Category: Accidents

Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013

July 14th, 2014 by

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The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:

At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.

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The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.

RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140616_R132014_Winchfield.pdf

 

Quote from the New Your Times

July 13th, 2014 by

“These events revealed totally unacceptable behavior. They should never have happened. I’m upset, I’m angry, I’ve lost sleep over this, and I’m working on it until the issue is resolved.”

DR. THOMAS FRIEDEN, director of the Centers for Disease Control and Prevention, which halted shipments of infectious agents from the agency’s labs after accidents with anthrax and flu pathogens.

- – -

What do you think? Time for advanced root cause analysis to get beyond “bad behavior” cause?

Accident Causes Red Bull Flood on Florida Highway

July 9th, 2014 by

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Wildlife along I-95 got a caffein overdose when a truck caring Red Bull was involved in an accident. It may be days before they go to sleep and some worried that the animals may take programmers jobs once fully fueled on caffeine. 

See the real story by CLICKING HERE.

Press Release from the UK RAIB: Accident to a track worker near Redhill, 24 June 2014

July 8th, 2014 by

NewImageSite of the accident

 RAIB is investigating an accident to a track worker who was supervising a gang carrying out track maintenance work near Redhill in Surrey. The accident occurred at about 10:40 hrs on 24 June 2014. The track worker was struck by a passenger train and suffered serious injuries.

The injured person was with a gang of eleven people engaged in undertaking repairs to the Up Quarry line between Redhill Tunnel and Quarry Tunnel. The train, a passenger service from Gatwick Airport to London Victoria, was travelling at about 80 mph (129 km/h).

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.

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Releases Report on Accident at Balnamore Level Crossing, Ballymoney, Northern Ireland, 31 May 2013

July 7th, 2014 by

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Here’s the Summary from the report:

At approximately 03:10 hrs on Friday, 31 May 2013, a car driver was forced totake action in order to avoid colliding with an engineering train that was traversing Balnamore automatic half barrier level crossing, which is located between Coleraine and Ballymoney stations on Northern Ireland Railways’ Belfast to Londonderry/ Derry line. The car subsequently struck metal fencing forming part of the crossing, causing minor injuries to its two occupants and damage to the car. The crew of the engineering train spoke with the car driver and then continued work without reporting the accident.

At the time of the accident, the engineering train was undertaking weed-spraying operations within a possession of the line, which meant that operation of passenger trains on the line had been suspended. Because the line was under possession, Balnamore level crossing, which is normally automatically operated by approaching trains, was being operated manually via its local controls. However, as the train passed over the crossing, its half barriers had not been lowered and its road traffic signals were not operating, even though this was required by the railway rules relating to this type of level crossing. This meant that the car driver did not have enough warning to stop his car before the level crossing became occupied by the train.

The RAIB has found that the team responsible for undertaking weed-spraying was routinely not complying with the rules relating to the operation of automatic half barrier level crossings within possessions. This was probably due to a combination of factors, including the team possibly having a low perception of the risks presented by this non-compliance and a desire by them to complete the weed-spraying more quickly. In addition, the team may have been influenced by the status of rules relating to the local control of other types of crossing in possessions and the method of work adopted at level crossings during a recent project.

The RAIB has also found that this non-compliance was not detected or corrected by safety checks conducted by Northern Ireland Railways. In addition, the investigation identified that the appointment of additional competent staff to operate crossings within the possession may have prevented the accident from occurring.

The RAIB has identified three key learning points. These are: 1) that the person in charge of a possession should correctly complete the form intended to help them keep track of level crossings; 2) that boarding moving trains, where it is prohibited, should be avoided; and 3) that accidents should be reported.

The RAIB has also made three recommendations addressed to Northern Ireland Railways. These relate to: 1) ensuring that activities undertaken at level crossings within possessions are subject to effective risk controls; 2) ensuring that method statements relating to track engineering are supported by risk assessments; and 3) increasing the opportunities for non-compliances to be detected and corrected.

