Category: Current Events

Monday Accident & Lessons Learned: Fatal accident involving a track worker near Newark North Gate station 22 January 2014

March 2nd, 2015 by

Summary from the UK Rail Accident Investigation Branch …

At around 11:34 hrs on 22 January 2014, a track worker was struck by a passenger train as it approached Newark North Gate station. He was part of a team of three carrying out ultrasonic inspection of two sets of points at Newark South Junction and was acting in the role of lookout. The accident happened around 70 metres south of the platforms at the station.

A few minutes before the accident, the lookout and two colleagues arrived at the yard adjacent to the tracks in a van. One colleague was in charge of carrying out the inspections and the other, the ‘controller of site safety’ (COSS), was in overall charge of the safety of the team. They had planned to carry out the inspections on lines that were still open to traffic in accordance with a pre-planned safe system of work. All three had many years of relevant experience in their respective roles and were familiar with the work site.

Upon arrival at the yard, the lookout and tester proceeded to the track to start the inspection work; the COSS remained in the van. Shortly after they had started the inspection, the 10:08 hrs London to Newark North Gate passenger service approached. It was due to stop in platform 3, which required it to negotiate two sets of crossovers. The train blew a warning horn and the two staff on site acknowledged the warning and moved to the nominated place of safety. However, just before the train moved onto the first crossover, the lookout turned to face away from the train, walked towards the station and then out of the position of safety. He moved to a position close to where he had been before the train approached, most probably to check for trains approaching in the opposite direction, having decided that the approaching train was proceeding straight into platform 1. Although the train braked and blew a second warning horn, the lookout did not turn to face the train until it was too late for him to take evasive action.

As a consequence of this accident, RAIB has made two recommendations and identified a learning point. The recommendations are addressed to Network Rail and relate to: 

  • improving work site safety discipline and vigilance, especially for teams doing routine work with which they are familiar; and 
  • improving the implementation of Network Rail’s procedures for planning safe systems of work so that the method of working that is chosen minimises the risk to track workers so far as is reasonably practicable, as intended by the procedure.

The learning point relates to improving the implementation of Network Rail’s competence assurance process by providing training and sufficient working time to enable front line managers to implement the associated procedures as intended by Network Rail. 

Download report: 
PDF icon 150216_R012015_Newark_North_Gate.pdf (5,166.00 kb)


Monday Accident & Lessons Learned: How Much Root Cause Analysis Can You Buy for $5.6 Million Dollars?

February 23rd, 2015 by

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Here are the headlines from The Bakersfield Californian:

“CPUC proposes $5.6 million fine against PG&E for 2012 demolition fatality in Bakersfield”

As reported by the papper, one of the findings of the PUC that led to the fine was:

“PG&E gave the CPUC an accident analysis prepared by Cleveland, as well as the utility’s own evaluation. But commission staff said both ‘failed to provide an adequate or comprehensive root cause analysis for the incident’ to help determine corrective actions.”

So here are some questions to consider:

  1. Do you require that your contractors perform adequate accident investigations?
  2. What root cause tools do your contractors use? Shouldn’t they be using TapRooT®?
  3. Are you waiting for fatalities to require better root cause analysis and incident investigation? Why don’t you have someone attend an 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course ASAP (this month?).
  4. Isn’t it time that you learned how to use root cause analysis proactively to stop fatalities before accidents happen? You should attend the Using TapRooT® Proactively Course.

How many lessons can your company learn from this accident?

UK RAIB Investigating Electrical Arcing and Fire Under a Train, Near Windsor, 30 January 2015

February 13th, 2015 by

NewImageThe damaged floor of the train

RAIB is investigating a train fire that occurred on the evening of Friday 30 January 2015, and which caused serious damage to the structure of the train.

The 19:53 hrs South West Trains service from Windsor & Eton Riverside to London Waterloo had travelled about 400 metres after starting from Windsor station, when a small bang was heard under the sixth carriage of the ten-carriage train, followed by about five seconds of severe sparking and flashing.

The train, which was formed of two class 458/5 electric multiple units and was travelling at about 15 mph at the time, stopped immediately. Some smoke entered the carriages through ventilators. There were two passengers in the sixth carriage, and they moved quickly into another part of the train. The guard of the train moved from the rear to the sixth carriage to investigate, and the driver also moved to the middle of the train. They could see that there was still smoke coming from below the sixth carriage, so the driver returned to the front of the train from where he contacted the signaller by radio to ask for the electric power to be switched off. While he was doing this, the floor of the sixth carriage was penetrated by fire, and smoke rapidly filled the vehicle.

