Category: Current Events
From the Rail Accident Investigation Branch …
At around 13:10 hrs on 25 July 2015, a passenger was dragged along the platform at Hayes & Harlington station, London, when the 11:37 hrs First Great Western service from Oxford to London Paddington departed while her hand was trapped in a door. The passenger, who had arrived on the platform as the doors were about to close, had placed her hand between the closing door leaves.
The train driver did not identify that the passenger was trapped and the train moved off, dragging the passenger along the platform. After being dragged for about 19 metres, the passenger lost her footing and fell onto the platform. The passenger suffered head, hand and back injuries.
RAIB’s investigation found that the passenger had deliberately placed her hand in the closing door in the expectation that it would re-open as a consequence. RAIB has concluded that after closing the doors of the train, the driver either did not make a final check that it was safe to depart, or that the check was insufficiently detailed to allow him to identify the trapped passenger. The driver may have been misled into thinking that it was safe to depart because a door interlock light in his cab had illuminated, indicating that the doors were closed and locked and he was able to take power.
Our investigation identified that the train driver and other railway staff held the same misunderstanding: if someone had a hand trapped in a door it would not be possible for the door interlock light to illuminate and a driver to take power. This is not the case, and the door was found to be compliant with all applicable standards after the accident.
As a consequence of this investigation, RAIB has made two recommendations.
The first, addressed to RSSB to review, and if necessary extend, its research into the passenger/train interface to understand passenger behaviour and identify means for deterring members of the public from obstructing train doors.
The second recommendation is addressed to operators and owners of trains similar to the one involved in the accident at Hayes & Harlington, is intended to continue and expand upon a current review into the practicability of fitting sensitive door edge technology to this type of train.
RAIB has also identified three learning points. The first concerns improving awareness among train drivers of the limitations of train door interlocking technology and the importance of the final safety check when dispatching a train.
The second concerns the potential for drivers to be distracted by the use of mobile communication devices while driving.
The third is aimed at train operators to have the necessary processes in place to identify drivers who are showing signs of sub-standard performance or not engaging positively with measures agreed as part of a Competence Development Plan and the provision of briefing and guidance material for driver managers to enable them to identify behaviours and attitudes which are inconsistent with those expected of train drivers.
For the complete report, see:
The following is a IOPG Safety Alert from the International Association of Oil & Gas Producers…
IOGP SAFETY ALERT
CORROSION COUPON PLUG EJECTED FROM PRESSURISED PIPELINE
Personnel accountable or responsible for pipelines and piping fitted with corrosion coupons.
A routine corrosion coupon retrieval operation was being conducted on a 28” crude oil pipeline. Two retrieval technicians were located in a below ground access pit, to perform the operation. The operation involved removal of the corrosion coupon carrier ‘plug’ from its threaded 2” access fitting on the pipeline. The plug was ejected at high velocity from the access fitting (pipeline pressure 103 bar), during the operation to ease the plug using a ring spanner to a maximum of ¼ turn (as per procedure) and before the service valve and retrieval tool were installed. A high volume of crude oil spilled from the pipeline via the access fitting. Fortunately, the two technicians escaped the access pit without injury from the plug projectile or crude oil release.
What Went Wrong?
The Venture is still in the process of conducting the incident investigation. Based on their findings to date, the most probable cause is that the threads of the access fitting were worn down to such an extent, that they were unable to restrain the plug upon minor disturbance (the ¼ turn of the plug).
- The access fitting was installed during pipeline construction in 1987. It is estimated to have been subject to over 140 coupon retrieval and installation cycles.
- Bottom-of-pipeline debris can cause galling of threads on stainless steel plugs, which in turn can damage the threads of carbon steel access fittings.
- The repair (chasing) of worn threads on access fittings is performed using an original equipment manufacturer supplied thread tap assembly service tool.
- In the presence of bottom-of-pipeline debris and thread damage, the repetitive removal of internal thread material, can lead to ever smaller contact surfaces, increasing contact stress, increasing wear rates and/or galling.
