it detected high levels of gas. Transocean, though, had set the system so that the general master alarm had to be activated manually.
The change had the Coast Guard’s blessing, but Mike Williams, an electronics technician who maintained the system, testified that he had raised concerns about the setup’s safety.
“They did not want people woke up at 3 o’clock in the morning due to false alarms,” he said.
Ms. Fleytas, 23, had graduated from maritime school in 2008 and had only been on the Horizon for 18 months. This was her first well-control emergency. But she had been trained, she said, to immediately sound the general master alarm if two or more sensors detected gas. She knew it had to be activated manually. She also knew how important it was to get crew members out of spaces filled with gas.
Yet with as many as 20 sensors glowing magenta on her console, Ms. Fleytas hesitated. She did not sound the general master alarm. Instead she began pressing buttons that told the system that the bridge crew was aware of the alarms.
“It was a lot to take in,” she testified. “There was a lot going on.”
Her boss, Yancy Keplinger, was also on the bridge. The alarms, in addition to flashing magenta, were making a warning sound. Mr. Keplinger said he kept trying to silence the alarms so he could think about what to do next. “I don’t think anybody was trained for the massive detectors that were going off that night,” he said.
Ms. Fleytas and Mr. Keplinger had another powerful tool at their fingertips — the emergency shutdown system. They could have used it to shut down the ventilation fans and inhibit the flow of gas. They could have used it to turn off electrical equipment and limit ignition sources. They could have even used it to shut down the engines.
They did none of these things.
Ms. Fleytas’s lawyer, Tim Johnson, said that with so much gas, explosions were all but inevitable. “I don’t think anything she could have done would have changed the situation out there,” he said. Mr. Keplinger’s lawyer, Steve Gordon, said the bridge crew faced “an insurmountable situation.”
As with the general master alarm, the effectiveness of the Horizon’s emergency shutdown system relied on human judgment. Transocean had been warned that the human element — the need for crew members to act quickly and correctly under stress — made the shutdown system vulnerable. In 2002, a safety consultant specifically urged Transocean to consider changing the system “so that human input is not critical for success.” Transocean says that having an automatic system is less safe.
Ms. Fleytas said it never occurred to her to use the emergency shutdown system. In any event, she explained, she had not been taught how to use it. “I don’t know of any procedures,” she said.
A Fine Mist of Gas
Most of the crew members still knew nothing about the unfolding emergency. They were sleeping, watching television, calling home, posting on Facebook.
On the drilling floor, inside the heavy tool room, Mr. Holloway found Mr. Barron pacing. They were both close to losing it. “I just remember the look on his face,” Mr. Holloway said. Mr. Holloway picked up a phone and started to dial Mr. Revette again. Then he froze. He realized he was enveloped in a fine mist of gas.
“I could just feel it and taste it,” he said. “It was smothering.”
He looked at Mr. Barron, and for the first time he panicked. He knew they were one spark from oblivion.
“Daniel, that’s gas,” he yelled. “We have to go.” He dropped the phone, and they ran down a set of stairs to the main deck.
Mr. Ezell’s stateroom was on the level below. After Mr. Anderson had told him to go to bed, Mr. Ezell had called his wife. He turned on his new 40-inch flat-screen television. About 15 minutes after hanging up with Mr. Anderson, his phone rang. It was Mr. Curtis, the assistant driller.
“We have a situation,” Mr. Curtis began.
“The well is blown out,” he said. Mud, he explained, was shooting to the top of the derrick. The drill shack’s windows were coated. They could not see a thing. After 33 years of offshore drilling, Mr. Ezell knew instantly that this was the nightmare they had all dreaded.
“Do y’all have it shut in?” he asked.
“Jason is shutting it in right now,” Mr. Curtis said. No one was better at shutting in a well than Mr. Anderson, but Mr. Curtis’s next words were a plea: “Randy, we need your help.”
Mr. Ezell grabbed his coveralls and socks. His boots and his hard hat were in his office. In the hall, he found Wyman Wheeler and Buddy Trahan, one of the Transocean V.I.P.’s, who had come down from the bridge. They asked what was going on. Mr. Ezell was so focused on getting to the drilling floor he did not respond.
Only minutes before the blowout, the drill shack had seemed to sense trouble. Mr. Revette and Mr. Anderson were overheard discussing puzzling pressure readings. They had also turned off the pumps removing mud from the well, and they had sent word that they were going to hold off on plugging it.
When the mud erupted, they reacted quickly, well data shows. They turned to their mightiest weapon, the 400-ton blowout preventer. It gave the men several different methods to shut in the well, the most extreme being a powerful set of hydraulic shears that could cut through drill pipe and seal the well.
A red button in the drill shack would activate the shears, yet Transocean’s well-control handbook said they should be used “only in exceptional circumstances.” It does not appear the button was pushed. The well data, though, indicates that the drilling team tried to use at least two other methods, both in keeping with Transocean’s guidelines. Neither worked.
The industry has long depicted blowout preventers as “the ultimate fail-safe.” But Transocean says the Horizon’s blowout preventer was simply incapable of preventing this blowout. Evidence is mounting, however, that the blowout preventer may have been crippled by poor maintenance. Investigators have found a host of problems — dead batteries, bad solenoid valves, leaking hydraulic lines — that were overlooked or ignored. Transocean had also never performed an expensive 90-day maintenance inspection that the manufacturer said should be done every three to five years. Industry standards and federal regulations said the same thing. BP and a Transocean safety consultant had pointed out that the Horizon’s blowout preventer, a decade old, was past due for the inspection.
Transocean decided that its regular maintenance program was adequate for the time being.
As the drilling team was trying to shut in the well, Paul Erickson, the chief mate on the Damon B. Bankston, a 262-foot work vessel moored to the Horizon, noticed something spilling off the rig. Then drilling fluids began cascading onto the ship. Dead seagulls fell, killed by the blowout’s blast. The Bankston’s captain radioed the Horizon’s bridge and was told to move to a safe distance.
In the engine control room, Doug Brown and his men overheard the conversation with the Bankston on their radios. Within arm’s reach was a console that gave them access to the emergency shutdown system. All they had to do was lift a plastic cover and hit a button and the engines would shut down in seconds.
It was not such an easy or obvious step to take.
Although they knew there was a well-control situation, they had no reason to believe that it was anything more than a routine kick. Nor did they know that highly explosive gas was gathering overhead.
There was risk in overreacting. If they killed the engines, the Horizon would drift from its position over the well, possibly damaging the drilling equipment and forcing costly delays. Indeed, Mr. Brown testified that he did not think he had the authority to hit the emergency shutdown. The practice was to “wait and listen” for instructions from the bridge, said William Stoner, one of the men with Mr. Brown.
