Category: Current Events

Monday Accident & Lessons Learned: Report by UK RAIB – Serious accident as a passenger left a train and became trapped in the train doors at West Wickham station last April

March 14th, 2016 by

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At around 11:35 hrs on 10 April 2015, a passenger was dragged along the platform at West Wickham station, south London, when the 11:00 hrs Southeastern service from London Cannon Street to Hayes (Kent) departed while her backpack strap was trapped in the doors of the train.

As it moved off, she fell onto the platform and then through the gap between the platform and train, suffering life-changing injuries.

The backpack strap became trapped when the train doors closed unexpectedly and quickly while she was alighting.

Testing showed that this potentially unsafe situation could only occur when a passenger pressed a door-open button, illuminated to show it was available for use, within a period of less than one second beginning shortly after the train driver initiated the door closure sequence.

RAIB identified this door behaviour, which was not known to the owner or operator, and issued urgent safety advice. In response to this, the railway industry undertook a review which identified 21 other types of train that permit passenger doors to be opened for a short period after door closure is initiated by train crew. The industry is now seeking ways to deal with this risk.

The train was being driven by a trainee driver under the supervision of an instructor. The service was driver only operation, which meant that before leaving West Wickham station, and after all train doors were closed, drivers were required to check that it was safe to depart by viewing CCTV monitors located on the platform. Two of these monitor images showed that a passenger appeared to be trapped but, although visible from the driving cab, neither the trainee driver nor the instructor was aware of this. Although the RAIB has not been able to establish why the trapped passenger was not seen before the train departed, a number of possible explanations have been identified.

As a result of this accident, RAIB has made two recommendations. The first, addressed to operators and owners of trains with power operated doors, is intended to identify and correct all train door control systems exhibiting the unsafe characteristics found during this investigation. The second, addressed to RSSB, seeks changes to guidance documents so that, where practicable, staff dispatching trains watch the train doors while they are closing, in addition to checking the doors after they are closed.

RAIB has also identified five learning points relating to: releasing train doors long enough to allow passengers to get on and off trains safely; effective checking of train doors before trains depart (and not relying on the door interlock light); design of door controls; and use of train driving simulators to raise drivers’ awareness of circumstances when it is not safe to depart from a station.

For the entire report, see:

https://assets.digital.cabinet-office.gov.uk/media/56d04f05e5274a10f9000001/R032016_160229_West_Wickham.pdf

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

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If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Monday Accident & Lessons Learned: Button Pushed “Accidentally” Shuts Down Refinery

March 7th, 2016 by

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Here’s the press report about an incident at a west coast refinery …

http://ww2.kqed.org/news/2016/02/26/martinez-refinery-incident-triggered-when-someone-hit-the-wrong-button

They think that someone working in the area accidentally hit a button that shut down fuel to a boiler. That caused a major portion of the refinery to shut down.

 At least one Causal Factor for this incident would be “Worker accidentally hits button with elbow.”

If you were analyzing this Causal Factor using the Root Cause Tree®, where would you go?

Of course, it would be a Human Performance Difficulty.

When you reviewed The Human Performance Troubleshooting Guide, you would answer “Yes” to question 5:

“Were displays, alarms, controls, tools, or equipment identified or operated improperly?”

 That would lead you do evaluating the equipment’s Human Engineering.

Under the Human-Nachine Interface Basic Cause Category, you would identify the “controls need improvement” root cause because you would answer “Yes” to the Root Cause Tree® Dictionary question:

“Did controls need mistake-proofing to prevent unintentional or incorrect actuation?”

That’s just one root cause for one Causal Factor. How many other Causal Factors were there? It’s hard to tell with the level of detail provided by the article. I would guess there was at least one more, and maybe several (there usually should be for an incident of this magnitude). 

At least one of the corrective actions by the refinery management was to initially put a guard on the button. Later, the button was removed to eliminate the chance for human error. 

Are there more human-machine interface problems at this refinery? Are they checking for them to look for Generic Causes? You can’t tell from the article.

Would you like to learn more about understanding human errors and advanced root cause analysis? Then you should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See public course dates at:

http://www.taproot.com/store/5-Day-Courses/

And click on the link for the continent where you would like to attend the training.

