Monday Accident & Lessons Learned: UK RAIB reports on fatal accident at Athelney level crossing, near Taunton, Somerset on 21 March 2013Posted: March 10th, 2014 in Accidents, Current Events, Investigations, Pictures
The following this the summary of the accident report from the UK Rail Accident Investigation Brach about a fatal accident at a level crossing in the UK. The full report includes four recommendations to improve level crossing safety. See the full report at: http://www.raib.gov.uk/cms_resources.cfm?file=/140224_R042014_Athelney.pdf
At about 06:23 hrs on Thursday 21 March 2013, a car drove around the barriers of Athelney automatic half barrier crossing, near Taunton in Somerset. This took the car into the path of a train which was approaching the crossing at high speed. The driver of the car was killed in the resulting collision.
The motorist drove around the barriers without waiting for a train to pass and the barriers to re-open. The level crossing was closed to road traffic for longer than normal before the arrival of the train, because of earlier engineering work that had affected the automatic operation of the crossing. The motorist may have believed that the crossing had failed with the barriers in the closed position, or that the approaching train had been delayed.
He did not contact the signaller by telephone before he drove around the barriers.The RAIB has made two recommendations to Network Rail. These relate to reducing the risk resulting from extended operating times of automatic level crossings andto modifying the location of the pedestrian stop lines at Athelney level crossing. A further recommendation is addressed to Network Rail in conjunction with RSSB,to consider means of improving the presentation of telephones at automatic level crossings for non-emergency use. One recommendation is addressed to the Office of Rail Regulation, to incorporate any resulting improvements which are reasonably practicable into the guidance it publishes on level crossings.
Press Release by the UK Rail Accident Investigation Branch: Passenger dragged a short distance by a train at Holborn stationPosted: March 8th, 2014 in Accidents, Current Events, Investigations, Pictures
Image showing a train in the westbound Piccadilly Line platform at Holborn station
The RAIB is investigating an incident in which a passenger was dragged for a short distance by a train departing from Holborn station on the London Underground system.
The incident occurred on the westbound Piccadilly Line platform at around 19:00 hrs on Monday 3 February 2014. The train had stopped normally in the platform and passengers had alighted and boarded. A member of staff on the platform (station assistant) signalled to the Train Operator to close the doors by raising a baton above his head. The Train Operator observed the raised baton and started to close the train’s doors. At this point a passenger arrived on the platform and moved towards the train, stopping as she realised that the doors were closing. As she stopped, the end of the scarf that she was wearing continued to swing towards the train and became trapped between the closing doors.
The Train Operator was unaware that the scarf was trapped in the door and after confirming that all doors were closed, started to move the train into the tunnel. The passenger was dragged along the platform by her scarf as the train started to move. The station assistant tried to help the passenger by holding on to her and they both fell to the ground. This resulted in the scarf being forcibly removed from the passenger’s neck and carried into the tunnel by the train.
The passenger suffered injuries to her neck and back and was taken to hospital; she is now recovering. The RAIB’s investigation will seek to understand the sequence of events and will examine the arrangements in place for safe despatch of trains from London Underground stations where station assistants are provided on the platform.
The RAIB’s investigation is independent of any investigation by the Office of Rail Regulation. The RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.
On July 17, 1981, a 32-ton, 12-foot long fourth floor walkway that spanned over and across the Hyatt Regency Kansas City lobby collapsed and crashed into the second floor walkway of equal size and weight. Both walkways landed in the lobby /atrium area where a dance competition (with approximately 1,600 people in attendance) was being held. The rescue operation lasted 14 hours, 114 people were killed and another 216 were injured.
Investigators found that changes to the design of the walkway’s steel tie rods were the cause of its failure.
$140 million was awarded to victims and their families, and the tragedy remains a classic model for the study of engineering ethics and errors. After the collapse, the lobby was reconstructed with only one crossing on the second floor, supported by several columns underneath it rather than being suspended from the ceiling.