But other than the two brief calls, each only seconds long, there were no communications or coordination among the bridge, the drill shack and the engine control room. The men in the engine control room did nothing.
Mr. Stoner saw more lights flicker on the console: someone had triggered an emergency shutdown of the electrical and ventilation systems near the drilling floor. Since the bridge and the engine control room had not hit the emergency shutdown, only the men in the drill shack could have done it. But those efforts to prevent an explosion on the drilling floor did not affect the engines.
Two of the rig’s six engines were running — No. 3 and No. 6 — and they were beginning to accelerate. The usual rumble was turning to a whine. A safety device, the “rig saver,” should have shut down the engines if they ran too fast. Yet the whine kept climbing. “Higher and higher and higher,” Mr. Brown recalled.
In the electronics shop next door, Mike Williams could hear Engine 3 revving. He pushed away from his desk to investigate.
Just then, his computer monitor exploded. Then, light bulbs began popping, one by one.
Explosions and Fire
Mr. Holloway and Mr. Barron were leaping rows of pipes, heading for the stairs that would take them down, off the main deck.
All the lights went out, casting them into darkness.
“Stay with me, Daniel,” he called.
They were turning down the stairs when they were buffeted by an explosion. Mr. Holloway felt an intense, stabbing pain in his ears. He steadied himself on the stair rail and pressed his hard hat to his head, as if it alone might shelter him.
The first big explosion centered on Engine 3, investigators believe. A second explosion centered on Engine 6. Caught in the crossfire were Mr. Brown’s engine control room and Mr. Williams’s electronics shop.
Mr. Williams was contemplating the remains of his computer when everything exploded. A door smashed his forehead. Blood streaming down his face, he clenched a penlight in his mouth and began crawling. He got to another door, only to be blown 30 feet back by the second blast.
He began crawling again. He climbed across two men in the engine control room. He assumed they were dead because they did not respond. (In fact, all four men in the engine control room survived, although all were injured.)
Mr. Williams made it to the lifeboat deck just outside the engine control room. The superstructure by Engine 3 had been blown away. But the two lifeboats looked intact. They were meant to hold 73 people, but he considered launching one on his own.
Instead, he decided to offer his help on the bridge.
All over the Horizon, the explosions hit crew members who until then had been oblivious to the threat. In the galley, Kenneth Roberts was washing dishes. The explosions knocked him out. “I woke up under a table,” he said. Virginia Stevens was working in the laundry. The blasts left her trapped and battered. “No warning, no nothing,” she said.
On the main deck, Carlos Ramos looked up at his boss, Dale Burkeen, who was operating the Horizon’s starboard crane. Mr. Ramos wanted to make sure that Mr. Burkeen was getting out. Instead, Mr. Burkeen, a father figure to many on the rig, tried to lay the crane boom in its cradle.
“Moments later, I saw him exit the cab and go down the spiral staircase while smoke and flames covered him whole,” Mr. Ramos said. The blast wave from the second explosion briefly extinguished the fire engulfing Mr. Burkeen, but it also knocked him headfirst to the deck.
Joseph Keith, running for the lifeboats, stumbled on Mr. Burkeen. He was facedown in a pool of blood, without a pulse, his head caved in.
On the other side of the deck, Mr. Sandell was blown to the back of his crane cab by the second explosion. “All I know is the whole deck blew up,” he recalled. A fireball, hundreds of feet high, enveloped the derrick and wrapped itself around his cabin. He could feel the heat building. He put his arms over his head and prepared for the end.
“No, God,” he said. “No.”
Trapped Below Deck
Mr. Ezell had just stepped into his office to get his boots and his hard hat when he was blown 20 feet into a bulkhead.
“I could hear everything deathly calm,” he said.
Twice he struggled to get up.
Twice he fell back.
“Either you get up,” he told himself, “or you’re going to lay here and die.”
He made it to his hands and knees, but he could not figure the way out. He felt a flow of air and followed it until he realized it was gas. He kept crawling, droplets of gas clinging to his face. His hand touched a body. There was a groan. It was Mr. Wheeler, buried in debris.
“Are you all right?” he asked.
“Hell no, I’m not all right,” Mr. Wheeler said. “Get this stuff off of me.”
Down the hallway, Mr. Ezell saw a flashlight beam. It was Stan Carden, the electrical supervisor, and Chad Murray, the chief electrician. Then the rig boss, Mr. Harrell, emerged from the remains of his stateroom. He had been in the shower and although he had managed to slip into coveralls, his feet were bare and he had been partially blinded by slivers of insulation. The gas made it hard to breathe.
Mr. Ezell told him about Mr. Wheeler.
“Yeah, O.K.,” Mr. Harrell said, disoriented and squinting. “I’ve got to see if I can find me some shoes.”
The men finally managed to get Mr. Wheeler up, but his leg was shattered and he could not walk.
“Y’all go on,” he said. “Save yourself.”
They ignored him.
A little way off, a voice called out: “God, help me.”
Mr. Ezell saw feet protruding from the wreckage. It was Mr. Trahan, the Transocean executive. He and Mr. Wheeler had been swallowed by a fireball that had roared down the corridor.
Somehow the men found a stretcher. While Mr. Carden and Mr. Murray carried Mr. Trahan away, Mr. Ezell waited with Mr. Wheeler.
“I told him I wasn’t going to leave him, and I didn’t,” Mr. Ezell said.
After the explosions, the chief engineer, Steve Bertone, raced from his room to the bridge. He did a quick survey of the rig’s condition. Its engines were dead. There was no power. The phones didn’t work. When he tried the handheld radios, they didn’t either. Meanwhile, he later wrote in a statement to the Coast Guard, Captain Kuchta was screaming at Ms. Fleytas for pushing the Horizon’s distress signal.
Then Mr. Williams arrived on the bridge, his face a mask of blood. He announced that the engine control room was gone.
“What do you mean gone?” Mr. Bertone asked.
Mr. Williams described the explosions, but the captain did not seem to absorb the news. “He looked at me with that dazed and confused deer-in-the-headlights look,” Mr. Williams testified.
The captain’s attorney, Kyle Schonekas, said no one could point to anything Mr. Kuchta “did or failed to do that caused any injury or loss of life.”
Without power, there was no way to fight the fire, no way to control the rig. They were on a “dead ship,” Mr. Bertone said.
Only after the explosions did the bridge crew finally hit the general master alarm.
It had been at least two minutes since the first gas alarms sounded, records and interviews show. And according to government officials and BP’s internal investigation, it had been nine minutes since mud had gushed onto the drilling floor, although Transocean has suggested that it might have only been six minutes.