For the complete report, CLICK HERE.

Monday Accident & Lessons Learned: OGP Safety Alert – WELLHEAD GLAND NUT/LOCKSCREW ASSEMBLY EJECTION

June 30th, 2014 by

OGP SAFETY ALERT

A gas well installation suffered a loss of containment when a gland nut and lockscrew assembly was ejected from a wellhead while the well was under pressure, shortly before commencing tubing installation. The release of gas resulted in a fire which caused the death of a field service technician.

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Lockscrews are commonly used in surface wellhead equipment to mechanically energize or retain internal wellhead components. Lockscrews are not standardized across the industry, so manufacturers’ procedures should always be used for operations that may require manipulation of lockscrews. Work involving gland nut and lockscrew assemblies should be done under the supervision of qualified service personnel from the wellhead equipment provider who have access to the operational procedures, key dimensions, and torque ratings necessary for correct use.

Operators should consider working with their wellhead equipment and service providers to validate the integrity of gland nut and lockscrew assemblies that are exposed to wellbore pressure in the field by taking the following steps:

 

  1. Verify adequate engagement of gland nuts;
  2. Confirm lockscrew assemblies’ torque values are consistent with manufacturer’s specifications;
  3. Inspect lockscrew assemblies for any debris or damage such as scarring or bending;
  4. Follow manufacturer’s procedures if checks show any of the above are inconsistent with the manufacturer’s specifications;
  5. Conduct a pressure test to rated maximum working pressure to ensure gland nut and lockscrew assemblies have pressure integrity;
  6. Consider isolating gland nut and lockscrew assemblies from wellbore pressure by having tubing hangers and adapters installed;
  7. Reinforce with relevant personnel training and the use of procedures to address hazards associated with performing work on wellhead assemblies exposed to wellbore pressure; and
  8. Review and implement appropriate engineering and well design controls (physical design of equipment) and administrative controls (procedures) to address the hazards of work involving gland nut and lockscrew assemblies.

These same validation steps should be taken prior to commencing any well work during which gland nut and lockscrew assemblies will be exposed to wellbore pressure.

safety alert number: 256
OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP 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.

 

 

Monday Accident & Lessons Learned: You Don’t Have to be in a High Risk Industry to be Killed on the Job

June 16th, 2014 by

 

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This fatal accident should remind all of us that you don’t have to be in a high risk occupation to be killed on the job. A forklift in the warehouse is all that is needed to provide the energy needed to start a fatal accident. See the press report here of a recent forklift fatality that is being investigated by OSHA:

http://www.pennlive.com/midstate/index.ssf/2014/06/jody_rhoads_amazon_osha.html

Proactive use of root cause analysis is needed in all sorts of industries to improve safety and prevent fatal accidents. Are you doing all you can to keep your employees safe?

Press Release from the UK RAIB: Derailment at London Paddington station 25 May 2014

June 12th, 2014 by

 

RAIB is investigating a derailment that occurred at London Paddington main line station, on Sunday 25 May 2014.

The train that derailed was an empty five car Class 360/2 passenger train (reporting number 5T08), manufactured by Siemens and operated by Heathrow Express. It was travelling from Old Oak Common to Paddington in preparation for entering passenger service.

At 05:20 hrs, both sets of wheels on the leading bogie of the third vehicle derailed to the left when the vehicle was about 150 metres from the buffer stops in platform 3 and travelling at between 12 and 14 mph (19.3 and 22.5 km/h).

The driver twice stopped the train after it derailed. On both occasions, unaware of what had happened, he restarted the train. As a consequence, the train ran nearly 100 metres in a derailed state and was finally stopped with the right side of the derailed bogie in a pit that was located between the rails, which lifted both wheels on the left side of the rear bogie off the rails. No one was injured.

Platform 3 remained closed for the remainder of the day.

