Category: Accidents

Monday Accident & Lessons Learned: The US Chemical Safety Board Releases Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

January 26th, 2015 by

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CSB Releases Safety Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

Safety Bulletin Notes Five Key Lessons to Prevent Hydraulic Shock

January 15, 2014, East Rutherford, NJ – Today the U.S. Chemical Safety Board released a safety bulletin intended to inform industries that utilize anhydrous ammonia in bulk refrigeration operations on how to avoid a hazard referred to as hydraulic shock.  The safety lessons were derived from an investigation into a 2010 anhydrous ammonia release that occurred at Millard Refrigerated Services Inc., located in Theodore, 
Alabama.

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The accident occurred before 9:00 am on the morning of August 23, 2010. Two international ships were being loaded when the facility’s refrigeration system experienced “hydraulic shock” which is defined as a sudden, localized pressure surge in piping or equipment resulting from a rapid change in the velocity of a flowing liquid. The highest pressures often occur when vapor and liquid ammonia are present in a single line and are disturbed by a sudden change in volume.

This abnormal transient condition results in a sharp pressure rise with the potential to cause catastrophic failure of piping, valves, and other components – often prior to a hydraulic shock incident there is an audible “hammering” in refrigeration piping. The incident at Millard caused a roof-mounted 12-inch suction pipe to catastrophically fail, resulting in the release of more than 32,000 pounds of anhydrous ammonia.
The release led to one Millard employee sustaining injuries when he fell while attempting to escape from a crane was after it became engulfed in the traveling ammonia cloud.  The large cloud traveled a quarter mile from the facility south toward an area where 800 contractors were working outdoors at a clean-up site for the Deepwater Horizon oil spill. A total of 152 offsite workers and ship crew members reported symptomatic illnesses from ammonia exposure. Thirty two of the offsite workers required hospitalization, four of them in an intensive care unit.

Chairperson Rafael Moure-Eraso said, “The CSB believes that if companies in the ammonia refrigeration industry follow the key lessons from its investigation into the accident at Millard Refrigeration Services, dangerous hydraulic shock events can be avoided – preventing injuries, environmental damage, and potential fatalities.”

Entitled, “Key Lessons for Preventing Hydraulic Shock in Industrial Refrigeration Systems” the bulletin describes that on the day before the incident, on August 22, 2010, the Millard facility experienced a loss of power that lasted over seven hours. During that time the refrigeration system was shut down. The next day the system regained power and was up and running, though operators reported some problems.  While doing some troubleshooting an operator cleared alarms in the control system, which reset the refrigeration cycle on a group of freezer evaporators that were in the process of defrosting. The control system reset caused the freezer evaporator to switch directly from a step in the defrost cycle into refrigeration mode while the evaporator coil still contained hot, high-pressure gas.

The reset triggered a valve to open and low temperature liquid ammonia was fed back into all four evaporator coils before removing the hot ammonia gas. This resulted in both hot, high-pressure gas and extremely low temperature liquid ammonia to be present in the coils and associated piping at the same time. This caused the hot high-pressure ammonia gas to rapidly condense into a liquid.  Because liquid ammonia takes up less volume than ammonia gas – a vacuum was created where the gas had been.  The void sent a wave of liquid ammonia through the piping – causing the “hydraulic shock.”

The pressure surge ruptured the evaporator piping manifold inside one of the freezers and its associated 12-inch piping on the roof of the facility. An estimated 32,100 pounds of ammonia were released into the surrounding environment.

Investigator Lucy Tyler said, “The CSB notes that one key lesson is to avoid the manual interruption of evaporators in defrost and ensure control systems are equipped with password protection to ensure only trained and authorized personnel have the authority to manually override systems.“

The CSB also found that the evaporators at the Millard facility were designed so that one set of valves controlled four separate evaporator coils. As a result, the contents of all four coils connected to that valve group were involved in the hydraulic shock event – leading to a larger, more hazardous pressure surge.

As a result, the CSB notes that when designing ammonia refrigeration systems each evaporator coil should be controlled by a separate set of valves.

The CSB found that immediately after discovering the ammonia release, a decision was made to isolate the source of the leak while the refrigeration system was still operating instead of initiating an emergency shutdown. Shutting down the refrigeration system may have resulted in a smaller release, since all other ammonia-containing equipment associated with the failed rooftop piping continued to operate.

A final key lesson from the CSB’s investigation is that an emergency shutdown should be activated in the event of an ammonia release if a leak cannot be promptly isolated and controlled. Doing so can greatly reduce the amount of ammonia released during an accident.

Even in Humor, You can learn about Root Cause and People from Dr. Deming

January 22nd, 2015 by

Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…

… your own actions.

… your understanding of other peoples actions.

… your past corrective or preventative actions.

Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.

To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance  excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.

To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit

If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw

Monday Accident & Lessons Learned: UK RAIB Report – Near-miss involving construction workers at Heathrow Tunnel Junction, west London, 28 December 2014

January 19th, 2015 by

UK Rail Accident Investigation Branch Press Release…

The UK RAIB is investigating an incident in which a train almost struck two construction workers, and collided with a small trolley, on the Up Airport line between Heathrow Airport Tunnel and the Stockley Flyover.

NewImageYellow engineering trolley underneath the train after the collision (image courtesy of Carillion)

The incident occurred at about 10:05 hrs on Sunday 28 December 2014 and involved train 1Y40, the 09:48 hrs service from London Heathrow Terminal 5 to London Paddington. The track workers jumped clear just before the approaching train struck a small engineering trolley that they had been placing on the line. The train, formed by a Class 332 electric multiple unit, was travelling at approximately 36 mph (58 km/h) when it struck the trolley. 

The two track workers were among a large number of people carrying out construction work on the approach to a new bridge that had been recently constructed adjacent to the existing Stockley Flyover. This new structure, which carries a new railway track over the mainline from London Paddington to Reading, was built as part of the Crossrail surface works being undertaken by Network Rail.

To enable this work to take place, parts of the operational railway in and around the construction site had been closed for varying periods during the few days before the incident. The two construction workers were unaware that the Up Airport line had returned to operational use a few hours before they started to place the trolley onto this line. They formed part of an eight person workgroup which included a Controller of Site Safety (COSS). The COSS and other group members were not with the two track workers at the time of the incident. The presence of temporary fencing, intended to provide a barrier between construction activities and the operational railway, did not prevent the two track workers accessing the open line.

Network Rail owned the infrastructure at the site of the accident and had employed Carillion Construction as the Principal Contractor for the construction works. The two track workers and the COSS were all employed by sub-contractors.

RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules are applied on large construction sites adjacent to the operational railway. It will also seek to understand the actions of the people involved, and factors that may have influenced their behaviour.

RAIB will also consider whether there is any overlap between this incident and the factors which resulted in an irregular dangerous occurrence at the same construction site on the previous day. This occurrence involved a gang of railway workers who walked along a line that was open to traffic, and without any form of protection, until other construction workers warned them that the line was open to traffic.

The RAIB investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

- – – – – 

What can we learn BEFORE the investigation is complete?

First, this “near-miss” was actually a hit.

In this case it was called a near-miss because no one was injured. However, the train and trolley were damaged and work was delayed. For operations, maintenance, and construction, this was an incident. In other words, it was a safety near-miss but it was an operation, maintenance, and construction hit.

Many incidents that don’t have immediate safety consequences do have immediate cost, productivity, and reliability consequences that are worthy of an investigation. And in this case, the operations incident also had potential to become a fatality. This even more reason to perform a thorough root cause analysis.

Remembering an Accident: Boston Molasses Disaster

January 15th, 2015 by

On January 15, 1919, the North end of Boston was one of the most congested neighborhoods in the entire world. There were about 40,000 people in a one mile square of geographic space. When a large molasses tank burst and a huge wave of molasses rushed through the streets at approximately 35 mph, 150 people were injured and 21 were killed.

