Category: Current Events

Happy Thanksgiving

November 27th, 2014 by

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

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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!

Monday Accident & Lessons Learned: OPG Safety Alert #261 – WELL CONTROL COMPLICATIONS ON FIRST WELL FOR NEW DRILLSHIP

November 17th, 2014 by

WELL CONTROL COMPLICATIONS ON FIRST WELL FOR NEW DRILLSHIP

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.

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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 http://info.ogp.org.uk/safety

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

 

Monday Accident & Lessons Learned: 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.

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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:

http://www.raib.gov.uk/cms_resources.cfm?file=/141009_R202014_Gloucester.pdf

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.

See:

http://nypost.com/2014/10/30/massive-drill-bit-nearly-skewers-packed-subway-car/

Washington Post reports: “Commercial spaceship suffers catastrophic failure, at least 1 dead”

October 31st, 2014 by

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The suborbital commercial flights give passengers a small taste of space travel by piloting international flights 62 miles above the Earth’s atmosphere for about $250,000 per seat.

So far, more than 700 prospective passengers have paid for tickets.

See:

http://www.washingtontimes.com/news/2014/oct/31/commercial-spaceship-suffers-catastrophic-failure-/

Forbes Reports: “… Nuclear Navy has the best safety record of any industry.”

October 30th, 2014 by

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Perhaps they should have said “process safety” record, but I won’t quibble. Here’s the quote:

America’s Nuclear Navy is one of the oldest and largest nuclear organizations in the world and has the best safety record of any industry.

And no one ever discusses it.

Well, not exactly. We’ve been discussing it for years! And the philosophy that keeps the Nuclear Navy safe is outlined in our Fatality Prevention Course and at the TapRooT® Summit.

See the article at:

http://www.forbes.com/sites/jamesconca/2014/10/28/americas-navy-the-unsung-heroes-of-nuclear-energy/

The article mentions the potential impact of budget cuts … a topic that worries many of us who know what it costs to maintain a flawless record – especially in the current environment of a shortage of ships and increased operating tempos.

Admiral Rickover was famous for telling a Congressman at a hearing that his question was “stupid.” What do you think he would say about saving a few million dollars but allowing process safety to degrade because of a shortage of funds with the ultimate result of an expensive nuclear accident that costs billion?

Stupid indeed.

Did Retiring Warthogs to “Save Money” Lead to The Recent Friendly Fire Accident In Afganistan?

October 30th, 2014 by

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And interesting article in the Washing Post suggests that using a B-1B for night time close air support and insufficient training led to the death of 7 Americans and 3 allies in a friendly fire accident.

See the story at THIS LINK and see what you think.

Monday Accident & Lessons Learned: UK RAIB Accident Report on a Passenger Becoming Trapped in a Train Door and Dragged a Short Distance at Newcastle Central Station

October 27th, 2014 by

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Here is a summary of the report:

At 17:02 hrs on Wednesday 5 June 2013, a passenger was dragged by a train departing from platform 10 at Newcastle Central station. Her wrist was trapped by an external door of the train and she was forced to move beside it to avoid being pulled off her feet. The train reached a maximum speed of around 5 mph (8 km/h) and travelled around 20 metres before coming to a stop. The train’s brakes were applied either by automatic application following a passenger operating the emergency door release handle, or by the driver responding to an emergency signal from the conductor. The conductor, who was in the rear cab, reported that he responded to someone on the platform shouting at him to stop the train. The passenger suffered severe bruising to her wrist.

This accident occurred because the conductor did not carry out a safety check before signalling to the driver that the train could depart. Platform 10 at Newcastle Central is a curved platform and safe dispatch is particularly reliant upon following the correct dispatch procedure including undertaking the pre-dispatch safety checks.

The investigation found that although the doors complied with the applicable train door standard, they were, in certain circumstances, able to trap a wrist and lock without the door obstruction sensing system detecting it. Once the doors were detected as locked, the train was able to move.

