Author Archives: Mark Paradies
Automation dependency is an interesting topic. Here’s what a recent CALLBACK from the Aviation Safety Reporting System had to say about the topic…
Monday Accident & Lessons Learned: Aviation Safety Reporting System CALLBACK Notice About Ramp SafetyPosted: October 17th, 2016 in Accidents, Current Events, Investigations
Here’s the start of the report …
This month CALLBACK features reports taken from a cross-section of ramp experiences. These excerpts illustrate a variety of ramp hazards that can be present. They describe the incidents that resulted and applaud the “saves” made by the Flight Crews and Ground Personnel involved.
For the complete report, see:
Summary from the UK Rail Accident Investigation Branch …
At 18:12 hrs on Thursday 16 June 2016, a two-car diesel multiple unit train, operated by Great Western Railway (GWR), was driven through open trap points immediately outside Paddington station and derailed. It struck an overhead line equipment (OLE) mast, damaging it severely and causing part of the structure supported by the mast to drop to a position where it was blocking the lines. There were no passengers on the train, and the driver was unhurt. All the the lines at Paddington were closed for the rest of that evening, with some services affected until Sunday 19 June.
For causes and lessons learned, see: https://www.gov.uk/government/publications/paddington-safety-digest/derailment-at-paddington-16-june-2016
Monda Accident & Lessons Learned: US CSB Report on 2014 Freedom Industries Contamination of Charleston, West Virginia Drinking WaterPosted: October 3rd, 2016 in Accidents, Current Events, Investigations
Here is the press release from the US Chemical Safety Board …
CSB Releases Final Report into 2014 Freedom Industries Mass Contamination of Charleston, West Virginia Drinking Water; Final Report notes Shortcomings in Communicating Risks to Public, and Lack of Chemical Tank Maintenance Requirements Report Includes Lessons Learned and Safety Recommendations to Prevent a Similar Incident from Occurring
September 28, 2016, Charleston, WV, — The CSB’s final report into the massive release of chemicals into this valley’s primary source of drinking water in 2014 concludes Freedom Industries failed to inspect or repair corroding tanks, and that as hazardous chemicals flowed into the Elk River, the water company and local authorities were unable to effectively communicate the looming risks to hundreds of thousands of affected residents, who were left without clean water for drinking, cooking and bathing.
On the morning of January 9, 2014, an estimated 10,000 gallons of Crude Methylcyclohexanemethanol (MCHM) mixed with propylene glycol phenyl ethers (PPH Stripped) were released into the Elk River when a 46,000-gallon storage tank located at the Freedom Industries site in Charleston, WV, failed. As the chemical entered the river it flowed towards West Virginia American Water’s intake, which was located approximately 1.5 miles downstream from the Freedom site.
The CSB’s investigation found that Freedom’s inability to immediately provide information about the chemical characteristics and quantity of spilled chemicals resulted in significant delays in the issuance of the “Do Not Use Order” and informing the public about the drinking water contamination. For example, Freedom’s initially reported release quantity was 1,000 gallons of Crude MCHM. Over the following days and weeks, the release quantity increased to 10,000 gallons. Also, the presence of PPH in the released chemical was not made public until 13 days after the initial leak was discovered.
The CSB’s investigation found that no comprehensive aboveground storage tank law existed in West Virginia at the time of the release, and while there were regulations covering industrial facilities that required Freedom to have secondary containment, Freedom ultimately failed to maintain adequate pollution controls and secondary containment as required.
CSB Chairperson Vanessa Allen Sutherland said, “Future incidents can be prevented with proper communication and coordination. Business owners, state regulators and other government officials and public utilities must work together in order to ensure the safety of their residents. The CSB’s investigation found fundamental flaws in the maintenance of the tanks involved, and deficiencies in how the nearby population was told about the risks associated with the chemical release.”
An extensive technical analysis conducted by the CSB found that the MCHM tanks were not internally inspected for at least 10 years before the January 2014 incident. However, the CSB report notes, since the incident there have been a number of reforms including passage of the state’s Aboveground Storage Tank Act. Among other requirements, the new regulations would have required the tanks at freedom to be surrounded by an adequate secondary containment structure, and require proper maintenance and corrosion prevention, including internal inspections and a certification process.
The CSB’s investigation determined that nationwide water providers have likely not developed programs to determine the location of potential chemical contamination sources, nor plans to respond to incidents such as the one in Charleston, WV.
Supervisory Investigator Johnnie Banks said, “The public deserves and must demand clean, safe drinking water. We want water systems throughout the country to study the valuable lessons learned from our report and act accordingly. We make specific recommendations to a national association to communicate these findings and lessons.”
TapRooT® Users … What do you do when you think there may be a problem with a procedure that contributed to a Causal Factor that led to an Incident?
Here’s a tip from the soon to be published book: TapRooT® Root Cause Analysis for Major Investigations.
To investigate problems in the Procedures Basic Cause Category:
- Get an unused copy of the procedure.
- Get the completed, signed-off or checked-off procedure (if sign-off/check-off is required).
- Get any reference material/documentation.
- Was procedure used?
- Was it signed-off properly?
- Verify technical accuracy of the procedure (table-top review).
- Verify usability of the procedure by performing a field walk-through. (Consider performing a Critical Human Action Profile, Appendix F, and reviewing potential human factors problems at the same time.)
- If problems are found, consider looking for generic causes in the procedure writing and review system.
That’s the start of the guidance provided in the book that will be published in November. Watch for our notice about the release and get your copy for guidance investigating all of the Basic Cause Categories on the back side of the TapRooT® Root Cause Tree®.
My favorite procedure related story was and investigation where the team doing the investigation said that the person who was injured was using a procedure. I asked to see it. They said:
“You want to see the procedure?“
I said “Yes.”
They sent someone off to get it.
They came back with a brown paper grocery bag.
They handed it to me.
I said, “What’s this?”
They said, “the procedure.”
I looked in the bag. There was nothing inside.
They said, “No look on the outside of the bag.”
There were hand written notes on the outside of the bag. Mainly equipment part numbers. That was …
ALWAYS ask for a procedure when someone says that a procedure was used. You might get a good laugh too!
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.’”