Watch this video and see what you think …
Photo of meteor from Chelyabinsk, Russia in 2013
If confirmed, here is a link to the first recorded fatality due to a meteorite strike in modern history. This would be one of the few appropriate uses of the Natural Disaster category on the Root Cause Tree®.
When doing a root cause analysis using TapRooT®, one of the top-level paths you can follow can lead you to Natural Disaster as a possibility. We note that this doesn’t come up very often. When you go down this path, TapRooT® makes you verify that the problem was caused by a natural event that was outside of your control.
I have seen people try to select Natural Disaster because there was a rainstorm, and a leak in the roof caused damage to equipment inside the building. Using TapRooT®, this would most likely NOT meet the TapRooT® Dictionary® definition of Natural Disaster. In this case, we would want to look at why the roof leaked. There should have been multiple safeguards in place to prevent this. We might find that:
The roofing material was improperly installed.
We do not do any inspections of our roof.
We have noted minor water damage before, but did not take action.
We have deferred maintenance on the roof due to budget, etc.
Therefore, the leaky roof would not be Natural Disaster, but a Human Performance issue.
The case of the meteorite strike, however, is a different issue. There are no reasonable mitigations that an organization can put in place that would prevent injury due to a meteorite. This is just one of those times that you verify that your emergency response was appropriate (Did we call the correct people? Did medical aid arrive as expected?). If we find no issues with our response, we can conclude that this was a Natural Disaster, and there are no root causes that could have prevented or mitigated the accident.
I’m going to be bringing you some examples of accidents and problems that are quickly listed as “equipment failure.” Take a look at these problems and ask yourself:
– Is this really an equipment problem?
– Have we looked deep enough into the actual reason that the equipment did not work as intended?
– Were there any safeguards that were in place that failed, or should have been in place and were not?”
Here’s an example that is just quickly labeled “equipment failure”. List the safeguards that you think should have been in place (and maybe were, maybe weren’t) to prevent the accident’s outcome.
Image of debris on track before the collision, looking east.
Train 1C89 approached on the right-hand track (image courtesy of a member of the public)
RAIB has today released its report into a collision between a train
and a fallen bridge parapet at Froxfield, Wiltshire, 22 February 2015
At around 17:31 hrs on 22 February 2015, a high speed passenger train (HST), the 16:34 hrs First Great Western service from London Paddington to Penzance, struck and ran over part of the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.
The train was fully loaded with around 750 passengers and was travelling at a speed of 86 mph (138 km/h) when the driver saw the obstruction. He applied the emergency brake but there was insufficient distance to reduce the speed significantly before the train struck the parapet. The train did not derail and came to a stop around 720 metres beyond the bridge. There were no injuries. The leading power car sustained damage to its leading bogie, braking system, running gear and underframe equipment.
The immediate cause of the collision was that the eastern parapet of Oak Hill Road overline bridge had been pushed off and onto the tracks, by a heavy goods vehicle which had reversed into it. The train had not been stopped before it collided with the debris because of delays in informing the railway about the obstruction on the tracks.
RAIB has made four recommendations relating to the following:
- installation of identification plates on all overline bridges with a carriageway unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a particular bridge are assessed as likely to be minor
- enhancing current road vehicle incursion assessment procedures to include consideration of the risk from large road vehicles knocking over parapets of overline bridges (two recommendations)
- introduction of a specific requirement in a Railway Group Standard relating to the onward movement of a train that is damaged in an incident, so that the circumstances of the incident and the limitations of any on-site damage assessment are fully considered when deciding a suitable speed restriction, especially when there are passengers on board.
RAIB has also identified two learning points, one for police forces regarding the importance of contacting the appropriate railway control centre immediately when the safety of the line is affected and the other for road vehicle standards bodies and the road haulage industry about the benefits of having reversing cameras or sensors fitted to heavy goods vehicles
Notes to editors
- The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
- RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
- For media enquiries, please call 020 7944 3108.
For the complete report, see:
On January 20, 1909, the temporary crib that was used in the construction of the Southwest Land and Lake Tunnel System caught fire around eight 0’clock in the morning. Unfortunately the structure was constructed out of wood, so once the fire started it spread rapidly. The cause of the fire is still unknown.
The men that where stuck on the structure tried to save themselves by jumping off the crib and floating on the ice while they waited for the rescue boats to fight their way through to the survivors. The exact number of victims couldn’t be calculated, because some of the workers where temporary laborers that the company never documented. It is believed that at least 70 men lost their lives in this terrible disaster.
To read more about this accident click on the link below.
Find and fix root causes at your facility before disaster strikes. Our 2-day root cause analysis course is offered globally and includes all of the essential tools necessary to successfully complete an investigation.
Learn more here: http://www.taproot.com/courses#2-day-incident
Monday Accident & Lessons Learned: CSB Investigation of the Chevron Richmond Refinery Crude Unit FireJanuary 18th, 2016 by Mark Paradies
See the link below to the pdf of the Dangerous Goods Safety Significant Incident Report Number 01-15 from the Government of Western Australia Department of Mines and Petroleum.
A Judge in California has ruled that PG&E must face charges that it knowingly and willfully violated minimum pipeline standards in the 2010 explosion that killed 8 people.
State regulators have already imposed $1.6 billion in civil sanctions. PG&E faces and additional $565 million in penalties as part of these charges.
Imagine the cost of this structure being built to hold the aftermath of the Chernobyl reactor accident.
Imagine what could have been saved if they had learned to prevent this accident by effective use of root cause analysis.
