What can you learn from a 1964 video?
How they viewed human performance was certainly different.
What do we know that helps us do better today?
Could better root cause analysis have helped them then? After all, an engine failure in a helicopter is a serious accident to blame on the pilot.
Could root cause analysis help learn more from this accident? How about a Safeguards Analysis before you hunt?
When a major accident happens, look out. The tradition is for “heads to roll.”
That’s right, people get fired.
Who get’s fired? Those that are seen as “part of the problem.”
You need to be part of the solution.
Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.
Then you are part of the answer … Not part of the problem.
Or you could just sit around and wait to get fired.
The choice is yours.
Get trained to use TapRooT® root cause analysis to solve problems. See:
Accident News: The Washington Times Reports “Amtrak train from D.C. derails in Philadelphia; 6 dead, dozens injured”May 13th, 2015 by Mark Paradies
I read an article in the Houston Chronicle about failed corrective actions at Blue Bell® Ice Cream.
It made me wonder:
“Did Blue Bell perform an adequate root cause analysis?”
Sometimes people jump tp conclusions and implement inadequate corrective actions because they don’t address the root causes of the problem.
Its hard to tell without more information, but better root cause analysis sure couldn’t have hurt.
Find out how TapRooT® Root Cause Analysis can help find and fix the root causes of problems by reading about TapRooT®’s history at:
On May 5, 1988, one of United States’ worst oil refinery explosions occurred in Norco, Louisiana. There were six employees that were killed and 42 local residents injured. The blast was said to have reached up to 3o miles away shattering windows, lifting roofs and sending a black fog over the entire town of Norco. Residents were forced to evacuate while officials died the fires down and gathered as much rubble as possible to recover any bodies. In order to discover the root cause of this disaster, the Federal Occupational Health and Safety Administration as well as the Environment Protection Agency came and investigated the scene to gather information. The only possible root cause they could find was the catalytic cracking unit, machine used to break down crude oil into gasoline, because it was at the center of the explosion, but there was no definite cause found. Overall, the amount of damage done cost Shell millions of dollars and set an incredible amount of fear into the residents.
Click below to download a report from the European Major Accidents Reporting System (eMARS) about contractor related safety.
Monday Accident & Lessons Learned: How Many People Will Die Waiting for Management to Implement an Effective Improvement Program?April 27th, 2015 by Mark Paradies
You see the results of ineffective improvement programs in the headlines …
Ten Die in Refinery Explosion
Four Asphyxiated in Confined Space Accident
Fire Kills There Workers
Forklift Accident Kills Teenage Worker
Scaffold Collapse Kills Two Construction Workers
Trench Collapse Kills Father of Three
Welder Killed When Tank Explodes
Eleven Killed in Offshore Platform Explosion
Mine Accident Kills 13
Perhaps you think these were just bad days. That accidents just happen. The truth is that most fatalities are the result of bad programs. They were accidents waiting to happen. If management had effective reactive and proactive improvement programs, these accidents, and others ones like them, would not have had to happen.
- Why didn’t management push for better safety improvement?
- Why wasn’t improving their improvement program one of their highest (or their highest) priority?
- How many people have to die to get management’s attention and make them get excited about investing in effective improvement?
The fatalities continue while we wait for the answer.
If YOU are excited about improving your improvement program and PREVENTING FATALITIES, I have a few ideas for you …
- Take your senior manager on a hazard walk around. Go to one or two places in your plant and challenge the manager to spot all the hazards (sources of energy that could cause a fatality). Did they miss height, lack of breathable air, moving equipment, or other sources that you have seen? Next, take several sources of energy and ask what are the safeguards that keep a fatal accident from happening. Then ask for each safeguard, when was the last time that the manager heard of an audit of the effectiveness of that safeguard? When was the last time the manager checked the effectiveness of that safeguard? Do this once a week and the manager will start thinking hazards, safeguards, and audits of safeguards effectiveness.
- Take your manager to the 2015 TapRooT® Summit. They will network with the leaders in performance improvement that attend the Summit and they can benchmark their improvement efforts against others. They will probably find that they have some good practices to share. But they will also discover some gaps in their programs that need improvement and best practices to make that improvement occur.
- Have on-site training for your management team. Consider the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. Or the Proactive Use of TapRooT® Course. One company even had all their Senior Project Managers (who manage construction programs over $500 million) attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. One of these senior managers pulled me aside to tell me that it was the most valuable management training he had ever had!
Don’t just sit around waiting for management to get excited about improvement after major accident. Prevent the accident. Get them excited about preventing fatalities!