The captain asked Ms. Fleytas to make an emergency announcement. She looked at her boss, Mr. Keplinger. “She said she couldn’t do it,” he said. “She looked pretty nervous.”
Although Ms. Fleytas disputes Mr. Keplinger’s account, it was Mr. Keplinger who got on the intercom.
“Fire, fire, fire,” he called out.
A Fighting Chance
There was still a way to keep the Horizon from sinking. Chris Pleasant saw it first.
Mr. Pleasant was one of the supervisors responsible for the blowout preventer. With the main deck on fire, he ran for the bridge with one thought: they needed to disconnect the rig from the blowout preventer — and therefore from the well itself. That would cut off the fire’s main source of fuel and give the Horizon a fighting chance.
He just needed to activate the emergency disconnect system. Like a fighter pilot hitting eject, it would signal the blowout preventer to release the Horizon. It would also signal it to seal the well, perhaps stopping the flow of oil into the Gulf of Mexico.
“I’m hitting E.D.S.,” he told the captain.
Witnesses differ about what happened next. But they agree on a basic point: even with the Horizon burning, powerless and gutted by explosions, there was still resistance to the strongest possible measure that might save the rig.
According to Mr. Pleasant, the captain told him, “No, calm down, we’re not hitting E.D.S.”
Mr. Bertone, the chief engineer, recalled someone hollering that they needed Jimmy Harrell’s approval.
As it happened, Mr. Harrell had finally made it to the bridge despite being half-blinded by insulation and gas. Ms. Fleytas recalled the captain asking Mr. Harrell’s permission to hit the emergency disconnect. Mr. Harrell said he told Mr. Pleasant to go ahead.
Mr. Bertone assumed that the Horizon was now freed from the Macondo. The inferno consuming the derrick would soon subside. If they could get the standby generators to work, he reasoned, they could start one of the remaining engines and fight the fires. The generators, however, were on the back end of the Horizon, just beyond the burning derrick. Someone would have to brave the flames to get to them.
Mr. Bertone said he was going. Mr. Williams and a third man, Paul Meinhart, said they would go, too.
The three crept along the rig’s edge, holding one another by the shirttails. But when they finally reached the generators, they could not get them to start.
Meanwhile, David Young, the chief mate, had discovered a new problem. Mr. Young was in charge of the Horizon’s two firefighting teams, which practiced each Sunday. After the explosions, he went to a fire locker and waited for his men to show up. Only one did.
“We weren’t trained to fight a blowout fire,” said Matt Jacobs, a firefighter who went straight to the lifeboats.
But the death knell for the Horizon was the emergency disconnect system itself. Like so many of the rig’s defenses, it failed to work for reasons that remain unclear.
The Horizon was still handcuffed to the well from hell. There was nothing left for the crew to do but to get off the doomed rig before they all died.
‘We Got to Go’
Mr. Holloway and Mr. Barron ran along a catwalk toward the rig’s forward lifeboat deck.
There were two lifeboats, with crew members assigned to one or the other. Mr. Holloway and a couple of other men climbed into lifeboat No. 1.
Then they waited.
They waited some more.
Where was everyone? Why weren’t they coming?
They felt the second explosion, and for a sickening moment, it seemed as if the lifeboat was going to plummet into the gulf. But it held fast.
Mr. Holloway climbed out. The door leading to the crew quarters had been blown open. He stepped into a darkened hallway. The theater was to his right, the mess hall to his left. He had been there a hundred times. But nothing was recognizable. Walls were caved in. Ceiling tiles dangled. Bits of insulation floated in the air. He went deeper, his flashlight shining ahead. He wanted to get people moving. Suddenly he became aware of a mass of dazed men coming toward him. Some were shirtless or shoeless or wearing only underwear.
Together, they made their way to the lifeboats.
Of all the emergency procedures on the Horizon, evacuation was the most practiced. But the routine rapidly disintegrated. Out on the now-crowded lifeboat deck, everyone could see, feel and hear the flames engulfing the derrick. Mr. Jacobs said it was “like staring into the face of death.”
The crew was supposed to first report to a supervisor. Yet many were simply piling into the lifeboats. Someone ordered the men to get out. “Needless to say that didn’t happen,” Benjamin Lacroix said.
Inside the enclosed lifeboats, heat and smoke were building. Men began screaming at the coxswains to launch. The burning derrick, they warned, might collapse on all of them. “We got to go,” they yelled. Some were crying.
Lifeboat No. 2 left first, without many of its assigned passengers, records and interviews show.
Darin Rupinski, the coxswain for lifeboat No. 1, refused to leave with empty seats. “Let me do my job,” he said.
Greg Meche had seen mayhem as an infantryman in Iraq. The fire and explosions ripping the Horizon apart were even more terrifying. “I never heard a bomb like that in Baghdad,” he said in an interview. He made a quick decision; he and a friend jumped into the gulf.
Mr. Holloway saw his friend Matt Hughes clinging to the handrail and urged him not to jump. But Mr. Hughes lost his footing and fell, glancing off the rig and cartwheeling into the water. Mr. Holloway climbed the rail, prepared to go after Mr. Hughes if he did not come up swimming.
The gulf, he recalled, was as calm as a “mud puddle.” At last, Mr. Hughes popped up and backstroked away.
Mr. Holloway was one of the last into lifeboat No. 1. Soon he noticed Mr. Harrell and a few others coming from the crew quarters, carrying someone on a backboard. It was Mr. Trahan, and he was in excruciating pain. His entire back had been burned. He had a deep puncture wound on his neck. His left calf was mangled, and his fingernails were gone.
But the backboard would not fit into the packed lifeboat. So they took Mr. Trahan off the board, and Mr. Holloway, Mr. Pleasant and others eased him into the boat and strapped him in.
Mr. Holloway turned to help Mr. Harrell. “I can’t see,” Mr. Harrell said. “What’s happening?”
“It’s me, Caleb, Mr. Jimmy. Just hang tight, and we’re going to get these straps on.”
But when it came time for Mr. Holloway to strap himself in, his hands would not cooperate. He fumbled and gave up. He could hear the nitrogen tanks bursting on the main deck. The heat was suffocating. He looked around for other members of his drilling crew. “Where are my guys?”
He began to pray. A passage from Isaiah came to him: “Yea, I will uphold thee with the right hand of my righteousness.”
10 Left Behind
Both lifeboats had left, but at least 10 people were still alive on the rig.
When Mr. Bertone, Mr. Williams and Mr. Meinhart finally made it back to the bridge from their attempt to start the generators, they found the captain, Ms. Fleytas and Mr. Keplinger still there.
“That’s it,” Mr. Bertone said to his men. “Abandon ship.” The captain said it was time to go, too.
