Author Archives: Mark Paradies
Develop success from failures.
Discouragement and failure are two of the surest stepping stones to success. ~ Dale Carnegie
UK Rail Accident Investigation Branch investigates electrical arcing and fire on a Metro train and parting of the overhead line at Walkergate station, Newcastle upon Tyne, on 11 August 2014Posted: August 29th, 2014 in Accidents, Current Events, Investigations, Pictures
Here’s the press release …
Electrical arcing and fire on a Metro train and parting of the overhead line
at Walkergate station, Newcastle upon Tyne, on 11 August 2014
RAIB is investigating an accident which occurred on the Tyne and Wear Metro system at Walkergate station on Monday 11 August 2014.
At 18:56 hrs a two-car Metro train, travelling from South Shields to St James, arrived at Walkergate station. While standing in the station an electrical fault occurred to a line breaker mounted on the underside of the train, which produced some smoke. It also caused the circuit breakers at the sub-stations supplying the train with electricity, via the overhead line, to trip (open). About one minute later power was restored to the train. There followed a brief fire in the area of the initial electrical fault and further smoke. Shortly afterwards, the overhead line above the train parted and the flailing ends of the wire fell on the train roof and one then fell on to the platform, producing significant arcing and sparks for around 14 seconds. Fortunately, there was no-one on the platform at the time. However, there were at least 30 passengers on the train who self-evacuated on to the platform using the train doors’ emergency release handles. The fire service attended but the fire was no longer burning. No-one was reported to be injured in the accident and there was no significant damage to the interior of the train.
Image courtesy of Tyne and Wear Metro
RAIB’s investigation will consider the sequence of events and factors that led to the accident, and identify any safety lessons. In particular, it will examine:
- the reasons for the electrical fault;
- the response of the staff involved, including the driver and controllers;
- the adequacy of the electrical protection arrangements; and
- actions taken since a previous accident of a similar type that occurred at South Gosforth in January 2013 (RAIB report 18/2013).
RAIB’s investigation is independent of any investigations by the safety authority. RAIB will publish its findings at the conclusion of the investigation. The report will be available on the RAIB’s website.
You can subscribe to automated emails notifying you when the RAIB publishes its report and bulletins.
RAIB would like to hear from any passengers who were on the train. Any information provided to assist our safety investigation will be treated in strict confidence. If you are able to help the RAIB please contact us by email on email@example.com or by telephoning 01332 253300
Compilation of aviation crashes … some fatal, some not.
FATALITY DURING CONFINED SPACE ENTRY
- Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube.
- After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased.
- A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness.
- On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.
What Went Wrong?
- Exposure to an oxygen-deficient atmosphere: The rope access team members (victim and co-worker) were unaware of the asphyxiation risk from the argon gas shielding.
- Gas test: There was no gas test done immediately prior to the confined space entry. The act of removing the upper foam sponge itself could have released (additional) argon, so any prior test would not be meaningful.
- Gas detectors: Portable gas detectors were carried, but inside a canvas bag. The co-worker did not hear any audible alarm from the gas detector when he descended into the space.
- Evacuation time: It took 20 minutes to bring the victim to the deck after communication failed.
Corrective Actions and Recommendations
- As a first step: assess whether the nature of the work absolutely justifies personnel entering the confined space.
- Before confined space entry:
- identify and communicate the risks to personnel carrying out the work
- define requirements, roles and responsibilities to control, monitor and supervise the work
- check gas presence; understand how the work itself may change the atmospheric conditions
- ensure adequate ventilation, lighting, means of communication and escape
- Ensure step by step work permits are issued and displayed for each work phase, together with specific job safety analyses
- During confined space entry:
- station a trained confined space attendant at the entrance to the space at all times
- ensure that communication and rescue equipment and resources are readily available
- carry and use portable/personal gas detectors throughout the activity
Review your yard confined space entry practice, keeping in mind the lessons learned from this incident.