There were eleven passengers on the train. The guard, assisted by the crew of another train that was in Windsor station, evacuated the passengers to the track, and helped them walk back to the station. The fire brigade were called, and confirmed by 20:50 that the fire was out. None of the passengers were hurt, but the guard was taken to hospital and treated for smoke inhalation.

RAIB’s preliminary examination found that the fire had originated in severe arcing in a junction box fixed under the carriage floor, where power cables from the collector shoes on either side on the train are connected to the main power cable (‘bus line’) which runs along the train. The arcing had burnt through the floor of the carriage, and had also destroyed parts of the structural members of the carriage body.

RAIB’s investigation will focus on the cable joint in this junction box, and how this joint was designed and assembled. It will also examine how the train’s structure and equipment, and the people in it, might have been protected from the consequences of a failure of this nature.

RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.

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







Monday Accident & Lessons Learned: Errors Under Pressure – What are the Odds?

February 9th, 2015 by

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Here’s a description of an car/train accident:

How could things go from a minor error and fender bender to a multi-fatality accident?

It happens when someone makes a bad decision under pressure.

Don’t think it couldn’t happen to you. Even with good training and good human factors design, under high stress, people do things that seem stupid when investigating an accident (looking at what happened in the calm light of the post accident investigation).

Often, the people reacting in a stressful situation aren’t well trained and may have poor displays, poor visibility, or other distractions. Their chance of choosing the right action? About 50/50. That’s right, they could flip a coin and it would be just as effective as their brain in deciding what to do in a high-stress situation.


FIRST: Avoid decisions under high stress. In this case, KEEP OFF THE TRACKS!

Never stop on a railroad track even when no trains are coming.

That’s true for all hazards.

Stay out from under loads. Stay away from moving heavy equipment.

You get the idea.

Don’t put yourself in a position where you have to make a split-second decision.


Always back off the tracks if possible. This is true even if you hit the gate and dent your car.

FINALLY: Think about how this train accident could apply to hazards at your facility.

Are people at risk of having to make split-second decisions under stress?

If they do, or if it is possible, a serious accident could be just around the corner.

Try to remove the hazard if possible.

How could have the hazard been removed in this case?

An overpass or underpass for cars is one way.

Other ideas? Leave them below as comments.

RAIB & BEA-TT Investigate Train Fire In Chunnel

January 28th, 2015 by

The UK RAIB and the French Bureau d’Enquetes sur les Accidents de Transport Terrestre (BEA-TT) are jointly investigating a fire on-board a train in the Channel Tunnel. For more information, see:

Monday Accident & Lessons Learned: The US Chemical Safety Board Releases Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

January 26th, 2015 by



CSB Releases Safety Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

Safety Bulletin Notes Five Key Lessons to Prevent Hydraulic Shock

January 15, 2014, East Rutherford, NJ – Today the U.S. Chemical Safety Board released a safety bulletin intended to inform industries that utilize anhydrous ammonia in bulk refrigeration operations on how to avoid a hazard referred to as hydraulic shock.  The safety lessons were derived from an investigation into a 2010 anhydrous ammonia release that occurred at Millard Refrigerated Services Inc., located in Theodore, 


The accident occurred before 9:00 am on the morning of August 23, 2010. Two international ships were being loaded when the facility’s refrigeration system experienced “hydraulic shock” which is defined as a sudden, localized pressure surge in piping or equipment resulting from a rapid change in the velocity of a flowing liquid. The highest pressures often occur when vapor and liquid ammonia are present in a single line and are disturbed by a sudden change in volume.

This abnormal transient condition results in a sharp pressure rise with the potential to cause catastrophic failure of piping, valves, and other components – often prior to a hydraulic shock incident there is an audible “hammering” in refrigeration piping. The incident at Millard caused a roof-mounted 12-inch suction pipe to catastrophically fail, resulting in the release of more than 32,000 pounds of anhydrous ammonia.
The release led to one Millard employee sustaining injuries when he fell while attempting to escape from a crane was after it became engulfed in the traveling ammonia cloud.  The large cloud traveled a quarter mile from the facility south toward an area where 800 contractors were working outdoors at a clean-up site for the Deepwater Horizon oil spill. A total of 152 offsite workers and ship crew members reported symptomatic illnesses from ammonia exposure. Thirty two of the offsite workers required hospitalization, four of them in an intensive care unit.

Chairperson Rafael Moure-Eraso said, “The CSB believes that if companies in the ammonia refrigeration industry follow the key lessons from its investigation into the accident at Millard Refrigeration Services, dangerous hydraulic shock events can be avoided – preventing injuries, environmental damage, and potential fatalities.”

