Category: Current Events
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:
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 2014August 29th, 2014 by Mark Paradies
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.
Image 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 firstname.lastname@example.org or by telephoning 01332 253300
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.
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
- 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
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/
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.
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
Hydrocarbon Process Reports: “Pemex Blast at Ciudad Madero Refinery Kills Four Workers, Injures More”August 12th, 2014 by Mark Paradies
An oil refinery in Ciudad Madero burst into flames earlier this week killing four workers. After evaluating the situation, officials determined that the refinery was under maintenance and not operating at the time of the fire. What caught fire? How did this happen? Reports indicated that this particular refinery, being the smallest of six in the company, may not have been producing it’s quota for daily production due to refining inefficiencies and infrastructure that went ignored for too long.
Fortunately, this accident forced the government to pass a law for private investments for the National Energy Industry. Consequently, they waited too long to invest in this maintenance and inefficiencies which lead to destruction.
Here’s the Executive Summary from the CDC Report:
The Centers for Disease Control and Prevention (CDC) conducted an internal review of an incident that involved an unintentional release of potentially viable anthrax within its Roybal Campus, in Atlanta, Georgia. On June 5, 2014, a laboratory scientist in the Bioterrorism Rapid Response and Advanced Technology (BRRAT) laboratory prepared extracts from a panel of eight bacterial select agents, including Bacillus anthracis (B. anthracis), under biosafety level (BSL) 3 containment conditions. These samples were being prepared for analysis using matrix-assisted laser desorption/ionization time-of-flight (MALDI- TOF) mass spectrometry, a technology that can be used for rapid bacterial species identification.
This protein extraction procedure was being evaluated as part of a preliminary assessment of whether MALDI-TOF mass spectrometry could provide a faster way to detect anthrax compared to conventional methods and could be utilized by emergency response laboratories. After chemical treatment for 10 minutes and extraction, the samples were checked for sterility by plating portions of them on bacterial growth media. When no growth was observed on sterility plates after 24 hours, the remaining samples, which had been held in the chemical solution for 24 hours, were moved to CDC BSL-2 laboratories. On June 13, 2014, a laboratory scientist in the BRRAT laboratory BSL-3 lab observed unexpected growth on the anthrax sterility plate. While the specimens plated on this plate had only been treated for 10 minutes as opposed to the 24 hours of treatment of specimens sent outside of the BSL-3 lab, this nonetheless indicated that the B. anthracis sample extract may not have been sterile when transferred to BSL-2 laboratories.
Why the Incident Happened
The overriding factor contributing to this incident was the lack of an approved, written study plan reviewed by senior staff or scientific leadership to ensure that the research design was appropriate and met all laboratory safety requirements. Several additional factors contributed to the incident:
Use of unapproved sterilization techniques
Transfer of material not confirmed to be inactive
Use of pathogenic B. anthracis when non-pathogenic strains would have been appropriate for
Inadequate knowledge of the peer-reviewed literature
Lack of a standard operating procedure or process on inactivation and transfer to cover all procedures done with select agents in the BRRAT laboratory. What Has CDC Done Since the Incident Occurred CDC’s initial response to the incident focused on ensuring that any potentially exposed staff were assessed and, if appropriate, provided preventive treatment to reduce the risk of illness if exposure had occurred. CDC also ceased operations of the BRRAT laboratory pending investigation, decontaminated potentially affected laboratory spaces, undertook research to refine understanding of potential exposures and optimize preventive treatment, and conducted a review of the event to identify key recommendations.
To evaluate potential risk, research studies were conducted at a CDC laboratory and at an external laboratory to evaluate the extent to which the chemical treatment used by the BRRAT laboratory inactivated B. anthracis. Two preparations were evaluated: vegetative cells and a high concentration of B. anthracis spores. Results indicated that this treatment was effective at inactivating vegetative cells of B. anthracis under the conditions tested. The treatment was also effective at inactivating a high percentage of, but not all B. anthracis spores from the concentrated spore preparation.
A moratorium is being put into effect on July 11, 2014, on any biological material leaving any CDC BSL-3 or BSL-4 laboratory in order to allow sufficient time to put adequate improvement measures in place.