NewImageImage of derailed vehicle at Paddington station

RAIB’s investigation will examine the sequence of events leading up to the derailment and will seek to identify the causes. This will include consideration of the design, maintenance and condition of both the track and the derailed vehicle.

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

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

Maintenance Error Causes Fire at Power Plant in Colorado

June 10th, 2014 by

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A mechanic opened the wrong end of a filter causing oil to spray on hot piping. The immediate flash fire caused extensive damage at the Martin Drake power plant run by Colorado Springs Utilities.

See the Colorado Springs Fire Department report here:

http://www.pennenergy.com/content/dam/Pennenergy/online-articles/2014/06/CSFD%2BDuty%2BReport%2Bfor%2BDrake%2BFire%2B052314.pdf

Press Release from the US CSB: CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

June 5th, 2014 by

 

CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

 Report Says Similar Accident Could Still Occur, Calls for Better Management
of Safety-Critical Elements by Offshore Industry, Regulators

 Houston, Texas, June 5, 2014— The blowout preventer (BOP) that was intended to shut off the flow of high-pressure oil and gas from the Macondo well in the Gulf of Mexico during the disaster on the Deepwater Horizon drilling rig on April 20, 2010, failed to seal the well because drill pipe buckled for reasons the offshore drilling industry remains largely unaware of, according to a new two-volume draft investigation report released today by the U.S. Chemical Safety Board (CSB).

CLICK HERE to access Overview
CLICK HERE to access Volume 1
CLICK HERE to access Volume 2

The blowout caused explosions and a fire on the Deepwater Horizon rig, leading to the deaths of 11 personnel onboard and serious injuries to 17 others.  Nearly 100 others escaped from the burning rig, which sank two days later, leaving the Macondo well spewing oil and gas into Gulf waters for a total of 87 days. By that time the resulting oil spill was the largest in offshore history.  The failure of the BOP directly led to the oil spill and contributed to the severity of the incident on the rig.

The draft report will be considered for approval by the Board at a public meeting scheduled for 4 p.m. CDT at the Hilton Americas Hotel, 1600 Lamar St., Houston, TX 77010.  The meeting will include a detailed staff presentation, Board questions, and public comments, and will be webcast at:

http://www.csb.gov/investigations/webcast/.

The CSB report concluded that the pipe buckling likely occurred during the first minutes of the blowout, as crews desperately sought to regain control of oil and gas surging up from the Macondo well.  Although other investigations had previously noted that the Macondo drill pipe was found in a bent or buckled state, this was assumed to have occurred days later, after the blowout was well underway.

After testing individual components of the blowout preventer (BOP) and analyzing all the data from post-accident examinations, the CSB draft report concluded that the BOP’s blind shear ram – an emergency hydraulic device with two sharp cutting blades, intended to seal an out-of-control well – likely did activate on the night of the accident, days earlier than other investigations found.  However, the pipe buckling that likely occurred on the night of April 20 prevented the blind shear ram from functioning properly.  Instead of cleanly cutting and sealing the well’s drill pipe, the shear ram actually punctured the buckled, off-center pipe, sending huge additional volumes of oil and gas surging toward the surface and initiating the 87-day-long oil and gas release into the Gulf that defied multiple efforts to bring it under control.

The identification of the new buckling mechanism for the drill pipe ­– called “effective compression” – was a central technical finding of the draft report.  The report concludes that under certain conditions, the “effective compression” phenomenon could compromise the proper functioning of other blowout preventers still deployed around the world at offshore wells.  The complete BOP failure scenario is detailed in a new 11-minute computer video animation the CSB developed and released along with the draft report.