Revisions to the EPA’s Risk Management Plan Involve Accident Investigation & Root Cause Analysis

March 3rd, 2016 by

President Obama issued Executive Order 13650 that directed agencies to improve chemical safety performance.  In response, the EPA is proposing changes to the RMP (Risk Management Plan) regulation. A preliminary copy of the changes have been published HERE (they have not yet been published in the Federal Register).

For readers interested in root cause analysis, the main changes start on page 28 in the Incident Investigation and Accident History Requirements section.

The revision to the regulation actually mentions “causal factors” and “root causes” that were not mentioned in the previous regulation. On page 33 the revision states:

Thus EPA is proposing to require a root cause analysis to ensure that facilities determine
the underlying causes of an incident to reduce or eliminate the potential for additional accidents
resulting from deficiencies of the same process safety management system.

The EPA document uses the following definition of a root cause:

Root cause means a fundamental, underlying, system-related reason
why an incident occurred that identifies a correctable failure(s) in management systems.

The revision document gives examples of poor investigations of near-miss accidents that did not get to root causes so that a future accident that included a fatality or severe injuries occurred. These examples include and explosion and fire at a Tosco refinery, an explosion at a Georgia-Pacific Resins facility, an explosion an fire at a Shell olefins plant, and a runaway reaction at a Morton International chemical plant. In each case, root causes of issues were not identified and fixed and this allowed a more serious accident to eventually occur.

Of course, I have said many times that I’ve never seen a major accident that didn’t have precursor incidents (call them near-misses if you must). Performing adequate root cause analysis of smaller incidents has always been one of the goals that we have suggested to TapRooT® Users and now even more fully support with the new Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book.

The document asks for comments on the proposed revision to the regulation (page 41):

  • EPA seeks comment on whether a root cause analysis is appropriate for every RMP reportable accident and near miss. 
  • Should EPA eliminate the root cause analysis, or revise to limit or increase the scope or applicability of the root cause analysis requirement? 
  • If so, how should EPA revise the scope or applicability of this proposed requirement? 
  • EPA also seeks comment on proposed amendments to require consideration of incident investigation findings, in the hazard review (§ 68.50) and PHA (§ 68.67) requirements. 
  • Finally, EPA seeks comment on the proposed additional requirement in § 68.60 to require personnel with appropriate knowledge of the facility process and knowledge and experience in incident investigation techniques to participate on an incident investigation team.

In the document, there is extensive discussion about defining and investigating near-misses. The section ends with …

  • EPA seeks comment on the guidance and examples provided of a near miss. 
  • Is further clarification needed in this instance? 
  • Should EPA consider limiting root cause analyses only for incidents that resulted in a catastrophic release?

The document also discusses time frames for completing investigations. Should it be 30 days, 60 days, six months? It’s interesting to note that many investigations of process safety incidents by the US Chemical Safety Board takes years. The EPA is suggesting that a one year time limitation (with the possibility of a written extension granted by the EPA) be the specified time limit.

The EPA is asking for feedback on this time limit:

  • EPA seeks comment on whether to add this condition to the incident investigation requirements or whether there are other options to ensure that unsafe conditions that led to the incident are addressed before a process is re-started. 
  • EPA also seeks comment on whether the different root cause analysis timeframes specified under the MACT and NSPS and proposed herein will cause any difficulties for sources covered under both rules, and if so, what approach EPA should take to resolve this issue.

The document also discusses reporting of root cause information to the EPA and suggests that common “categories” of root causes be reported to the EPA. The document even references an old (1996) version of the TapRooT® Root Cause Tree® and a potential list of root cause categories, They then request comments:

  • EPA seeks comment on the appropriateness of requiring root cause reporting as part of the accident history requirements of § 68.42, as well as the categories that should be considered and the timeframe within which the root cause information must be submitted.

Although I am flattered to be the “father” of this idea that root causes should be reported so that they may be learned from, I’m also concerned that people may think that simply selecting from a list of root causes is root cause analysis. Also, I’ve seen many lists of root causes that had bad categorization. The main problem is what I would call “blame” categorization. I’m not sure if the EPA would recognize the importance of the structure and limits that need to be enforced to have a good categorization system. (Many consultants don’t understand this, why should the EPA?)