Since the incident, CDC has put in place multiple steps to reduce the risk of a similar event happening in the future. Key recommendations will address the root causes of this incident and provide redundant safeguards across the agency, these include:
The BRRAT laboratory has been closed since June 16, 2014, and will remain closed as it relates to work with any select agent until certain specific actions are taken
Appropriate personnel action will be taken with respect to individuals who contributed to or were in a position to prevent this incident
Protocols for inactivation and transfer of virulent pathogens throughout CDC laboratories will be reviewed
CDC will establish a CDC-wide single point of accountability for laboratory safety
CDC will establish an external advisory committee to provide ongoing advice and direction for laboratory safety
CDC response to future internal incidents will be improved by rapid establishment of an incident command structure
Broader implications for the use of select agents, across the United States will be examined.
This was a serious event that should not have happened. Though it now appears that the risk to any individual was either non-existent or very small, the issues raised by this event are important. CDC has concrete actions underway now to change processes that allowed this to happen, and we will do everything possible to prevent a future occurrence such as this in any CDC laboratory, and to apply the lessons learned to other laboratories across the United States.
RETIREMENT OF THE ROOT CAUSE NETWORK™ NEWSLETTER
After 121 issues, we’ve decided to retire the Root Cause Analysis Network™ Newsletter and publish all of our root cause analysis information in our weekly TapRooT® Expert and Friends Newsletter. This means you will occasionally see longer content (CLICK HERE for an example) on this blog and in the weekly newsletter.
We also decided that we will start republishing articles from the over 20 years of great writing in the Root Cause Network Newsletters™ as blasts from the past. That will help new readers catch up on some of the great ideas that we’ve shared over the years and that are still as good as the day they were published. Look for the first of these articles in September.
To make sure that you get the TapRooT® Expert and Friends Newsletter, CLICK HERE to register. Also, tell others who need the latest root cause analysis ideas to register at the link above.
Editor of the Root Cause Network™ Newsletter
President, System Improvements
A fatal gas blast in Taiwan’s biggest port city, Kaohsiung included 24 fatalities and 271 injured, four of which were policemen and fire fighters. Some of the nearby, uninjured residents assisted the injured by assembling makeshift stretchers, while the remaining 1,212 residents were relocated to safer grounds.
What was the root cause of this massive explosion? Local officials are still investigating. As of right now, their assessment is that there was a gas leak in a sewage pipeline that contained propylene, a gas used to make plastic and fabrics. This incident has been described as an “earthquake-like explosion” that knocked out thousands of local residents power and gas supply.
There are two main propylene producers in the area as well as two large oil refineries that are under investigation. All the sewage pipes in the city are being checked for further evidence and to see which company the particular pipe line that exploded is linked to. Until then, each of these companies have experienced stock share drops and are taking as many precautionary measures as possible to prevent a second explosion.
See the story at:
Monday Accident & Lessons Learned: RAIB Investigation of Uncontrolled evacuation of a London Underground train at Holland Park station 25 August 2013August 4th, 2014 by Mark Paradies
Here’s the summary of the report from the UK RAIB:
At around 18:35 hrs on Sunday 25 August 2013, a London Underground train departing Holland Park station was brought to a halt by the first of many passenger emergency alarm activations, after smoke and a smell of burning entered the train. During the following four minutes, until the train doors still in the platform were opened by the train operator (driver), around 13 passengers, including some children, climbed out of the train via the doors at the ends of carriages.
The investigation found that rising fear spread through the train when passengers perceived little or no response from the train operator to the activation of the passenger emergency alarms, the train side-doors remained locked and they were unable to open them, and they could not see any staff on the platform to deal with the situation. Believing they were in danger, a number of people in different parts of the train identified that they could climb over the top of safety barriers in the gaps between carriages to reach the platform.
A burning smell from the train had been reported when the train was at the previous station, Notting Hill Gate, and although a request had been made for staff at Holland Park station to investigate the report, the train was not held in the platform for staff to respond. A traction motor on the train was later found to have suffered an electrical fault, known as a ‘flash-over’, which was the main cause of the smoke and smell.
A factor underlying the passengers’ response was the train operator’s lack of training and experience to deal with incidents involving the activation of multiple passenger emergency alarms.
The report observes that London Underground Limited (LUL) commenced an internal investigation of the incident after details appeared in the media.