Download and read report at National Institute of Standards and Technology:
A 45-year-old food company worker lost part of two fingers that were caught in a rotating drum. The HSE inspector stated that if the machine was properly guarded, the accident wouldn’t have happened. In addition to fines, the company was also banned from using the machine until it was sufficiently guarded. (Read full story on Brent & Kilburn Times.)
Underestimating the power of projectiles, relying on your friends to lift you up, (or catch you when you fall), taking a shortcut – these are all subtitles to funny videos recently posted by Mashable that underscore decisions people make that they immediately regret.
Here is a link to the videos: http://mashable.com/2014/03/03/i-regret-everything/
On a more serious note, it reminds me of the weekly eNewsletter we put together – we include regular columns like “How Far Away is Death” and “Monday Accidents and Lessons Learned” and yes, we always include a joke for our readers too, but sometimes it takes looking at destructive consequences of actions that people take and later regret before we are inspired to make a change and keep our workplaces safer.
If you’re not a subscriber, won’t you join our community of experts around the world as we work together to change the way the world solves problems? Here is our recent weekly edition:
Mark Paradies, President of System Improvements, Inc./TapRooT®, presents a view of lessons *not* learned according previous reports related to Deepwater Horizon & Texas City. In this 2013 Global TapRooT® Summit presentation he critiques the failure to learn and prevent accident recurrence, and offers suggestions to improve investigations.
View four-part video of this presentation:
Time to start planning for hot weather! What are management’s responsibilities to make sure that workers are safe when things get hot? See this OSHA press release:
An industrial worker in the UK who was cutting posts narrowly escaped death when he couldn’t disable a machine he was trapped in as he was pulled toward a band-saw. Although he lost his arm in the accident, he is grateful to be be able to tell his story. (Read story on thewestcountry.co.uk.)
Would you like help reducing serious injuries at your facility? Mark Paradies has an upcoming 2-day Pre-Summit course with important ideas to revolutionize your fatality/major accident prevention programs and start you down the road to eliminating major accidents.
Monday Accident & Lessons Learned: Penetration and obstruction of a tunnel between Old Street and Essex Road stations, LondonPosted: February 24th, 2014 in Accidents, Current Events, Investigations, Pictures
The UK Rail Accident Investigation Branch investigated the penetration and obstruction of a tunnel between Old Street and Essex Road stations in London. Here is a summary of the report:
“During the morning of Friday 8 March 2013, a train driver reported that flood water was flowing from the roof of a railway tunnel north of Old Street station near central London. The driver of an out-of-service passenger train was asked to examine the tunnel at low speed and check for damage. The driver stopped short of the water flow and reported that two large drills (augers) had come through the tunnel wall and were fouling the line ahead of his train.
The augers were being used for boring piles from a construction site about 13 metres above the top of the tunnel. The operators of the piling rig involved were unaware that they were working above an operational railway tunnel. Its position was not shownon the site plan, or on any map available to either the developer or the local planning authority. As a consequence, Network Rail was not consulted during the planning application stage and was unaware of the construction activity.
The RAIB has determined that approximately half of the piles required for the new development would have intersected with the tunnel had they had been constructed. It has identified two learning points from this incident which are relevant to the construction industry: clients and design teams should be aware of the importance of information shown on land ownership records; and those carrying out investigations for proposed developments should be aware that not all railway tunnels are shown on Ordnance Survey mapping.
The RAIB has also made five recommendations: three are addressed to railway infrastructure managers, and relate to: the provision of information to organisations undertaking property-related searches; the provision of information on the location of railway tunnels and associated subterranean structures; and the identificationof development work by third parties. One recommendation is made to the British Standards Institution relating to the enhancement of a British Standard, and one recommendation is addressed to the Department for Communities and Local Government relating to a recommendation made by the RAIB in 2007 which has not been implemented.”
To see the complete report, visit:
On February 13, 1981, a series of sewer explosions destroyed more than two miles of streets in Louisville, Kentucky. The explosions were caused by ignition of hexane vapors discharged from a Ralston-Purina soybean processing plant located near the University of Louisville.