Entitled, “Key Lessons for Preventing Hydraulic Shock in Industrial Refrigeration Systems” the bulletin describes that on the day before the incident, on August 22, 2010, the Millard facility experienced a loss of power that lasted over seven hours. During that time the refrigeration system was shut down. The next day the system regained power and was up and running, though operators reported some problems.  While doing some troubleshooting an operator cleared alarms in the control system, which reset the refrigeration cycle on a group of freezer evaporators that were in the process of defrosting. The control system reset caused the freezer evaporator to switch directly from a step in the defrost cycle into refrigeration mode while the evaporator coil still contained hot, high-pressure gas.

The reset triggered a valve to open and low temperature liquid ammonia was fed back into all four evaporator coils before removing the hot ammonia gas. This resulted in both hot, high-pressure gas and extremely low temperature liquid ammonia to be present in the coils and associated piping at the same time. This caused the hot high-pressure ammonia gas to rapidly condense into a liquid.  Because liquid ammonia takes up less volume than ammonia gas – a vacuum was created where the gas had been.  The void sent a wave of liquid ammonia through the piping – causing the “hydraulic shock.”

The pressure surge ruptured the evaporator piping manifold inside one of the freezers and its associated 12-inch piping on the roof of the facility. An estimated 32,100 pounds of ammonia were released into the surrounding environment.

Investigator Lucy Tyler said, “The CSB notes that one key lesson is to avoid the manual interruption of evaporators in defrost and ensure control systems are equipped with password protection to ensure only trained and authorized personnel have the authority to manually override systems.“

The CSB also found that the evaporators at the Millard facility were designed so that one set of valves controlled four separate evaporator coils. As a result, the contents of all four coils connected to that valve group were involved in the hydraulic shock event – leading to a larger, more hazardous pressure surge.

As a result, the CSB notes that when designing ammonia refrigeration systems each evaporator coil should be controlled by a separate set of valves.

The CSB found that immediately after discovering the ammonia release, a decision was made to isolate the source of the leak while the refrigeration system was still operating instead of initiating an emergency shutdown. Shutting down the refrigeration system may have resulted in a smaller release, since all other ammonia-containing equipment associated with the failed rooftop piping continued to operate.

A final key lesson from the CSB’s investigation is that an emergency shutdown should be activated in the event of an ammonia release if a leak cannot be promptly isolated and controlled. Doing so can greatly reduce the amount of ammonia released during an accident.

Will Falling Oil Prices Put the Cost-Cutting Ax to Safety Improvement?

January 22nd, 2015 by


It’s easy for a CEO and management to claim to support safety. But the proof comes when times get tough.

The price of oil has declined more that 50% in just six months. That has the oil field in crisis mode. Knee jerk budget cuts, travel restrictions, and layoffs have already started.

What does this mean to safety improvement? Many oil industry safety professionals get ideas about ways to improve by attending the TapRooT® Summit, networking with industry leaders and performance improvement experts, hearing about the latest best practices that will help them solve their toughest problems, and developing plans to take safety to a whole new and better level. But if travel budgets are slashed and conferences are not allowed, these new best practices won’t be learned, safety improvement will stop, and lives that could have been saved will be lost.

Now is the time for management to show their commitment to safety improvement. They can stand up, resist the fear of low oil prices, and demand that safety improvement continues even in times of budget restraint.

After all, safety is not just a priority that can be discarded when times get tough. Safety is a value that must be supported every day, year in and year out, in good times and bad, or people will start to believe that safety is option and the only real value is profit.


Don’t let safety improvement become an unsupported slogan. Register for the TapRooT® Summit today!

Monday Accident & Lessons Learned: UK RAIB Report – Near-miss involving construction workers at Heathrow Tunnel Junction, west London, 28 December 2014

January 19th, 2015 by

UK Rail Accident Investigation Branch Press Release…

The UK RAIB is investigating an incident in which a train almost struck two construction workers, and collided with a small trolley, on the Up Airport line between Heathrow Airport Tunnel and the Stockley Flyover.

NewImageYellow engineering trolley underneath the train after the collision (image courtesy of Carillion)

The incident occurred at about 10:05 hrs on Sunday 28 December 2014 and involved train 1Y40, the 09:48 hrs service from London Heathrow Terminal 5 to London Paddington. The track workers jumped clear just before the approaching train struck a small engineering trolley that they had been placing on the line. The train, formed by a Class 332 electric multiple unit, was travelling at approximately 36 mph (58 km/h) when it struck the trolley. 