In the city of Chernobyl, Ukraine in April of 1986, there was a major accident in the city’s largest nuclear power plant. The inadequately trained personnel paired with a flawed reactor design did not produce smooth results. The lack of safety precautions caused a steam explosion and fire that released 5% of the radioactive reactor core into the environment. Onsite death toll totaled to two plant workers, however, the overall death toll, due to the release of the radioactive poison, totaled to 56. In order to decrease the amount of poison released and put the fires out, officials poured sand and boron over the entire site. Additionally, they covered the plant with a concrete structure, but that still did not prevent all the residents from relocating and over 9,000 of them being diagnosed with cancer several months later.
Read this article from the United States Nuclear Regulatory Commission for more detailed information: http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/chernobyl-bg.html
Below is a video of the 20 year anniversary news story that ABC News covered in 2006. Take a look at just how deadly and devastating this accident was.
Being proactive is just one way you can help prevent a catastrophic event such as this one. 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.)
As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section:
“Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 for more than 160 million work-hours. This equals one lost-time incident for every 6.2 million hours on the job. These numbers are a testament to our safety record and a reason why we are in the top tier of safest companies in the industry.”
CB&I’s lost time incident rate is 50 times better than the industry average (.03 compared to 1.5). That might make you wonder, how do they do that?
Answering that question is learning from a lack of accidents!
Here are a couple of thoughts that I have…
First, when you see this kind of success, you know it is because of management, supervisory, and employee involvement in accomplishing a safe workplace. Everybody has to be involved. There can’t be finger pointing and blame. Everybody has to work together.
Second, I know CB&I is a TapRooT® User. CB&I has trained TapRooT® Investigators to find and fix the root causes of incidents and, thereby, keep major accidents (LTI’s and fatalities) from occurring.
So, congratulations CB&I on your excellent performance! Congratulations on the lives you have saved and the injuries you have avoided!
If you are interested in having industry leading safety performance, perhaps you should get your folks trained to find and fix the root causes of problems by using advanced TapRooT® root cause analysis. Find out about our courses at THIS LINK.
And consider attending the 2015 Global TapRooT® Summit on June 1-5 in Las Vegas. You can:
- meet industry leaders who are achieving world-class performance
- benchmark your programs with their programs
- learn industry leading best practices
- get motivated to take your safety performance to the next level.
See the 2015 Global TapRooT® Summit schedule at:
Watch this video and see if you think they learned all the lessons they should have learned …
If you are a ship’s captain, it looks like this…
A press release from the UK RAIB:
RAIB is investigating an incident that occurred at 17:25 hrs on Saturday 7 March 2015, in which train reporting number 1Z67, the 16:35 hrs service from Bristol Temple Meads to Southend, passed a signal at danger on the approach to Wootton Bassett junction, Wiltshire. The train subsequently came to a stand across the junction. The signal was being maintained at danger in order to protect the movement of a previous train. However, at the time that the SPAD occurred, this previous train had already passed through the junction and was continuing on its journey. No injuries, damage or derailment occurred as a result of the SPAD.
Wootton Bassett junction is situated between Chippenham and Swindon stations on the Great Western main line and is the point at which the line from Bristol, via Bath, converges with the line from South Wales. It is a double track high speed junction which also features low speed crossovers between the up and down main lines (see figure below for detail).
Wootton Bassett junction in 2012 – the lines shown from left to right are the Up Goods,
Up Badminton, Down Badminton, Up Main and Down Main (image courtesy of Network Rail)
The junction is protected from trains approaching on the up main from Chippenham by signal number SN45, which is equipped with both the Automatic Warning System (AWS) and the Train Protection and Warning System (TPWS). This signal is preceded on the up main by signal SN43, which is also equipped with AWS and TPWS. The maximum permitted line speed for trains approaching the junction from this direction is normally 125 mph. However, on 7 March, a temporary speed restriction (TSR) of 85 mph was in place on the approach to signal SN45. A temporary AWS magnet had been placed on the approach to signal SN43 to warn drivers of this TSR.
A diagram of the layout of Wootton Bassett junction – note that some features have been omitted for clarity (not to scale)
The train which passed signal SN45 at danger consisted of steam locomotive number 34067 ‘Tangmere’, and its tender, coupled to 13 coaches. The locomotive is equipped with AWS and TPWS equipment.
The RAIB’s preliminary examination has shown that, at around 17:24 hrs, train 1Z67 was approaching signal SN43 at 59 mph, when it passed over the temporary AWS magnet associated with the TSR. This created both an audible and visual warning in the locomotive’s cab. However, as the driver did not acknowledge this warning within 2.7 seconds, the AWS system on the locomotive automatically applied the train’s brakes. This brake application should have resulted in the train being brought to a stand. In these circumstances, the railway rule book requires that the driver immediately contact the signaller.
