Monday Accident & Lessons Learned: Was the Baker Report a Failure?

Posted: April 14th, 2014 in Accidents, Performance Improvement

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For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well to name the most prominent), the Baker Report is a famous independent review of the failure of process safety at BP.

I was reading a discussion about process safety and someone brought up the Baker Report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”

The initial Panel Statement at the start of the report includes this quote:

“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”

I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.

What do you think?

Was the report successful? Did it cause change and help BP have an improved process safety culture?

Or did the report fail to cause change across the company?

And if it failed, why did it fail?

Let me know your ideas by leaving your comments by clicking on the comments link below.

Friday Joke: New Type of Submarine

Posted: April 11th, 2014 in Accidents, Jokes, Pictures

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Doesn’t it need a snorkel?

How Far Away is Death?

Posted: April 8th, 2014 in Accidents, Human Performance, Video

Not too far on this day in 1983…

Monday Accident & Lessons Learned: Incident Report from the UK Rail Accident Investigation Branch: Tram running with doors open on London Tramlink, Croydon

Posted: April 7th, 2014 in Accidents, Current Events, Human Performance, Investigations, Pictures

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There were eight recommendations made by the UK RAIB. here’s a summary of the investigation:

On Saturday 13 April 2013 between 17:33 and 17:38 hrs, a tram travelling from West Croydon to Beckenham Junction, on the London Tramlink system, departed from Lebanon Road and Sandilands tram stops with all of its doors open on the left-hand side. Some of the doors closed automatically during the journey, but one set of doors remained open throughout the incident. The incident ended when a controller monitoring the tram on CCTV noticed that it had departed from Sandilands withits doors open, and arranged for the tram to be stopped. Although there were no casualties, there was potential for serious injury.

The tram was able to move with its doors open because a fault override switch, which disables safety systems such as the door-traction interlock, had been inadvertently operated by the driver while trying to resolve a fault with the tram. The driver didnot close and check the doors before departing from Lebanon Road and Sandilands partly because he was distracted from dealing with the fault, and partly because he did not believe that the tram could be moved with any of its doors open. The design of controls and displays in the driving cab contributed to the driver’s inadvertent operation of the fault override switch. Furthermore, breakdowns in communication between the driver and the passengers, and between the driver and the controller, meant that neither the driver nor the controller were aware of the problem until after the tram left Sandilands.

The RAIB has made eight recommendations. Four of these are to Tram Operations Ltd, aimed at improving the design of tram controls and displays, as well astraining of staff on, and processes for, fault handling and communications. Two recommendations have been made to London Tramlink, one (in consultation with Tram Operations Ltd) relating to improving cab displays and labelling and one on enhancing the quality of the radio system on the network. One recommendation is made to all UK tram operators concerning the accidental operation of safety override switches. The remaining recommendation is to the Office of Rail Regulation regarding the provision of guidance on ergonomics principles for cab interface design.


For the complete report, see:

Glen Deveaux dies after accident while vacationing in Mexico

Posted: April 6th, 2014 in Accidents

Thought that I’d pass along this sad news to all the TapRooT® Users who knew Glen from previous TapRooT® Summits, or who had worked with him.

Glen had an accident in February while on vacation and died yesterday after surgeries to try to save his life.

I do not have any information about where to send condolences to his family or any memorials, but if other TapRooT® Users have information, please post it in the comments.






Was it Taxes, Bad Decicions, or a “Complex Chain of Events” that caused the grounding of the drilling rig Kulluk near Kodiak Island?

Posted: April 4th, 2014 in Accidents, Current Events, Investigations


Alaska winters are notorious. And the seas in the Gulf of Alaska are particularly bad in mid-winter. The Houston Chronicle reported that Rear Admiral Thomas Ostebo said, “the most significant factor was the decision to attempt the voyage during the winter in the unique and challenging operating environment of Alaska.”

Interestingly, Shell may have been encouraged to move the rig because if they didn’t, they might have to pay the state of Alaska a multi-million dollar tax bill. 

See the whole story at:

Preliminary (Spring) SnapCharT® of the Lost Flight MH 370

Posted: March 31st, 2014 in Accidents, Current Events, Documents, Investigations, Pictures

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(Photo of remains from cockpit fire of an Egypt Air 777 while parked at a gate in Cairo)


One of our TapRooT® Users sent the attached PDF of a SnapCharT® for the loss of Malaysia Air MH 370. 

Have a look. See what you think. Then leave comments here…


Fallout of the GM Safety Recall

Posted: March 31st, 2014 in Accidents, Current Events

“General Motors issued a new recall of 1.5 million vehicles Monday, part of an effort to assure buyers that it’s moving faster to fix safety defects in its cars and trucks.