The two track workers were among a large number of people carrying out construction work on the approach to a new bridge that had been recently constructed adjacent to the existing Stockley Flyover. This new structure, which carries a new railway track over the mainline from London Paddington to Reading, was built as part of the Crossrail surface works being undertaken by Network Rail.

To enable this work to take place, parts of the operational railway in and around the construction site had been closed for varying periods during the few days before the incident. The two construction workers were unaware that the Up Airport line had returned to operational use a few hours before they started to place the trolley onto this line. They formed part of an eight person workgroup which included a Controller of Site Safety (COSS). The COSS and other group members were not with the two track workers at the time of the incident. The presence of temporary fencing, intended to provide a barrier between construction activities and the operational railway, did not prevent the two track workers accessing the open line.

Network Rail owned the infrastructure at the site of the accident and had employed Carillion Construction as the Principal Contractor for the construction works. The two track workers and the COSS were all employed by sub-contractors.

RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules are applied on large construction sites adjacent to the operational railway. It will also seek to understand the actions of the people involved, and factors that may have influenced their behaviour.

RAIB will also consider whether there is any overlap between this incident and the factors which resulted in an irregular dangerous occurrence at the same construction site on the previous day. This occurrence involved a gang of railway workers who walked along a line that was open to traffic, and without any form of protection, until other construction workers warned them that the line was open to traffic.

The RAIB 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.

- – – – – 

What can we learn BEFORE the investigation is complete?

First, this “near-miss” was actually a hit.

In this case it was called a near-miss because no one was injured. However, the train and trolley were damaged and work was delayed. For operations, maintenance, and construction, this was an incident. In other words, it was a safety near-miss but it was an operation, maintenance, and construction hit.

Many incidents that don’t have immediate safety consequences do have immediate cost, productivity, and reliability consequences that are worthy of an investigation. And in this case, the operations incident also had potential to become a fatality. This even more reason to perform a thorough root cause analysis.

UK RAIB Press Release: Investigating tram derailment near Mitcham Junction, London, 29 December 2014

January 12th, 2015 by

At about 23:55 hrs on Monday 29 December 2014, a tram travelling from New Addington to Wimbledon on the Croydon Tramlink system became derailed shortly after leaving the tram stop at Mitcham Junction, while travelling at about 11 km/h (7 mph). There were about 20 passengers, plus the driver, on board the tram, and no-one was hurt. There was some minor damage to the tram.

To the west of Mitcham Junction tram stop, the single tram line becomes two lines at a set of spring-operated points. On leaving the tram stop, the tram driver noticed that an indicator, which shows the position of these points, was indicating that the points were not correctly set. He stopped the tram before reaching the points, and after speaking to the tramway control room by radio, he left the tram and used an operating lever to manually move the points until he observed that the indicator was showing that they were correctly set. He then drove the tram slowly over the points, but the centre bogie and one wheelset of the trailing bogie became derailed.



Image showing derailed tram near Mitcham Junction

RAIB’s investigation will focus on the points mechanism and the way that it behaves in degraded operating conditions.

RAIB’s investigation is independent of any investigation by the railway industry or the Office of Rail Regulation.

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

Monday Accident & Lessons Learned: UK RAIB Investigations of an unauthorised entry of a train onto a single line at Greenford

January 12th, 2015 by

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Unauthorised entry of a train onto a single line at Greenford

20 March 2014

 From the UK Rail Accident Investigation Branch:

At around 11:55 hrs on Thursday 20 March 2014, the 11:36 hrs passenger train from London Paddington to West Ruislip, operated by Chiltern Railways, passed two consecutive signals at danger near Greenford, west London. It was stopped when a signaller sent an emergency radio message to the driver. Although no-one was hurt in the incident, the unauthorised entry of a train onto a single line creates the potential for a serious collision.

A freight train had passed the junction at Greenford shortly before the passenger train was due. Because the freight train was still occupying the line between Greenford and South Ruislip, the signaller at Greenford kept the signal at the junction at danger. The passenger train, travelling at about 20 mph (32 km/h), passed this signal and the next one, 142 yards (130 metres) further on, which was also at danger. It passed over the junction and onto the single-track section towards South Ruislip, which was still occupied by the freight train. The train had travelled about one mile (1.6 km) beyond Greenford by the time that the driver received the emergency radio message.

The investigation found that the driver of the passenger train did not react to the two signals at danger, for reasons which are not certain. It is possible that he had formed the impression that the train had been given clear signals through Greenford, because of his interpretation of the meaning of the signal preceding those that he passed at danger, and he had not been stopped by signals at Greenford in the recent past.