In 2004, although the parties involved in the train’s design and its approval for service were aware of this hazard, the risk associated with it was not formally documented or assessed. The train operator undertook a risk assessment in 2010 following reports of passengers becoming trapped. Although they rated the risk as tolerable, the hazard was not recorded in such a way that it could be monitored and reassessed, either on their own fleet or by operators of similar trains.

As a consequence of this incident, RAIB has made six recommendations. One of these is for operators of trains with this door design to assess the risk of injuries and fatalities due to trapping and dragging incidents and take the appropriate action to mitigate the risk.

Two recommendations have been made to the train’s manufacturer. One of these is to reduce the risk of trapping on future door designs, and the other to review its design processes with respect to hazard identification and recording.
One recommendation has been made to the operator of the train involved in this particular accident. This is related to the management of hazards associated with the design of its trains and assessment of the risks of its train dispatch operations.

Two recommendations have been made to RSSB. One is to add guidance to the standard on passenger train doors to raise awareness that it may be possible to overcome door obstruction detection even though doors satisfy the tests specified within the standard. The other recommendation is the consideration of additional data which should be recorded within its national safety management information system to provide more complete data relating to the risk of trapping and dragging incidents.

See the complete report here:

http://www.raib.gov.uk/cms_resources.cfm?file=/140918_R192014_Newcastle.pdf

6,600,000 Preventable Deaths

October 24th, 2014 by

What is the key intervention for preventing 6,600,000 death? You may be surprised by this solution, which is also the key intervention for reducing Ebola outbreak. It is the simple act of handwashing with soap. Invest 12 minutes of your time viewing this video and learn about the power of handwashing.

Did you know that TapRooT® is recognized worldwide as a premier “knowledge broker”? Stay in the know with relevant root cause analysis tips by joining our weekly email list:

http://www.taproot.com/contact-us

Some recent tips include:

Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry: (View video.)

Missed Opportunities: (Read post.)

What Makes a World Class Root Cause Analysis System? (View video.)

Monday Accident & Lessons Learned: Remove the Hazard – Snow & Ice Removal

October 13th, 2014 by

What do you have planned to keep walkways clear this winter?

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Here are some tips for snow and ice removal from WeatherChannel.com: (Read tips.)

Top 10 OSHA Citations in 2013

September 30th, 2014 by

OSHA published the top 10 OSHA citation from October 1, 2012 to September 20, 2013 (the federal government’s fiscal year 2013). here’s the list:

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What do you think?

Are these the top safety problems in the US? The biggest hazards your employees face?

Or is this just a list of what OSHA looks for when they do an inspection?

Let me know your thoughts by leaving a comment.

Monday Accident & Lessons Learned: Hot Work on Tanks Containing Biological or Organic Material

September 29th, 2014 by

This week accident information is from the US Chemical Safety Board …

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CSB Chairperson Moure-Eraso Warns About Danger of Hot Work
on Tanks Containing Biological or Organic Material

 Begin Statement

Earlier this month a team of CSB investigators deployed to the Omega Protein facility in Moss Point, Mississippi, where a tank explosion on July 28, 2014, killed a contract worker and severely injured another. Our team, working alongside federal OSHA inspectors, found that the incident occurred during hot work on or near a tank containing eight inches of a slurry of water and fish matter known as “stickwater.”

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 The explosion blew the lid off the 30-foot-high tank, fatally injuring a contract worker who was on top of the tank. A second contract worker on the tank was severely injured. CSB investigators commissioned laboratory testing of the stickwater and found telltale signs of microbial activity in the samples, such as the presence of volatile fatty acids in the liquid samples and offgassing of flammable methane and hydrogen sulfide.

The stickwater inside of the storage tank had been thought to be nonhazardous. No combustible gas testing was done on the contents of the tank before the hot work commenced.

This tragedy underscores the extreme importance of careful hot work planning, hazard evaluation, and procedures for all storage tanks, whether or not flammable material is expected to be present. Hot work dangers are not limited to the oil, gas, and chemical sectors where flammability hazards are commonplace.