The RAIB has found evidence that the driver of 1Z67 did not bring the train to a stand and contact the signaller after experiencing this brake application. Evidence shows that the driver and fireman instead took an action which cancelled the effect of the AWS braking demand after a short period and a reduction in train speed of only around 8 mph. The action taken also had the effect of making subsequent AWS or TPWS brake demands ineffective.
Shortly after passing the AWS magnet for the TSR, the train passed signal SN43, which was at caution. Although the AWS warning associated with this signal was acknowledged by the driver, the speed of the train was not then reduced appropriately on the approach to the next signal, SN45, which was at danger. Because of the earlier actions of the driver and fireman, the TPWS equipment associated with signal SN45 was unable to control the speed of the train on approach to this signal.
As train 1Z67 approached signal SN45, the driver saw that it was at danger and fully applied the train’s brakes. However, by this point there was insufficient distance remaining to bring the train to a stand before it reached the junction beyond SN45. The train subsequently stopped, standing on both the crossovers and the up and down Badminton lines, at around 17:26 hrs. The signalling system had already set the points at the junction in anticipation of the later movement of 1Z67 across it; this meant that no damage was sustained to either the train or the infrastructure as a result of the SPAD.
The RAIB has found no evidence of any malfunction of the signalling, AWS or TPWS equipment involved in the incident.
The RAIB’s investigation will consider the factors that contributed to signal SN45 being passed at danger, including the position of the temporary AWS magnet associated with the TSR. The investigation will also examine the factors that influenced the actions of the train crew, the adequacy of the safety systems installed on the locomotive and the safety management arrangements.
RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.
We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation.
These findings will be available on the our website.
The Houston Chronicle published an article by Rafael Moure-Eraso of the Chemical Safety Board that was titled: “Hazardous work takes toll on Latinos”.
In the article, Rafael Moure-Eraso claims that among Latinos “… fatality and injury rates are disproportionately high.” He provides statistics on Latino fatalities and injuries in various industries. He references a report that states the obvious (as many Latinos are recent immigrants, they tend to get lower paying and more dangerous jobs). He also states that Latinos are more likely to be at risk as residents near chemical plants (once again, obviously rich people usually don’t sit their mansions next to chemical plants and the poor are more likely to buy cheap housing in a less desirable locations – like next door to an industrial site).
The article seems to be a mix of environmental justice political speech and a call for new federal regulations to improve chemical plant safety.
He ends the article with:
“You can’t put a price on someone’s life. Latinos help drive the country’s economy working hard for companies big and small, often in dangerous occupations. They have a right to safer workplaces and communities.”
That made me think …
- Are new rights (the right to safety … whatever that is) and new federal programs really the way to improve safety in the workplace?
- Do accidents really target specific races?
- Would a federally run workplace be safer than those run by commercial companies?
- Would safety improve faster with more federal direction?
- Does the government know better than those in commercial industry how to improve safety?
- What does management at major companies need to do if they want to avoid a whole new level of “one size fits all” government regulation of process safety and industrial safety?
These are all very interesting questions that take considerable thought. I’d be interested in your opinions. Leave a comment here.
Like this if you are a fire fighter…
The UK Rail Accident Investigation Branch announced the start of two rail incident investigations.
The first is an investigation of the injury of a passenger that fell between a London Underground train while being dragged by the train. See the preliminary information at:
This is an accident that was prevented from being worse by the alert actions of the train’s operator.
The second incident was container blown off a freight train. The preliminary information can be found here:
Here’s a CSB video …
What do you think? Has PSM improved in the past ten years? What can we learn?
Is “inherently safer designs” the answer?
Are PSM regulations going to stop accidents?
Are government approaches to PSM inadequate?
Are the suggestions of the CSB inadequate?
Leave your comments here.
On March 20, 1905, 58 employees died and 150 people were injured during a boiler explosion in Brockton, Massachusetts. Among the 300+ employees who worked at the factory, about 100 went unharmed.
The Grover Shoe Factory is the largest boiler disaster ever recorded in American Industrial Industry.
What happened? An over-worked pressure boiler exploded and shot through the roof of the factory causing the roof to collapse. The floors below collapsed because of the extra weight added by each collapsing floor, leaving the workers trapped in the rubble.
The combination of broken gas lines, air, and ventilation caused the factory and the buildings around it to become a blazing inferno.
The boiler traveled several hundred feet causing damages to a number of buildings and eventually landing on a house.
To read the full PDF about this incident click here.