Special thanks to TapRooT® Instructor, Jim Whiting for sending in the video.
The UK Rail Accident Investigation Branch published a report about a tram hitting a pedestrian in Manchester, UK.
A summary of the report says:
At about 11:13 hrs on Tuesday 12 May 2015, a tram collided with and seriously injured a pedestrian, shortly after leaving Market Street tram stop in central Manchester. The pedestrian had just alighted from the tram and was walking along the track towards Piccadilly.
The accident occurred because the pedestrian did not move out of the path of the tram and because the driver did not apply the tram’s brakes in time to avoid striking the pedestrian.
As a result of this accident, RAIB has made three recommendations. One is made to Metrolink RATP Dev Ltd in conjunction with Transport for Greater Manchester, to review the assessment of risk from tram operations throughout the pedestrianised area in the vicinity of Piccadilly Gardens.
A second is made to UK Tram, to make explicit provision for the assessment of risk, in areas where trams and pedestrians/cyclists share the same space, in its guidance for the design and operation of urban tramways.
A further recommendation is made to Metrolink RATP Dev Ltd, to improve its care of staff involved in an accident.
For the complete report, see:
In these videos (Part One and Part Two above), Alan Smith introduces fascinating case studies of serious incidents he has been involved in and lessons learned. He is the former Head of Major Crime Operations – Grampian Police, Scotland. As a career detective, he was the lead investigator in numerous homicide investigations. He is a Certified TapRooT® Instructor/Facilitator and has in-depth experience in numerous offshore tragedies including Piper Alpha and the MV Bourbon Dolphin. He is an Accredited Senior Investigator in Counter Terrorism and Kidnap and Ransom. Alan is the former Chair of the Scottish Senior Investigating Officer’s Conference.
Alan will be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit, August 1 & 2, San Antonio. He will also be leading a special session you don’t want to miss: Risk Assessing the Perfect Murder.
It’s not too late to register for the 2016 Global TapRooT® Summit!
Automation versus manual human control … the result? Tesa predicts a 50% reduction in crashes even with their first version (and more with later revisions).
Here is the story …
Here’s the video – go to the 22 minute point to watch the comments about autonomous driving cars.
What do you think? Will automation drastically cut the accident rate?
Electrical energy helps us in many ways, but when it is misused and an arc flash occurs … perhaps this video will help people get the message that arc flash precautions are important!
WARNING – GRAPHIC CONTENT AT VARIOUS POINTS – DON’T WATCH IF YOU WILL BE UPSET
Want to learn more about arc flash safety? We have a session about it at the 2016 Global TapRooT® Summit. The session titled “Arc Flash Prevention” is from 1:40-2:50 on Thursday in the Safety Best Practices Track.
Scott King and Terry Butler will present Employee and contractor protection utilizing general electrical principles as referenced by OSHA and NFPA 70E 2015 guidelines and qualified low voltage safety training.
Learning Objectives for this session include:
- Provide an overview of the importance of Arc Flash Safety
- Understanding Electrical Hazards
- Safe Work Practices
- Incident Energy Exposure Levels
- Risk Assessment Analysis
- Personal Protective Equipment (PPE)
- Safety Training
See the complete 2106 Global TapRooT® Summit schedule at:
And register for the Summit at:
Since 2011 more than 2,000 accidents involving horses and riders have occurred on Britain’s roads.
Here is a video with lessons learned about a fatal accident involving equipment (a scissor lift).
But there is an additional lesson that we can learn.
Every worksite should have a supervisor perform a quick Safeguard Analysis before people start work.
In this case, power lines were an obvious hazard (high voltage). And getting equipment with booms or lifts near them would cause the natural Safeguard (distance) to fail. If this Safeguard Analysis had been performed proactively, the worker could have been warned OR the actions (visually warnings and signage) could have been implemented to prevent the fatality.
Don’t wait for a fatality. Use TapRooT® to proactively prevent fatalities.
Would you like to learn to use TapRooT® to look for problems before accident, quality problems, and other failures happen? Then you should attend the upcoming TapRooT® for Audits Course on August 1-2 in San Antonio, Texas (just before the 2016 Global TapRooT® Summit on August 3-5). Register here:
The Wall Street Journal announced that BP incurred $56 Billion in expenses from the Deepwater Horizon explosion and spill. And the end is still not in sight.
BP’s CFO said “It’s impossible to come up with an estimate [of future costs].”
Of course, those costs don’t include the lives lost and the negative PR that the company has received.
How much is a best in class process safety program worth? As BP’s CFO says …
It’s impossible to come up with an estimate.
If you would like to learn best practices to improve your safety performance and make your programs “best in class,” the at ten the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
What? You say YOUR COMPANY CAN’T AFFORT IT? Can it afford $56 Billion? The investment in your safety program is a pittance compared with the costs of a major accident. Your company should put spending on safety improvement BEFORE other investments … especially in difficult times.
If you are a senior manager, don’t wait for your safety folks to ask to attend the Summit. Send them an e-mail. Tell them you are putting a team together to attend the Summit with you to learn best practices to prevent major accidents. Ask them who would be the best people to include on this team. Then get them all registered fot the Summit.
Remember, the Summit is GUARANTEED.
Attend the Summit and go back to work and use what you’ve learned.
If you don’t get at least 10 times the return on your investment,
simply return the Summit materials and we’ll refund the entire Summit fee.
Wow! A guaranteed ROI. How can we be so sure that you will return to work with valuable ideas to implement? Because we’ve been hosting these Summits for over 20 years and we know the “best of the best” attend the Summit and we know the value of the ideas they share each year. We’ve heard about the improvements that Summit attendees have implemented. Being proactive is the key to avoiding $56 Billion dollar mistakes.
So don’t wait. Get your folks registered today at:
A lot of bad days start with bad decisions. For example, when you decide to take a selfie with a 4-foot rattlesnake… (Read story.)
The following is a video of a fatal accident. The vehicle drove around a tow truck sent to block the underpass and past a worker waiving his arms to stop her. She drove into water about 17 feet deep. DON’T watch the video if it will upset you. For others, hopefully you can use this to teach others to avoid standing water during flooding.
The explosion at the West Fertilizer Plant was thought to have been a tragic accident. However, the Associated Press has reported that the Alcohol, Tobacco, and Firearms, and Explosives Agency (ATF) has said that the fire that caused the explosion was “intentionally set.”
Here is a TV report link:
Harrison Ford was hit by a heavy, hydraulically operated door while filming the new Star Wars movie. He suffered a broken leg. The UK Health & Safety Executive charged Foodles Productions (UK) Ltd. with four criminal violations and the company will have it’s first court hearing on May 12th.
Now the question – or lesson learned …
- Will criminal charges make movie actors safer?
- Do studios already have incentives to keep their actors safe?
What do you think? Leave your comments here…
Wow. Quite an eye-opening Washington Post article describing a report published in the BMJ. A comprehensive study by researchers at the John Hopkins University have found that medical mistakes are now responsible for more deaths in the US each year than Accidents, Respiratory Disease, and Strokes. They estimate over a quarter million people die each year in the US due to mistakes made during medical procedures. And this does NOT include other sentinel events that do not result in death. Researchers include in this category “everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.” Other tidbits from this study:
- Over 700 deaths each day are due to medical errors
- This is nearly 10% of all deaths in the US each year
What’s particularly alarming is that a study conducted in 1999 showed similar results. That study called medical errors “an epidemic.” And yet, very little has changed since that report was issued. While a few categories have gotten better (hospital-acquired infections, for example), there has been almost no change in the overall numbers.
I’m sure there are many “causes” for these issues. This report focused on the reporting systems in the US (and many other countries) that make it almost impossible to identify medical error cases. And many other problems are endemic to the entire medical system:
- Insurance liabilities
- Inadequate reporting requirements
- Poor training at many levels
- Ineffective accountability systems
- between patient care and running a business
However, individual health care facilities have the most control over their own outcomes. They truly believe in providing the very best medical care to their patients. They don’t necessarily need to wait for national regulations to force change. They often just need a way to recognize the issues, minimize the local blame culture, identify problems, recognize systemic issues at their facilities, and apply effective corrective actions to those issues.
I have found that one of the major hurdles to correcting these issues is a lack of proper sentinel event analysis. Hospitals are staffed with extremely smart people, but they just don’t have the training or expertise to perform comprehensive root cause analysis and incident investigation. Many feel that, because they have smart people, they can perform these analyses without further training. Unfortunately, incident investigation is a skill, just like other skills learned by doctors, nurses, and patient quality staff, and this skill requires specialized training and methodology. When a facility is presented with this training (yes, I’m talking about TapRooT®!), I’ve found that they embrace the training and perform excellent investigations. Hospital staff just need this bit of training to move to the next level of finding scientifically-derived root causes and applying effective corrective actions, all without playing the blame game. It is gratifying to see doctors and nurses working together to correct these issues on their own, without needing some expensive guru to come in and do it for them.
Hospitals have the means to start fixing these issues. I’m hoping the smart people at these facilities take this to heart and begin putting processes in place to make a positive difference in their patient outcomes.
“We are going to find out who is to blame because that is the frustrating part about health and safety accidents such as this. When we go back, when we read the report, we find out each and every time that it was preventable. That’s why we need to learn from this,” Kevin Flynn, Ontario’s labour minister, told reporters Tuesday afternoon.
That’s a quote from CP 24, Toronto’s Breaking News. See the story and watch the video interview about the accident here:
Is there a lesson to be learned here?
Interestingly, the “contractor” performing the work in this accident was a branch of the Ontario government.
On April 3rd, an Amtrak passenger train collided with a backhoe that was being used by railroad employees for maintenance. Two maintenance workers were killed, and about 20 passengers on the train were injured. For those that are not familiar with the railroad industry, I wanted to discuss a system that was in place that was designed to help prevent these types of incidents.
Many trains are being back-fitted with equipment and software that is collectively known as positive train control (PTC). These systems include sensors, software, and procedures that are designed to help the engineer safely operate the train. It is designed to allow for:
- Train separation and collision avoidance
- Speed enforcement
- Rail worker safety
For example, as the train approaches a curve that has a lower speed limit, a train with PTC would first alert the engineer that he must reduce speed, and then, if this doesn’t happen, automatically reduce the speed or stop the train as necessary to prevent exceeding tolerance. Another example is that, if maintenance is known to be occurring on a particular section of track, the train “knows” it is not allowed to be on that particular section, and will slow / stop to avoid entering the restricted area. The system can be pretty sophisticated, but this is the general idea.
Notice that I described the system as a series of sensors, software, and procedures that make up PTC. While we can put all kinds of sensors and software in place, there are still procedures that people must follow for the system to operate properly. For example, in in order to know about worker safety restrictions on a particular piece of track, there are several things that must happen:
- The workers must tell the dispatcher they are on a specific section of track (there are very detailed procedures that cover this).
- The dispatcher must correctly tell the system that the workers are present.
- The software must correctly identify the section of track.
- The communications hardware must properly communicate with the train.
- The train must know where it is and where it is going.
- The workers must be on the correct section of track.
- The workers must be doing the correct maintenance (for example, not also working on an additional siding).
- If being used, local temporary warning systems being used by the workers must be operating properly. For example, there are devices that can be worn on the workers’ bodies that signal the train, and that receive a signal from the train.
- Proper maintenance must be performed on all of the PTC hardware and software.
As you can see, just putting a great PTC system in place involves more than just installing a bunch of equipment. Workers must understand the equipment, its interrelation with the train and dispatcher, how the system is properly initialized and secured, the limitations of the PTC system, etc. People are still involved.
For the Washington Amtrak crash, we know that there was a PTC system in place. However, I don’t know how it was being employed, if it was working properly, were all the procedures being followed, etc. I am definitely not trying to apportion any blame, since I’m not involved in the investigation. However, I did want to point out that, while implementation of PTC systems is long overdue, it is important to realize that these systems have many weak points that must be recognized and understood in order to have them operating properly.
Humans will almost always end up being the weak link, and it is critical that the entire system, including the human interactions with the system, be fully accounted for when designing and operating the system. Proper audits will often catch these weak barriers, and proper investigations can help identify the human performance issues that are almost certainly in play when an accident occurs. By finding the human performance issues, we can target more effective corrective actions than just blaming the individual. Our investigations and audits have to take the entire system into account when looking for improvements.
For the 25th year, the AFL-CIO has produced a report about the the state of safety and health for American workers. The report states that in 2014, 4,821 workers were killed on the job in the U.S., and approximately 50,000 died from occupational diseases. This indicates a loss of 150 workers each day from hazardous conditions.
READ the full report.
Read story here.
The following sequence is from the Clarence Bee …
First, an air conditioning unit for a power supply room failed.
No big deal … There’s an automatic backup and a system to notify the engineer.
Oops … It failed too.
Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?
Sorry. In the “heat” of the moment, he pushed the “kill” button.
Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it.
Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.
What can you learn from this incident?
- Do your people know what to do when things go wrong?
- Do you do drills?
- Are things clearly labeled?
- Are there response procedures?
- How long has it been since people were trained?