Down on the lifeboat deck they found Mr. Ezell, Mr. Carden and Mr. Murray tending to Mr. Wheeler on a gurney. They gently put him in a life vest.
“My leg,” Mr. Wheeler moaned.
The plan was for everyone to leave in an inflatable raft, a backup to the lifeboats. But this plan, too, went awry. For all the evacuation drills, they had never rehearsed inflating and lowering the raft. They had trouble freeing it from the deck, more trouble keeping it level and more trouble still getting it loaded.
Small explosions kept going off around them, sending projectiles every which way. Intense waves of heat were now coming up from under the rig.
“I honestly thought we were going to cook right there,” Mr. Bertone said.
In his written Coast Guard statement, Mr. Bertone said the captain suggested leaving Mr. Wheeler behind. Mr. Bertone wrote that he “pushed past” the captain, shoved Mr. Wheeler’s gurney into the raft and climbed in himself.
The captain’s lawyer disputed Mr. Bertone’s statement, saying Captain Kuchta acted in “an incredibly heroic and skilled manner.”
The raft, far from full, began to descend, leaving several people on the deck. The raft pitched and spun wildly, spilling Mr. Wheeler from his stretcher. Ms. Fleytas said it felt like they were “free falling,” and when it hit the gulf, she went tumbling into the water. The raft’s remaining occupants were stuck under a burning, exploding, sinking oil rig, and they couldn’t find the paddles.
Mr. Bertone jumped in the water and tried to drag the raft away. Others did, too. Then, out of the smoke, he saw someone plunging at him.
It was the captain.
He barely missed Mr. Bertone.
Another crew member fell through the smoke. It was Mr. Keplinger.
Mr. Bertone could make out Mr. Williams up on the helicopter pad. He watched him sprint and then leap, his legs churning as he arced into the sea.
Try as they might, they could not get the raft away from the rig. It turned out the raft was still tied to it. Captain Kuchta thought fast. He swam to a rescue boat launched by the Bankston, fetched a knife and returned to cut the raft free.
On the Bankston
It seemed to take the lifeboats forever to get to the Bankston.
When lifeboat No. 1 arrived, Mr. Holloway scrambled up a ladder to the deck. He was quickly put to work directing the injured to a makeshift triage area. But he kept looking for his drilling crew. He kept asking others if they had seen his guys. No one had.
Eventually he went to sign in with a man who had a list of the crew. The name of everyone who had reported in was highlighted. Mr. Holloway scanned the list. Only two names from his team were marked — his and Mr. Barron’s.
He felt sick and heartbroken all at once. Eleven men were missing, including Dale Burkeen, Dewey Revette, Steve Curtis, Jason Anderson and Mr. Holloway’s buddy, Adam Weise. All but Mr. Burkeen had been working either on the drilling floor or just below it.
The life raft arrived, and Mr. Wheeler was rushed to the triage area. He seemed close to passing out from the pain, yet when he saw Mr. Holloway, he managed a question.
“Hollywood, who made it?” he asked.
Mr. Holloway avoided answering him directly. “I didn’t have the heart to tell him,” he said.
After the Coast Guard arrived and moved Mr. Wheeler and the other injured off the Bankston by air, Mr. Holloway searched for a place inside the ship where he would not have to watch the Horizon burn, a private spot where he could at last weep for his friends.
Out on the deck, the Horizon’s crew gathered in groups. Across the water, the rig hissed and groaned as it began to list. The mighty derrick finally crashed. Several crew members said it was like watching your home burn.
In quiet conversations, they tried to make sense of what had happened. That so many had escaped seemed a miracle, but why had the rig’s defenses failed? What had the drilling crew seen?
They turned to Mr. Holloway for answers. “There was nobody else to ask,” he said.
Mr. Harrell stayed with his crew on the deck. He looked as if he were carrying the weight of the entire disaster. Some thought he might be having a heart attack. Crew members took turns trying to comfort him. He kept saying he wished he could turn back time.
“I don’t know what happened,” he told Mr. Holloway.
“I don’t either, Mr. Jimmy.”
The next morning was clear and calm. The Horizon, receding in the distance, burned brightly. The crew gathered on the Bankston’s deck. Shoulder to shoulder, they formed a large circle. A BP manager explained that they were headed to Port Fourchon, La.
Mr. Lindner, the former English teacher, interrupted.
“We should really say something for our fallen,” he said.
The group fell silent.
Patrick Morgan, an assistant driller, spoke up first.
“Our Father,” he said, and with that everyone joined in the Lord’s Prayer.
2010年12月26日 星期日
臺灣大學法律學院環境永續政策與法律研究中心
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2010年12月25日 星期六
慎重其事
2010年12月25日 與 Ken 談些日本的獨特的防止安全手法
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羽越線事故から２年 再発防止改めて訴え
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庄内町のＪＲ羽越線で２００５年、特急列車が脱線・転 覆して５人が死亡、３３人が負傷した事故から２ ５日で２年を迎えた。同町内ではＪＲ東日本主催の追悼 慰霊式が営 ...
晚上在NHK 新聞看到他們慎重其事: 祭 2005年的交通事故
羽越線事故から２年 再発防止改めて訴え
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庄内町のＪＲ羽越線で２００５年、特急列車が脱線・転 覆して５人が死亡、３３人が負傷した事故から２ ５日で２年を迎えた。同町内ではＪＲ東日本主催の追悼 慰霊式が営 ...
