Author Archives: Mark Paradies
Here is a link (click of picture below) to a Callback publication about accidents and Fatigue …
Here is a quote:
“The NTSB 2016 “Most Wanted List” of Transportation Safety Recommendations leads with, ‘Reduce Fatigue-Related Accidents.” It states, “Human fatigue is a serious issue affecting the safety of the traveling public in all modes of transportation.’”
This incident notice is from the UK Rail Investigation Branch about an overspeed incident at Fletton Junction, Peterborough on 11 September 2015.
At around 17:11 hrs on 11 September 2015, the 14:25 hrs Virgin Trains East Coast passenger train service from Newcastle to London King’s Cross passed through Fletton Junction, near Peterborough at 51 mph (82 km/h) around twice the permitted speed of 25 mph (40 km/h). This caused the carriages to lurch sideways resulting in minor injuries to three members of staff and one passenger.
It is likely that the train driver had forgotten about the presence of the speed restriction because he was distracted and fatigued due to issues related to his family. Lineside signs and in-cab warnings may have contributed to him not responding appropriately as he approached the speed restriction and engineering controls did not prevent the overspeeding. Neither Virgin Trains East Coast, nor the driver, had realised that family-related distraction and fatigue were likely to be affecting the safety of his driving. Virgin Trains East Coast route risk assessment had not recognised the overspeeding risks particular to Fletton Junction and Network Rail had not identified that a speed limit sign at the start of the speed restriction was smaller than required by its standards.
The incident could have had more serious consequences if the train had derailed or overturned. The risk of this was present because the track layout was designed for a maximum speed of 27 mph (43 km/h).
As a consequence of this investigation, RAIB has made five recommendations. Two addressed to Virgin Trains East Coast relate to enhancing the management of safety critical staff with problems related to their home life, and considering such issues during the investigation of unsafe events.
A recommendation addressed to Virgin Trains East Coast and an associated recommendation addressed to Network Rail relate to assessing and mitigating risks at speed restrictions.
A further recommendation to Network Rail relates to replacement of operational signage when this is non-compliant with relevant standards.
RAIB report also includes learning points relating to managing personal problems that could affect the safety performance of drivers. A further learning point, arising because of a delay in reporting the incident, stresses the importance of drivers promptly reporting incidents which could have caused track damage. A final learning point encourages a full understanding of the effectiveness of safety mitigation provided by infrastructure and signalling equipment.
For more information see:
All TapRooT® Users have experienced the effectiveness of using the Root Cause Tree® and Dictionary to find the specific root causes of a particular incident. They fix these causes and eliminate (or at least reduce) the chance of identical repeat incidents.
Here is the question …
Can we do more?
The answer is … YES!
In the TapRooT® System, the next step after determining the specific root causes is to identify the Generic root causes.
What is a Generic root cause?
The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.
These are the causes that are present across the organization. Think of it as looking at the big picture.
If you have a problem with a procedure, what in the procedure writing system is allowing the problem to exist?
If you have a training issue, what in the way you develop and provide training or test people for proficiency is causing problems?
Get the idea?
Sometimes using the Corrective Action Helper® Guide can help you identify Generic Causes.
To do this we use this three step process:
For each root cause identified using the Root Cause Tree® Diagram:
- Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
- Ask: “Does the same problem exist in more places?”
- Ask: “What in the system is causing this Generic Cause to exist?”
Once you identify the systemic cause (or causes), you fix them!
You then need to do a system wide evaluation to correct all the problems that exist from the old system by implementing the changes recommended for the new system.
Once you complete these corrective actions, you have fixed the immediate issues and made sure that you won’t create new issues in the future.
That’s going beyond simple root cause analysis.
Success teaches us nothing; only failure teaches.
Admiral Hyman Rickover
Here’s a link to the story: http://www.abc.net.au/news/2016-07-25/baby-dies-at-bankstown-lidcombe-hospital-after-oxygen-mix-up/7659552
An Oxygen line had been improperly installed in 2015. It fed nitrous oxide to a neonatal resuscitation unit rather than oxygen.
The Ministry of Health representative said that all lines in all hospitals in New South Wales installed since the Liberal government took over in 2011 will be checked for correct function.
What can you learn from this?
Think about your installation and testing of new systems. How many Safeguards are in place to protect the targets?
Mark Paradies will be talking about root cause analysis at the 2016 Parenternal Drug Associations / Federal Drug Administration Joint Regulatory Conference in Washington, DC, on Tuesday. See page 8 (Session A3) at:
See you there!
From the UK Rail Accident Investigation Branch…
On 1 August 2015 at about 11:11 hrs, a freight train travelling within a work site collided with the rear of a stationary freight train at 28 mph (45 km/h).
Engineering staff had authorised the driver of the moving freight train to enter the work site at New Cumnock station, travel about 3 miles (4.8 km) to the start of a track renewal site, and bring the train to a stand behind the stationary train.
There were no injuries but the locomotive and seven wagons from the moving train and eleven wagons from the stationary train were derailed; the locomotive and derailed wagons were damaged. One wagon came to rest across a minor road. There was also substantial damage to the track on both railway lines.
The immediate cause was that the moving train was travelling too fast to stop short of the rear of the stationary train when its driver first sighted the train ahead. This was due to a combination of the train movement in the work site not taking place at the default speed of 5 mph (8 km/h) or at caution, as required by railway rules, and the driver of the moving train believing that the stationary train was further away than it actually was.
An underlying cause was that drivers often do not comply with the rules that require movements within a work site to be made at a speed of no greater than 5 mph (8 km/h) or at caution.
As a consequence of this investigation, RAIB has made four recommendations addressed to freight operating companies.
One relates to the monitoring of drivers when they are driving trains within possessions and work sites.
Two recommendations relate to implementing a method of formally recording information briefed to drivers about making train movements in possessions and work sites.
A further recommendation relates to investigating the practicalities of driving freight trains in possessions and work sites for long distances at a speed of 5 mph (8 km/h) or at other slow speeds, and taking action to address any identified issues.
RAIB has also identified three learning points including:
the importance of providing drivers with all of the information they need to carry out movements in possessions and work sites safelya reminder to provide drivers (before they start a driving duty) with information about how and when they will be relievedthe importance of engineering staff giving instructions to drivers through a face to face conversation when it is safe and practicable to do so.
Elvis says: “Put the blame on me…”
Every hour has sixty golden minutes,
each studded with sixty diamond seconds.
Admiral Hyman Rickover