In a video message to employees posted Monday, CEO Mary Barra said the new recall resulted from a push to review potential safety issues and resolve them more quickly.

It’s part of the fallout from the recall last month of more than 1.6 million small cars for defective engine switches. The defect is linked to 12 deaths, and GM is facing multiple investigations into how it handled the recall. GM first began investigating the switches in 2004.

“Something went wrong with our process in this instance, and terrible things happened,” Barra said.


Read the full article here:

Monday Accident & Lessons Learned: Houston Oil Spill Marks Exxon Valdez Anniversary

Posted: March 31st, 2014 in Accidents, Current Events




“It’s been said that history repeats itself. It’s doubtful that the author of that saying had oil spills in mind at the time – and even less likely the Exxon Valdez oil spill. Still, the irony of this weekend’s collision and spill near Galveston Bay, Texas on the eve of the 25th anniversary of the 1989 Exxon spill has been hard to ignore.

Approximately 168,000 gallons of crude oil has been leaking into the Houston Ship Channel and Galveston Bay since Saturday — when a barge being pulled by a towboat collided with a cargo ship in the channel off the coast of Texas City, Texas.”

Click here for the full story:

Three Mile Island Accident Anniversary: The Nuclear Industry Discovers Human Factors

Posted: March 28th, 2014 in Accidents, Human Performance, Investigations


Five days of panic. 140,000 residents voluntarily evacuate. Fourteen years of clean-up.

The 35th anniversary of the Three Mile Island Nuclear Disaster.

On the midnight shift on March 28, 1979, things started to go wrong at TMI. A simple instrument problem started a chain of events that led to a core meltdown.

I can still remember that morning.

I was learning to operate a nuclear plant (S1W near Idaho Falls, ID) at the time. I was in the front seat of the bus riding out to the site. The bus driver had a transistor radio on and the news reported that there had been a nuclear accident at TMI. They switched to a live report from a farmer across the river. He said he could smell the radiation in the air. Also, his cows weren’t giving as much milk.

the midnight shift on March 28, 1979, things started to go wrong at TMI. A simple instrument problem started a chain of events that led to a core meltdown.

I was learning to operate a nuclear plant (S1W near Idaho Falls, ID) at the time. I can still remember that morning. I was in the front seat of the bus riding out to the site. The bus driver had a transistor radio on and the news reported that there had been a nuclear accident at TMI. They switched to a live report from a farmer across the river. He said he could smell the radiation in the air. Also, his cows weren’t giving as much milk.

Years later, I attended the University of Illinois while also being a Assistant Professor (teaching midshipmen naval weapons and naval history). I was the first in a new program that was a cooperative effort between the Nuclear Engineering and Psychology Departments to research human factors and nuclear power plants. My advisor and mentor was Dr. Charles O. Hopkins, a human factors expert. In 1981-1982, he headed group of human factors professionals who wrote a report for the NRC on what they should do to more fully consider human factors in nuclear reactor regulation.


As part of my studies I developed a course on the accident at TMI and published my thesis on function allocation and automation for the next generation of nuclear power plants.

So, each year when the anniversary of the accident comes around I think back to those days and how little we have learned (or should I say applied) about using good human factors to prevent industrial accidents.


Monday Accident & Lessons Learned: NTSB Reveals Root Causes of Sissonville Pipeline Failure

Posted: March 24th, 2014 in Accidents, Current Events, Investigations



OH&S Occupational Health and Safety Online reports:

“The National Transportation Safety Board listed two related factors as the probable causes of the natural gas pipeline rupture on Dec. 11, 2012, in Sissonville, W.Va. NTSB posted its accident report in the case March 10 and included in it one recommendation to the federal Pipeline and Hazardous Materials Safety Administration and three recommendations to Columbia Gas Transmission Corporation, which owns and operates the pipeline.”

See the rest of the article here:

NTSB Finds Undetected Corrosion in Sissonville Pipeline Failure

View NTSB’s  full accident report here:

Pipeline Accident Report Enbridge Incorporated Hazardous Liquid Pipeline Rupture and Release


Do you think the NTSB conducted a thorough investigation? Do their corrective actions put the proper safeguards in place?

Share your opinions in the comments below: Photo courtesy of

BBC Reports: “Gleision mine deaths: Manslaughter trial to start”

Posted: March 24th, 2014 in Accidents, Current Events, Pictures

In 2011 four miners died in a flooding  accident at the Gleision drift mine in Wales, UK.