The CSB draft report also revealed for the first time that there were two instances of mis-wiring and two backup battery failures affecting the electronic and hydraulic controls for the BOP’s blind shear ram.  One mis-wiring, which led to a battery failure, disabled the BOP’s “blue pod” – a control system designed to activate the blind shear ram in an emergency.  The BOP’s “yellow pod” – an identical, redundant system that could also activate the blind shear ram – had a different miswiring and a different battery failure.  In the case of the yellow pod, however, the two failures fortuitously cancelled each other out, and the pod was likely able to operate the blind shear ram on the night of April 20.

“Although both regulators and the industry itself have made significant progress since the 2010 calamity, more must be done to ensure the correct functioning of blowout preventers and other safety-critical elements that protect workers and the environment from major offshore accidents,” said Dr. Rafael Moure-Eraso, the CSB chairperson. “The two-volume report we are releasing today makes clear why the current offshore safety framework needs to be further strengthened.”

“Our investigation has produced several important findings that were not identified in earlier examinations of the blowout preventer failure,” said CSB Investigator Cheryl MacKenzie, who led the investigative team.  “The CSB team performed a comprehensive examination of the full set of BOP testing data, which were not available to other investigative organizations when their various reports were completed.  From this analysis, we were able to draw new conclusions about how the drill pipe buckled and moved off-center within the BOP, preventing the well from being sealed in an emergency.”

The April 2010 blowout in the Gulf of Mexico occurred during operations to “temporarily abandon” the Macondo oil well, located in approximately 5,000-foot-deep waters some 50 miles off the coast of Louisiana.  Mineral rights to the area were leased to oil major BP, which contracted with Transocean and other companies to drill the exploratory Macondo well under BP’s oversight, using Transocean’s football-field-size Deepwater Horizon drilling rig.

The blowout followed a failure of the cementing job to temporarily seal the well, while a series of pressure tests were misinterpreted to indicate that the well was in fact properly sealed.  The final set of failures on April 20 involved the Deepwater Horizon’s blowout preventer (BOP), a large and complex device on the sea floor that was connected to the rig nearly a mile above on the sea surface.

Effective compression, as described in the draft report, occurs when there is a large pressure difference between the inside and outside of a pipe.  That condition likely occurred during emergency response actions by the Deepwater Horizon crew to the blowout occurring on the night of April 20, when operators closed BOP pipe rams at the wellhead, temporarily sealing the well.  This unfortunately established a large pressure differential that buckled the steel drill pipe inside the BOP, bending it outside the effective reach of the BOP’s last-resort safety device, the blind shear ram.

“The CSB’s model differs from other buckling theories that have been presented over the years but for which insufficient supporting evidence has been produced,” according to CSB Investigator Dr. Mary Beth Mulcahy, who oversaw the technical analysis.  “The CSB’s conclusions are based on real-time pressure data from the Deepwater Horizon and calculations about the behavior of the drill pipe under extreme conditions.  The findings reveal that pipe buckling could occur even when a well is shut-in and apparently in a safe and stable condition.  The pipe buckling – unlikely to be detected by the drilling crew – could render the BOP inoperable in an emergency.  This hazard could impact even the best offshore companies, those who are maintaining their blowout preventers and other equipment to a high standard.  However, there are straightforward methods to avoid pipe buckling if you recognize it as a hazard.”

The CSB investigation found that while Deepwater Horizon personnel performed regular tests and inspections of those BOP components that were necessary for day-to-day drilling operations, neither Transocean nor BP had performed regular inspections or testing to identify latent failures of the BOP’s emergency systems. As a result, the safety-critical BOP systems responsible for shearing drill pipe in emergency situations – and safely sealing an out-of-control well – were compromised before the BOP was even deployed to the Macondo wellhead.  The CSB report pointed to the multiple miswirings and battery failures within the BOP’s subsea control equipment as evidence of the need for more rigorous identification, testing, and management of critical safety devices.  The report also noted that the BOP lacked the capacity to reliably cut and seal the 6-5/8 inch drill pipe that was used during most of the drilling at the Macondo well prior to April 20 – even if the pipe had been properly centered in the blind shear ram’s blades.