環保資訊 月刊
環保資訊 月刊
環保資訊 月刊簡介 | |
| 『環 保資訊』係財團法人豐泰文教基金會發行的一份期刊。自1992年9月創刊至2001年3月，『環保資訊』以平面季刊方式發行，合計出版35期；每期印製約 4,000份，以中小型工廠、醫院、環保科技公司、學術機構、政府機關以及圖書館為主要贈閱對象。其內容涵蓋環境、安全與衛生之觀念、技術與經驗，期能協 助中小型工廠將環安衛視為企業經營中的重要一環，藉由環安衛管理策略與技術來降低生產成本、減少污染、提升企業形象。 自2001年4月份起，『環保資訊』已自平面季刊轉型為電子月刊，其涵蓋的範疇亦已大幅擴展。透過本網站讀者可按月收到豐富、即時的環境、安全與衛生等相關資訊。 「讓將來的世代與我們分享有限的自然資源」是我們的信念。希望藉由本刊能讓更多讀者收到環保資訊，並進一步共同為提升國內一般環境與作業環境的品質盡一分心力。 |
2010年12月24日 星期五
企業安全文化經驗談 (張慶麟)
2010年12月25日 Ken Chang 來幫忙設Skype
我提起他的著名文章
我提起他的著名文章
『環保資訊』月刊第77期 企業安全文化經驗談 |
張慶麟 台灣杜邦股份有限公司安全管理諮詢顧問 美商業凱科技股份有限公司台灣分公司工安顧問 | ||
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摘 要 以台灣杜邦企業安全文化為例，說明如何建立企業安全文化，並簡要申論評估企業安全文化的內容及協助中小型企業建立企業安全文化的方法。 一、前言 愛因斯坦曾說：“這個世界之所以危險，並非肇因於險惡的人，而是肇因於縱容惡行的人們。” "The world is a dangerous place to live; not because of the people who are evil, but because of the people who don't do anything about it." --- Albert Einstein 台灣經過這些年來在安全衛生上的努力，各方面都有顯著的進步。但隨著企業的急劇成長，營運日趨複雜，災害損失在世界上排名甚高，社會的安全環境改善趨緩，企業與全民的權益因而受到相當的影響。為突破瓶頸，乃紛紛開始注重推展企業安全文化。 現在積極推動的兩兆雙星計劃，因投資龐大，風險龐雜，舉凡產業的資產保險、工作人員與包商的勞健保、企業的社會與環保責任險、社會經濟環境變動的風險等， 範圍不斷擴大，風險管理的範疇早已超越傳統工業安全衛生的範圍。從先進國家的經驗及研究中可看出，單一個人或單位難以擔負與確保企業全部的安全，必須全員 參與、人人關心，形成安全文化，才能降低風險，確保安全。 台灣企業界因此亟需了解何謂企業安全文化，如何建立安全文化，以及如何改善安全績效，確保投資效益。大型與國際性的企業或有人力從事研究與推展，或可尋求 國際顧問公司或組織的協助，但中小型企業因資源條件有限，面對此課題不知如何因應，政府及相關組織乃積極籌畫協助之道。 台灣杜邦公司中壢廠是杜邦公司在亞洲區最大最早的單位，自1979年起積極推展安全文化後，三年內開始連續獲得政府獎勵，成為台灣安全的模範單位，十年內在杜邦全球140個工廠中排名第七，獲世界金屬衝製業最高安全紀錄獎。本人躬逢其盛，特將相關經驗加以整理，期從實務經驗中歸納一些做法，以供中小企業於推展安全文化時之參考。
二、何謂企業安全文化 文化與安全一樣，都是抽象名詞，其內涵只有經由具體的設施與活動才能顯現出來。企業安全文化是企業整體文化不可分割的一環，相互影響，因此討論安全文化 時，必須考慮企業文化，甚至社會文化的影響。再者，身處於文化中的人們往往習焉而不察，需與外界比較之後，才易於發現出其文化的獨特性。 事實上本人在杜邦工作期間，杜邦並未正式推動所謂的《安全文化運動》。但現在回想起來，從加入杜邦的第一天開始，時時刻刻都受其安全文化的薰陶，工作的重心可說是在依據總公司的要求，協助主管人員，運用各種組織及活動，建立適合台灣營運需要的企業安全文化。 安全文化一詞，是在三哩島及車諾比爾等重大核能事故發生後，核能界注意到安全文化的缺陷是造成事故的主因，因此開始積極研究安全文化，期能避免事故再次發 生。嗣後經各國學者專家的擴大研究與推廣，對安全文化下了種種定義。網站上及國內外的書籍、雜誌對安全文化的定義已有詳細的介紹，國內有些教授對此頗有研 究，本文不擬一一列舉，僅依照個人經驗將其定義簡單說明如下： 企業安全文化是企業的安全管理內在思想理念與外在具體表現的整體總稱，這包括硬體設施與軟體管理的整體表現。 比如說，到杜邦的工廠參觀時，你會發現沒有人跑步，樓梯兩邊都有扶手，每一個人都使用扶手、一步一階上下樓梯，都照規定穿戴好安全鞋、安全眼鏡、安全帽等 防護具。若有來賓跑步、不用扶手或未戴用防護具，旁邊的杜邦員工會立刻提醒糾正。因此你會感覺到其安全管理的特殊之處，其實這就是安全文化的具體表現之 一。(杜邦安全文化的一些具體表現，請參見附件一)。
三、台灣杜邦安全文化的起源 文化變革可分為漸進的演變、急劇的革命以及對基本觀念的改變。台灣杜邦可說是同時進行這三種改變。而塑造杜邦中壢廠企業安全文化則有三個重要因素：關鍵的事件，關鍵的人物與主要的活動。現將這三因素分別說明於後。(台灣杜邦推動安全文化時間表，請參見附件二)。 杜邦公司於1968年成立台灣分公司於台北，1970年設中壢廠，初期員工約50人，協助台北公司進口杜邦產品的分裝作業以節省關稅與運費。1972年杜邦購併專門製造大型電腦連接器的百格電子(Berg Electronics) (當時個人電腦尚未問世)。因台灣模具技術員及作業員具有成本優勢，1975年決定將部分賓州製造業務移至台灣，員工乃增至350人。首任連接器廠長除負責擴廠建廠事宜，亦開始籌組安全組織、編纂安全手冊、印發安全通報，但工安事件仍不斷發生。1978年底塑造部某作業員發生嚴重的失能傷害事件(關鍵的事件)後，公司高層乃決定改派曾任賓州類似工廠Clearfield廠及最大廠Fishing Creek廠廠長的米德立先生(Terry Miller)(關鍵的人物)來台擔任中壢廠廠長，積極整頓安全，準備再擴大營運至1000人的規模。(安全文化絕非一天造成的，杜邦安全文化淵遠流長，杜邦先生與安全文化的起源，請參見附件三；杜邦累積兩百年經驗的安全管理原則，請參見附件四)。 米德立廠長到任前即指示工業關係部經理招聘全職的安全工程師及訓練主任各一名，負責自美國引進安全管理計劃與訓練的工作(以前都是由相關經理兼任)。當時我因任滿油輪三副一年從歐洲返台休假，看到杜邦徵人啟事，經參加徵試錄取，於1978年9月加入台灣杜邦股份有限公司，擔任亞洲區首位安全工程師。到任後前三個月的工作包括：了解中壢廠的現況，到各部門觀察工作內容，到中華民國安全衛生協會上課，取得安全衛生管理員的資格(當時台灣尚未有安全衛生管理師的課程)，接著協助籌畫1979年安全計劃。次年5月到美國受訓，蒐集資料，輔導建立安全組織與計劃。