As everyone who reads the Root Cause Analysis Blog knows, I am always preaching the enhanced use of root cause analysis to improve safety, process safety, patient safety, quality, equipment reliability, and operations. But I am hesitant to jump aboard a bandwagon to write federal regulations that require good management. Yes, I understand that lives are at stake. But every time a government regulation is written, it seems to cement a certain protocol and discourages progress. Imagine all the improvements we have made to TapRooT® since 1996. Would that progress be halted because the EPA cements the “categorization” of root causes in 1996? Or even worse… what if the EPA’s categories include “blame” categories and managers all over the chemical industry start telling investigators to stop looking for other system causes and find blame related root causes? It could happen.

I would suggest that readers watch for the publication of EPA’s revision of the RMP in the Federal Register and get their comments in on the topics listed above. You can’t blame the EPA for making bad regulations if you don’t take the opportunity to comment when the comments are requested.

Monday Accident & Lessons Learned: Is Human Error the Root Cause of the German Train Crash?

February 29th, 2016 by

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When the press covers an accident, they like instant answers, The BBC is reporting that “human error” is to “blame” for the cause of two trains crashing head on in Germany. Here’s the article:

http://www.bbc.com/news/world-europe-35585302

Of course, prosecutors are pressing charges against the area controller who “… opened the track to the two trains and tried to warn the drivers.”

What do you think … is “human error” THE cause?

BP Rig Supervisor Robert Kaluza Found Not Guilty

February 26th, 2016 by

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The last of the federal prosecutions are finally concluding. Robert Kaluza was found not guilty of violating the federal Clean Water Act for missing indications of the blowout of the Macondo well. The accident killed 11 workers and both Kaluza and Donald Vidrine were initially charged with manslaughter, but those charges were later dropped.

Vidrine and Kaluza were not the only people charged as a result of the spill. BP employee Kurt Mix was prosecuted for obstruction of justice after he deleted text messages on this phone. Mix wasn’t involved in the accident, but was involved in trying to find ways to stop the spill. His ordeal ended last November when, after his initial conviction was overturned on appeal, he accepted a plea bargain to a misdemeanor charge for deleting the text messages without company permission.

Note that these engineers were the highest level company personnel prosecuted after the spill. No senior executives face charges.

Kurt Mix will be speaking at the 2016 Global TapRooT® Summit about his experience and the effect that it might have on other first responders and people being asked questions after an accident. If you don’t think that federal prosecutions could impact your incident investigations, come hear Kurt’s story and then decide.

The 2016 Global TapRooT® Summit is being held in San Antonio, Texas, on August 1-5. For more information about the keynote speakers, see:

http://www.taproot.com/taproot-summit/keynote-speakers

Monday Accident & Lessons Leaned: Sure Looks Like an Equipment Failure … But What is the Root Cause?

February 25th, 2016 by

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When you look up in the air and this is what you see … it sure looks like an equipment failure. Bit what is the root cause? 

That’s what DTE Energy will be looking into when they investigate this failure.

How do you go beyond “It broke!” and find how and why and equipment failure occurred? We recommend using techniques developed by equipment expert Heinz Bloch and embedded in the Equifactor® Module of the TapRooT® Software.

For more information about the software and training, see:

http://www.taproot.com/products-services/equipment-troubleshooting

Accident: Collapse of Didcot Power Station

February 24th, 2016 by

Footage of the collapse …

It was being demolished. Here are two news stories …

Using the Essential TapRooT® Techniques to Perform Apparent Cause Analysis

February 17th, 2016 by

If you are in the nuclear industry you have probably read my rant on apparent cause analysis. I said that apparent cause analysis was a curse.

The curse as been lifted!

We published a book that describes how to use TapRooT® for low-to-moderate risk incidents. And this new way of using TapRoot® is perfect for apparent cause analysis!

EssentialsBook

What’s in the 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

WHEN CAN YOU BUY THIS NEW BOOK??? NOW!!!

See this link: 

http://www.taproot.com/products-services/taproot-book

Monday Accident & Lessons Learned: A Fatality Can Happen Anyplace

February 15th, 2016 by

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The New York Daily News reported that a bakery worker at Ream’s Market was killed.