- Smaller thread contact surfaces reduce the ability of the access fittings to restrain plugs.
- In this incident, the original equipment manufacturer supplied thread tap assembly service tool had been used routinely for every plug coupon retrieval and installation cycle without the use of flushing oil to remove debris from the threads.
Corrective Actions and Recommendations:
Lessons Learned –
- As yet, there is no standard method to determine internal thread condition of on-line corrosion probe/coupon original equipment manufacturer access fittings. Thread condition is not easily inspected.
- The risk posed by long term use of thread tap assembly service tools on access fittings, has not been previously identified.
Action taken in originating company –
Temporarily suspend all corrosion coupon retrieval operations on pressurised lines furnished with threaded access fittings in the 6 o’clock position (bottom of pipeline). This provides time to complete the investigation and complete work with the original equipment manufacturer to develop clear guidance on the maximum number of retrieval cycles.
- A subsequent notification will be issued based on the completed investigation and original equipment manufacturer tests*. In this alert any changes to guidance or maintenance routines (i.e. how and when these type operations can be recommenced) will be advised.
- The temporary suspension does not cover retrieval operations on lines which are depressurised.
* the use of ‘no go’ gauges for checking access fittings after every use of a thread tap assembly service tool or access fitting body seat reamer, is being explored.
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.
Safety Alert Number: 273
IOGP Safety Alerts http://safetyzone.iogp.org
The Kappa Delta Rho Fraternity presented Mark Paradies, President of System Improvements with the Ordo Honoris Award for device to his fraternity and the world. Part of this service to the world was Mark’s development and teaching of the TapRooT® Root Cause Analysis System to save lives, improve product quality, and improve workplace productivity by finding and fixing the root causes of accidents and incidents.
The errors reported in this Aviation Safety Reporting System “Call Back” article are simple but serious. If you load a plane wrong, it could crash on takeoff. Click on the picture of the article below to read the whole report.
These simple errors seem like they are just an aviation problem. But are there simple errors that your people could make that could cause serious safety, quality, or production issues? maybe a Safeguard Analysis is in order to see if the only Safeguard you are relying on could fail due to a simple human error.
Monday Accident & Lessons Learned: Is the Information Collected as Part of an Accident Investigation “Privileged” – Canadian Court RulesAugust 1st, 2016 by Mark Paradies
The Occupational Health and Safety Act (“OHS Act”) in Canada requires an employer to conduct and investigation and prepare a report following an accident in the workplace. But an Aberta Queens Bench ruled that the obligation does not “foreclose or preclude” the employer’s ability to claim privilege over information collected during an internal investigation into the incident.
Want to learn more? See the article about the Alberta v Suncor Energy case at:
This Accident shares a “Call Back” Report from the Aviation Safety Reporting System that is applicable far beyond aviation.
In this case, the pilot was fatigued and just wanted to “get home.” He had a “finish the mission” focus that could have cost him his life. Here’s an excerpt:
I saw nothing of the runway environment…. I had made no mental accommodation to do a missed approach as I just knew that my skills would allow me to land as they had so many times in past years. The only conscious control input that I can recall is leveling at the MDA [Rather than continuing to the DA? –Ed.] while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at the flight instruments as I began…an uncontrolled, unconscious 90-degree turn to the left, still looking for the runway environment.
To read about this near-miss and the lessons learned, see:
Derailment of freight train near Angerstein Junction, south east London, 3 June 2015
At about 12:10 hrs on 3 June 2015, one wagon of an empty freight train derailed on the approach to Angerstein Junction, near Charlton in south east London. The train continued over the junction, derailing two further wagons, before it stopped on the Blackheath to Charlton line. The three derailed wagons were partly obstructing the line used by trains travelling in the opposite direction. No other trains were involved in the accident and no-one was injured, but there was significant damage to the railway infrastructure.
The wagons derailed because the leading right-hand wheel on one of them was carrying insufficient load to prevent the wheel climbing up the outer rail on a curved section of track. The insufficient load was due to a combination of the suspension on that wheel being locked in one position, a twisted bogie frame and an intended twist in the track.
