Category: Accidents

Monday Accident & Lessons Learned: Severe Hand Injury – What is the Root Cause?

August 24th, 2015 by

This video is graphic. Don’t watch if the sight of blood makes you queasy…

Go to video …

(more…)

What does a bad day look like?

August 20th, 2015 by

Just like this if you own a monster truck…

Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at editor@taproot.com.

Remembering an Accident: Sayano-Shushenskaya Hydro Power Plant Disaster

August 17th, 2015 by

On August 17, 2009, 75 people were killed when a turbine failed at the Sayano-Shushenskaya Power Station in the southern region of the Russian Federation. The turbine that failed had been vibrating for a long time before the accident occurred. A report published in Power Magazine suggests that it was predictable and preventable. The report revealed the terror of that day:

image“Water was washing away people from the turbine gallery into the river. Some of them were later caught and rescued. Some were not. The staff later learned that the turbine gallery was not equipped with proper emergency exits. There were also some miraculous rescues. One worker was washed by the torrent of water filling the turbine gallery up into the ceiling, where he managed to grab some ventilation equipment and hold on until being rescued. Others led employees to safety using cell phones as flashlights.”

http://www.powermag.com/investigating-the-sayano-shushenskaya-hydro-power-plant-disaster/

Have worst case scenarios at your facility ever kept you awake at night? View our course listing and learn how to go deeper into the causes of human error and equipment failure to find and fix the real root causes:

http://www.taproot.com/courses

 

Monday Accident & Lessons Learned: IOGP SAFETY ALERT- GAS BREAK-OUT FROM OIL-BASED MUD WHILE RUNNING CASING

August 10th, 2015 by

IOGP SAFETY ALERT GAS BREAK-OUT FROM OIL-BASED MUD WHILE RUNNING CASING

What Happened?

  • The event took place on a 3000 HP Land Drilling Rig while running 9 7/8” casing in the 12 ¼” hole section of an unconventional well. Well was vertical.
  • Well architecture consists of 20” Surface Casing at 945m, 13 3/8” casing at 3348 m at 12 ¼” hole section at 4794m.
  • Run 9 7/8” casing to 4793m.
  • After landing casing, circulated 9 7/8” casing, increasing pump rates from 0.70 m3/min to 1.45 m3/min and SPP of 450 kPa.At 2000 strokes into bottoms up, returns diverted through the manifold. Maximum gas of 2500 units observed prior to going through MGS.
  • Circulate through choke at 1.0 – 1.5 m3/min. Initial casing pressure of 170 kPa and SPP of 570 kPa. Casing pressure spiking at 5800 strokes to 9500 kPa and decreasing to 2100 kPa as bottom up strokes expired.
  • Significant amount of gas observed at surface. Approximately 5 m3 of invert drilling fluid was spilled over from open bottom poor boy degasser (MGS) while circulating bottoms up.
  • Shut in well & monitored for pressure evaluation.
  • Observed increase in SIDPP & SICP.
  • Continued to monitor pressure evolution.
  • Pressure stabilized at SIDPP 300 kPa & SICP 450 kPa.
  • Performed drillers method well kill and stabilized well with mud weight of 1750 kg/m3.
  • Well was static prior to bottoms up circulation (some reports noted minor flow when landing mandrel hanger).
  • During the bottoms up, returns were diverted to MGS as a precaution for trip gas and because pump pressure was much less than expected.
  • The gain was not noticed until the well was circulated once the casing was on bottom.
  • The section was drilled with a narrow mud-weight window.

What Went Wrong?

  • Gas entered the wellbore while well was static.
  • Insufficient hydrostatic pressure to prevent influx of formation fluid.
  • Well flow checks were inconsistent prior to tripping to run casing and were not sufficient to indicate potential influx of formation fluid into the well.
  • Circulation rate was adjusted to take into account the reduced volume of the annulus associated with the casing as compared to the large annular volume associated with drill pipe to ensure that the annular velocity was the same. However, this still resulted in the gas entrained in the drilling fluids coming to surface at a rate that exceeded the capacity of the MGS.
  • Choke was in the 100% open position as it should be when gas arrived at the surface because of concerns about exceeding MAASP. This resulted in maximum flow to the MGS exceeding the off-gassing and flaring capacity of the MGS flare system.
  • Possibly drilled too far into the HPHT pressure ramp in 12 ¼” hole section.

