Taproot

17 have been confirmed dead with the death toll expected to rise to 28. See:

http://online.wsj.com/article/SB10001424127887323463704578494841690795414.html

The next time someone says they used 5-Whys to investigate an accident, just thing …

5-Whys = Root Cause Analysis Malpractice

Because 5-Whys is almost always root cause analysis malpractice. If you don’t believe it, assign someone who is good at 5-Whys to analyze a problem and someone who is good at using TapRooT® to analyze the same problem. Look at the results and you will see what I’m talking about.

That’s the lesson learned for today.

See:

http://news.yahoo.com/probe-begins-conn-commuter-trains-crash-070249473.html

1,127 workers were killed in what is reportedly the worst disaster in the history of the global apparel industry.

One survivor said she heard from colleagues that cracks had appeared in the building and was reluctant to enter but was told by management that there was no problem. The building owner had been accused of using shoddy building materials and building extra floors, and then filling them with heavy equipment:

Read more in the Los Angeles Times:

http://www.latimes.com/news/world/worldnow/la-fg-wn-bangladesh-building-collapse-search-for-bodies-20130513,0,3014839.story

West, Texas, May 16, 2013 – As other agencies wrapped up their on-site investigations into the ammonium nitrate explosion at West Fertilizer in West, Texas, the U.S. Chemical Safety Board (CSB) announced its work to examine all aspects of the tragedy will continue in the town of West, at the Western Regional Office in Denver, and at the agency’s headquarters in Washington, DC.

The CSB deployed a team of approximately 18 investigators and other technical experts within 24 hours of the incident on April 17, and has maintained an almost continuous presence in West since then.  The sudden blast led to at least 14 fatalities, approximately 200 injuries, and widespread damage and destruction in the small town of West, Texas, located between Dallas and Waco. 

CSB Chairperson Rafael Moure-Eraso said, “On behalf of our investigation team and the board, I would like to thank the mayor, fire and police officials, community members and West Fertilizer employees for their outstanding cooperation with the CSB during an extraordinarily difficult period.  Our hearts go out to the residents, employees, and emergency responders and we want everyone to know we are fully committed to providing a thorough public account of all the factors that led to this catastrophe. After a disaster of this scale, it is essential to pursue improved safety as we look toward the future.”

CSB Western Regional Office Director Don Holmstrom said, “The CSB will be examining many issues surrounding the explosion such as the safe storage and handling of ammonium nitrate, the siting of vulnerable public facilities and residential units near the facility, and emergency responder safety. In addition, the investigation will examine the adequacy of national standards, industry practices, and regulations for the safe storage and handling of ammonium nitrate.”

CSB investigation areas of inquiry will include ammonium nitrate safe handling and storage standards here and in other countries such as the UK and Australia; land use planning and zoning practices for high-hazard facilities in relation to schools, public facilities, and residential areas; ammonium nitrate detonation mechanisms; the effectiveness of regulatory coverage including OSHA, EPA, and the State of Texas; whether there are inherently safer products or safer ways to store and mitigatethe damage should a fire or explosion occur. The investigation will examine the emergency response during the fire at West, and practices, including preparedness, fire codes, and guidelines for good practices found in other jurisdictions.

Dr. Moure-Eraso stressed the CSB does not issue fines or penalties of any kind, or seek civil or criminal sanctions. “We do not look for individual fault or blame with regard to actions taken before an accident or in response to them.  Rather, we produce what are called root cause investigations.”

The CSB is in the process of conducting witness interviews and gathering documents and other evidence. It has documented blast damage and patterns in the community, and will engage in testing chemical samples and conducting a thorough analysis of the nature and magnitude of the blast, and its actual and potential consequences.

Chairperson Moure-Eraso said, “This accident produced far more offsite community damage and destruction than any we have investigated since the agency opened its doors in 1998.  We will release information and findings when possible as we continue our work, and in the end will issue a comprehensive root cause report with recommendations.  We also encourage members of the public and stakeholders to share information directly with the CSB as the investigation progresses.”

The CSB established a Facebook page, www.facebook.com/WestExplosion, to exchange information with the public concerning the investigation.

For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496.

There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.

How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.

Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.

Here are the links:

Mark’s General Session Talk About Fatality Prevention from the 2013 Summit

Marks Talk About SIF Prevention from the 2013 Summit (Part 1)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 2)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 3)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 1)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 2)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 3)

Mark’s Slides About Rickover & Process Safety from the 2010 Summit

Rickover’s Testimony to Congress About Reactor Safety (Process Safety)

I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.

For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.

Image of runaway maintenance vehicle at Glasgow Queen Street

The RAIB is investigating a serious accident caused when a road-rail maintenance vehicle ran away and struck scaffolding in a tunnel near Glasgow Queen Street High Level station on Sunday 21 April 2013.