As a consequence of this investigation, RAIB has made three recommendations.
The first, addressed to VTG (the wagon owner), seeks improvements to its wagon maintenance processes.
The second, also addressed to VTG, seeks liaison with industry to improve understanding of how wagon suspension wear characteristics relate to maintenance processes.
The third, addressed to Network Rail, seeks a review of infrastructure arrangements at the accident location.
The report also includes a learning point reinforcing a previous recommendation intended to encourage use of currently available wheel load data to enable identification of wagons with defects or uneven loads that are running on Network Rail’s infrastructure.
To see the complete report, go to:
The above information and report are from the UK Rail Accident Investigation Branck. See their web site at:
I just went through the attendance list for the 2016 Global TapRooT® Summit and I was impressed. What a great bunch of people we are having come together in San Antonio!
For me, as President of System Improvements and one of the creators of the TapRooT® Root Cause Analysis System, the Summit always seems like old home week or a high school reunion. I get to see some of our clients that have been working hard to save lives, improve quality, and keep their companies from getting a black eye.
We’ve been doing these Summits since 1994 and you might not believe it but, I’ve been learning new and valuable stuff at the Summit every year.
So for all of you coming to the 2016 Global Summit,
I CAN’T WAIT TO SAY “HOWDY!”
And get caught up on what you have been doing to make the world a better place.
And for those who haven’t signed up yet,
What? You don’t know why you should attend? You need the knowledge shared at the Summit to …
SAVE YOUR COMPANY $$$
Those are business critical topics that you need to make your company best in class.
See the Summit brochure at:
See the Summit agenda at:
If you need more convincing, let me plead with you to attend. Watch this video…
Can command and control improve safety?
According to this ABC article, Chinese government has “ordered” improvements in safety. Yet 11 people died in an accident at an Aluminum Corp. of China aluminum plant when equipment they were dismantling fell on them. The article also mentions the chemical explosion that killed 173 people in the port city of Tianjin last year.
What are you doing to improve safety?
Can you or your management “order” improvements?
Perhaps you need to learn root cause analysis and best practices and skills to make your safety program world class?
If you want next year to be better than this year, sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
Pick the advanced course that will help you learn the skills you need to to improve your company’s performance.
Then pick the best practice sharing sessions at the Summit that will help you meet the biggest challenges that face your company.
Learn from your peers from around the world (see the LIST here).
Learn from people in your industry and other industries (see the LIST here).
And don’t forget our Summit GUARANTEE:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
With a guarantee like this one, you have nothing to lose and everything to gain!
Here’s a summary of the report from the UK Rail Accident Investigation Branch about a derailment at Godmersham, UK:
“At around 21:40 hrs on 26 July 2015, a passenger train derailed after striking eight cows that had gained access to the railway at Godmersham in Kent, between Wye and Chilham stations. There had been a report of a cow on the railway an hour earlier, but a subsequent examination by the driver of the next passing train did not find anything. There were no further reports from other trains that passed before the accident occurred.
The train involved in the accident was travelling at 69 mph (111 km/h) at the point of impact. There were 67 passengers on board plus three members of staff; no injuries were reported at the time of the accident. Because the train’s radio had ceased to work during the accident, the driver ran for about three-quarters of a mile towards an oncoming train, which had already been stopped by the signaller, and used its radio to report the accident.
The accident occurred because the fence had not been maintained so as to restrain cows from breaching it, and because the railway’s response to the earlier report of a cow on the railway side of the fence was insufficient to prevent the accident. In addition, the absence of an obstacle deflector on the leading unit of the train made the derailment more likely.
As a result of this accident, RAIB has made five recommendations addressing the fence inspection process, clarification of railway rules in response to reports of large animals within the boundary fence, the fitting of obstacle deflectors to rolling stock (two recommendations), and the reliability of the train radio equipment.