safety alert number: 259
OGP Safety Alerts http://info.ogp.org.uk/safety/
The successful warrior is the average man, with laser-like focus. ~ Bruce Lee
A deadly pipeline gas explosion in San Bruno, California has the state government of California involved to investigate what the root cause was. It has been reported that the alleged local gas company, Pacific Gas and Electric Co., has been working with the California Public Utilities Commission in a corrupted relationship resulting in unfair and dishonest regulations. It was also reported that after pleading guilty, the grand jury accused them of 28 counts of safety violations. Mayor Jim Ruane has recognized this and ensured that there will be an independent monitor to investigate the company to restore the public’s confidence.
Additionally, more reports have indicated that PG&E was at fault for a similar incident in 2010 including a gas explosion and failure to comply with regulations. It is suspected that they also obstructed the National Transportation Safety Board by falsely denying that they ignore federal pipeline inspection requirements. Now current investigations are showing that PG&E played a large role in organizing an upcoming gas safety conference causing many to question the quality of the conference. Once revealed, protests caused cancellation of the conference and less confidence in the company.
PG&E describes this as a “tragic accident” and it is suspected that they are in denial in order to keep up the integrity of the business. They claim to be unsure if their employees are making bad judgments as opposed to blatant violations. Officials will continue to investigate as the trials also continue in hopes of an answer and compromise.
Just before starting the exercise …
Teams working on their incidents …
Instructions just prior to the presentations …
Teams presenting …
For more information about TapRooT® Root Cause Analysis Courses, see:
Don’t stand under a load (or nearly under a load)! Click this video link below to watch…
Monday Accident & Lessons Learned: OPG Safety Alert – Well Control Incident – Managing Gas Breakout in SOBMPosted: August 18th, 2014 in Accidents, Investigations
Safety Alert Number: 258
OGP Safety Alerts http://info.ogp.org.uk/safety
While drilling at a depth of 4747m, the well was shut-in due to an increase in returns with a total gain of 17bbls recorded. The well kill needed an increase in density from 1.40sg to 1.61sg to achieve a stable situation. With the well open the BHA was pumped out to the shoe and tripped 400m to pick up a BOP test tool to perform the post-kill BOP test.
The BOP and choke manifold test were performed as well as some rig maintenance. The BHA was then tripped into the hole and the last 2 stands were washed to bottom. Total pumps-off time without circulation was 44 hours.
Gas levels during the bottoms-up initially peaked at around 14% and then dropped steadily to around 5%. HPHT procedures were being followed and this operation required circulation through the choke for the last 1/3 of the bottoms up. This corresponds to taking returns through the choke after 162m3 is circulated.
After 124 cubic metres of the bottoms-up had been pumped the gas detector at the bell nipple was triggered. Simultaneously, mud started to be pushed up out of the hole, reaching a height of around 1 joint above the drill floor. The flow continued for around 30 seconds corresponding to a bubble of gas exiting the riser. The pumps and rotation were shut down, followed by closure of the diverter, annular and upper pipe rams. Approximately 2bbls of SBM were lost over-board through the diverter line. The flow stopped by itself after just a few seconds and casing pressure was recorded as zero. No-one was on the drill floor at the time and no movement, damage or displacement of equipment occurred.
After verifying that there was no flow (monitored on the stripping tank) the diverter was opened and 10 cubic metres of mud used to refill the riser, equal to a drop in height of 56m.
The riser was circulated to fresh mud with maximum gas levels recorded at 54%. This was followed by a full bottoms up through the choke.
A full muster of POB was conducted due to the gas alarms being triggered.
What Went Wrong?
Conclusion – An undetected influx was swabbed into the well during the BOP test which was then circulated up inadvertently though a non-closed system breaking out in the riser.
- Stroke counter was reset to zero after washing 3 stands to bottom (this resulted in 136 cubic metres of circulation not being accounted for in the bottoms up monitoring).