The Train Protection and Warning System (TPWS) was fitted to the train and to both the signals, but it did not intervene to apply the brakes of the train, as it was intended to do. This was because the on-train TPWS equipment had self-isolated when the driver prepared the train for departure from Paddington. The isolation of the equipment was indicated by a flashing light in the cab, but the driver still drove the train.

Although the signaller at Greenford wished to stop the train by sending an emergency call on the GSM-R radio system, he did not attempt to do so because the information presented by the radio equipment in the signal box suggested to him that any message he sent would not reach the train. Instead, he contacted Marylebone signal box, which was able to send a message to the train.

RAIB has made three recommendations. One is addressed to Chiltern Railways, and covers the need for a review of the company’s driver management processes. The other two, addressed to Network Rail, cover the configuration of the GSM-R radio system as it affects the ability of signallers to directly contact trains that are within their areas of control, and the training given to signallers in the use of the GSM-R system. RAIB has also identified two learning points: one for signallers, relating to the use of delayed clearance of signals to warn train drivers of the state of the line ahead, and the other for train operating companies, relating to the upgrading of on-train TPWS equipment.

To see the complete report and all recommendations, see:


January 5th, 2015 by



The rig was involved in well preparation for the forthcoming execution of a gravel pack operation. After earlier setting a Gravel Pack packer on the well, later it became impossible to circulate in direct (possibly plugged ports in string): only possible to circulate in reverse. This made Gravel Pack operation impossible. Decision was made to POOH wet to surface.

The ongoing operation at time of event was POOH with 4 ½ PH6 tubing work string – with Setting Tool and 2 3/8” tubing tail pipe – to inspect Service Tool for indications of inability to circulate.

  • Fluid in well was 1.07sg Brine.
  • Tubing string was being pulled wet.Losses observed at approximately 1.2m3/hr.
  • Tubing work string was 220m from surface at time of incident. Fluid returns were bubbling at the bell nipple (swabbing while pooh workstring-no gain yet). Crew estimated off-bottom kick situation. Closed annular to bullhead the well to push any gas influx into formation.

Operations details after calling town (drilling superintendent):

  1. Pump 5m3 High Viscosity pill bullheading same at a flow rate not exceeding 800 lpm and at a stand pipe pressure not exceeding 1400 psi.
  2. Pumps were stopped and lined up with active pit, then approximately 7m3 1.07 sg brine was bullheaded. First, the flow rate was maintained around 400 lpm and stand pipe pressure remained below 1500 psi.
  3. Increased gradually the flow rate (to 1100 lpm) and the stand pipe pressure increased regularly up to 2300 psi.
  4. The Tool pusher called the driller to ask him why he was pumping at a stand pipe pressure higher than 2000 psi – the driller replied the Company Man told him 2500 psi was the limit.
  5. 220m+/- of 4 ½” tubing and 2 7/8” wash pipes along with the Service Tool Assembly were ejected from the well. Strong noise and vibrations were noted by several witnesses while the pipe was being ejected.
  6. The pipe hit the Elevator and was deviated outside the mast, hitting the monkey board and went up over the Monkey Board and out through the derrick space.
  7. The projectile started to drop down in an X-shape. It eventually fell on the ground, missing the company man’s and the service companies’ cabins by less than 1 meter,
  8. The Rig HSE/Meeting Room Cabin was destroyed.
  9. Damage was made to the concrete block fence wall inside the cluster situated just behind the Company Man Office.
  10. From Company Man Office to Well Center the Tubing string landing point was measured at 60m.
  11. The elapsed time of the entire event according to witnesses, took less than 30 sec (faster than a man running down the stairs from the rig floor).
  12. Driller remained on Rig Floor during ejection. He immediately stopped the rig pumps then went to the BOP panel. He did not close the pipe rams as he had little hope this would be of any help. He decided to close the Blind Shear Rams. Then he left the rig floor and went to the main muster point.
  13. The Company Man and Tool Pusher both ran to the remote control panel. The Tool Pusher arrived first and activated the Blind Shear Rams, then realized that the driller had already done it.
  14. All personnel proceeded to the Muster Points.
Immediately after the incident…
  1. The Head Count was 100% – no one had been injured.
  2. The Driller went back to the Rig Floor and resumed the Bullheading Operation against the Blind Shear Rams.
  3. The day after the incident (Saturday 9 November), piece of tubular was found at 105m from the well outside the cluster.