The hexane leaked straight into the sewer system, where it spread into the lines under adjacent homes. It is a miracle that there were no fatalities. Ralston-Purina paid $18 million to the Louisville Metropolitan Sewer District and more than $8.9 million to 16,000 plaintiffs in a lawsuit.
View dramatic images of the Friday the 13th explosion and read more here.
On August 14, 2013, UPS Airlines Flight 1354 crashed and burst into flames short of the runway on approach to Birmingham–Shuttlesworth International Airport. Both pilots of the cargo plane were pronounced dead at the scene of the crash.
The Federal Aviation Administration issued new rules aimed at ensuring airline pilots have sufficient rest 2 years ago, and proposed to include cargo airlines in draft regulations, but exempted them when final regulations were released, citing cost.
Read the rest of the story on The Washington Post.
Learn more about tell-tale signs of fatigue-related mistakes at the 2014 Global TapRooT® Summit. Summit speaker Bill Sirois, Senior Vice President and Chief Operating Officer for Circadian Technologies, will be speaking about fatigue and human performance.
Fatigue in the workplace is difficult to measure, and it is even more difficult to identify as a causal factor of accidents and injuries. However, fatigue does contribute to human errors including errors in judgment, risk-taking behaviors, clouded decision-making, ability to handle stress and reaction time.
Join us for the Human Error Reduction and Behavior Change track, April 9 – 11, 2014 in Horseshoe Bay, Texas, to hear this talk.
LEARN MORE on the Summit website.
REGISTER NOW for the Human Error Reduction and Behavior Change track.
We report, you decide … Read the story and see what you think …
Press Release from the UK Rail Accident Investigation Branch: Fatal accident involving a track worker, near Newark Northgate station, 22 January 2014Posted: February 10th, 2014 in Accidents, Current Events, Investigations
RAIB is investigating an accident involving a track worker who was carrying out lookout duties near Newark Northgate station. The accident occurred at about 11:40 hrs on 22 January 2014. The track worker was struck by a passenger train and suffered fatal injuries.
The track worker was part of a gang of three engaged in the inspection of two sets of points to the south of the station. The train, a passenger service from King’s Cross, was approaching from the south at around 26 mph (42 km/h) and was heading into platform 3 as scheduled.
RAIB’s investigation will consider the sequence of events and factors that may have led to the accident, and identify any safety lessons.
RAIB’s 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.
While working underwater to attach tanks to re-float the Costa Concordia, a Spanish diver severely cut his leg on a steel sheet and was temporarily pinned beneath the water. Another diver freed the man and brought him to the surface, but he died later.
See the whole story here:
Press Release from the UK Rail Accident Investigation Branch: Serious near-miss involving a welding gang at Bridgeway user worked crossing, near Shrewsbury, 16 January 2014Posted: February 5th, 2014 in Accidents, Current Events, Investigations, Pictures
From the UK RAIB web site:
RAIB is investigating a serious near-miss involving a welding gang at Bridgeway user worked crossing, near Shrewsbury.
The accident occurred just before midnight on 16 January 2014 and involved train 1J76, the 22:36 hrs service from Manchester Piccadilly to Shrewsbury. At the point of impact the train, formed by a class 175 diesel multiple unit operated by Arriva Trains Wales, was travelling at approximately 85 mph (136 km/h). It braked to a stand in around half a mile (0.8 km).
Seconds before the collision a member of staff jumped off the trolley and clear of the train. A van, inside which another member of staff was unloading equipment, was parked close to the railway and was very nearly struck by the train. Although the train did not derail, it suffered significant damage, including a ruptured fuel tank. The member of staff who jumped clear suffered minor injuries.
The trolley was being loaded on the up line to move equipment southwards, towards Shrewsbury, to undertake a weld repair. However, this line was still open to traffic to allow train 1J76, the last train of the evening, to approach (the down line had been blocked by arrangement with the controlling signaller based in Cardiff).
Image of trolley underneath the damaged train (courtesy of Network Rail)
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 were applied. It will also seek to understand the actions of the track workers involved, and factors that may have influenced their behaviour and attitudes.