That’s a lesson that everyone can learn.
Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day! If you’d like to subscribe, contact Barb at firstname.lastname@example.org.
Monday Accident & Lessons Learned: REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS MEASURED IN THE RESERVOIR LEADING TO KICKDecember 21st, 2015 by Mark Paradies
IOGP SAFETY ALERT
REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS
MEASURED IN THE RESERVOIR LEADING TO KICK
Course of events:
- Drilled 6×7″ hole section, ran screens and set hanger.
- Displaced from 1.18 SG drilling fluids to 1.05 SG brine.
- Closed in based on 600 l influx (PP estimated to be 1.09 SG)
- Circulated out gas and displaced to 1.15 SG brine (using drillers method)
What Went Wrong?
Factors which contributed to the incident:
- Brine weight reduction
- Pore pressure prognosis
- Lack of pressure point coverage of all sands during drilling
Corrective Actions and Recommendations:
- Several pressure points where taken in the reservoir and these were used to reduce to mud weight from 1,08 sg to 1,05 sg brine. This reduction turned out to result in too great a weight decrease, since there were two small sand zones exposed that where not picked up on the log. It is important not to place to great a reliance on pressure points taken during the section, since there can be small zones that have not been caught on the log that may have a different pressure.
- Instead of displacing the well to kill mud during the second circulation of the drillers method, the team decided to displace to a higher weight brine. This meant that they would continue operations faster, after the kill, than would have been the case if they displaced to drilling mud.
safety alert number: 269
IOGP Safety Alerts http://safetyzone.iogp.org
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP 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.
See the video by clicking on link below.
IOGP SAFETY ALERT
FATALITY WHILE TRIPPING PIPE
Country: USA – North America
Location: OFFSHORE : Mobile Drilling Unit
Incident Date: 20 October 2015
Type of Activity: Drilling, workover, well services
Type of Injury: Struck by
View of pipe stand in lower fingerboard
A Deepwater drill crew was tripping in the hole with drill pipe.
As they were transferring a stand of pipe out of the setback area with a hydraracker, the stand caught on a finger at the 51′ lower fingerboard.
As the hydraracker continued to move, tension caused the pipe to bow and the pipe was released from the lower tailing arm with significant force toward the setback area striking and fatally injuring the employee.
What Went Wrong?
This investigation for this event is ongoing.
Corrective Actions and Recommendations:
While this incident is still under investigation, drilling rig operators using fingerboards with latches are recommended to:
- Review and assess applicability of NOV Product Information Bulletin 85766409 and NOV Safety Alert Product Bulletin 95249112
- Verify a system is in place to confirm the opening and closing of fingerboard latches (by way of CCTV or spotter)
- Ensure personnel are kept clear of the setback area
Safety Alert Nnumber: 268
IOGP Safety Alerts http://safetyzone.iogp.org/
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP 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.
For those still interested (the accident occurred in 2011) there is a report out by the IAEA on the Fukushima Nuclear Plant Accident (caused by a tsunami).
Aside from the info in the report, I find it interesting when a report comes out way after an accident has occurred (in this case more than four years later).
My question is, is learning possible this late after an accident or has everyone already moved on? Since the regulators have already issued regulatory requirements and many utilities have already taken action … is the report just for historical documentation?
What do you think?
Manslaughter charges were dropped against the two BP Engineers in-charge on the ill-fated Deepwater Horizon. Donald Vidrine did plead guilty to one misdemeanor violation of the Clean Water Act.
A beautiful day for sailing … maybe …
Here is a link to the significant incident report:
It seems from the report that the appropriate seat belt was present. Therefore the only applicable action in the “Action required” section is:
“Workers should be instructed, through training and inductions, regarding the importance of using the seatbelts provided in vehicles to reduce the impact of potential collisions.”
In my instant root cause analysis using the Root Cause Tree®, I wonder why there wasn’t a Standards, Policies, and Administrative Controls Not Used Near Root Cause. That would get me to dig more deeply into the Enforcement NI root cause.
What do you think? Was this a training root cause that needs a training corrective action?
Leave your comments below…
The last paragraph of the article was:
“Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.“
So here is what the Aiken Standard wrote about the SRNS root cause analysis:
“Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”
What do you think? Did they look into Management System causes?
If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident?
In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures.
I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes.
This is how a culture of expediency exists alongside a culture of blame.
What can you learn from this incident?
One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame.
An article in the Aiken Standard got me thinking again about the topic of safety stand-downs (this time called a “safety pause”).
These temporary “stop work” activities where safe work practices are suppose to be reviewed, and where new emphasis is suppose to be applied to ensure safety, are common in government operations (this time a DOE site) and the nuclear industry. I’ve written about them before:
- Monday Accident & Lessons Learned: When is a “Safety Standdown” a “Standdown”
- Monday Accident & Lessons Learned: Mistakes at TVA Reactors Results in Safety Stand Down
- Nuclear Plant “Near-Miss” in Canada Leads to Safety Stand Down
- 22 Near-Fatal Accidents in 12 Months at a UK Steel Mill – Is a Safety Standdown Adequate?
The safety pause at Savannah River Nuclear Solutions is a really long pause. It started on September 11 after a September 3 incident in the H Canyon – HB Line portion of their operations where Plutonium was being handled.
An SRNS spokesperson is quoted by the paper as saying that: “SRNS is a stronger, healthier company as a result of these actions and we are working for sustained improvement.”
Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the “pause” to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.