Despite the multiple maintenance problems found in the Deepwater Horizon BOP, which could have been detected prior to the accident, CSB investigators ultimately concluded the blind shear ram likely did close on the night of April 20, and the drill pipe could have been successfully sealed but for the buckling of the pipe. 

“Although there have been regulatory improvements since the accident, the effective management of safety critical elements has yet to be established,” Investigator MacKenzie said.  “This results in potential safety gaps in U.S. offshore operations and leaves open the possibility of another similar catastrophic accident.”

The draft report, subject to Board approval, makes a number of recommendations to the U.S. Department of Interior’s Bureau of Safety and Environmental Enforcement (BSEE), the federal organization established following the Macondo accident to oversee U.S. offshore safety. These recommendations call on BSEE to require drilling operators to effectively manage technical, operational, and organizational safety-critical elements in order to reduce major accident risk to an acceptably low level, known as “as low as reasonably practicable.”

“Although blowout preventers are just one of the important barriers for avoiding a major offshore accident, the specific findings from the investigation about this BOP’s unreliability illustrate how the current system of regulations and standards can be improved to make offshore operations safer,” Investigator MacKenzie said.  “Ultimately the barriers against a blowout or other offshore disaster include not only equipment like the BOP, but also operational and organizational factors.  And all of these need to be rigorously defined, actively monitored, and verified through an effective management system if safety is to be assured.”  Companies should be required to identify these safety-critical elements in advance, define their performance requirements, and prove to the regulator and outside auditors that these elements will perform reliably when called upon, according to the draft report.

The report also proposes recommendations to the American Petroleum Institute (API), the U.S. trade association for both upstream and downstream petroleum industry. The first recommendation is to revise API Standard 53, Blowout Prevention Equipment Systems for Drilling Wells, calling for critical testing of the redundant control systems within BOP’s, and another for new guidance for the effective management of safety-critical elements in general.

CSB Chairperson Rafael Moure-Eraso said, “Drilling continues to extend to new depths, and operations in increasingly challenging environments, such as the Arctic, are being planned.  The CSB report and its key findings and recommendations are intended to put the United States in a leading role for improving well-control procedures and practices.  To maintain a leadership position, the U.S. should adopt rigorous management methods that go beyond current industry best practices.”

Two forthcoming volumes of the CSB’s Macondo investigation report are planned to address additional regulatory matters as well as organizational and human factors safety issues raised by the accident.

Court Rules BP Must Pay Clean Water Act Fines for Deepwater Horizon/Macondo Blowout

June 5th, 2014 by

BP tried to argue that Transoceans equipment failed (the blowout preventer) but the court rulesd that the well owners must pay the fines. For details, see:

http://fuelfix.com/blog/2014/06/04/court-bp-must-pay-clean-water-act-fines-for-spill/

BBC Reports Heat Exhaustion Incident Aboard British Nuclear Sub

June 5th, 2014 by

Interesting incident was reported by the BBC. See the details here:

http://www.bbc.com/news/uk-england-devon-27694389

This should remind everyone to brief folks on heat exhaustion as the temperatures soar this summer.

OSHA Heat Exhaustion

“Normalization of Deviance” – The Cause of Accidents in a Complex Era?

June 2nd, 2014 by

A quote from the New York Times article:

“Another sociologist, Diane Vaughan, has written extensively about Challenger and served on the commission that investigated the Columbia horror. She has advanced the theory of ‘normalization of deviance,’ meaning that in many organizations — NASA certainly being no exception — some problems and risks are understood to be acceptable — part of doing business, if you will. Take those problematic O rings on Challenger. Their erosion had been evident on earlier launchings, but flying with them became routine. To Ms. Vaughan, NASA’s decision to forge ahead on that fateful January day in 1986, despite new concerns about the O rings that were raised, did not reflect cold, bottom-line thinking or an amoral bending of rules. ‘They applied all the usual rules,’ she told Retro Report. Regrettably, they did so ‘in a situation where the usual rules didn’t apply.’”