  • Gravel Pack string was plugged creating inability to circulate direct and thus to execute the Gravel Pack program.
  • According to witnesses, squeeze pressure range was given by Company man to the Driller as 2000 – 2500 psi.
  • No formal risk assessment performed for Bull Heading operation for this Work-over operation.
  • No recalculation was done for this emergency non-routine Bull Heading well control operation either on site or at base by Company and Drilling Contractor.
  • Nobody on site neither in office recognized Well Control situation as critical.
  • Top drive was disconnected and drill pipe closed on TIW valve. 220m assembly closed on annular.
  • The Tripping Fast Shut In Procedure does not mention pipe rams closure.
  • There is no Bull Heading procedure available.


  • Lack of risk awareness concerning contained Pressure hazards. Upward push on the assembly while bullheading not anticipated despite gravel pack operations experience on site.
  • No Job risk Analysis performed prior bullheading. No consequential analysis.
  • Bullheading operation considered as routine.
  • Due to underestimation of the criticality of the operation ongoing (Bull Heading) by all (site and base): Identify all critical operations/tasks including Bull Heading in drilling operations.
  • Prioritize Well Control and Critical Operations by base team at every point of Program execution.
  • Dedicated ‘critical activities’ section to be added in all operational programs (drilling, Workover, rig less) describing how to recognize a well control situation and which procedure to be applied. Each procedure completed by a Risk Assessment made available to the work crew which they can use as a basis for further review.
  • Training plan to be immediately set up for full IWCF compliance of the Completion and Well Intervention personnel.

Safety Alert Number: 264
IOGP Safety Alerts


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.

Blast from the Past – SI Releases Computerized Root Cause Analysis Workstation!

January 2nd, 2015 by

January 1994 – 21 years ago!

The first computerized root cause analysis workstation was released by System Improvements on January 1994. We called it the “Investigation Team Workstation”. What did it include?

1. MacTapRooT® Software (version 1.0 – Mac version).

2. Events & Causal Factors Charting Template and MacFlow Software (version 1.0 – mac version).

3. A Macintosh Plus.

4. A portable inject printer.

5. A Mac backpack to haul it all.

This was semi-portable and way ahead of it’s time. 

I thought I had a picture of me using it (I actually took it on a plane to use in an investigation) but I can’t seem to find it (way before digital pictures – we were still using Polaroids for investigation photos). 

We sold several to clients who wanted to computerize their root cause analysis (we actually became a Mac reseller for a short period of time). 

We even updated the workstation to the PowerBook 165 when they came out later in 1994.

If anyone out there has a picture of our state-of-the-art system, send it to me!

Do You Follow the Instructions? (Miller Auto Darkening Helments)

December 19th, 2014 by

A TapRooT® User sent us this warning to distribute …

 Miller Auto Darkening Helmets 

The manufacturer’s safety instructions found in the top of the Miller Auto Darkening Helmet states the following:
Do not weld in the overhead position while using this helmet.

This warning was noticed by Vale employees after reading the warning label in the top of the helmet.

Although auto darkening helmets are an often used tool, they must be used as per manufacturer’s directions and design.

Please see the pictures below for further clarification.





PC World Headline: “Human error root cause of November Microsoft Azure outage”

December 18th, 2014 by

There they go again. HUMAN ERROR as a root cause.

See the story at:

Haven’t they read my article at:

Human error is a symptom, not the root cause.

Attend a TapRooT® Course and find out how you can find and fix the real causes of human error.

Monday Accident & Lessons Learned: OPG Safety Alert 262 – Shallow Gas Leads to Well Control Incident

December 15th, 2014 by


  • The well is located in a well-known, shallow gas prone area.
  • Deep gas wells with high pressurized layers.
  • Crowded platforms with wells anti-collision complex management.
  • SIMOPS including construction and well intervention
  • After each incident, procedures for shallow section drilling were enhanced.

The sequence of events were:

  • 0:00 – Skid rig on well. Batch drilled 12 ¼’’ hole section + 9 5/8’’ intermediate casing
  • 08:30 – Cleaned out CP 24’’ with 17 ½’’ BHA to 131m
  • 16:30 – Drilled 12 ¼’’ hole to 286m with 1.15+ SG mud. Heavy losses (67 m3/h)
  • 20:20 – Homogenize mud to 1.12 SG
  • 20:33 – Resume drilling to 296m. Heavy losses (70 m3/h)21:10 – Spot 10m3 LCM pill. POOH wet.
  • 22:20 – Well swabbing and started to flow. Closed diverter. Started pumping 1.12 SG mud at high flow rate.
  • 23:04 – Pumped kill mud 1.50 SG, followed by sea water at high rate.
  • 00:30 – Flow outside CP. Well out of control. Full rig evacuation.