Corrective Action & Recommendations:

A definitive HPHT well control procedure will be developed for drilling operations in noted area.

  • Review MGS Sizing calculations for maximum anticipated gas rates. Understand capacity of oil based mud to absorb gas.
  • Develop a log sheet to better monitor and finger print trip gas, bottom’s up gas, connection gas and background gas to better understand potential behaviour at surface.
  • Drilling engineering team initiate and lead researching and acquiring a better way of determining needed mud weight trip margin requirements for making trips to log or run casing, with a better understanding of the fluids system EMW and ECD’s.

safety alert number: 266
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.

London office: 209-215 Blackfriars Road, London SE1 8NL, United Kingdom    T. +44 (0)20 3763 9700    F. +44 (0)20 3763 9701    E. reception@iogp.org

Stop the Sacrifices

July 30th, 2015 by

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Over a decade ago, I wrote this article to make a point about stopping construction fatalities. I’ve reposted it because it is missing from the archives. Does it still apply today? Perhaps it applies in many other industries as well. Let me know by leaving a comment.

StopSacrifices.pdf (click to open the pdf)

When is a safety incident a crime? Would making it a corporate crime improve corporate and management behavior?

July 29th, 2015 by

NewImage

I think we all agree that a fatality is a very unfortunate event. But it may not be a criminal act.

When one asks after an accident if a crime has been committed, the answer depends on the country where the accident occurred. A crime in China may not be a crime in the UK. A crime in the UK may not be a crime in the USA. And a crime in the USA may not be a crime in China.

Even experts may disagree on what constitutes a crime. For example, University of Maryland Law Professor Rena Steinzor wrote an article on her blog titled: “Kill a Worker? You’re Not a Criminal. Steal a Worker’s Pay? You Are One.” Her belief is that Du Pont and Du Pont’s managers should have faced criminal prosecution after an accident at their LaPorte, Texas, facility. She cited behavior by Du Pont’s management as “extraordinarily reckless.”

OSHA Chief David Michaels disagrees with Professor Steinzor. He is quoted in a different article as saying during a press conference that Professor Steinzor’s conclusions and article are, “… simply wrong.”

The debate should raise a significant question: Is making an accident – especially a fatal accident – a corporate crime a good way to change corporate/management behavior and improve worker safety?

Having worked for Du Pont back in the late 1980’s, I know that management was very concerned about safety. They really took safety to heart. I don’t know if that attitude changed as Du Pont transformed itself to increase return on equity … Perhaps they lost their way. But would making poor management decisions a crime make Du Pont a safer place to work?

Making accidents a crime would definitely making performing an accident investigation more difficult. Would employees and managers cooperate with ANY investigation (internal, OSHA, or criminal) IF the outcome could be a jail sentence? I can picture every interviewee consulting with their attorney prior to answering an investigator’s question.

I believe the lack of cooperation would make finding and fixing root causes much more difficult. And finding and fixing the root causes of accidents is extremely important when trying to improve safety. Thus, I believe increased criminalization of accidents would actually work against improving safety.

I believe that Du Pont will take action to turn around safety performance after a series of serious and sometimes fatal accidents. I think they will do this out of concern for their employees. I don’t think the potential for managers going to jail would improve the odds that this improvement will occur.

What do you think? Do you agree or disagree. Or better yet, do you have evidence of criminal proceedings improving or hindering safety improvement?

Let me know by leaving a comment below.