The CSB has now examined three serious hot work incidents—all with fatalities—involving hot work on tanks of biological or organic matter. At the Packaging Corporation of America (PCA), three workers were killed on July 29, 2008, as they were performing hot work on a catwalk above an 80-foot-tall tank of “white water,” a slurry of pulp fiber waste and water.  CSB laboratory testing identified anaerobic, hydrogen-producing bacteria in the tank.  The hydrogen gas ignited, ripping open the tank lid and sending workers tumbling to their deaths.

On February 16, 2009, a welding contractor was killed while repairing a water clarifier tank at the ConAgra Foods facility in Boardman, Oregon. The tank held water and waste from potato washing; the CSB investigation found that water and organic material had built up beneath the base of the tank and decayed through microbial action, producing flammable gas that exploded.

Mixtures of water with fish, potatoes, or cardboard waste could understandably be assumed to be benign and pose little safety risk to workers. It is vital that companies, contract firms, and maintenance personnel recognize that in the confines of a storage tank, seemingly non-hazardous organic substances can release flammable gases at levels that cause the vapor space to exceed the lower flammability limit. Under those conditions, a simple spark or even conducted heat from hot work can prove disastrous.

I urge all companies to follow the positive example set by the DuPont Corporation, after a fatal hot work tragedy occurred at a DuPont chemical site near Buffalo, New York. Following CSB recommendations from 2012, DuPont instituted a series of reforms to hot work safety practices on a global basis, including requirements for combustible gas monitoring when planning for welding or other hot work on or near storage tanks or adjacent spaces.

Combustible gas testing is simple, safe, and affordable. It is a recommended practice of the National Fire Protection Association, The American Petroleum Institute, FM Global, and other safety organizations that produce hot work guidance. Combustible gas testing is important on tanks that hold or have held flammables, but it is equally important—if not more so—for tanks where flammables are not understood to be present. It will save lives.

END STATEMENT

More resources:

http://www.csb.gov/e-i-dupont-de-nemours-co-fatal-hotwork-explosion/

http://www.csb.gov/packaging-corporation-storage-tank-explosion/

http://www.csb.gov/seven-key-lessons-to-prevent-worker-deaths-during-hot-work-in-and-around-tanks/

http://www.csb.gov/motiva-enterprises-sulfuric-acid-tank-explosion/

http://www.csb.gov/partridge-raleigh-oilfield-explosion-and-fire/&?nbsp;

 

Monday Accident & Lesson Learned: Fatal accident at Barratt’s Lane No.2 footpath crossing, Attenborough, Nottingham, 26 October 2013

September 22nd, 2014 by

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The UK Rail Accident Investigation Branch issued a report about the fatal accident of a train striking a pedestrian at a footpath crossing near Nottingham, UK. See the entire report and the one lesson learned at:

http://www.raib.gov.uk/cms_resources.cfm?file=/140821_R182014_Barratts_Lane.pdf

Monday Accident & Lesson Learned: Wheelchair / Baby Stroller Rolls onto the Tracks

September 15th, 2014 by

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The UK Rail Accident Investigation Branch has published a report about two accidents where things (a wheelchair and a baby stroller) rolled onto the tracks.

To see the report and the one lesson learned, CLICK HERE.

Monday Accident & Lessons Learned: NTSB Investigation – Grounding and Sinking of Towing Vessel Stephen L. Colby”

September 8th, 2014 by

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Below is the NTSB investigation PDF. Read it and see what you think of the “probable cause” of the accident …  “The National Transportation Safety Board determines that the probable cause of the grounding and sinking of the Stephen L. Colby was the failure of the master and mate to ensure sufficient underkeel clearance for the intended transit through the accident area.

See the whole report here:

Colby.pdf

 

 

Houston Chronicle reports: “Judge rules BP was grossly negligent in oil spill”

September 4th, 2014 by

This is big news in that the fines for the spill are multiplied and could reach $18 billion dollars. See the whole story at:

http://fuelfix.com/blog/2014/09/04/judge-rules-bp-was-grossly-negligent-in-oil-spill/

Houston Chronicle reports: “Halliburton Reaches $1.1 Billion Gulf Spill Settlement”

September 2nd, 2014 by

Halliburton’s agreement caps the amount of money it will pay and significantly cuts into the legal liabilities it faces. See the story at:

http://fuelfix.com/blog/2014/09/02/halliburton-reaches-1-1-billion-gulf-spill-settlement/