What Went Wrong?

The cause of the incident could be listed as follows:

1. Supervision on rig

  • POOH wet (no pump out)
  • Continue with pulling operations, despite swabbing, until well kicked in. Shallow gas procedure not followed

2. Mud weight

  • Inconsistency in MW control and reporting
  • Pack off at 291m interpreted as a (new) loss zone

3. Documentation

  • No comprehensive instructions concerning total loss situation

Corrective Actions and Recommendations

  • Maintain a continuous awareness on shallow gas hazard, even when the shallow gas section has already been penetrated in other wells. This aims at avoiding routine approach hence complacency.
  • The standard drilling Instructions should be enriched and reinforced with lessons learnt e.g. Management of Change, the required concentration of KCl for the top hole section, the threshold of heavy losses, hole cleaning procedure for the top hole, responsibility assignment for key personnel, ‘Ready to drill’ checklist.


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.

Safety Alert Number: 262
OGP Safety Alerts

Monday Accident & Lessons Learned: Don’t Wear a Scarf!

December 1st, 2014 by

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A woman, trying to board a London Underground train, stopped when the doors of the train shut. But her scarf swung forward and was trapped in the doors.

As the train pulled forward, she was dragged along the platform. A member of the staff tried to catch hold of her and help, but this caused her to fall to the platform.

The scarf was eventually pulled from around her neck and into the tunnel, still trapped in the train door.

The woman suffered injuries to her neck and back but was lucky that she wasn’t dragged into the tunnel and onto the tracks.

What are the lessons learned? See the UK RAIB report.

Or just stop wearing scarfs!

Happy Thanksgiving

November 27th, 2014 by

Here is my Thanksgiving posting. I post it every year, lest we forget.


In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!

One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.

During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.

The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.

With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.

Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.

The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.

Is this the root cause of Thanksgiving?

This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:

“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”

William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.

Monday Accident & Lessons Learned: Fatality Near-Miss Because of Corrective Actions NI or Corrective Action NYI

November 24th, 2014 by

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A recent rail accident report by the UK Rail Accident Investigation Branch described a facility maintenance failure that could have caused a fatality. Here’s a brief excerpt from the report:

 “At about 16:00 hours on Thursday 1 August 2013, concrete cladding fell from the bridge spanning Denmark Hill station, London, and most of the debris landed on platform 1. … The concrete cladding had been added to the bridge structure in about 1910 and fell because of gradual deterioration of the fixing arrangements. Deterioration of the cladding fixing arrangements had been reported to Network Rail over a period of at least four years but the resulting actions taken by Network Rail and its works contractor were inadequate.”

Under the Management System portion of the TapRooT® Root Cause Tree® you will find Corrective Actions Need Improvement and Corrective Actions Not Yet Implemented root causes under the under the Corrective Action near root cause. We used to abbreviate these CANYI and CALTA in the old days (Corrective Action Not Yet Implemented and Corrective Actions Less Than Adequate).

The TapRooT® theory of management requires that management implements effective corrective action once they are aware of a problem. The corrective action must not only be effective, but also it must be implemented in a timely manner (commensurate with the risk the problem presents). 

In this case, I would probably lean toward the Corrective Action Not Yet Implemented root cause, although, the Corrective Action Needs Improvement root cause might apply to the previous inadequate temporary fixes. 

What can you learn from this?

Does your management support effective timely corrective actions? Or do you have a large backlog of ineffective fixes? Maybe you need corrective action improvements!


November 17th, 2014 by


This incident occurred whilst drilling the first well following new rig commissioning and start-up. While drilling into suspected sand, the rig experienced a kick. The well was shut in with 180 psi Shut In Drill Pipe Pressure SIDPP), 14 BBLS gained, 270 psi Shut In Casing Pressure (SICP), 12.3 PPG MW (surface) in the hole. Several attempts were made to circulate; pipe was stuck and packed off. A riser mud cap of 13.4 PPG was installed and the well monitored through the choke line (static). The well was opened and monitored to be static. The stuck pipe was freed, circulation re-established and the well was again shut it. The Driller’s Method was then used to displace the influx from the well.