- Review of Monitoring While Drilling Annular Pressure memory logs identified several swabbing events identified – main event was when the BOP test tool was POOH from the wellhead – ESD as measured by APWD dropped to 1.59sg on 10 or 11 occasions.
- Swabbing was exacerbated by Kill Weight Mud not having sufficient margin above PP.
Corrective Actions and Recommendations:
- Take into account all washing to bottom for any circulation where bottoms up is to be via choke.
- Tool Pushers shall cross check the bottoms up calculation and joint agreement on reset of the stroke counter.
- All BHA tripping speeds to be modeled so that potential swabbing operations are identified and so that tripping speed limits can be specified.
- Verify, when possible, actual swabbing magnitude using PWD memory logs (ie after a trip out of the hole).
- Pumping out (even inside liner/casing) shall be considered in tight tolerance liner/drilling BHA. Modeling shall be used to underpin the decision.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.
The only place where success comes before work is in the dictionary. ~ Vidal Sassoon
Job Opening: Strategy & Root Cause Analysis Manager – Global Financial Business – Leeds, West Yorkshire, UKPosted: August 14th, 2014 in Job Postings
Every company I’ve worked with has an existing improvement program.
Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some still have a long ways to go, but have started their improvement process.
No matter where you are, one question that always seems to come up is …
“What should we improve next?“
The interesting answer to this question is that your plant is telling you if you are listening.
But before I talk about that, let’s look at several other ways to decide what to improve…
1. The Regulator Is Emphasizing This
Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.
2. Management Hot Topic
Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…
- A recent accident (at your facility or someone else’s).
- A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
- That the CEO has a new initiative.
You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.
3. Industry Initiative
Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.
All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.
So how should you decide what to improve next?
By listening to your plant/facility.
What does “listening to you plant” mean?
To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.
Reactively collecting signals comes from your accident, incident, near-miss investigation programs.
It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.
I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.
Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.
Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).
Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.
Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler - see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)
Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.
Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.
Hydrocarbon Process Reports: “Pemex Blast at Ciudad Madero Refinery Kills Four Workers, Injures More”Posted: August 12th, 2014 in Accidents, Current Events
An oil refinery in Ciudad Madero burst into flames earlier this week killing four workers. After evaluating the situation, officials determined that the refinery was under maintenance and not operating at the time of the fire. What caught fire? How did this happen? Reports indicated that this particular refinery, being the smallest of six in the company, may not have been producing it’s quota for daily production due to refining inefficiencies and infrastructure that went ignored for too long.
Fortunately, this accident forced the government to pass a law for private investments for the National Energy Industry. Consequently, they waited too long to invest in this maintenance and inefficiencies which lead to destruction.
Students are having a great time in Seattle learning how to apply TapRooT® Root Cause Analysis System to solve problems.
Here are a couple of pictures of Ameber Bickerton, one of our newest contract instructors, teaching…
Amber is from Calgary and has been involved in safety for 12 years. See her LinkedIn profile at:
Here’s the Executive Summary from the CDC Report:
The Centers for Disease Control and Prevention (CDC) conducted an internal review of an incident that involved an unintentional release of potentially viable anthrax within its Roybal Campus, in Atlanta, Georgia. On June 5, 2014, a laboratory scientist in the Bioterrorism Rapid Response and Advanced Technology (BRRAT) laboratory prepared extracts from a panel of eight bacterial select agents, including Bacillus anthracis (B. anthracis), under biosafety level (BSL) 3 containment conditions. These samples were being prepared for analysis using matrix-assisted laser desorption/ionization time-of-flight (MALDI- TOF) mass spectrometry, a technology that can be used for rapid bacterial species identification.