RAIB has made six recommendations to LUL. These seek to achieve a better ergonomic design of the interface between the train operator and passenger emergency alarm equipment, to improve the ability of train operators to respond appropriately to incidents of this type, and to ensure that train operators carryradios when leaving the cab to go back into the train so that they can maintain communications with line controllers. LUL is also recommended to review the procedures for line controllers to enable a timely response to safety critical conditions on trains and to ensure continuity at shift changeover when dealing with incidents. In addition, LUL is recommended to review the training and competencies of its staff to provide a joined-up response to incidents involving trains in platforms and to reinforce its procedures on the prompt and accurate reporting of incidents so that they may be properly investigated.
Monday Accident & Lessons Learned: UK RAIB Accident Report – Near-miss at Butterswood level crossing, North Lincolnshire, 25 June 2013July 28th, 2014 by Mark Paradies
The UK Rail Accident Investigation Branch issued a report about a train/car near miss at a crossing. Here is a summary of the report:
At around 07:35 hrs on Tuesday 25 June 2013 a passenger train was involved in a near-miss with a car on a level crossing near Butterswood in North Lincolnshire. The train passed over the level crossing with the barriers in the raised position and the road traffic signals extinguished. No injuries or damage were caused as a result of the incident.
Normally, the approach of the train would have automatically initiated the closure of the crossing. However, the crossing was not working normally because the power supply to the crossing equipment had been interrupted. The crossing was of a type where train drivers are required to check that it is not obstructed as they approach and that it has operated correctly. A flashing light is provided for this purpose, just before the crossing, with a flashing white light displayed if the crossing has correctly closed against road users, and a flashing red light displayed at all other times (including those occasions when the crossing has failed to close on the approach of a train). The driver of the train involved in the near-miss did not notice until it was too late to stop that the flashing light was indicating that the crossing was not working normally, and was still open for road traffic.
The RAIB’s investigation found that the train driver had the expectation that the crossing would operate normally as the train approached and that he had not focused his attention on the flashing light at the point where he needed to confirm that the crossing had operated correctly for the passage of his train. Although the level crossing had probably failed around nine hours before the incident, the fact of its failure was not known to any railway staff.
The investigation also found that the crossing was not protected with automatic warning system equipment and that the maintenance arrangements at the crossing were not effective in ensuring reliable performance of the equipment. In addition, the train operator’s briefing material did not clearly explain to drivers their role in respect of failures at this type of level crossing.
The RAIB has identified four key learning points relating to non-provision of the automatic warning system at locations where it is mandated by standards, recording of the condition of assets during inspection, storage of batteries, and involving people with relevant technical expertise in industry investigations into incidents and accidents.The RAIB has made four recommendations. Three recommendations have been made to Network Rail addressing the indications given to train drivers approaching crossings where they are required to monitor the crossing’s status, improvements to the reliability of power supplies to crossings such as Butterswood and considering remote monitoring of the power supply at similar crossings. One recommendation has been made to First TransPennine Express regarding the briefing that it gives its drivers on this type of level crossing.
For the complete report, see:
Are you prepared for a tornado at your facility?
Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …
See the story at EHS Today.
OGP Safety Alert
WELL CONTROL INCIDENT
While drilling 8″1/2 hole section @ 5052m with 1.51 SG MW, observe well flowing during pipe connection. Shut well in w/ 76 bbls gain. Establish 550psi SIDPP and 970psi SICP.
It took more than 7 minutes for the Driller to shut in after the well flowing situation was recognized (9 minutes 52 seconds total pumps off until well shut in) as follows: “The Mud Logger calls the dog house to inform the Driller that he has seen a gain in the trip tank; the Assistant Driller takes the call and communicates the information to the Driller. As the Driller is in the process of raising the blocks, he waits until the blocks are at 26m and calls the pit room to check that there is nothing that would affect the trip tank volume. He then waited for the return call which confirms nothing would affect the trip tank. The Driller switches over to the flow line as the trip tank is now nearly full and then lowers the TDS and screws back into the string at the rotary table. The string is then picked up and spaced out to close the annular mid joint; the Driller then unlocks the compensator. The annular is then closed by the Assistant Driller who is at the panel and the lower fail safes on the choke line are opened to monitor pressures.
Well was controlled using Drillers Method to circulate/increase MW up to 1.63 SG & decrease gas levels prior to open the well.