 

Monday Accident and Lessons Learned: FAA Lessons Learned from Transport Airplane Accidents

July 20th, 2015 by

NewImage

What can you learn from transport aircraft accidents? See the FAA Lessons Learned from Transport Plane Accidents page and find out. See:

http://lessonslearned.faa.gov/index.cfm

Monday Accident & Lessons Learned: Graniteville Train Accident

July 13th, 2015 by

Have you ever seen this video about the 2009 train derailment in Graniteville, SC? 

Could have we learned these lessons before people were killed?

What were the Safeguards?

July 9th, 2015 by

I love to use Safeguard Analysis to examine incidents and determine Causal Factors. 

What were the Safeguards keeping this officer safe and how did they fail? (A failed Safeguard is usually a Causal Factor.)

Watch and leave a comment about your ideas …

Robot Made a Human Error and a Worker was Killed

July 8th, 2015 by


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The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.

A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.

Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?

http://www.bbc.co.uk/newsbeat/article/33359005/man-crushed-to-death-by-robot-at-car-factory

 

Monday Accident & Lessons Learned: Lessons Learned from 5 Chemical Accidents

July 6th, 2015 by

Lessons learned from five accidents reported by EU and OECD Countries. See:

http://ec.europa.eu/environment/seveso/pdf/mahb_bulletin2.pdf

Read insights on lessons learned from accidents reported in the European Major Accident Reporting System (eMARS) and other accident sources.

47 accidents in eMARS involving contractor safety issues in the chemical or petrochemical industries were examined. Five accidents were chosen on the basis that a contract worker was killed or injured or was involved in the accident.

What do you think? Leave your comments below.

BP to Pay $18.7 Billion for Environmental Damage Caused by the Deepwater Horizon Oil Spill

July 3rd, 2015 by

It is the largest environmental settlement ever.

BP will pay the US Government,Alabama, Florida, Louisiana,Mississippi, and Texas $18.7 billion to compensate for environmental damage done by the Deepwater Horizon spill.

For more info, see: http://www.nytimes.com/2015/07/03/us/bp-to-pay-gulf-coast-states-18-7-billion-for-deepwater-horizon-oil-spill.html?emc=edit_th_20150703&nl=todaysheadlines&nlid=60802201&_r=0

Would you know if your corrective action resulted in an accident?

June 30th, 2015 by

“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.

No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions.  On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.

You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:

1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)

2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)

3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!

4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.

Simple… yes? Maybe? Feel free to post your examples and thoughts.

Monday Accident & Lessons Learned: Broken Leg caused by Fall From Ladder Cost Company $2.4 Million

June 29th, 2015 by

The Chicago Tribune reported “Fall from ladder nets Merrillville man $2.4 million jury verdict.”

Part of the reason that the company was found liable is that the ladder was “out of code.” It had been produced before standards for ladders were developed. 

Have any old ladders out there that need to be replaced?

Monday Accident & Lessons Learned: Complacency?

June 22nd, 2015 by

Is thinking that you are the best a sign of potential problems? (Especially for “routine” work?)

By any measure, the X-31 was a highly successful flight research program at NASA’s Dryden Flight Research Center, now the Armstrong Flight Research Center. It regularly flew several flights a day, accumulating over 550 flights during the course of the program, with a superlative safety record. And yet, on Jan. 19, 1995, on the very last scheduled flight of the X-31 ship No. 1, disaster struck.

View the video below or read about it here:  http://www.nasa.gov/centers/dryden/news/X-Press/stories/2004/013004/new_x31.html

Leave your comments below. Complacency? Leave your comments below.

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

Monday Accident & Lessons Learned: Forklift Accident

June 15th, 2015 by

A tragic workplace accident.

A life lost.

You see the resolve on the faces in this video to never lose a co-worker … a friend … to this type of accident again.

What do you think about “paying attention” for preventing potential tragedies such as this?  Leave your comments below and let’s share ideas to find and fix root causes.

Monday Accident & Lessons Learned: Fire Truck Accident & Lessons Learned

June 1st, 2015 by

What do you think of this accident investigation and lessons learned?

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