This protein extraction procedure was being evaluated as part of a preliminary assessment of whether MALDI-TOF mass spectrometry could provide a faster way to detect anthrax compared to conventional methods and could be utilized by emergency response laboratories. After chemical treatment for 10 minutes and extraction, the samples were checked for sterility by plating portions of them on bacterial growth media. When no growth was observed on sterility plates after 24 hours, the remaining samples, which had been held in the chemical solution for 24 hours, were moved to CDC BSL-2 laboratories. On June 13, 2014, a laboratory scientist in the BRRAT laboratory BSL-3 lab observed unexpected growth on the anthrax sterility plate. While the specimens plated on this plate had only been treated for 10 minutes as opposed to the 24 hours of treatment of specimens sent outside of the BSL-3 lab, this nonetheless indicated that the B. anthracis sample extract may not have been sterile when transferred to BSL-2 laboratories.
Why the Incident Happened
The overriding factor contributing to this incident was the lack of an approved, written study plan reviewed by senior staff or scientific leadership to ensure that the research design was appropriate and met all laboratory safety requirements. Several additional factors contributed to the incident:
Use of unapproved sterilization techniques
Transfer of material not confirmed to be inactive
Use of pathogenic B. anthracis when non-pathogenic strains would have been appropriate for
Inadequate knowledge of the peer-reviewed literature
Lack of a standard operating procedure or process on inactivation and transfer to cover all procedures done with select agents in the BRRAT laboratory. What Has CDC Done Since the Incident Occurred CDC’s initial response to the incident focused on ensuring that any potentially exposed staff were assessed and, if appropriate, provided preventive treatment to reduce the risk of illness if exposure had occurred. CDC also ceased operations of the BRRAT laboratory pending investigation, decontaminated potentially affected laboratory spaces, undertook research to refine understanding of potential exposures and optimize preventive treatment, and conducted a review of the event to identify key recommendations.
To evaluate potential risk, research studies were conducted at a CDC laboratory and at an external laboratory to evaluate the extent to which the chemical treatment used by the BRRAT laboratory inactivated B. anthracis. Two preparations were evaluated: vegetative cells and a high concentration of B. anthracis spores. Results indicated that this treatment was effective at inactivating vegetative cells of B. anthracis under the conditions tested. The treatment was also effective at inactivating a high percentage of, but not all B. anthracis spores from the concentrated spore preparation.
A moratorium is being put into effect on July 11, 2014, on any biological material leaving any CDC BSL-3 or BSL-4 laboratory in order to allow sufficient time to put adequate improvement measures in place.
Since the incident, CDC has put in place multiple steps to reduce the risk of a similar event happening in the future. Key recommendations will address the root causes of this incident and provide redundant safeguards across the agency, these include:
The BRRAT laboratory has been closed since June 16, 2014, and will remain closed as it relates to work with any select agent until certain specific actions are taken
Appropriate personnel action will be taken with respect to individuals who contributed to or were in a position to prevent this incident
Protocols for inactivation and transfer of virulent pathogens throughout CDC laboratories will be reviewed
CDC will establish a CDC-wide single point of accountability for laboratory safety
CDC will establish an external advisory committee to provide ongoing advice and direction for laboratory safety
CDC response to future internal incidents will be improved by rapid establishment of an incident command structure
Broader implications for the use of select agents, across the United States will be examined.
This was a serious event that should not have happened. Though it now appears that the risk to any individual was either non-existent or very small, the issues raised by this event are important. CDC has concrete actions underway now to change processes that allowed this to happen, and we will do everything possible to prevent a future occurrence such as this in any CDC laboratory, and to apply the lessons learned to other laboratories across the United States.
People often say that motivation doesn’t last.
Well, neither does bathing – that’s why we recommend it daily. ~ Zig Ziglar
Pictures from the Final Exercise at the Lake Tahoe 2-Day Incident Investigation and Root Cause Analysis CoursePosted: August 6th, 2014 in Courses, Pictures, TapRooT
Here are pictures of hard working teams using TapRooT® to find the root causes of incidents that they brought to the class…
Can you “picture” yourself using advanced root cause analysis (TapRooT®) to solve your companies toughest problems? If you haven’t been to a course yet, sign up now. See upcoming courses at: