Category: Accidents

Monday Accident and Lessons Learned: Train Collision at Preston Station

June 26th, 2017 by

A train traveling from York to Blackpool North at about 6 mph collided with the buffer stop in platform 3C at Preston station. The buffer stop is a part of the Preston platform that allows the train driver to slow down in enough time.

The camera footage from the station showed the train essentially hit the brakes quickly upon approaching the buffer stop causing the inevitable collision. Fortunately there were no fatalities, however two crew members and thirteen passengers reported injuries.

So, what happened? The report states the operator was a trainee being supervised. When approaching the platform, the trainee was trained and advised to operate the brake controller but accidentally operated the power controller instead. But was it his fault? The supervisors?

At TapRooT® we believe and teach a blame-free philosophy. Firing or reprimanding the trainee or trainer wouldn’t ultimately fix what happened or prevent it from recurring.

(Source: https://www.gov.uk/government/publications/safety-digest-102017-preston/passenger-train-collision-with-buffer-stop-at-preston-station-1-april-2017)

What does a bad day look like?

June 20th, 2017 by

It looks like when Aunt Carol shows up.

Monday Accident and Lessons Learned: Incorrect Pressure Gauge

June 19th, 2017 by

Incorrect Pressure Gauge

Correct Pressure Gauge

The IOGP recently released that in September 2015, the incorrect pressure gauge was used on a high pressure supply line causing a high pressure release. When investigating, they found that the two gauges are identical in appearance, were stored in the same place and were stored in the incorrect place for convenience purposes. What are the corrective actions? Better storage of all pressure gauges, check all gauges before installing them, and check all current gauges to ensure they are being used correctly.

What are your thoughts on this incident? The investigation? The corrective actions?

(Resource: IOGP Safety Alerts)

Troubleshooting and Root Cause Analysis Issues Keep Military from Finding and Fixing the Causes of Oxygen Issues on Military Aircraft

June 15th, 2017 by

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Let me start by saying that when you have good troubleshooting and good root cause analysis, you fix problems and stop having repeat incidents. Thus, a failure to stop problems by developing effective corrective actions is an indication of poor troubleshooting and bad root cause analysis.

Reading an article in Flight Global, I decided that the military must have poor troubleshooting and bad root cause analysis. Why? Because Vice Admiral Groskiags testified to congress that:

“We’re not doing well on the diagnosis,” Grosklags told senators this week.
“To date, we have been unable to find any smoking guns.”

 What aircraft are affected? It seems there are a variety of problems with the F/A-18, T-45, F-35. F-22, and T-45. The article above is about Navy and Marine Corps problems but Air Force jets have experience problems as well.

Don’t wait for your problems to become operation critical. Improve your troubleshooting and root cause analysis NOW! Read about our 5-Day TapRooT® Root Cause Analysis Team Leader Course HERE.

Flint Water Crisis: 5 Michigan Officials Charged with Involuntary Manslaughter

June 15th, 2017 by

 

Yesterday, five Michigan officials were charged with involuntary manslaughter related to the Flint, Michigan water crisis. Recall that in 2014, Flint switched its water source from Detroit to the Flint River in part to save money. It didn’t take long before residents noticed a difference in the way their water tasted and smelled.  The water caused some residents to get life-threatening Legionnaires disease and the medical community identified higher levels of lead in children’s blood (this type of exposure to lead can lead to developmental issues).

Learn more on NPR.

News stories like this are tragic because they are avoidable.  TapRooT® Root Cause Analysis shifts thinking from ineffective blame to effective solutions.  TapRooT® can be used proactively too to avoid these types of devastating problems from ever happening.

Learn more in our 2-day or 5-day root cause analysis courses.

 

Monday Accidents and Lessons Learned: Collapsed Bridge onto Railway Lines

June 12th, 2017 by

In Leicestershire, a bridge built in 1840 partially collapsed causing debris and chunks to fall directly onto an open railway. This bridge had recently been investigated due to its age and lack of current engineering best practices. They found a water leak coming from the water main, but this was not considered an imminent threat at the time. A work order for the leaking water main was issued and construction began. Later the same evening of the initial work, the pressure from the water leak ruptured. The result of this bridge collapse were better than they could have been. No fatalities or even injuries. However, the railway line was obstructed and required clean up of all the debris. What could they have done differently when performing this investigation? Could this incident have been prevented?

(Resource: https://www.gov.uk/raib-reports/partial-collapse-of-a-bridge-onto-open-railway-lines-at-barrow-upon-soar)

 

Monday Accidents and Lessons Learned: Fatal Rail Accident in Croyden, London

June 5th, 2017 by

In November, a tram car approaching the Sandilands junction fell on its side going around a curve. Although the investigation is still ongoing, the initial finding is that the tram was traveling at approximately 70km/h when going around the curve, which is 50km/h faster than permitted. This increased speed caused the train car to fall on its side and slide an additional 25 km. As a result, there were 7 fatal injuries and 51 hospitalized passengers.

Read more here:

https://assets.publishing.service.gov.uk/media/582c4614ed915d14ae00000a/IR012016_161116_Sandilands_Jn.pdf

Construction Safety: Human Cost, OSHA Fines and Lawsuits…

June 5th, 2017 by

Knowing that each year about 900 construction workers do not come home to their families after work, safety on construction work sites must be taken seriously.

AGC, the Associated General Contractors of America recently published a study together with Virginia Tech, “Preventing Fatalities in the Construction Industry”. There are some interesting findings:

  • Dangerous Lunch Hour: construction site fatalities peak at noon, and are much lower on Fridays than Monday through Thursday
  • Small Contractors (less than 9 employees) are overrepresented in the statistics, with a fatality rate of 26 per 100,000 workers
  • Fully 1/3 of fatalities are from falls, and about 29% from Transportation incidents with e.g trucks or pickups
  • More experienced workers are not safer: fatalities start increasing after age 35 and keep growing so that 65 year olds are at the highest risk
  • Industrial projects are the most dangerous, followed by Residential and Heavy construction projects

The consequences of a fatality are devastating. There is a great human cost where families will have to deal with grief as well as financial issues. For the company there may be OSHA fines, law suits and criminal investigations. There really is no excuse for a builder not to have an active safety program, no matter how small the company.

Basic safety activities include providing and checking PPE and fall protection, correct use of scaffolding and ladders, on- going safety training, check- ins and audits. It is also a good idea to actively promote a safety culture, and to use a root cause analysis tool to investigate accidents and near misses, and prevent them from happening again.

The TapRooT® Root Cause Analysis methodology is a proven way of getting to the bottom of incidents, and come up with effective corrective actions. Focus is on human performance, and how workers can be separated from hazards like electricity, falls or moving equipment.

We can organize on- site training, or start by signing up for a public course. We offer the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as well as the introductory 2-Day TapRooT® Root Cause Analysis Training class.

Be proactive, do not let preventable accidents catch up with you… call us today!

#TapRooT_RCA #safety

Remembering an Accident: Ixtoc I Oil Spill

June 5th, 2017 by

On June 3, 1979, a major oil spill occurred. Pemex, a Mexican oil company, was drilling in a deep oil well using one of their rigs, Sedco 135. While drilling, mud began to circulate within the well and slowly fill the well column. As it began to fill with mud, the pressure became too much causing Sedco 135 to blow. This oil spill lasted months resulting in hundreds of thousands of barrels of oil spilled into the Gulf of Mexico. They implemented a variety of reactive measures to contain it such as putting steel, iron and lead balls into the well to slow the spill, drilling relief wells, placing barriers and skimmers nears bays and lagoons, and spraying chemical dispersants. This process lasted approximately 10 months costing Pemex close to $100 million.

This major oil spill was about 30 years prior to Deepwater Horizon. Why do these major oil spills happen? What can they do to prevent them? How can we learn from them?

(Resource: https://en.wikipedia.org/wiki/Ixtoc_I_oil_spill)

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

Screen Shot 2017 05 31 at 1 20 19 PM

Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

What does a bad day look like?

May 30th, 2017 by

You know it’s a bad day when:

You get to work and find a “60 Minutes” news team waiting in your office.

You turn on the evening news and they are showing emergency routes out of the city.

Nothing you own is actually paid for.

Your kids start treating you the same way you treated your parents.

The health inspector condemns your office coffee maker.

The gypsy fortune teller offers to refund your money.

You dig around in your purse for your iPhone, while you’re talking on it.

Your son calls you at 3 a.m., and he’s not doing a semester abroad.

You try to check in at the gym using your Starbucks Card.

The smoke detector starts beeping at 2:30 a.m. (why can’t the battery fail at 2:30 p.m.?)

Monday Accident and Lessons Learned: Gatwick Express Rail Accident, Balham

May 29th, 2017 by

August 7, 2016, a fatal accident occurred on the Gatwick Express that transports people to and from Gatwick Airport in London. When passing through Balham, South London, a passenger decided to stick his head out of the window at the same time the train passed a signal gentry going approximately 61 mph. The accident was fatal and tragic. Unfortunately the UK Rail didn’t have any regulations on securing the windows so passengers can’t open them. After investigating, two recommendations and one learning point were identified. Click here to read their results and the full story.

Interviewing & Evidence Collection Tip: The Value of a Planning SnapCharT®

May 24th, 2017 by

Hello and welcome to our new weekly column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.

If you are a TapRooT® user, you know that the SnapCharT® is the first step in conducting a root cause investigation.  It doesn’t matter if you’re investigating a simple incident or major accident – SnapCharT® is always the starting line.

A SnapCharT® is a simple method for drawing a sequence of events.  It can be drawn on sticky notes or in the TapRooT® software.  Sometimes we refer to the SnapCharT® in it’s initial stages as a “planning” SnapCharT®. So why is a SnapCharT® essential for evidence collection and interviewing?

When you begin an investigation, you are working with suppositions, assumptions and second hand information. The planning SnapCharT® will guide you to who you need to interview and what evidence you need to collect to develop a factual sequence of events and appropriate conditions that explain what happen during the incident. Remember, a fact is not a fact until it is supported by evidence.  

The planning SnapCharT® is used to:

  • develop an initial picture of what happened.
  • decide what information is readily available and what needs to be collected immediately.
  • establish a list of potential witnesses to interview.
  • highlight conflicts that exist in the preliminary information.
  • plan the next steps of interviewing and evidence collection.

The SnapCharT® provides the foundation for solid evidence collection.  Learn how to create a SnapCharT® by reading, “Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents or register for our 1-day Interviewing and Evidence Collection Course in Houston, Texas on November 8, 2017.  We also offer this course as a one or two-day onsite course that can be customized for your investigators.

How has SnapCharT® helped you plan your investigative interviews and evidence collection?  If you’ve never used a SnapCharT®, how do you think a planning SnapCharT® would be helpful to you? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

See you next week!

What does a bad day look like?

May 23rd, 2017 by

It could start like this! One of our instructors captured this photo. It would only take a second for this scenario to turn into a very bad day.

Remembering an Accident: West Loch Disaster, Pearl Harbor Base

May 23rd, 2017 by

On the Pearl Harbor U.S. Naval Base on May 21, 1944, there was a major explosion. Of course this was during World War II so one would think or assume it was another attack, but in fact, this was caused by the U.S. Navy themselves. Before they knew it, a large fire broke out where they kept the Landing Ships, Tanks. This fire then spread onto the Operation Forager that was being prepared for another Japanese attack. The final result of this massive fire was six sunken Landing Ships, Tanks, 163 fatalities and 396 injuries.

So, what exactly happened? The probably cause was determined to be an operation error when unloading a mortar round. It detonated on the spot and the fire spread from there. The U.S. Navy couldn’t let this incident repeat so they immediately began implementing a corrective action to change their weapon handling practices.

(Resource: https://en.wikipedia.org/wiki/West_Loch_disaster)

Monday Accident and Lessons Learned: Baltimore School District and Maryland Public Transit Driver Qualifications

May 22nd, 2017 by

In 2016, there was a collision between a school bus and a public transit bus. After an investigation, they found that the process for checking the qualifications of the drivers initially and continuing to do so over time was severely inadequate. As a corrective action, they implemented a new process to audit the drivers’ qualifications and the hiring process to ensure the future drivers are up to par.

Read more here:

https://www.ntsb.gov/investigations/AccidentReports/Pages/HSR1702.aspx

What does a bad day look like?

May 9th, 2017 by

Well, it could start with shenanigans like this.

Freeze on New RMP Rule linked to the ATF announcement about the West, TX, Fertilizer Explosion

May 5th, 2017 by

The new EPA RMP rule which had an effective date March 14, 2017, has been “frozen” under the Trump administration regulatory freeze until February 19, 2019.

The main reason for the freeze in the case of the RMP rule is that the rule modifications were largely based on the West, TX fertilizer explosion. However, two days before the comment period ended, the ATF announced that they suspected that the West, TX, fertilizer explosion was NOT an accident, but rather was an intentional act.

Now the whole rule is being reconsidered.

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

What does a bad day look like?

May 2nd, 2017 by

It could begin innocently enough.

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