The maintenance vehicle was a mobile elevating working platform (MEWP) that was equipped with both rubber wheels for road running and steel rail wheels for operation on the railway. It was intended to be used for engineering work on a section of track which was under possession (temporarily closed to normal train services).

The runaway started at the Keppochhill road-rail access point, a location within the possession where boarding laid between, and to either side of, the rails provides a flat surface allowing road-rail vehicles to be manoeuvred onto the track. This access point is on a section of railway which slopes downwards at a gradient of about 1 in 45 towards, and through, Queen Street High Level Tunnel before running onto level track as it enters Queen Street High Level station. Shortly before 03:00 hrs the MEWP was being transferred from its rubber tyred road wheels onto its rail wheels. During this manoeuvre the machine operator was controlling the machine by means of a remote control unit which was connected to the machine by a length of cable. As the rail wheels were lowered onto the track the MEWP started to run down the gradient, through the tunnel and into the station where it stopped about one mile (1.6 km) from the access point (and before reaching the buffers at the end of the platform).

No-one was onboard the MEWP as it ran away. However, while passing through the tunnel, the MEWP struck some scaffolding which was being erected as part of the planned engineering work and a person working on this scaffolding was seriously injured. Other members of staff working on the track were able to move clear of the runaway vehicle because they either heard its approach or were warned by mobile telephone.

A preliminary examination by the RAIB has shown that the runaway occurred because the brakes acting on the rail wheels were inadequate to stop the vehicle on the gradient and the road to rail transfer was not carried out correctly. The examination also showed that the MEWP ran through the tunnel without lights.

Rail wheel brakes on MEWPs of the type involved in the accident were intended to be effective on gradients of up to 1 in 29. Testing carried out to date suggests that the brakes may not always perform to this standard. Consequently additional restrictions have been placed on the use of this type of MEWP.

The RAIB’s investigation will identify:

- the sequence of events that led to the runaway;
- the factors influencing the actions of those involved in the operation of the machine as it was being placed onto the track;
- the actual capability of the rail wheel brakes;
- the design, approval, maintenance and/or testing processes that were applied to this type of MEWP; and
- the reasons for the loss of lighting on the runaway vehicle.

The RAIB’s investigation is independent of any investigations by the safety authority (the Office of Rail Regulation).

The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

What ever happened to all back emergency and right full rudder?

Better to learn in training than to learn by an accident!

Here’s the article about an incident at the AECL NRU Reactor at Chalk River:

http://www.thedailyobserver.ca/2013/05/09/aeclto-explain-near-miss

Here are my favorite two quotes from the article…

The initial report states: “Root cause has not yet been determined, but human error was a major contributor to the event.”

and also, “A safety stand down was held with the crew of each shift to discuss the importance of the event and event free tools that should have been used.”

Ahhh … the good old event-free tools.

Wonder what the human factors problems were?

Brig. Gen. James Lukeman relieved Lt. Col. Andrew McNulty, Capt. Kelby Breivogel and Chief Warrant Officer 3 Douglas Derring nearly two months after a 60 mm mortar tube exploded killing seven Marines. Here’s the story:

http://abcnews.go.com/US/wireStory/relieved-command-marine-training-accident-19142881#.UY7rSuDdFZE

What do you think when discipline is given prior to completing an accident investigation?

Some amazing quotes in the LA Times story:

“Utility giant Pacific Gas & Electric should pay a record $2.25-billion penalty for a 2010 natural gas explosion in San Bruno that killed eight people and devastated a neighborhood, regulators recommended Monday.”

“A report released Monday by the Commission’s Safety and Enforcement Division said its investigators found more than 100 violations by the company, some dating back decades.”

“‘Imposing a fine for each violation … would result in tens of billions of dollars of fines, which is more than PG&E’s net worth,’ the report said.”

“Regulators said they agreed on $2.25 billion “‘Because PG&E needs to retain its creditworthiness in order to be able to pay for its improvements in the safety of its facilities, as well as to procure natural gas and electric power.’”

What is the cost of an accident? Seems like this one could come close to bankrupting the company. Will they have any money left for improvement?

The Reuters’ article quotes Rachel Moreno, a spokeperson for the Texas State Fire Marshal’s Office as saying:

“The investigators have been able to narrow down the origin to the fertilizer and seed building on site, and we also know that what caused the explosion was the ammonium nitrate. What we don’t know is exactly why.”

For the whole article, see:

http://www.reuters.com/article/2013/05/07/us-usa-explosion-texas-idUSBRE9460GP20130507

Accident kills 60 but fighting to control mines kills 400. See:

http://www.voanews.com/content/gold-mine-collapse-kills-60-in-sudans-darfur-region/1653193.html

Image showing a tram on the Croydon network

The RAIB is investigating an incident in which a tram departed from two consecutive tram stops in Croydon with all four doors on one side open. Nobody was injured in the incident, but passengers were standing in the vicinity of the open doors and there was the potential for a serious accident to occur.