See the BBC story at:


And a story in the South Wales Evening Post at: 

CSB Pledges to Release the Deepwater Horizon Accident Investigation in 2014

Posted: March 19th, 2014 in Accidents, Current Events, Investigations

This news was in the CSB’s 2015 budget request. It said:

Deepwater Horizon – The CSB’s investigation into the Deepwater Horizon/Macondo accident of April 2010 continues, and the CSB has achieved significant legal victories during FY 2013. In April 2013 a federal judge in Houston upheld the CSB’s jurisdiction to conduct the investigation, and overruled the rig operator Transocean in its effort to block the release of information to the CSB. On July 23, 2013, the United States Court of Appeals for the Fifth Circuit in New Orleans, Louisiana, ruled in favor of the CSB and refused to stay the lower court’s decision. As a result of this ruling, the CSB has gained access to vital documents and information subpoenaed throughout the course of the agency’s investigation. Access to these documents will allow the CSB to evaluate factors that no other agency has investigated in detail, such as the role of human and organizational factors in this catastrophic accident.

The CSB’s investigation findings will be published in three separate volumes. The first two volumes are scheduled to be released in the spring of 2014, and the third volume will be released in the summer of 2014.”

A three volume report … Keep your Summer reading schedule open.

Missing Malaysian Airlines 777 – How Do You Investigate When the “Facts” Are Few & Far Between?

Posted: March 17th, 2014 in Accidents, Current Events, Investigations


Before the news broke, the Malaysia Airlines Flight 370 seemed to have disappeared without a trace. As I watched coverage of the mysterious “accident,” I thought that people might be interested in how one would investigate the disappearance and others like this where the facts are few and far between. Below, I set out how to do that using TapRooT®.

First, all TapRooT® Users know you start with a SnapCharT®.

The first problem you encounter with this incident is … what goes in the circle?

The circle on the SnapCharT® is the incident – usually the worst thing that happened. But in this case we don’t know what happened.

Should the circle be losing contact with the jet?

Perhaps. At least until we find out more about what happened.

Next, we lay out the sequence of events. Some of the events are pretty easy to detail. The flight seemed pretty routine to start with. But then things start to diverge from a normal fight sequence. Tracking equipment is turned off (not lost instantaneously as one would expect if there was a massive mechanical failure or explosion), and the plane then seems to have changed course and descended. As of now, changing course and descending are dotted boxes (assumptions) since we aren’t sure of these “facts”.

This is where the SnapCharT® gets even more difficult to draw. New information seems to be available every day from different sources. One would add this information to the chart using dotted boxes and ovals (events and conditions) keeping track of the source for each piece of information. One would then try to find more evidence to either confirm or eliminate each of these new pieces of information and redirect the investigation to find more information.

The SnapCharT® would become the main source of information and help direct the investigation by suggesting where investigators should focus their attention to help narrow down the seemingly large number of possibilities for “What happened?”
Note that at this point we are nowhere near identifying the “accidents” root causes. Until you have a fairly complete sequence of events, you aren’t ready to identify causal factors and start finding root causes.

I hope this give you some ideas the next time you start an investigation of a mysterious accident. And I hope, for the sake of all those involved and their loved ones, this investigation finds the true root causes of the flight’s disappearance so they can feel some sense closure.

Please leave your comments below. 

Monday Accident & Lessons Learned: Worker Killed in Accident Aboard Nuclear Sub in India

Posted: March 17th, 2014 in Accidents, Current Events, Performance Improvement, TapRooT

One worker was killed and two were injured aboard a nuclear submarine under construction in India.

Was it some high tech nuclear accident? No. I was a simple pressure test of a hydraulic tank. 

This accident once again shows that failure to control simple energy is often the cause of fatalities.

See the whole story here:

Could this accident have been prevented? Yes. How? Find out at the Proactive Use of TapRooT® Course being held on April 7-8. 

Monday Accident & Lessons Learned: UK RAIB reports on fatal accident at Athelney level crossing, near Taunton, Somerset on 21 March 2013

Posted: March 10th, 2014 in Accidents, Current Events, Investigations, Pictures

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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:


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 station

Posted: 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.




Remembering An Accident: Two Suspended Hotel Walkways Collapse July 17, 1981 – 114 Killed

Posted: March 7th, 2014 in Accidents, Video


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:


Food Company Fined after Worker Suffers Partial Amputation of Fingers

Posted: March 4th, 2014 in Accidents, Current Events

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.)

Don’t Make a Decision You’ll Someday Regret – Join Our Community Today

Posted: March 4th, 2014 in Accidents, Jokes
1981 Louisville, Kentucky Sewer Explosion

1981 Louisville, Kentucky Sewer Explosion

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:

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:

Lessons *Not* Learned from Deepwater Horizon & Texas City (and How to Improve Investigations)

Posted: March 3rd, 2014 in Accidents, Best Practice Presentations, Presentations, Summit

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:

Part One

Part Two

Part Three

Part Four

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