RAIB will assess the railway industry’s current strategy for undertaking work of this type, and will review the actions taken in response to previous RAIB recommendations relating to the safety of track workers.
What will the cost be at the end of the final BP-Deepwater Horizon trial? Houston Chronicle story provides possibilities…Posted: February 3rd, 2014 in Accidents, Current Events
The story in the Houston Chronicle has the following paragraph:
“Barbier’s rulings on how much oil spilled and other issues, including whether BP was grossly negligent and how to apportion fault among participants in the Macondo well project, will trigger penalty proceedings that could set the company’s environmental fines up to $18 billion. That’s $6 billion more than the company collected in profit in 2012.“
Next time you wonder about what might be the cost of an accident, perhaps your projections aren’t high enough???
For the complete article, see:
Another quote from the article put doubt on the idea that this suit would end BP’s liabilities:
Click on the image above for a PowerPoint of the temperature alarms during reentry.
Press Release from the UK Rail Accident Investigation Branch: Engineering train collision at Kitchen Hill, near Penrith, 12 January 2014Posted: January 30th, 2014 in Accidents, Current Events, Investigations
The RAIB is carrying out a preliminary examination into a collision at Kitchen Hill, 3 miles north of Penrith station on the West Coast Main Line.
At 13:25 hrs on Sunday 12 January 2014, train 6L42 (comprised of 10 ballast wagons and a locomotive at each end) was travelling in a work site when it collided with the back of a stationary ballast train that was standing at the board marking the end of the work site. Train 6L42 was travelling at around 19 mph at the time of the impact. As a consequence of the collision, the buffers of the first wagon on train 6L42 overrode those on the leading locomotive; and the leading bogie of the wagon and the trailing bogie of the locomotive became derailed.
When the driver of train 6L42 saw that a collision was imminent he applied the emergency brake and jumped from his cab, sustaining serious injuries. The derailment caused damage to the track which required local repairs, and some limited damage to the rolling stock involved.
The RAIB’s preliminary examination will examine the rules applicable to the management of engineering train movements, and the regulation of their speed, in work sites. It will also examine the way in which key information was communicated between the parties involved.
The RAIB will consider previous similar accidents; in particular the collision between two engineering trains at Leigh-on-Sea in April 2008 (report 24/2009), and a stoneblower and ballast regulator near Arley in August 2012 (report 12/2013).
The RAIB’s preliminary examination is independent of any investigation undertaken by the Office of Rail Regulation.
At the conclusion of the preliminary examination the RAIB will publish its findings on the RAIB website.
What Happened to the CSB investigation of the Macondo Blowout and Explosion (Deepwater Horizon Accident)?Posted: January 29th, 2014 in Accidents, Investigations, Pictures
(Picture from the CSB web site page on the Macondo Investigation. See: http://www.csb.gov/macondo-blowout-and-explosion/)
You might remember that on April 20, 2010, the Deepwater Horizon experienced a blowout, explosion, fire, and sank shortly thereafter.
You might also remember that several members of Congress asked the Chemical Safety Board to investigate the accident.
What you don’t remember is the investigation report.
Why? Because the report has not been published.
In 2012, the CSB announced that a draft report was imminent (due in July) and the final report would be published in 2013.
It is now well into 2014 (closing in on two years later) and no draft report has been released.
If you were assigned to investigate an accident and almost four years later you hadn’t published a draft of your report, what would your management say?
Also, if a report is published four years after an accident, how much impact can it have? Hasn’t the industry moved on by the time the report is released?
Timeliness of investigations and findings are certainly issues that need discussion.
Perhaps the CSB should adopt timeliness guidelines for investigations and reports. What would you suggest as the longest time that an investigation should be allowed to continue? Leave your comments here.
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Some of the comments have focussed on the delay caused by Transocean deciding to fight the jurisdiction of the CSB subpoenas, Therefore, I’ve attached the March 2013 decision. Note that the CSB knew about Transoceans’ decision to resist the subpoenas when they abounded that they would be releasing a preliminary report in 2012.