RAIB has also identified two learning points for the railway industry, relating to the railway’s response to emergency situations, including the response to reports of large animals within the boundary fence and the actions to take following an accident.
Here is a link to read the report…
The UK Rail Accident Investigation Branch published a report about a tram hitting a pedestrian in Manchester, UK.
A summary of the report says:
At about 11:13 hrs on Tuesday 12 May 2015, a tram collided with and seriously injured a pedestrian, shortly after leaving Market Street tram stop in central Manchester. The pedestrian had just alighted from the tram and was walking along the track towards Piccadilly.
The accident occurred because the pedestrian did not move out of the path of the tram and because the driver did not apply the tram’s brakes in time to avoid striking the pedestrian.
As a result of this accident, RAIB has made three recommendations. One is made to Metrolink RATP Dev Ltd in conjunction with Transport for Greater Manchester, to review the assessment of risk from tram operations throughout the pedestrianised area in the vicinity of Piccadilly Gardens.
A second is made to UK Tram, to make explicit provision for the assessment of risk, in areas where trams and pedestrians/cyclists share the same space, in its guidance for the design and operation of urban tramways.
A further recommendation is made to Metrolink RATP Dev Ltd, to improve its care of staff involved in an accident.
For the complete report, see:
For one mom, it looked like her vacation cruise ship pulling away from the dock without her but with her children on it.
Lesson learned: Don’t miss the boat.
The Wall Street Journal announced that BP incurred $56 Billion in expenses from the Deepwater Horizon explosion and spill. And the end is still not in sight.
BP’s CFO said “It’s impossible to come up with an estimate [of future costs].”
Of course, those costs don’t include the lives lost and the negative PR that the company has received.
How much is a best in class process safety program worth? As BP’s CFO says …
It’s impossible to come up with an estimate.
If you would like to learn best practices to improve your safety performance and make your programs “best in class,” the at ten the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
What? You say YOUR COMPANY CAN’T AFFORT IT? Can it afford $56 Billion? The investment in your safety program is a pittance compared with the costs of a major accident. Your company should put spending on safety improvement BEFORE other investments … especially in difficult times.
If you are a senior manager, don’t wait for your safety folks to ask to attend the Summit. Send them an e-mail. Tell them you are putting a team together to attend the Summit with you to learn best practices to prevent major accidents. Ask them who would be the best people to include on this team. Then get them all registered fot the Summit.
Remember, the Summit is GUARANTEED.
Attend the Summit and go back to work and use what you’ve learned.
If you don’t get at least 10 times the return on your investment,
simply return the Summit materials and we’ll refund the entire Summit fee.
Wow! A guaranteed ROI. How can we be so sure that you will return to work with valuable ideas to implement? Because we’ve been hosting these Summits for over 20 years and we know the “best of the best” attend the Summit and we know the value of the ideas they share each year. We’ve heard about the improvements that Summit attendees have implemented. Being proactive is the key to avoiding $56 Billion dollar mistakes.
So don’t wait. Get your folks registered today at:
This is old news to most (or should be) but OSHA finally published the long awaited rule on injury reporting:
So now that information will become more public will companies improve their records to stay out of view? Some things to think about:
*If they did not care about worker’s safety before, why would they care now?
*Will anyone even pay attention?
*Will management put more pressure on the operation to reduce rates?
*Will management give the operation additional resources to accomplish it?
*Will the media misuse the information? Will it be used politically?
*Did you just become your PR Department’s best bud or worst enemy?
*Will it actually help companies choose better business partners? (many companies have been requiring rates during the RFP process anyway)
*Is everyone else in the organization now throwing in their 2 cents on how you run your business?
I look at this a few ways:
*If you already have a good program and record, this should be of little concern to you from the public information standpoint.
*Assuming that is the case, as a former corporate safety manager, I see this as a HUGE cost for companies to comply. But there has been (and still is) plenty of time to get things in place.
At the end of the day, you cannot control regulations. But can you control your injuries? You bet.