四、企業安全文化涵蓋的項目
在推動安全管理，建立安全文化時陸續執行了許多安全計劃。現將其要項(主要的活動) 說明於下，加上一些心得，或可提供中小企業於建立安全文化時之參考 (詳細推展安全文化的主要事項，請參見附件五)： (一)、最高主管的決心與以身作則 1.中壢廠的最高主管就是廠長。米廠長到任後兩年內，每日進廠後必定親自到全廠走一遍，與大家打招呼，並執行安全檢查。我則負責跟班紀錄與分發相關單位追蹤改善。一直到各部門安全檢查日漸上軌道後，廠長才漸漸減少檢查次數。 2.米廠長品德高尚、做事認真、態度溫和、極為尊重員工、為員工謀福利，贏得全體員工尊敬。五年後米廠長任滿調回美國時，我已奉派到美國總公司上班，聽說送行時全廠員工依依不捨，全體大哭相送，真是空前感人。米先生現已退休住在賓州，不久前尚有email聯絡，因年事已高，不便遠行，恐難再來台訪問。 3.心得：最高主管若不是真心，並以身作則，則很奇妙的，不論是任何人種的員工都會立刻知道，開始陽奉陰違，安全文化絕對難以成功。 (二)、各級主管及專業人員的參與 1.米廠長到任後，除指示由一級主管、安衛、廠務、醫護、工會人員重組中央安全衛生委員會每月開會外，另新增10個安全小組委員會(當時十個小組委員會的名稱請參見附件六)，亦每月至少開會一次，強制規定所有主管與專業人員必須至少參加一個小組委員會，召集人由一級主管擔任。我除了擔任中央安全衛生委員會秘書外，也是所有小組委員會的當然委員，負責輔導與協調的工作。 2.心得：各級主管與專業人員若不親身參與，則不但難以真正了解安全管理，安全文化也無法建立。此外因輪流參加各委員會，員工有了跨部門共同的經驗與語言，不但員工成長迅速，團隊精神更加堅強。 (三)、全員參與 1.廠內安全委員負責籌畫1979年年度計劃與每月安全主題時，米廠長指示年度主題為"Individual Involvement --- Our Road to Safety"(人人關心、事事安全)。每月另有個別安全主題，印製精美年度計劃卡給每位員工。在春節過後召開全廠安全年度計劃啟動典禮大會(Kick Off Meeting)，每人並獲贈安全紀念品一份。以後每年都有同樣的典禮與活動。 2.各種安全活動及小組委員會廣邀一般員工與工會成員參加。並利用安全獎頒獎或假期舉辦各種安全園遊會、安全郊遊、野餐、燈謎、歌唱、短劇等活動，廣邀員工家屬朋友參加，擴大參與蔚為風氣。所有公司用品及贈品一律優先採購與安全衛生環保相關的物品或加印安全標語。 3.重新購置品質良好的安全眼鏡，安全鞋，耳塞，耳罩，絕緣衣，手套等防護具，安排廠商到廠服務，確保員工戴用。 4.心得：很多杜邦退休或離職的員工（甚至家屬）告訴我，離開杜邦後印象最深刻的就是安全，全家人安全習慣養成後不易改變，家裡的服裝及日用品很多都印有杜邦的安全標識。 (四)、安全會議徹底溝通 1.在杜邦談到安全員工不能說不知道。以安全會為例，每月安全主題由廠內安全委員會負責印製安全通告或安全教材一份，各部門必須依據內容召開安全會議，所 有安全會議缺席人員均由主管負責個別補課並簽名，會議記錄副本由廠內安全委員會監督，必須百分之百完成溝通。 2.心得：百分之百的溝通才能有共同的經驗，共同的語言。 (五)、直線主管制明確規定責任範圍 1.各單位主管的安全責任範圍與其業務範圍一致，每一寸土地都有明確的負責人，應變與溝通的範圍亦與平時相同，緊急時易於執行成功。 2.心得：權責合一是最合理的管理方式。 (六)、安全委員會積極運作 1.杜邦的安全計劃幾乎都是透過安全委員會來運作的。將十個小組安全委員會提出並經中央安全衛生委員會審核的計劃彙總起來，加上一些安全室特殊的工作，差不多就是全廠年度的安全計劃了。 2.心得：小組安全委員會若沒有主管親身參與大力支持，很快就會流於形式與空談。 (七)、不斷執行各種稽查 1.除廠長與安全室隨時機動檢查外，所有部門的主管每月自行安全檢查一次，生產線每週檢查一次，作業人員對危險機台每班檢查一次，安全稽查委員會每月跨部門檢查全廠一次，涵蓋所有作業與區域。 2.杜邦總公司依照工廠的規模及業務性質，定期稽查全球工廠安全管理制度一次。中壢廠大約每一年半一次。每次稽查報告都發給該事業單位全球最高主管，是工廠安全績效的重要指標，也是廠長升遷的重要依據。因此各廠莫不全力以赴，準備經年。 3.心得：不斷的稽查是一種走動式的管理，對確保安全與溝通有極大的助益。全面性的稽查是專業，必須公正客觀，勇於發掘問題，管理階層亦須虛心接受，才能達到不斷改進的目的。 (八)、安全管理手冊與作業程序 1.1978年之前安全管理手冊是由一位經理整編而成的英文版草稿，從未發行過。我們另行成立了安全標準小組委員會負責編譯中英對照版安全管理手冊。所有安全規則及作業程序都要中文化、本地化，安全才能落實在本地的生活中。 2.各部門依照安全標準小組委員會規定的格式自行建立詳細的安全作業程序，經該部門主管及委員會安全室會審後生效。 3.杜邦總公司的安全稽查人員也要求所有安全標示與資料必須使用當地作業人員看得懂的文字或圖案。 4.心得：當時因有些一級主管是外國人所以需要中英對照，後因本地化而刪除英文部份，其後又因國際化而將部份英文加回。安全規定及作業程序都要員工參與訂定、合理化，才易於徹底執行。 (九)、全面推展訓練 1.除 聘請專人翻譯印發杜邦安全叢書，走路安全漫畫小冊，旅館安全卡、急救及化學安全卡等資料外，陸續從國外引進人因工程、製程危害與工業衛生等訓練。