Theories ensued after the disaster. Some said the tanks were intentionally set to explode by anarchists, and others believed the fermenting of the molasses led to the explosion. In the end, it was discovered the person who oversaw the construction of the tank wasn’t an engineer or an architect. He couldn’t even read a blueprint!

According to folklore, residents claim that on a hot summer day, the area still smells of molasses.

What is your blueprint for investigating incidents and finding and fixing root causes, and can everyone read it? Our 2-day TapRooT® Course provides all the essentials and is designed for everyone, from beginner to expert. (Learn more.)

UK RAIB Press Release: Investigating tram derailment near Mitcham Junction, London, 29 December 2014

January 12th, 2015 by

At about 23:55 hrs on Monday 29 December 2014, a tram travelling from New Addington to Wimbledon on the Croydon Tramlink system became derailed shortly after leaving the tram stop at Mitcham Junction, while travelling at about 11 km/h (7 mph). There were about 20 passengers, plus the driver, on board the tram, and no-one was hurt. There was some minor damage to the tram.

To the west of Mitcham Junction tram stop, the single tram line becomes two lines at a set of spring-operated points. On leaving the tram stop, the tram driver noticed that an indicator, which shows the position of these points, was indicating that the points were not correctly set. He stopped the tram before reaching the points, and after speaking to the tramway control room by radio, he left the tram and used an operating lever to manually move the points until he observed that the indicator was showing that they were correctly set. He then drove the tram slowly over the points, but the centre bogie and one wheelset of the trailing bogie became derailed.

 

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Image showing derailed tram near Mitcham Junction

RAIB’s investigation will focus on the points mechanism and the way that it behaves in degraded operating conditions.

RAIB’s investigation is independent of any investigation by the railway industry or the Office of Rail Regulation.

The UK RAIB will publish their findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available at http://www.raib.gov.uk.

Monday Accident & Lessons Learned: UK RAIB Investigations of an unauthorised entry of a train onto a single line at Greenford

January 12th, 2015 by

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Unauthorised entry of a train onto a single line at Greenford

20 March 2014

 From the UK Rail Accident Investigation Branch:

At around 11:55 hrs on Thursday 20 March 2014, the 11:36 hrs passenger train from London Paddington to West Ruislip, operated by Chiltern Railways, passed two consecutive signals at danger near Greenford, west London. It was stopped when a signaller sent an emergency radio message to the driver. Although no-one was hurt in the incident, the unauthorised entry of a train onto a single line creates the potential for a serious collision.

A freight train had passed the junction at Greenford shortly before the passenger train was due. Because the freight train was still occupying the line between Greenford and South Ruislip, the signaller at Greenford kept the signal at the junction at danger. The passenger train, travelling at about 20 mph (32 km/h), passed this signal and the next one, 142 yards (130 metres) further on, which was also at danger. It passed over the junction and onto the single-track section towards South Ruislip, which was still occupied by the freight train. The train had travelled about one mile (1.6 km) beyond Greenford by the time that the driver received the emergency radio message.

The investigation found that the driver of the passenger train did not react to the two signals at danger, for reasons which are not certain. It is possible that he had formed the impression that the train had been given clear signals through Greenford, because of his interpretation of the meaning of the signal preceding those that he passed at danger, and he had not been stopped by signals at Greenford in the recent past.

The Train Protection and Warning System (TPWS) was fitted to the train and to both the signals, but it did not intervene to apply the brakes of the train, as it was intended to do. This was because the on-train TPWS equipment had self-isolated when the driver prepared the train for departure from Paddington. The isolation of the equipment was indicated by a flashing light in the cab, but the driver still drove the train.

Although the signaller at Greenford wished to stop the train by sending an emergency call on the GSM-R radio system, he did not attempt to do so because the information presented by the radio equipment in the signal box suggested to him that any message he sent would not reach the train. Instead, he contacted Marylebone signal box, which was able to send a message to the train.

RAIB has made three recommendations. One is addressed to Chiltern Railways, and covers the need for a review of the company’s driver management processes. The other two, addressed to Network Rail, cover the configuration of the GSM-R radio system as it affects the ability of signallers to directly contact trains that are within their areas of control, and the training given to signallers in the use of the GSM-R system. RAIB has also identified two learning points: one for signallers, relating to the use of delayed clearance of signals to warn train drivers of the state of the line ahead, and the other for train operating companies, relating to the upgrading of on-train TPWS equipment.

To see the complete report and all recommendations, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/141222_R292014_Greenford.pdf

Monday Accident & Lessons Learned: EJECTION OF WORKSTRING DURING BULL-HEADING OPERATIONS

January 5th, 2015 by

IOGP Safety Alert # 264 – EJECTION OF WORKSTRING DURING BULL-HEADING OPERATIONS

WHAT HAPPENED

The rig was involved in well preparation for the forthcoming execution of a gravel pack operation. After earlier setting a Gravel Pack packer on the well, later it became impossible to circulate in direct (possibly plugged ports in string): only possible to circulate in reverse. This made Gravel Pack operation impossible. Decision was made to POOH wet to surface.

The ongoing operation at time of event was POOH with 4 ½ PH6 tubing work string – with Setting Tool and 2 3/8” tubing tail pipe – to inspect Service Tool for indications of inability to circulate.

  • Fluid in well was 1.07sg Brine.
  • Tubing string was being pulled wet.Losses observed at approximately 1.2m3/hr.
  • Tubing work string was 220m from surface at time of incident. Fluid returns were bubbling at the bell nipple (swabbing while pooh workstring-no gain yet). Crew estimated off-bottom kick situation. Closed annular to bullhead the well to push any gas influx into formation.

Operations details after calling town (drilling superintendent):

  1. Pump 5m3 High Viscosity pill bullheading same at a flow rate not exceeding 800 lpm and at a stand pipe pressure not exceeding 1400 psi.
  2. Pumps were stopped and lined up with active pit, then approximately 7m3 1.07 sg brine was bullheaded. First, the flow rate was maintained around 400 lpm and stand pipe pressure remained below 1500 psi.
  3. Increased gradually the flow rate (to 1100 lpm) and the stand pipe pressure increased regularly up to 2300 psi.
  4. The Tool pusher called the driller to ask him why he was pumping at a stand pipe pressure higher than 2000 psi – the driller replied the Company Man told him 2500 psi was the limit.
  5. 220m+/- of 4 ½” tubing and 2 7/8” wash pipes along with the Service Tool Assembly were ejected from the well. Strong noise and vibrations were noted by several witnesses while the pipe was being ejected.
  6. The pipe hit the Elevator and was deviated outside the mast, hitting the monkey board and went up over the Monkey Board and out through the derrick space.
  7. The projectile started to drop down in an X-shape. It eventually fell on the ground, missing the company man’s and the service companies’ cabins by less than 1 meter,
  8. The Rig HSE/Meeting Room Cabin was destroyed.
  9. Damage was made to the concrete block fence wall inside the cluster situated just behind the Company Man Office.
  10. From Company Man Office to Well Center the Tubing string landing point was measured at 60m.
  11. The elapsed time of the entire event according to witnesses, took less than 30 sec (faster than a man running down the stairs from the rig floor).
  12. Driller remained on Rig Floor during ejection. He immediately stopped the rig pumps then went to the BOP panel. He did not close the pipe rams as he had little hope this would be of any help. He decided to close the Blind Shear Rams. Then he left the rig floor and went to the main muster point.
  13. The Company Man and Tool Pusher both ran to the remote control panel. The Tool Pusher arrived first and activated the Blind Shear Rams, then realized that the driller had already done it.
  14. All personnel proceeded to the Muster Points.
Immediately after the incident…
  1. The Head Count was 100% – no one had been injured.
  2. The Driller went back to the Rig Floor and resumed the Bullheading Operation against the Blind Shear Rams.
  3. The day after the incident (Saturday 9 November), piece of tubular was found at 105m from the well outside the cluster.

WHAT WENT WRONG?

  • Gravel Pack string was plugged creating inability to circulate direct and thus to execute the Gravel Pack program.
  • According to witnesses, squeeze pressure range was given by Company man to the Driller as 2000 – 2500 psi.
  • No formal risk assessment performed for Bull Heading operation for this Work-over operation.
  • No recalculation was done for this emergency non-routine Bull Heading well control operation either on site or at base by Company and Drilling Contractor.
  • Nobody on site neither in office recognized Well Control situation as critical.
  • Top drive was disconnected and drill pipe closed on TIW valve. 220m assembly closed on annular.
  • The Tripping Fast Shut In Procedure does not mention pipe rams closure.
  • There is no Bull Heading procedure available.

CORRECTIVE ACTIONS & RECOMMENDATIONS

  • Lack of risk awareness concerning contained Pressure hazards. Upward push on the assembly while bullheading not anticipated despite gravel pack operations experience on site.
  • No Job risk Analysis performed prior bullheading. No consequential analysis.
  • Bullheading operation considered as routine.
  • Due to underestimation of the criticality of the operation ongoing (Bull Heading) by all (site and base): Identify all critical operations/tasks including Bull Heading in drilling operations.
  • Prioritize Well Control and Critical Operations by base team at every point of Program execution.
  • Dedicated ‘critical activities’ section to be added in all operational programs (drilling, Workover, rig less) describing how to recognize a well control situation and which procedure to be applied. Each procedure completed by a Risk Assessment made available to the work crew which they can use as a basis for further review.
  • Training plan to be immediately set up for full IWCF compliance of the Completion and Well Intervention personnel.

Safety Alert Number: 264
IOGP Safety Alerts http://safetyzone.iogp.org/

DISCLAIMER

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP 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.

What does a bad day look like?

January 1st, 2015 by

By comparison, is your day really that bad?

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Keeping TapRooT® Investigations Out of Court

December 18th, 2014 by

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We would all agree that performing accident investigations and investigations of quality issues to prevent repeat accidents is a good idea. But some may be reluctant to perform investigations because of the legal liability they think the investigation report may represent.

Of course, they are at least partially right. Frequently, significant accidents result in lawsuits. And if your investigators aren’t careful, they may put poorly chosen words or even un-true statements in their investigation reports. Thus, company counsel or outside counsel may prefer that the actual accident investigation reports be excluded from evidence in a court proceeding to reduce the liability that an accident investigation report may represent.

Excluding a report performed after an accident to look for ways to prevent future accidents is a protected activity under federal law. FRE Rule 407, Subsequent Remedial Measures, states:

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

How can you help preserve your right to exclude your report from discovery and use at trial? Outside counsel for one of our clients has suggested that all TapRooT® users add one of the following preambles or appendices to every TapRooT® Investigation. We thought this sounded like a good idea, so we are passing along the following preambles or appendices for you to consider when writing your investigations….

For safety investigations at a company, the preamble suggested by the attorneys is as follows:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

COMPANY TapRooT® Investigation Preamble

In order improve COMPANY’s overall safety performance and to prevent or significantly reduce the likelihood of the same or a similar work-related incident/injury/illness (“incident”) from reoccurring, COMPANY conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant performance problems and/or equipment failures that may arise from time to time during its operations. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow COMPANY to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within COMPANY’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes COMPANY management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of COMPANY’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures COMPANY may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging COMPANY to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage COMPANY to take, or at least not discourage them from taking steps in furtherance of added safety.

Incidents, injuries and illness may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors and/or vendors. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT® inasmuch as COMPANY management has no control over errors made by these vendors except expected conformance with their duties owed to COMPANY.

Even though COMPANY makes every effort to determine what happened during an incident and to minimize future incidents through the COMPANY investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT® determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside COMPANY retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

For quality investigations subsequent to an issue with a product, the following preamble/appendix is suggested:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

VENDOR TapRooT® Investigation Preamble

In order improve VENDOR’s overall quality performance and to prevent or significantly reduce the likelihood of the same or a similar quality issues from reoccurring which may lead to work-related incident/injury/illness or client related issues (“incident”), VENDOR conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant quality and/or performance problems and/or equipment failures that may arise from time to time during the use or manufacture of its products. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow VENDOR to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within VENDOR’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes VENDOR management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of VENDOR’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures VENDOR may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging VENDOR to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage VENDOR to take, or at least not discourage them from taking steps in furtherance of added safety and quality.

Incidents, injuries, illness, and quality issues may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors, vendors, and/or clients. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT inasmuch as VENDOR management has no control over errors made by these third parties except expected conformance with their duties owed to VENDOR.

Even though VENDOR makes every effort to determine what happened during an incident and to minimize future incidents through the VENDOR investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside VENDOR retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

Of course, before adopting any advice to reduce potential liabilities in future courtroom actions, you should consult your own in-house or outside counsel. They may modify the forms provided above or have other wording that they prefer.

So consider the advice provided above and get your own protective wording added to all your standard reports. We are looking at ways to add this to the TapRooT® Software and we’ll let you know when we’ve figured out a way to do it. Until then, we suggest manually adding the wording to your official final reports.

Monday Accident & Lessons Learned: OPG Safety Alert 262 – Shallow Gas Leads to Well Control Incident

December 15th, 2014 by

SHALLOW GAS LEADS TO WELL CONTROL INCIDENT

  • The well is located in a well-known, shallow gas prone area.
  • Deep gas wells with high pressurized layers.
  • Crowded platforms with wells anti-collision complex management.
  • SIMOPS including construction and well intervention
  • After each incident, procedures for shallow section drilling were enhanced.

The sequence of events were:

  • 0:00 – Skid rig on well. Batch drilled 12 ¼’’ hole section + 9 5/8’’ intermediate casing
  • 08:30 – Cleaned out CP 24’’ with 17 ½’’ BHA to 131m
  • 16:30 – Drilled 12 ¼’’ hole to 286m with 1.15+ SG mud. Heavy losses (67 m3/h)
  • 20:20 – Homogenize mud to 1.12 SG
  • 20:33 – Resume drilling to 296m. Heavy losses (70 m3/h)21:10 – Spot 10m3 LCM pill. POOH wet.
  • 22:20 – Well swabbing and started to flow. Closed diverter. Started pumping 1.12 SG mud at high flow rate.
  • 23:04 – Pumped kill mud 1.50 SG, followed by sea water at high rate.
  • 00:30 – Flow outside CP. Well out of control. Full rig evacuation.

What Went Wrong?

The cause of the incident could be listed as follows:

1. Supervision on rig

  • POOH wet (no pump out)
  • Continue with pulling operations, despite swabbing, until well kicked in. Shallow gas procedure not followed

2. Mud weight

  • Inconsistency in MW control and reporting
  • Pack off at 291m interpreted as a (new) loss zone

3. Documentation

  • No comprehensive instructions concerning total loss situation

Corrective Actions and Recommendations

  • Maintain a continuous awareness on shallow gas hazard, even when the shallow gas section has already been penetrated in other wells. This aims at avoiding routine approach hence complacency.
  • The standard drilling Instructions should be enriched and reinforced with lessons learnt e.g. Management of Change, the required concentration of KCl for the top hole section, the threshold of heavy losses, hole cleaning procedure for the top hole, responsibility assignment for key personnel, ‘Ready to drill’ checklist.

Disclaimer

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.

Safety Alert Number: 262
OGP Safety Alerts http://info.ogp.org.uk/safety/

Monday Accident & Lessons Learned: Fatal Auto Accidents

December 8th, 2014 by

REDWRECK

If a fatality happens at a business, OSHA descends to investigate. The company must come up with corrective actions that will make sure the accident never happens again.

When a traffic accident happens, police investigate. A ticket is given to the party at fault. And a lawsuit is probably filed. But nobody ever talks about making sure the accident never happens again. Root causes aren’t mentioned unless it is excessive speed, drunk driving, or distracted driving … and are those really root causes?

What is the difference?

Why are fatal traffic accidents seemingly acceptable?

Could we learn from fatal car accidents and make sure they never happen again?

What would have to change to make this learning possible?

Could we save 10,000, 20,000, or 30,000 lives per year here in the US?

Remembering An Accident: The Halifax Explosion

December 6th, 2014 by

On December 6, 1917, a ship traveling to France that carried approximately 9,000 tons of wartime explosives caught fire after a collision in the Halifax Harbour. The fire quickly ignited the explosives. Approximately 1,800 were killed and 9,000 were injured by the fire, debris and collapsed buildings.

Here is an article on History.com: http://www.history.com/this-day-in-history/the-great-halifax-explosion

And following is a video of the footage after the explosion, showing devastation and relief effort. 

We’ve all read the headlines about catastrophic events. Don’t let an accident of this magnitude devastate your city.  Learn root cause analysis techniques to investigate near-misses, and take proactive steps to avoid a major disaster. (Click here to find out more about TapRooT® Root Cause Analysis Training.)

Monday Accident & Lessons Learned: Don’t Wear a Scarf!

December 1st, 2014 by

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A woman, trying to board a London Underground train, stopped when the doors of the train shut. But her scarf swung forward and was trapped in the doors.

As the train pulled forward, she was dragged along the platform. A member of the staff tried to catch hold of her and help, but this caused her to fall to the platform.

The scarf was eventually pulled from around her neck and into the tunnel, still trapped in the train door.

The woman suffered injuries to her neck and back but was lucky that she wasn’t dragged into the tunnel and onto the tracks.

What are the lessons learned? See the UK RAIB report.

Or just stop wearing scarfs!

Monday Accident & Lessons Learned: Fatality Near-Miss Because of Corrective Actions NI or Corrective Action NYI

November 24th, 2014 by

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A recent rail accident report by the UK Rail Accident Investigation Branch described a facility maintenance failure that could have caused a fatality. Here’s a brief excerpt from the report:

 “At about 16:00 hours on Thursday 1 August 2013, concrete cladding fell from the bridge spanning Denmark Hill station, London, and most of the debris landed on platform 1. … The concrete cladding had been added to the bridge structure in about 1910 and fell because of gradual deterioration of the fixing arrangements. Deterioration of the cladding fixing arrangements had been reported to Network Rail over a period of at least four years but the resulting actions taken by Network Rail and its works contractor were inadequate.”

Under the Management System portion of the TapRooT® Root Cause Tree® you will find Corrective Actions Need Improvement and Corrective Actions Not Yet Implemented root causes under the under the Corrective Action near root cause. We used to abbreviate these CANYI and CALTA in the old days (Corrective Action Not Yet Implemented and Corrective Actions Less Than Adequate).

The TapRooT® theory of management requires that management implements effective corrective action once they are aware of a problem. The corrective action must not only be effective, but also it must be implemented in a timely manner (commensurate with the risk the problem presents). 

In this case, I would probably lean toward the Corrective Action Not Yet Implemented root cause, although, the Corrective Action Needs Improvement root cause might apply to the previous inadequate temporary fixes. 

What can you learn from this?

Does your management support effective timely corrective actions? Or do you have a large backlog of ineffective fixes? Maybe you need corrective action improvements!

Remembering An Accident: San Juanico Disaster

November 19th, 2014 by

On November 19, 1984, a series of explosions caused one of the deadliest industrial accidents in the history of the world.  The explosions occurred at a storage and distribution facility for liquified petroleum gas belonging to Petroleos Mexicanos. It is believed that the explosion started with a gas leak which caused a plume that grew large enough to be transported by the wind and reach a flare pit where it ignited.

The explosions and fires demolished most of the town of San Juan Ixhuatepec, and it is estimated that up to 600 people died and 5,000 – 7,000 people suffered severe injuries. The fire created such an inferno that most corpses were reduced to ashes, making it hard to determine who perished.