The video presents Interesting concepts about accident causes. Mark Paradies, President of System Improvements, will present a talk about Normalization of Deviance at the 2015 Global TapRooT® Summit. Watch for more information as Summit planning progresses. The 2015 Global TapRooT® Summit will be held on June 1-5, 2015 in Las Vegas, NV.

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Report: Collision at Buttington Hall user worked crossing, Welshpool, 16 July 2013

June 2nd, 2014 by

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Here’s the summary of the UK RAIB’s report:

At 11:44 hrs on Tuesday 16 July 2013 a collision occurred between a passengertrain and a farm trailer at Buttington Hall farm crossing near Welshpool on the line between Shrewsbury and Machynlleth. The tractor driver and two other people nearby sustained minor injuries and two passengers on the train were injured and taken to hospital, but were discharged later that day.

The train involved was operated by Arriva Trains Wales and consisted of two 2-car units. It was travelling at 120 km/h (75 mph) at the time of the collision. The train was running from Birmingham International to Aberystwyth and Pwllheli and there were 140 passengers and two crew members on board. On the day of the accident, the farm crossing was being used by tractors bringing in a harvest from fields on the opposite side of the line to the farm. The farmer had appointed a contractor to carry out the harvesting operation, and an attendant had been provided at the crossing to phone the signaller and operate the gates.

The accident occurred because the system of work in use at the crossing was inherently unsafe, leading to ineffective control of road vehicle movements over the crossing and frequent use of the crossing without the signaller being contacted. This system broke down. There were also underlying management factors:

  • the harvest contractor did not implement an effective safe system of work at the crossing;
  • Network Rail’s process for risk assessment of these types of crossing did not adequately deal with periods of intensive use; and
  • Network Rail’s instructions to users of these crossings did not cover periods of intensive use.

The RAIB has made three recommendations:

  • main line infrastructure managers should improve the risk assessment process at these crossings to take into account the increased risk during periods of intensive use;
  • main line infrastructure managers should define safe and practical methods of working to be adopted at these crossings during periods of intensive use; and
  • RSSB should update the level crossing risk management toolkit to reflect the changes brought about by the second recommendation.

The RAIB has also noted a learning point from an observation made during the investigation concerning the prolonged closure of an adjacent level crossing on a main road after the accident.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140327_R062014_Buttington_Hall.pdf

Remembering an Accident: The Flixborough Explosion

June 1st, 2014 by

On June 1, 1974, 28 employees were killed and 36 injured during a massive vapor cloud explosion at the Flixborough Works of Nypro (UK) Limited. Additionally, hundreds of people offsite were injured and over 1,800 houses and 167 businesses in the surrounding communities were damaged.

The investigation indicated that the explosion may have been caused by a failure of a temporary piping modification. Thirty tons of cyclohexane vapor were released when the piping failed, and when the vapor cloud found an ignition source, the energy released was equivalent to about 16 tons of TNT.

Open the .pdf of the Report of Court of Inquiry:

http://www.catastrophic-events.com/docs/Flixborough.pdf

Learn how to lead your team in root cause analysis and avoid major incidents where lives are lost and workers and community members are injured:

http://www.taproot.com/courses#5-day-root

UK RAIB Press Release: Collision at Loughborough Central on the Great Central Railway (GCR), 12 May 2014

May 30th, 2014 by

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 RAIB is investigating a collision that occurred at around 12:35 hrs on Monday 12 May 2014 between an unmanned runaway train and a set of five coaches that was stabled on the down main line about 450 metres on the approach to Loughborough Central station. Nobody was injured as a result of the collision, although significant damage was sustained by some of the rail vehicles involved. The GCR was not open to the public when the collision occurred.