訓練部門 也協助引進防衛駕駛訓練，編製機車安全教材及各種射出成型、衝床、維修等專業訓練，英語訓練等課程，全員編列訓練經費及目標，全面推展訓練。 2.心得：訓練與實務相結合，安全文化才能紮根久遠 (十)、整頓設施，建立預防保養制度 1.米廠長到任後，除每日稽查內容有甚多硬體的改善外，另責成廠務部門將機台依作業流程與動線方向重新排列整齊，並將原來擠在水溝中的電源、氣源等管線全部提高至天花板架上，以顏色清楚標示。 2.購置堆高機，裝設調車，加裝局部通風，購置防火櫃、溢漏處理箱、碼頭板，裝設全廠救火機、區域氣源緊急開關閥、廚房消防系統等。 3.所有機台一律改裝至少兩層以上的安全連鎖裝置，並一律修改為單一上鎖設計，以便執行上鎖程序。 4.所有設施均參考美國廠預防保養制度，由維護部指派專人費時一年建立主動預防保養制度。 5.心得：安全設施的整頓費用在最初三年內概估大約是原有建廠費用的1/4，可見其決心之一斑。一般業主若侈言安全第一，卻連基本的設施都不願花錢改善，則安全文化必會成為空談。硬體設施若不積極從事預防保養，則設備很快就會毀壞，而成為安全事件的根本原因之一。 (十一)、引進製程危害管理 1.杜邦因連續發生重大災變，於1986年推出製程危害管理計劃。嗣後美國政府將之採用為法規，我國政府亦採用為審查危險性作業的規定。其中製程危害檢討係有系統的檢討危害與對策，對災害預防大有助益。 2.杜邦因化工業遭受社會的重大阻力，率先推出CAER (Community Awareness and Emergency Response) 計劃，主動與社區溝通。此項計劃後為化工業界接受並予以擴大，改稱責任照顧計劃(Responsible Care)，並在各國推行，製程危害管理亦為其主要項目之一。 3.心得：員工從詳細的製程危害檢討中，不但增進思考能力，並建立對製程安全的信心。 (十二)、啟用前檢查授權基層 1.機台啟用前由現場員工、主管、工安維修人員、製程安全小組委員會輪值委員共同檢查。只要有任何一票反對，機台就必須鎖起來不准生產，只有廠長才能在安排好臨時保護措施後特准生產。事實上米廠長從未特准生產過。 2.心得：信任員工安全文化，員工才有賦能與負責的表現。 (十三)、安全事件調查 1.不論是否有傷害，所有事件都要立即調查真因以防止再發生，公佈相互學習，安全室要做整體分析，作為以後安全計劃的重點方向。 2.心得：將急救箱由合格急救員專人保管，用三聯單，人員姓名必須保密才可確保事故的填報。 (十四)、安全競賽獎勵 1.總公司依照連續累積安全工時，每月將全球140廠排名一次。並依照連續安全工時，每半年到三年頒發董事會安全獎一次。中壢廠於1980年首次獲獎，杜邦總裁親自抵台頒獎，並邀請內政部長，工檢所長，勞工司長等官員參加典禮，盛況空前。每次頒獎每位員工都會獲得安全獎紀念品一份。 2.各部門依照人數分組，每季舉辦廠外安全競賽一次。全組無事故則每位員工都獲得安全獎紀念品一份。 3.心得：競賽難易應適當，獎品應有實用及紀念價值才有效益。 (十五)、引進安全觀察訓練 1.1986年引進杜邦安全觀察訓練教材，費時四個月才完成訓練。政府單位乃要求於領取當年安全榮譽獎時演出STOP短劇一齣，供大家參考。 2.心得：很多主管於訓練後表示稽查能力大增，也更能與員工溝通，收穫良多。 3.STOP是杜邦公司開發以行為為導向的安全管理系統，可單獨採用以改善安全稽查的技巧，也可作為整體安全管理的體系，因此特別適合中小企業使用，學者專家後來將此類以行為為導向的安全管理系統稱為BBS (Behavioral Based Safety)。台灣各界引進BBS的時間表及其檢討，請參見附件七。另本人有關杜邦引進STOP的報告《杜邦STOP安全觀察訓練計劃執行實務》一文，請參閱《消防與防災科技雜誌》第二期。 (十六)、以廠為校為家為榮 1.中壢廠之乳白色廠房、綠地花園、向日葵鑄鐵遮陽牆、一對荷花池噴泉、紅色杜邦地標等設計，屢次獲得工業區最佳美化獎，員工薪資福利名列前茅，員工三代同堂所在多有，流動率極低，人人均以公司為榮。 2.心得：工會領袖之一退休時回贈公司獎牌曰亦校亦家，大家在工廠中不斷學習、成長、成家、立業，真是亦校亦家。
五、台灣企業安全管理制度現況 台灣業界大多依照安全衛生法令設有勞工安全衛生委員會與自動檢查制度。但缺點甚多，例如全員參與度不足，過分倚賴安全衛生人員，工安檢查不確實，明顯的硬 體缺失長期未發現及改善，安全衛生人員專業能力不足，員工訓練不確實，未確實嚴格要求遵守安全操作程序，災害預防應變計劃不完備，未設置正確的操作手冊 等。總之，由於業主不重視，安衛人員不專業，安全管理制度往往流於報表化、形式化。類似的災害不斷發生，業主與包商、廠商與客戶都互相推諉。大家認為工安 衛只是不得不做的必要之贅，能省就省，當然無法進入PCDA的良性管理循環。 簡單的說，要改善安全管理制度，政府應從下列三項着手： 1. 激發業主的改善意願：改善勞健保及產險制度。以美國職災自負額為例，高達台幣八百萬以上，因此業主莫不兢兢業業，深恐職災造成公司重大損失。必須要讓業主了解推動安全文化的利益，才能激發業主的改善意願。(台灣杜邦公司推動安全文化的利益摘要，請參見附件八)。 2. 培養一般人員的安全意識：從幼稚園教育做起，各級學校教育的重點應包括安全衛生環保的知識與警覺性。美國從幼稚園起就經常練習緊急應變，國民從小處變不驚。911世貿大樓死傷人數相對於許多國家同等狀況為低，即得利於美國從小安全教育的成功。 3. 提升安衛人員的專業程度：安衛人員的專業必須與國際專業的做法接軌，勿自限於現有安全衛生管理人員之學習與範疇。 只有同步推進上述三項，才能促使企業建立安全文化，進入PCDA良性管理循環的境界。