The article mentions that her clothes caught on the mixer and the woman was “sucked in.”

What can you learn from this accident?

Fatalities can happen anywhere.

What can you do to prevent fatalities?

First, know your hazards.

This industrial mixer had the potential to kill.

What were the safeguards to keep employees from getting cloths caught and then be sucked into the mixer?

Being careful just wasn’t enough.

Have you performed a detailed analysis of your facility’s hazards, safeguards, and targets?

Learn your lesson and get started before a fatality happens!

Mark Paradies has 24,000 Direct LinkedIn Connections

February 10th, 2016 by

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If you are interested in advanced root cause analysis, join my network. Send me an invitation to connect at:

http://www.linkedin.com/in/markparadies

Will They Really Find the Root Causes?

February 3rd, 2016 by

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The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

Monday Accident & Lessons Learned: UK RAIB Report – Collision at Froxfield

January 25th, 2016 by

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Image of debris on track before the collision, looking east.
Train 1C89 approached on the right-hand track (image courtesy of a member of the public)

 

RAIB has today released its report into a collision between a train
and a fallen bridge parapet at Froxfield, Wiltshire, 22 February 2015

 

At around 17:31 hrs on 22 February 2015, a high speed passenger train (HST), the 16:34 hrs First Great Western service from London Paddington to Penzance, struck and ran over part of the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.

The train was fully loaded with around 750 passengers and was travelling at a speed of 86 mph (138 km/h) when the driver saw the obstruction. He applied the emergency brake but there was insufficient distance to reduce the speed significantly before the train struck the parapet. The train did not derail and came to a stop around 720 metres beyond the bridge. There were no injuries. The leading power car sustained damage to its leading bogie, braking system, running gear and underframe equipment.

The immediate cause of the collision was that the eastern parapet of Oak Hill Road overline bridge had been pushed off and onto the tracks, by a heavy goods vehicle which had reversed into it. The train had not been stopped before it collided with the debris because of delays in informing the railway about the obstruction on the tracks.

Recommendations

RAIB has made four recommendations relating to the following:

  • installation of identification plates on all overline bridges with a carriageway unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a particular bridge are assessed as likely to be minor
  • enhancing current road vehicle incursion assessment procedures to include consideration of the risk from large road vehicles knocking over parapets of overline bridges (two recommendations)
  • introduction of a specific requirement in a Railway Group Standard relating to the onward movement of a train that is damaged in an incident, so that the circumstances of the incident and the limitations of any on-site damage assessment are fully considered when deciding a suitable speed restriction, especially when there are passengers on board.

RAIB has also identified two learning points, one for police forces regarding the importance of contacting the appropriate railway control centre immediately when the safety of the line is affected and the other for road vehicle standards bodies and the road haulage industry about the benefits of having reversing cameras or sensors fitted to heavy goods vehicles

Notes to editors

  1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
  2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
  3. For media enquiries, please call 020 7944 3108.

For the complete report, see:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/493315/R022016_160120_Froxfield.pdf

SpaceX Rocket ALMOST Lands – Equipment Failure?

January 18th, 2016 by

So close!

SpaceX attempted to land the first stage of their Jason 3 launch vehicle on their Autonomous Spaceport Drone Ship this weekend. The video shows the stage softly touching down, and then toppling over. Elon Musk tweeted that the leg did not fully latch prior to touchdown, and folded up when the stage weight was applied. He said it looks like the collet between the leg extension tube segments did not hold due to icing prior to launch.

While this is a cool video, it got me thinking about using the correct type of equipment for the application. for example, Musk said they use a “collet” between the leg segments. A collet is a friction device that holds 2 tubes together. Not necessarily a positive locking device. It appears that ice prevented full extension and therefore full friction from being applied, and the leg collapsed.

What do you think? Is a collet the correct type of device to hold a static load like this in place? My thoughts: I think a more simple locking pin that drops into place, or a circumferential collar that drops into a slot, would be a much more reliable locking device, rather than something that depends on friction for support.

Still, what an awesome landing attempt!

What Does an Accident Cost? After $1.6 Billion in Sanctions, PG&E Faces More Fines.