The tram involved was operating a service between West Croydon and Beckenham Junction. During the first part of its journey the tram was delayed on a number of occasions due to a succession of fault indications in the cab alerting the driver to a possible problem with a parking brake on one of the tram’s bogies. On each occasion the driver spoke to the controller and, after receiving instructions on how to deal with the fault, was able to continue the journey.

At some point during this early part of the journey it is believed that a switch was operated in the driving cab which had the effect of by-passing some safety systems on the tram, including the door interlocking arrangements that would normally prevent the tram from moving with one or more doors open.

At Lebanon Road tram stop, there was further dialogue between the tram driver and the controller. The tram then departed with all four doors on the left-hand side open and reached a maximum speed of 27 km/h (17 mph) while travelling towards Sandilands tram stop. At some point between the two stops, three of the four doors closed automatically, as they are designed to do after remaining open for two minutes.

At Sandilands, with the driver and controller unaware of the problem with the doors, they focused on dealing with the parking brake fault. The tram departed from Sandilands with all of the left-hand doors open again. By this stage, the controller was monitoring the tram’s departure on CCTV and noticed that the doors were open. He immediately contacted the driver and instructed him to stop. The driver then closed the doors and the tram was taken out of service at the next stop.

The RAIB’s investigation will identify the sequence of events that led to the incident. In particular, it will focus on:

- the content and application of procedures for dealing with faults on trams;
- the design, configuration and labelling of controls, indicators and other equipment within the driving cab of the tram involved in the incident; and
- the training and monitoring of tram drivers and controllers with a particular emphasis on fault handling.

The RAIB’s investigation is independent of any investigation by the safety authority (the Office of Rail Regulation).

The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

A train carrying toxic chemicals derailed near Ghent causing one death and 49 injuries. CLICK HERE to see the rest of the story.

The report has three learning points. Read the report and see if you think the right lessons were learned. See:

http://www.raib.gov.uk/cms_resources.cfm?file=/130425_R052013_Dunblane.pdf

A contract cleaner was killed when he fell into an operating meat blender at an Interstate Meat Distributors plant in Oregon. Deputy Nate Thompson said that the death was a “tragic industrial accident” and that the police didn’t suspect foul play. It took until the next day to disassemble the machine and remove his remains.

The AP story said:

“An OSHA report on the plant from last fall found machines were not locked during the tear-down process for cleaning. The inspector said an ‘’unexpected start-up of the machine’’ could cause injuries.”

“Melanie Mesaros, Oregon OSHA spokeswoman, cautioned against jumping to conclusions.”

“Mesaros said the agency inspected DCS Sanitation Management’s operations in 2001, 2002 and 2004, finding no violations.”

The OSHA investigation isn’t expected to be completed for months.

What do you think? Tragic accident or preventable accident?

The courtroom part of phase one of the BP Deepwater Horizon trial ended almost two weeks ago and the Judge has given parties two months to submit briefs to summarize how they see the evidence in the case.

The Judge specifically asked the parties to address the following questions:

1. What is the standard for finding “gross negligence” or “willful misconduct” under the Clean Water Act and the Oil Pollution Act of 1990?

2. What is the standard for a finding of punitive damages under general maritime law? Is this a different standard than under the Clean Water Act or the Oil Pollution Act, and if so, how?

3. In order to find that a party acted with gross negligence, is it necessary to find that there be at least one single act or omission that equates to gross negligence, or can such a finding be based upon an accumulation or a series of negligent acts or omissions?

4. Can an act or omission that is not itself causal of the accident nevertheless be considered in determining whether a party engaged in conduct constituting gross negligence?

5. In order to find gross negligence, is it sufficient if only employees on the rig are guilty of such conduct, or is it necessary to find that this level of conduct was attributable to shore-based or management-level employees?

6. Does compliance with Mineral Management Services (or other applicable) regulations preclude a finding of gross negligence regardless of whether a defendant knew or should have known that its conduct or equipment was unsafe, or violated accepted engineering standards?

7. Does the fact that a party acted with “industry standards” preclude a finding of gross negligence?

The New Orleans Times-Picay published two stories that provide a good overview of the end of the courtroom phase of the trial and the path forward. The first story deals with the trial and the path forward (CLICK HERE for the article).

The second story outlines the judges order to the parties including the questions asked above (CLICK HERE for that article).

Phase two of the trial is scheduled to start in September and it may be a year before the judge decides on the questions of the case.