Monday Accident & Lessons Learned: RAIB Investigation Report – Road Rail Vehicle Runs Away, Strikes Scaffold

September 1st, 2014 by

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Here is the summary of the report from the UK Rail Accident Investigation Branch:

At about 03:00 hrs on Sunday 21 April 2013, a road rail vehicle (RRV) ran away as it was being on-tracked north of Glasgow Queen Street High Level Tunnel on a section of railway sloping towards the tunnel. The RRV ran through the tunnel and struck two scaffolds that were being used for maintenance work on the tunnel walls. A person working on one of the scaffolds was thrown to the ground and suffered severe injuries to his shoulder. The track levelled out as the RRV ran into Glasgow Queen Street station and, after travelling a total distance of about 1.1 miles (1.8 kilometres), it stopped in platform 5, about 20 metres short of the buffer stop.

The RRV was a mobile elevating work platform that was manufactured for use on road wheels and then converted by Rexquote Ltd to permit use on the railway. The RRV’s road wheels were intended to provide braking in both road and rail modes. This was achieved in rail mode by holding the road wheels against a hub extending from the rail wheels. The design of the RRV meant that during a transition phase in the on-tracking procedure, the road wheel brakes were ineffective because the RRV was supported on the rail wheels but the road wheels were not yet touching the hubs. Although instructed to follow a procedure which prevented this occurring simultaneously at both ends of the RRV, the machine operator unintentionally put the RRV into this condition. He was (correctly) standing beside the RRV when it started to move, and the control equipment was pulled from his hand before he could stop the vehicle.

The RRV was fitted with holding brakes acting directly on both rail wheels at one end of the vehicle. These were intended to prevent a runaway if non-compliance with the operating instructions meant that all road wheel brakes were ineffective. The holding brake was insufficient to prevent the runaway due to shortcomings in Rexquote’s design, factory testing and specification of maintenance activities. The lack of an effective quality assurance system at Rexquote was an underlying factor. The design of the holding brake was not reviewed when the RRV was subject to the rail industry vehicle approval process because provision of such a brake was not required by Railway Industry Standards.

The RAIB has identified one learning point which reminds the rail industry that the rail vehicle approval process does not cover all aspects of rail vehicle performance. The RAIB has made four recommendations. One requires Rexquote to implement an effective quality assurance system and another, supporting an activity already proposed by Network Rail, seeks to widen the scope of safety-related audits applied by Network Rail to organisations supplying rail plant for use on its infrastructure. A third recommendation seeks improvements to the testing process for parking brakes provided on RRVs. The final recommendation, based on an observation, relates to the provision of lighting on RRVs.

To read the whole report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140717_R152014_Glasgow_Queen_Street.pdf

UK Rail Accident Investigation Branch investigates electrical arcing and fire on a Metro train and parting of the overhead line at Walkergate station, Newcastle upon Tyne, on 11 August 2014

August 29th, 2014 by

Here’s the press release …

Electrical arcing and fire on a Metro train and parting of the overhead line
at Walkergate station, Newcastle upon Tyne, on 11 August 2014

RAIB is investigating an accident which occurred on the Tyne and Wear Metro system at Walkergate station on Monday 11 August 2014.

At 18:56 hrs a two-car Metro train, travelling from South Shields to St James, arrived at Walkergate station. While standing in the station an electrical fault occurred to a line breaker mounted on the underside of the train, which produced some smoke. It also caused the circuit breakers at the sub-stations supplying the train with electricity, via the overhead line, to trip (open). About one minute later power was restored to the train. There followed a brief fire in the area of the initial electrical fault and further smoke. Shortly afterwards, the overhead line above the train parted and the flailing ends of the wire fell on the train roof and one then fell on to the platform, producing significant arcing and sparks for around 14 seconds. Fortunately, there was no-one on the platform at the time. However, there were at least 30 passengers on the train who self-evacuated on to the platform using the train doors’ emergency release handles. The fire service attended but the fire was no longer burning. No-one was reported to be injured in the accident and there was no significant damage to the interior of the train.