December 28th, 2015 by

A Judge in California has ruled that PG&E must face charges that it knowingly and willfully violated minimum pipeline standards in the 2010 explosion that killed 8 people. 

State regulators have already imposed $1.6 billion in civil sanctions. PG&E faces and additional $565 million in penalties as part of these charges. 

For more information, see: http://www.gasprocessingnews.com/news/pge-to-face-most-charges-over-deadly-california-gas-pipeline-blast.aspx

Monday Accident & Lessons Learned: REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS MEASURED IN THE RESERVOIR LEADING TO KICK

December 21st, 2015 by

IOGP SAFETY ALERT

REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS
MEASURED IN THE RESERVOIR LEADING TO KICK

Course of events:

  • Drilled 6×7″ hole section, ran screens and set hanger.
  • Displaced from 1.18 SG drilling fluids to 1.05 SG brine.
  • Closed in based on 600 l influx (PP estimated to be 1.09 SG)
  • Circulated out gas and displaced to 1.15 SG brine (using drillers method)

What Went Wrong?

Factors which contributed to the incident:

  • Brine weight reduction
  • Pore pressure prognosis
  • Lack of pressure point coverage of all sands during drilling

Corrective Actions and Recommendations:

  • Several pressure points where taken in the reservoir and these were used to reduce to mud weight from 1,08 sg to 1,05 sg brine. This reduction turned out to result in too great a weight decrease, since there were two small sand zones exposed that where not picked up on the log. It is important not to place to great a reliance on pressure points taken during the section, since there can be small zones that have not been caught on the log that may have a different pressure.
  • Instead of displacing the well to kill mud during the second circulation of the drillers method, the team decided to displace to a higher weight brine. This meant that they would continue operations faster, after the kill, than would have been the case if they displaced to drilling mud.

Source Contact:

safety alert number: 269
IOGP Safety Alerts http://safetyzone.iogp.org

Disclaimer

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. 

 

Monday Accident & Lessons Learned: FATALITY WHILE TRIPPING PIPE

December 14th, 2015 by

IOGP SAFETY ALERT

FATALITY WHILE TRIPPING PIPE

Country: USA – North America
Location: OFFSHORE : Mobile Drilling Unit
Incident Date: 20 October 2015   
Type of Activity: Drilling, workover, well services
Type of Injury: Struck by
Function: Drilling

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View of pipe stand in lower fingerboard

 A Deepwater drill crew was tripping in the hole with drill pipe.

As they were transferring a stand of pipe out of the setback area with a hydraracker, the stand caught on a finger at the 51′ lower fingerboard.

As the hydraracker continued to move, tension caused the pipe to bow and the pipe was released from the lower tailing arm with significant force toward the setback area striking and fatally injuring the employee.

What Went Wrong?

This investigation for this event is ongoing.

Corrective Actions and Recommendations:

While this incident is still under investigation, drilling rig operators using fingerboards with latches are recommended to:

  • Review and assess applicability of NOV Product Information Bulletin 85766409 and NOV Safety Alert Product Bulletin 95249112
  • Verify a system is in place to confirm the opening and closing of fingerboard latches (by way of CCTV or spotter)
  • Ensure personnel are kept clear of the setback area 

Safety Alert Nnumber: 268 
IOGP Safety Alerts http://safetyzone.iogp.org/

Disclaimer

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.

 

 

Reuters Reports: “BP spill manslaughter charges dropped, one guilty of environmental crime”

December 3rd, 2015 by

Manslaughter charges were dropped against the two BP Engineers in-charge on the ill-fated Deepwater Horizon. Donald Vidrine did plead guilty to one misdemeanor violation of the Clean Water Act.

For more info, see: http://uk.reuters.com/article/2015/12/02/uk-bp-spill-charges-idUKKBN0TL26M20151202 

Monday Accident & Lessons Learned: Is Training the Right Corrective Action for this Fatal Accident?

November 30th, 2015 by

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Here is a link to the significant incident report:

http://www.dmp.wa.gov.au/Documents/Safety/MSH_SIR_230.pdf

It seems from the report that the appropriate seat belt was present. Therefore the only applicable action in the “Action required” section is:

Workers should be instructed, through training and inductions, regarding the importance of using the seatbelts provided in vehicles to reduce the impact of potential collisions.” 