Two of the best ways to lower your injury rates? Do better investigations and audits. Why not join us for a future course? You can see the schedule and enroll HERE
The explosion at the West Fertilizer Plant was thought to have been a tragic accident. However, the Associated Press has reported that the Alcohol, Tobacco, and Firearms, and Explosives Agency (ATF) has said that the fire that caused the explosion was “intentionally set.”
Here is a TV report link:
Harrison Ford was hit by a heavy, hydraulically operated door while filming the new Star Wars movie. He suffered a broken leg. The UK Health & Safety Executive charged Foodles Productions (UK) Ltd. with four criminal violations and the company will have it’s first court hearing on May 12th.
Now the question – or lesson learned …
- Will criminal charges make movie actors safer?
- Do studios already have incentives to keep their actors safe?
What do you think? Leave your comments here…
This video has a few four letter words so turn your sound off if you would be offended … but the footage is spectacular.
The Nuclear Energy Institute published a white paper titled:
To summarize what is said, the nuclear industry went overboard putting everything including the kitchen sink into their Corrective Action Program, made things too complex, and tried to fix things that should never have been investigated.
How far overboard did they go? Well, in some cases if you were late to training, a condition report was filed.
For many years we’ve been preaching to our nuclear industry clients to TARGET root cause analysis to actual incidents that could cause real safety or process safety consequences worth stopping. We actually recommend expanding the number of real root cause analyses performed while simplifying the way that root cause analyses were conducted.
Also, we recommended STOPPING wasting time performing worthless apparent cause analyses and generating time wasting corrective actions for problems that really didn’t deserve a fix. They should just be categorized and trended (see out Trending Course if you need to learn more about real trending).
We also wrote a whole new book to help simplify the root cause analysis of low-to-medium risk incidents. It is titled:
Those who have read the book say that it makes TapRooT® MUCH EASIER for simple investigations. It keeps the advantages of the complete TapRooT® System without the complexity needed for major investigations.
What’s in the new book? Here’s the Table of Contents:
Chapter 1: When is a Basic Investigation Good Enough?
Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System
- Find Out What Happened & Draw a SnapCharT®
- Decision: Stop or More to Learn?
- Find Causal Factors Using Safeguard Analysis
- Find Root Causes Using the Root Cause Tree® Diagram
- Develop Fixes Using the Corrective Action Helper Module
- Optional Step: Find and Fix Generic Causes
- What is Left Out of a Basic Investigation to Make it Easy?
Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation
Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation
The TapRooT® Process for simple incidents is just 5 steps and is covered in 50 pages in the book.
If you are looking for a robust techniques that is usable on your simple incidents and for major investigations, LOOK NO FURTHER. The TapRooT® System is the answer.
If you are in the nuclear industry, use TapRooT® to simplify the investigations of low-to-moderate risk incidents.
If you are in some other industry, TapRooT® will help you achieve great results investigating both minor incidents and major accidents with techniques that will help you no matter what level of complexity your investigation requires.
One more question that you might have for us ,,,
How does TapRooT® stay one (or more) steps ahead of the industry?
- We work across almost every industry in every continent around the world.
- We spend time thinking about all the problems (opportunities for improvement) that we see.
- We work with some really smart TapRooT® Users around the world that are part of our TapRooT® Advisory Board.
- We organize and attend the annual Global TapRooT® Summit and collect best practices from around the world.
We then put all this knowledge to work to find ways to keep TapRooT® and our clients at the leading edge of root cause analysis and performance improvement excellence. We work hard, think hard, and each year keep making the TapRooT® Root Cause Analysis System better and easier to use.
If you want to reduce the cumulative impact of your corrective action program, get the latest TapRooT® Book and attend our new 2-Day TapRooT® Root Cause Analysis Course. You will be glad to get great results while saving time and effort.