The train consisted of a Class 37 locomotive coupled to a single preserved Travelling Post Office (TPO) coach. It ran away on the down main line, with the TPO coach leading, from a position opposite Quorn signal box for a distance of about 1.8 miles (2.9 km) before the collision occurred.

The RAIB’s preliminary examination has shown that the locomotive had been used during the morning of 12 May to undertake shunting operations within a section of line, around 4.4 miles (7 km) in length, that was closed to normal railway traffic (ie it was under a ‘possession’). As part of these shunting operations, the locomotive had been coupled to the TPO coach, although the braking systems of the locomotive and coach were not connected.

At around 11:50 hrs, the train was left unattended on the down main line opposite Quorn signal box (still within the possession). At this location the line has a 1 in 330 gradient, descending towards Loughborough. This descending gradient becomes steeper beyond Quorn before reducing and subsequently levelling out on the approach to where the collision occurred.

Evidence suggests that, before leaving the train unattended, the crew applied the locomotive’s air brakes, shut-down its engine and applied a single wheel scotch (also known as a chock) underneath one of the locomotive’s wheels. Neither of the two parking brakes (also known as hand brakes) on the locomotive were applied (the TPO coach is not equipped with a parking brake). While the train was unattended it ran away in the direction of Loughborough and exited the possession. Fortunately, no staff were working on the portion of line over which the train ran away.

The set of five coaches which was struck by the train had been stabled on the down main line outside of the possession and within the station limits of Loughborough Central station. The set had been secured by the parking brake of one of its coaches.

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

Remembering An Accident: How Centralia, Pennsylvania Became a Ghost Town

May 27th, 2014 by

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At one time there were over 1,000 residents who lived in the mining town of Centralia, Pennsylvania. By 2010, it was a ghost town of ten residents. What happened?

Fifty-two years ago, on May 27, 1962, an exposed coal seam was ignited by a fire in the town’s dump. The fire was intentionally set by the fire department to tidy up the town for Memorial Day.

After the coal seam was ignited, fire spread underground throughout mines that ran under homes and businesses, threatening the town’s residents with potential poisonous gases and dangerous sinkholes. Rather than put the fire out which would have cost tremendous resources, the residents were relocated and buildings were taken down.

Books have been written about it, “Fire Underground” (David DeKok) and “The Day the Earth Caved In: An American Mining Tragedy” (Joan Quigley). Today it is a town filled with unkempt streets, smoldering earth, and ominous warning signs.

Still burning over 50 years later, it is ranked as one of the worst mine fires in the history of the United States.

Worst case scenarios like these can keep us up at night! Rest easier by feeling equipped to find the real root causes of accidents and incidents. Learn all the essentials of TapRooT® Root Cause Analysis in just two days:

http://www.taproot.com/courses#2-day-incident

Monday Accident & Lessons Learned: Hot McDonald’s Coffee Lawsuit – The REAL Facts

May 26th, 2014 by

In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training we briefly discuss the famed 1994 lawsuit in which a woman (Stella Liebeck) spilled hot McDonald’s coffee on her lap and sued the company in response. It’s been held up in popular culture as an example of Americans’ propensity to sue over any issue just to make a buck.

You, however, know from our 5-Day course that the root causes of the woman’s serious injuries were due to McDonald’s unsafe coffee temperature.

Learn the real facts about the lawsuit in this 12-minute video. It’s a great quick example of gathering facts before making the judgment. Warning: You’ll see photos of Ms. Liebeck’s third degree burns from 5:11 to 5:21.

Haven’t attended our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, but interested in learning to investigate incidents like this in your facility? Click here to find out how our course will teach you to find and fix the root causes of serious health, safety, quality, and environment issues in your workplace.

More Mis-Measurements – This Time It’s a Train in France

May 23rd, 2014 by

You would think that making new trains the right width to fit into all the stations would be in the design specs. But not so fast for these trains in France. See:

http://news.yahoo.com/red-faces-french-trains-too-wide-stations-103141069.html

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