In my instant root cause analysis using the Root Cause Tree®, I wonder why there wasn’t a Standards, Policies, and Administrative Controls Not Used Near Root Cause. That would get me to dig more deeply into the Enforcement NI root cause. 

What do you think? Was this a training root cause that needs a training corrective action?

Leave your comments below…

Monday Accident & Lessons Learned: “Safety Pause” – Does It Work?

November 16th, 2015 by

An article in the Aiken Standard got me thinking again about the topic of safety stand-downs (this time called a “safety pause”).

These temporary “stop work” activities where safe work practices are suppose to be reviewed, and where new emphasis is suppose to be applied to ensure safety, are common in government operations (this time a DOE site) and the nuclear industry. I’ve written about them before:

The safety pause at Savannah River Nuclear Solutions is a really long pause. It started on September 11 after a September 3 incident in the H Canyon – HB Line portion of their operations where Plutonium was being handled.

An SRNS spokesperson is quoted by the paper as saying that: “SRNS is a stronger, healthier company as a result of these actions and we are working for sustained improvement.”

Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the “pause” to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.

WSJ: “Dam Failure Points to Rise in Mine Woes”

November 9th, 2015 by

In 2011 the mining recession started. The price of commodities (iron ore, copper, and other metals) suffered when demand from China dropped. This recession was somewhat independent from the housing crash of 2008.

What is the natural tendency of an industry faced with falling prices and falling demand? To cut costs. And that happened across the mining industry. 

The Wall Street Journal is now pointing to the increased number of fatalities at large mining companies “when most are enacting heavy cost cuts as they battle to remain profitable amid a downturn in world commodity prices.” (See articles here and here.)

This negative press coverage by the WSJ resulted from the recent dam failure at a mine co-owned by BHP and Vale (the mine operator is named Samarco) (see article here). 

Has cost cutting led to increased mining accidents? Will falling oil prices result in more oil industry fatalities? It is difficult to prove a cause and effect link but statistics point to negative trends.

Monday Accident & Lessons Learned: Well Kick Due to Liner Top Seal Failure

November 9th, 2015 by

IOGP SAFETY ALERT

WELL KICK DUE TO LINER TOP SEAL FAILURE

After several attempts and a dedicated leak detection run, the 7” and 5” x 4-1/2” liner were inflow tested successfully to max difference of +10 bar.

Ran completion in heavy brine and displaced well to packer fluid (underbalanced).

Rigged up wireline pressure control equipment to install plug and prong in tubing tailpipe. While RIH with the plug on WL, a sudden pressure increase was observed in the well. Pressure increased to 125 bar on the tubing side.

Attempted to bleed off pressure, but pressure increased to 125 bar immediately.

Continued operation to install plug, pressure up tubing and set production packer.

Performed pump and bleed operation to remove gas from A-annulus. The general gas alarm was triggered during his operation due to losing the liquid seal on the poorboy degasser.

Continued pump and bleed operation until no pressure on tubing and A-annulus side, and the tubing and A-annulus were tested successfully.
NewImageWhat Went Wrong?

Failure of the 5″ liner hanger and 5″ tie-back packer.

Corrective Actions and Recommendations:

Difficult to bleed out gas in a controlled way due to sensitive choke and no pressure readings from poorboy degasser.

When performing pump and bleed operations, line up to pump down one line and take returns in a different line to optimize the operation.

Consider adequacy of the testing of the 5″ liner hanger.

Safety Alert Number: 267
IOGP Safety Alerts http://safetyzone.iogp.org/

Disclaimer:

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.

New EPA Refinery Regulation Requires Root Cause Analysis of Upset Emission Events

November 5th, 2015 by

The new EPA emission regulation (not yet published in the Federal Register, but available here), requires a root cause analysis and corrective actions for upset emission releases including flare events.

Not only is a root cause analysis with corrective actions required, but a second event from the same equipment for the same root cause would trigger a diviation of the standard (read “fine”). In addition, the same device with more than 3 events per 3 years or the combination of 3 releases becomes a deviation.

This means it is time for effective, advanced root cause analysis of emission events. Time to send your folks to TapRooT® Root Cause Analysis Training!

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