Author Archives: Mark Paradies
For those in the Northeast who have had to deal with so much snow, shutting the office because of 3 inches might sound stupid. But in Knoxville, we aren’t used to snow and the hills make getting around hazardous (especially when so many people never learned to drive on snow and don’t even have all season tires).
So … SI will be closed today. Hopefully this won’t be like the ice storm last week (three days out with hazardous conditions).
Monday Accident & Lessons Learned: How Much Root Cause Analysis Can You Buy for $5.6 Million Dollars?Posted: February 23rd, 2015 in Accidents, Current Events, Performance Improvement
Here are the headlines from The Bakersfield Californian:
“CPUC proposes $5.6 million fine against PG&E for 2012 demolition fatality in Bakersfield”
As reported by the papper, one of the findings of the PUC that led to the fine was:
“PG&E gave the CPUC an accident analysis prepared by Cleveland, as well as the utility’s own evaluation. But commission staff said both ‘failed to provide an adequate or comprehensive root cause analysis for the incident’ to help determine corrective actions.”
So here are some questions to consider:
- Do you require that your contractors perform adequate accident investigations?
- What root cause tools do your contractors use? Shouldn’t they be using TapRooT®?
- Are you waiting for fatalities to require better root cause analysis and incident investigation? Why don’t you have someone attend an 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course ASAP (this month?).
- Isn’t it time that you learned how to use root cause analysis proactively to stop fatalities before accidents happen? You should attend the Using TapRooT® Proactively Course.
How many lessons can your company learn from this accident?
If you are at a Russian beach, maybe like this…
The damaged floor of the train
RAIB is investigating a train fire that occurred on the evening of Friday 30 January 2015, and which caused serious damage to the structure of the train.
The 19:53 hrs South West Trains service from Windsor & Eton Riverside to London Waterloo had travelled about 400 metres after starting from Windsor station, when a small bang was heard under the sixth carriage of the ten-carriage train, followed by about five seconds of severe sparking and flashing.
The train, which was formed of two class 458/5 electric multiple units and was travelling at about 15 mph at the time, stopped immediately. Some smoke entered the carriages through ventilators. There were two passengers in the sixth carriage, and they moved quickly into another part of the train. The guard of the train moved from the rear to the sixth carriage to investigate, and the driver also moved to the middle of the train. They could see that there was still smoke coming from below the sixth carriage, so the driver returned to the front of the train from where he contacted the signaller by radio to ask for the electric power to be switched off. While he was doing this, the floor of the sixth carriage was penetrated by fire, and smoke rapidly filled the vehicle.
There were eleven passengers on the train. The guard, assisted by the crew of another train that was in Windsor station, evacuated the passengers to the track, and helped them walk back to the station. The fire brigade were called, and confirmed by 20:50 that the fire was out. None of the passengers were hurt, but the guard was taken to hospital and treated for smoke inhalation.
RAIB’s preliminary examination found that the fire had originated in severe arcing in a junction box fixed under the carriage floor, where power cables from the collector shoes on either side on the train are connected to the main power cable (‘bus line’) which runs along the train. The arcing had burnt through the floor of the carriage, and had also destroyed parts of the structural members of the carriage body.
RAIB’s investigation will focus on the cable joint in this junction box, and how this joint was designed and assembled. It will also examine how the train’s structure and equipment, and the people in it, might have been protected from the consequences of a failure of this nature.
RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.
RAIB will publish the findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on their website.
System Improvements has promoted operational excellence for over a decade (almost two). The TapRooT® Root Cause Analysis System is an excellent to to use both for reactive and proactive analysis to solve problems and achieve operational excellence.
SI is now a sponsor of the Operational Excellence Society. You can join the society for free. See:
And click on the “register” button on the top of the page.
Sometimes I get the impression that some managers think that performance improvement is an optional activity that can be cut to meet budget goals. That view surprises me because I think that performance improvement is an essential activity that can’t be cut because it supports activities that:
- Stop Fatalities
- Reduces Regulatory Conflict
- Avoids Major Financial Losses
- Keeps Clients Happy
- Eliminates Bad Press
- Improves Operational Efficiency and Equipment Reliability
After all, can you really afford deaths, regulatory initiatives, major losses, unhappy clients, bad press, and broken, inefficient operations?
If your performance improvement program isn’t world class, you are inviting disaster. And disaster is expensive. Every cent you save by reducing effective performance improvement efforts will come back to you in expensive accidents, incidents, plant upsets, equipment downtime, and regulatory headaches.
So, the next time management has a great idea to cut the performance improvement budget, remind them what the budget does for them. Remind them of the losses avoided and the good nights of sleep they get and how bad it will be when things go haywire.
Here’s a description of an car/train accident:
How could things go from a minor error and fender bender to a multi-fatality accident?
It happens when someone makes a bad decision under pressure.
Don’t think it couldn’t happen to you. Even with good training and good human factors design, under high stress, people do things that seem stupid when investigating an accident (looking at what happened in the calm light of the post accident investigation).
Often, the people reacting in a stressful situation aren’t well trained and may have poor displays, poor visibility, or other distractions. Their chance of choosing the right action? About 50/50. That’s right, they could flip a coin and it would be just as effective as their brain in deciding what to do in a high-stress situation.
FIRST: Avoid decisions under high stress. In this case, KEEP OFF THE TRACKS!
Never stop on a railroad track even when no trains are coming.
That’s true for all hazards.
Stay out from under loads. Stay away from moving heavy equipment.
You get the idea.
Don’t put yourself in a position where you have to make a split-second decision.
SECOND: NEVER TRY TO BEAT A TRAIN or PULL IN FRONT OF A TRAIN.
Always back off the tracks if possible. This is true even if you hit the gate and dent your car.
FINALLY: Think about how this train accident could apply to hazards at your facility.
Are people at risk of having to make split-second decisions under stress?
If they do, or if it is possible, a serious accident could be just around the corner.
Try to remove the hazard if possible.
How could have the hazard been removed in this case?
An overpass or underpass for cars is one way.
Other ideas? Leave them below as comments.