Here’s a link to the story in the Houston Chronicle:

http://blog.chron.com/newswatch/accidents-fall-at-houston-red-light-camera-intersections/

The story says that:

“In the five months after Houston voters forced city officials to turn off a camera surveillance system that fined motorists for running red lights, traffic accidents at those 50 intersections with 70 cameras have decreased 16 percent, according to recently released data.”

There were lot’s of reasons given by officials for this unexpected outcome. Everything from the “weather was good” to “the camera’s had trained people to be safer.”

The interesting statistic that no one mentioned was that it is usual for rear-end collision to increase when red light cameras are installed because, to avoid a ticket, people slam on their brakes when a light turns red and they get rear ended.

There are at least two lessons that I think you can learn from this article.

1. People don’t know how to trend infrequently occurring accident statistics.

In this case, no one on either side of the argument used advanced trending techniques to prove their point. Instead, they chose the statistics that best fit their argument and claimed that those stats proved their point.

2. Sometimes corrective actions can have unintended consequences.

Several times in the past we’ve discussed red light cameras as an enforcement tool and the consequences that the tool could have on accident statistics. Our general opinion is that the cameras would be great for raising revenue but would do little to improve safety. For several reasons, rear end collisions were an unintended consequence of red light cameras that tend to increase accident rates at intersections where the devices were installed. So all people looking to improve performance should learn that your corrective actions may have other consequences than the ones you intend them to have!

A recent MSHA accident investigation of a fatal mine accident cited the mining company for having insufficient management systems (click HERE to read a story about the report).

What can you learn from this accident?

Have you reviewed your management systems to see if they are complete and adequate?

Image showing Athelney Automatic half barrier crossing

At about 06:23 hrs on Thursday 21 March 2013, train 1A73, the 05:46 hrs First Great Western service from Exeter St. Davids to London Paddington struck a car which was crossing the railway at Athelney level crossing near Taunton, Somerset. The driver of the car, who was its sole occupant, was killed in the collision.

The crossing is of the automatic half barrier type. At such crossings one barrier on each side of the railway is automatically lowered to block half of the road and thus prohibit approaching vehicles from passing through. The lowering of the barriers is preceded by the operation of flashing road traffic signals, which then continue to operate until the barriers are raised.

Evidence gathered to date suggests that the car had been detained at the crossing with the barriers down and the road traffic signals working correctly. The car was then driven round the crossing barriers and onto the crossing where the collision occurred.

The crossing closure sequence would normally be automatically initiated by an approaching train. For trains approaching at the maximum permitted speed of 100 mph (160 km/h), the warning lights start to flash around 27-28 seconds before the train arrives, and the barriers start to lower around 20 seconds before the train arrives. However, on this occasion the crossing closure sequence commenced earlier. This was because the previous train, an engineers’ on-track machine, had passed through the crossing in the opposite direction to normal. Under these circumstances, the configuration of the signalling controls at the crossing meant that the closure sequence started when the signaller set the route through the crossing for train 1A73.

The RAIB’s investigation will examine the sequence of events and the factors that may have influenced the actions of the car driver. It will also include an assessment of the design of the signalling controls for Athelney level crossing and a review of the arrangements made to manage the risk from automatic level crossing barriers being in the lowered position for variable periods of time.
The RAIB’s investigation is independent of any investigation by the safety authority (the Office of Rail Regulation) or the British Transport Police.
The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

Accident site at West Drayton

The RAIB is investigating a serious accident which occurred on a four track section of the Great Western main Line, near West Drayton, approximately 12½ miles west of London Paddington, on Friday 22 March 2013.

At around 10:37 hrs, the 09:07 hrs First Great Western service from Oxford to London Paddington was passing between West Drayton and Hayes & Harlington when it struck and seriously injured a track worker. The worker was employed through a labour agency and was part of a group undertaking survey work on or near railway lines which remained open to traffic. His role at the time of the accident was that of ‘intermediate lookout’.

The role of the intermediate lookout was to observe a ‘distant lookout’ and pass on any warnings of approaching trains to a ‘site lookout’ positioned with the people undertaking work on or near the line. When undertaking these duties he was required to look for westbound trains while standing in a position of safety at all times.

The RAIB’s investigation will consider the sequence of events that led to the accident and the factors that caused the intermediate lookout to undertake his duties when standing too close to the line used by eastbound trains. It will also review the planning of the work, its management on site, training and competency.

The RAIB’s investigation is independent of any investigation by the safety authority (the Office of Railway Regulation) or the British Transport Police.

The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

See the Chevron report at:

http://cchealth.org/hazmat/pdf/2012_0806_chevron_30day_report_7th_Apr12.pdf

See the story here …

http://www.chron.com/communityblogs/atmosphere/article/Official-12-bodies-recovered-after-West-plant-4447434.php?utm_source=WhatCountsEmail&utm_medium=breaking_news&utm_campaign=20130419_BN4447434

The article says that 200 were injured by the fire and blast.