Wow. Quite an eye-opening Washington Post article describing a report published in the BMJ. A comprehensive study by researchers at the John Hopkins University have found that medical mistakes are now responsible for more deaths in the US each year than Accidents, Respiratory Disease, and Strokes. They estimate over a quarter million people die each year in the US due to mistakes made during medical procedures. And this does NOT include other sentinel events that do not result in death. Researchers include in this category “everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.” Other tidbits from this study:
- Over 700 deaths each day are due to medical errors
- This is nearly 10% of all deaths in the US each year
What’s particularly alarming is that a study conducted in 1999 showed similar results. That study called medical errors “an epidemic.” And yet, very little has changed since that report was issued. While a few categories have gotten better (hospital-acquired infections, for example), there has been almost no change in the overall numbers.
I’m sure there are many “causes” for these issues. This report focused on the reporting systems in the US (and many other countries) that make it almost impossible to identify medical error cases. And many other problems are endemic to the entire medical system:
- Insurance liabilities
- Inadequate reporting requirements
- Poor training at many levels
- Ineffective accountability systems
- between patient care and running a business
However, individual health care facilities have the most control over their own outcomes. They truly believe in providing the very best medical care to their patients. They don’t necessarily need to wait for national regulations to force change. They often just need a way to recognize the issues, minimize the local blame culture, identify problems, recognize systemic issues at their facilities, and apply effective corrective actions to those issues.
I have found that one of the major hurdles to correcting these issues is a lack of proper sentinel event analysis. Hospitals are staffed with extremely smart people, but they just don’t have the training or expertise to perform comprehensive root cause analysis and incident investigation. Many feel that, because they have smart people, they can perform these analyses without further training. Unfortunately, incident investigation is a skill, just like other skills learned by doctors, nurses, and patient quality staff, and this skill requires specialized training and methodology. When a facility is presented with this training (yes, I’m talking about TapRooT®!), I’ve found that they embrace the training and perform excellent investigations. Hospital staff just need this bit of training to move to the next level of finding scientifically-derived root causes and applying effective corrective actions, all without playing the blame game. It is gratifying to see doctors and nurses working together to correct these issues on their own, without needing some expensive guru to come in and do it for them.
Hospitals have the means to start fixing these issues. I’m hoping the smart people at these facilities take this to heart and begin putting processes in place to make a positive difference in their patient outcomes.
“We are going to find out who is to blame because that is the frustrating part about health and safety accidents such as this. When we go back, when we read the report, we find out each and every time that it was preventable. That’s why we need to learn from this,” Kevin Flynn, Ontario’s labour minister, told reporters Tuesday afternoon.
That’s a quote from CP 24, Toronto’s Breaking News. See the story and watch the video interview about the accident here:
Is there a lesson to be learned here?
Interestingly, the “contractor” performing the work in this accident was a branch of the Ontario government.
Everything was going great for Michael Daughtery, owner of LabMD, a company that tested blood, urine, and tissue samples for urologists. He was living the dream. That is, until one of his managers who had been using LimeWire file-sharing to download music inadvertently shared patient medical records with it. It was a violation of company policy to have it on her computer.
The story goes from bad to worse. Read “A leak wonded this company. Fighting the Feds finished it off” on Bloomberg.
In one day, your whole life could change. Wouldn’t it be great if you never got that phone call that disaster has struck your company?
We have several exclusive Pre-Summit Courses coming up in August that can help you keep your company from facing a crisis such as this. TapRooT® for Audits, Understanding and Stopping Human Error, Risk Assessment & Management and more.
View them here.
We also offer a Medical track immediately following the special 2-day courses at the 3-day Global TapRooT® Summit. Learn more here.
We hope to meet you in San Antonio, Texas during Global TapRooT® Summit week to help you solve your business-critical issues.
The following sequence is from the Clarence Bee …
First, an air conditioning unit for a power supply room failed.
No big deal … There’s an automatic backup and a system to notify the engineer.
Oops … It failed too.
Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?
Sorry. In the “heat” of the moment, he pushed the “kill” button.
Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it.
Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.
What can you learn from this incident?
- Do your people know what to do when things go wrong?
- Do you do drills?
- Are things clearly labeled?
- Are there response procedures?
- How long has it been since people were trained?