六、中小型企業如何建立安全文化實施安全審核 中小型企業若想建立安全文化必須有下列條件： 1. 最高主管必須有最堅定的決心與道德觀 2. 必須提供必要的訓練 3. 必須不斷及定期機動及全面的稽查 4. 必須尋求專業的支援與指引 但現在推動安全文化可能的困難點有： 1. 最高主管不願負責並以身作則 2. 坐視困難發生不求改善 3. 不知如何去做 4. 社會助力少阻力大 此外推動安全文化要注意： 1. 不可陽奉陰違 2. 要儘量與所有工作整合，不可過度倚靠工安人員 3. 安全原則不可任意退讓 4. 不可三分鐘熱度 5. 不可缺少正確的安全政策 在推動安全文化可能的問題點： 1. 只求短期解決方案 2. 訂定非零傷害事件的新目標 3. 迫使傷害事件報告地下化 (附件九為推動安全文化目標的範例)。 是否已建立安全文化可經由專家審查或由員工意見調查得知。附件十為建立安全文化後可察覺到的改變與徵候，亦可作為安全文化評估與審查的標準。網站上有多種安全審查表及意見調查表可公開使用，請利用Google搜索直接查看，此處不詳述。 此外勞委會、各地檢查所、工業局、安衛研究所、工研院環安中心、產基會、安全衛生協會、台灣安全研究與教育學會、各大專院校環安衛科系、安全衛生環保品管 技師與顧問認證公司、以及台灣杜邦公司安全管理諮詢部等單位，都有從事安全衛生環保管理訓練與輔導的人員。中小企業可向這些單位尋求支援，經整體評估，參 考本文內容，選擇適合項目開始做。只要堅持下去，必能建立可長可久的安全文化。 附件一 杜邦安全文化在生活中的具體表現： 1.除立即危險外，不准跑步 2.上下樓梯一步一級，使用扶手 3.一次只開一個抽屜 4.檔案櫃及架子加以固定防止傾倒 5.檔案櫃上禁放鬆散物品 6.物品除臨時標示外不得放在地上，物品放在定位 7.各種開關一律清楚完整標示說明 8.確實配戴防護具 9.集會前先說明安全逃生注意事項 10.開會議程首先檢討安全 11.業務一定將安全事項納入考慮 12.日常見面經常討論安全及相關新聞 13.辦活動一定考慮安全 14.鼓勵家人都注意安全 附件二 杜邦在台灣中壢廠推動安全文化時間表： 1977 台灣某作業員發生失能傷害 1978 新廠長米德立到任，新增專任安全與訓練主管 1978 重組中央安全衛生委員會 1978 廠長開始每日安全稽查 1979 調派上述專任安全與訓練主管二人至美國友廠受訓 1979 總公司初步稽查 (差) 1979 編印安全手冊，翻譯安全作業叢書 1979 開始整頓機台及設備 1981 總公司正式安全稽查 (好) 1981 安全工程師調至總公司擔任稽查工程師 1983 安全工程師調回台灣，加強工業衛生計劃 1985 整修餐廚及工業衛生計劃 1986 推出安全觀查訓練 1987 推動製程危害管理 1990 推動預防人因工程危害 1993 獲美國安全總會頒發衝製業安全最高記錄獎 1993 中壢廠轉讓美國HMM集團改名康旭 1998 再轉讓法國法馬通集團名稱不變 附件三 杜邦先生與安全文化的起源 1802 年杜邦先生應美國傑佛遜總統之邀，於德拉瓦州白蘭地河畔利用水力研磨木炭、硝石、硫磺，為美國自製火藥之嚆矢，用以取代從歐洲進口易潮濕失靈的黑火藥。杜邦先生設置了面河的安全牆，訂定了安全程序及規則，並以身作則，全家住在工廠旁邊，以確保工廠之安全。 附件四 杜邦累積兩百年經驗的安全管理原則 1. 一樣重要原則 2. 零的原則 3. 直線責任 4. 人人有責 5. 建立高標準以身作則 6. 建立安全組織 7. 不斷訓練宣導 8. 系統安全管理 9. 必須稽查改善 10. 工作外安全一樣重要 11. 與社區社會共存共榮 附件五 推展安全文化的主要事項： 1. 最高主管以身作則 2. 各級主管及專業人員親身參與 3. 人人參與活動 4. 安全委員會 5. 安全手冊 6. 全面推展訓練 7. 安全會議 8. 安全檢查 9. 安全事件調查 10. 整頓設施設備 11. 預防保養制度 12. 啟用前檢查 13. 作業程序與規則 14. 直線及區域責任制 15. 安全競賽 16. 工作外安全活動 17. 製程危害檢討與管理 18. 充分分享安全事故經驗與資訊 19. 定期全球及區域安全大會 20. 總公司指引及工程標準 21. 總公司每月安全競賽 22. 總公司安全獎 23. 總公司定期稽查 附件六 早期杜邦中壢廠中央安全衛生委員會設立的小組委員會： 1. 廠內安全小組委員會 2. 廠外安全小組委員會 3. 啟用前檢查小組委員會 4. 製程安全小組委員會 5. 危險物品小組委員會 6. 職業健康小組委員會 7. 安全稽查小組委員會 8. 安全標準小組委員會 9. 運輸安全小組委員會 10.事故調查小組委員會 附件七 BBS在台灣 1985: 零災害運動 (預知危險，指認呼喚) 1986: 台灣杜邦STOP 1993: 中油安全教練 1999: 中普氣體SOS 2002: 杜邦安全諮詢LSUP 2003: 台積電，安全研究與教育學會 BBS的檢討 多偏重於硬體稽查，一開始不論東西方人都不習慣緊迫觀察與被人觀察，較多單向式指揮教導，較少雙向導引式溝通共識虛應故事，未追查根本原因，徹底改善 附件八 杜邦在台灣推展安全文化獲得的利益 1.杜邦保持零職災，節省大量保險費 2.增進管理能力，降低對外資敵意，避免山頭主義 3.培養大量具有安全管理能力的專業人才 4.引進杜邦安全管理制度與資訊分享台灣 5.支援杜邦其他投資案使杜邦成為台灣最大的外資企業 6.杜邦員工家庭成為安全家庭 7.員工及其家庭有助於塑造社會安全習慣 附件九 建立安全文化後可見的改變與徵候：(可作為問卷評估標準) 1.管理者真心承諾 2.傷害率降低 3.員工對安全的態度變化 4.員工參與度增高 5.潛在事件報告增加 6.安全的對話增加 7.安全文化的效益 附件十 安全文化目標範例： 1. 以身作則，拒絕打折扣 2. 建立程序 3. 不做危險的行為 4. 團隊精神--人人都重要 5. 積極上下溝通 6. 高度訓練 7. 共同價值 8. 提供足夠資源 9. 維持高度整潔 10. 以在公司為榮
作者簡介： 張慶麟 現職 台灣杜邦股份有限公司安全管理諮詢顧問 美商業凱科技股份有限公司台灣分公司工安顧問 經歷 1981 美國杜邦稽查工程師 1983 中壢廠資深安全工程師 1987 杜邦安環衛主任、副理 1993 康旭公司 (原杜邦中壢廠) 安環衛經理 1994 康旭人資安衛廠務處長 1999 杜邦光罩行政工安處長 2002 中普氣體亞洲環安總監 2002 台灣安全學會秘書處長 2003 杜邦安全顧問 2004 業凱科技工安顧問 |
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