SanJuanico20

Learn more about the disaster.

When something catastrophic happens, companies often discover a series of errors and process flaws that were present all along. Advanced root cause analysis skills can help you uncover these error and flaws.  Visit our training page to find a course near you:

http://www.taproot.com/courses

 

 

Monday Accident & Lessons Learned: UK RAIB Report – Freight train derailment near Gloucester

November 10th, 2014 by

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Here’s the summary of the report:

At about 20:15 hrs on 15 October 2013, a freight train operated by Direct Rail Services, which was carrying containers, derailed about 4 miles (6.4 km) south west of Gloucester station on the railway line from Newport via Lydney. It was travelling at 69 mph (111 km/h) when the rear wheelset of the last wagon in the train derailed on track with regularly spaced dips in both rails, a phenomenon known as cyclic top. The train continued to Gloucester station where it was stopped by the signaller, who had become aware of a possible problem with the train through damage to the signalling system. By the time the train stopped, the rear wagon was severely damaged, the empty container it was carrying had fallen off, and there was damage to four miles of track, signalling cables, four level crossings and two bridges.

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The immediate cause of the accident was a cyclic top track defect which caused a wagon that was susceptible to this type of track defect to derail. The dips in the track had formed due to water flowing underneath the track and although the local Network Rail track maintenance team had identified the cyclic top track defect, the repairs it carried out were ineffective. The severity of the dips required immediate action by Network Rail, including the imposition of a speed restriction for the trains passing over it, but no such restriction had been put in place. Speed restrictions had repeatedly been imposed since December 2011 but were removed each time repair work was completed; on each occasion, such work subsequently proved to be ineffective.

The type of wagon that derailed was found to be susceptible to wheel unloading when responding to these dips in the track, especially when loaded with the type of empty container it was carrying. This susceptibility was not identified when the wagon was tested or approved for use on Network Rail’s infrastructure.

The RAIB also observes: the local Network Rail track maintenance team had a shortfall in its manpower resources; and design guidance for the distance between the wheelsets on two-axle wagons could also be applied to the distance between the centres of the bogies on bogie wagons.

The RAIB has made seven recommendations. Four are directed to Network Rail and cover reviewing the drainage in the area where the train derailed, revising processes for managing emergency speed restrictions for cyclic top track defects, providing track maintenance staff with a way of measuring cyclic top after completing repairs, and investigating how cyclic top on steel sleeper track can be effectively repaired. Two are directed to RSSB and cover reviewing how a vehicle’s response to cyclic top is assessed and amending guidance on the design of freight wagons. One is directed to Direct Rail Services and covers mitigating the susceptibility of this type of wagon to cyclic top.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/141009_R202014_Gloucester.pdf

Tulsa Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Final case studies being presented in our Tulsa, Oklahoma course.

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For more information on our public courses click here or to book your own onsite course click here.

San Antonio 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Students presenting their final case studies on day 5 of the course. Students always learn something new in the case that they brought to be reviewed.

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For more information on our public courses click here or to book your own onsite course click here.

New York Post reports: “Huge drill almost skewers packed subway car”

November 4th, 2014 by

Once again, human error in the news …

A tragedy nearly occurred when a giant drill bit almost penetrated a subway full of people in New York.

See:

http://nypost.com/2014/10/30/massive-drill-bit-nearly-skewers-packed-subway-car/

Airplane Crashes: Pilot and People in a Simulator Die

November 4th, 2014 by

plane-crash-julie-click-kester1

Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.

I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.

Washington Post reports: “Commercial spaceship suffers catastrophic failure, at least 1 dead”

October 31st, 2014 by

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The suborbital commercial flights give passengers a small taste of space travel by piloting international flights 62 miles above the Earth’s atmosphere for about $250,000 per seat.

So far, more than 700 prospective passengers have paid for tickets.

See:

http://www.washingtontimes.com/news/2014/oct/31/commercial-spaceship-suffers-catastrophic-failure-/

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