During the first circulation, a high gas alarm, from the shaker exhaust sensor, initiated a rig muster. The well was shut in and monitored. The shaker gas detectors and ventilation were checked and found operable. As the well kill was re-started, mud vented from the Mud Gas Separator (MGS) siphon breaker line, and all the shaker gas sensors alarmed. The rig was called to muster a second time. The well was shut in (indications were that gas had blown through the degasser liquid seal) and monitored. The liquid seal was lost and the well was immediately shut in. The liquid seal was flushed again and well kill started up but again lost the liquid seal and the well was shut in. Further investigation of the MGS identified a blind skillet plate in the spool piece between the MGS and main gas vent line which blocked the normal path for gas flow and misdirected the gas to the shaker room. The skillet plate had been installed during construction to prevent rainwater from entering the MGS.

The blind skillet plate was removed and the well kill re-started without further incident. No injuries were reported.

NewImageFigure 1: Blind flange located on top of vessel near deck ceiling. Not easily detected.


Figure 2Removed blind flange from the 12” vent line of the mud gas separator.

What Went Wrong?

  1. Uncertainty about the pore pressure below base of salt resulted in the mud weight being too low to prevent an influx.
  2. Malfunction of the mudlogger gas sampling system during drilling operations led to unrepresentative gas unit data.
  3. A 12-in blind skillet plate installed in the MGS main gas vent line during rig construction was not removed before operations began.
  4. Personnel on the rig did not fully understand the operation of the MGS to prevent subsequent gas releases in the shaker room.

Corrective Actions and Recommendations

  1. Include in rig contractors’ procedures for rig acceptance, flange management procedures to ensure that temporary blanking flanges or skillets, installed during construction or commissioning, are removed prior to hand-over to operations. Verification of rig contractor’s procedures to be in operator’s practices.
  2. Develop detailed instructions and procedures for preventative maintenance and calibration of the surface mud logging gas detection equipment that includes daily visual inspection of the gas trap impeller. Documentation for inspection and maintenance is to be maintained on the rig.
  3. Include critical items provided by Third Parties in the Safety Critical Equipment list and its associated controls.
  4. Implement awareness training for rig crews on the MGS Operating Procedure, LEL readings, mudlog gas detection, and significance and consequence of gas releases.

Source Contact

Safety alert number: 261 OGP
Safety Alerts


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: UK RAIB Report – Freight train derailment near Gloucester

November 10th, 2014 by

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Here’s the summary of the report:

At about 20:15 hrs on 15 October 2013, a freight train operated by Direct Rail Services, which was carrying containers, derailed about 4 miles (6.4 km) south west of Gloucester station on the railway line from Newport via Lydney. It was travelling at 69 mph (111 km/h) when the rear wheelset of the last wagon in the train derailed on track with regularly spaced dips in both rails, a phenomenon known as cyclic top. The train continued to Gloucester station where it was stopped by the signaller, who had become aware of a possible problem with the train through damage to the signalling system. By the time the train stopped, the rear wagon was severely damaged, the empty container it was carrying had fallen off, and there was damage to four miles of track, signalling cables, four level crossings and two bridges.

Screen Shot 2014 10 10 at 9 59 07 AM

The immediate cause of the accident was a cyclic top track defect which caused a wagon that was susceptible to this type of track defect to derail. The dips in the track had formed due to water flowing underneath the track and although the local Network Rail track maintenance team had identified the cyclic top track defect, the repairs it carried out were ineffective. The severity of the dips required immediate action by Network Rail, including the imposition of a speed restriction for the trains passing over it, but no such restriction had been put in place. Speed restrictions had repeatedly been imposed since December 2011 but were removed each time repair work was completed; on each occasion, such work subsequently proved to be ineffective.

The type of wagon that derailed was found to be susceptible to wheel unloading when responding to these dips in the track, especially when loaded with the type of empty container it was carrying. This susceptibility was not identified when the wagon was tested or approved for use on Network Rail’s infrastructure.

The RAIB also observes: the local Network Rail track maintenance team had a shortfall in its manpower resources; and design guidance for the distance between the wheelsets on two-axle wagons could also be applied to the distance between the centres of the bogies on bogie wagons.

The RAIB has made seven recommendations. Four are directed to Network Rail and cover reviewing the drainage in the area where the train derailed, revising processes for managing emergency speed restrictions for cyclic top track defects, providing track maintenance staff with a way of measuring cyclic top after completing repairs, and investigating how cyclic top on steel sleeper track can be effectively repaired. Two are directed to RSSB and cover reviewing how a vehicle’s response to cyclic top is assessed and amending guidance on the design of freight wagons. One is directed to Direct Rail Services and covers mitigating the susceptibility of this type of wagon to cyclic top.

For the complete report, see:

New York Post reports: “Huge drill almost skewers packed subway car”

November 4th, 2014 by

Once again, human error in the news …

A tragedy nearly occurred when a giant drill bit almost penetrated a subway full of people in New York.


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