What Went Wrong?
Kick zone actual PP exceeds predicted PP range by ~0.07 SG EMW.
But actual PP < ECD (well not flowing while pumping).
76-bbl Kick Volume due to lengthy shut in Vs. ~30-bbl actual Kick Tolerance (KT) calculated from actual ~0.1 SG EMW Kick Intensity (design KT was 80 bbls calculated from maximum predicted PP). Note: There was gas in the influx, but no H2S. According to kick pressure & volume analysis, it is possible that part of the kick was liquid (influx density calculation). Influx density helped evacuating the kick w/out exceeding MAASP & fraccing @ shoe on exceeded KT.
Corrective Actions and Recommendations:
- Flow check each connection prior to starting the physical breaking of the tool joint (rather than flow check during connection).
- Ensure effective monitoring of the Mud Logging fingerprint screen during pumps-off real-time (connection & mid-stand “long connection test”).
- Correct shut-in procedure to be enforced & applied.
- Perform unannounced simulated kicks (kick drills).
- Whenever possible, implement a Well-Full-of-Gas capable casing design so that KT is not limited.
safety alert number: 257
OGP Safety Alerts http://info.ogp.org.uk/safety/
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.
The Christian Science Monitor reported that the spokesperson for the Kremlin’s Investigative Committee (a police body) said:
“As it is a man-caused accident, it is obvious that there are people responsible for it, so soon there will be suspects in the case.”
Later the International Business Times published this headline:
“Moscow Subway Accident: 2 Arrested Metro Workers Failed To Properly Supervise Track Switch Repair, Authorities Say”
It seems the two arrested supervised a job where a track switch was re-wired with the wrong wire.
Twenty-one have died, over a hundred were injured, and over 1000 people had to be evacuated from the subway after the accident.
What do you think? Will discipline solve the problem? Or does a real root cause analysis need to be done?
SmartGridNews.com reports “The U.S. grid is the worst in the industrialized world (outages are up 285%!)”July 15th, 2014 by Mark Paradies
The article starts with …
“Power outages in the United States are up an astonishing 285% since 1984. The U.S. ranks last among the top nine Western industrialized nations in the average length of outages. That dismal performance costs American businesses as much as $150 billion every year according to the EIA.“
It also has a map of power outage by state:
CLICK HERE to see the whole article.
Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013July 14th, 2014 by Mark Paradies
The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:
At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.
The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.
RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.
For the complete report, see:
“These events revealed totally unacceptable behavior. They should never have happened. I’m upset, I’m angry, I’ve lost sleep over this, and I’m working on it until the issue is resolved.”
DR. THOMAS FRIEDEN, director of the Centers for Disease Control and Prevention, which halted shipments of infectious agents from the agency’s labs after accidents with anthrax and flu pathogens.
- – -
What do you think? Time for advanced root cause analysis to get beyond “bad behavior” cause?
What’s “trending” on the Root Cause Analysis Blog? Here are the top 10 blog article by your votes (clicks) this year…
8. Press Release from the US CSB: CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico
See the Navy Times story at:
Wildlife along I-95 got a caffein overdose when a truck caring Red Bull was involved in an accident. It may be days before they go to sleep and some worried that the animals may take programmers jobs once fully fueled on caffeine.
See the real story by CLICKING HERE.
Site of the accident
RAIB is investigating an accident to a track worker who was supervising a gang carrying out track maintenance work near Redhill in Surrey. The accident occurred at about 10:40 hrs on 24 June 2014. The track worker was struck by a passenger train and suffered serious injuries.
The injured person was with a gang of eleven people engaged in undertaking repairs to the Up Quarry line between Redhill Tunnel and Quarry Tunnel. The train, a passenger service from Gatwick Airport to London Victoria, was travelling at about 80 mph (129 km/h).
RAIB’s investigation will consider the sequence of events and factors that may have led to the accident, and identify any safety lessons.
RAIB’s investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.
Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Releases Report on Accident at Balnamore Level Crossing, Ballymoney, Northern Ireland, 31 May 2013July 7th, 2014 by Mark Paradies
Here’s the Summary from the report:
At approximately 03:10 hrs on Friday, 31 May 2013, a car driver was forced totake action in order to avoid colliding with an engineering train that was traversing Balnamore automatic half barrier level crossing, which is located between Coleraine and Ballymoney stations on Northern Ireland Railways’ Belfast to Londonderry/ Derry line. The car subsequently struck metal fencing forming part of the crossing, causing minor injuries to its two occupants and damage to the car. The crew of the engineering train spoke with the car driver and then continued work without reporting the accident.
At the time of the accident, the engineering train was undertaking weed-spraying operations within a possession of the line, which meant that operation of passenger trains on the line had been suspended. Because the line was under possession, Balnamore level crossing, which is normally automatically operated by approaching trains, was being operated manually via its local controls. However, as the train passed over the crossing, its half barriers had not been lowered and its road traffic signals were not operating, even though this was required by the railway rules relating to this type of level crossing. This meant that the car driver did not have enough warning to stop his car before the level crossing became occupied by the train.
The RAIB has found that the team responsible for undertaking weed-spraying was routinely not complying with the rules relating to the operation of automatic half barrier level crossings within possessions. This was probably due to a combination of factors, including the team possibly having a low perception of the risks presented by this non-compliance and a desire by them to complete the weed-spraying more quickly. In addition, the team may have been influenced by the status of rules relating to the local control of other types of crossing in possessions and the method of work adopted at level crossings during a recent project.
The RAIB has also found that this non-compliance was not detected or corrected by safety checks conducted by Northern Ireland Railways. In addition, the investigation identified that the appointment of additional competent staff to operate crossings within the possession may have prevented the accident from occurring.
The RAIB has identified three key learning points. These are: 1) that the person in charge of a possession should correctly complete the form intended to help them keep track of level crossings; 2) that boarding moving trains, where it is prohibited, should be avoided; and 3) that accidents should be reported.
The RAIB has also made three recommendations addressed to Northern Ireland Railways. These relate to: 1) ensuring that activities undertaken at level crossings within possessions are subject to effective risk controls; 2) ensuring that method statements relating to track engineering are supported by risk assessments; and 3) increasing the opportunities for non-compliances to be detected and corrected.
For the complete report, CLICK HERE.
See the article at Gas Processing News:
Monday Accident & Lessons Learned: OGP Safety Alert – WELLHEAD GLAND NUT/LOCKSCREW ASSEMBLY EJECTIONJune 30th, 2014 by Mark Paradies
OGP SAFETY ALERT
A gas well installation suffered a loss of containment when a gland nut and lockscrew assembly was ejected from a wellhead while the well was under pressure, shortly before commencing tubing installation. The release of gas resulted in a fire which caused the death of a field service technician.
Lockscrews are commonly used in surface wellhead equipment to mechanically energize or retain internal wellhead components. Lockscrews are not standardized across the industry, so manufacturers’ procedures should always be used for operations that may require manipulation of lockscrews. Work involving gland nut and lockscrew assemblies should be done under the supervision of qualified service personnel from the wellhead equipment provider who have access to the operational procedures, key dimensions, and torque ratings necessary for correct use.
Operators should consider working with their wellhead equipment and service providers to validate the integrity of gland nut and lockscrew assemblies that are exposed to wellbore pressure in the field by taking the following steps:
- Verify adequate engagement of gland nuts;
- Confirm lockscrew assemblies’ torque values are consistent with manufacturer’s specifications;
- Inspect lockscrew assemblies for any debris or damage such as scarring or bending;
- Follow manufacturer’s procedures if checks show any of the above are inconsistent with the manufacturer’s specifications;
- Conduct a pressure test to rated maximum working pressure to ensure gland nut and lockscrew assemblies have pressure integrity;
- Consider isolating gland nut and lockscrew assemblies from wellbore pressure by having tubing hangers and adapters installed;
- Reinforce with relevant personnel training and the use of procedures to address hazards associated with performing work on wellhead assemblies exposed to wellbore pressure; and
- Review and implement appropriate engineering and well design controls (physical design of equipment) and administrative controls (procedures) to address the hazards of work involving gland nut and lockscrew assemblies.
These same validation steps should be taken prior to commencing any well work during which gland nut and lockscrew assemblies will be exposed to wellbore pressure.
safety alert number: 256
OGP Safety Alerts http://info.ogp.org.uk/safety/
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.