NewImageImage courtesy of Tyne and Wear Metro 

RAIB’s investigation will consider the sequence of events and factors that led to the accident, and identify any safety lessons. In particular, it will examine:

  • the reasons for the electrical fault;
  • the response of the staff involved, including the driver and controllers;
  • the adequacy of the electrical protection arrangements; and
  • actions taken since a previous accident of a similar type that occurred at South Gosforth in January 2013 (RAIB report 18/2013).

RAIB’s investigation is independent of any investigations by the safety authority. RAIB will publish its findings at the conclusion of the investigation. The report will be available on the RAIB’s website. 

You can subscribe to automated emails notifying you when the RAIB publishes its report and bulletins.

RAIB would like to hear from any passengers who were on the train. Any information provided to assist our safety investigation will be treated in strict confidence. If you are able to help the RAIB please contact us by email on enquiries@raib.gov.uk or by telephoning 01332 253300

Monday Accident & Lessons Learned: OPG Safety Alert #259 – FATALITY DURING CONFINED SPACE ENTRY

August 25th, 2014 by

 

FATALITY DURING CONFINED SPACE ENTRY

  • Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube.
  • After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased.
  • A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness.
  • On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.

 

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What Went Wrong?

  • Exposure to an oxygen-deficient atmosphere: The rope access team members (victim and co-worker) were unaware of the asphyxiation risk from the argon gas shielding.
  • Gas test: There was no gas test done immediately prior to the confined space entry. The act of removing the upper foam sponge itself could have released (additional) argon, so any prior test would not be meaningful.
  • Gas detectors: Portable gas detectors were carried, but inside a canvas bag. The co-worker did not hear any audible alarm from the gas detector when he descended into the space.
  • Evacuation time: It took 20 minutes to bring the victim to the deck after communication failed.

Corrective Actions and Recommendations

Lessons:

  • As a first step: assess whether the nature of the work absolutely justifies personnel entering the confined space.
  • Before confined space entry:
    - identify and communicate the risks to personnel carrying out the work
    - define requirements, roles and responsibilities to control, monitor and supervise the work
    - check gas presence; understand how the work itself may change the atmospheric conditions
    - ensure adequate ventilation, lighting, means of communication and escape
  • Ensure step by step work permits are issued and displayed for each work phase, together with specific job safety analyses
  • During confined space entry:
    - station a trained confined space attendant at the entrance to the space at all times
    - ensure that communication and rescue equipment and resources are readily available
    - carry and use portable/personal gas detectors throughout the activity 

ACTION

Review your yard confined space entry practice, keeping in mind the lessons learned from this incident.

safety alert number: 259 

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

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SFGate Reports: “PG&E Pleads Not Guilt in San Bruno Blast Case”

August 19th, 2014 by

A deadly pipeline gas explosion in San Bruno, California has the state government of California involved to investigate what the root cause was. It has been reported that the alleged local gas company, Pacific Gas and Electric Co., has been working with the California Public Utilities Commission in a corrupted relationship resulting in unfair and dishonest regulations. It was also reported that after pleading guilty, the grand jury accused them of 28 counts of safety violations. Mayor Jim Ruane has recognized this and ensured that there will be an independent monitor to investigate the company to restore the public’s confidence.

Additionally, more reports have indicated that PG&E was at fault for a similar incident in 2010 including a gas explosion and failure to comply with regulations. It is suspected that they also obstructed the National Transportation Safety Board by falsely denying that they ignore federal pipeline inspection requirements. Now current investigations are showing that PG&E played a large role in organizing an upcoming gas safety conference causing many to question the quality of the conference. Once revealed, protests caused cancellation of the conference and less confidence in the company.

PG&E describes this as a “tragic accident” and it is suspected that they are in denial in order to keep up the integrity of the business. They claim to be unsure if their employees are making bad judgments as opposed to blatant violations. Officials will continue to investigate as the trials also continue in hopes of an answer and compromise.

See:

http://www.sfgate.com/bayarea/article/PG-amp-E-pleads-not-guilty-in-San-Bruno-blast-case-5695990.php

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